There are words in many languages that have no good English equivalent. During my work in Haiti, I’ve noticed my Haitian colleagues on occasion exhaling a phrase — “tet chaje” — which literally means “head charged.” More accurately, it describes a sense of being overwhelmed or conveying disbelief or frustration. Based on my limited experiences in the field, I can only begin to imagine the burnout that local providers face in resource-limited settings.
Unlike in places like the United States, where responsibility is shared within each role (we have scores of hospitalists in our department and dozens of resident physicians to assist on the wards), resource-limited settings often only have one person who is responsible 24/7 for a particular function in the health care system. Moreover, as outsiders in global health, eventually we all have the luxury of stepping away from chaos, and going home to health care centers with seemingly unlimited resources. In stark contrast, our local Haitian colleagues have little respite and are left to work in an imperfect system doing the best they can with the resources at hand. Their efforts are almost never adequately recognized; not by their own institutions, and not by any form of popular media willing to capture their dedication and commitment. Few positive feedback loops exist.
To mitigate burnout, health care organizations in the US have increasingly gone out of their way to recognize the dedication of staff. I’ve noticed that a few days in every month in our hospital there is an event recognizing the role played by different groups within the health care team. Sometimes it is a luncheon for nurses, an appreciation event for interns, or a thank you afternoon party for social workers. Activities like this may seem trivial at first (and even wasteful given the severe resource shortages in other places), but to workers who face arduous hours, who are constantly exposed to suffering, and whose efforts are not adequately acknowledged on a day-to-day basis — every small gesture counts, and likely helps to bring into focus why they do this work in the first place.
I often wonder how we can provide better encouragement and support to our local colleagues working in places like rural Haiti. Outsiders come and go, but the backbone of a health care system must rely on locals — doctors, nurses, community health care workers, mental health professionals, physical therapists, and countless others coming together and coordinating efforts in impossible settings. Contrary to common beliefs — local professionals choose to work in such settings. They forgo higher paying jobs in capital cities or abroad, and work with neglected populations because they share the same passion for social justice that foreigners do (though they may lack the Twitter following or a blog for self-promotion).
Increasingly, outsiders are being erroneously hailed as messiahs. In reality, we aim to serve a specific purpose — to exchange knowledge, skills, and provide backup if needed. To be frank, local providers are impressive since they possess an intimate connection to the population we hope to serve and also an enviable fund of knowledge. On rounds, my internal medicine colleague Dr. Pierre would often answer my questions before my electronic brain (smart phone) had loaded. Additionally, he recited best practices despite sometimes never having access to the described diagnostics or treatments.
Similarly, my roommate Dr. Hamiltong, a general surgeon, performed complex surgeries alone that would inevitably involve multiple sub-specialties in the US. Their skills inspire me, but they will likely not be captured on magazine covers, or celebrated at global health conferences. While excellent patient care is foremost in all our efforts as providers, in the case of our local colleagues some recognition would be well-deserved. To be clear, I am not advocating that we massage individual egos, but that there be a consistent recognition of local staff (as opposed to the prevalent practice in global health circles of applauding outsiders for their great “sacrifice” for working in faraway places).
Recently, at the Lancet Global Health 2035 launch event at UCSF, economists and medical professionals discussed the real possibility of dramatic improvement in health care outcomes if low and middle-income countries started adequately investing in health care. Though it was inspiring to hear about the possibility of preventing millions of deaths by 2035, I believe that if these dreams are to be realized, a fundamental prerequisite is ensuring that there is adequate local staff present for implementation. Already a disturbing trend I witnessed during my brief time in Haiti was many physicians around me studying for the United States Medical Licensing Examination — presumably so that they could relocate and earn a fair wage, be appreciated as professionals, and function in a system where there is minimal (different) frustration. Credit needs to be given where it is due, and it is essential we find ways to support and encourage our amazing colleagues so that they may continue to be leaders and agents of change in their home countries.