Doctors Want Comfort to Stay in Haiti

(Baltimore Sun Photo)

Doctors want Comfort to stay in Haiti; U.S. considers ending mission
By Robert Little

Baltimore Sun reporter

March 3, 2010

The Navy hospital ship Comfort discharged its last remaining patient last weekend and is anchored in Port-au-Prince harbor, empty but for its 993- member crew, waiting for military leaders to decide whether it still has a role in the U.S. response to January's deadly earthquake in Haiti.

Pentagon officials won't say what the ship's next step is. But as signs mount that the floating medical center is preparing to leave Haiti six weeks after it arrived, so is the clamor rising from doctors on the ground in the battered country who say earthquake victims still need the Comfort's equipment and skills.

"We haven't figured out what the end of this looks like yet," said Dr. Andrew N. Pollak, an orthopedic surgeon at Maryland Shock Trauma Center in Baltimore who is returning to Haiti on Friday to work at the crumbled St. Francois de Sales Hospital in the capital. "Until we do, until the capabilities improve on the ground, the Comfort is the only solution for some people."

Dr. Randy Sherman, a University of Southern California plastic surgeon who has worked with the Navy, is pleading with officials to keep the Comfort in Haiti. "The ship provides such a special capability, fills such a big hole, that to lose it is catastrophic," he said.

He called the 1,000-bed ship "the medical equivalent to 85 fighter pilots on an aircraft carrier," adding: "If you take away the aircraft carrier, what are they going to do?"

Designed as a floating emergency room for treating combat injuries, the Baltimore-based Comfort arrived Jan. 19 and quickly was overwhelmed with patients who had suffered fractures, crush injuries, infections and other consequences of the earthquake a week earlier. In a city whose medical infrastructure was slight before the disaster, it arrived as the best-equipped, most capable medical treatment facility in the country and was quickly flooded with complicated cases. Its medical staff has treated more than 1,000 Haitian patients and performed nearly 850 surgeries.

New admissions declined weeks ago as patients with untreated injuries became increasingly scarce and have nearly come to a halt in recent days as the ship continued to discharge patients to clinics and medical facilities on land. According to a Navy officer on the Comfort, the only Haitian treated on board Tuesday was a young boy who received a CT scan, then was taken ashore. During peak operations, the ship had a crew of 1,288; nearly 300 have left.

Navy officials acknowledge the diminished workload but won't say much about the Comfort's future.

"The ship is still there," said Jose Ruiz, a spokesman for the Pentagon's Southern Command, which is overseeing the military's relief efforts in Haiti. "And it will remain there until Southcom determines that her capabilities are no longer required to support the mission."

Privately, Navy officials say the Comfort's workload tailed off as fewer patients with earthquake-related injuries appeared at Haiti's ground-based clinics and triage centers seeking care. And while the ship initially accepted some patients with diseases, complicated pregnancies or other conditions unrelated to the earthquake, the Navy chose to focus on disaster relief and avoid the intractable public health issues and primary care shortcomings that troubled Haiti long before the quake.

Doctors who left the ship recently said the need for a full-service surgical center in Port-au-Prince was not always apparent from on board.

"We weren't getting a lot of calls," said Dr. Andrew R. Burgess, an orthopedic surgeon who returned to Florida last weekend from a volunteer tour on the Comfort. "I know people say there are a lot of patients out there that could use its services, but someone needs to do a survey and determine just who they are and where."

Sherman, medical director for the aid organization Operation Smile, has worked at two ground clinics in Haiti since the earthquake and said any perceived shortage of patients comes from poor communications rather than the resolution of the country's medical needs.

"There is no doubt" there are enough earthquake victims to keep the Comfort busy, he said. He has asked top Navy officials to keep the Comfort in Haiti and proposed staffing it primarily with civilian medical workers. He thinks it could operate at high volume for at least three more months.

Sherman, Pollak and others tell the same story: They say the country is replete with patients whose orthopedic injuries have healed improperly and require complex surgeries that only the Comfort can provide.

Many patients treated in the days after the earthquake had bones set with external pins in tent hospitals without X-rays, they say, and those injuries need to be reset to give the patients functional limbs.

"The problem is the second wave of these," Sherman said. "There is this large, large subset of patients who require additional treatment, and the nature of that treatment is more complicated and highly instrumental."

The civilian doctors say they appreciate that their viewpoint is solely a medical one, while the Navy's decision to deploy a ship like the Comfort must consider financial, political and diplomatic issues.

"The question the government needs to answer, as unemotionally as it can, is whether it's justified spending the millions of dollars that the ship costs to care for the number of patients who need it," Burgess said.

The Navy did not immediately respond to a request to detail the cost of the Comfort's mission to Haiti.

Copyright © 2010, The Baltimore Sun

Order Must Follow Chaos

(Photo by John Carroll)

Published at www.nejm.org
March 3, 2010


Haiti — A View from the Ship


One of the first children I cared for after my arrival on the USNS Comfort, the U.S. Navy's floating medical treatment facility docked at Port-au-Prince, Haiti, was a 10-month-old boy who had been brought to the ship nearly dead from malnutrition. Prior to the earthquake, there had been little food, and he had been fed only a few times per week. When the earthquake hit, his mother covered him with her body. His aunt heard his cries and pulled him from underneath her dead sister. In the days following the earthquake, his kwashiorkor progressed to the point that when I met him in the ICU, his whole body was swollen and he could not move. Food works miracles, however, and over the next weeks, fed first by NG tube, then bottle, and finally spoon, he thrived, sat up, and grabbed for the food. When he was reunited with his aunt and ready for discharge, we gave instructions that he should go somewhere where he would be assured of adequate food and shelter — but that is a tall order in Haiti, as we realized.

The first phase of Haiti's earthquake disaster is nearly over. The hundreds of patients who were cared for on the Comfort and required amputations and orthopedic repair of terrible fractures have mostly left the ship. Those hundreds are but a drop in the bucket compared with the number of injured remaining on shore. The vast majority of the hospitals that used to function in Port-au-Prince were destroyed. Large segments of the population are living in the streets and in makeshift tents that will not be waterproof in the coming rainy season. Although there are many charitable and U.S. government organizations working in Port-au-Prince, the problems of sanitation, clean water, and food distribution are far from solved.

Before the earthquake, Haiti had one of the highest child mortality rates in the Western Hemisphere. Many of the patients brought to the ship were undernourished and anemic as well as injured. When the rains come, this vulnerable population will be exposed to dysentery and malaria as well as starvation.

Over the coming months, a concerted effort must be made to develop safe housing and food and water supplies as well as to ensure adequate orthopedic follow-up and access to prosthetics for the thousands of amputees. Somehow, order must emerge from the chaos of the current relief efforts. If not, the second phase of the earthquake disaster may be worse than the first, and being pulled from the rubble will prove to have been but a temporary reprieve.


Marjorie Curran, M.D.
MassGeneral Hospital for Children, Boston, MA.

No potential conflict of interest relevant to this article was reported.

This article (10.1056/NEJMpv1002319) was published on March 3, 2010, at NEJM.org.

Medical Ethics and the Earthquake

(Photo by John Carroll)

The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response

Ofer Merin, M.D., Nachman Ash, M.D., Gad Levy, M.D., Mitchell J. Schwaber, M.D., and Yitshak Kreiss, M.D., M.H.A., M.P.A

Within 48 hours after the massive earthquake that struck Port-au-Prince, Haiti, on January 12, the government of Israel dispatched a military task force consisting of 230 people: 109 support and rescue personnel from the Israel Defense Forces (IDF) Home Front Command and 121 medical personnel from the IDF Medical Corps Field Hospital. The force's primary mission was to establish a field hospital in Haiti.

We landed in Port-au-Prince 15 hours after leaving Tel Aviv and began to deploy immediately. The first patients arrived at our gates and were admitted even before the hospital was fully built, within 8 hours after our equipment arrived. In its 10 days of operation, the field hospital treated more than 1100 patients.

Our mission was to extend lifesaving medical help to as many people as possible. The need to manage limited resources that fell far short of the demands continuously presented us with complex ethical issues. Every mass-casualty event raises ethical issues concerning the priorities of treatment, but the Haiti disaster was exceptional in several ways. Haiti is a poor country with minimal civil facilities, and the earthquake's destruction of infrastructure left millions of people homeless and hundreds of thousands in need of medical assistance. When we arrived, there was no functioning authority coordinating the distribution of the available medical resources. We were faced with the challenge of establishing an ethical and practical system of medical priorities in a setting of chaos.

Our hospital was designed to contain 60 inpatient beds, including 4 in the intensive care unit (ICU). It had one operating room with a single table. In view of the initial absence of functioning nearby medical facilities and the dire need for medical services, we extended our hospitalization capacity to its maximum of 72 patients and added a second operating table.

Under normal circumstances, triage involves setting priorities among patients with conditions of various degrees of clinical urgency, to determine the order in which care will be delivered, presuming that it will ultimately be delivered to all. After the Haitian earthquake, however, it was impossible to treat everyone who needed care, and thus the first triage decision we often had to make was which patients we would accept and which would be denied treatment. We were forced to recognize that persons with the most urgent need for care are often the same ones who require the greatest expenditure of resources. Therefore, we first had to determine whether these patients' lives could be saved.

Our triage algorithm consisted of three questions: How urgent is this patient's condition? Do we have adequate resources to meet this patient's needs? And assuming we admit this patient and provide the level of care required, can the patient's life be saved?

