Haiti After the Earthquake

by Paul Farmer

  In the months after the earthquake, substantial promises were made about rebuilding the physical infrastructure of General Hospital but progress has been very slow. On February 17, 2010, Nicolas Sarkozy became the first French president to visit its long-independent former slave colony. President Sarkozy toured Port-au-Prince with President René Preval and promised 207 million euros in aid, including the cancellation of 56 million euros in Haitian debt held by France. France and the United States have promised to provide equal co-funding totalling $50 million to go to rebuilding efforts at HUEH. As of this writing, no reconstruction of HUEH has begun under this support, although a feasibility study has been launched.

  Unfortunately, this deferred promise to Haiti is but the latest in a centuries-old series. Haiti’s history of poverty, environmental destruction, and political chaos, often sown outside its borders, has been discussed elsewhere in this book. Recently, increasing international debt and the austerity of “structural adjustment” has further diminished an impoverished public sector. Basic political, civil, social, and economic rights, including the right to health, cannot be assured by the weakened state. The public sector lacks both the physical and social environment required to create good health for its citizens and adequate health care resources for illness prevention and treatment.

  In the popular media, and even in much of the technical and scholarly reporting on Haiti, it has been noted far too frequently that this island nation is “no stranger to suffering.” This is a fact, but it is rarely given a full context. Unlike the facts of nature—the unrelenting shifts of the earth’s crust or the seasonal Atlantic storm circulations that yearly threaten the region—this fact can be changed. The disaster on January 12, 2010, was an unnatural disaster at the dangerous intersection of a natural trigger (the magnitude 7.0 earthquake centered 13 km below the Carrefour neighborhood of Port-au-Prince) and an absolutely unnatural vulnerability created in Haiti by centuries of political, economic, environmental, and social forces.

  Seismologists frequently write: “Earthquakes don’t kill people. Buildings kill people.” The earth’s movements are not the basic pathophysiology (the unique, disease-defining characteristic) of “earthquake illness.” Earthquake illness is a disease of social construction, its severity determined more by the capability of buildings to withstand seismic activity than by the intensity of a tremor. The capability to respond as emergency and health care workers depends, as we’ve seen tragically in Haiti, almost entirely on how physical and human infrastructure fare on shaking ground.

  On February 27, 2010, a magnitude 8.8 earthquake, one of the most powerful recorded in human history, occurred off the coast of Chile. It is dangerous to compare tragedies such as the earthquakes that occurred in Chile and Haiti, but a number of differences are striking. The earthquake in Chile was five hundred times more forceful than the disaster in Haiti, yet best estimates suggest that nearly three hundred thousand people died in Haiti while fewer than six hundred died in Chile. Fewer buildings fell and fewer people died.

  It is our responsibility as human beings and as those who care about the present and future of Haiti, not to forget that manmade conditions allowed this unnatural disaster to take such a devastating toll. These conditions took more than two hundred years to create; they could be reversed in much less time. But unless our historic memory is long enough and our analysis of the tragedy is deep enough, efforts to respond—however generous—will be insufficient. If suffering from earthquakes is a disease of social determination, most meaningfully inflected by poverty, than to prevent the next January 12 we must change the social context in which people live.

  The international humanitarian response to the earthquake in Haiti, while inadequate to the continuing needs of the Haitian people, seems nearly as unprecedented as the disaster. The generosity, attention, and love shown to Haiti in the weeks and months following the earthquake was humbling and inspiring. Yet for Haitians and those in solidarity with the nation, the speed at which Haiti faded from the headlines was frightening. Without serious and coordinated efforts to address the root conditions that caused the unspeakable suffering beginning on January 12, 2010, another disaster like this will assault Haiti. The trigger may be rain or a microbe; it may be continued deforestation or a malnourished body; it could be another earthquake. In the fall of 2010, we saw tremendous, unnecessary suffering and death from cholera—a disease that has not affected Haiti for at least one hundred years. But if the structural and social conditions for Haitians do not change, the question is not whether another tragedy will occur but when.

