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.”

The Irish and the Haitians Probably have Much in Common

An Irish farmer returning from the market where he sold his pig reported: "Well, I didn't get as much as I expected, but then I didn't expect I would."

--John McCarthy

Gangs in Soleil...Deja vu Again!

(Photo by John Carroll)

My wife and I lived in Haiti during large parts of 2006 and 2007.

Kidnappings, gangs, the UN occupation of Haiti, and political unrest were all hot and dangerous topics du jour.

This article and video about Haiti after the earthquake is scary.

Growing Risk in Haiti

See this New York Times slide show.

Frandy's Tent

Frandy is a young Haitian Hearts patient and friend of ours. He also works for us in Port-au-Prince.

Frandy's home in Carrefour was destroyed in the earthquake.

The picture above is Frandy with his mother in the background.

He and his mother are two of the thousands of displaced people in Haiti living in tents or under tarps.

Please go to Frandy's blog.

Marie

We lost Marie.

Rainy Season Not Yet Here

Haiti: Survivors Face New Fear

By MJ Smith
(Photo by John Carroll)

Port-au-Prince - The rain came in the middle of the night, turning the ground under tents made of blankets into mud, and all anyone could do at Haiti's sprawling homeless camps was be thankful it was not May.

They sought better cover or just stayed where they were. Some were resigned to not sleeping.

"You've got to stand up," said Markson Jean, a 24-year-old who lives with his three-year-old child in a massive camp at what used to be a country club golf course on a hilltop overlooking Port-au-Prince.

Haitians who survived the collapse of their homes in last month's devastating earthquake that killed more than 200 000 now fear something that may at first seem far less threatening: rain.

Downpours like the one early on Thursday have provided a reminder that the heavy rain season begins around May even as 1,2 million people made homeless by the quake remain living in camps or in the streets.

Besides the obvious concern that homeless camps will be consumed by mud, the rains also threaten to create a nightmare health scenario unless functioning latrines and drainage can be built in time.

The UN humanitarian coordinator, Kim Bolduc, said last week that the Champ de Mars camp near the destroyed National Palace, where about 16 000 people are living, had already "turned into an almost dangerous area" due to poor sanitation.

Aid workers are rushing out tarpaulins in a bid to provide everyone with some kind of shelter before the heavy rains, but officials admit that they will only provide basic protection even if they can be distributed to everyone in time.

They are also working to build latrines, but UN officials recently estimated that only five to 10 percent of what was needed had been completed.

"No matter what, though, it's not going to be pretty," Anthony Banbury, the deputy head of the UN mission here, recently told AFP.

Officials have chosen to focus on distributing tarpaulins instead of tents in part because they can reach more people faster.

"There is an impression out there that we will be able to turn around and build transitional shelter with framing and all that by the rainy season. Forget it," said Canadian Deputy Commanding General Nicolas Matern of the Haiti Joint Task Force.

"It ain't going to happen. We don't have the resources nor the time to do it."

The strategy is a hard one for many desperate Haitians to accept.

Some waiting in line recently to collect tarpaulins - including those who said they arrived at 3.00am for the distribution that began more than seven hours later - said the material was not nearly enough.

After Thursday's rain at the golf club camp, where a vast patchwork of makeshift tents housing thousands stretches downhill on what used to be bright green grass, Haitians dug small trenches to keep their tiny living spaces from flooding again.

They hung clothes from rope, dragged mattresses out to dry and washed clothes. Others waited in line for vaccinations.

"Water came in over the ground," said Clautide Berlice, 32, as she washed clothes in a small basin outside her shelter made of blankets and wood.

"It was really hard."

Ten people live in her shelter near the top of the hill at the golf course, where the view extends past collapsed buildings and ruined neighbourhoods toward the Caribbean Sea.

The camp is better off than others, with many tarpaulins being used as opposed to scrap material, though there is plenty of that as well.

Old signs were turned into walls, while thin tree branches were being nailed together to form frames.

Some said they had been provided with food rations such as rice. Others said they had yet to be given anything.

Elisoi Mista, 64, carried sticks for his makeshift tent in one hand and a machete in the other. He too said water had entered the shelter where his wife and two children live the night before.

His house collapsed in the quake, but he and his family were not inside at the time.

"God has given me a chance," he said.

"Because we are still alive." - Sapa-AFP



Published on the Web by IOL on 2010-02-19 11:12:35



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Returning Home to Haiti

(Photo by Jennifer Carroll)

Published at www.nejm.org February 19, 2010

Returning Home to Haiti — Providing Medical Care after the Earthquake.

