HEALING A WOUNDED COUNTRY
The independent medical humanitarian organization Médecins Sans Frontières/ Doctors Without Borders has been providing health care in Haiti for 19 years. After the earthquake hit, its regular cadre of 800 field staff in Port-au-Prince quickly expanded to 3,400 people working in 26 hospitals and clinics. Two representatives from the organization explain why restoring Haiti’s health care system to what it was before the quake would be a travesty — because Haitians deserve so much better. Paul McPhun and Kevin Coppock offer some ideas for how to get it right this time.
Paul McPhun and Kevin Coppock
Il y a maintenant 19 ans que l’organisme humanitaire indépendant Médecins sans frontières fournit des soins médicaux en Haïti. Au lendemain du séisme, il a rapidement augmenté son effectif de terrain de 800 à 3 400 personnes, qui travaillent actuellement dans 26 cliniques et hôpitaux de Port-au-Prince. Deux de ses représentants expliquent ici qu’il serait dérisoire de rétablir le système de santé tel qu’il l’était avant le séisme, puisque les Haïtiens méritent beaucoup mieux. Paul McPhun et Kevin Coppock proposent quelques idées visant à créer cette fois un système de santé digne de ce nom.
he immediate emergency phase may be over, but the long-term work is just beginning, and it’s no less an emergency,” warned Karline Kleijer, Médecins Sans Frontières (MSF) head of mission, a mere seven weeks after the January 12 earthquake. The future remains uncertain for essential health care in the affected region of Haiti. Before the catastrophe, more than half of the Haitian population could not afford health care. More than 70 percent of them were reported to be living on less than US$2 per day. The capital, Port-au-Prince, a city of 3.5 million people, with many living in slums, had 21 public health facilities and only four hospitals. These fee-for-service facilities lacked medical staff, equipment and supplies. Haiti’s health care system before the earthquake was insufficient to address the basic medical needs of the population in Portau-Prince. Now, in the aftermath of the earthquake, the level of medical need has increased dramatically. As we write this Policy Options article, more than two months after the cataclysm, many of the smaller medical organizations have left or are leaving. MSF sees a limited, and certainly inadequate, response to providing basic shelter to the displaced. Reflecting back on the aftermath of previous natural disasters in Haiti leaves us far less convinced than others who see the outpouring of global compassion for earthquake victims as an indicator that everything will turn out for the better in the end. Will there be sufficient medical capacity to deal with the large numbers of patients requiring postoperative care,
specifically rehabilitative and psychological care, over a longer period? How many Haitians will suffer from living in inhumane, undignified living conditions in overcrowded and violent camps without access to adequate shelter and sanitation? Will many of Haiti’s displaced experience a second traumatic displacement when the hurricane season slams them in June? Will there be enough medical capacity, after six months to one year, to deal with the normal levels of medical emergencies experienced by cities of this size? MSF medical teams already in Haiti on the night of the earthquake faced extreme conditions: severe injuries, small fires burning, corpses on the streets, frantic crowds searching desperately for buried loved ones and widespread levels of physical devastation. The wounded poured into MSF’s makeshift hospitals on the streets. Our staff struggled to treat the influx, while at the same time trying to locate their own colleagues and families, many trapped in rubble.
