by Paul Farmer
Pape’s suggestion was fine by me. I wanted to focus on health to drown out the mounting clamor about everything from land tenure to urban planning. The challenges of rebuilding a single hospital were daunting enough; coordinating diverse interests to help the Haitians rebuild a health system would require energy and time and resources. Clinton knew I felt overwhelmed by our broad brief. He knew I felt out of place when it came to discussing rebuilding industry and roads and civil society, and that I wished to work in the arena I knew best.
During President Clinton’s visit to GHESKIO on February 5, both Pape and Larsen suggested to him that my energies be focused on the health sector. Clinton made a joke of it: “Farmer, did you pay them to say this?” A moment later, an American nurse brought us an infant with a congenital heart defect. “This child needs surgery at once,” she said to the President, who took the baby in his hands. He turned to me and said, “Okay, Paul, make sure this boy gets the care he needs. Can you do that?” I nodded. That was something I knew how to do.
We’d received patients like this boy, named Héros, for years at our facilities in central Haiti. Most were cared for in Cange, but some ended up, as he later did, in Harvard’s affiliate hospitals. Héros needed open-heart surgery (if less urgently than averred), a procedure that wasn’t yet possible in Haiti. That was one of the reasons we were taking the Minister of Health’s recommendations about Mirebalais seriously: Haiti needed at least one state-of-the-art hospital. In the interim, there was the hospital in Cange—far from state-of-the-art but still a decent place to practice medicine. I was anxious to return. It was one month after the quake, and I still didn’t feel as if I’d been home.
Returning to Cange would lessen my persistent anxiety regarding friends and others still unaccounted for—an anxiety all of us shared. Most had found their way onto grim lists: dead, injured, safe. But for weeks, some few remained unaccounted for, and families kept on hoping against hope. Little by little, and often late at night, I whittled my own list: my brother-in-law injured; a number of colleagues dead; most of my nearest and dearest safe. Nonetheless, I counted close to fifty colleagues and friends who had lost their lives in the space of a minute.
My colleagues and patients, almost all of them Haitian, were safe because the network of hospitals and clinics we’d built up over the years was well outside the quake zone. I wanted to get back to Cange, although I wasn’t much needed there: my coworkers had their hands full since day two when the first waves of injured survivors began arriving from the capital. They had sent many doctors and nurses to help out in the burgeoning camps in Port-au-Prince. (Haitian physicians working with Partners In Health in rural Rwanda, Malawi, Lesotho, and Burundi also returned to the capital to pitch in.) But in the chaos of the broken city, I thought more and more about getting back to Cange, if only for a couple of days, to see friends and family. My sister-in-law, a nurse-anesthetist in Cange, was in the OR almost around-the-clock, but I knew we’d find time to catch up.
I was also anxious to see Father Fritz and Yolande “Mamito” Lafontant, the elderly couple who had been like surrogate parents to me since 1983. Although their house was damaged and their daughter’s home destroyed, they’d survived the quake because they too were in central Haiti. Many of their friends were not so fortunate. Their lives beyond Cange had been focused on Haiti’s Episcopal Church, which had been battered by the quake: Saint Trinity Cathedral, with its famous murals, had been leveled, as had the diocesan offices and the convent. The bishop’s wife was badly injured and had taken refuge in Cange; she needed to get to the Comfort and perhaps, my colleagues thought, to the United States. I hoped to be helpful on that score. It was a relief to make rounds in a hospital that was clean and orderly and busy. Mostly, however, I wanted to spend a night in my own house.
The drive to Cange used to take well over three hours, even though it’s less than fifty miles from Port-au-Prince. The road had recently been repaved, and had cut the time, and the jolts and aches, in half. I convinced Claire Pierre to go with me. We hadn’t yet left the quake zone, and had seen few neighborhoods, or even vistas, without fallen buildings and debris. But the wreckage became less frequent as we drove north, disappearing altogether a few miles outside the city.