In the first days of our deployment, most of the patients we saw had recently been removed from the rubble. The majority had limbs that were compromised by open, infected wounds. Untreated, open fractures meant infection, gas gangrene, and ultimately death. Clearly, the sooner after injury the patient received medical attention, the better his or her chances of survival. Late-arriving patients who already had sepsis had a poor chance of survival. But there was no clear cutoff time beyond which patients could not be saved; each case had to be evaluated individually.

One of the dilemmas we had to confront repeatedly was whether to accept a patient with a crush injury. In such patients, rhabdomyolysis often develops, with resulting impairment of renal function. Given the absence of functioning dialysis facilities, the chances of survival in this scenario were low.

The potential for rehabilitation was an additional consideration in the triage process. Patients who arrived with brain injuries, paraplegia secondary to spinal injuries, or a low score on the Glasgow Coma Scale were referred to other facilities. Since we had neither a neurosurgical service nor computed tomography, we believed it would be incorrect to use our limited resources to treat patients with such a minimal chance of ultimate rehabilitation at the expense of others whom we could help. But denying care to some patients for the benefit of others was not a course of action that came readily to physicians accustomed to treating all who seek care.

Patients who had just been rescued presented another dilemma. We believed it would be inappropriate to deny treatment to a patient who had survived days under the rubble before a heroic rescue, even though this policy meant potentially diverting resources from other patients with a better chance of a positive outcome. Indeed, one patient who was rescued a week after the quake was brought to us in dire condition. She was admitted, was intubated, and underwent surgery but ultimately did not survive.

After we admitted a patient, additional decisions had to be reached. We needed to optimize the utilization of our ICU beds. At least one of these four beds was designated as a postoperative recovery bed for the first hours after surgery, leaving us with two to three available ICU beds. Using one of these beds for a patient with an extremely severe condition could mean rendering this resource unavailable to others for long periods. Our policy was to try to use these beds for patients whom we anticipated being able to stabilize in 24 hours or less. The practical implication of this prioritization scheme was that hospitalized patients who were deemed to have a small chance of survival were not likely to be treated in the ICU.

To deal with the ethical aspects of decisions regarding patient placement and treatment options, we created a system of ad hoc ethics committees. The physician who was directly in charge of caring for a certain patient would present the case to a panel of three senior physicians, who would decide how to proceed — a system that relieved individual physicians of the burden of determining a given person's fate. Decisions that were reached by the committee were recorded and became part of the patient's file.

From the outset, our hospital functioned at full capacity. With the exception of patients requiring urgent care, we operated on the basis of a one-to-one exchange between discharges and admissions. Given this policy and the level of activity, in order to function effectively, we also adopted a policy of very early discharge. Patients with infected open fractures were admitted, were operated on, and underwent débridement as needed. They received perioperative intravenous antibiotics and were discharged the next morning. The patients received a full-course supply of oral antibiotics and a discharge letter and were asked to come for follow-up within the next several days. At the entrance to the hospital, we had a waiting area that accommodated approximately 20 patients, most with open fractures. These were patients whom we had already triaged and decided to admit, and they were now awaiting hospitalization. With the discharge of each patient, a new patient could be hospitalized. Our policy of very early discharge permitted us to treat more than 100 patients per day in a facility with 72 beds.

This policy, while necessary, clearly did not allow us to provide in-house medical care for the duration for which we are accustomed to providing it in a nondisaster setting. Moreover, the problematic nature of early discharge was exacerbated by the unique environment in which we were working: there was no functioning health care system in the community, many patients were homeless, and many children in our care had no adult guardian. To discharge patients effectively, staff members engaged in discharge planning. We relied on the United Nations and other relief organizations to aid in the postdischarge management of care. With time, more and more groups started to operate, some of them backed by large facilities (such as the USNS Comfort). The presence of these groups allowed us to revise our discharge policies, since some of the groups opened referral centers.

Our guidelines for triage, management, and discharge were subject to continuous reevaluation and revision, but throughout our deployment, we were guided by our objective of providing lifesaving medical care to as many people as possible.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.


Source Information

From the Trauma Unit and Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, and Hebrew University Faculty of Medicine — both in Jerusalem (O.M.); the Israel Defense Forces Medical Corps Field Hospital, Tel Hashomer (O.M., G.L., M.J.S., Y.K.); the Israel Defense Forces Office of the Surgeon General, Tel Hashomer (N.A.); the Departments of Radiology (G.L.) and Consultative Medicine and the Division of Epidemiology and Preventive Medicine (M.J.S.), Tel Aviv Sourasky Medical Center, Tel Aviv; and the National Center for Infection Control, Israel Ministry of Health, Tel Aviv (M.J.S.) — all in Israel.

This article (10.1056/NEJMp1001693) was published on March 3, 2010, at NEJM.org.

Touch Rounds

(Photo by John Carroll)
Ministry of Touch — Reflections on Disaster Work after the Haitian Earthquake

Annekathryn Goodman, M.D.

After the January 12 earthquake, I traveled with a national disaster team from the Department of Health and Human Services to Haiti, where we set up a mobile tent hospital on the sites of a devastated school and a nearby adolescent clinic. My 2-week deployment was marked by sensory overload. There was the hot sun, the humidity, and the swirling mosquitoes. The air was full of dust and smoke from burning bodies and burning tires. The smell of diesel fuel from our generator was mixed with those of decomposition, garbage, and unwashed bodies. The sound of women and children weeping in sorrow and pain joined the noise of roosters crowing from 4 in the morning until noon, the drone of the generator, and the throb of rescue helicopters. But at dusk, voices of the earthquake survivors rose in gospel song from the tent city next to our camp and seemed to weave a tapestry of solace.

Despite the horror of unburied dead, crushed homes, and twisted streets, Port-au-Prince burst forth with color. Women and children wore beautiful bright pink and purple dresses and ribbons in their hair. In the schoolyard where we worked, a mango tree displayed one stubborn, bright red flower.

Patients soon filled our two tents, dressing station, and surgical unit. They lay on canvas cots, 10 to 14 to a tent, their bodies mapping out the stories of their agonies. I walk among them. Guillame, at age 18, is in early labor. She is living in the tent city out on the soccer field, in a tent with six other people. Stella and her newly delivered baby, Samson, sleep quietly face to face. They will return to the sidewalk where she was living. Christi, age 13, lies with a leg wound. Sévère, age 58, has a right humerus fracture and left leg wound. Stephanie, 28 years old and 25 weeks pregnant, comes in with abdominal pain and an open, draining leg laceration. She is living with her father, mother, sister, and brother out in the open in a park. She ate one bowl of rice 24 hours ago. Next to her lies a nameless woman who has just had her leg amputated. She is in pain, and she starts to sing a song of suffering.

On my first day in Haiti, knowing no Creole, I resort to smiling and waving. Everyone responds. I study people's smiles and read the messages in their eyes — pain, resignation, amusement, irony, grief. On the second day, I begin what I come to call "touch rounds." Even without an interpreter, I can visit each cot and touch a face, an arm, or a hand and receive a touch in return. The patients and I develop our own handshake: a finger catch, thumb grip, fist pound, and finally the hand to the heart. This hand gesture causes general hilarity, and everyone wants to participate.

By the second week, more patients are coming through. I miss some of their names. Rounds with the rest of the team are focused and directed: Patient 350 has a closed right femur fracture and abrasion to the left leg. Patient 304 has a left lower leg fracture, right ankle fracture, L4 fracture, and paraplegia. There is Patient 275, who has an open-wound, left bilateral malleolar ankle fracture. Patient 307 sustained a closed right femur fracture and has a left external fixator. Patient 335, an 84-year-old woman with a macerated body who was found under the rubble after 10 days, is receiving comfort care and morphine. She is dying quietly in a corner. Patient 328 is a 19-year-old man who was under the rubble for 3 days and came in with a partial amputation of his right hand and a clostridial infection. He now has the horrifying and painful contortions of tetanus. Patient 250, who has a gunshot wound that fractured his right tibia, now has a fever of 102°F. We move on, quickly seeing more and more patients with injuries of numbing and nightmarish similarity.

I return when I can to touch patients and learn their names. This is a place of lost treasures: lost lives, families, limbs, homes, work, wishes, hopes, and futures. It is easy to lose one's name here. Out under the rubble, it is easy to lose one's body. I notice that people hold their hands up to the sky, palms up in supplication, as if they are asking God to hold them.

One day, members of the U.S. Army's 82nd Airborne Division, who are quartered with us, go into a field and rescue injured, unattended children. The camp is now filled with the sounds of children weeping. We become a team of huggers and cradlers. We take turns holding the babies. As I wander around in the evening, I pass the pharmacist holding a baby who has had an above-the-knee amputation, rocking him while he dispenses medications. Another baby is being carried around by one of the EMT–firemen while he checks an electrical line. A nurse, Madonna-like despite her work boots and lived-in uniform, is cradling a small boy who appears inconsolable. I sit with three small children in what is now called the children's tent. They all respond to hugs. They all cry when put down, a deep primal wail that speaks of their fear and their psychic wounds. I suspect this pain will linger long after their physical pain is relieved.

Each day, a new woman in active labor arrives. In my last 24 hours in Haiti, four women deliver their babies in our hospital. Each difficult labor reflects the trauma and insecurity of this shifting world. I notice that every woman in labor wants to be held. We develop a system whereby one of us sits behind the woman and holds her, another rubs her back, and I sit or kneel near her, touching her belly and legs, whispering words of encouragement. I pray, and I watch the woman's face for clues as the labor progresses. After the lost children arrive, I notice the similarities in the way we cradle them and the way we hold the laboring women. This ministry of hugs reflects our desperate attempt to stabilize the random, cruel chaos in this world of loss and grief.

