Haiti After the Earthquake

by Paul Farmer

  I watched my former trainees (and there were many others, Haitian and American) with pride and gratitude. Claire could not be dissuaded from working twenty hours a day, taking no time to mourn the loss of many lifelong friends or the fact that her mother’s home had been flattened, taking with it nearly every memento of her childhood. Evan stuck close to Lassègue, trying to help manage the influx of volunteers, some of them prickly, while nursing his own grief. (After a dozen years with Partners In Health, he’d lost friends, too.)

  Claire and Evan were soon joined by a handful of medical residents from Boston, one of them Haitian-American and all of them willing to work on the logistics of connecting the disparate worlds of the patients, Haitian providers (from homeless, hungry medical students to returning nurses), volunteers, and even the military. The U.S. Air Force 1st Special Operations Wing took over coordination of the airport within days of the quake; working with them afforded the only means by which we could airlift patients to the ship or other remote sites.6

  It was, for all of us, an entirely unprecedented circumstance. We were never sure what to do and were left with doubts about “disaster-relief expertise,” even when those we encountered proclaimed surety. We wanted to be rescued by expertise, but we never were—this was the long, hard lesson of the quake.

  To give readers a sense of what it was like in those first few days after the quake, at least for some of the doctors and nurses and patients, let me describe the events of a single afternoon and evening at the General Hospital. At least I believe it was a single night, a very long one, although none of us were taking notes. My guess is that it was day eight after the quake, because the Comfort was steaming into port and tents dotted the hospital grounds. These tents—a Red Cross tent, a Dartmouth tent, a Médecins Sans Frontières tent, and on and on—were at times like fractious federations. (There were even Scientologists in bright yellow t-shirts, though I didn’t know how to explain to my Haitian colleagues what they were doing because I hadn’t a clue what it was.)

  In one tent, I spied a Haitian doctor standing anxiously over a thirty-four-year-old man who thought he’d escaped serious injury when his parents’ house collapsed around him but now presented in respiratory distress. He looked whole but was gasping for breath. I was surprised when he addressed me by name and in English: “Dr. Paul, I know you from Cange. Help me, please. I can’t breathe!”7 This was the first and only time a patient there addressed me in English, and I immediately recognized him as the son of an acquaintance from Port-au-Prince. I had stayed many times with my closest Haitian friends, Father Fritz and Yolande “Mamito” Lafontant, in a house across the street from the one the patient’s father was building in a neighborhood called Christ-Roi. (Mamito and Father Fritz had taken me in as a volunteer in 1983 and would later help found Zanmi Lasante and Partners In Health.) Much of the area, including the young man’s large stone-and-cement house, had been leveled by the quake, while the Lafontants’s house, though damaged, was still standing.

  “How are you? What happened?” (I responded in Creole, not wishing to burden the man with a language that his wife, standing by his side, did not understand and which he spoke imperfectly even when not short of breath.)

  His story came tumbling out in shreds: part of a wall had fallen on his legs; it took him an hour to free himself, but he was soon up and helping others in the neighborhood. “I felt okay,” he said, “but my right leg hurt.” He touched his right thigh. “It was only three days later that I suddenly couldn’t breathe.” The gasping itself was unnerving; his oxygen-saturation level suggested he should not be able to speak at all. I asked one of the Boston nurses, from Children’s Hospital, to give him morphine, which pretty reliably eases such respiratory distress. What we really needed was to get him transferred to the Comfort and hooked up to mechanical ventilation—a “breathing machine,” a procedure that would have been step one in a properly equipped hospital—while we tried to figure out what was wrong with him. But it was almost dark when he arrived, and the choppers needed to get him there were grounded for the night.

  A physical exam revealed a high fever and minor abrasions on his legs. (Even these can be portals of entry for infection.) He’d been treated with antibiotics in another facility—the General Hospital was the third one in which he’d sought care—but an x-ray suggested severe pneumonia. We gave him a broad-spectrum antibiotic, and tried to treat him for blood clots that might have traveled from the large veins in his legs to his lungs. But we didn’t have the right formulation of blood thinner on hand.

