Hypertension in Haiti: the challenge of best possible practice.

On the fourth anniversary, it is impossible to discuss hypertension in Haiti without acknowledging the almost incalculable negative impact of the January 12, 2010 earthquake. It was catastrophic not only in terms of death and physical injury, but also the widespread destruction of a tenuous infrastructure and public health system. Yet, paradoxically, this virtual blank slate could be an opportunity to develop an innovative pragmatic approach to the equally devastating problem of hypertension as the most common contributing cause of death in Haiti. Rising Phoenix-like literally from the ashes and rubble, there are lessons to be learned from the Haiti experience, as a potential model for the management of hypertension in the community in low resource venues in the Caribbean and beyond. Haiti has very poor comparative outcomes, and specific challenges related to high prevalence stroke, renal failure, and heart failure as negative prognostic consequences of undiagnosed and uncontrolled hypertension. There are severe public health challenges related to salt education, as well as societal challenges related to negative social determinants of health and disease, and the structural violence of overwhelming poverty. Pragmatism is necessary as we attempt to combine the tenets of evidence based medicine with reality based medicine restrictions imposed by low resource. It is through the generation of Best Possible Practice (BPP) models of care that colleagues can develop systems of mutual knowledge sharing, service, and support. This approach extends to screening and diagnosis, where there is no electricity for semi- or automatic manometric devices and requisite need to train in manual/ auscultatory technique, to education and curricula built specifically around a flexible hypertension community management guideline as the accepted standard to aspire to. A successful approach requires solid guiding principles, including a commitment to best attainable quality and value(s). It also requires standing together as a community of dedicated medical professionals.