The team becomes close, and many of us meet in the evening to hold hands and say a prayer for each other and for our patients. I tell the story of "stone soup," and we each put an ingredient into our metaphoric stone soup; love, hope, security, strength, thankfulness, passion, skill, and luck. Then we reflect on how together we can make something rich and nourishing that binds us together and keeps us whole. Beyond our gathering in the smoky dusk, we hear the voice of survival singing.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

From the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston.

This article (10.1056/NEJMp1002311) was published on March 3, 2010, at NEJM.org.

Monumental Disposal Problem

Tuesday, March 2, 2010

Haiti confronts a monumental disposal problem
By Ken Ellingwood

Los Angeles Times

PORT-AU-PRINCE, Haiti

When a city crashes to the ground, how do you dispose of it?

Six weeks after an earthquake reduced Port-au-Prince to ruins, Haitian and foreign officials who hope to build a new capital first have to confront the wreckage of the old one.

The capital is a panorama of rubble: collapsed and half-fallen stores, banks, apartment buildings and homes, hillsides covered by broken shacks that fell like dominoes. Gnarled steel rebar lies all over in massive tangles, like a thousand Medusas.

The amount of debris is stunning. Officials estimate they will have to clean up as much as 25 million cubic yards of material — enough to fill the Louisiana Superdome five times over. By comparison, detritus from the destroyed World Trade Center amounted to about 1 million cubic yards.

Haiti's leaders, working with officials from the United Nations and United States, last week approved a rubble-disposal plan that is expected to take at least two years to complete.

The initial phase focuses on clearing debris from drainage ditches and around the most congested encampments in order to help shift people away from areas prone to flooding before spring rains arrive at the end of March.

"We don't have the luxury of stepping back and doing this in a relaxed way," said Mike Byrne, a Federal Emergency Management Agency (FEMA) official who co-chairs a multilateral committee on debris here.

The longer-term cleanup will involve an armada of front loaders, excavators and trucks. Haitian President Rene Preval has said the effort will require 1,000 dump trucks for 1,000 days — which U.S. planners say is fairly accurate.

"We're going to have to go 24-7 on this," said Byrne, who was the government's point man in the World Trade Center cleanup.

Haitian officials have identified a handful of possible disposal sites, which are to include facilities for hazardous materials, separating refuse and crushing the concrete chunks. Early assessments indicate 90 percent of the debris can be recycled into road-building material, melted or put to other uses, Byrne said.

Many Haitians are attacking the broken mounds on their own. Impatient homeowners and businesspeople with means have hired digging machines and workers to clear their properties. Concrete debris has been dumped hurriedly along the side of one of the main roads leaving the city.

Destitute Haitians have sought to turn rubble into opportunity. The destruction has spawned a new scavenging specialty in a city where jobs were already scarce. Around the city, residents clamber over the chalky piles with undersized hammers, shovels, hacksaws and, most often, bare hands.

"Everybody has to figure out a way to survive until things get back in place," said Demarseilles Nelson, who after half a day of scavenging with bare hands had piled his wheelbarrow with a 3-foot-high stack of metal scraps. His yield included a manual typewriter that appeared to date to the days of Francois "Papa Doc" Duvalier, the 1960s-era dictator.

Impromptu scrap markets have sprung up where enterprising young men with homemade scales buy steel rebar they drag away by hand or in shabby wheelbarrows.

In one forlorn corner of the city, amid dust and truck exhaust, 16-year-old Nahem Inora was offering 4 cents a pound for the metal. He said he planned to resell it to big-time traders for about 7 cents a pound. He had arrived that morning with $20 and had burned through half of it within hours.

"I would be more successful if I had more money to buy steel," Inora said. Waiting to sell their treasure were two boys who had carried and dragged a grimy sack loaded with 2-foot lengths of rebar.

The piles of rubble entomb an unknown number of dead — a reality that will require sensitivity when it comes to clearing. That could mean digging by hand in places where bodies are believed buried.

Copyright © The Seattle Times Company

Haiti's Important Business Women

MARCH 3, 2010

Global Aid Is No Relief for Small Haitian Businesses
By DAVID LUHNOW (Wall Street Journal)

PORT-AU-PRINCE, Haiti—Business for Ilia Alsene, one of Haiti's ubiquitous "marchands"—or merchants—who sell food and beverages at curbside stalls here, is a lot worse since the country's devastating earthquake. But Ms. Alsene doesn't blame the quake so much as the international relief effort that followed.

"I have fewer customers now because they are handing out free food down the street," says the 52-year-old, pointing to the nearby Champs de Mars plaza where aid organizations regularly hand out food to tens of thousands of people camped there in tents.

View Full Image
Julie Platner for The Wall Street Journal Ilia Alsene, seen selling food in Port-au-Prince, says free-food handouts near her stall have hurt her business.
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After the Jan. 12 quake, which killed as many as 300,000 people, the world launched a massive relief effort to bring food, water, medicine and other supplies to needy Haitians. The U.S. alone has spent more than $665 million, official figures show.

But only a tiny fraction of that money is being spent in Haiti, buying goods from local businesses. Worse, the aid is having the unintended consequence of making life harder for many businesses here, because of competition from free goods brought in by relief agencies. The damage to Haitian companies is making it harder for them to get back on their feet and create the jobs the country needs for a lasting recovery.

U.S. officials acknowledge that the aid effort has bypassed local businesses, but say the scope of the disaster made getting relief supplies in quickly a priority. They also say they will be buying more products from Haiti as the relief effort shifts to longer-term rebuilding.

Alex Zamor's drinking-water factory is operating again at near full capacity after suffering damage from the earthquake. But he still hasn't rehired 200 employees at the factory because sales are so weak. He blames free water handed out by the relief effort.

"Of course we welcome the relief, but nobody wants to buy water if there's free water on the streets," he says. Mr. Zamor says international relief agencies should be sourcing more of their products for the relief effort from Haiti itself. "We should be helping Haitian companies instead of companies in Florida," he says.

In most disaster relief, only a tiny fraction of aid money goes through the local government. And as little as 5% of the budgets of humanitarian agencies is spent locally in the countries they help, according to Peace Dividend Trust, a Canadian nongovernmental organization.

"Every dollar that is spent locally is a dollar spent twice, because it will help create the jobs that Haiti needs to recover," says Marlene Otis, the Haiti country director for Peace Dividend Trust.

Tom Adamson, a transplanted Canadian, runs one of only two mattress companies in Haiti. Three of his 10 retail stores around the country were destroyed, and his factory suffered minor damage. But he says the biggest effect from the quake has been increased competition.

In the weeks after the temblor, a mattress company in the Dominican Republic sent 10,000 foam mattresses for the relief effort, getting import duties at the border waived. He and U.S. officials say nearly all relief supplies don't get charged import taxes. Meanwhile, Mr. Adamson's mattress company has a container of chemicals used to make foam mattresses stuck for months in Haitian customs, where is still being asked to pay import taxes.

"Things like this make it very hard for me to compete," he says.

Officials at the U.S. Agency for International Development, which is running the relief effort for the U.S. government, say many Haitian businesses were on their knees following the quake and in no shape to handle orders. Quality is another consideration, and products like plastic tarpaulins are being purchased in the U.S. because they can better withstand Haiti's rainy season, said Carleene H. Dei, AID's Haiti mission director.

But she said the scope for local businesses to participate as suppliers and contractors in the rebuilding will grow significantly.

"We are very cognizant of the fact that the way to develop Haiti is to work with local organizations," said Ms. Dei, whose sleeps in a cot in her office because her home was destroyed in the quake. "We are making every effort to do that."

AID has been mandated by the U.S. and Haitian governments to use local suppliers and expertise as much as possible. But one hurdle is AID's strict regulations, which call for dealing with companies that have a proven track record and transparency. That makes it more difficult to deal with smaller Haitian firms, many of which don't have outside auditors, for instance.

Peace Dividend Trust, the Canadian NGO, tries to act as a matchmaker for relief organizations and local companies. Even before the quake, the group built up a database of Haitian companies and posted it on a Web site (www.haiti.buildingmarkets.org) so procurement officers know what is available locally.

To overcome doubts about local producers, Peace Dividend workers visit each company to ensure that it is a legally incorporated firm and has quality products. "There's a deficit of confidence in local producers that we're trying to overcome," says Ms. Otis.

One sensitive area in the sourcing of relief goods is food. The U.S. government buys the rice it distributes in Haiti from American farmers. When France began handing out sacks of rice during a visit here by French President Nicolas Sarkozy, the bags bore a stamp that said the rice was from Haiti.

A U.S. official acknowledged that donation of food brought in from other countries tends to depress prices for local producers, but said it would be a temporary effect. The official stressed that the U.N. World Food Program, which is feeding hundreds of thousands of Haitians a day, will begin trying to buy as much locally grown food as possible.

Frederic Madsen, CEO of Brasserie Nationale d'Haiti SA, Haiti's largest beverage company and only beer maker, says the fate of his company is closely tied to the fate of Haiti's marchands, women like Ms. Alsene. "When women like that don't make enough money, they stop buying my products," he says. "They are the backbone of this economy."

—José de Córdoba and Ianthe Jeanne Dugan contributed to this article.
Write to David Luhnow at david.luhnow@wsj.com

Copyright 2009 Dow Jones & Company, Inc. All Rights Reserved

The UN in Haiti Now

March 2, 2010

U.N. Is Faulted as Lacking Coordination of Aid and Security in Haiti
By NEIL MacFARQUHAR (New York Times)

UNITED NATIONS — Humanitarian efforts by the United Nations in Haiti have lacked sufficient coordination with local organizations in delivering aid and establishing security, according to an independent assessment released on Tuesday.