As I left an anesthesiology lecture on January 12, someone stopped me to ask whether I had checked on my family in Port-au-Prince. When he explained that there had been an earthquake, I breathed a sigh of relief — earthquakes, I reassured him, are a frequent occurrence in my country. It was not until I saw the news on television moments later that I realized the gravity of the situation.

Born and raised in Port-au-Prince, I completed medical school at the Université d'État d'Haiti and then served as a general practitioner for Haiti's Department of Public Health in the port city of Jacmel. When I came to Boston to start a residency in anesthesiology, I did not expect to be returning to my homeland after only 6 months of training to apply what I had learned.

I hastily prepared to return to Port-au-Prince to help in any way I could. Another Haitian resident and three faculty members from our department decided to accompany me. Together, we gathered medical supplies donated by Boston-area hospitals and took a minimum of personal items, all stuffed in duffel bags. We flew directly to Port-au-Prince on a chartered plane, arriving 96 hours after the earthquake, on Saturday, January 16.

From the airport, we traveled to a makeshift hospital where two big tents, originally intended as warehouses, were filled to capacity with earthquake victims. There were two double rows of cots set less than a foot apart from one another. Every cot held a patient, and injuries ranged from minor wounds to severe, life-threatening ones. Men, women, children, babies, elderly patients — all were crowded together in this chaotic scene. The suffocating heat and stench brought me back instantly to the harsh realities of health care in Haiti.

Most patients had limb fractures, many of which were open and infected. Others had gangrene of their limbs, necessitating immediate amputation. There was hunger, dehydration, and pain. One could hear patients screaming during dressing changes and from the pain of accidental movement of fractured body parts. Some were sobbing over loved ones they had lost. Others slept, owing to extreme fatigue, in spite of the environment.

Critically injured patients who seemed more likely to survive were transferred to better-equipped field hospitals. Those who were clearly not going to make it were hydrated and received analgesics. No supplemental oxygen was available.

When we arrived at the field hospital, no operating room had yet been set up. There were about 30 physicians and 20 nurses caring for approximately 300 patients. My anesthesia colleagues and I provided nursing care, since there was no setting in which to perform surgical procedures. We started intravenous lines and administered analgesics and antibiotics, and those of us who spoke Creole began translating for other health care personnel.

That evening, the team saw a 9-year-old boy die from sepsis due to gangrene in his arm. Surgeons and anesthesiologists then made the bold decision to amputate gangrenous limbs of young, otherwise-healthy patients, despite of the lack of an adequate operating room. The first attempt at an amputation took place under a mango tree with light provided by flashlights and the patient under intravenous general anesthesia. The patient died during the procedure. The second patient, an 18-year-old, required a right arm amputation. He survived.

The following morning, in bright daylight, after only a few hours of sleeping on tables or on the sidewalk, we decided to create an operating room, using some dividers and three dining tables. We had a fair number of useful surgical tools, but there was only one pulse oximeter and one blood-pressure cuff. Still, we performed two operations at the same time to take advantage of the daylight, since we had no other source of bright light.

On the first day, we performed eight amputations and three débridements. The improvised operating room functioned for 5 days, during which the team performed a total of 22 amputations and 68 other procedures. There was an improvised recovery area where a pediatric ICU nurse cared for the patients. There were no additional deaths during surgery or in the recovery room. This experience taught me the value of ketamine — the mainstay of our anesthetic management.

As jarring as these details may seem, all this was not entirely new to me. In medical school, I had encountered similar scenarios, though at the time I lacked the resources to help. Now, for the first time, with some limited supplies, I was able to truly help those under my care. For these patients, the small amount of antibiotics and intravenous fluids we brought made the difference between life and death.


Paul B. Delonnay, M.D.
Boston Medical Center
Boston, MA

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

This article (10.1056/NEJMpv1001789) was published on February 19, 2010, at NEJM.org.

Haitian Woman Walks 30 Miles with Broken Leg to Find her Child

(Photo by Jennifer Carroll, pre-earthquake.)