What didn’t disappear were the spontaneous settlements. By the beginning of February, they stretched into the empty plain—almost a desert in the dry season—between the city and the mountain chain separating it from the Central Plateau. Some of these camps boasted proper tents; others were crafted mostly of tarps, plastic, and tin; none were very orderly. Alongside the road leading across the plain were groups of people carrying tools and materials to build more camps. With no trees or water, but many cacti, this wide-open space looked more like a bit of arid west Texas than a tropical island. It was hard to imagine how anyone encamped there would get by for even a few days. And more refugees were coming, we’d heard.
We traveled over the first mountain range and into the lower Central Plateau, which had more trees. There too we saw the beginnings of new settlements—“IDP camps” in UN argot because they were peopled by internally displaced persons—and wondered if those pitching them were originally from these parts or simply seeking refuge from the chaos and aftershocks of the city. We didn’t stop in Mirebalais, the lower plateau’s chief town, although we’d promised to meet with the mayor about our plans to rebuild their hospital—a project spearheaded by Dr. David Walton and a Boston contractor, Jim Ansara, who had been in Haiti on and off since the quake. If we were to proceed in keeping with the wishes of local and national authorities, we needed to go back to the drawing board on the proposed hospital, because some of our partners—the Health Ministry, the medical and nursing schools, and the General Hospital—were in shambles or ruins. Although David and Jim had asked me to stop by the proposed construction site, I was too anxious to get home. We reached Cange by late afternoon.
Although it seemed like an oasis now, Cange had once been a treeless squatter settlement: an internally displaced persons camp established after the valley was flooded by a huge hydroelectric dam.43 When I first saw it, in 1983, it was a mix of tin- and thatch-roof huts and lean-tos and had almost nothing in the way of cement buildings. The place could’ve used a few tarps. Father Fritz had built a school and chapel there, and together with others, we’d built a clinic that, over a decade, would be transformed into a hospital. (Specialty clinics, a blood bank, operating rooms, and staff dormitories were added piecemeal.) The school became a magnet school, and the chapel enlarged into a church that could seat almost a thousand. Trees planted in the eighties had taken root, and the hilltop and valley below were now forested. Most people who visited, and even many who lived and worked there, had forgotten that Cange had been nothing more than a squalid refugee camp less than thirty years ago.
Although it was a far cry from the Harvard teaching hospitals, and poorly designed compared to what we were planning in Mirebalais, the hospital in Cange had become a medical Mecca in Haiti over the years. Free or heavily subventioned care and a good pharmacy and labs drew more patients and then more staff, which drew still more patients. The hospital and clinics became the de facto providers of last resort for afflictions too numerous to count.
After the quake, it was only to be expected that Cange would be a refuge for the injured and a docking station for those seeking to help them. When Claire and I arrived, the campus was overrun. There were ambulances and vehicles and a throng of people around the church (although it was Saturday), and a huge crowd encamped around the hospital. People were lying on mats and sheets near the clinics. Nurses and doctors and all manner of helpers in surgical scrubs were moving between the church and the hospital and the central warehouse.
Although the campus was mobbed with patients and providers, it was the most orderly scene Claire and I had witnessed since the quake. Before we went to pay our respects to Father Fritz and Mamito, we wove through the crowd in front of the church. After stepping aside for two men c
arrying a woman on a stretcher, we went inside and I caught my breath: the entire church had become a post-op ward. The pews were gone, and from lintel to altar lay row upon row of mattresses. Above the altar, a black Christ (a beautiful batik from Uganda) presided over a scene of expert mercy: there were casts and external fixators and suction dressings on almost all the patients.
Expert mercy is what the wounded needed and seemed to be receiving. Unlike the scene at the General Hospital, the ersatz post-op ward was clean and smelled it. There was no groaning or weeping, in part because of adequate analgesia; the only noise came from patients and family members praying or singing and from hushed clinical conversations as doctors and nurses—mostly Haitian, but some from the United States and Ireland, Louise’s home country—tended to the patients. It was, somehow, uplifting, and we hadn’t yet set foot in the hospital or clinics. An internist-pediatrician from the Brigham, Koji Nakashima, came by to welcome us back. He looked exhausted but told us that almost everyone lying there would make it.