he first phase of the medical response with mass casualties lasted about 10 to 14 days. Several MSF hospitals were severely damaged. Survivors pulled patients and other staff — both dead and wounded — from the rubble. La Trinité trauma centre collapsed with patients and staff inside, including our most senior surgeon, Erick Edouard, who was one of the seven MSF employees killed in the quake. The Maternité Solidarité emergency obstetrics hospital managed by MSF Canada was rapidly evacuated as it was on the brink of collapse. Babies don’t stop being born when disaster hits, and POLICY OPTIONS APRIL 2010
Paul McPhun and Kevin Coppock nificant ways. First, it directly affected the urban capital infrastructure, and consequently the capacities of all governmental, United Nations, non-governmental and private agencies to respond. Second, because it hit densely populated areas of poorly planned and unregulated settlements within the capital, the scale of immediate medical need MSF medical teams already in Haiti on the night of the among those injured was earthquake faced extreme conditions: severe injuries, small massive. This exceeded the fires burning, corpses on the streets, frantic crowds searching caseload managed during desperately for buried loved ones and widespread levels of the 2004 tsunami or in the Pakistan earthquake of physical devastation. The wounded poured into MSF’s makeshift hospitals on the streets. Our staff struggled to treat 2005. This combination meant a huge need on the the influx, while at the same time trying to locate their own one hand and severe chalcolleagues and families, many trapped in rubble. lenges to the response on the other. in Port-au-Prince. However, flights of the street in front of the collapsed with supplies and disaster experts were hospital, team members worked 24 he medium-term response in Haiti diverted to the Dominican Republic hours straight until patients filled every leads to several important questions. because the small airport in the Haitian available space on the ground. Emergency and postoperative Care. capital was damaged and overloaded Patients arrived with multiple and Will sufficient medical capacity with flights competing to land, and the open fractures, crushed limbs, remain in the country to provide qualair traffic priorities remained unclear. deformed faces, skull fractures, spinal ity postoperative care? As more and We desperately needed dialysis cord injuries and life-threatening more medical organizations are leavmachines to save the lives of the many burns. Teams concentrated on wound ing, the answer is unclear. In Port-aupatients suffering from crush syncleaning, debridement and dressing, Prince there is a virtual marketplace for drome. It was unspeakably frustrating and fracture stabilization. Infection of the recycling of patients to other for medical teams to watch patients untreated wounds set in quickly since health care providers. In the last week die for the lack of dialysis — the the entire population was living outof February alone, MSF received 200 machines were en route to Port-auside. Within the first week medical patients from medical groups pulling Prince, only to be diverted from landteams encountered gangrenous out of the country. ing. There is no doubt that problems at wounds, hemorrhagic shock and sep“Emergency surgery is one thing, the main airport resulted in severe ticemia, as well as a type of renal failbut lack of, or inefficient, postoperative delays in the provision of urgently ure known as crush syndrome. care will result in long-term hospitalizaneeded life-saving assistance. In the In Haiti, an estimated 300,000 tion or even in life-long physical disabilend, most MSF supplies were routed people were wounded at once. This ities,” explained Nico Heijenberg, an through the Dominican Republic, called for a drastic approach to triage, MSF physician working in Haiti. where MSF established a supply base in with priority given to persons who With so many injured, patients Santo Domingo. Even if this is a longer could survive with the smallest who are living in unsanitary and rudiroute, it provided a more stable and amount of resources possible. Most of mentary conditions, postoperative comreliable option for the initial months, the international doctors and nurses plications such as wound infections are as the airport and the seaport, even if responding to the quake, including to be expected. Likewise, with so many open, remained overburdened. MSF staff, were accustomed to triage severe traumas, spinal injuries and By the end of the first week, MSF that prioritized persons with lifeamputated limbs, the need for longestimated we had treated more than threatening injuries that could take up term medical rehabilitation is high. 3,000 wounded people in the Haitian a lot of resources. Sometimes switchAdded to the burden of postoperacapital and performed more than 400 ing gears was difficult. tive care are the daily medical emergensurgeries (of these, about 10 percent Logistical teams searched damcies experienced within any city the were amputations). aged MSF hospitals for equipment, size of Port-au-Prince, Carrefour and This natural disaster in Port-aumaterial and drugs. Contingency Léogâne. What capacity will exist to Prince differed from others in two sigstocks were kept specifically for emertreat the daily influx of car and motormore than a few were delivered outside that night amid the chaos. In the meantime, MSF teams rapidly set up emergency first aid posts and focused on stabilizing the hundreds of wounded who sought our care. They rigged makeshift lighting with generators, cars and flashlights. In four corners
gency preparedness scenarios, allowing MSF to rapidly start working. However, we never envisioned a disaster of this scale; materials were quickly used up in the first weeks of response. We expended significant effort to secure direct landing access for essential medical and nonmedical supplies
OPTIONS POLITIQUES AVRIL 2010
Healing a wounded country
Haiti â€” The Carrefour feeding centre run by MSF Holland.
cycle accidents, people injured trying to recover their property from destroyed buildings, burn victims resulting from tents catching fire with paraffin stoves, violence-related trauma such as gunshot wounds and stabbings, and other emergencies such as complications during pregnancy? In October 2009 alone MSF admitted 1,470 patients into its emergency obstetrics hospital. Access to general hospital care will be the next emergency. How many people will die because of an inadequate capacity to deal with daily medical emergencies? MSF is currently managing one of the few in-patient therapeutic feeding centres targeting moderately and acutely malnourished children. These are increasingly being referred from other organizations working in camp settings. In the matter of a few weeks 60 children were admitted into care.