Published at www.nejm.org February 17, 2010


The GHESKIO Field Hospital and Clinics after the Earthquake in Haiti — Dispatch 3 from Port-au-Prince


After the January 12 earthquake in Haiti, the Port-au-Prince clinic of the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) became a refugee camp and an emergency field hospital (see slide show), in addition to remaining a clinic for patients with AIDS or tuberculosis. Our field hospital was established 7 days after the earthquake, with the arrival of a surgical team from the U.S. Department of Health and Human Services (DHHS). During the past 4 weeks, the 80-member DHHS team has seen more than 2500 patients, 40% of them less than 18 years of age. The surgeons have performed 278 major surgeries; the most common included placement of external fixators to stabilize fractures, débridement of necrotizing soft-tissue infections, and lifesaving amputations. The hospital is now seeing mostly minor surgical cases and infectious diseases. Patients with the most complicated cases have been stabilized and evacuated by helicopter to the U.S.N.S. Comfort, a 500-bed naval hospital ship in Port-au-Prince Bay.

Tetanus is a major problem; tetanus vaccines were in short supply after the earthquake, and many Haitians are not vaccinated. So far, we have seen two children and one adult with advanced tetanus. One died, one is recovering, and one was evacuated to the U.S.N.S. Comfort.

A looming question is what happens to disabled patients in need of additional operations and rehabilitation when the international medical teams depart. The Haitian medical system in Port-au-Prince has been devastated and is not prepared to handle the tens of thousands of patients with amputations, paralysis, or major fractures who will need months or years of care. GHESKIO is opening a rehabilitation center; international rehabilitation experts are assessing the needs, we are securing supplies, and we will train Haitian occupational and rehabilitation therapists.

Children are now presenting with diarrhea, febrile illnesses, respiratory tract infections, and scabies superinfected with staphylococcus and streptococcus. Before the earthquake, Haiti had one of the world's highest levels of food insecurity. Childhood malnutrition is now a worsening problem; mothers have no food, pots, or cooking fuel. Children who were chronically malnourished before the earthquake are becoming severely malnourished. Children who were severely malnourished before the earthquake are dying. Many infants were separated from their injured mothers and abruptly weaned from breastfeeding. These babies are not receiving adequate feeding and hydration; they are presenting to the field hospital in critical condition, with severe dehydration.

GHESKIO has established an emergency nutrition program for refugees and patients. We are providing supplementary feeding for children less than 5 years of age and pregnant women, conducting surveillance and rehabilitation for severe malnutrition, promoting exclusive breast-feeding, and providing replacement feeding for babies without mothers.

Caring for children who have been separated from their families in the course of emergency rescue and care is extremely difficult. We received a group of patients by helicopter who had been rescued from a collapsed church 30 miles away. The group included seven unaccompanied children under 12 years of age, two of them babies. One 2-year-old boy had an above-the-knee amputation and was evacuated to the U.S.N.S. Comfort. His mother arrived several days later, having walked 30 miles with a fractured leg, checking every hospital along the way for her child. She arrived in tears, holding her son's picture. A GHESKIO pediatrician will board the U.S.N.S. Comfort to identify and reunite this boy with his mother. A sustained effort is needed to reunite injured children with their families.

In the meantime, the GHESKIO AIDS and Tuberculosis Clinic has continued to provide outpatient care to patients with AIDS or tuberculosis. We also operate an inpatient tuberculosis sanatorium. Since the earthquake, 85% of our 6000 patients with AIDS — including 907 enrolled in therapeutic clinical studies sponsored by the U.S. National Institutes of Health — have returned for their medications and clinical follow-up. Patients are being seen in an outdoor courtyard, since neither staff nor patients trust clinic buildings.

HIV-prevention services have also resumed. In the 7 days before the earthquake, GHESKIO provided voluntary HIV counseling and testing to a median of 120 patients per day. Since the earthquake, we have provided these services to approximately 32 patients per day.

Continuing tuberculosis treatment and prevention in Port-au-Prince is critical, since tuberculosis spreads easily in poor, crowded housing. The GHESKIO tuberculosis sanatorium at Signeau collapsed. It housed 80 patients, including several with multidrug-resistant (MDR) tuberculosis; 4 patients died, and a number are missing. We have traced all our patients with MDR tuberculosis, and they are receiving their medications.

In addition, the National Tuberculosis Sanatorium in Port-au-Prince was severely damaged, and several hundred of its patients are dispersed in refugee camps without medications. We have established a field sanatorium at GHESKIO, with tents for patients with tuberculosis who suffered trauma and need postoperative care, patients with MDR tuberculosis, and others requiring inpatient care.