  No successful strategy for creating lasting, positive change is simple. But in terms of public health, some directions are clear: investment must be made in the public sector, including the rebuilding of a better General Hospital and sustained investment in the material and human resources needed to provide health care for all Haitians. From the perspective of the National University, this investment must include improved and continuing education.

  If nursing students at HUEH were able to recommit themselves to their studies—just four months after losing their classmates, under tents covering the patch of rubble where their school once stood—the very least we can do as an international community is to assure that a similar tragedy won’t visit Haiti again.

  DOCTORS IN TENTS

  DR. DUBIQUE KOBEL

  On the 12th of January,I was working at the health center where my wife, Nadège, had a job. She was ill that day, so I was filling in for her. After work, I went straight home to study for my board exam in community medicine, which was scheduled for the following day.

  When I got home, Nadège was in the dining room with her mother and our baby girl, Annabelle. I ate and was going to our room to take a bath when suddenly the ground tilted. Having lived through several earthquakes in Cuba, I realized what was happening. I made my way to the dining room and saw Nadège’s mother, with Anna in her arms, crying out “Jesus, Jesus.” She shouted at Nadège to pray with her. Nadège’s little brother was chanting psalms. I told them all to take shelter with me at the edge of the room. As we stood there, I remembered that the night before, from about 11 P.M. to midnight, the dogs had been barking a lot and running in every direction.

  We lived in a house with two levels, and usually we heard a crowd upstairs, creating lots of noise. But that day the house was eerily silent. When the shaking subsided a bit, we made it to the stairs and got out of the house. Around us, we saw multistory houses collapsed on themselves. Even then we didn’t understand the magnitude of the disaster. At some point, we realized that people were dusty with sand and cement, some were rolling around on the ground, some were screaming, and others were covered with blood. We began to understand the gravity of the situation.

  I turned to look toward the side of the nearby hills, where buildings were toppling like dominoes, each collapsing into the next. A cloud of white dust rose into the sky, mingled with the cries and screams of the wounded.

  We decided to head toward Pont Rouge, where my mother lived. I needed news of her, at any cost. Along the way, I came upon James, an old friend from Cuba. His arm had been broken. My shock gave him the impression that I was laughing, and he said: “Kobel, there’s an earthquake and you’re laughing.” I told him what I had lived through and where we were going.

  On our way to Pont Rouge, we saw fallen towers, collapsed houses and public buildings, and smashed cars. Motorcyclists were carrying the injured, and people were screaming and running in all directions. Anxiety and uncertainty were writ on every face, as those who survived tried to find out the fate of their missing families and loved ones.

  At Pont Rouge, neighbors told me that my father’s house had collapsed and that my mother and brothers were at Parc Jean-Marie Vincent. I went there to search for them. As the evening’s shadows began to fall, it was hard to see, and I called out my mother’s and my brothers’ names. Someone told me where to find them, and we joined one of my sister’s-in-law, the wife of m
y brother Wendy, and my four-month-old nephew, along with other children and women. At least four women gave birth in the camp that night.

  Then I went to Christ the King in Delmas 3 to inquire about my father and my other brothers. My pilgrimage continued back to Pont Rouge to reassure my mother about the fate of my father. I walked to Petionville to check on another loved one. The entire journey, I saw many dead lying on the road and on the sidewalks. Beside the Church Altagrace in Delmas, I greeted an old friend, a priest, praying with a large gathering of the faithful. We talked a bit, and I continued on my way. It was risky to travel on foot because of the live wires on downed electrical towers and the continuing tremors. Luckily, the people I had gone to see were unharmed.

  Around one o’clock in the morning, I returned to our house, which looked as though it had been made of cardboard. I ran inside and took a few suitcases, some milk for Annabelle, and a lamp. Back outside, I saw that the devastation blocked my previous route. I found another way back to my family and arrived at Parc Jean-Marie Vincent about 2:30 A.M.

  The next day, we had to find something to eat and drink. We had nothing but what I took from the house, and had lost our bearings. The park was like a public canteen, with people sharing what little they had with one another. A strong wind began to blow, and people began to scream and run, fearing a tsunami in the wake of the earthquake. During the panic, we were separated for a few hours before being reunited back at the Parc.