Exposure to wind and rain. For how long will the unhealthy and precarious living conditions of the Haitian homeless and displaced continue? The UN estimates approximately 200,000 are living in 300 resettlement sites throughout the affected region. The living conditions of many of the displaced are shameful. Many of the settlement sites are simply not large enough to accommodate tents and shelters for so many. People express fear of living in these camps. We hear numerous stories of robberies inside the camps, intimidation and extortion on the few jobs available and â€” even if not yet recorded in high numbers â€” a lot of reference to rape taking place. Almost all of the settlements rely on drinking water being trucked in and treated on site. The majority of
sites have insufficient water or space for bathing privately, putting children and women at risk of exposure to harassment and abuse. A huge need is the absence of latrines, leading to shameful and undignified living conditions. Most camps have far in excess of 100 persons per latrine. Environmental health conditions in camp settings are generally poor. Water and sanitation are often at or below minimum thresholds, and families are densely crowded in temporary shelters. In these conditions, diarrheal, respiratory, vector-borne and other diseases flourish. Further exacerbating the situation, people are often weakened by illness, exposure to the elements and poor nutrition, making them less able to fight off infection. Even before the earthquake, diseases such as dengue, POLICY OPTIONS APRIL 2010
Paul McPhun and Kevin Coppock malaria, typhoid fever and others were highly endemic. In a weakened population, there is not only an increased likelihood of infectious disease, but also an increase in mortality. Given the health risks, the priority should be to quickly identify alternatives to the precarious camp shelters, particularly as the onset of rains will likely make these temporary settlements even more untenable.
those locations that are not as severely affected by the rains. June marks the official start to this year’s hurricane season, when even the best tented structures may prove inadequate and unsafe. While it is impossible to play the prophet, insights from the past can illuminate the future. If this is the case, MSF does not share Bill Clinton’s optimism that the earthquake was an opportunity “to build [Haiti] a functioning, modern state for the first time.” In 2008 Haiti was struck by two tropical storms and two hurricanes in succession. Five weeks after the hurricane, 10,000 out of a total population of 200,000 were still living on roofs, in tents or in fragile shacks
maintain a reasonable access to basic health services for these vulnerable populations? It is through out patient services that most complications can be identified, treated or referred before they become life threatening. Prior to the earthquake, these public services were available only for a fee, and were not targeted at those in greatest need anyway. While we all hope that the Haitian Ministry of Health (MoH) will quickly get back on its feet, its capaciolving this problem is far from ty was insufficient to meet the preeasy. Organizations involved in earthquake medical needs of the providing shelter are torn between crepopulation. With so many hospitals ating large planned settlements, destroyed, the migration of homeless encouraging people to build tempoMoH medical staff and the lack of rary housing within the cities, and infrastructure, how much can we moving people to rural areas to move expect the MoH to recover? in with host families who are In Haiti, an estimated 300,000 people Will the combined capacity of also strained by limited incomes. were wounded at once. This called the MoH and the remaining The chosen strategy was to for a drastic approach to triage, with medical organizations be sufficient to cover even the basic, discourage large planned settlepriority given to persons who could life-saving needs of the earthments. The response for shelter survive with the smallest amount of quake-affected population? is split into three phases first, The shared operations of MSF provide emergency shelter such resources possible. Most of the in Port-au-Prince in recent as tents and plastic sheeting; international doctors and nurses years have cost in the region of second, provide resources for responding to the quake, including C$20.5 million a year. This temporary shelter that will MSF staff, were accustomed to triage equalled two-thirds of the entire withstand the heavy rains and Ministry of Health budget for winds expected to begin the that prioritized persons with lifefirst of May; finally, rebuild. threatening injuries that could take Haiti. More than two months on, International donors have up a lot of resources. Sometimes many people still lack even basic long been reluctant to invest in switching gears was difficult. shelter and are living in crowdgovernment-managed proed, unsanitary camps spread grams in Haiti for fear of poor made of scrap wood and bed sheets. throughout the cites. Even phase one accountability, mismanagement and Instead of reducing our medical has been desperately slow. Now two corruption. The country has also sufoperations, as is usually the case in large settlements are being planned, fered years of brain drain of its experithis type of natural disaster, MSF was with the incentive of assistance to make enced and qualified human resources, forced to scale up. In the city of people move there. as many have sought to emigrate and Gonaïves, MSF started a temporary It will probably be precipitation join the diaspora in Canada and the hospital in a new site to replace the that changes the current status of the US. city hospital buried in mud. Nine displaced camps. As the rainy season As a result most of the aid money months later, when MSF handed starts, many of these sites will be going into the Haitian health sector what was intended to be a temporary washed away or become impossible to has been channelled through implestructure over to the local health live in. This will sadly be the impetus menting partners such as NGOs and authorities, the city hospital was still that drives those who still have homes others working in the private sector. full of mud, despite the huge out— damaged or not — or access to This leaves the Ministry of Health litpouring of financial assistance and extended family to overcome their tle option but to implement user-feemedia attention the hurricanes had earthquake fears and return to living based services for patients and cost generated. indoors. The remainder will likely go recovery systems for medicine, therethrough another phase of resettleIncreased vulnerability, decreased by excluding those who can least ment, either to prepared camps or to health care? What capacity is there to afford to pay.
