Friday, February 12, 2010

Pastors Keep Community Spirit Going in Haiti

By Gene Gincherman, M.D.
Emergency physician and Go Team member

While on a trip outside Port-au-Prince (PaP)during a recent medical mission to Haiti, I noticed one essential quality to people's suffering there: namely, it's essential loneliness.

It was less prevalent in PaP, where people are closer together and seem to have more of a sense of community. In smaller villages, it seemed like more people fended for themselves. Some of them seemed to spend their whole days sitting in makeshift tents, not doing much.

It seems to me that if that idleness is allowed to continue, it will lead to despair, and further suffering. One experience on this trip gave me a glimmer of hope for the future. We happened to be visiting on Sunday, a day a lot of people in Haiti go to church. As a consequence, we got to meet with five different pastors.

Considering the lack of civil authority, they seemed to be the inspiration for their communities. They were interested in every aspect of daily lives, from fulfilling the spiritual needs to providing food, medial care and building latrines.

If Haiti is going to recover and overcome not just the outcome of the earthquake, but also years of mismanagement, suffering, and corruption, they need more people like the pastors we met.

Wednesday, February 10, 2010

"How Will Haiti Recover?"

Alicia Hernandez
RN and Go Team member

My last few days in Haiti were a new experience as I responded to a call for volunteers suddenly needed in the Petit Goave region of Haiti to replace the volunteers leaving the mobile clinic sites there on Friday.

A doctor from Chicago, Stacy, and I set out apart from the rest of International Medical Corps (IMC), and arrived to the mobile clinic where just two IMC nurses had been working with Haitian staff for a week.

It was a tent clinic in one of the tent city Internally Displaced People (IDP) camps that served the people living there mainly with primary care issues. The tent was supplied mostly only with oral medications and some wound care materials. The IMC nurses gave us a quick debriefing at around 11 a.m. and left us on our own by noon. Talk about getting your feet wet.

We jumped into the over 100 people waiting to be seen as the clinic had not opened that morning at the usual time. They were waiting for us to arrive with the restock of medications. We quickly began rolling through the patients.

I triaged with a quick initial assessment and vitals while Stacy and two other Haitian doctors saw and prescribed medications for each patient. Everyone got something if only multi-vitamins, although generally at least three different things from the Haitian doctors - mainly to treat coughs, UTIs, [other] infections, scabies and gastritis. Most were mild enough to send "home" with oral medications. We did receive one obviously sick man - most likely with TB - on our first day.

The dilemma was then where to send the patient as we did not have the capacity to care for him in the tent. We decided to send him with our personal driver to the nearest hospital. We found out later the hospital is currently only staffed with one doctor and one nurse. It has no functioning X-ray or laboratory. Stacy and myself had a debrief that night with the one other IMC staff staying in Petit Goave, Pascal the French logistician, about the current situation.

Pascal´s job had been to arrange everything for us from accommodations to transport to interpreters as well as everything for the mobile clinics - tents, staff, supplies and sites - and gathering all the info we needed to best serve in our clinics. He was our "go to" for more supplies to request from IMC or from other area NGOs and for knowledge on what services are available where.

Pascal Made A Big Job Easy

It was a big job - but he´s been doing this for over 15 years in so many disaster zones around the world he made it look almost easy. He said Haiti has been his hardest assignment yet. So Friday night the three of us figured out that there is an MSF - Medicins Sans Frontier, a.k.a. Doctors without Borders) hospital 45 minutes away. That was a better option for a referral than the nearby non-functioning hospital. We also set a plan to open a second new clinic on Saturday that Stacy and a few of the Haitian staff would go to while I would stay in the current clinic with the rest of our current Haitian staff.

Pascal said we would each have our driver although that didn´t quite get arranged in time and I manned the clinic with no phone, no driver, and no other IMC staff. It was me and five Haitian health care workers and over 100 patients again.

A Sick Girl - Typhoid

I was impressed at how well the Haitians were running things. It was all fine until we received a very sick girl, potentially with typhoid. I had no driver to take her to the hospital or way to contact anyone to ask for help. She had shortness of breath, cough with dark sputum, vomiting, diarrhea, and temperature of 104. The Haitian plan was to give her an antibiotic injection and some Tylenol and keep her on the examination table there to recheck her temperature after an hour or so.

If it started to decrease, they would send her home and tell her mother to just bring her back on the next clinic day, which was Monday, for another injection unless she improved. This girl really would have benefited from IV fluids, repeated IV antibiotics, and closer monitoring. I kept checking on her to make sure she was still breathing, as she looked grim, lying face-down on the cot, eyes slit, no movement. The scream she let out with the antibiotic injection was some extra reassurance she was still very much alive.