Diagnosing tuberculosis requires a substantial laboratory infrastructure (for radiology, microscopy, and mycobacterial culture). To our knowledge, the GHESKIO clinical laboratory is the only functioning tuberculosis laboratory in Haiti. We are performing tuberculosis diagnostics for our patients for patients at other field hospitals, and on sputum samples sent by helicopter from the U.S.N.S. Comfort, where physicians are vigilant to prevent a tuberculosis outbreak.



Jean William Pape, M.D.
GHESKIO Center
Port-au-Prince, Haiti
Center for Global Health, Weill Cornell Medical College
New York, NY

Protecting the Children of Haiti

Published at www.nejm.org February 17, 2010

Protecting the Children of Haiti

Satchit Balsari, M.D., M.P.H., Jay Lemery, M.D., Timothy P. Williams, M.S.W., M.Sc., and Brett D. Nelson, M.D., M.P.H., D.T.M.&H.

(Photo by John Carroll)


Haiti has long had difficulty in protecting its children from harm. The earthquake that struck the country on January 12 destroyed much of the capital, Port-au-Prince, as it killed many government officials and United Nations (UN) workers and left as many as 230,000 people dead and many thousands injured. In the wake of this sweeping disaster, the plight of Haiti's children has acquired new and terrible dimensions.

On January 24, we went to Haiti as members of a team sent by the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University to conduct a multisite rapid assessment of child-protection needs in the post-earthquake environment, where it was already evident that children were at grave risk of abandonment, abuse, and trafficking. The focus was on the current systems and practices for identifying and caring for unaccompanied children and for tracing those who had been separated from their families and reuniting them with parents or guardians. Longer-term interventions to promote the welfare, rights, and safety of this population were also examined.

In 9 days, we interviewed more than 25 stakeholders in Haiti, including government officials, local staff members, humanitarian aid workers, and representatives of domestic and international nongovernmental organizations and UN agencies. We visited field hospitals, clinics, shelters, and orphanages, along with observing risk-assessment practices and participating in meetings of UN "clusters" (groups focused on individual service sectors).

Children constitute almost half of Haiti's population of 9 million. Before the earthquake, an estimated 350,000 children lived in "orphanages," yet only 50,000 of them had no living parents.1 Desperately poor families have often felt compelled to place children in residential care facilities, only to return later and find that they have been given away for adoption. Throughout the world, many families have historically relinquished their children when they reached a tipping point due to unmanageable birth rates; parental death, disability, or unemployment; physical insecurity; displacement; or natural disasters.2 In pre-earthquake Haiti, many families had already reached such a crisis.

Local officials estimate that there are about 350 registered orphanages in the country and about twice as many unregistered and unregulated ones. Even most registered institutions do not meet international UN guidelines. A related long-standing threat to child protection has been the common practice of sending children away as restavèks (Creole for "stay with") to live with others in exchange for work. An estimated 150,000 to 500,000 restavèks work essentially as unpaid domestic laborers, with little or no access to education or recreation and subject to physical, mental, and sexual abuse.3 The restavèk situation and the practice of institutionalizing children reflect the extreme destitution of Haitian families. Thus, the earthquake occurred against a background of economic extremity driving family separation, aggressive trafficking networks, inadequate law enforcement, and a growing global demand for adoptive children.

Parents died and families were splintered as a result of the earthquake. In the rush to provide emergency care, injured adults and children were often scattered, taken to the nearest available health care facilities, and sometimes transferred, without records, to other centers. This situation prevailed for a month, during which time little, if any, demographic or registration information was collected at sites of care or settlement. Critical early opportunities to record, identify, and trace children and families were lost. The lack of data has impaired all aspects of child-protection efforts.

Irregular settlement adds further risk. By January 31, there were 1.1 million Haitians in need of shelter in Port-au-Prince and the surrounding communes, living in 591 documented improvised settlements — some of which, like the Petionville Club, hosted as many as 100,000 refugees.4 Children and young people in these dense settlements are easy targets for organized crime, violence, and sexual exploitation.

