The Haitian Earthquake and Academic Emergency Medicine

“… everyone has a heart that is sensitive to the suffering of others.”—Mencius On January 12, 2010, at 16:53 local time, a 7.0 Mw earthquake struck 25 km west of Port-au-Prince, Haiti, causing one of the worst disasters in human history. The world community responded with one of its greatest outpourings of concern and support. This article summarizes the response to that disaster, especially as it relates to emergency care, and describes the role of academic emergency medicine. We do not intend a rigorous academic analysis; Haiti was in many ways unique. Haiti is the poorest country in the Western Hemisphere, with a per-capita gross domestic product (GDP) of only 1,300 USD.1 This is corrected for local purchasing power (PPP), which means that it overestimates the ability of Haitians to purchase goods and services on the world market. Indeed, one of the immediate effects of the earthquake was to dramatically increase the local price of goods. According to our Haitian colleagues the price of food tripled in the first few days, and although food aid arrived quickly, the market price remains high. In addition, Haiti has little economic infrastructure, and perhaps one-fourth of its GDP is from remittances from Haitians working abroad. Haiti’s poverty is not only financial; it extends to basic natural and human resources. One of the most stunning examples of this is apparent when flying into the country. The east side of Hispaniola is within the Dominican Republic and much is verdant green. The west side of the island is Haiti and is almost completely deforested. The standard measure of human development is the United Nations Human Development Index (UN-HDI). This combines life expectancy, literacy, and school enrollment with the natural log of the per-capita GDP corrected for PPP. Haiti’s HDI is 0.532, which ranks it 149th of 182 countries. In addition, Haitian incomes are highly maldistributed and there are large income disparities. This is commonly measured with the Gini index, which compares a nation’s actual income distribution (the “Lorenz curve”) to the line of absolute equality. Haiti’s index is 59.2—the eighth worst among the 134 listed in the CIA’s Factbook.1 When the earthquake hit the initial damage was enormous. Estimates are that a quarter of a million people died, a third of a million were seriously injured, and over a million became homeless. All these numbers are probably crude estimates, because records were lost or never kept. When we drove through Port-au-Prince, most of the buildings appeared severely damaged or destroyed and few appeared safe. The survivors were living in tents made of bed sheets, pitched in open areas and parks throughout the city. By the second month after the quake, tens of thousands of multiperson tents had arrived and efforts were being made to provide waterproof tarps before the start of the rainy season. These may be the standard local housing for the next few years. Flying over the city in April, the city is dotted with blue tarps, marking the tent cities. The earthquake damaged or destroyed all of the local hospitals. Two days after the earthquake, only one hospital was in operation.2 Although many reopened quickly, unsafe buildings, demolished wards, and lost equipment meant that there was little surgical or inpatient care available. We were told that almost half of the physicians and nurses at the University Hospital were killed in the quake. The USNC Comfort and field hospitals provided most of the initial critical surgical capacity. The international response was quick and massive but was hampered by the destruction of the port and damage to the small international airport. Over 150 nations supplied support. Dozens if not hundreds of nongovernmental organizations (NGOs) were providing relief within days. Haiti has had a long dependency on outside aid, and perhaps 3000 NGOs were active before the quake.3 A total of 2.1 billion USD was donated in the first month, and an additional 1.3 billion USD was pledged. It is estimated that 11 billion are needed (http://www.reliefweb.int). For those of us with domestic experience in disaster medicine, this was a very atypical mission. The disaster was massive, orders of magnitude worse than the others we had responded to. The response was equally massive. Initially there was no clear overall disaster response framework. The UN Cluster system appeared to have failed, unlike the success seen in the Asian tsunami. There was little coordination among the initial players and no functioning referral systems. The lack of a clear and effective authority was a crux problem. The Haitian government was marginally effective prior to quake and heavily damaged. In fact, most government buildings were completely destroyed and many employees were killed. The direct effect of this was apparent when some of us delivered paperwork to government officials who had been forced to relocate to an upper-middle class residential area. This neighborhood appeared completely undamaged; even the stucco was intact. The UN had been responsible for peacekeeping and international coordination, but it also had been heavily damaged, and almost half of its staff and leadership were killed. As a result neither the Haitian government nor the UN was able to quickly transition to a disaster management team. This caused the vast number of NGOs and arriving aid workers to function in a highly uncoordinated environment, a situation that was described by early responders as a “free-for-all.” The situation was aggravated by the Haitian health care situation prior to the earthquake. Haiti is a low-resource setting with little marginal capacity. Although the demographic transition to an older urban population is well under way, “tropical” diseases are still common. Hepatitis A and B, malaria (chloroquine sensitive Plasmodium