Below is an excerpt of the Doctors Without Borders six month report on Haiti. The full report is available here.
Introduction: One Million Under Canvas
The disaster in Haiti was such an intense blow to a poor and densely packed urban population that it presented new challenges of scale and complexity on every level for the relief effort. Although MSF was in the country before the earthquake hit, the organization was stretched to its limits by the urgency and extent of the medical needs. The organization’s financial resources were generously augmented by millions of individual donors, but the sudden pressure on its medical, technical and managerial staff was unprecedented.
The report sets out the ways in which those people, the Haitian and international staff, struggled to answer the challenges thrown up by the earthquake. They know that the response could never be sufficient, that even the core medical action in the early days was overwhelmed by the suffering. And that the wider need of the Haitian people for the restoration of some dignity and hope to their lives has been painfully slow to be realized.
The dust laid down by the thousands of buildings that were crumpled and split by the huge tremors in January has now been washed into pools and gulleys in the streets of Port-au-Prince. The rains that were the next threat to the survivors have been falling for weeks and the predictable misery for the hundreds of thousands without homes is now relentless. And it will likely get worse as what is expected to be a bad hurricane season looms on the horizon.
Many people who escaped from the falling buildings six months ago are still too afraid to seek shelter in the ruins. They remember the after-shocks and have heard the scientific gossip about more quakes to come. They huddle under the flimsiest tarpaulin or tent, chase and recover them when they get blown away, and stay with their new neighbors in the straggling city settlements. From the air, Port-au-Prince has ragged lakes of tarpaulin blue. There is protection against the sun and showers but not tropical downpours or cyclones. The relief effort has kept the people alive but it is not easing some of their greatest suffering. The conditions of life are raw and levels of frustration are increasing.
The level of violence in Port-au-Prince is a permanent concern. Before the earthquake, MSF was treating people with bullet wounds and victims of sexual violence in Martissant and Trinité. Beyond these important medical needs, the generalised insecurity requires special attention. However, MSF’s medical data do not show an increase in the number of victims of violence after the earthquake. The overall figures for five months show 2,147 patients treated for violence related trauma and another 264 for gunshot wounds.
Today, the medical provision for the majority of the citizens has been substantially improved since the quake and in some respects is better than before it. Numbers of poor people who before the disaster were effectively excluded from the public and private systems are now able to get attention. The range of medical care in new, temporary structures and in some of the
surviving hospitals and clinics is substantially greater and nearer to the people, although issues of quality remain. The concern is that so much of this depends on a continuing international commitment and there are real questions about its sustainability. The Ministry of Health has a plan for the next 18 months that has free care for some vulnerable groups at its core. But all this needs external funding and the reconstruction of lasting facilities. The private sector, which has always been significant in Haiti, was badly hit too and is struggling to recover. The other constraint is the lack of trained professionals. The earthquake destroyed 60 percent of the health facilities and 10 percent of the medical staff were either killed or left the country. Haiti has always exported talent and those who survived the quake are still heading abroad.
Food and water
The availability of food and water has also improved substantially since the quake, although for most people it is still less secure than in their lives before. The massive World Food Program distributions were effective and although there is concern whether they reach all of the most vulnerable groups in the communities, MSF has not seen evidence of growing malnutrition. The water issue is less clear because the free distribution in the first three months has been changed to a charge system, which complicates non-charging relief distributions like MSF’s and puts a strain on so many people without jobs and income. The concern here is that this is not something that MSF specializes in, it is not a core medical activity and the organization’s resources are being stretched because of the lack of response from other providers.
Sanitation and shelter
Similar concerns apply even more forcefully to the sectors of sanitation and shelter. In sanitation provision there have been improvements since the dire conditions shortly after the quake, but in some communities like Cite Soleil or the camps of Carrefour Feuilles, MSF is one of very few organizations with a presence. MSF is playing a role with latrines, waste disposal and hygiene provision in many other parts of the earthquake affected area, which often goes well beyond the standard work at the medical facility and the surrounding community. At the same time there are big challenges that are not being resolved by the wider relief and reconstruction effort. There is just one waste dump for the city, which is full to overflowing. No alternative has been decided on and the rainy season is compounding the problems of access and pollution. Large parts of the city are at sea level, so latrines should be emptied very regularly. They are not. In the camps, the inadequate provision adds to the likelihood that heavy rains will wash sewage through the living areas.