  We had to keep Annabelle in our arms all day long. Exhausted, my mother-in-law was inspired to make a makeshift bed for the baby consisting of a plastic tub, some cloths, and a mosquito net. The corpses rotting in the streets attracted swarms of flies, which covered Annabelle’s net and also found their way inside it. She was still covered with dust, and had to be changed often. While we were in the park, she caught conjunctivitis twice.

  We spent our days on the street in Charlotin and evenings at the Parc Jean-Marie Vincent. I was always worried because the situation in the park was intolerable. People had nowhere to put their waste and were burning their trash so the air smelled foul. However, we thought it best to stay put at the park because all the movements from place to place were not good for Annabelle. We needed some stability, so we tolerated the presence of flies on everything we touched and people fighting all day long, some even throwing stones. Finally, portable toilets were installed, but the smell was even worse when they drained. My mother-in-law did everything in her power to protect Annabelle from the stench, putting cologne on her face and body. We ultimately spent five months living in those conditions.

  Although we were refugees in the park, we saw that the people there needed care and understood that it was our job as physicians to take care of them. We couldn’t remain indifferent to their suffering. Word that doctors were working in the camp spread quickly, and wounded people started arriving from every direction.

  As graduation gifts, in Cuba, we had each received a kit including stitching materials, so we started to operate. Cases beyond our competence and equipment we referred to Centre Ste Catherine in Cité Soleil, where a Cuban surgeon was operating. The days passed thus. Nadège’s younger brother paid for us to travel to the pharmacy to buy some medicine, and we did the best we could in those unsustainable, unhygienic conditions.

  At the end of January, we met Dr. Lambert, Pierre-Paul, and Maxo from Zanmi Lasante, Partners In Health. They were planning to visit Caradeux, Dadadou, and Plant 2004. I told them about our work at the park, the number of refugees there, and the conditions, and then I asked them to visit. We had never been visited by a government representative, although I had met a foreign journalist and a Haitian journalist in the Parc. The Sisters of Charity, dressed in blue, arrived but left after a short while because they didn’t work in the health sector.

  The doctors from Zanmi Lasante did come, and they stayed to serve the people living in Parc Jean-Marie Vincent. We joined their team, initially as volunteers. As funds were raised, we were hired and have been part of the Zanmi Lasante team ever since. They have supported us and allowed us to continue our work up to this very moment.

  For the country of Haiti, the earthquake of January 12 was a fatal blow. For me, it was an unforgettable experience. I grew up, matured, and realized what life is, real life. The earthquake changed my way of seeing and understanding things and marked me indelibly. Nothing surprises me now.

  So much has been destroyed that only traces of our old life remain in our new one. When we first began to offer care to patients in Parc Jean-Marie Vincent, Nadège and I used a table and chairs that I retrieved from our home—these are now part of the furniture at Clinic Zanmi Lasante.

  THOSE WHO SURVIVED

  NAOMI ROSENBERG

  When the earthquake hit Haiti on January 12, 2010, Seleine Gay, a twenty-seven-year-old mother of three, was selling juice underneath a local hospital in Port-au-Prince. She managed to squirm out from under two stories of fallen concrete, her leg destroyed, and hobble to the closest hospital. For days she lay there with only a bit of gauze wrapped around her rotting leg and no medication for the pain. Her husband and children were not allowed in the hospital due to the crowds and chaos. Seleine gave birth to her first child in her early teens and, before the earthquake, was making just enough money each day to find some food and water for her family. For five days she lay still, stared at the ceiling, and prayed.

  On Saturday, January 16, several doctors came by. Seleine heard a man say that she would surely die by morning. A few hours later, with no time to say goodbye to her family, she was evacuated from Port-au-Prince in the middle of the night. She arrived in Philadelphia, a city she would know, for months, only through the narrow windows of the hospital.

  Seleine had not been to school in Haiti and could not read or write. She was given consent forms and heard discussions of a do not resuscitate order; these were foreign to her, but she learned how to mark an X when handed a pen. Her lower leg had to be amputated the day she arrived, surgeons sparing her knee and thigh in a BKA (below the knee) procedure. They tried to comfort her by cheerfully telling her that some people “still play tennis” with a BKA and prosthetic device.