One consequence was a surge in the sexual abuse of women and girls living in camps for the displaced, with some young girls trading sex for shelter, said Emilie Parry, an aid consultant who helped write the evaluation of the United Nations’ effort for Refugees International, a nonprofit organization that advocates on behalf of refugees.

“Women reported to us that there has been a lot of violence and sexual abuse at nighttime,” Ms. Parry said, noting that there is no system of nighttime patrols in the makeshift camps where many displaced people have been living.

“By all accounts, the leadership of the humanitarian country team is ineffectual,” said the report, based on 10 days of evaluations in February. The report, titled “Haiti: From the Ground Up,” also acknowledged that the scale of the disaster made the response a singular challenge.

Closer work with Haitian organizations, as well as better knowledge about conditions, would also enhance the ability of local groups to deal with problems long after the international groups left, Ms. Parry said.

The report suggests a number of ways to improve the delivery of aid, including allowing more participation by Haitian organizations whose leaders are now living among as many as several million displaced earthquake victims.

While the United Nations does not actively discriminate against such groups, it effectively bars them through a lack of advertising and the system of passes that are needed to attend meetings, Ms. Parry said. Appointing liaison officers dedicated to such groups would help, the report suggests.

It also recommended that the United Nations appoint one person responsible for leading the team distributing humanitarian aid in the country, rather than have the responsibility be among many tasks taken on by senior management.

Finally, it suggested that the United Nations’ assessments had not delved adequately into the heart of all the temporary camps, where hundreds of thousands of people still lack shelter and other basic needs. The report recommends that the United States government beef up its budget for disaster assistance and that it, too, should coordinate more with local groups.

“There is too much of a gap, too many people are being left out of the response,” Ms. Parry said.

Human Rights Watch issued a similar report two weeks ago, noting the lack of adequate shelter and saying that it had documented three rapes connected to poor security. Asked about the reports then, Anthony Banbury, a senior United Nations official in Haiti, was criticized for saying that the number of rapes “almost elates me.”

Mr. Banbury issued a statement later saying that he had not meant to minimize the seriousness of the three rapes, but to suggest that efforts to maintain some security were working because the number was relatively low.

The United Nations has given shelter materials to more than 523,000 people, or 40 percent of those in need, said Martin Nesirky, the spokesman for Secretary General Ban Ki-moon, with 232,000 additional tarpaulins and 22,000 tents en route. The World Food Program and partner organizations have delivered food assistance to 4.3 million people, Mr. Nesirky said.

Catherine Bragg, the deputy humanitarian coordinator, said the scale of the destruction in Haiti, as well as the death of 100 United Nations staff members, including the most senior officials, had initially hampered relief efforts.

“It is the most complex humanitarian response we have ever had to deal with,” said Ms. Bragg, adding that the United Nations had brought some order to utter chaos. “It would be very easy to make negative comments about how things are coordinated.”

John Holmes, the departing United Nations humanitarian coordinator, has said publicly that the organization’s response was uneven. He demanded that United Nations staff members do a better job of coordinating relief efforts.

The United Nations has tried not to discriminate between Haitian and international organizations, with local groups accounting for about 15 percent of the groups participating in the effort in Haiti, said Stephanie Bunker, the spokeswoman for the humanitarian aid office. “We would like to increase the balance,” she said.

Aids and the Earthquake

(Photo by John Carroll)

Global support needed to help Haiti meet AIDS needs, UN report says

Sat, Feb 27 2010 22:48 CET
by The Sofia Echo Staff –

The country most affected by HIV in the Caribbean region – needs the world’s support in bolstering its defence against the spread of AIDS in the wake of the January 12 2010 catastrophic earthquake, according to a United Nations report.

"It is unprecedented to have such a huge natural disaster in a country with a high HIV prevalence," Michel Sidibé, Executive Director of the Joint UN Programme on HIV/AIDS (UNAIDS), which issued the new publication, said, according to the UN News Service.

Before the January 12 quake, there were about 120 000 people living with HIV in Haiti, out of a total population of about three million. The country’s epidemic is driven largely by heterosexual sex and more than half of those living with HIV are women.

Most of the structural damage caused by the magnitude-7.0 quake occurred in three departments – Sud-Est, les Nippes and Ouest, where the capital, Port-au-Prince is located – where nearly 60 per cent of all people living with HIV in Haiti reside. More than half of the anti-retroviral treatment sites in Haiti are also situated in those three departments.

With more than a million people taking refuge in temporary shelters, they are at greater risk of violence, including sexual and gender-based violence, Sidibé said. "Programmes are urgently needed to reduce vulnerabilities to HIV and ensure protection."

Makeshift treatment clinics under tents have popped up to increase access to treatment, but the Ministry of Health estimates that less than 40 per cent of the 24 000 people living with HIV who were on treatment before the disaster have access them.

As Haiti experiences a critical interruption of HIV services and programmes, stepped up support is vital for the country to allow it to regain momentum towards reaching universal access goals for HIV prevention, treatment, care and support.

The new UNAIDS report has identified seven priority areas, including rebuilding health systems, protecting the displaced from HIV and revitalising HIV prevention programmes.

Haiti’s annual AIDS budget was $132 million prior to the earthquake, and UNAIDS believes that a further $70 million will be necessary to meet the country’s immediate response needs over the next six months.

The UN Office for the Co-ordination of Humanitarian Affairs (OCHA) reported that about 285 000 houses had been damaged or destroyed in the earthquake, and government and humanitarian organisations, as well as engineers, are working to register the displaced and plan relocation sites for those who cannot return to their homes.

Spokesperson Elisabeth Byrs said that creating adequate sanitary conditions and waste disposal systems is also essential to mitigate the risk of a large-scale outbreak of disease.

She said that the $1.44 billion revised humanitarian appeal launched earlier in February 2010 by the UN and its aid partners – the largest-ever in the wake of a natural disaster – is 48 per cent funded, but expressed concern that the portion for agriculture has only received eight per cent of the funds requested.

The UN Children’s Fund (Unicef) and its partners are setting up provisional schoolrooms in Port-au-Prince and other areas, as schools destroyed in the quake are being rebuilt.

Haiti’s educational system, said Marc Vergara of the agency, virtually ceased to function in affected areas, leaving about 2.5 million children out of school after the earthquake.

Together with the ministry of education, Unicef is helping to establish more than 150 tent schools to get children back to school before April.

With more than half of school-age children not attending classes prior to the quake, the agency’s goal is to "build back better" to create conditions to allow many young Haitians to attend school for the first time.

Bulgarian National Television said on February 27 2010 that so far, the Bulgarian Red Cross had raised about 400 000 leva for assistance to victims of the devastating earthquake in Haiti.

The funds had collected within a month and a half, the main donors are people with low incomes.

Separately, by February 25, Hope for Haiti's Children, an initiative in Bulgaria, had received 1.6 million leva in donations from Bulgaria, a statement by Unicef Bulgaria said.

This means that through these two separate initiatives, Bulgarian citizens had given more than two million leva - about a million euro - to help victims of Haiti's earthquake.

Chile's Quake Different than Haiti's

(Photo by John Carroll)

Chile was ready for quake, Haiti wasn't
By FRANK BAJAK
ASSOCIATED PRESS WRITER


PORT-AU-PRINCE, Haiti -- The earthquake in Chile was far stronger than the one that struck Haiti last month - yet the death toll in this Caribbean nation is magnitudes higher.

The reasons are simple.

Chile is wealthier and infinitely better prepared, with strict building codes, robust emergency response and a long history of handling seismic catastrophes. No living Haitian had experienced a quake at home when the Jan. 12 disaster crumbled their poorly constructed buildings.

And Chile was relatively lucky this time.

Saturday's quake was centered offshore an estimated 21 miles (34 kilometers) underground in a relatively unpopulated area while Haiti's tectonic mayhem struck closer to the surface - about 8 miles (13 kilometers) - and right on the edge of Port-au-Prince, factors that increased its destructiveness.

"Earthquakes don't kill - they don't create damage - if there's nothing to damage," said Eric Calais, a Purdue University geophysicist studying the Haiti quake.

The U.S. Geological Survey says eight Haitian cities and towns - including this capital of 3 million - suffered "violent" to "extreme" shaking in last month's 7-magnitude quake, which Haiti's government estimates killed some 220,000 people and left about 1.2 homeless. Chile's death toll was in the hundreds.

By contrast, no Chilean urban area suffered more than "severe" shaking - the third most serious level - Saturday in its 8.8-magnitude disaster, by USGS measure. The quake was centered 200 miles (325 kms) away from Chile's capital and largest city, Santiago.

In terms of energy released at the epicenter, the Chilean quake was 501 times stronger. But energy dissipates rather quickly as distances grow from epicenters - and the ground beneath Port-au-Prince is less stable by comparison and "shakes like jelly," says University of Miami geologist Tim Dixon.

Survivors of Haiti's quake described abject panic - much of it well-founded as buildings imploded around them. Many Haitians grabbed cement pillars only to watch them crumble in their hands. Haitians were not schooled in how to react - by sheltering under tables and door frames, and away from glass windows.

Chileans, on the other hand, have homes and offices built to ride out quakes, their steel skeletons designed to sway with seismic waves rather than resist them.

"When you look at the architecture in Chile you see buildings that have damage, but not the complete pancaking that you've got in Haiti," said Cameron Sinclair, executive director of Architecture for Humanity, a 10-year-old nonprofit that has helped people in 36 countries rebuild after disasters.

Sinclair said he has architect colleagues in Chile who have built thousands of low-income housing structures to be earthquake resistant.