  In minutes, the morphine kicked in and he was feeling well enough to ask, in one of his first complete sentences, for something to eat. His oxygen-saturation reading had improved some, but we still wanted him out of the tent and onto the Comfort as soon as possible. Although the morphine was responsible for his improvement, it wouldn’t last long, nor would it treat his problems at their root. Fearing he wouldn’t survive the night without mechanical ventilation, Evan and others tried to line him up for transfer.

  We had many other patients to see that night. A slight elderly woman at the other end of the tent was wracked by the spasms of tetanus—the first of many cases we would see that week and the next. White-haired and weighing about ninety pounds, she had tears rolling down her cheeks. Every few minutes she would go rigid with potentially bone-breaking and suffocating spasms. The slightest stimulus triggered them; she needed to be in a dark, quiet room. But that would move her far away from medical care because, with frequent aftershocks shaking the foundations of the hospital, no one wanted to work inside.

  At one point, I ducked outside for a breath of fresh air, and saw a young woman, perhaps twenty-five, lying on a stretcher outside, all alone in the pitch dark. Had she died? No, she was breathing and warm to the touch. I said hello and asked how she was feeling; she raised her hand and said, simply, “I think my legs are broken.” I looked at an x-ray that had been tucked under her feet: both of her femurs were fractured high up, near the pelvis. I asked if she’d received anything for her pain; she had not. She had no family presen—that was clear. She feared that her parents and infant daughter had perished. “The roof fell on us,” she said and began to weep quietly. The best feeling I had during that wretched evening was bringing her pain medications, which soon led to what might have been her first sleep in days.8 Her orthopedic injuries could be repaired, but as far as the emotional ones, who knew?

  On one of those first days, Ophelia Dahl, the director of Partners In Health, had come down in a plane full of supplies and surgeons. She had also been working in Haiti since 1983, and it had changed her life as it changed mine. She was at the General Hospital that night, if memory serves. “Why aren’t there more pain meds?” was one of her first questions. She was headed up to central Haiti to check on our teams there but was spending that night in the city. Ophelia and I were surveying the spectacle in the hospital—the misery and the pain, but also the mercy and compassion—and thinking the same thing: why Haiti?9

  As would be the case on many evenings, we had no shortage of work and no reason to leave, except if we didn’t we would be exhausted and useless the next day. I tried to corral my coworkers into rest. It was almost midnight, and we’d made some progress: we’d secured for the young man in respiratory distress the promise of a transfer to the Comfort by helicopter at daybreak; the old woman with tetanus had received antibiotics and heavy doses of diazepam (she would make it, I thought, if she didn’t require mechanical ventilation); a number of patients with major trauma were now, like the young woman alone in the dark, resting thanks to pain meds.

  As we prepared to leave, I heard an argument breaking out in English. A couple of Haitian-American doctors were yelling at some incredulous American surgeons. They were clashing over control of the operating rooms, which had never attracted much interest during all the years that poor Haitians in need of surgical interventions died unattended, even in this hospital of last resort.10 One of the surgeons seemed to want m
e to referee the argument, but although there was much to say, it seemed the very worst place and time to say it. No one had energy to mediate disputes. So I hid in Claire’s mother’s car, waiting for Ophelia, Evan, and the others, until we finally left the hospital for houses further up the hill, away from the worst damage. We were spent. As our car climbed through a wrecked and darkened neighborhood, a dog darted in front of us and we heard a thud. No one said a word.

  Most of my colleagues were staying with Claire’s extended family. (Her godmother had taken in scores of volunteers and newly homeless family members, including Claire’s mother.) But I headed back to the wooden (and thus safer) house of close friends in Pétionville, arriving shortly after midnight. They lived far above the heat and odor of the vast, blacked-out city below. My host Maryse had even put flowers in my room, as she always did. There was a bottle of water by my bed and, aside from the white noise of a whirring fan, blessed silence.

