by Paul Farmer
Vanessa Kerry, a doctor who has worked with PIH for many years, and her father, Senator John Kerry, stepped in to help immediately. Dr. Kerry made contact with USAID and others to help pave the way for the necessary permissions. Senator Kerry, as head of the Foreign Relations Committee, had taken a leadership role in congressional efforts following the earthquake, and a member of his staff guided us in requesting the appropriate permissions to proceed with evacuations. Tremendous efforts were made by those in the network of government agencies tasked with various Haiti assignments to get us landing slots and alert Homeland Security to our arrival. Given the life-ordeath urgency of getting some patients to the hospital, we were able to get permission for some of them to go through customs without passports and photo identification—patients’copies of which had been destroyed in the earthquake, and the original documents destroyed along with Haiti’s National Archives—in time to save their lives.
A medical evacuation company donated its plane and crew for what would become our first post-earthquake evacuation. The pilot and plane nurses were far more than a flight crew. One in-flight nurse had served in the U.S. Army and would later prove a strong advocate and a whatever-it-takes friend as conditions in Port-au-Prince made it difficult to land, load patients, and take off in the time needed to give them the best chance of survival.
At 8:05 P.M., as the plane took off from Fort Lauderdale, three PIH doctors—Evan Lyon, Joia Mukherjee, and Louise Ivers—were in Port-au-Prince, making their way to the damaged General Hospital, where many patients had gathered. People later asked, “How was that one group chosen?” The patients would likely tell you, “Only God knows. Obviously God has a plan for my life.” But we used the principles of the Right to Health Care program, which prioritizes patients who would die without care, who could not be treated in their own country, and whose lives could be saved with a relatively straightforward intervention readily available in the United States. Hundreds if not thousands of people fit that description that night in Port-au-Prince. Our doctors had to choose five: the plane could carry four patients who could sit and one who could lie flat. In the end, our doctors chose Seleine Gay; a four-year-old boy, Given Dorsinde Denera; Given’s father Marcel Denera; a twenty-one-year-old orphan, Rose Sherline Pluviose; and a thirty-three-year-old mother of three, Berlyne Bernard. With little discussion, our patients were brought out of the hospital into an ambulance and jostled through Port-au-Prince to a plane waiting on the runway at the airport.
Upon arrival in Philadelphia, U.S. Customs and Border Protection opened the door to the tiny plane, and the patients were loaded on board an ambulance, smelling of urine and blood and dying flesh. The immigration intake process was mercifully quick. By 5:55 A.M. on Sunday, January 17, the group was traveling to Hospital of the University of Pennsylvania and Children’s Hospital of Philadelphia (CHOP), where teams in both hospitals worked tirelessly to save the patients’ lives.
The weeks of surgeries, tests, procedures, and appointments that followed are difficult to chronicle. All three adult women required amputations—two upon arrival and one a few days later after a brief attempt to save her foot. The wounds were gangrenous; after each woman’s initial operation, doctors would need, again and again, to “revise the stump,” each time taking off a bit more bone to stay ahead of infection. It is difficult to know what each person was feeling during that time. I spent the days racing back and forth among the women, who were dignified and gracious under the most difficult of circumstances. It was a lengthy stay: Seleine and Rose Sherline remained in the hospital until February 23, Berlyne was discharged on March 4, and Given left the hospital during the last week of March.
By September 2010, nine months after the earthquake, twenty-one people had been evacuated from Haiti to Philadelphia in the care of Partners In Health. Thirteen of them had been hours away from death. Our patients and their guardians ranged in age from two months to fifty years. Their education, socioeconomic status, and life experiences are as varied as those of any twenty-one strangers plucked out of a disaster anywhere in the world. Now, in many ways, this community of circumstance has become a family. Ricot Noel, who arrived in April, now says “We live like brothers and sisters. If one of us is sad, thinking about what happened, we can know. We just know.”
Many times, the Haitians in Philadelphia referenced January 12 as “the day I died.” Sometimes they also referenced January 17 or January 31 as “the day God saved me.” Today they are all recovering. The tools and comforts of modern medicine have been made available with great success. They are healing from injuries and illnesses that threatened to take their lives within twenty-four to forty-eight hours had they not been evacuated from Haiti. And yet the complexity of survival in United States is overwhelming. Among just this one group in Philadelphia, the list of losses is long: five limbs, the ability to walk, a wife, a mother, seven neighbors, nine houses, two businesses, possessions too numerous to count. These patients were uprooted and dislocated from their families, from a language they understand, from their country full of people with a common experience and grief. They are still trying to make sense of what happened to them.