In Haiti, by contrast, there is no building code.

Patrick Midy, a leading Haitian architect, said he knew of only three earthquake-resistant buildings in the Western Hemisphere's poorest country.

Sinclair's San Francisco-based organization received 400 requests for help the day after the Haiti quake but he said it had yet to receive a single request for help for Chile.

"On a per-capita basis, Chile has more world-renowned seismologists and earthquake engineers than anywhere else," said Brian E. Tucker, president of GeoHazards International, a nonprofit organization based in Palo Alto, California.

Their advice is heeded by the government in Latin America's wealthiest nation, getting built not just into architects' blueprints and building codes but also into government contingency planning.

"The fact that the president (Michelle Bachelet) was out giving minute-to-minute reports a few hours after the quake in the middle of the night gives you an indication of their disaster response," said Sinclair.

Most Haitians didn't know whether their president, Rene Preval, was alive or dead for at least a day after the quake. The National Palace and his residence - like most government buildings - had collapsed.

Haiti's TV, cell phone networks and radio stations were knocked off the air by the seismic jolt.

Col. Hugo Rodriguez, commander of the Chilean aviation unit attached to the U.N. peacekeeping force in Haiti, waited anxiously Saturday with his troops for word from loved ones at home.

He said he knew his family was OK and expressed confidence that Chile would ride out the disaster.

"We are organized and prepared to deal with a crisis, particularly a natural disaster," Rodriguez said. "Chile is a country where there are a lot of natural disasters."

Calais, the geologist, noted that frequent seismic activity is as common to Chile as it is to the rest of the Andean ridge. Chile experienced the strongest earthquake on record in 1960, and Saturday's quake was the nation's third of over magnitude-8.7.

"It's quite likely that every person there has felt a major earthquake in their lifetime," he said, "whereas the last one to hit Port-au-Prince was 250 years ago."

"So who remembers?"

On Port-au-Prince's streets Saturday, many people had not heard of Chile's quake. More than half a million are homeless, most still lack electricity and are preoccupied about trying to get enough to eat.

Fanfan Bozot, a 32-year-old reggae singer having lunch with a friend, could only shake his head at his government's reliance on international relief to distribute food and water.

"Chile has a responsible government," he said, waving his hand in disgust. "Our government is incompetent."

U.S. Military in Haiti

(Photo by John Carroll)

US military weighs role in battered Haiti

By ANNE FLAHERTY
The Associated Press
Friday, February 26, 2010; 9:51 PM

PORT-AU-PRINCE -- U.S. military officials are deliberating how long American troops should stay in Haiti to tend to its earthquake-battered population, knowing that work remains but reluctant to take on much of the rebuilding that could commit the force to the region for years.

The timing of troop withdrawals is a difficult decision that strikes at the heart of how the U.S. military is viewed around the world: a powerful force with deep pockets that can accomplish a lot in a short period of time.

But senior officials have made clear that the military won't stay forever, simply because it can.

"We're very deliberate about this," said Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, in his first visit to Haiti since the 7.0-magnitude earthquake struck on Jan. 12.

The primary goal of U.S. forces is to provide security, he told reporters after inspecting the city's port, which a team of Navy and Army divers are close to salvaging so that ships can begin to move cargo ashore without relying on highly specialized military equipment.

Mullen noted those improvements, along with a drop off in the number of urgent medical cases.

Going forward, "we will have enough troops here to meet the security requirement," Mullen said.

Perhaps the best example of how the military mission has changed in the six weeks since the quake struck is the patient load aboard the USNS Comfort, the giant Navy hospital ship floating offshore Port-au-Prince.

At its peak in late January, the ship had some 540 patients and nearly 1,400 staff. That number began to drop rapidly as field hospitals on shore ramped up capacity and the most acute cases were treated and those patients released.

After discharging 75 more patients about a week ago, there are now only seven patients still aboard the USNS Comfort. The ship still maintains about 970 personnel.

Mullen toured the ship and praised the staff for their work. When he asked what they do all day, the staff responded: "Cleaning, sir."

Throughout Haiti, the U.S. military mission still draws some 11,000 troops - 6,000 on the ground and 5,000 floating offshore. But their mission has fundamentally changed.

Marines, among the first to arrive with food and water, are now helping to coordinate among the myriad relief agencies and nongovernmental organizations from around the world. Infantry soldiers from the 82nd Airborne Division deployed to ensure riots didn't break out have now cleared some 40 blocks of rubble from downtown and are helping engineers move in to rebuild.

Officials say the situation in the impoverished Caribbean nation remains dire, and the population needs medical treatment, shelter, food and water. They also say that conditions could dramatically worsen as the rainy season sets in and if aftershocks from the earthquake occur.

But for the military, already stretched thin by two wars, the goal is to hand off much of the responsibility to civilian aid agencies now operating in Haiti.

"When I say 'we,' I really mean the government of Haiti, and the international community," Mullen said.

© 2010 The Associated Press

"We Wail with You, Haiti"

(Photo by John Carroll of La Promesse, the grade school that collapsed in Port-au-Prince in 2008. Approximately 90 students and teachers were killed.)

February 26, 2010

‘We Wail With You, Haiti’
By KIRK SEMPLE

On Jan. 13, the day after the earthquake that upended Haiti, Garry Pierre-Pierre, editor and publisher of The Haitian Times, moved the center of operations for his weekly newspaper from Brooklyn to a tent in the backyard of a damaged apartment building in Port-au-Prince. If he was going to cover one of the most transformative events in the history of the country and its diaspora, he knew there was only one place for him to be.

“The human factor is sometimes missing in stories about faraway places,” said Mr. Pierre-Pierre, who has since published a steady stream of articles that provided an intimate and sensitive portrayal of events on the ground. “I knew if I didn’t go, we also would not have provided it.”

Mr. Pierre-Pierre and his colleagues at The Times have written a portrait of one street in Port-au-Prince and its survivors, for example, and another article about the challenges faced by a team of doctors, including some Haitian-Americans, from New York.

In another report, in the Jan. 20-26 issue, the paper detailed the desperate exodus of Haitians from the capital, including a mother with two small children, one of whom had a heart ailment, and a metal worker anxious both to let his mother know that he had survived and to get back to work.

It is no surprise that The Times and New York’s three other weekly Haitian newspapers, Haiti Liberté, Haiti Observateur and Haiti Progres, have been dominated by stories about the disaster.

But many of the hundreds of other ethnic newspapers in New York — like the daily Novoye Russkoye Slovo, a Russian paper, and El Tiempo de New York, a Hispanic weekly — have run stories revealing particular perspectives on the earthquake and its aftermath.

The weekly Peruanisimo News, for example, reported on a fund-raiser for Haiti in Paterson, N.J. The fund-raiser was organized by Peruvians, and Paterson is a stronghold of the Peruvian population in the region.

The New York Carib News wrote about post-earthquake psychological counseling for Caribbean vendors on Flatbush Avenue, supplied by a Brooklyn hospital and a Caribbean-American business group. And Thikana, a Bangladeshi weekly based in Long Island City, Queens, exhorted Bangladeshis in the United States and elsewhere in the world to donate generously to relief efforts.

Here are excerpts from local Albanian, Chinese and Filipino newspapers.

•

Haiti in Our Minds


A wail is a type of sound any human being would find difficulty hearing. It is not borne out of emotional stress, but rather of grieving souls and broken spirits. As of this writing, there is constant wailing in Haiti. A catastrophic earthquake struck the capital three days ago, destroying almost every edifice and burying about 100,000 people to their untimely deaths. It is a disaster of unimaginable proportion and could certainly cause a grave humanitarian crisis...

There are reports that Filipinos that are members of the United Nations peacekeeping team are among those trapped in the ruins of collapsed buildings. The Philippine ambassador to the U.N., Hilario Davide, said that all Filipinos in the team are accounted for. This is a time when we all become one in grief with our fellow human beings. This is a time when nationalities cease to exist. This a time when we must do whatever we can to send help to those affected by the killer quake. We Filipinos are not strangers to this situation. In September of 2009, we ourselves were devastated when Typhoon Ondoy struck our capital. The world came together to aid us in those dark times. Now is our chance to reciprocate the good will that we received...

Haiti may be across the oceans, but we are all human beings, and we share their pain. We wail with you, Haiti.

—TED REYES, Jan. 18

The Filipino Express, based in Jersey City, has a weekly circulation of 35,000.

•

Fate of Hundreds of Smuggled Chinese Unknown

In recent years, Haiti has become an important junction for smuggled Chinese on their way to the United States. As a result of the heavy casualties of the earthquake in the region, the status of hundreds of smuggled Chinese waiting to go to the United States is uncertain...

Chen, a Fujian family association administrator, said that there are some smuggled ethnic Chinese that have been hidden inside Haitian residences through arrangements made by snakeheads, that these smuggled Chinese would not in any way be registered with the local government and that for this reason they could be easily overlooked during any rescue attempt. Fujian family associations in New York are calling on the Haitian government, Chinese peacekeeping forces and international rescue teams to look into the safety of the smuggled Chinese. An overseas Chinese community leader revealed that a woman from Changle had called New York asking for help in inquiring about the whereabouts of her son in Haiti. She said, "It's enough that he's alive. Whether or not he makes it to the United States is not important."

—CAO JIAN, Jan. 14

Translation from Mandarin by Jeffrey E. Singer

The World Journal, founded in 1976, is the largest Chinese-language newspaper in North America, with a circulation of 300,000. Its New York headquarters are in Whitestone, Queens.

