by Paul Farmer
I returned to Haiti four days after that initial departure and quickly got back to the tasks at hand, working frantically with a team of colleagues on a series of new projects: providing assistance at the general hospital and developing healthcare services at some of the spontaneous settlement camps. Things remained chaotic, but we were slowly getting our own communications lines in order and assigning each team member a specific task. Our interface with the U.S. military was now an almost everyday occurrence. The USNS Comfort , a U.S. Navy medical treatment vessel, arrived the same day that I returned. Docking two miles off the coast of Haiti, it served as a much-needed tertiary referral hospital for the most severely injured. A Brigham and Women’s Hospital junior doctor, one of our residents in Global Health Equity, arrived to join our team. Handing him a cell phone, I asked him if he would manage our patient transfers. “Do you need me to call you about them?” he asked. “Only if you need my help,” I replied. Days later, I overheard him calling out GPS coordinates for a helicopter landing zone near our own main hospital in Cange. Despite this being his first working trip to Haiti and with almost no Creole or French skills, he not only had quickly started coordinating our own transfers of patients, but had also figured out how to leverage the goodwill and determination of the U.S. military stationed at the General Hospital and was organizing military helicopter flights for evacuations. At the General Hospital, all but one of our staff reported positive experiences with the U.S. military, describing their willingness on an individual level to do whatever they could and attempts to make their own “big machine” of an organization flex to accommodate the shifting humanitarian needs.
Military involvement in humanitarian activities has become increasingly common since the end of the cold war. Nonmilitary humanitarian actors (typically aid agencies and nongovernmental organizations but also others) must fulfill their role to decrease human suffering by providing services with impartiality. In situations of conflict or violence, association or perception of an association with any one side can prevent those who want to help from gaining access to victims and can also endanger staff. One set of guidelinesb for interactions of nonmilitary agencies with military agencies in conflict notes: “The most important distinction to be drawn is whether the military group with which humanitarians are interacting is, has become, or is perceived to be a party to the conflict or not.”c Association with military, even if the particular task of the military at that time is to provide support or to reduce human suffering, can have serious consequences for aid organizations.
In post-earthquake Haiti, the U.S. military mission was officially humanitarian. Reflecting President Obama’s “whole of government response” to the crisis,d the U.S. military worked under the direction of the U.S. agency for international development (USAID). The choice of military actors to assist in humanitarian assistance was controversial, but in pragmatic terms, the budget, human resources, and logistics assets of the U.S. military are well beyond those of USAID. At the height of the U.S. military footprint, some twenty-two thousand troops were in Haiti or offshore providing assistance, compared to some hundreds of USAID civilian workers—many of whom were seconded from other nations’ programs.
At the time of the earthquake, the deputy commander of U.S. Southern Command had been in Haiti. I believe that his personal determination to relieve human suffering set the conditions for his command of Joint Task Force Haiti. For the most part, the troops that he led displayed respect and diligence in their pursuit of supporting the victims of the earthquake. He and his team became a familiar site at a huge temporary settlement camp in Port-au-Prince where my Haitian colleagues and I spent many hours and days during the subsequent months. Haitian community leaders, themselves survivors living in the settlement camp with almost fifty thousand other people, from whom I regularly take my cues, were and are avid fans of the assistance from U.S. military. One day, several of them called me aside and said with glee about the U.S. troopers: Gade Doktè Louise—bòt yo sal. “Look, Dr. Louise: They got their boots dirty.” So often, people offering help (so-called humanitarian actors included) are not willing to get into the grimy part of the work.
Political and military motivation should be separate from humanitarian assistance. By definition, humanitarianism requires impartiality, which is not possible if aid is delivered as a tool to sway opinions, to win support, or to advance one ideology over another. As an organization that partners first and foremost with the poor, PIH look to those we serve for legitimacy and also to determine what is in their best interest. Paul Farmer wrote in 2003:NGOs must, therefore, take great care in attending to their mission of service to the afflicted; because this is the only way they can truly represent the needs of the victims, and avoid common mistakes and historical irresponsibility. It is when we ignore legitimacy in our pursuit of “effective” developmental models, or when we ignore problems that don’t fit our own conceptions of what is wrong or how to fix it, that NGOs find themselves complicit in the violence they mean to stop or, at the very least, allay.
Pragmatic solidarity is what allows us to be discerning in which partnerships benefit our patients, and which ones may harm them.e
In truth, no one group or individual has a monopoly on humanitarian actions or goals. The sheer devastation of the earthquake, the flattening of infrastructure, logistics capacity, and medical care, and the loss of key leaders in governmental and nongovernmental sectors required a huge, multifaceted effort. In the face of such catastrophe, we could not afford to ignore military assets. If military cannot by definition be humanitarian actors, they can surely accomplish humanitarian tasks. In Haiti in those first weeks and months, we needed and I welcomed all who came with a humanitarian task in mind, a determination to help achieve the common objective of saving lives and reducing suffering, and a willingness to get their boots dirty.