This disaster has imposed a massive socioeconomic burden on a country that was already struggling with poor governance and an impoverished population. Stripped of all assets by the earthquake, a growing number of families are parting with their children. Given Haiti's unregulated borders, weak law-enforcement practices, and insufficient numbers of international monitors, traffickers face few deterrents. There is growing consternation among child-protection workers about the lack of financial and human resources for protecting Haiti's vulnerable child population, which is estimated by some at 1 million.5

The restavèk phenomenon and unregulated "orphanages" pose challenges to the placement of unaccompanied children. Although international standard practice is for orphans to be promptly returned to their relatives or communities, the restavèk option and severe poverty make community-based solutions problematic. Many aid workers feel compelled to consider institutional placement as a safer interim solution. But safe institutions are hard to come by. We encountered several hospitals where unaccompanied children whose treatment was complete were not being released for lack of a safe discharge plan (though in the first few weeks after the earthquake, many unaccompanied children had been discharged to the street). Representatives of orphanages visit camps and hospitals daily, and there is no effective mechanism for distinguishing safe residential care facilities from fronts for trafficking.

Adoption is sometimes seen as a viable alternative in the face of destitution. Experience from past disasters and conflicts, however, suggests that adoptions in the immediate wake of such crises carry a high risk of permanent removal of children who are not actually orphans — a practice that inevitably inflames latent nationalist sentiment in the affected region. The fields of child human rights and child psychology place great emphasis on maintaining the integrity of the family unit, where children have the best chance of being raised in a loving, intimate environment. There is great need now to provide care for thousands of children, including those with medical and other postoperative needs, and in some instances temporary protection status or adoption across borders might be acceptable. But a much better system for tracing children and protecting borders must first be implemented, to reduce the risk that children will be torn from their own families who, given the means, would nurture and care for them.

Improved family-tracing procedures, border control, effective scrutiny of international adoptions in line with the Hague Convention on Protection of Children and Cooperation in Respect of Intercountry Adoption, and more stringent oversight of orphanages are urgently needed to forestall further abuse. We believe that all aid workers, including voluntary health care professionals, should receive training in child-protection norms and be sensitized to the prevalence of child abandonment, abduction, and trafficking. Child-protection basics, including identification procedures and record keeping, reestablishment of educational opportunities, creation of child-friendly spaces (set up specifically for children in crises to address their physical and psychosocial needs in a stable, trustworthy environment), and health interventions, must be ramped up rapidly. Additional steps must be taken to strengthen local governmental and policing institutions charged with child protection, specifically the Ministry for Social Welfare and Research and the Brigade for the Protection of Minors.

A sustained strategy must be developed to mitigate the distress and insecurity of affected children. The challenges of tracing and family reunification must be addressed through streamlined data-acquisition systems, heightened public awareness, and community-driven monitoring initiatives. Attention to child welfare and disability-related needs is essential, even as economic strategies are found to enable families and communities to achieve a reasonable standard of living. A common refrain heard among aid workers is that to ensure safe childhoods, families must be given a fair chance to be economically viable — which requires investments in health, education, vocational skills, sustainable livelihoods, microfinancing, and improved agricultural practices.

A senior aid worker spoke for many seasoned responders when he said, "We must be firmly committed to this notion of building back Haiti better. We must not accept the restavèk phenomenon as the inevitable. We must build a society free of restavèks. Children belong in their communities." This goal will be difficult to achieve. Yet, as the UN's special rapporteur recently remarked, "The human security of every child is of utmost importance to the sustainable development of a society based on human rights and [is] a precondition for sustainable peace."3

An imaginative, bold solution is required. Recovery from an earthquake is always complex and slow, but Haiti's children should not be made to wait and suffer. One million vulnerable children are a very large share of Haiti's future and of ours.


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

Garfield's House in Port-au-Prince

Haitians Need Shelter

(Photo by John Carroll)

Heurese, our Haitian Hearts patient, travelled from Bainet to Carrefour today. Bainet is on the southern coast of Haiti.

This afternoon she called and reported that the capital is "very dirty". When I asked her where she was going to sleep tonight, she calmly replied "on the ground in Carrefour".

Another Haitian e mailed today stating that he and his family needed a tent.

Lack of shelter is a big issue everywhere in Haiti but especially in the Port-au-Prince area.

Port-au-Prince is built on the side of a mountain. Many more lives will be lost in the coming months unless hundreds of thousands of people can be moved to higher areas and provided with adequate shelter and clean water.

Can't we do this? We all have Twitter, Blogger, Facebook, and a seemingly infinite number of smart phones. We have technology out the kazoo.

But do we have the heart?

Please see article from the BBC below.


Haiti Tent Need Urgent, UN Says

The United Nations has urged countries to rush tents to Haiti to help protect more than one million people made homeless by January's earthquake.

"We need latrines, we need field tents, we need plastic sheets so that people can cover themselves," said the UN's top official in Haiti, Edmond Mulet.