It is the central work of any doctor to help the patient in front of her. The tension between serving those in front of you and seeking to reduce the risk of their ending up in front of you, as Paul Farmer has described, keeps many of us up at night. We try hard to plan our next moves thoughtfully and delineate in our mind’s eyes the communities we serve and the institutions we choose to align ourselves with. At times, the possibility of erasing the ever-widening gap between the world’s rich and poor becomes reality in the experience of one small group of individuals. In this case, institutions answered the call and a community came together to heal the sick and comfort the suffering.
How do we care for the sick and injured after they are here? What are the responsibilities of those who bring them? How far should we go to make them healthy? The Partners In Health model emphasizes the concept of accompaniment, be it for patients in Haiti’s rural Central Plateau or Boston’s chronic disease clinic. A community health worker is hired and trained to deliver medications each day, as needed, and to return to the hospital with a checklist of deliveries and any relevant medical information they’ve collected while visiting their patients. Accompagnateurs, as we call those community health workers, have been the backbone of twenty years of work in rural Haiti, constantly teaching one another and the newer teams in Rwanda, Malawi, and Lesotho the best ways to provide high-level care under difficult physical, economic, cultural, and geographical conditions.
In Philadelphia, our program remains true to form. During the initial weeks, I spent hundreds of hours in the hospital talking to doctors, joining patients for various tests and procedures, helping them make phone calls home, and trying to provide consistency in lives that had been torn apart. A call to all PIH donors and supporters drew enormous response. We needed for these families anything and everything one might need in daily life—the basics of food, shelter, clothes, and transportation. Our patients arrived with literally the clothes on their backs—some without even shoes. A local contractor put together a team of men who spent twenty hours a day rebuilding a house that had been donated for the patients to live in. The contractor remembered the earthquake in Mexico City, near the city of his birth, and quickly learned how to make the house handicap-accessible and otherwise ease group living for the Haitians. Local donors visited the hospital with fresh fruit and supplies from their own homes, and they continued to help with rides, with outings in an effort to make the days more fun, and by paying for any number of things. We simply could not have cared for these patients as we did without the network of generous and compassionate people that PIH has built throughout the country.
As the patients grew stronger and were able to leave the hospital, we moved them into the house and hired three Haitian home health aides to help with bandage changes, to supervise medications, to cook and clean, and to navigate the was
hing machine, grocery store, and bus system. As the months passed, we had become a family. We spend many nights eating together and many weekends in one another’s homes celebrating birthdays and anniversaries or simply passing the time. When there was a death in my own family last year, my Haitian family attended the funeral. They wouldn’t have it any other way.
It is hard to know what will come next for these families. Some were given an “indefinite” stamp to stay in the United States. Others were granted two years. Some will be healthy enough by then that they could go back to Haiti. Two of the children will need years of follow-up that would be best provided in a country with abundant tertiary care. But physicians in Haiti would certainly do their best with physical therapy and additional surgeries if necessary.
As an organization, we are facing difficult decisions about the future of these patients. PIH brings patients here for treatment and, when that treatment is complete, helps them get home—healthy and often with social supports such as school fees, a new house, and clothes for the other children in the family. This “turnover” allows us to continue bringing new patients to the United States for care while spending the bulk of our resources in the countries in which we work. Should these cases be any different? We grapple with the ways in which we could continue to provide support. PIH often struggles with how to allocate money between needs in Haiti and organizational or patient needs in the United States. These patients are no exception. As difficult decisions arise, we do our best to make them mindfully. And I watch carefully to see how Sherline negotiates difficult terrain in her wheelchair, knowing that sidewalk quality on a Philadelphia street is light-years away from the roads and rocky terrain of rural or even urban Haiti.
In August, I spent a week with my family in the Outer Banks in North Carolina, a spot we visit each year. It is a sacred time away from the daily grind of work and school. This year, three of the children from Haiti—Given, Bettina, and Lolo—came with me. I hoped to give their parents a break for the first time in six months, and to give the kids a chance to leave the house and experience a week at the beach. When we arrived, the kids eyed my family and our surroundings with suspicion and wonder. They stayed close those first few hours, clinging to me and refusing even to go to the bathroom by themselves. By the end of the week, the kids were playing in the sand with my young cousins while I read upstairs. They were willing to interrupt their time outdoors only to yell “cornflakes please” to the closest adult and then sprint into the house in their wet bathing suits for a quick refueling.
Given sprinted in his walking cast and tenderly put sunscreen on his mountain of scar tissue. Bettina waited twice a day for her medications. The kids wanted to shower multiple times each day, marveling and giggling at the free-flowing warm water and the fact that they weren’t in Haiti anymore; there weren’t hundreds of others waiting, jostling, and yelling for them to hurry up so others could share in the limited resource. Lolo, the fifteen-month-old who had lost his mother in the earthquake, had nightmares, screaming and inconsolable at 3 A.M. The four of us shared a king-size bed decorated with a seashell comforter.