•

Famous Famiglia Donates $12,000 for the Victims in Haiti


This horror of catastrophic dimensions hit hard Pierre Louis, the Haitian immigrant who lost six members of his family in this national tragedy. This loss touched even more personally the owners of Famous Famiglia, the Kolaj brothers (Paul, George, John and Tony), as well as the brothers Idrizi, employers of Pierre Louis, here in New York City. They organized a candlelight vigil in one of their restaurants accompanied with an initiative to help Pierre Louis and his people. The young voices of the Harlem Choir were invited to perform several songs. An all-day fund-raiser was launched in the restaurant, which is situated in Midtown Manhattan, with all the proceeds of the day, about $12,000, going to a humanitarian relief fund dedicated to help Haiti. A representative of the American Red Cross Haiti Relief Fund thanked the owners of Famous Famiglia for their generosity in these hard times for the people of Haiti. It is worth remembering that the Kolaj brothers, who are ethnic Albanians, were involved also in the fund-raising campaign held a few days earlier to help the flooding victims in the area of Shkodra, in northern Albania.

—HALIL MULA, Jan. 22

Translation by Ruben Avxhiu

Illyria, published twice a week, is an Albanian-language newspaper with a circulation of 10,000 and has offices in Manhattan.

U.S. Rice Doesn't Help Haitian Farmer

(Photo by John Carroll)


US rice doesn't help struggling Haitian farmer

PAISLEY DODDS/Associated Press Writer

POND-SONDE, Haiti (AP) - Haiti's rice farmers are dismayed. It's nearly harvest time in this fertile valley where the bulk of Haiti's food is grown, and they're competing once again with cheap U.S. imported rice.

Just down the road, vendors are undercutting them, selling the far less expensive grain. Subsidized U.S. rice has flooded Haiti for decades. Now, after the Jan. 12 quake, 15,000 metric tons of donated U.S. rice have arrived.

"I can't make any money off my rice with all the foreign rice there is now," said Renan Reynold, a 37-year-old farmer who makes an average of about $600 a year. "If I can't make any money, I can't feed my family."

Last month's catastrophic earthquake that killed an estimated 200,000 people and spurred emergency food needs for more than 4 million has raised a familiar predicament for aid organizations — how to help without undermining Haiti's fragile economy.

This nation born nearly 200 years out of a slave revolt hasn't been able to feed itself for more than two decades and now imports most of its food.

Since the quake, aid groups have spearheaded cash-for-work programs, some of which intend to help struggling farmers pay for seed. They're also helping with irrigation and crop diversification projects and working with Haiti's government to analyze soil.

But little is being done to change endemic problems, according to Jean Andre Victor, a Haitian agronomist. He is among analysts who believe Haiti needs radical agricultural reforms — not constant food aid.

"There's a long history in Haiti of groups like USAID flooding the market with rice and other imports," said Victor. "This is not what we need. We need real help and that means completely changing the agricultural system."

Agricultural production accounted for nearly half of gross domestic product in the 1970s. It now amounts to less than a third.

And U.S. rice imports have long eclipsed Haitian production, due in part to smaller local yields because of environmental degradation and the lowest rice import tariffs in the Caribbean community.

The earthquake has only exacerbated needs in farming provinces. The government says more than a half-million people have fled the capital for provinces, which lack the infrastructure and food to sustain such a population surge. The coming rains will only make things worse.

When the earthquake hit, Haiti was recovering from about $1 billion in crop damage from 2008 tropical storms. Now, farmers lack cash to buy seeds for the planting season that begins in two weeks, and food prices have already risen 10 percent since the quake.

Aid organizations say families caring for displaced people are spending their savings to feed new arrivals and consuming food stocks.

"Rural areas experiencing the highest levels of displacement from Port-au-Prince and surrounding areas are the most affected," said Dick Trenchard, Assessments Coordinator for the U.N.'s Food and Agriculture Organization in Haiti.

The U.S. Agency for International Development, which has been working in Haiti for decades, is providing more than $400 million in earthquake aid with U.S. taxpayers set to give some $113 million in food aid alone this year.

But U.S. farmers also stand to benefit from the earthquake.

Last year, Washington paid farmers some $12.9 billion in subsidies, which critics say have unfairly deflated international prices. That makes it harder for poorer nations to develop their economies by expanding markets abroad.

Paul O'Brien of Oxfam America says the lessons of the harm of flooding a country like Haiti with subsidized rice should have been learned a long time ago.

"The days are gone when we can throw up our hands in terms of unintended consequences; we know now what these injections can do to markets," he said. "The question we want asked is what is being done to guarantee long-term food security for Haitians."

Haiti's 2008 food price riots prompted President Rene Preval to announce subsidies that would lower the price of rice. And still, there is plenty of malnutrition.

Some 2.4 million Haitians — out of a population of nearly 10 million — cannot afford the minimum daily calories recommended by the World Health Organization.

With planting season just weeks away for crops including beans and spinach, the Haitian government is looking at ways to boost agricultural production.

But donors often sink more money into emergency aid than such long-term projects.

The U.N. Food and Agriculture Organization has warned only 8 percent of a $23 million appeal to help Haiti revive food production has been funded.

James Woolley, a senior agronomist working with USAID in Haiti, said the multiple challenges that must be addressed in order to boost production include the country's small farming plots and persistent litany ofnatural disasters.

One way of attacking the problem of getting Haiti to be able to feed itself again is to focus on diet.

Before the 1970s, Haitians only ate rice once or twice a week, getting starch from other local staples like sorghum and manioc, Woolley said.

Today, rice is a staple but often U.S.-subsidized rice costs less than locally grown crops. On Friday, a 25-kilogram (55-pound) bag of US rice cost about $36, compared with $60 for the same size sack of Haitian rice.

USAID said it is investigating reports that bags of donated rice are being sold on the market and studying whether its policies in Haiti are having adverse effects on local markets.

"USAID conducts regular analyses in Haiti and across the world to make sure that our food aid does not serve as a disincentive to local production," Moira Whelan, a spokeswoman for USAID in Washington, D.C., said in an interview Thursday.

Whelan would not respond, however, when asked what the analyses had determined in Haiti.

U.S. intervention in Haitian agricultural policy is not without precedent.

In the 1970s, fearing indigenous pigs could spread swine fever, the United States — in conjunction with USAID — moved to replace all of Haiti's hearty Creole pigs with pigs from Iowa. The end result was the fragile U.S. pigs often became sick, preferred expensive feed and had fewer litters.

Reynold, meanwhile, stands hunched over the small rice paddy he rents from a property owner and hopes opportunity will come out of Haiti's latest crisis.

He needs cheap credit, cheaper fertilizer and more government aid, he said.

"Each year, it gets harder to survive."

Order out of Chaos

(Photo by John Carroll)

Published at www.nejm.org February 24, 2010

Civil–Military Collaboration in the Initial Medical Response to the Earthquake in Haiti

Paul S. Auerbach, M.D., Robert L. Norris, M.D., Anil S. Menon, M.D., Ian P. Brown, M.D., Solomon Kuah, M.D., Jennifer Schwieger, M.D., Jeffrey Kinyon, D.O., Trina N. Helderman, M.D., and Lynn Lawry, M.D.

Two days after Haiti's devastating earthquake, a medical relief team made up in part of four emergency physicians and four emergency nurses from Stanford University Hospital and three emergency physicians from Columbia University Medical Center traveled under the auspices of the International Medical Corps, a nonprofit organization based in Los Angeles, to provide emergency medical support. After an all-night bus ride from the Dominican Republic, the team arrived at the Hôpital de l'Université d'État d'Haiti in Port-au-Prince on the morning of January 17. The scene we faced was apocalyptic. Approximately 800 victims were within the hospital compound, most of them outdoors. A damaged building was filled with the patients deemed in greatest need of emergency surgery. Hundreds of patients awaited evaluation and treatment. An internal medicine ward was packed with patients with crush and other severe soft-tissue injuries, amputations, open and infected fractures, compartment syndromes, hemorrhagic shock, and other conditions threatening to life and limb. In a central wooded area outside, the ground was barely visible for the suffering people, many of whom had distorted limbs, maggot-infested wounds, deforming facial injuries, skull fractures, and spinal cord injuries. A single operating room with a few tables was staffed by overworked surgeons who amputated limbs and débrided infected tissue. The morgue was overflowing, and approximately 40 bodies were stacked near the medical ward.

For the next 2 days, we practiced continuous battlefield medicine. Working side by side with a few other physicians and nurses, we did our best to evaluate every patient. Two of our physicians and two nurses initially staffed the preoperative area, one physician and a nurse cared for 60 to 80 critically ill patients in the ward, two physicians and a nurse triaged and treated the patients outside, and the remaining physicians and nurse assisted in areas of greatest immediate need. We carried backpacks filled with syringes of injectable narcotics and antibiotics to reduce pain when splinting shattered bones and to treat infections. We improvised by adding povidone–iodine to saline-filled intravenous bags to irrigate wounds before dressing them. We rapidly exhausted our supplies of splints and casting material. Since there was no cold chain (temperature-controlled supply chain), we could not store either tetanus toxoid or tetanus immune globulin. The stoic patients endured our treatments and thanked us.

On the second and third days, as access to the country and hospital improved, American, Swiss, Canadian, Norwegian, Haitian-American, French, and Spanish volunteer physicians, predominantly from nongovernmental organizations and universities, arrived and worked side by side to bring order to patient flow. On January 20, the third day after our arrival, we were awakened by an earthquake of magnitude 5.9. We raced to the hospital. By the time we arrived, the patients who had been inside the hospital had fled outdoors and new patients had entered the compound. We reevaluated as best we could. Although some of the newly abandoned buildings were subsequently cleared by engineers, the patients refused to reenter them. By midday, the ambient temperature was in the low 90s and the ground temperature higher. There were too few tarpaulins and tents to cover the patients. Without shade, the patients' condition deteriorated rapidly, and some of them had heatstroke. On that day, we diagnosed two cases of tetanus and many instances of gangrene. Without radiographs, facilities for laboratory tests, or other diagnostic capabilities, all diagnoses were made by physical examination.

