Haiti Earthquake Relief, Phase Two — Long-Term Needs and Local Resources

A month and a half after January's devastating earthquake in Haiti, the National Organization for the Advancement of Haitians, a U.S.-based nonprofit organization with a division dedicated to improving health care in Haiti, sent in teams of U.S. physicians and other health care professionals, primarily of Haitian descent, as the acute phase of disaster response was ending. As part of this group, I worked in a makeshift hospital in Tabarre, a section of northeast Port-au-Prince.

As a first-generation Haitian-American and an internist, I expected to be prepared for the situation I was walking into. Haiti was a country I knew, I spoke the language, I understood the people, and by this point I had been watching the disaster on television daily for over a month. I knew that with the threat to life no longer minute to minute but week to week, the long-term recovery phase was beginning. According to my relatives in Haiti, the initial shock was passing. Dead victims had been cleared from the streets, families were either reunited or mourning their losses, the roads were somewhat drivable, and food and water were slowly making their way to survivors. Yet when I came face to face with the disaster, I realized that the media hadn't even begun to capture the extent of the devastation. Seeing Haiti through a framed television screen had given me only a snapshot of destroyed buildings, misplaced families, and stories of loss and survival.

When you're on site, there is no television to turn off, no place to avert your gaze, no way to avoid hearing endless conversations about loss and devastation — and fears about worse to come. Nor could I turn off the unrelenting heat, or the airborne dust from the rubble of destroyed buildings, or the smoke rising from burning bodies, wood, and rubber. As I looked around, not a single standing building interrupted my line of sight in any direction. Every street was spilling over with masses of displaced people, many of them young children, stuck in a strange purgatory with no place to stay and no place to go.

I soon saw that the Haitian people were paralyzed by fear. In the middle of the night, while coworkers and I were asleep inside a small home that had survived the earthquake, a minor tremor (measuring 4 on the Richter scale) knocked me out of bed. Immediately, people were screaming in the streets, afraid that “the next big one” was upon them. Neighbors yelled frantically, telling us to get out, that they could hear the building cracking. The next thing I knew, I was sleeping in a tent — the most secure and comfortable option. At that point, my only solace lay in focusing on what I could control — what little I could offer as a physician.

(FigurePostoperative Care for a Young Amputee.)

At our makeshift hospital, we were past the heroic stage of rescuing bodies from the rubble and performing emergency lifesaving surgeries. Now the delayed effects of the earthquake, which affected an estimated 1.4 million people, were manifesting themselves. Inconsistent wound care and rehabilitation for trauma victims and amputees resulted in a multitude of patient visits for infections, disabilities, and complications from delayed treatment, such as gangrene and sepsis. The dust and smoke in the air led to respiratory illnesses, including severe asthma, flares of chronic obstructive pulmonary disease, bronchitis, and pneumonia. According to the World Health Organization (WHO), respiratory infections are now the main cause of illness, followed by trauma or injury, diarrhea, and suspected malaria.1 Crowding and poor sanitation in rapidly growing tent settlements were creating or exacerbating medical problems, particularly in children. Mobile clinics from Tabarre provided targeted, large-scale treatment of postoperative infections and therapies for outbreaks of lice and scabies in orphanages. Before the earthquake, diarrheal illness accounted for 17% of deaths in children under the age of 5 years. Now, in addition to the already contaminated water supplies and poor sanitation, the rainy season will increase the risk of acute respiratory infection, diarrhea, and waterborne and vectorborne diseases, including dengue, typhoid, and malaria. In anticipation of this onslaught, the WHO is undertaking large-scale vaccination campaigns and tasking mobile health clinics with identifying outbreaks quickly in order to limit the associated morbidity and mortality.

In addition, the chronic diseases that patients had been ignoring since the earthquake were rearing their ugly heads. Several patients arrived after having interrupted their treatment for tuberculosis or HIV, with no records of their previous regimens. Large numbers of patients — some who had had no regular health care before the earthquake and others whose care had been interrupted — now presented with acute manifestations of their uncontrolled chronic diseases, in the form of hypertensive emergencies, strokes, seizures, and diabetic ketoacidosis. Although many medications were available, donors had provided a supply of drugs that generally were not targeted to chronic health problems. In Tabarre, despite the fact that we limited each patient to only 10 to 15 pills at a time, the medications in highest demand — such as basic antibiotics, asthma inhalers, and hypertension and diabetes medications — became scarce, while boxes of others, such as intravenous amiodarone, remained untouched.

(FigureEmergency Room at a Field Hospital.)

Public health problems affecting women, ranging from sexual violence to a lack of obstetrical care, were also exacerbated by the earthquake. We treated women and girls as young as 12 years of age for newly acquired sexually transmitted infections (STIs). Many women reported being the victims of forced sexual encounters in the tent settlements. Though these reports are unconfirmed, increasing numbers of reports by health care workers of STIs and sexual violence have led to an official WHO investigation and a targeted assessment of women's health care needs.2,3

Ultimately, it became clear to me that the most important resource for the ongoing relief effort is the one most threatened by the earthquake: the local people. Though I had not been back to Haiti in 15 years and was there for only 2 weeks, the local people were what enabled me and my colleagues, both emotionally and logistically, to provide care to more than 800 patients a day. Local volunteers — who constituted about half our staff, though they could easily have been devoting time to their own recovery instead — spent every day, sunrise to sunset, making it possible for us to provide care. They triaged patients, organized the physicians, distributed medications, and rose to any necessary task. Patients were grateful that the Haitian diaspora was returning to help. Despite their own loss and tragedy, they would laugh at my American-accented Creole and tell me how proud they were of me for coming back. Neighbors living in tents in their backyards cooked a full breakfast and dinner for me and several coworkers every day. In exchange for our provision of a 2-week proverbial Band-Aid, the people helped, encouraged, and took care of us. While international volunteers come and go, the local people will remain the backbone of the recovery process, and integrating them into international relief efforts will be vital.

The road to recovery will be long, and with the rainy season beginning, circumstances will get worse before they get better. Six months after the 2005 earthquake in South Asia, a similar pattern of respiratory infections, diarrhea, infectious disease outbreaks, poor sanitation, and insufficient shelter persisted and worsened despite a strong initial relief response.4 In Haiti, the initial response has also been strong, and we have learned from previous disasters what to anticipate in the months and years to come. Clear insight into the changing medical needs, together with the collaboration of the strong-willed Haitian people, will drive an effective effort to rebuild Haiti and, I hope, make it stronger than ever.

http://www.nejm.org/doi/full/10.1056/NEJMp1003839#t=article