POLICY OPTIONSAPRIL 2010

69

DOSSIER

OPTIONS

T he immediate emergency phase may be over, but thelong-term work is just beginning, and it’s no less anemergency,” warned Karline Kleijer, Médecins Sans

Frontières (MSF) head of mission, a mere seven weeks afterthe January 12 earthquake. The future remains uncertain foressential health care in the affected region of Haiti.

Before the catastrophe, more than half of the Haitianpopulation could not afford health care. More than 70 per-cent of them were reported to be living on less than US$2per day. The capital, Port-au-Prince, a city of 3.5 millionpeople, with many living in slums, had 21 public healthfacilities and only four hospitals. These fee-for-service facil-ities lacked medical staff, equipment and supplies. Haiti’shealth care system before the earthquake was insufficient toaddress the basic medical needs of the population in Port-au-Prince. Now, in the aftermath of the earthquake, thelevel of medical need has increased dramatically.

As we write this Policy Options article, more than twomonths after the cataclysm, many of the smaller medicalorganizations have left or are leaving. MSF sees a limited,and certainly inadequate, response to providing basic shel-ter to the displaced. Reflecting back on the aftermath of pre-vious natural disasters in Haiti leaves us far less convincedthan others who see the outpouring of global compassionfor earthquake victims as an indicator that everything willturn out for the better in the end.

Will there be sufficient medical capacity to deal withthe large numbers of patients requiring postoperative care,

specifically rehabilitative and psychological care, over alonger period? How many Haitians will suffer from living ininhumane, undignified living conditions in overcrowdedand violent camps without access to adequate shelter andsanitation? Will many of Haiti’s displaced experience a sec-ond traumatic displacement when the hurricane seasonslams them in June? Will there be enough medical capacity,after six months to one year, to deal with the normal levelsof medical emergencies experienced by cities of this size?

MSF medical teams already in Haiti on the night of theearthquake faced extreme conditions: severe injuries, smallfires burning, corpses on the streets, frantic crowds search-ing desperately for buried loved ones and widespread levelsof physical devastation. The wounded poured into MSF’smakeshift hospitals on the streets. Our staff struggled totreat the influx, while at the same time trying to locate theirown colleagues and families, many trapped in rubble.

T he first phase of the medical response with mass casual-ties lasted about 10 to 14 days. Several MSF hospitals

were severely damaged. Survivors pulled patients and otherstaff — both dead and wounded — from the rubble. La Trinitétrauma centre collapsed with patients and staff inside, includ-ing our most senior surgeon, Erick Edouard, who was one ofthe seven MSF employees killed in the quake. The MaternitéSolidarité emergency obstetrics hospital managed by MSFCanada was rapidly evacuated as it was on the brink of col-lapse. Babies don’t stop being born when disaster hits, and

HEALING A WOUNDEDCOUNTRYPaul McPhun and Kevin Coppock

The independent medical humanitarian organization Médecins Sans Frontières/Doctors Without Borders has been providing health care in Haiti for 19 years. Afterthe earthquake hit, its regular cadre of 800 field staff in Port-au-Prince quicklyexpanded to 3,400 people working in 26 hospitals and clinics. Two representativesfrom the organization explain why restoring Haiti’s health care system to what it wasbefore the quake would be a travesty — because Haitians deserve so much better.Paul McPhun and Kevin Coppock offer some ideas for how to get it right this time.

Il y a maintenant 19 ans que l’organisme humanitaire indépendant Médecins sansfrontières fournit des soins médicaux en Haïti. Au lendemain du séisme, il arapidement augmenté son effectif de terrain de 800 à 3 400 personnes, quitravaillent actuellement dans 26 cliniques et hôpitaux de Port-au-Prince. Deux deses représentants expliquent ici qu’il serait dérisoire de rétablir le système de santétel qu’il l’était avant le séisme, puisque les Haïtiens méritent beaucoup mieux. PaulMcPhun et Kevin Coppock proposent quelques idées visant à créer cette fois unsystème de santé digne de ce nom.