"The rains are coming. I don't think we are going to be able to shelter all these people in time," he warned.

He was speaking after Haiti aid talks with EU and US officials in Spain.

Heavy rain fell on Thursday in Haiti, forcing many people to scramble for shelter.

The massive 12 January earthquake killed up to 230,000 people in and around the Haitian capital, Port-au-Prince.

Homeless quake victims are still sheltering in makeshift camps scattered across the ruined capital. Sanitation is a major problem, with aid workers warning of the threat of disease spreading.

Spain, the current holder of the EU presidency, says the homeless Haitians must be relocated as soon as possible.

The talks in La Granja, near the Spanish town of Segovia, were aimed at better co-ordinating the aid effort by the EU, UN and US.

Leaked e-mail

The UN says its appeal for $576m (£366m; 420m euros) in emergency funding for Haiti has now been 95% met.

The EU's aid for Haiti, including planned pledges, totals nearly 309m euros, of which 120m euros is European Commission money.

On a visit to Haiti on Wednesday the French President, Nicolas Sarkozy, pledged 270m euros in reconstruction aid for the former French colony.

The UN head of humanitarian affairs, John Holmes, has criticised the performance of aid agencies in Haiti.

In a leaked e-mail to agencies, Mr Holmes - who visited Haiti after the earthquake - said a lot had been achieved but that much of their efforts had been poorly co-ordinated and resourced, weakening confidence in their ability to deliver help.

He said major humanitarian needs had not been met, particularly in relation to shelter and sanitation.

Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/8522732.stm

Published: 2010/02/18 17:50:53 GMT

© BBC MMX

Letter to Haiti: A Love Poem

Letter to Haiti: A Love Poem
Posted: 02/17/1016


"Desire....The opposite is death. So do you wonder? How could you possibly wonder!"
-Blanche DuBois

Dear Haiti,

I thought I would write you as
A beautiful but destitute woman:
Everyone wanted you; no one would marry you.
No one dared marry you,
Not that you cared for marriage.
But you are not that woman.

So, then I tried Hemingway-
No, better Graham Greene-
Breakfasts of kumquats and rhum-coke calm;
A strange epoch in which time stood still
Save for the slow decay of the gingerbread porch.
But that was all just picked up from what I read later.

Next, I looked for something in your shapes:
There was your physical form, a Siamese twin
Trying to wrest herself free, to be on her own;
Or, there was the way your name sounds like Hades in English,
And in French, like high,
And when you say it, like I.
But no accent or point of view quite captured you.

The truth is I don't remember you in a word or a story.
And, being away from you for so long,
My memory has had to filter through all the talk
Of impatient longings to write your ending.
I thought I would write you tragically,
But that too was a borrowed impulse.

Still, there is a tone, a quality of sound,
Of air, a sensibility that stays with me.
You taught me to see colors
I cannot find anywhere else.
The closest I've come-
A dusty turquoise, let's say-
Is always slightly too muted or too dark.
The pinks are too aggressive - not your pink.
But sometimes, when the daylight is warm and wide,
I'll notice I'm wearing your colors,
Painting the streets with them,
Giving them away to friends.

You are a gorgeous one. Everyone agrees.
I remember your beasts and your flowers,
Though I can't recall their names.
I can still hum pieces of your lullabies,
Though I couldn't sing them from start to end.
Even now I can ask for ice cream in your creole,
But I wouldn't know how to write it down.
And, after all this time, I can still picture
Your steamy mountains,
Your beaches of black sand
Sparkling like powdered onyx,
Your women carrying
Heavy loads on their heads. No hands!
In your care, I learned to do it too.

Now I see you. There you are
Walking up the hill
Balancing a basket of fruit on your head.
You cannot find your children.
You will keep looking, I know.
I was a sensual child in your lap.
We are all like that with you.
We all love to touch your world.
You will keep walking up the hill.
I have seen you do it before.
You are stronger than your buildings.
Your head is level. Your babies are laughing.


Nelly Lambert, a Ph.D. student in English and American literature at Catholic University, lived in Haiti as a child, from 1983-1987

Reflections on Haiti...a Must Read

My friend David Volk sent me this e mail written by Rob Chamberlin.


From: Rob Chamberlin
Sent: Sat, Feb 13, 2010 8:38 am
Subject: Reflections on Haiti


Hi Friends and Family,

I hope that this email finds you all well, and that you all had a good week.