For our first 3 days, there was minimal local law enforcement. The complexity of caring for so many seriously injured and ill patients was made worse by the commotion caused by the uncontrolled numbers of persons who gained access to the compound. On the third day, on the order of General Douglas Fraser, Commander of the U.S. Southern Command, 80 soldiers (including 5 medics) from C Company, 1st Battalion, 325th Airborne Infantry Regiment, were deployed from Fort Bragg, N.C., to the hospital. They remained for a few days and were then replaced by 130 other soldiers, including 10 medics, from B Company, 2nd Battalion.

With the arrival of the military, security was immediately established, including gate access, a perimeter surveillance, and crowd control. The soldiers' presence was an altogether positive development for the medical teams. By maintaining order and limiting the crowds of onlookers, they gave us more ready access to our patients. The military medics assisted us in evaluating and treating patients in the field and tents. They also carried stretchers and hauled supplies. When the U.S. Navy's hospital ship Comfort arrived on January 20, we began to transfer our sickest patients by navy helicopter to its more than 300 medical personnel, its operating rooms, and its 500 beds. We transferred 53 patients on the first day and another 95 during the rest of that week. In addition, the military airlifted 15 patients to the Baptist Haiti Mission Hospital (a transfer that until the arrival of the army had required a trip of 1 to 2 hours in the back of a pickup truck). Transferring patients to the Comfort required moving them first to waiting field litter ambulances (FLAs), each of which held four litters. The soldiers were essential in helping us move patients from the treatment areas to the FLAs. Once loaded, the patients were driven to a landing zone and then taken by helicopter to the Comfort. If we had not been able to transfer patients to the Comfort, many more lives would have been lost.

The support of the U.S. military was unequivocally integral to the success of the medical mission. The military supplied us with critical equipment and supplies, such as tents to establish our emergency room, stretchers, medications, food, and water. The soldiers who assisted us in the hospital compound brought not only skill but also a "can do" attitude and energy to a medical staff that was stretched to its physical and emotional limits. We saw consistent professionalism, competence, and compassion in the American soldiers.

There were challenges, too, in the civil–military collaboration, and we can apply the lessons learned to future disaster-response situations. As in most disasters, clarity of messaging was a problem. During the first day on which patients were airlifted to the Comfort, instructions from the ship regarding the number and types of patients to transfer were unclear. This issue was clarified the next day, when the navy provided a list of the types of cases that were best served by its facility (e.g., complicated extremity injuries, obstetric cases, and maxillofacial injuries) and those that were not (pelvic fractures, closed head injuries, complete spinal cord lesions, and cases requiring assisted ventilation). To facilitate patient flow and transfer, FLA locations and estimated times of arrival could have been better communicated. Although the delays were always understandable in the context of the disaster, the situation would have been improved by a clear and reliable form of communication between the civilian and military relief efforts at the ground level.

For the first week of transfers, we were not allowed to send patients' family members from the hospital to the Comfort. In a situation marked by chaos and profound social disruption, survivors, particularly children, may become separated from their families, so it is vitally important to try to keep families together. Initially there was no protocol for obtaining information from the ship on the status of transferred patients. It took several days to establish a hotline with the navy for this purpose. Disaster-relief planning should provide for communication channels between family members in such circumstances. It should also provide means of repatriating patients and reuniting families. Early consideration must be given to simple discharge planning, as well as to the creation of temporary residences to receive patients who have been treated and stabilized, to open up precious hospital space.

Because the soldiers assigned to the hospital were always subject to immediate reassignment, we might have lost their help at a moment's notice. Fortunately, there was no lapse in coverage. There should, however, be soldiers whose main responsibility is to protect and support the medical mission and who are not subject to reassignment, unless the circumstances are dire.

We are aware of the complexity and sensitivity of interactions between nongovernmental organizations and the military. Nobody is perfect, and neither were we. But in this disaster response, the collaborative interaction between civilian medical teams and the military in responding to the initial casualties of the Haiti earthquake could serve to inform policies and procedures for future disasters. Working together, we achieved order out of chaos.


Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.


Source Information

From the Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA (P.S.A, R.L.N., A.S.M., I.P.B.); the Department of Emergency Medicine, New York–Presbyterian Hospital–Columbia University Medical Center, New York (S.K., J.S., J.K.); Lafayette Emergency Care, Lafayette, IN (T.N.H.); and the Office of the Assistant Secretary of Defense for Health Affairs, Falls Church, VA (L.L.).

This article (10.1056/NEJMp1001555) was published on February 24, 2010, at NEJM.org.

Haitians Expected to Return to Ravaged Neighborhoods....Are they Kidding?

(Photo by John Carroll)

February 26, 2010
Haiti Wants Refugees Back in Ravaged Neighborhoods
By THE ASSOCIATED PRESS
Filed at 10:13 a.m. ET

PORT-AU-PRINCE, Haiti (AP) -- Relief officials have changed tack and are urging Haiti's earthquake homeless to return to their destroyed neighborhoods as the rainy season fast approaches.

Officials had initially planned to build big camps outside Port-au-Prince. They still anticipate creating some settlements, but they decided this week to instead emphasize getting people to pack up their tents and tarps and go home.

For that to be possible, authorities will need to demolish hundreds if not thousands of buildings and remove mountains of rubble.

A 20-minute downpour Thursday evening gave a taste of the approaching rainy season and the problems it will bring. People dashed for shelter down streets streaming with runoff while trash clogged gutters and turned depressions into ponds.

Haiti's government weather service lifted its warning of heavy rains Friday morning, but advised people to remain vigilant as chilly winds and dark clouds moved through Port-au-Prince.

Floods and mudslides threaten hundreds of thousands living in camps, and many dwellings are severely damaged or clinging to the sides of hillsides.

At a camp housing 40,000 people in the hills overlooking the capital, Matin Bussreth ran for cover from his bedsheet-tent to a neighbor's plastic tarpaulin during the drenching Thursday night.

''It's a deplorable moment,'' Bussreth said. ''I heard they might be giving out tents. I hope someone will be giving me one.''

Some of the hundreds of Haitians who lined up at a downtown site Thursday to register for the new campaign to resettle many of the 1.2 million homeless back in their old neighborhoods expressed skepticism about the plan. Relief officials also acknowledged the immense challenges.

''There will be flooding. There will be discomfort, misery. And that's not avoidable,'' a top U.N. official for Haiti, Anthony Banbury, told a New York news conference this week.

Gerald-Emile Brun, an architect with the government's reconstruction committee, agreed. ''Everything has to be done before the start of the rainy season, and we will not be able to do it,'' he said Thursday.

Brun suggested that Haitians, who expect little of their corrupt and inefficient government, may largely be left to sort it out themselves.

Camp dwellers -- the capital alone has some 770,000 -- welcomed the idea of swapping flimsy makeshift tents in the city's fetid center for something more stable. But that didn't mean they wanted to return to their quake-ravaged neighborhoods.

Jean Petion Simplice, a 44-year-old father living with his two boys, wife and mother-in-law under a scrap of sheet in the capital, said he feared returning to his district, which is a shambles.

''They're going to remove us from here, but they won't tell us where we're going,'' he complained as he joined a line of hundreds to get registered at the Champ de Mars, in the shadow of the collapsed National Palace.

The International Organization for Migration began registration at the plaza Wednesday, collecting people's old addresses in hopes that most can be resettled relatively quickly in their old neighborhoods.

The camp is home to some 60,000 people and was chosen to begin registration because about 45 percent of its residents come from a single Port-au-Prince neighborhood, Turgeau, said U.S. Air Force Lt. Col. John Blackwell, who is involved in coordinating the plan.

Not everyone will be able to return to their neighborhood, but relief officials expect to know within two weeks who can after determining which structures are viable and which must be demolished, Blackwell said.

Mark Turner, spokesman for the International Organization for Migration, said that ''this is the big new strategy, our big push right now'' -- to decongest overcrowded and unsanitary camps. ''Most people have some kind of tent or structure. We want to be able to tell people, 'Just pack it up and take it home.'''

Haitian President Rene Preval described the new plan Thursday to visiting Brazilian President Luiz Inacio Lula da Silva, saying the idea is to create small camps of 50-100 tents.

Brun described a lengthy process to get the new strategy moving. Blackwell said engineers have only assessed about 25 percent of the Turgeau neighborhood -- so it will take at least until late March to sufficiently clear enough rubble to enable resettlement of the throngs jamming the Champ de Mars.

Officials say the government would compensate owners for land taken, but land tenure is a politically volatile issue in Haiti, where the courts are clogged with tens of thousands of land disputes.

''The lack of identified land is the dominating issue for shelter,'' said a report released Thursday by a ''shelter cluster'' of U.N., U.S. and independent groups working with the government on the issue. So for now, priority is going to the plan to resettle people on the ruins of their old homes or close by.

------

Associated Press writers Frank Bajak, Jonathan M. Katz and Dario Lopez Mills in Port-au-Prince and John Heilprin at the United Nations contributed to this report.

Haiti Worse than Iraq

(Photo by John Carroll)

War Zone? Worse: Haiti Lies in Utter Ruin, Soldiers Say
THE FAYETTEVILLE OBSERVER

For soldiers of the 82nd Airborne's 2nd Brigade Combat Team, the similarities between Haiti's capital and the major cities of Iraq are striking.