  In the days following her operation, Seleine was lively, confident, and efficient. She fed and bathed herself before dressing and carefully massaged the stump she referred to as “her baby.” Nurses and doctors trailed in and out of her room. Visitors from a nearby church and Haitians living in Philadelphia came to offer support.

  Two weeks after her arrival, however, Seleine began to not eat or sleep. When she asked her husband, still in Haiti, about their children, he told her he had sent them away. For days she couldn’t find them as they were shuffled from relative to relative. One of every twenty calls she made to Haiti would be answered, only to be disconnected after a few seconds. Her amputation led to several infections, and Seleine did not understand the operations that were necessary in their wake. Every setback made her feel like she was failing her assignment to recover. She lay still, stared at the ceiling, and prayed.

  Each of the patients who survived the earthquake and came to Philadelphia for treatment has a harrowing, tragic and important story. It is impossible to tell each of those stories here, but I can share a bit more of Seleine’s story. I hope the others’ stories will also be told one day.

  On Tuesday, January 12th, as the world learned of the hundreds of thousands injured by the earthquake, countless surgical, medical, and supply teams began preparing to deploy to Haiti. Those working in Port-au-Prince, however, quickly realized that it would be days before visiting surgeons could begin operating in makeshift field hospitals set up throughout the city. One walk among the thousands lying injured in General Hospital also made it clear that many would not survive to see the arrival of those teams.

  On Friday, January 15, Dr. Joia Mukherjee, Medical Director of Partners In Health, suggested that PIH consider evacuating some of the injured for surgical care. For years, PIH had been operating a Right to Health
Care (RTHC) program, which brings patients to the United States and elsewhere when care is not available in their home countries. Many RTHC patients require cardiac surgery; occasionally we provide chemotherapy or surgical intervention for young cancer patients easily treated with the tools of modern medicine. PIH triages these patients, lines up institutions willing to donate treatment, shepherds families through the arduous passport and visa processes, and then addresses the need for clothes, food, and other supplies upon the patients’ arrival. A PIH staff member stays with patients and their families through tests, operations, and appointments, careful to understand the treatment so that he or she can offer comprehensive and meaningful guidance and support during a tremendously difficult time. When patients are ready to leave the hospital, we also place them in a home and assist throughout the outpatient treatment while preparing them to return to their home country with whatever follow-up care is necessary.

  Described this way, the process sounds tidy, but it never is. For a young rural Haitian, often ill for years, leaving the countryside for potentially lifesaving treatment can be a harrowing experience. The abrupt transition from illness to health and from rural Haiti to the cutting edge of modern scientific research and medicine can be both lifesaving and brutal. Whenever our staff picks up a patient arriving in Boston, usually in the middle of the night due to flight schedules, and whisks him or her to the hospital emergency room, we find ourselves face-to-face with the gross inequities that cause many to suffer greatly from treatable, preventable illness and injury.

  After Dr. Mukherjee’s January 15 request that we look into evacuation for the injured, the RTHC team set to work. I immediately contacted my home institution, the Hospital of the University of Pennsylvania (HUP), while others went to our contacts at hospitals in Boston to see what they would be willing to do. Dr. Richard Shannon, Chair of Internal Medicine at HUP, responded within the hour. “I have contacted the CEO of HUP. Let’s do it.” Without a doubt, this quick response made possible the days and weeks of work that would follow. With HUP’s guarantee of free care for the injured regardless of their ability to pay (often the most difficult piece to put into place in the pre-earthquake era), we could approach the many United States government institutions responsible for immigration and say confidently that transport and treatment for the dying had already been arranged. We would simply need permission to leave Haiti and enter the United States. However, obtaining these permissions was not a simple matter in a place where the nucleus of government and the majority of government facilities had been destroyed. Our contacts in the embassies, immigration offices, and airport in Haiti were no longer available. The city of Port-au-Prince was in chaos, and the air traffic control tower was out of commission. The United States military was taking over the airport, and getting a landing slot in Haiti became a Herculean task.