LOPITAL JENERAL STRUGGLES TO SURVIVE
EVAN LYON
Dedicated to Dr. Alix Lassegue, Ms. Marlaine Thompson, and the heroic staff of l’Hôpital Université d’Etat d’Haïti
The Haitian State University Hospital, l’Hôpital Université d’Etat d’Haïti (HUEH), is known in Port-au-Prince and beyond as The General Hospital, Lopital Jeneral. It is the largest public hospital in Haiti and the nation’s most important medical institution. The national medical and nursing schools occupy the same campus, with roots reaching back to the era immediately following Haiti’s independence in the first years of the nineteenth century. Until 2002, when the initial class of physicians graduated from Haiti’s first private medical school, Notre Dame University, the State University was one of very few providers of physician education in Haiti. Generations of Haitian medical professionals proudly claim HUEH as their alma mater despite the fragile infrastructures of the hospital and university, which have weathered many storms, including political change, military unrest, rapid urbanization, hurricanes, and continuous financial stress.
Lopital Jeneral is often the only facility available in the nation for medical specialty referral and care. It is also, sadly, a hospital of final resort for the destitute sick and dying. Among the rich and the poor, the general consensus is that anyone with means would seek care at another center before going there. HUEH is at once a proud national teaching hospital, an essential referral hospital, and a physically and financially poor facility where clinicians struggle to provide quality compassionate care under crippling conditions. Those who work in Haiti have long been witness to this struggle. The devastating earthquake that rocked Haiti on January 12, 2010, revealed the conditions at the hospital to a worldwide audience.
Everyone has seen photographs of the crumbled domes of the previously grand National Palace. Lopital Jeneral sits one block behind the National Palace. At the moment of the earthquake, two-thirds of the hospital was destroyed. The surgical hospital, emergency room, and main operating suites were rendered unusable; all pediatric facilities and half of the internal medicine wards were destroyed; the lab and its equipment were
reduced to rubble; and the chronically understocked pharmacy was left in shambles. The State University School of Nursing collapsed while the second-year students sat in a lecture, killing nearly the entire class, along with several of their professors. Perhaps 125 to 150 people died in this one building alone.
On the night of January 12, the HUEH campus was rent by the cries of the hurt and dying—and filling rapidly with more casualties from the disaster. A courageous few staff tended to the injured with flashlights and the few materials they could salvage.
As the sun rose on the morning of the 13th, the extent of the devastation to the campus became clearer. The structural damage, itself immense, paled in light of the human suffering that flooded the hospital as patients—first tens and then hundreds—arrived, searching, too often in vain, for care.
Although many of the hospital staff were now homeless, a brave number of them, as well as Haitian friends and volunteers, came immediately to the hospital to offer their assistance, displaying the same bravery it takes to run toward a burning building. The first foreign assistance workers from the International Medical Corps (IMC), a United States-based nonprofit humanitarian organization, arrived within twenty-four hours to find a devastated campus and very few staff members able to work. By the second and third days, more outside assistance arrived to support the Haitian staff and the IMC in triaging patients, prioritizing the hundreds in need of urgent surgery, and providing first aid and medical treatment as materials allowed. Teams from NGOs around the world, including the International Red Cross, Medécins du Monde, Swiss Humanitarian Aid, Medécins Sans Frontières, and a number of smaller organizations such as Partners In Health/Zanmi Lasante (PIH/ZL), quickly followed. In those first few days, much of the effort was simply stopping the bleeding and attending to the dying.
At the moment the earthquake struck, I was in a clinic caring for people living with HIV in Montgomery, Alabama—applying skills I had learned in Haiti to aid another poor community. During that first night, like everyone connected to Haiti, I did not sleep. It was nearly impossible to gather news from loved ones in Haiti, or much information at all.
A year-long volunteer posting, a few blocks from HUEH, had introduced me to Haiti in 1996. Until I moved to Alabama in 2009, my work centered on Haiti—as a teacher, as a community health volunteer and human rights advocate, and as a physician. When the earthquake struck, I felt, like so many others, that I had no choice but to return there. At Partners In Health’s direction, I went to HUEH to volunteer as a doctor—and more important, as part of a team working as a bridge between the Haitian public health system, HUEH leadership, and the many international volunteer relief workers.
When I arrived at HUEH with colleagues from PIH, on the fourth day after the catastrophe, approximately fifteen hundred sick and injured people were spread around the grounds of the hospital, seeking shade or creating shelter from salvaged materials. Many had nothing more than a cloth sheet for cover. A small, newer building at the top of the sprawling campus that had not been seriously damaged by the earthquake was quickly converted into basic operating rooms. Narcotic pain medicines were in very short supply and available only during surgery, with perhaps one dose following. There was no oxygen, making inhaled gas general anesthesia impossible. Operating time was limited by daylight, though teams pushed into the night wearing headlamps. Conditions were clean but far from sterile. Basic surgical supplies were limited, to say nothing of the simple but specialized hardware needed to mend a broken bone. Our surgical teams were forced to resort to a hardware store hacksaw for amputation: a tragic and lasting image of what patients faced in Port-au-Prince’s largest hospital.
