Haiti After the Earthquake (2 page)

This quarter-century has been, for us, one of satisfying growth in spite of disappointments and the dashing of many of the hopes awakened by the fall of the Duvalier dictatorship in 1986. If this book has a central metaphor, it's one taken from clinical medicine: the earthquake can be understood as an “acute-on-chronic” event. It was devastating because a history of adverse social conditions and extreme ecological fragility primed Port-au-Prince for massive loss of life and destruction when the ground began shaking on January 12. For this reason, the account is not linear but rather follows clinical logic: it explores the acute-on-chronic disaster that occurred on January 12 and its origins in Haiti's troubled history.

A sound account of the quake must go deep into Haiti's history to illuminate what caused the chronic disabilities, engendered over five centuries by transnational social and economic forces with deep roots in the colonial enterprise. Haiti was born of resistance to this enterprise, and therein lies both the strength and disability of the new polity—the reactive and reticulated pattern of growth registered in the nineteenth century and in the past one, when Haiti became anchored more formally in the “American hemisphere” through a nineteen-year military occupation by its oldest neighbor. When the U.S. Marines withdrew in 1934, they left a superficial calm and a social class that relied heavily on the army as the arbiter of political transitions.

Historians often claim that their discipline reveals the significance of current social processes, and they are right: the decades preceding
the quake set the stage not only for what occurred during the acute event but also for the challenge of reconstruction. Following a brief review of Haitian history—which is, necessarily, a review of the history of the New World—we return to the challenge of reconstruction after the temblor of 2010. In the years before it, we saw that Haiti had become a veritable “Republic of NGOs,” home to a proliferation of goodwill that did little or nothing to strengthen the public sector. Thus did clinics sprout up without much aid to the health system; thus did schools arise by the hundreds even as the Ministry of Education faltered; thus did water projects appear even as water security (like food security) was enfeebled.

This was the situation pre-quake, as described in this book. Efforts to rebuild after the quake needed to draw on the sudden attention of the world and the generous promises and pledges to craft a new way of doing business that did not further weaken the Haitian government. It's hard to imagine public health without a public sector, and the same could be said for public education and public works. And so this book recounts efforts to stand up a “recovery commission” to address the dysfunctional system of humanitarian aid that, good intentions aside, has become another obstacle to Haiti's recovery and sovereignty.

It's the argument of this book that rebuilding capacity—public or private—in Haiti requires sound analysis of what, exactly, has gone so wrong in the previous four decades. To accomplish this—what doctors call diagnosis and prescription—we've had to abandon anxieties about representation and about intruding in the text both as narrators and as characters. Every account is personal. Most of those who contributed to the relief efforts described here are not included (though we've tried to thank some of them in the acknowledgments). We've also sought to focus on the shortcomings of the quake response, rather than the victories.

In academic circles, few rewards are given for this sort of candor, or for failing to include all the key actors on the scene. But knowing that a quarter of a million voices were silenced on a single night and that more recent problems (such as cholera) are part of the same tragedy encourages us to offer these personal and place-specific narratives.

Whether these narratives are termed “history's first draft” or simple first-person accounts, they constitute our collective effort to recount and account: to recount what happened before it slips from our memories and to account for what placed Haiti, a country we all love, at such extreme risk well before January 12, 2010.

This book, with all its limitations, is offered as a humble tribute to those who perished that day, to those who live on with their injuries, visible and invisible, and to those who continue to stand with the Haitian people. Among them are the tens of thousands who responded to the suffering caused or worsened by the earthquake, including those who supported, quietly and from afar, the imperfect efforts described in these pages.

O
n January 13,
the day after an earthquake struck Haiti's capital, I finally got through to Dr. Alix Lassègue, the medical director of Port-au-Prince's largest hospital and a longtime friend. The hospital's real name is l'Hôpital de l'Université d'Etat d'Haïti, but most people call it the General Hospital. I began trying to reach Lassègue a couple of hours after the quake. His cell phone number, like all the other numbers I tried, led to a recorded message or an ominous buzz. From what we knew at the time, the hospital was smack in the middle of the quake zone. The facility sat among a dozen government buildings, including the medical and nursing schools, and we could see from live reports that most of those buildings had collapsed—during business and school hours. It was clear that our work as health providers in Haiti would be changed forever.

So now what? It was hard to know how to prioritize anxieties, and as a doctor, I thought immediately of the General Hospital. It wasn't hard to imagine the enormity of need in this struggling public facility which had, in the best of times, too many patients, too few staff, and far too few resources. After dozens of tries, it was almost a shock when I connected to Lassègue on a colleague's cell phone.

“What do you most need?” I asked.

Lassègue would hear this question again and again over the next weeks and months, usually with scant practical outcome, but this
was early in the game—less than twenty-four hours after the quake. Of course he needed just about everything, including electricity, supplies, salaries, and medications; the hospital had been scrambling for all these even before the quake. He gave me a long and fairly specific list. He needed materials and labor to repair the damaged parts of the hospital, and engineers able to assess the structural integrity of the buildings still standing. He needed help trying to save the lives of those still trapped under collapsed buildings abutting the hospital grounds, including not only the nursing school next door—“a total loss, I fear, and all in it”—and nearby federal buildings, but also houses, businesses, and schools. “It's much worse than we thought,” Lassègue said. “Just managing proper disposal of the bodies is overwhelming us.” He needed help moving casualties out of the courtyards and into the morgue but couldn't do that because the power was down. (“Why move bodies into the morgue,” he asked, “without means of preserving them?”) I didn't say much during the call because I'd never contemplated such problems.