Litter and rubble line smelly streets in neighborhoods with tall metal gates and houses built almost exclusively of concrete.

Only here, the soldiers see far more destruction, devastation and suffering.

"I've been to over 30 countries, and I've never seen anything like this." said Maj. Richard Ojeda, a 2nd Brigade Combat Team officer.

Soldiers with the 2nd Brigade began arriving in Haiti shortly after last month's devastating earthquake. Many of them also have served two tours in the war in Iraq.

Like Ojeda, many of the soldiers said they were shocked by Haiti's devastation.

The earthquake killed an estimated 230,000 people, injured about 300,000 more and destroyed or severely damaged a quarter of a million homes.

Despite the relief efforts, downtown Port-au-Prince remains littered with the rubble from flattened houses and businesses.

Other buildings lean precariously, as if a strong sneeze could topple them. In many places, the stench of death has faded, replaced by the odor of urine.

People who chose not to flee to one of the giant tent villages around the city now live in the streets and alleys.

Dieudonne Alexandre flew from Florida after the quake and found her family in one of those filthy alleys. Her mother, three sisters and a niece and nephew died in the earthquake. The rest of the family lives beneath a blue tarp. Their one mattress is less than 10 yards from spots on the ground they and their neighbors use as toilets.

Alexandre has been sleeping outside with them while trying to get visas that would allow some of her family to enter the United States. Her first request was denied.

"They don't have no water. They don't have no food to eat. They don't have nothing," Alexandre said. "We live in hell."

Thousands treated

About 3,200 2nd Brigade soldiers -- along with a few hundred other Fort Bragg troops -- are part of the U.S. government's ongoing efforts to help Haiti rebound.

Arriving days after the earthquake, soldiers worked to save lives. Medics dealt with severed limbs, infected gashes and broken bones. Infantrymen delivered food and water to desperate survivors. Routes were cleared to allow evacuees to safely make it to the airport and to allow aid to go to the hardest-hit areas.

Members of the 2nd Brigade have treated 9,800 patients and helped distribute about half a million bottles of water, a million meals and 12 million pounds of bulk food, a spokesman for the brigade said in an e-mail.

The 2nd Brigade was prepared for the mission. As the nation's global response force ready to deploy at a moment's notice, the brigade had run multiple-day practice drills for emergencies that would require their assistance.

That advance preparation is slowly paying off. Amid Haiti's filth and destruction lie signs of progress.

Street markets have returned. Women fry flour and plantains to peddle on the sidewalks. Others hawk bottles of soda and rum. Lottery shops have reopened. And the rubble, for the most part, has been cleared from the streets, pushed onto the sidewalks to allow traffic to pass.

Focus on food

For the past two weeks, soldiers have focused mainly on helping the World Food Program's food surge. With the search-and-rescue mission declared over, rubble removal came to a temporary halt in favor of rice distribution.

The U.N.'s plan for the rice handouts, which are coming to a close -- was to provide at least 2 million people with enough rice to last two weeks.

Looters and scammers selling tickets on the street hampered the process. But Shannon Oliver of Catholic Relief Services and other aid workers say the food distribution would have been little more than a series of riots without the military's presence.

Soldiers are quick to point out that they aren't in charge here: The Haitian government and international aid groups have that responsibility.

Lost Limbs in Haiti

February 23, 2010

Countless Lost Limbs Alter Life in Haiti’s Ruins
By DEBORAH SONTAG (New York Times)

PORT-AU-PRINCE, Haiti — “Don’t cut off my leg!” Fabienne Jean screamed repeatedly as she was carried through the gates of the General Hospital here after the earthquake. “I’m a dancer. My leg is my livelihood. Please, don’t take my leg.”

After four days on the hospital’s cluttered grounds, lying among what she described as the “dead and living all mixed up,” Ms. Jean was wheeled into an operating tent where her crushed, infected right leg was amputated below the knee.

“It is a sad story,” Ms. Jean, 31, a slim, graceful woman who danced for the Haitian National Theater, said recently, massaging her bandaged stump. “But what can I do? I can’t kill myself because of this, so I have to learn to live with it.”

More than a month after the earthquake, thousands of new amputees are facing the stark reality of living with disabilities in a shattered country whose terrain and culture have never been hospitable to the disabled.

Some remain in hospital tents swarming with flies; others have moved to makeshift post-surgical centers; and those who healed quickly, like Ms. Jean, have been discharged to the streets, where they now live. All need continuing care in a nation with no rehabilitation hospital, few physical therapists, no central prosthesis factory since the quake and a skeletal supply of crutches, canes and wheelchairs gradually being reinforced by donations.

“The situation for newly disabled persons is very delicate,” said Michel Péan, Haiti’s secretary of state for the integration of the disabled. “They urgently need not only medical care but food and a place to live. Also, we cannot forget those disabled before the disaster who, because of their handicap, are having trouble getting access to humanitarian aid.”

Rough estimates of the number of new amputees are based on information from overburdened hospitals that did not keep good records of surgeries. The Haitian government believes that 6,000 to 8,000 people have lost limbs or digits. Handicap International estimates that 2,000 to 4,000 Haitians underwent amputations, and many thousands more suffered complicated fractures, some of which could turn into amputations if not managed well.

Dr. Péan, who is blind and serves in a relatively new post as government advocate for people with disabilities, said that Haiti’s disabled — some 8 percent of the population even before the quake — had long been treated as second-class citizens. But the government has recently taken legal steps to recognize their rights and opened offices to serve them in the countryside, he said.

Ideally, Dr. Péan said, post-earthquake reconstruction could provide an opportunity to make Port-au-Prince, Haiti’s capital, more accessible to people with disabilities and the impetus to create a national institute for rehabilitation.

For the moment, though, the urgent focus is on the uncertain present: making sure the thousands who underwent life-saving amputations have a future.

Handicap International, based in France, has been coordinating the postdisaster rehabilitation effort with CBM, a Germany-based Christian disability group, and with the Haitian government. Its volunteers — about five dozen therapists, nurses, technicians and community workers — have been providing postsurgical care and physical therapy at 12 hospitals here, and the organization is setting up a prosthetics workshop, too.

“We know that persons with injuries and disabilities are going through a difficult time right now, but they should not feel they’re alone,” said Aleema Shivji, an emergency response specialist with the group. “There are services available, and they’re increasing by the day.”

Recently, Caryn Brady, a physical therapist from Canada, made rounds through the sweltering postoperative tents outside the General Hospital. The patients there are being seen by such a revolving cast of international medical professionals, with charts so poorly kept that scribbled messages on bandaged stumps communicate the essentials: “See again on Feb. 23. Thanks. (Smiley face.)”

Bedside, Ms. Brady led Emmanuel Souverain, a university student whose right arm was amputated, through a series of exercises meant to prevent contractures and keep his muscles healthy for a prosthesis — although there is no plan yet to manufacture upper-body prosthetics.

Proceeding on to Mana Alexandre, 22, a double amputee in a white slip, Ms. Brady smiled when Ms. Alexandre showed off, bicycling her two leg stumps fiercely, a proud smile on her face. After more exercises, Ms. Alexandre moved, with the therapist’s guidance, into a wheelchair, but worried about how to get back into bed.

“Well,” her petite, dimple-faced mother, Evenie Belizaire, said, “I’ve been lifting you your whole life, with God’s help.”

Ms. Alexandre’s stumps dangled over the seat of the wheelchair. “At home, there are chairs with a padded extension that can slide out and provide support,” Ms. Brady said. “But maybe they can find a board?”

The need to adapt is challenging for all new amputees, but here newly discharged patients like Ms. Jean, the dancer, do not even have homes in which to recover or level, paved surfaces on which to plant their crutches or walkers.

On a recent afternoon, Ms. Jean sat on a plastic chair in front of her family’s new home, a small green tent on a rocky hillside. Her sister-in-law stood behind her, stroking Ms. Jean’s long, fine braids protectively as she spoke.

“Dancing was my hobby, my work, my passion, my everything,” Ms. Jean said. She dug out her purse and offered up a couple of photographs of herself in folkloric costume: one, a Judith Jamison-like pose, the other, a slinky Carnival performer. “That was me,” she said. “The before pictures.”

When her house shook violently on the day of the earthquake, Ms. Jean had been preparing to shower. She ran outside in her underwear, a towel wrapped around her waist, she said.

Standing beside a wall, she breathed in relief at having escaped before her home partly collapsed. And then the wall fell on top of her. Pulling herself out of the rubble, she found her leg snapped in two, bound it together with her towel and hopped back into her house to retrieve some clothes.

Ms. Jean does not remember who took her to the hospital, a scene of utter chaos. Two days later, a doctor promised to try to save her leg, she said, but she never saw him again. She lost her leg four days after the earthquake, and her emotions have oscillated since.

After 10 days, the hospital sent Ms. Jean to a makeshift rehabilitation center near the mass graves in Titanyen. An American prosthetics specialist, Dennis Acton, who examined her there, described the place as a kind of “squalid homeless shelter for amputees.”

From there, Ms. Jean was discharged, with a walker, to her doting family. Her father, Roigner Trazile, 48, dabbing at his eyes, said that his hope in life had been lost along with his dancing daughter’s leg.

“Before, when she actually had two legs, I thought she would become somebody, and then I would become somebody, too,” he said.

But, Ms. Jean said that “some foreigners” — Mr. Acton, actually, who was there with a team from New Hampshire — have promised her not only a regular prosthetic but a high-performance one, too, that could allow her to dance again.

“O.K.,” she said, smiling. “I am waiting.”