Haiti After the Earthquake (20 page)

Carmen, also from the Central Plateau, lost both legs to the quake. “I was sitting near a big wall,” she recalled in a matter-of-fact voice, “and the wall fell down on my legs. My legs were crushed. I went to the General Hospital and was referred to the Mirebalais hospital. They removed both of my legs.”

Both Shelove and Carmen recovered thanks to the work of surgeons and nurses and people like Koji Nakashima and a physical therapist from Miami, Carmen Romero. Fitted for prostheses at a
nearby hospital, Shelove learned how to stand, and then, less than six months after the quake, to walk. For most of Haitian history, losing a limb, especially a leg, was a sure ticket to beggar status; disability begets pauperism among those working in agriculture.
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Carmen was one of the first amputees to take steps, in her case on bilateral prostheses. And Shelove was among those inspired by Carmen's determination to learn to live fully in spite of her disability: “When Carmen arrived, she just put the prostheses on and she stood up! And I had this brace on my other leg, so I couldn't stand up. She asked, ‘you aren't going to push yourself to stand up? Okay, just stay that way!' She was showing off playing soccer. And this encouraged me to try harder. Even when my leg was hurting, I tried to walk.”
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Not all patients who had surgeries fared so well. Some never got the prostheses and wheelchairs and rehabilitation care needed to live normal lives again, and exceedingly few have been able to find work. It was in part anxiety about such fates that fueled widespread resistance to certain surgical interventions such as amputation. One could find, in the first months after the quake, online articles about hasty amputations, for example, “Surgeon Seeks to Prevent ‘Unnecessary Amputations' in Haiti's Earthquake Zone.”
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A sound caution, perhaps, but there were scores of survivors who could have done better—or survived longer—with an amputation. Many of the patients we saw in the first week after the quake, Shelove and Carmen among them, knew almost immediately that they needed amputation but had trouble getting medical attention. A few more days, and both would have died of gangrene or sepsis.

That said, amputation was a hard procedure to recommend, especially when, as was often the case, the patients were children or young adults. This anxiety accounts for some of the delays, and it was fully shared by the physicians, especially when we knew patients personally. One such patient was Sanley, the daughter of a friend from Cange. I'd know her since she was born nineteen years ago. She'd been on my grim list, in the injured category, since her older brother told me she'd gone back to Cange for care. “She hurt her right foot, but it's not too bad.” This meant she slipped off my
unaccounted-for list; she'd be in good hands. But his diagnosis was off the mark: the teams there found multiple fractures in her ankle and heel and reluctantly recommended amputation. Her family, dismayed by this treatment plan, took her over the border to a hospital in the Dominican Republic. But they feared she was a low priority there, in wards crowded with Dominican and Haitian patients. She traveled back to Cange, in blazing pain and without analgesia, and was seen by a plastic surgeon from the Brigham, a physician I'd worked with for years. Like her family, I wanted to hear that her leg might be saved. “A limb-sparing procedure might just be possible,” Chris Sampson said cautiously. “But it would need to be done at the Brigham and in several stages. It might not work, but given her age, it might be worth a shot.”

So we made plans to get her to Boston. Sanley, a girl of sunny disposition who'd been living a nightmare month of pain and fear of losing her limb, smiled for the first time in a long time: she was going to Boston, where medical miracles were routine. By the time this decision had been made, the Partners In Health team had become expert at medical evacuations, and she was soon en route to the Brigham. I spoke with her by phone on the bumpy ride from Cange to Port-au-Prince. She'd had pain meds and was sunny again, sure she'd be fixed by the Harvard doctors. “Thank you so much,” she repeated over and over.

But it was not to be. A half-dozen radiologists and as many surgeons reviewed her case, arguing every angle. Amputation was the consensus. None of us felt bad about having taken so long to reach the decision, and I was deeply grateful to Dr. Sampson, who treated her as if she were his daughter or mine. Sanley's mother asked me to break this news to her. It was terribly painful; Sanley was sobbing in her room while her mother wept silently outside. Sampson reminded me then that one of the surgical residents, a former student of ours, had undergone an above-the-knee amputation as a child and subsequently became a competitive skier. Most people who worked with her—she stood long hours in the OR—had no idea that she was an amputee. I asked her to speak with Sanley. These conversations
helped her, as did the prospect of being free from incessant pain. After the procedure, which occurred fully six weeks after the quake, the worst of her pain soon subsided; all her problems had emanated from her crushed right foot. Within a week or so, Sanley turned back into herself and began planning her future, which she regarded as more promising than ever.