“

OPTIONS POLITIQUESAVRIL 2010

70

more than a few were delivered outsidethat night amid the chaos.

In the meantime, MSF teams rapid-ly set up emergency first aid posts andfocused on stabilizing the hundreds ofwounded who sought our care. Theyrigged makeshift lighting with genera-tors, cars and flashlights. In four corners

of the street in front of the collapsedhospital, team members worked 24hours straight until patients filled everyavailable space on the ground.

Patients arrived with multiple andopen fractures, crushed limbs,deformed faces, skull fractures, spinalcord injuries and life-threateningburns. Teams concentrated on woundcleaning, debridement and dressing,and fracture stabilization. Infection ofuntreated wounds set in quickly sincethe entire population was living out-side. Within the first week medicalteams encountered gangrenouswounds, hemorrhagic shock and sep-ticemia, as well as a type of renal fail-ure known as crush syndrome.

In Haiti, an estimated 300,000people were wounded at once. Thiscalled for a drastic approach to triage,with priority given to persons whocould survive with the smallestamount of resources possible. Most ofthe international doctors and nursesresponding to the quake, includingMSF staff, were accustomed to triagethat prioritized persons with life-threatening injuries that could take upa lot of resources. Sometimes switch-ing gears was difficult.

Logistical teams searched dam-aged MSF hospitals for equipment,material and drugs. Contingencystocks were kept specifically for emer-

gency preparedness scenarios, allow-ing MSF to rapidly start working.However, we never envisioned a disas-ter of this scale; materials were quicklyused up in the first weeks of response.

We expended significant effort tosecure direct landing access for essen-tial medical and nonmedical supplies

in Port-au-Prince. However, flightswith supplies and disaster experts werediverted to the Dominican Republicbecause the small airport in the Haitiancapital was damaged and overloadedwith flights competing to land, and theair traffic priorities remained unclear.

We desperately needed dialysismachines to save the lives of the manypatients suffering from crush syn-drome. It was unspeakably frustratingfor medical teams to watch patientsdie for the lack of dialysis — themachines were en route to Port-au-Prince, only to be diverted from land-ing. There is no doubt that problems atthe main airport resulted in severedelays in the provision of urgentlyneeded life-saving assistance. In theend, most MSF supplies were routedthrough the Dominican Republic,where MSF established a supply base inSanto Domingo. Even if this is a longerroute, it provided a more stable andreliable option for the initial months,as the airport and the seaport, even ifopen, remained overburdened.

By the end of the first week, MSFestimated we had treated more than3,000 wounded people in the Haitiancapital and performed more than 400surgeries (of these, about 10 percentwere amputations).

This natural disaster in Port-au-Prince differed from others in two sig-

nificant ways. First, it directly affectedthe urban capital infrastructure, andconsequently the capacities of all gov-ernmental, United Nations, non-gov-ernmental and private agencies torespond. Second, because it hit dense-ly populated areas of poorly plannedand unregulated settlements within

the capital, the scale ofimmediate medical needamong those injured wasmassive. This exceeded thecaseload managed duringthe 2004 tsunami or in thePakistan earthquake of2005. This combinationmeant a huge need on theone hand and severe chal-lenges to the response onthe other.

T he medium-term response in Haitileads to several important questions. Emergency and postoperative Care.

Will sufficient medical capacityremain in the country to provide qual-ity postoperative care? As more andmore medical organizations are leav-ing, the answer is unclear. In Port-au-Prince there is a virtual marketplace forthe recycling of patients to otherhealth care providers. In the last weekof February alone, MSF received 200patients from medical groups pullingout of the country.

“Emergency surgery is one thing,but lack of, or inefficient, postoperativecare will result in long-term hospitaliza-tion or even in life-long physical disabil-ities,” explained Nico Heijenberg, anMSF physician working in Haiti.