I've returned from my trip to Haiti, and thought I'd share some of my thoughts. Overall, I'm so grateful that I got down to Haiti, but it was hard to see and, as much as I try to fight against being overwhelmed, it was at times overwhelming.

This email is rather long, so I'll put in little section heads so you can just read the parts that may be of interest to you.

Work
Briefly about what I was doing - I was sent down to mainly support another Brigham resident who is working with Partners in Health, Natasha Archer. Natasha's role has been to be the PIH representative at the University Hospital (general hospital) in Port-au-Prince. The hospital is the city's biggest hospital, and is right in the center of town where there was so much damage. PIH was called in to support the hospital administration, and help be a liason between all the other medical NGO's working at the hospital and the hospital administration. We are also supplying volunteer physicians to the hospital. One of my projects was working with a hospital administrator to develop a system to track all the foreign volunteers working at the hospital. Another project was to help the hospital statistician develop a system for recording epidemiological information about patients. They already have such a system in place, but they just needed to adjust it to the new situation of staffing/physical structure. I also helped schedule and manage our volunteers. The PIH team stayed in tents in the courtyard of a school about 30 minutes away. We had medical and nursing teams from Philadelphia, Boston, NYC, and Miami, for a total of about 25 medical volunteers. And finally I did clinical work on a couple of nights. It was quite a challenge to try to make clinical decisions with limited tests (only a cbc is available at night, and no imaging) and limited medications. The patients themselves were amazingly grateful and tolerant.

Current hospital set-up
Only 1 hospital building, of about 10, is stable enough for patients. So most of the patients are being cared for in about 20 tents set up on the hospital grounds. There are medical teams there from Norway, Switzerland, Denmark, Canada, Spain, Peru, the US, Israel, and Belgium. People are divided up among functions - the Swiss managed pediatrics, the Norwegians were doing surgery, the Belgiums ran the dialysis unit (very important as crush injuries can lead to kidney failure), the Americans did ED/surgery/medical care, the Israelis did surgery, etc. There was also a strong US military presence at the hospital, which provided good security but often with unnecessary verbal aggression.

The physical damage from the earthquake
The University Hospital is right downtown, where there is a lot of destruction. Not to dramatize things, but just to give a sense of the damage I'll share a few stories. Driving into the hospital, I would say that 30% of houses/buildings had crumbled flat, and another 50% were damaged enough to be uninhabitable. I reflected one morning that, as long as you had survived the earthquake, it would be better for your house to have crumbled flat than to be cracked and too unstable to inhabit. Even before rebuilding their homes, I wonder how these people will find the money/equipment to even tear down their homes.
Some streets had almost no one on them as the whole street was full of destroyed houses. Some roads had rubble fallen into them so much that the street became a 1-lane road. One of the hardest parts of working at the University Hospital was that the nursing school was destroyed with over 100 nursing students killed under the rubble. In the heat of the day, the stench from the nursing school was horrible. In a country so in need of medical care, it was a wrenching reminder of the long-term devastating effects of the earthquake. Outside of another building I saw 2 partially decayed dead bodies recently uncovered from the rubble. It was just so sad.

Jimmy's experience of the earthquake
Jimmy (Bos's son, with whom I lived when I was a Peace Corps volunteer) told me about his experience of the earthquake. He was outside the hospital because he was accompanying his friend and his friend's pregnant wife who was going to get a c-section. His friend's wife went in to the OR, and Jimmy went out to buy medicines for them. Then the earthquake hit. Jimmy saw the building across from the hospital crumble. He saw cars and trucks that couldn't stear getting tossed left and right, hitting pedestrians. He saw people fall to the ground. After the 30-seconds of quake, Jimmy ran to find his friend. His wife had luckily not had her c-section, although another woman was in the middle of her c-section and died during the earthquake. They then walked for hours, looking for family and friends, as there was no cell phone service. He assumed his 2 younger brothers were dead, as well as his step-mother and others back in his hometown of Vialet. There were frequent after shocks, causing continued destruction and loosening of unstable cement blocks. Jimmy saw one man get killed when an aftershock caused a cinder block to fall 2 stories and hit the man. They walked down the center of the street as best as they could, as to avoid further tumbling of debris from buildings. Eventually, he and his siblings all found each other, and by some miracle all were alive and well. However, friends of theirs who went to their apartment house presumed that they were dead because the house was ruined. Jimmy's youngest brother ran down the stairs of their apartment during the earthquake, with the stairs literally crumbling behind him. The next day there were thousands of people who had all slept in the public plaza. Yet everyone was terrified all night because they heard that the earthquake had caused the earth to split and create caverns in some places. So, they couldn't go into building because they might fall, and they didn't want to stay on the ground out of fear it would open up beneath them. The next day, waves of rumors would spread through this crowd that a tsunami was coming, so there would be a stampede up to higher ground, with badly injured people left behind. After a second night of sleeping outside, Jimmy and his siblings gathered up their remaining money to buy a bus ticket back to their hometown of Vialet.