I continued to work, with glances at her every few minutes. A temperature check showed a slight decrease. After a couple of hours, with my last glance, she was gone. They had sent her home. There was no means to do anything more.

I still think about her days later and only hope she will be alright. Saturday Pascal had worked to secure us another driver and to find names of villages with potential need for more mobile clinics either due to vast quake damage and displaced persons or loss of the existing health care source from the quake.

Collapsed Buildings Common

Sunday was spent visiting these villages and assessing need. Collapsed buildings around Petit Goave are as common as in Port-au-Prince but with less open spaces, as in city parks. Actual tent cities were not as common. Tents simply lined the streets. Driving took some careful maneuvering and I can only imagine living in one of those tents where cars constantly pass only inches away.

One of the villages we visited was as poor and as devastated as anywhere we had seen. There were collapsed buildings on top of the poverty that already exists. It was also a place on the coast where the ocean floor had shifted and the water level rose and flooded everything near the coast. As we were driving through, Pascal said, "I´m sure there´s need here but where are the tents?"

It was interesting to learn there had to be obvious need resulting from the earthquake in order for us to spend the donor money there and help. They couldn't just simply need help. In another village, they had a fine standing facility that once served as a clinic. The complicated task then was to find out why it wasn't functioning now. Was it functioning prior to the quake? Was the facility damaged in some way? Were there staff losses? Were they just not showing up to work now because the government stopped paying salaries - or did they stop paying them because they stopped showing up? So many complexities involved in disaster relief, especially in a place like Haiti where the health care system was barely functioning in the first place.

Mission by Boat
There was another site Pascal had heard of that wasn´t reachable by car, only by boat from Petit Goave that was rumored to be affected by the quake and had received no services or even visits from outsiders since. So we put together a mobile boat clinic and sent them out Monday to do the assessment and [set up a] new clinic there at the same time. Apparently it was a success. Medical services were brought there and they were affected by the quake, losing their water source as well as their usual means of receiving medicine and food.

I had three and a half short days in Petit Goave and saw and learned so much. And I hopefully helped some as well. "Short" and "hopefully helped some" are two of my main thoughts as we head home now.

The biggest thought, however, is how will Haiti recover? How long will it take? What more can we do? What more can I do? How do I go home and back to life there? Haiti will stay with me now. I feel a responsibility to spread that to others. To get them more help, and to get back and do more. This leaving now is not the end of anything.

"...Why Did We All Do It?"

Gene Gincherman, M.D.
Emergency doctor and Go team member

As all of us start to decompress a bit in the Dominican Republic after our work in Haiti, more and more thoughts come to mind. It seems that the most fundamental question is: Why did we all do it?
It seems to me that the answer lies somewhre between doing it completely out of altruistic notion of trying to help people around you who are suffering horribly and going on an ego trip to prove something to oneself.
People who are in Haiti to save the world burn out too fast,and become a liabiity to themselves. People who go on an ego trip are unable to become good team players and destroy the sense of community that immediately develops in such austere and stressful environment.
I am proud to sat that the Johns Hopkins team has developed a sense of togetherness from the start, which played a tremendous role in our ability to take care of each other and our patients.

Tuesday, February 9, 2010

"Everyone is Sleeping Outside. Everyone"

Beth Sloand
RN and Go Team member

We drive 45 minutes each way, from the hospital in Port-au-Prince to Gressier. It has been an eye-opening experience, since prior to this I have only been between the hospital and hotel, a 5-minute drive.

* Everyone is sleeping outside. Everyone. Those who have their homes flattened, those whose homes have cracks, and all others. Everyone is afraid to sleep or work in any of the buildings until an official government engineer inspects a building and finds it safe to re-inhabit. This affects Port-Au-Prince and all the towns we passed on the way to Gressier. I suspect it affects the third of the country most heavily hit by the earthquake.

* Sleeping outside means that people are gathered together in tents to sleep. Tents are mostly sticks lashed together with sheets or towels or shirts stretched across. Sometimes, cardboard or tin or other materials are added to the mix. The tents are in large areas, such as parks or open spaces, all packed together. They are also pitched in small areas, such as the median strip of highways. Daily life goes on in front and within these tent areas -- people wash their clothes and their children, prepare their meals and eat. There is little privacy, a luxury here.