Lassègue kept talking. “What I need most,” he concluded, “are surgical teams—surgeons and anesthesiologists and nurses and post-op care and medications. And generators.” It was a relief to hear these specific requests, because they were needs we could address. I promised to get the word out and to join him as soon as I could, but our connection was lost and I'm not sure he heard the last bit.

I'd been to the General Hospital many times over the previous twenty-five years, usually with a heavy heart. When we at Zanmi Lasante sent our patients to Port-au-Prince, it was never good. They needed something we couldn't provide in central Haiti—usually a diagnostic test or procedure. Often, these patients had already been to the General Hospital or to some other facility in the city. They were almost always people who needed medical care but had been effectively shut out from receiving it because they were poor and couldn't pay the fees most clinics and hospitals demanded for consultations, lab tests, and medications. “Free care” was never free because even the most basic services had hidden costs. The General Hospital was surrounded by scores of small for-profit private pharmacies and labs
that counted on referrals and income for the sale of everything from surgical gloves, sold by the pair, to the most basic medicines and lab tests.

The dire need of Haiti's destitute sick for even basic medical services was the reason we'd founded Partners In Health and Zanmi Lasante a quarter century ago. These organizations had grown significantly in the decade before the quake: our Haitian colleagues—numbering in the thousands—ran a dozen public hospitals stretching from the Dominican border to the coast at Saint-Marc. For many poor Haitians, these hospitals had become a last line of defense, and we tried never to refer patients to other facilities unless absolutely necessary. When we had no choice but to refer them, we would try to send patients along with any medicines or supplies they might need—from antibiotics to intravenous solutions to gloves for their examining physicians—as well as some cash. We also sent a doctor or nurse to accompany them, because in our experience, too many patients sent elsewhere were simply, in medical jargon, “lost to follow-up.” In the United States, the expression “lost to follow-up” means that a patient in question cannot be reached for the continuation of care. But in the case of Haitian public hospitals, without reliable partners to help with resources ranging from staff to medication to electricity, patients were sometimes lost to follow-up within the facilities themselves. In years past, I'd visited patients in the General Hospital who'd been occupying a bed for days and hadn't yet seen a qualified physician. I'd also seen patients who'd gone without a proper meal in days. (Their families were expected to bring food.)

I do not mean to disparage the General Hospital. As the years went by, we had more and more sympathy for the country's largest public hospital and for those running it. For the most part, these Haitian health professionals were doing their best but could not function without proper salaries and without the tools of our trade. Some senior doctors there were as talented as any I'd met in hospitals at Harvard and other parts of the world. And many had showed up within hours of the quake. Indeed, one of the constants in the days after the earthquake was the presence of Dr. Lassègue and the chief of nursing, Marlaine Thompson.

But the entire Haitian health system was underfunded, and its flagship hospital was in sorry shape. The shortcomings of the hospital could be readily traced to a lack of funding and the imposition of a fee-for-service model in a country where the majority of people, and certainly those most at risk for illness and injury, didn't have money.
¹
Although a key function of a university hospital is to train health care professionals, the lack of resources to run the hospital or pay workers made it a difficult training environment. Before the quake, the General Hospital was rocked by strikes and work stoppages; key supplies were often out of stock. Some friends of the hospital had taken small steps to help colleagues there provide better services, including supplying meals to inpatients—especially to those admitted with some complication of malnutrition.

The shortage of trained clinicians able to provide care to the poorest patients remained an enormous problem; doctors and nurses left for other countries or were siphoned off to better-equipped and better-paying nongovernmental organizations and private hospitals. Given the weakness of the public-sector hospitals, and the faltering “flagship” public hospital, many of our supporters wondered why we sought to direct attention there in the hours after the quake. Why not aid the private (and NGO) hospitals instead? Most of those NGOs and hospitals were not mandated to provide care for all comers. Even if they'd been established to help the poor, they had no binding obligation—legal or otherwise—to open their doors to every patient needing medical attention. As mediocre as it was, the General Hospital remained Haiti's provider of last resort. And it was smack in the middle of the quake zone. We knew from the beginning, from the hours after the quake, that the hospital would soon be overrun. That's why we promised to help.

Within a day of making that promise, I hitched a ride, with surgeons and other doctors, on one of the first private planes bound for Haiti. Although my recent trips to the country had been as a UN Deputy Special Envoy, a volunteer post under Bill Clinton, I made it clear that I was making this trip as a private citizen and as a doctor. Traveling there “under the radar” on behalf of the United Nations had been difficult in previous months. But January 12 changed that.
The UN headquarters had collapsed in the quake, and most of its leadership was unaccounted for. No one in that beleaguered institution was likely to object to violations of protocol.

I was soon reunited with many of my colleagues from Zanmi Lasante and Partners In Health, most of them doctors working in Haiti: Louise Ivers, an infectious disease specialist who weathered the quake as the only physician in sight in the midst of dreadful losses and injuries in a hard-hit part of town; Joia Mukherjee, the medical director of Partners In Health; and David Walton, an internist and former student who'd worked in Haiti for a decade or more. Claire Pierre, an internist who'd grown up in Haiti and then trained in the United States, flew in with me and rarely left my side in the first days. All were volunteers from Harvard.

I haven't yet mentioned by name many of my Haitian coworkers. Most of them were fully engaged, a few at the General Hospital but most in the hospitals and clinics that we'd built up over the preceding years. These facilities were situated north and west of the epicenter, and from day one, my colleagues were preparing for waves of injured survivors fleeing the quake zone. By day three, the first wave had already crashed upon them.