With so many injured, patientswho are living in unsanitary and rudi-mentary conditions, postoperative com-plications such as wound infections areto be expected. Likewise, with so manysevere traumas, spinal injuries andamputated limbs, the need for long-term medical rehabilitation is high.

Added to the burden of postopera-tive care are the daily medical emergen-cies experienced within any city thesize of Port-au-Prince, Carrefour andLéogâne. What capacity will exist totreat the daily influx of car and motor-

Paul McPhun and Kevin Coppock

MSF medical teams already in Haiti on the night of theearthquake faced extreme conditions: severe injuries, smallfires burning, corpses on the streets, frantic crowds searchingdesperately for buried loved ones and widespread levels ofphysical devastation. The wounded poured into MSF’smakeshift hospitals on the streets. Our staff struggled to treatthe influx, while at the same time trying to locate their owncolleagues and families, many trapped in rubble.

POLICY OPTIONSAPRIL 2010

71

cycle accidents, people injured trying torecover their property from destroyedbuildings, burn victims resulting fromtents catching fire with paraffin stoves,violence-related trauma such as gun-shot wounds and stabbings, and otheremergencies such as complications dur-ing pregnancy? In October 2009 aloneMSF admitted 1,470 patients into itsemergency obstetrics hospital. Access togeneral hospital care will be the nextemergency. How many people will diebecause of an inadequate capacity todeal with daily medical emergencies?

MSF is currently managing one ofthe few in-patient therapeutic feedingcentres targeting moderately and acute-ly malnourished children. These areincreasingly being referred from otherorganizations working in camp settings.In the matter of a few weeks 60 childrenwere admitted into care.

Exposure to wind and rain. For howlong will the unhealthy and precari-ous living conditions of the Haitianhomeless and displaced continue?The UN estimates approximately200,000 are living in 300 resettlementsites throughout the affected region.The living conditions of many of thedisplaced are shameful. Many of thesettlement sites are simply not largeenough to accommodate tents andshelters for so many. People expressfear of living in these camps. We hearnumerous stories of robberies insidethe camps, intimidation and extor-tion on the few jobs available and —even if not yet recorded in high num-bers — a lot of reference to rape tak-ing place.

Almost all of the settlements relyon drinking water being trucked inand treated on site. The majority of

sites have insufficient water or spacefor bathing privately, putting childrenand women at risk of exposure toharassment and abuse. A huge need isthe absence of latrines, leading toshameful and undignified living con-ditions. Most camps have far in excessof 100 persons per latrine.

Environmental health conditionsin camp settings are generally poor.Water and sanitation are often at orbelow minimum thresholds, and fam-ilies are densely crowded in tempo-rary shelters. In these conditions,diarrheal, respiratory, vector-borneand other diseases flourish. Furtherexacerbating the situation, people areoften weakened by illness, exposureto the elements and poor nutrition,making them less able to fight offinfection. Even before the earth-quake, diseases such as dengue,

Healing a wounded country

Haiti — The Carrefour feeding centre run by MSF Holland.

MSF

OPTIONS POLITIQUESAVRIL 2010

72

malaria, typhoid fever and otherswere highly endemic. In a weakenedpopulation, there is not only anincreased likelihood of infectious dis-ease, but also an increase in mortality.

Given the health risks, the priorityshould be to quickly identify alterna-tives to the precarious camp shelters,particularly as the onset of rains willlikely make these temporary settle-ments even more untenable.

S olving this problem is far fromeasy. Organizations involved in

providing shelter are torn between cre-ating large planned settlements,encouraging people to build tempo-rary housing within the cities, andmoving people to rural areas to movein with host families who arealso strained by limitedincomes.

The chosen strategy was todiscourage large planned settle-ments. The response for shelteris split into three phases first,provide emergency shelter suchas tents and plastic sheeting;second, provide resources fortemporary shelter that willwithstand the heavy rains andwinds expected to begin thefirst of May; finally, rebuild.

More than two months on,many people still lack even basicshelter and are living in crowd-ed, unsanitary camps spreadthroughout the cites. Even phase onehas been desperately slow. Now twolarge settlements are being planned,with the incentive of assistance to makepeople move there.