* There seem to be increasing numbers of sturdy tents from NGOs. “Shelterbox” provides beautiful tents for families, and I am seeing more and more of them in some parts of Port-au-Prince. That is a great thing, because many fear the rainy season and the difficulties it will cause people who are in flimsy dirt-floor tents.

* The condition of the roads, never very stellar in Haiti, is getting worse each day. As we drive to Gressier, our driver and translator exclaim periodically when we encounter a new split or depression in the road, probably caused by the frequent aftershocks. Says translator Denise, “the earthquake crashed the road more, and cut it worse.”

* An increasing problem: trash. Trash pick-up seems to be on hold as any large trucks and resources are dealing with the bigger issue of earthquake rubble. Meanwhile, people have nowhere to put the mounds of trash -- plastic bottles, cartons, wrappers, etc. Haitians tend to use and reuse whatever they can, so there is much less trash per person here than in the U.S., but what is here is simply adding up and combining with the dirty water in the streets. We saw one whole street with a continuous mound of trash 6 feet wide and 4 feet high that went on and on. People climbed over it to get to the other side of the street. Children played along the edge, a public health problem brewing. This also makes driving difficult, as you have to weave around the trash piles, as well as slow down for the new cracks in the road and avoid other rubble and wires. (There was one tangle of wires hanging across a street we routinely travel. One day last week, it had dipped so low that there was a spark when our bus went under it and didn’t quite clear. The next day, the wires were removed, thank goodness.)

* Clean-up crews of citizens have taken to the street. Men and women, young and old. We saw hundreds with blue T-shirts, armed with shovels and brooms and wearing masks to protect their lungs from the thick dust that is in the air. By the end of the day, there was a visible improvement in the look of some neighborhoods. These crews are dealing with the small jobs along the side of the road and the walkways. These folks are doing all the work by hand. I have heard that this effort is funded by the UN or an NGO, but am not sure exactly who or what. Certainly someone has provided the shirts. Bigger machinery must come to remove the huge concrete slabs and chunks of concrete bricks from destroyed buildings.

* Crushed buildings seem fair game for scavengers. In these circumstances, people are struggling to survive, and they are willing to dig through rubble to pick up pieces of wire, wood, and other items that they will reuse.

* Food distribution is a tricky business. We pass one area where the UN and U.S. soldiers stand a few feet apart in a long line to provide security as the distribution occurs. Some programs are giving the food to the women to bring home to families. Once, there was a brewing protest -- it seemed people didn’t like the method of distribution.

* Generally, a sort of daily life has somewhat returned. People are seen walking along the street, moving their wares to sell, bringing home food, children playing, etc. The streets we have seen are mostly quiet. There is no sense of violence or lack of safety that I have observed. One exception is when a foreigner sticks a camera out the window to snap a photo of people bathing or the tent camps, etc. Then there is usually an angry one or two people who yell in protest. Understandable.

The "End of the Road"

Tom Kirsch, M.D.
Emergency doctor and Go Team leade

I spent the last 3 days doing assessments. We were trying to identify areas with unmet needs to see if International Medical Corps can fill the gaps. We drove out of Port-au-Prince (PaP) to the west, down the long peninsula that reaches far into the Caribbean Sea to the towns of Leogane and Petit Goave. The road passes directly over the quake's epicenter and so the damage there was far greater than in PaP.

In some towns more than 90 percent of the buildings had collapsed. At points the road was ripped and roiled with larger fissures slashing along and across the road.
The area we went to was literally at the "end of the road."

The road started as a poorly maintained ribbon of asphalt that was more potholes than smooth and gradually faded away into a scrubby dirt track only suited for feet. Initially we drove through alternating areas of forest, banana or sugar cane farms, or crumbled towns. The dirt road started as a turn that ran south towards the mountains out of the town of Leogane through an essentially flattened town with few functioning buildings. Then it headed Southeast, paralleling a briskly flowing creek that was lined with shacks and concrete houses.

Only the shacks were really left because they were made of wood and palm fronds and metal sheets rather than the brittle and poorly reinforced concrete that crumbled into dust.

There were three scattered IDP (internally displaced people) camps along the roads. They were haphazard affairs with tents and shacks thrown together in closely-packed groups made from an assortment of tarps, scrap wood, and old, rusted corrugated metal sheets. The road ended at the last camp.

It was the worst of the lot. Only yesterday Save the Children had delivered tarps - which had been used to create shelters of a variety of interesting configurations. But there was nothing else there. They did have the creek which was used for drinking and washing and bathing and probably as a toilet.

