Although minor procedures, from draining abscesses to tubal ligations, were done intermittently ever since clinical services were first offered in Cange, it was not until 1993 that an operating room was built. With the arrival of a full-time obstetrician-gynecologist, over the next several years the OR was used regularly to address obstetrical emergencies. Short-term medical missions from the United States became increasingly surgical over time, but there were neither general surgeons nor anesthesiologists on staff. As the number of patients seeking care for the major morbidities of TB, HIV, diarrheal disease, and chronic noncommunicable diseases grew, more and more patients with surgical disease also came to l’Hôpital Bon Sauveur seeking care. By the late 1990s, there was increased recognition of the need to treat a variety of routine, urgent, and emergent surgical diseases. To meet these needs, ZL built a second OR and a 15-bed surgical ward, and between 2000 and 2002 hired a general surgeon as well as two additional obstetrician-gynecologists. Through an agreement with the Cuban Ministry of Health, another general surgeon came to the hospital in 2002. An ophthalmologist was hired in 2003 and, with the help of the Haitian Red Cross, a proper blood bank was installed.
By 2005, ZL’s public-private partnerships at small regional hospitals and clinics, along with hundreds of attendant community health workers, served as a network referring patients from across the entire Central Plateau to l’Hôpital Bon Sauveur for evaluation and surgery. Staff at all of the expansion sites are trained in basic surgical resuscitation and stabilization, and referrals are facilitated by Zanmi Lasante/Ministry of Health-owned ambulances in emergency cases or through the provision of transportation stipends to patients with nonurgent problems. Operating rooms at two of the largest expansion sites, Hinche and Belladères, have recently been refurbished and staffed with a full-time obstetrician and nurse anesthetist (NA) for emergency obstetrical care. A Médecins Sans Frontières (MSF)-led NA training program began at l’Hôpital Bon Sauveur in 2006; six nurses from ZL and other parts of Haiti are currently enrolled.
To better understand the volume and variety of surgical procedures at l’Hôpital Bon Sauveur, we undertook a retrospective review of the surgical cases performed between January 2002 and September 2005. We reviewed the operating room logs maintained by the surgical and anesthesia staff for patient age, place of residence, date of procedure, type of procedure, and the specialty involved. Distance traveled to the hospital was estimated as the crow flies based on patients’ place of residence. Table displays the characteristics of surgical patients served at l’Hôpital Bon Sauveur between January 2002 and September 2005. A total of 2,601 patients underwent 2,900 procedures, ranging from simple incision and drainage to complicated cardiothoracic surgeries.
Characteristics of surgical patients at l’Hôpital Bon Sauveur, Cange, Haiti, 2002–2005
Two notable findings confirmed our experiential understanding of the l’Hôpital Bon Sauveur surgical program. First, the total number of patients seeking services has increased significantly, from 241 patients in 2002 to 762 during the first nine months of 2005. Second, the geographic distribution of patients has expanded: in 2002, more than 80% of patients lived within 50 km of the hospital. By 2005, however, more than half the patients traveled over 50 km to Cange for care—a significant journey to a rural, remote area of the country. This expanding catchment area points to the significance of PIH/ZL’s accompagnateur model, which allows patients who might otherwise not seek care to be identified and referred from their communities and later followed up in their homes as necessary, but also the importance of providing free care to those who need it. By 2005 a third of all patients undergoing surgery at l’Hôpital Bon Sauveur reported their place of residence to be the capital city of Port-au-Prince—the site of the largest public hospital in the country as well as numerous private surgical practices, all of which require fees for services. The widening geographic distribution of the ZL patient base over time presents convincing evidence of the surgical service’s importance not just to the Central Plateau region, where the hospital is located, but to the country as a whole, as cost and/or quality of care are prohibitive factors even when other facilities are available.
A wide variety of surgical pathology was addressed at l’Hôpital Bon Sauveur, with common procedures dominating the census (Table ). General surgery accounted for almost half (47.6%) of all cases, obstetrical and gynecological cases a third (32.6%) of all cases, and urologic, plastic, neurologic, ophthalmologic, and cardiothoracic cases the remainder. Visiting specialists on short-term missions, largely from the United States, performed operations not normally performed by the staff general surgeons, such as prostatectomy, extraventricular drain placement, and cleft lip repair. One case of mitral valvuloplasty surgery with the use of an extracorporeal bypass circuit was performed by visiting surgeons in 2002.
Surgical procedures performed at l’Hôpital Bon Sauveur, Cange, Haiti, 2002–2005a