It will probably be precipitationthat changes the current status of thedisplaced camps. As the rainy seasonstarts, many of these sites will bewashed away or become impossible tolive in. This will sadly be the impetusthat drives those who still have homes— damaged or not — or access toextended family to overcome theirearthquake fears and return to livingindoors. The remainder will likely gothrough another phase of resettle-ment, either to prepared camps or to

those locations that are not as severelyaffected by the rains.

June marks the official start to thisyear’s hurricane season, when even thebest tented structures may prove inad-equate and unsafe.

While it is impossible to play theprophet, insights from the past can illu-minate the future. If this is the case, MSFdoes not share Bill Clinton’s optimismthat the earthquake was an opportunity“to build [Haiti] a functioning, modernstate for the first time.”

In 2008 Haiti was struck by twotropical storms and two hurricanesin succession. Five weeks after thehurricane, 10,000 out of a total pop-ulation of 200,000 were still livingon roofs, in tents or in fragile shacks

made of scrap wood and bed sheets.Instead of reducing our medicaloperations, as is usually the case inthis type of natural disaster, MSF wasforced to scale up. In the city ofGonaïves, MSF started a temporaryhospital in a new site to replace thecity hospital buried in mud. Ninemonths later, when MSF handedwhat was intended to be a temporarystructure over to the local healthauthorities, the city hospital was stillfull of mud, despite the huge out-pouring of financial assistance andmedia attention the hurricanes hadgenerated.

Increased vulnerability, decreasedhealth care? What capacity is there to

maintain a reasonable access to basichealth services for these vulnerablepopulations? It is through out patientservices that most complications canbe identified, treated or referred beforethey become life threatening. Prior tothe earthquake, these public serviceswere available only for a fee, and werenot targeted at those in greatest needanyway.

While we all hope that theHaitian Ministry of Health (MoH) willquickly get back on its feet, its capaci-ty was insufficient to meet the pre-earthquake medical needs of thepopulation. With so many hospitalsdestroyed, the migration of homelessMoH medical staff and the lack ofinfrastructure, how much can we

expect the MoH to recover?Will the combined capacity ofthe MoH and the remainingmedical organizations be suffi-cient to cover even the basic,life-saving needs of the earth-quake-affected population?The shared operations of MSFin Port-au-Prince in recentyears have cost in the region ofC$20.5 million a year. Thisequalled two-thirds of the entireMinistry of Health budget forHaiti.

International donors havelong been reluctant to invest ingovernment-managed pro-grams in Haiti for fear of poor

accountability, mismanagement andcorruption. The country has also suf-fered years of brain drain of its experi-enced and qualified human resources,as many have sought to emigrate andjoin the diaspora in Canada and theUS.

As a result most of the aid moneygoing into the Haitian health sectorhas been channelled through imple-menting partners such as NGOs andothers working in the private sector.This leaves the Ministry of Health lit-tle option but to implement user-fee-based services for patients and costrecovery systems for medicine, there-by excluding those who can leastafford to pay.

Paul McPhun and Kevin Coppock

In Haiti, an estimated 300,000 peoplewere wounded at once. This called

for a drastic approach to triage, withpriority given to persons who couldsurvive with the smallest amount of

resources possible. Most of theinternational doctors and nurses

responding to the quake, includingMSF staff, were accustomed to triage

that prioritized persons with life-threatening injuries that could takeup a lot of resources. Sometimes

switching gears was difficult.

POLICY OPTIONSAPRIL 2010

73

Public hospitals have historicallybeen plagued with strikes, and havestruggled with issues of internalcorruption as health care workers feelforced to find ways to compensate fortheir lack of regular income. Thehealth care agenda was largely over-looked at the last international donorconference in 2009, which ignoredMSF appeals that it be given priority.