Monday, February 8, 2010

"Children...Suffer In Silence

Beth Sloand
Pediatric Nurse Practitioner and Go Team member

The hospital is mostly outside in tents. Tents come from the Red Cross and Red Crescent of various countries. There are six pediatric tents. The infant tent has about 30 little cribs crowded inside - only a few inches separating them. IVs hang from tent strings. There are no chairs in the tents, so parents sit on their child’s bed. In the infant tent, parents slept under babies’ cribs at night on a piece of cardboard or sheet or whatever they had.

The American military, all in full uniform fatigues, and the Scientologists, with bright gold T-shirts, distribute food at times. A funny combo. There are two pediatric orthopedic tents, since orthopedic injuries predominate from the earthquake. Lots of broken femurs as well as other bones.

Children mostly suffer in silence. There is little crying in any of the pediatric tents. There is some pain medication given, but not regularly. Children tend to be stoic; they are not used to life being comfortable. Everyone is on antibiotics to treat or prevent infections.

Parents seem to have a pleading look in their eyes, or maybe it is my imagination. For all those hospitalized, a predictable hurdle is discharge. How do you discharge people who have no home?

Conditions in the tent camps scattered throughout the city are much worse, and it is difficult to know that recovering surgical patients will be living there.
I worked in the ER Monday, joining a team of about 16 nurses and physicians. It's a hopping place. We saw 470 patients. The range was wide -- a woman who had just been hit by a car, a man who was found unconscious on the street, a child with an infected orbital fracture, as well as those with back pain and headaches and fevers. We have a lab with basic capabilities; radiology that works for simple films, and a limited pharmacy. Supplies are available, but not always what you need or want. There are some Haitian nurses and physicians who are very helpful when they are around.
It is a loud place, with lots of yelling and people talking. The outside venue doesn’t lend itself to tranquility, and there are several patients being seen in the small area. We have three ER tents. In Tent 1, where I worked, I lined up kids and adults -- three or four -- on the edge of the bed, and then worked through them.
The questions are redundant: What brings you here? When did the pain start? Have you sought other care? And so on... My translator, Stevenson, was helpful and reliable. We often have to move patients off the bed for a more seriously wounded or ill person who arrives. Then we see them on a chair if available, or just standing. Not optimum, but it works.

Friday, February 5, 2010

A Place We Call 'The Forest'

Tom Kirsch, M.D.
Emergency physician and Go Team leader

There is a place in the hospital we call "The Forest."
It is the place where the lost souls end - a purgatory or limbo.
In reality it is just a courtyard with some semblance of shade from the scraggy trees and tarps strung among them. It is a square of dirt and scattered grass further by an ‘X’ of concrete walkways with a dead fountain at the crossing.

Originally it was a patient care area when the hospital was so inundated, filled completely with old beds and cots and blankets with tarps strung between trees; and then a further "forest" of intravenous poles and dripping fluids. We cleared out all the ill people a week ago and cleaned out the trash and feces.

Now it is just limbo - a miniature refugee camp. There are about 35 people still there, setting up camp on the old and mostly broken hospital beds. They have converted the IV poles into tent poles to hold up their tarps. They have brought in sheets and blankets and pillows and dishes and other small reminders of the homes they used to have. They do dishes, but don’t need to cook since food is available and there is clean water and port-a-potties.

This is the place where we let those with nowhere else to go to wander off to after we have completed their medical therapy. We aren’t supposed to transfer patients there because there is no one who is responsible to care for these people - we don’t have the staff.) But sometimes we mention to the most desperate people that they can just walk over there and grab an empty bed until the hospital administration decides they are no longer welcome.

Bernard is one of the lost souls. He is a thin, craggy, elderly gentleman with fizzy grey hair and a lost look in his eyes. He came in, or was brought in for unclear reasons, and was too confused or demented to give us a coherent story.

He had a paralyzed left wrist, most likely from a nerve-compression injury after the earthquake and was clearly dehydrated and maybe malnourished. He had no family or friends or the ability to tell us where to find anyone. We gave him fluids and food and a splint and he was done. But there was nothing else for him.

I walked him to the forest and sat him in a bed in the shade. I go by daily to see him. He sits there patiently, legs dangling from the rusted hospital bed. Always in the same spot with old foam boxes of food at his side, biting the corners off the little bags of water that the volunteers bring by, and then sucking out the contents. I never see him talk, or even walk, always just sitting there and watching. I wonder what he sees and wonder if he remembers.

There are so many lost souls like him that it is incomprehensible. They come and go like tides every day. Some stay in our Forest.