As February drew to a close, many of us realized that we'd been working for six weeks without a day off, without a moment to think or pray, without a chance to take stock of what so many had endured or been spared by luck or fate. Father Eddy Eustache, the director of Zanmi Lasante's mental health team, was among those counseling us all to slow down and take stock of our losses. The quake had killed so many, had maimed so many, and had disrupted families and friendships. The caregivers were worn down; we hadn't seen our children. (My own nephews had joined Didi and our children in Rwanda, an ocean away, and, although unharmed, were sundered from their parents for months.) For six weeks, it was all earthquake, all the time, and we were the lucky ones: more than a million people were living under tents and tarps. As March approached, tempers began to flare and even those blessed with sunny dispositions were tired or frustrated or anxious. Some of those working hardest felt unappreciated. We needed to pause and reflect, but also to celebrate something.

But what might we celebrate? We settled on a long-planned graduation ceremony. From the beginning, we knew that service delivery would never be enough. How could we improve the quality of these services and also proffer them to more people in rural Haiti and elsewhere? Training had to figure in our strategy. A group of Harvard physicians, including Jim Kim and Joia Mukherjee, were working with our Haitian and African colleagues to codify a training program in “global health delivery.” The stars in that firmament were the Haitian doctors who had led programs across Haiti and parts of Africa in the preceding decade, and we wanted to acknowledge their
work and studies in public health and program implementation with a sort of diploma in global health delivery. We had planned the ceremony for late January but of course had to postpone it. But on February 27, representatives of Harvard Medical School (two deans), the Brigham and Women's Hospital (the new president and her predecessor), the Haitian Health Ministry (including the Minister), Partners In Health (Ophelia Dahl and many others), and the Clinton Foundation gathered in Cange for a moving graduation ceremony that included patient testimonies and speeches in English and French. (Claire Pierre, David Walton, and I took turns translating, since it was heavy going, emotionally.) It was the first celebratory moment since the quake, and celebrate we did—although one diploma was awarded posthumously, to Mario Pagenel.
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There were other happy reunions, too. My mentor Howard Hiatt, who had served for a decade as dean of the Harvard School of Public Health and had since dedicated himself to global health and Partners In Health, described one such reunion—between some of our patients in Cange and visiting USNS
Comfort
staff. In truth, we had almost kidnapped these doctors, including Lieutenant Commander Dr. Jeffrey Stancil. (We'd promised to have them back on board that night, which was patently impossible.) They went along with the ruse and were happy to see some of the patients they'd cared for, as Dr. Hiatt wrote:

Celebrations remained rare in Haiti, and March brought mounting anxiety as all those involved in relief efforts began thinking in earnest about reconstruction. It took me weeks to finish reading
The Best and the Brightest
. I'd been meaning to read it for years and had pinched it from a friend's bookshelf. It's about not only Vietnam but also the ways in which the fog of war and undue confidence in the trappings of power can lead, and did lead, to disaster. For me, it was also about people affiliated with academic institutions and the choices they made decades ago. Two months after the quake, as we took stock of the damage, assessed rescue and relief efforts, and considered what might happen in the coming months and years of reconstruction, I finally finished Halberstam's book.

Reading and reflection led some of us to record our experiences. This was surely part of my job as a professor, and it was about that time that I decided to write this book. The earthquake and our responses to it posed anew questions I'd struggled with while spanning the uneven worlds between Harvard and Haiti. Broadly, how could we diminish the growing inequalities in the world, which lead to, or (for those shy about claims of causality) are associated with, so much death, disability, and social instability? More specifically, just how “natural” a disaster was the one that struck Haiti on January 12? What made Haiti peculiarly vulnerable to the quake, as it was vulnerable to the storms of 2004 and 2008? How much of this vulnerability was social, rather than natural, and caused by bad policies, foreign and homegrown? What is the role of massive development agencies, and their contractors, in rebuilding whole cities and towns? What are the proper roles for the thousands of nongovernmental agencies that give Haiti its equivocal nickname, “the Republic of NGOs?”

These are old questions, both in Haiti and without, that often generate self-serving (and sometimes contradictory) responses and acrimonious debate. Even when the topic is seemingly innocuous—providing health care to the Haitian poor should be pretty uncontroversial—there is a great deal of discord and heat. Given the acrimony and discord, and the life-and-death power struggles to which anyone working in Haiti in recent decades has been witness, it's tempting to focus on immediate clinical questions. In the quake's aftermath, most doctors did just that. But what are the appropriate roles for doctors when responding to disasters, natural and unnatural? We're there to bind wounds, stanch bleeding, and treat those already injured, certainly. But does the physician also have a special obligation to think broadly about etiology, diagnosis, and treatment? Finally, as a physician-educator, what is the role of the American research university, one of the most direct channels into the halls of power (as described by Halberstam), in addressing the great social problems of our time? (The quake in Haiti surely ranked as one such problem.) In a social field littered with humanitarian groups, NGOs, and UN peacekeepers, we needed to rethink the ways in which we might draw on academic medical centers and on universities in general.