  But I couldn’t sleep. In the dim reaches of misery, insomnia is a constant companion, especially when twenty-first-century people die of nineteenth-century afflictions—minor injuries and simple fractures as well as pneumonia, tuberculosis, and other infections, such as tetanus, preventable with a vaccine available for pennies. I was pursued by the sights and smells and sounds of the day: the unrelieved pain; patients and doctors sprinting outside during an aftershock; the young man in respiratory distress (Had we given him everything that might tide him over until he reached the ship? If only we had more blood thinners and the right lab equipment!); the arguments and competition between different dispensers of “disaster relief” over the privilege of looking after people who had long been neglected; the grief of my former students (among the most competent of the lot, but they too were spent); the solidity of the hospital’s Haitian leadership; the unrelieved pain (Why didn’t we have, at the very least, more analgesia for those with awful trauma?); and pervading all, the charnel-house odor from the morgue and under the rubble. I tried especially to forget the morgue. But counting sheep kept turning into the grim process of counting the dead. I even thought of the hapless dog. The image of the man who couldn’t breathe was still with me as dawn approached. (Had he survived the night? Surely the floating hospital could save him?)

  Hanging on to this hope, I fell into a deep sleep. But after just an hour or so, I was shaken alert by a large aftershock. The wood of the house strained and creaked; the paintings in the room tilted; the water bottle at my bedside started to tremble. My host yelled for us to “get out of the house right now!” The sun was coming up, and I watched impassively as the water bottle fell to the floor. I heard those in the house scrambling to get out, and saw, in my mind’s eye, the crushed limbs of people trapped in countless other houses during the quake. I knew I should move and thought of my children, who had spent the recent holidays in Haiti but, by the grace of God, had been spared the fate of so many a few days after they left. It would have been prudent to bolt down the stairs and into the street.

  But I didn’t move a leaden muscle and did not wake again until the sun was high in the sky.

  2.

  PRAXIS AND POLICY

  The Years before the Quake

  Although many of those who came to Haiti right after the quake claimed to have expertise in disaster relief, there was ample reason for skepticism. From the beginning, we struggled to help the injured and otherwise afflicted, but it wasn’t always clear what needed to be done. We continued in this emergency mode for days, furnishing direct care to the injured and displaced, while trying to make (or help others make) decisions about the coordination and delivery of services. This tension was everywhere: on the one hand, a particular injured or sick person, but on the other, decisions about shelter or clinical services for hundreds of thousands of displaced people. Most of the policy decisions were, of course, not being made by physicians. But never before had my medical colleagues been pushed to think harder about challenges so far removed from clinical care.

  In many ways, however, this tension—between serving those right in front of you and seeking to reduce the longer-term risk of others ending up in front of you—has been the chief tension of my work for years. This tension has animated the work of my students, trainees, and coworkers, too, because poverty and inequality are the drivers of most of the diseases and misfortunes we see. Even an earthquake is not only a “natural” disaster, just as the destructiveness of Hurricane Katrina and the storms that struck Haiti in 2004 and 2008 were influenced by many factors besides weather. These events reveal the social roots of disaster.1 It’s an undisputed fact that, even before the quake, Haiti, Latin America’s first independent nation, was plagued by political, economic, and ecological fragilities. Part of this book’s project is to examine how Haiti and its institutions became so weak: to lay out the history of the chronic ailment. The other main topic of this book—beyond an account of the quake—is this tension between praxis and policy: the struggle between direct service, which is what doctors are supposed to provide, and policy, which is what politicians and legislators are supposed to formulate with, in theory, the guidance of the citizenry they represent.