falciparum), dengue, typhoid, rabies, filariasis, leptospirosis, anthrax, tuberculosis, tetanus, and intestinal parasites are endemic. These infections are really diseases of poverty and most U.S. physicians are unfamiliar with their presentations. HIV/AIDS is declining (prevalence is estimated at only 2.3%), but it is most common in the urban young adults who make up the bulk of the Port-au-Prince population. In addition, responders faced persistent language barriers. Haiti is a Francophone- and Creole-speaking country in a hemisphere that speaks Spanish and English. Translation was difficult to arrange at first. We received reports that some NGOs had initially used members of international criminal gangs that had been freed when the national prison collapsed.4 The near-complete collapse of infrastructure made the usual model of disaster response untenable. In most disasters local resources, including established emergency services and spontaneous lay responders, provide the immediate life-saving response. However, this initial phase was hampered by baseline lack of resources and the scale of this disaster. Typically, this initial response is rapidly augmented by outside resources that respond to the disaster area and by the transfer of patients out of the disaster zone to undamaged facilities. The specifics of the earthquake and generally poor construction standards rendered the few remaining facilities unsafe. Consequently, few patients could be initially transferred. There was an immediate need for emergency care, particularly for trauma and orthopedic surgery, which overwhelmed both local resources and the initial response. What was needed was a very rapid response by self-contained medical units. Transportation, shelter, medical and surgical materials, supplies, sanitation equipment, security personnel, and even food and water needed to be externally supplied. Unsupported aid workers drained local resources and put themselves at risk. The necessary personal requirements were also unique. The ability to work in a chaotic environment was crucial. Workers needed to be flexible. They needed to be comfortable supplying surgical support and performing triage. Our patients included adults and children. Obstetric, neonatal, and mental health problems were common. The volume was huge and providers often needed to treat and discharge patients into the tent cities without being certain of the diagnosis. Physicians needed to be able to do their own tests and function with an extremely limited lab. A comprehensive knowledge base of “tropical” medicine, hygiene, and acute care was essential as were disaster response skills such as knowledge of communications, safety, and incident command. Emergency physicians and particularly academic emergency physicians seemed to be overrepresented among the early responders. We believe that this was because we have characteristics that make us uniquely suited for this role. Emergency physicians view disaster medicine as part of their field: multicasualty incidents are a regular occurrence, we train for hospital-based and regional disasters, formal education in disaster care is incorporated into residency programs, and emergency medicine offers fellowship training in disaster medicine. Disasters are, by definition, emergencies, and emergency physicians are used to working in chaos. Teamwork is essential in a disaster and emergency physicians are used to working in a flexible team environment. Academic physicians have specific advantages. The need for a very rapid response favors large physician groups with flexible time commitments. Disaster response is often viewed as a departmental mission; this means not only that providers are willing to go but that their colleagues are willing to back them up. In addition, we suspect that academics tend to have a broader knowledge base than most physicians, which is very useful when working in a foreign environment. This experience provided new lessons and the opportunity to reinforce lessons learned from prior disasters. While it may seem apparent, the balance between timeliness and the depth of the response is important. Small groups responded faster, but large teams brought infrastructure and breadth. Both were needed, and we have yet to achieve the correct balance. We also know that despite the scale, disasters are local events. As such, local knowledge was key, and working with local physicians was very helpful. Haitian physicians recognized illnesses and could determine, for example, that this febrile child probably did not have malaria because it was early in the season and it looked more like pneumonia. They were aware of local protocols and referral patterns. Their knowledge of local demographic and medical data reduced uncertainty and facilitated work-ups. Availability of a support structure was critical. Logistics, shelter, sanitation, and security are not done best by physicians. Pharmacy, radiology, and ultrasound were essential, as was operating capability. Emergency physicians are generally competent generalists, but we wish we were better at surgical assisting and obstetrics. Social issues were important; providers needed to understand the limitations of the scene and medical infrastructure. They needed to be willing to live and work in an austere environment and they needed to “check their ego at the border.” Would we do it again? Our patients and Haitian colleagues make that answer an easy yes. What is needed now is infrastructure. It will take years to rebuild shelter, water, and sanitation. Port-au-Prince needs better structures, building codes, and enforcement. A few tons of rebar would have made a huge difference. The social infrastructure also needs to be rebuilt. Educational facilities, in particular, were devastated. The disaster is not over, it is merely evolving. We believe that there is a long-term role for academic emergency medicine in helping to rebuild the medical infrastructure. Of course we will go back.