Monday, February 15, 2010
Dispatch from Port-au-Prince
(Photo by John Carroll)
The following dispatch was written by Dr. Jean Pape. Dr. Pape has been medical director of a large HIV/Tuberculosis medical center in Port-au-Prince for many years. His medical complex was turned into a refugee center after the earthquake.
Even though this article is somewhat dated, it is still worth reading today.
Published at www.nejm.org January 27, 2010
The Earthquake in Haiti — Dispatch from Port-au-Prince
Jean William Pape, M.D., Warren D. Johnson, Jr., M.D., and Daniel W. Fitzgerald, M.D.
At 4:53 p.m. on Tuesday, January 12, an earthquake killed or gravely injured hundreds of thousands of people in Port-au-Prince, Haiti. Even more were left homeless. The devastation is incomprehensible.
Chaos followed, since the centers of law, order, and functioning society were destroyed or suffered severe losses. The Haitian national palace, government ministries, and police stations collapsed with major losses of life. The headquarters of the United Nations was in rubble, and hundreds of staff members were missing. Banks, churches, food stores, hospitals, hotels, schools, and communications capabilities were destroyed.
As a result, piles of bodies lay in the streets. The only useful places for providing medical care were empty spaces — parks and fields. A city in need of hundreds of trauma centers had two or three.
Four staff members from the organization with which we are associated, the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (known as GHESKIO), died, several were severely injured, and many lost family members or were left homeless. A few GHESKIO staff members were able to reach our clinic in the center of Port-au-Prince on Wednesday, January 13. Several clinic buildings suffered severe damage and were not habitable. Others were damaged but usable.
The GHESKIO staff saw trauma patients and handed out antiretroviral drugs to patients with AIDS. As word spread that GHESKIO was "open," more patients came, many of them critically injured; refugees began camping on a field next to our clinic (see slide show).
By Thursday, January 14, we had 1000 refugees, many of them seriously injured. GHESKIO staff members provided chlorinated water to refugees, identified the most critically injured, bandaged them, and provided care. We did not have an operating room.
We communicated with the U.S. Embassy and offered GHESKIO as a site for a field hospital. We now had a functioning electric generator, vehicles, water, an open field, and functioning Internet access. Most important, we had our Haitian medical staff, who could triage patients, provide postoperative care, and translate.
For 3 days, we waited. The U.S. embassy pushed hard, but the airport was the bottleneck. Equipment, supplies, surgeons, and other medical personnel arrived from around the world but could not be coordinated, secured, and moved two miles to our clinic. The U.S. Army and a Department of Health and Human Services (DHHS) field hospital arrived on Sunday, and the hospital was operational on Monday, January 18.
By January 22, ten days after the earthquake, we are focused on three missions. First, we must provide food, water, sanitation, and security to thousands of earthquake refugees. We obtained food from relief agencies but hesitated to distribute it directly for fear of a riot. We therefore hired 40 women who work as street vendors. We provide them with cooking oil and food, which they prepare and distribute free of charge.
Our water comes from a well at GHESKIO. Running water is not available in Port-au-Prince. We initially chlorinated the water in barrels, but we have now obtained six filters.
We need latrines for the thousands of refugees. When we have shovels, picks, and wheelbarrows, we can hire people to dig the latrines. We are beginning to see patients arrive with severe diarrhea and typhoidlike fevers.
Security is now our biggest concern. Five thousand prisoners escaped from the National Penitentiary, which was a short distance from our clinic. They have infiltrated our refugee camp. They are armed and organizing. The U.S. Army protects the DHHS field hospital but is not responsible for the refugee camp or the GHESKIO clinic. The walls around our facility collapsed, and our clinics are open to the streets. There is no electricity in the city, and there are no lights at night. Our clinic staff and the refugees are frightened. It is increasingly difficult and dangerous to distribute food and water. More security forces are needed. A barbed-wire perimeter and solar-powered street lights would make the camp and clinic safer.
The U.S. field hospital initially hired its own Haitian translators, with good English as the primary requirement. Many of the new hires were deportees from U.S. prisons who had just escaped from the penitentiary. We removed them and got Haitian students to volunteer as translators.
Our second mission is to support the field hospital. More than 95% of the medical problems we saw in the first week were trauma-related. The number and severity of fractures are unbelievable. We are now starting to see gunshot wounds. Our DHHS field hospital has 70 U.S. volunteer doctors and nurses providing emergency and surgical care. They are saving hundreds of lives.
We are supporting the American DHHS surgeons. Haitian doctors are triaging in the refugee camp and providing postoperative care. We have obtained a large tent for 100 people from the Swiss Red Cross and are using it as a postoperative center. We are now using the GHESKIO x-ray machine, since the mobile hospital did not have one. We are using our private vehicles as ambulances.
Diesel fuel for vehicles and generators is scarce. The U.S. field hospital ran out of fuel, and we provided them with diesel. We just received a shipment of 2000 gallons from our friends at Partners in Health and the Clinton Foundation, and we were able to get another 1000 gallons from a local supplier.
Coordination between the supply chain and patients is urgent. At present, we do not know the capacity of the different hospitals. A patient may be painstakingly taken to a hospital only to find out that the hospital cannot offer the services needed, either because they are not available or because the hospital is overcrowded. In some cases, it is the availability of surgical supplies, such as external fixators, that can limit services; none are available right now at either the GHESKIO clinic or the University Hospital.
We are working with the minister of health to develop a comprehensive hospital-capacity inventory and information system by dividing the city into regions. We want hospitals to indicate their capacity and the availability of services. Since this information is likely to change every 2 to 3 hours, each hospital should provide hourly updates. This information should be centralized at the Ministry of Health and given to all radio stations to inform the population where to go for care.
Our third mission is to continue providing medications for our 7000 patients with AIDS and tuberculosis. Before the earthquake, we developed an emergency plan for our patients in the event of a political upheaval or hurricane. Patients have been routinely provided with an extra 2-week supply of important drugs. Patients were counseled to come to the clinic if possible or to go to one of four predesignated GHESKIO drug-distribution centers in the city. This plan was put into effect the day after the earthquake and is working.
A GHESKIO clinic team is providing HIV and tuberculosis care. Staff members carpool because fuel is limited. Each car owner receives 5 gallons of diesel. An emergency shipment of drugs was brought to our clinic 1 week after the earthquake by a team from PEPFAR (the President's Emergency Plan for AIDS Relief). They continued to unload medications during a severe aftershock. We are working with drug distributors in the Dominican Republic to organize a truck delivery of large quantities of medication.
We try to contact patients by cell phone, but most patients do not have electricity to charge their batteries. One of our doctors went on a popular radio station to announce that GHESKIO is open and also provided the names of hospitals in the countryside that can provide drugs. About 65% of our patients are coming to the clinic, although public transportation is very limited. Another 15% receive their medications at four designated delivery sites. Approximately 20% of patients are unaccounted for.
Financial and other disclosures provided by the authors are available at NEJM.org.
From the GHESKIO Center (J.W.P.) and the Center for Global Health, Weill Cornell Medical College, Haiti (J.W.P., W.D.J.) and New York (D.W.F.).