In Washington, in the weeks priorto the installation of the Obama admin-istration, the dominant view of healthcare funding for Haiti was disappoint-ing. “Why would the USA prioritize theaccess to health care of 7 millionHaitians when we have up to 40 millionAmericans in a similar situation?” aCapitol Hill official challenged.

I f there is going to be a sustainedcommitment to Haitians following

this tragic disaster, it will be essentialto have a commitment to the fundingof public health services, the develop-ment of a health plan tailored to theneeds of Haiti’s impoverished popula-tion, incentives to encourage thereturn of health and other profession-als and strong coordination in thehealth sector. MSF will continue tolobby the government and donorcountries at every opportunity to pro-mote these propositions.

There have been unprecedentedfinancial commitments made to Haitifollowing the earthquake, somethingin and of itself that will motivatedonor-dependent organizations todevelop programs in order to simplyspend the money. Likewise, manyorganizations have received massivesums of private income, MSF included.To cast a critical eye inwards, MSF wason the point of scaling down opera-tions in Port-au-Prince before the

earthquake to two operational sec-tions, aiming for greater efficiency anda rational approach to needs in Haiticompared to other contexts aroundthe world, and also to rebalance ourglobal priorities for medical humani-tarian assistance.

After the earthquake MSF nowhas five operational sections in Haiti,with a combined planned budget of

more than C$68.4 million for 2010alone. NGOs, including ourselves,need to think critically about how torationalize efforts to meet the plenti-ful needs in Haiti in a way that aimsto limit, as far as possible, duplica-tion of services and competition foractivities or “intervention space,”and be accountable for the responsi-bility increased financial independ-ence offers. Not as easy or as obviousas it sounds.

The health and well-being ofHaitians is clearly at great risk in theshort, medium and long terms. It isunclear what capacity for the provi-sion of emergency and general healthservices will remain in the countryover the coming months. It is equal-ly unclear how quickly the Ministryof Health can resume responsibilitygiven the severe impact on infrastruc-ture, financing and staffing thisearthquake has had. Immediateneeds are already apparent, and theseare no longer only linked to theemergency care that resulted fromthe earthquake itself. As time goeson, health care providers are adapt-ing their programs to meet the gener-al health needs of the population.Many are not prepared or committedto do this, and will leave or havealready left.

The crisis of homelessness and dis-placement remains unresolved.

Temporary camps are precarious, andincreasingly threatened by the onset ofrains. Living conditions are poor andwill, over time, contribute to anincrease in preventable disease.

A ccess to health services for poorHaitians in Port-au-Prince was

already inadequate before the earth-quake, with very few free or suffi-

ciently subsidized healthprograms to provide essen-tial care to a populationwhere the majority livebelow poverty thresholdsin precarious settlements.Re-building the formerlevel of services is there-fore clearly not enough,

and re-introducing user-fee-basedhealth services or cost- recovery pro-grams for a population that is noweven more vulnerable will deny thosewith the greatest need access toessential life-saving care.

Unless international donors andkey stakeholders place sufficient pri-ority on proper and accessible healthcare in Haiti, the future, both shortand medium term, looks bleak. As evi-denced in the past, the internationalcommunity has failed to maintain asustained commitment by investingin public health services and not justthe private sector, embracing theneed for free or subsidized healthservices and supporting the develop-ment of a long-term health plan.Without this the vast majority ofhealth programs will continue to berun in parallel to those of the MoH,with little effective coordination, andwith models aimed at restoring thepast services instead of models aimedat reaching those in greatest need,with the highest health risks.

Paul McPhun is the Toronto-based opera-tions manager for Médecins SansFrontières/Doctors Without Borders, andKevin Coppock is humanitarian affairsliaison for the organization in Canada.Both McPhun and Coppock joined theemergency response in Haiti after theJanuary 12 earthquake.

Healing a wounded country

International donors have long been reluctant to invest ingovernment-managed programs in Haiti for fear of pooraccountability, mismanagement and corruption. The countryhas also suffered years of brain drain of its experienced andqualified human resources, as many have sought to emigrateand join the diaspora in Canada and the US.