(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
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