It was soothing to be in Cange and to see Mamito and Fritz and all of our coworkers; it was soothing to see something orderly and clean and almost calm. The hospital was more than full, the ORs had not been closed since the quake, and the church wasn’t the only facility transformed into a post-op ward.
It was an uplifting sight, but there had been heavy losses. Our team mourned friends, colleagues, and family members. Fritz and Mamito had just buried their son-in-law, who had a heart attack right after the quake. We lost interns in medicine and social work. We lost colleagues such as Dr. Mario Pagenel, an eccentric young family-practice doctor who worked in Boucan Carré and in other Zanmi Lasante sites, always insisting that we maintain a “self-critical dialogue” through academic presentations and discussions. On the afternoon of the earthquake, he’d been hard at work on one such presentation when his home collapsed upon him. We never found proof of his death in the rubble where his house had once stood.
Many coworkers lost family. Samahel, a tireless and resourceful pharmacist, lost his parents, his brother, and all but one of his children. In an e-mail, he wrote that the only thing keeping him going was that his wife and infant son had survived. One nurse, Naomie Marcelin, rushed home from Cange to Port-au-Prince, where she found that her sister and niece had been crushed as a church fell apart around them. Like many of our team whose families were torn apart by the quake, she returned to work the next day. Naomie told one journalist who was visiting Cange, “Yes, I lost my sister and niece. I told myself I can’t have them back. So if I can help sick people get better, that is exactly what my sister would want me to do. I’m helping other people stay alive. That is my strength.”44
Many had shown the same strength, and it was good to see them in Cange. One was a student of mine, Thierry Pauyo, who was born in Montréal to Haitian parents. During his first year at Harvard Medical School, Thierry told me that his dream was to work as a surgeon in Haiti, a place he had never visited but regarded, somehow, as home. As a senior medical student, he got his wish: Thierry lived in central Haiti during the latter half of 2009, learning new skills while improving the quality of surgical care. He stayed with his aunt and uncle in Port-au-Prince on weekends, at long last meeting and befriending the rest of his extended family. On January 12, eight of his cousins became orphans. He brought them all to Cange for the time being.
Thierry had been in the OR nonstop since the quake, but he asked me to see a patient with him that night—a woman with a massive soft-tissue defect. “Half her thigh is gone,” said Thierry. “The bone is exposed.” This turned out to be a friend who I’d been hoping to transfer to the Comfort. She was woozy from pain meds but managed a few words. As we removed her dressings to examine the wound—it was clean—Thierry also spoke of his own loss and new responsibility. His chief concern, he said, was getting his cousins to Montréal, where his parents could take them in. And then, he added, his next order of business would be to return to Haiti to get back to work. The patient smiled at him and said, “Dr. Paul, what a nice boy he is. And what a good doctor.” We transferred her to the Comfort the next day, and Thierry stayed on in Cange. She seemed more worried about Thierry than about her own mangled leg. Such was my student’s first taste of his homeland.45
Returning to Cange was a relief in part because I got to move some of my friends and coworkers from one part of the grim ledger to another. The lists were often changing, and not all the injured and maimed would survive. But Cange reminded me that many would survive and that the Haitian people have long been resilient in the face of tribulation.
It was important for all of us to remember the saves and recoveries. On another night in central Haiti, in another hospital, an elderly man grabbed my arm and said: “Haiti is finished.” Two younger Haitians, a doctor whose family home in Petit-Goâve was turned to rubble and a former patient who was enrolled in nursing school at the time of the quake, overheard the comment. “No,” they both said. “Ayiti pʹap peri” (“Haiti will never be finished”).
