Humanitarianism in Haiti

A year after the earthquake in Haiti, health-care providers continue to volunteer in an attempt to fill our Caribbean neighbor’s medical void. In recent years, several domestic and international natural disasters have captured the attention of the medical community and the public at large. Yet, the Haitian crisis seems to have received more United States–based medical “help” for multiple reasons, such as the proximity between the two nations; 200 years of cultural connections; longstanding American medical projects in Haiti; the enormity of the disaster; and, most importantly, the dire need of the Haitian people.

The complexities of going into a disaster zone and working in a country with a weak public health system are numerous and need to be examined critically. International nongovernmental organizations (NGOs) and Haitian health-care providers on the ground mobilized immediately after the disaster. They were joined by an avalanche of good samaritans from a geographically diverse group of hospitals, American NGOs, and communities started through social-networking sites like Facebook. The response created a unique dynamic in Jimani, a dusty city in the Dominican Republic that borders Haiti. At the public hospital in Jimani, Dominican physicians worked tirelessly, treating crush injuries in patients flown and driven in from Port-au-Prince. Up the road, at Good Samaritan Hospital, an international crew of health-care providers organized themselves to provide care. Admirably, the outpatient surgical center cared for hundreds of patients and housed volunteers, assisted by an NGO deputized to run the center prior to the storm.

Despite the valiant efforts, there were a few glitches. There were abundant concerns about professionalism. While awaiting helicopter transfer of patients to hospitals in larger Dominican cities, transporters could be found videotaping the process with smartphones while holding stretchers. Some critically ill patients were transferred to facilities too overburdened and underequipped to care for them. Poor coordination occasionally exacerbated the chaos and frenzy of activity. In one instance, an American military helicopter was called to pick up a pediatric patient not authorized to be picked up. The patient’s father was devastated that his critically ill son was not going to the American medical ship, and the helicopter made an unnecessary landing at Good Samaritan.

Reaction to the crisis has highlighted the need to increase resources in Haiti and the Dominican Republic to handle disasters and care for the critically ill or injured. Disaster training and preparation should enhance the response and relief effort; untrained volunteers can participate in disaster relief but should not direct it. Interested individuals may consider taking a Fundamentals of Disaster Management course (www.sccm.org/FCCS_and_Training_Courses/FDM/Pages/default.aspx) or receive advanced training in emergency management. These potential pitfalls were well anticipated by the Israeli military in its disaster response. It recognized that ethical dilemmas would exist for the team in Haiti, due to the limited resources. Therefore, it created an ad hoc ethics committee and a realistic triage system to support its staff in making treatment decisions (Merin et al. N Engl J Med. 2010;362[11]:e38). Today, limitations persist beyond the disaster’s acute phase. Field hospitals run by foreign healthcare providers remain, and medical decisions are made daily by individuals who do not normally practice in resource-limited environments, a learning experience for foreign health-care providers and an unnecessarily traumatic one for patients and physicians.

The war in Iraq provides a relevant example of alternative management systems. Cannon and Smith described providing care for critically ill Iraqi pediatric trauma patients and inadvertently winning the “hearts and minds” of the local people around their base in Balad. The airmen intervened because a lack of facilities led to a 70% mortality rate for critically ill patients. Their experience led them to suggest a “landmark” partnership between NGOs and the military to supplement the Iraqi medical system (Cannon and Smith. Crit Care Med. 2009;37:2322). The contrast between providing medical care in the Iraqi war effort vs the Haitian humanitarian effort is immense, but there is one important similarity. The military presence, in both situations, substantially improved medical care. Amundson and colleagues described their experience on the hospital ship USNS COMFORT in Haiti where they took care of a diverse group of patients, including the critically ill (Amundson et al. Ann Intern Med. 2010; 152[11]:733). The USNS COMFORT initially partnered with Project Hope to allow civilian medical personnel aboard. After the ship left, however, the American military had a much more limited partnership with the medical relief effort. NGOs continued to run busy field hospitals, and the military provided supplies, occasional personnel, and technical advice, as able. The lack of an ongoing formal partnership with the military led to a loss of expertise that could have benefited the continuing relief effort. It is our personal belief that the military staying formally involved in the medical process in Haiti could have increased our overall ability to serve our Haitian patients. Yet, not all situations are similar. Many times, it may not be feasible or even in an NGO’s best interest to work with the military, but it should be considered.

After the acute and subacute phases of a disaster situation, the most important way to continue to improve medical care is to engage a local resource. In the long term, local organizations understand how to deliver more effective health care to their own populace. Long before the world focused on earthquake-ravaged Haiti, a community center in Petit Gauve, a small city 2 hours outside of Port-au-Prince, provided health care to its local residents in recent years. The Henri Gerard Desgranges Foundation (HGD, hgdfoundation.wordpress.com) has struggled to reopen its school and health clinic after the disaster due to a lack of funding and medical staff. The foundation’s lab was destroyed, and fewer Haitian physicians are present, but the patients remain. Between 50 and 200 patients a day are seen at HGD, with specific days focused on obstetrics and pediatrics. The center has had volunteers from the US, Canada, and France rotating in for 1-week to 2-month stints. The contribution of foreigners is commendable, but the clinic’s future depends on the ability of Haitian physicians to resume management.

Medical providers who wish to volunteer in Haiti should evaluate whether their money, time, and effort would be better spent in helping existing Haitian resources rebuild rather than going on week-long volunteer missions. A moment of reflection on the personal motivation for a medical mission may profoundly impact the choice to go to a disaster zone. Haitians need our “help,” but we must be more discriminating in how we extend our helping hands.

Dr. Nitin Puri
Cooper Hospital
Robert Wood Johnson University of
Medicine and Dentistry of New Jersey
Camden, NJ
and
Lt. Col. Terence Lonergan, USAF, MC
Emergency Medicine Staff Physician
Wilford Hall Medical Center
Lackland AFB, San Antonio, TX

The opinions expressed are those of the authors and not those of the Department of Defense or the US Air Force.