  For years, I’d sought to face this challenge through direct service to the poor—especially those affected by infectious diseases—and, as a professor at Harvard Medical School, by writing and teaching about the large-scale forces that shape vulnerability to suffering and premature death. This dual mandate is, as I’ve said, a fact of life for my students, trainees, and for all my colleagues at Partners In Health. We work in a dozen nations—including the United States—where the poor suffer disproportionately. During my first decade in Haiti, I mostly left policy alone, except to critique it. In books and articles, my colleagues and I sought to bridge the gap between service and policy or at least to help inform policy discussions. But writing for an academic audience is not the same as sitting through policy meetings and diplomatic conferences. Academic physicians, including those in the field now called social medicine, would be hard-pressed to show concrete ways in which research and writing shape health policy or lead to improved implementation of services.

  Health care does not exist in a separate universe from politics. Fiscal policy, infrastructure, wages, taxation—all affect the practice of medicine, and we learned, over the years, that seeking to improve health policy was one of the best ways to defend the modest gains we’d achieved for our patients. This effort to link praxis and policy started on the local level. For example, our work with Haiti’s national tuberculosis and AIDS programs in the late eighties began in a handful of towns and districts. A few years later, thanks in large part to Dr. Jim Kim, another founder of Partners In Health and then also a Harvard faculty member, and to Dr. Jaime Bayona, a Peruvian colleague, we became more engaged in international health policy debates about tuberculosis, including the more difficult-to-treat forms of drug-resistant tuberculosis. “Difficult-to-treat” did not mean “untreatable,” we argued, again and again, in meetings and in obscure medical journals.2 Unlike many in the international agencies we sought to persuade, we had direct clinical experience treating patients with drug-resistant tuberculosis, and we could claim some degree of authority thanks to high cure rates in Haiti and Peru.

  These debates led us to Russia, which was facing epidemics of drug-resistant tuberculosis, as the United States had faced a few years prior. In Russia and elsewhere in the former Soviet Union, these epidemics were large and were proving especially deadly inside prisons. 3 The financier-philanthropist George Soros had donated more than twelve million dollars to provide tuberculosis care in Russian prisons. He’d asked our team to help because conventional treatment approaches were failing to cure patients with drug-resistant strains. But the program as conceived still did not have enough financing for second-line medications (needed to treat drug-resistant tuberculosis) or enhanced lab capacity, which would permit clinicians to discern which patients needed such drugs. When we asked Soros for more money, instead of saying yes, as we ex
pected, he said no. It would be a mistake, he explained, to let governments off the hook.

  It was this work (and Soros himself) that led me in the 1990s to visit the White House, where Hillary Clinton became a patron of our efforts to raise the standard of tuberculosis care in Russian prisons and elsewhere. (TB was not a regional epidemic, but a global threat.) She soon also became a friend and mentor. Over the next decade I saw firsthand how high-level policy interventions could open up new—and sometimes vast—possibilities for improved delivery of services to the poor and marginalized. In one prison in western Siberia, we worked with the Russian Ministry of Justice, to bring case-fatality rates from 26 percent (more than a quarter of those on treatment died) to close to zero within two years.4 The drugs were expensive, but they worked, and better planning and pooled procurement would drive costs down further. In its first year of operation, the Gates Foundation supported an ambitious program to scale up these complex interventions in Peru while also augmenting efforts in Russia.

  The tuberculosis pandemic was one complex health problem among many, and neither Russia’s prisons nor Lima’s slums were the world’s poorest settings. Other epidemics were spreading in Africa, even as science gave us new tools to fight them. By the close of the millennium, it was obvious that we needed a radically different approach to the health problems of the poor. Existing models were premised on the idea that public health and medicine should be cheap. But these anemic approaches wouldn’t do much to lessen the burden of disease on the poor. Those on the front lines encountered millions with AIDS and tuberculosis and malaria, and also every imaginable cancer and noncommunicable disease. Because these patients were poor before they became sick, we needed something other than fee-for-service models. We also needed heavy investments in infrastructure, training, and direct services, especially for the bottom billion—the poorest and most marginalized. Implementation was the biggest challenge—and figuring out how to finance it.