We were in Lascahobas, and the evening was mild and starlit, as if a million miles from the quake zone. But the quake had come to Lascahobas. My former patient, Natacha, and the young physician, Christophe Milien, were reminders that no one in Haiti was untouched by the quake: both were now homeless, as were their families. Dr. Christophe asked me to see another patient who represented the sorrow and burden of Haiti’s chronic social problems. Roseleine was not a trauma patient, not in the sense of so many we’d seen in the past month. Dr. Christophe mentioned that she was a teenager with severe tuberculosis. “Both lungs are badly damaged,” he said, “and she’s emaciated.” The young doctor, an obstetrician who had been running the community hospital there, paused a bit and added, “I think she’s very depressed. She’s an orphan.”
Natacha perked right up when she heard this. Since the quake, she’d been living in a tent with other Partners In Health volunteers, pitching in however she could. “This sounds like a job for me,” she said with her usual confidence. She had survived her own teenage trauma: not only tuberculosis, but drug-resistant tuberculosis. Back in the nineties, she’d been the youngest patient in the tuberculosis referral center in Cange—the only place in the entire country, back then, that provided treatment for tuberculosis’ drug-resistant forms. In the course of that year, Natacha went from being skeletal and depressed and coughing up blood to being one of our bestloved patients. Everyone cheered when she returned to high school and cheered again when she decided to pursue nursing studies. If Natacha was confident she could help Roseleine, she spoke not as a nursing student but as a survivor. “I will know how to cheer her up,” she said. She was living proof that Haiti would never be finished.
Roseleine was as Dr. Christophe diagnosed: gaunt and depressed. Her chest film was as bad as he’d said, but even worse was what doctors term her “social history.” Roseleine was indeed an orphan, but also a restavèk—a child servant who had been abused for years and hadn’t even started school. She wept as she recounted her travails, which had worsened when she got sick. The day before the quake, the family for whom she toiled kicked her out, and she’d been wandering the streets since, looking for help, coughing and gasping for air. It was a terrible story but not wholly unfamiliar to me or my former patient. Natacha assured Roseleine that she’d recovered from the same affliction when she was a teen. Roseleine’s eyes were fixed resolutely on the floor without any signs of hope. But the two doctors present shared Natacha’s optimism: we were pretty sure we could cure Roseleine’s lung disease and her malnutrition. We left her alone with Natacha to talk about her other acute needs—and her emotional ones, too.
Haiti would never be finished if it continued to count as citizens people like Dr. Christophe and our indefatigable, if homeless, student nurse, Natacha. We met patients as inspiring and confident as the caregivers, and some of the patients became caregivers.
The stories of two survivors, Shelove and Carmen, who reached the hospital in Cange af
ter sustaining severe injuries during the quake, are a case in point. Shelove was born in Boucan Carré, the same isolated town that had required a veritable international coalition to build a bridge connecting it to the rest of the Central Plateau. But like so many young people from rural Haiti—Shelove was twenty-five on the eve of the quake—she saw no future in the dwindling agricultural sector in which her parents toiled, so she went off to school in Port-au-Prince. She leavened her studies with hard work, attending school by day and moonlighting as a waitress.
On January 12, Shelove was in her aunt’s apartment—on the third floor of a six-story building—along with her sister and a half-dozen aunts and cousins. When the three floors of shoddy cement construction overhead rained down on them, Shelove, more fortunate than most, was buried in the debris, her left leg crushed. “The house was just shaking and shaking,” she recounted, “and soon I was falling down with the wall. And then I had a big block of cement on my legs. When I touched it, I knew my leg was crushed . . . I thought that I would never walk again.”46 Two cousins, nine and eighteen, perished in the rubble; the survivors sustained severe injuries.
Shelove managed to crawl into the street, caked in fine powder from the wreckage—the telltale mark of many in Port-au-Prince that afternoon. She soon passed out. After lying there for two days, alongside others maimed by the quake and now without food or water, an aid worker from Médecins Sans Frontières found her and bandaged her leg. This emergency care in situ wasn’t much help, since Shelove needed surgery and any physician would have known what procedure was needed—amputation. As chance would have it, a Haitian priest on his way to central Haiti loaded Shelove into his truck and delivered her to the doorstep of the hospital in Cange. Our surgical team recommended amputating immediately, before her crushed limb became gangrenous. She remembered little of that discussion and nothing of the procedure itself.