By far the biggest threat to people’s living conditions is the failure to provide any substantial, robust shelter. Sheeting and tents were never anything more than a very temporary solution. They have a life expectancy of around six months. MSF itself distributed significant quantities of tents but some form of reconstruction should have begun in June and July so that people would then be able to move into at least semi-permanent shelters. Very little of this has happened.
Decisions about land allocation have been very slow. The tents are starting to deteriorate and the rain is exposing the problem. Even without a hurricane, the wet season will be enough by itself to complete the misery of the people caught in the open.
MSF has focussed a very substantial part of its global resources on Haiti in the last six months. The peak of that emergency phase activity was around the two-months mark, when some 350 international staff were working there. They were needed because it took longer than usual to find and recruit all of the Haitian staff to run the massively expanded medical projects. At its peak in March there were 26 separate facilities—a number that included hospitals, rehabilitation centers, and general medical centers. Following the consolidation of some of these facilities and a shift in priorities, MSF now manages 19 health structures. MSF also runs 16 operating theatres and has more than 1100 beds available at its various locations. Overall, since the earthquake and up to May 31, MSF has provided medical care to more than 173,000 patients and performed over 11,000 surgical operations.
This report records some of the thinking that went into choices made around strategy and deployments. It contains testimony from staff and patients who have seen the different faces of MSF’s work. It sets out the ways in which MSF is spending the generous donations it received from so many people around the world and it sketches some of the ways that the organization is committing itself to the future of medical action in Haiti. But first, this report looks at the past, the long history of MSF in Haiti and what it tells us about the fragile condition of everything even before the disaster.
A History of Vulnerability
When MSF began its continuous presence in Haiti in 1991, the emphasis was largely on rehabilitation of hospitals and health facilities that were crumbling and unsanitary. The work was accompanied by training for surgeons and anaesthetists. There was some direct medical action through surgery and a considerable amount of water and sanitation provision around the hospitals but the majority of MSF’s engagement was in supporting a very under-resourced and fragile health system. There were also periodic emergency responses to floods and hurricanes.
That began to shift after 2000 when the first attempts started to reduce maternal mortality in one of the health districts. This marked the beginning of what has been an ongoing commitment to maternity and obstetric care. But the big evolution of MSF’s work happened as the country descended into political turmoil and violence in the middle of the decade.
In 2004, MSF opened a surgical project in Port-au-Prince that is still running in a new setting of Trinite Trauma Center, the only comprehensive emergency treatment facility in the country. Wound treatment became vital for a constant stream of casualties from street fighting. MSF was located at the heart of the violence in the capital when other organizations had left. Between 2005 and 2007, MSF worked in Choscal hospital in the slum of Cite Soleil as fighting went on between armed gangs and the UN peacekeeping forces. The lack of emergency care in the public health sector and the surge in violence led to the establishment in 2006 of the Martissant emergency room and mobile clinics in that slum area of the capital. In the following year, MSF increased its capacity to work with the victims of sexual violence when it opened the Pacot Center. That facility also provided rehabilitation with physiotherapy and psychological care.
At the same time, extreme levels of maternal mortality combined with frequent sexual violence brought MSF to deliver emergency obstetric services in the Jude Anne hospital in Port-au-Prince and later on in Maternite Solidarite. New peri-natal services were also started, along with voluntary testing and counselling for HIV.
And Haiti’s frail infrastructure is constantly exposed to savage natural disasters. In 2008, the northern city of Gonaives was flooded by a hurricane and MSF worked there for several months in an 80-bed hospital and running mobile clinics in the camps where people had to subsist in temporary shelters.
The main lesson of those 19 years work in the country was that for the majority of Haitians, the health system was almost out of reach. In Port-au-Prince, many of the poor have been highly dependent on MSF’s free emergency services. Fees charged by the public and private health facilities made care unaffordable for most people. Public hospitals and clinics were often plagued by management problems, strikes and shortages of staff, drug and medical supplies. Patients could be turned away because the hospitals were full and they had to abandon treatment when they ran out of money.
One of the clearest statistical indicators of this poverty of care is in the life expectancy for women. It is estimated at 58.8 years. And with maternal mortality at 630 deaths per 100,000 – 50 times the rate in the United States next door – giving birth can be more than hazardous.
The shocking truth of MSF’s experience as a major medical and humanitarian organization in Haiti is that even without the risk of violence, Haiti’s people are exposed to life threatening suffering and neglect. The country could hardly have been less well-placed to deal with the huge additional demands that a natural catastrophe would place on its medical resources.