OPTIONS POLITIQUES AVRIL 2010
Healing a wounded country Public hospitals have historically been plagued with strikes, and have struggled with issues of internal corruption as health care workers feel forced to find ways to compensate for their lack of regular income. The health care agenda was largely overlooked at the last international donor conference in 2009, which ignored MSF appeals that it be given priority.
earthquake to two operational sections, aiming for greater efficiency and a rational approach to needs in Haiti compared to other contexts around the world, and also to rebalance our global priorities for medical humanitarian assistance. After the earthquake MSF now has five operational sections in Haiti, with a combined planned budget of
Temporary camps are precarious, and increasingly threatened by the onset of rains. Living conditions are poor and will, over time, contribute to an increase in preventable disease.
ccess to health services for poor Haitians in Port-au-Prince was already inadequate before the earthquake, with very few free or sufficiently subsidized health International donors have long been reluctant to invest in programs to provide essential care to a population government-managed programs in Haiti for fear of poor the majority live accountability, mismanagement and corruption. The country where below poverty thresholds has also suffered years of brain drain of its experienced and in precarious settlements. qualified human resources, as many have sought to emigrate Re-building the former level of services is thereand join the diaspora in Canada and the US. fore clearly not enough, In Washington, in the weeks prior more than C$68.4 million for 2010 and re-introducing user-fee-based to the installation of the Obama adminalone. NGOs, including ourselves, health services or cost- recovery proistration, the dominant view of health need to think critically about how to grams for a population that is now care funding for Haiti was disappointrationalize efforts to meet the plentieven more vulnerable will deny those ing. “Why would the USA prioritize the ful needs in Haiti in a way that aims with the greatest need access to access to health care of 7 million to limit, as far as possible, duplicaessential life-saving care. Haitians when we have up to 40 million tion of services and competition for Unless international donors and Americans in a similar situation?” a activities or “intervention space,” key stakeholders place sufficient priCapitol Hill official challenged. and be accountable for the responsiority on proper and accessible health bility increased financial independcare in Haiti, the future, both short and medium term, looks bleak. As evience offers. Not as easy or as obvious f there is going to be a sustained denced in the past, the international as it sounds. commitment to Haitians following community has failed to maintain a The health and well-being of this tragic disaster, it will be essential sustained commitment by investing Haitians is clearly at great risk in the to have a commitment to the funding in public health services and not just short, medium and long terms. It is of public health services, the developunclear what capacity for the provithe private sector, embracing the ment of a health plan tailored to the sion of emergency and general health need for free or subsidized health needs of Haiti’s impoverished populaservices will remain in the country services and supporting the develoption, incentives to encourage the over the coming months. It is equalment of a long-term health plan. return of health and other professionly unclear how quickly the Ministry Without this the vast majority of als and strong coordination in the of Health can resume responsibility health programs will continue to be health sector. MSF will continue to given the severe impact on infrastrucrun in parallel to those of the MoH, lobby the government and donor ture, financing and staffing this with little effective coordination, and countries at every opportunity to proearthquake has had. Immediate with models aimed at restoring the mote these propositions. needs are already apparent, and these past services instead of models aimed There have been unprecedented are no longer only linked to the at reaching those in greatest need, financial commitments made to Haiti emergency care that resulted from with the highest health risks. following the earthquake, something the earthquake itself. As time goes in and of itself that will motivate on, health care providers are adaptPaul McPhun is the Toronto-based operadonor-dependent organizations to ing their programs to meet the genertions manager for Médecins Sans develop programs in order to simply al health needs of the population. Frontières/Doctors Without Borders, and spend the money. Likewise, many Many are not prepared or committed Kevin Coppock is humanitarian affairs organizations have received massive to do this, and will leave or have liaison for the organization in Canada. sums of private income, MSF included. already left. Both McPhun and Coppock joined the To cast a critical eye inwards, MSF was The crisis of homelessness and disemergency response in Haiti after the on the point of scaling down operaplacement remains unresolved. January 12 earthquake. tions in Port-au-Prince before the
POLICY OPTIONS APRIL 2010
Published on Apr 1, 2010
Two MSF representatives from the operations team explain why restoring Haiti’s health care system to what it was before the quake would be a...