Nine months after the earthquake, we reviewed the numbers: more than two hundred thousand dead; more than twenty thousand amputations; a million injured; more than a million homeless. Enormous effort has gone into saving the lives of the small number of people who arrived in Philadelphia. In this we see both the mission of Partners In Health and, more generally, the heart of medicine. Although we are always allocating limited resources based on the greatest good for the greatest number, we never consider a single effort to be “a drop in the bucket” or energy wasted. If we did, our organization would have stopped the moment we were spending ten thousand dollars to treat a single AIDS patient in rural Haiti or in our first effort to make life-saving chemotherapy available to a young woman afflicted by breast cancer there. Now we are proud to say that both treatments, both tools of modern medicine widely accessible in the “developed” world, are available to patients in Haiti. Moreover, their use is no longer truly extraordinary or expensive there. We, the world’s wealthy, must have the courage to dream big for the communities we serve and to take on the challenge of turning high hopes into reality. Today, in early 2011, it is devastating to realize that “dreaming big” for families in Haiti may consist of clean water for a household wracked by cholera, or a new home for a family living under a tarp in Port-au-Prince. But the patients here in Philadelphia are living testimony to what is not only possible but required if we are to fulfill our mission of providing comprehensive, high-quality health care to the destitute sick.
I am proud to declare that these twenty-one lives are worth extraordinary effort. Some people have asked: “Couldn’t you have used that money to help even more people in Haiti?” Medicine cannot stop to argue when there is a patient suffering on the ground. The great joy of a life in medicine is that ability and that mandate: to do whatever it takes for the patient in front of you. No matter how deep the tragedy, or how expansive, we continue our work—one patient at a time.
FIRST WE NEED TAXIS
TIMOTHY T. SCHWARTZ
What do they do?I am in Léogâne, epicenter of the earthquake, ten days after it struck. I am addressing the question to Joseph (not his real name).
Few people on earth could be better qualified to answer the question. Joseph is an American foreign service officer who has spent his thirty-two-year career in some of the poorest, disaster-wrenched countries on earth: Congo, Rwanda, Nigeria, Angola, Sudan, and now, for the past four years, Haiti.
The people I am asking him about are two officials from DART, the United States Disaster Assistance Response Team. Who could be more qualified to organize logistics than an organization with a name like that? They are some forty feet away, doing the same thing that Joseph already did: interviewing a pair of paramedics from the United States.
The paramedics are two among hundreds of people who got tired of seeing the thousands of untreated Haitians on television, packed into clinics, sitting in streets and empty lots waiting for medical attention. And so they got off their couches, bought plane tickets, and came to Haiti to do something about it. For three days, they have been treating hundreds of patients a day.
The DART officers are scribbling in notebooks; the paramedics are talking and surely saying the same things they said to me and Joseph. Next, the DART officers will interview the Cuban doctors and a half dozen German paramedics from another independent aid agency, all of whom Joseph and a series of other officials—Canadian, U.S. Navy, UN—have interviewed, and all of whom are tired of being asked the same questions—most importantly, “What can we do to help you?”—and receiving no help in return.
“I don’t know what the hell they do,” Joseph replies, squinting at them. “They usually don’t even leave the office.”
After the DART officers have visited all the other doctors and paramedics, Joseph and I are huddled with them. Joseph has introduced me, explaining that I am an anthropologist who has worked in Haiti for the past twenty years and that I have volunteered. The two DART officers, a man and a woman in their mid-thirties, are stone-faced. As we talk, I am imagining that, after ten days of rescue chaos, this is finally the beginning of a coordinated aid effort. These people, I am thinking, are the real thing. They’re feeling out the zone, taking notes, and in another couple days, the United States will come in here and put everything in order.
For the sake of efficiency, I volunteer to visit all the other aid agencies in town and gather information. The DART officers think that would be a big help. They can go on to the next town with Joseph; I will stay here and get the data. This way they can maximize their time out here in the field. It’s agreed.
Léogâne is a small town, covering less than a square mile. And it’s starting to fill up with NGOs and medical agencies.
Daphne Mervil, a student at Léogâne Université Episcopal d’Haïti nursing school, tells me, “Within hours after the earthquake struck, we had mo
re than five hundred injured people.” The nursing students and their two instructors did the best they could to care for the injured. They stacked the dead behind the building and laid the wounded back out in the field. The first doctor, an American, arrived Friday, three days after the earthquake. But significant help did not begin arriving until the following Monday, seven days after the quake, when Joseph and I visited the first time. Now the help seems massive.
I am standing next to a large Canadian flag listening to the public relations representative of a Canadian field hospital. They have twenty beds, meds, and can see two hundred patients per day. Next, I am with the director of the Medécins Sans Frontières (MSF). Around us men are carrying poles. A bed goes by. Tents are going up. I’m jotting it all down. Lists of doctors, psychologists, surgeons, nurses.