General reflections
nothing too profound, just some thoughts that I had while down there

Good intentions - It's such a tough thing, sometimes, figuring out how best to serve. Every foreigner I saw at the University Hospital had good intentions for being there. Sometimes it seems evident to me that someone's attitude about helping is not necessarily based in principles of respect and solidarity - such as the soldier who was explaining to another how you have to aim above someone's head when you are shooting into a car because the bullet will get deflected down by the windshield, but you have to aim low when you shoot from a car because the bullet will get deflected up. Or the guy American doctor doing medical care at the hospital, who explained to me that we can't provide too good of care while we were there because then the Haitians would get too "used to" good care. Or the guy from Boston who wants to be helpful so he works with a statistician on a project that perhaps the statistician knows how to do already, or perhaps take him away from something that is more important. And yes, the army guy is providing security, which really is needed. And the NGO guy is helping to provide medical care to the sick. And the Boston guy (that's me), well he's a lost cause. Yet, while good intentions are important, they aren't enough. I think we do have to be critical of 'hero's', and we do have to take a stand that certain approaches to helping are harmful. And it seems that certain principles should guide our efforts of service, so that we don't live out that saying of roads paved with good intentions.

Hard working Haitians - I was amazed at how hard some of the Haitians were working, in the face of such a catastrophe. Someone made the comparison that this was the equivalent in life-lost to about one hundred 9/11's. In the face of that, it's sometimes impressive that anyone can come into work at all. The overall director of the hospital and the administrative director both slept at the hospital, and would often wake up at 2am to continue doing work. The statistician slept in his car, awakened every morning around 4am by relentless mosquito bites. I'm sure that every Haitian working at that hospital had some family member or friend who died, yet they were still coming in to work. And not to glorify the Haitians, because there were still some struggles - getting nurses to record medications that were given, beaurocracy that sometimes delayed access to needed equipment, etc. But, in the face of such tragedy, I was impressed.

PIH - It was a real privilege to work with Partners in Health. I got to spend time with a number of PIH folks - some Brigham residents who work with PIH, a young guy doing logistics for PIH, Joia Mukherjee, the medical director for PIH, Paul Farmer, one of the founders of PIH. I just found myself inspired and challenged by these people. Joia has an amazing fire and passion for living out one of PIH's moto's - "Providing a preferential option for the poor in healthcare". In conversations I often found myself saying "yah, that's right", and getting fired up about inequalities, or beliefs, or approaches to addressing issues of poverty. And there was a combination of respect for Haitians, a belief that things (not just related to the earthquake, but related to inequalities in the world) can get a better, and a commitment to forever working on this, that just felt right.

Trying not to be overwhelmed - In the face of all of this destruction, I found myself often feeling totally overwhelmed. However, while I do not know how Haiti will recover from this, I think that despair is a luxury that Haitians can't afford, and neither can we. Because despair and being overwhelmed can just lead to paralysis and inaction. I had a moment of clarity around this one night when I went to the hospital and got a sign-out for patients in one of the tents. A sign-out is the brief patient notes that one doctor leaves for a next doctor who coming in for the next shift. I looked at the sign-out: 54 year old man with pneumonia; 36 year old woman who had a lower leg amputation; 23 year old woman with extremely elevated blood sugar levels; 66 year old man with high blood pressure, right lower arm amputation and infected wound; 65 year old woman with altered mental status and a tender abdomen. Somehow, reading this sign-out reduced these problems to things we know how to take care of. We know how to treat pneumonia, we know how to treat wound infections, we know how to treat high blood sugars. The context may seem overwhelming, the logistics daunting, the scope immense, but we know what to do. It was a moment of hope, in a sense. These are not unsolveable problems. It takes resources, time, investment, and knowledge, but there are solutions.

Those are some of my thoughts. I hope you are all well.

Peace,
Rob