By the fourth day, more than one thousand patients had been identified as needing major surgery, including amputation, bone repair, and cleaning of dead and infected tissue. That day, we performed between thirty and forty procedures. It took eight days to obtain the antitetanus vaccine we needed. The clinical teams watched helplessly as deadly cases of tetanus and gangrene accumulated day upon day, affecting tens of victims at a time. Unknown numbers of patients who died from infection, blood loss, and simpler medical illnesses might have survived if the hospital had withstood the earthquake.
Even if the hospital campus had been built to withstand an earthquake of this magnitude—as it would have been in a nation not beset by centuries of underdevelopment—and even if the necessary supplies had been available, HUEH would not have been able to function in those first weeks without its staff. As the largest public hospital in Haiti, HUEH employs more than two thousand people. Every single employee was affected by the disaster. Many died. Many more were rendered instantly homeless, tending to basic needs and to injured family and friends with whatever materials they could find. Nearly everyone suffered severe psychological trauma. As is the case throughout Haiti, and especially in the public sector, General Hospital had too few medical professionals even before the earthquake. Senior faculty at HUEH are paid about one-tenth of what they could earn in a private clinic. The situation is even worse for clinical nurses and nurse educators, the vast majority of whom are required to work more than one job to make ends meet. The hospital’s cardiology department was relatively strong before the earthquake, with six practicing and teaching faculty. One cardiologist died in the disaster; two others will not return. The entire internal medicine faculty was reduced to fifteen individuals.
The General Hospital also houses the central morgue for the city of Port-au-Prince. Despite the lack of electricity on the campus and the resulting lack of refrigeration, the morgue was the natural place to gather the majority of the casualties that occurred on January 12, 2010, at 4:53 P.M. and in the hours, days, and weeks that followed. No one who worked there will ever forget the image of the dead, stacked and overflowing around the morgue. Nor can we forget the sight of loaders working around the clock to move those who had died to mass graves in dump trunks, their headlights illuminating a scene of unspeakable horror and sadness. The pavement around the morgue remained slick with bodily fluids for several weeks. The smell of dying was everywhere and unrelenting.
In the first days after the earthquake, many remarked how peaceful the streets of Port-au-Prince seemed, even as open spaces were being claimed as camps for the displaced. The darkness and silence of the capital was broken only by the candles or cooking fires of the homeless and the hushed sounds of crying, conversations, and prayer. Dozens of Zanmi Lasante (Partners In Health) doctors and nurses, as well as a few foreign volunteers, circulated throughout Port-au-Prince until 2 and 3 each morning, moving supplies, transporting the wounded, and organizing to provide assistance wherever a foothold could be found. We never worried about our safety on or off the HUEH campus in the two weeks after the disaster.
In stark contrast to the reality in the capital, media outlets around the world began reporting on increasing insecurity and the threat to foreign aid workers in Port-au-Prince. We witnessed hundreds of calm and organized aid shipments and read in the press about unruly crowds and near riots. One breathless article reported that the doors of the national penitentiary had been thrown open, allowing four thousand dangerous prisoners to run amok in the streets. In reality, prisoners had escaped, but with pretrial detention rates of 80 percent, four out of five prisoners in Haiti have merely been accused of a crime. This majority had not yet come before a judge for trial, acquittal, or conviction. Legal scholars in Haiti and the United States estimate that there were no more than three hundred to four hundred dangerous criminals among the escapees. Nonetheless, a compelling and alarming narrative was set in motion.
Superficial intelligence gathering and reporting had tragic consequences for the disaster response efforts at General Hospital and many facilities throughout Port-au-Prince. An already weak supply chain—including a partially destroyed, single-runway airport and devastated machinery at Port-au-Prince’s only deepwater port—was further throttled by rumors of danger in the streets. Supplies stopped arriving inside the disaster zone
due to these false rumors. Lifesaving medicines, surgical supplies, food, and water collected on the tarmac and in warehouses as patients died in unsupplied hospitals.
Within two weeks of the disaster, a number of volunteer aid workers arrived in the town of Milot, more than 150 miles and six hours from Port-au-Prince. The undamaged Hôpital Sacré Coeur addressed all the surgical patients near Milot within forty-eight hours, and relief workers were left idle for days. Everyone was safe, but there were no patients. Without false concerns about security in Port-au-Prince, perhaps these volunteers could have been where they were most needed. With a narrow window in which to address life-threatening injuries immediately after the disaster, lives were lost because of this kind of missed chance.
By the time eight weeks had passed since the disaster, the majority of foreign aid organizations had left the HUEH campus. Two organizations—the International Medical Corps and ZL/PIH—continued to provide volunteer clinicians to attempt to meet the hospital’s needs. More than a dozen other voluntary organizations assisted with safe water, sanitation, logistics, and supplies. For four months, the emergency department was housed in a series of tents near the entrance of the hospital, an extremely challenging setting for intensive care.
Even as a majority of the wards were housed in crowded and impossibly hot tents, clinical rounds by Haitian and visiting physicians resumed. Along with the routine staff, medical and surgical residents returned to work. By May 2010, a new class of Haitian interns had begun their training and nursing students were back to their studies under tents pitched in a gravel field where their school once stood.