Haiti After the Earthquake (50 page)

Now here I stood on the airport runway, ready to escape briefly from the crumbling city, the terrifying aftershocks, and the stench of death. Although my Partners In Health colleagues had arrived to help and urged me to take a break, I was overcome with the feeling that I was abandoning them.

One close colleague stepped off the private plane on which I would later that day hitch a ride home. We hugged. I was relieved to know that reinforcements were arriving. My voice was hoarse with dust as I shouted instructions over the roar of jets, struggling to transfer ninety-six hours of information in five minutes. Spotting U.S. soldiers in uniform, my colleague asked: “Have there been any episodes of violence yet?” What kind of violence did he mean? “The soldiers against the Haitians,” he said.

I was frustrated by this immediate negativity. It was not the first time since the earthquake that I'd felt this way. Days earlier, sitting in a corner of the temporary UN office where we had found an Internet connection, another much admired colleague and I had a tense exchange after she described the United States as “occupying Haiti again.” She had seen U.S. soldiers prevent Haitians from entering the General Hospital to search for relatives. Through my lens, exhausted, having witnessed firsthand the scale of the devastation and desperate for the sight of those who could really help, both colleagues' characterization of U.S. action seemed too negative, compounding my feelings that nothing would work, and that we should expect only the worst. Their interpretation didn't acknowledge the possibility that great power could be used for good.

Certainly not everyone in Partners In Health agrees on the issue of military involvement in humanitarian activities. Most of my colleagues had not yet worked in a disaster situation where military assets might be necessary. My days in the crisis offered context in which to view this situation. The comments of both colleagues were founded in a healthy suspicion based on Haiti's history with militaries, the U.S. military in particular, and on our own organization's experiences in Haiti.

Partners In Health in Haiti began in 1983, twenty-five years into the brutal dictatorship of the Duvalier family, and witnessed a violent Haitian military rule from 1991–1994, before the Haitian army was demobilized in 1995 by President Aristide. Older Haitians remember still the U.S. military occupation of 1917–1954. Even beyond this legacy, most civilians have just cause for skepticism and distrust at the sight of foreign armed forces on their soil.

Unlike some aid organizations, PIH/ZL (Partners In Health/Zanmi Lasante) has no strict doctrine regarding collaboration or interactions with military on professional or social levels, although written policy prohibits weapons inside our vehicles and clinics. In general, our aim is to forge partnerships with other groups, recognizing the complex set of experiences and skills that in collaboration will provide sustained improvement in conditions for the people in the areas in which we work. During my tenure in Haiti, we have used a commonsense approach to military collaborations. When UN forces arrived to stabilize the country after President Aristide's departure in 2004, PIH had both planned and unplanned interactions with MINUSTAH by virtue of their three bases near us in the Central Plateau and Artibonite departments.

My perception of MINUSTAH in rural Haiti before the earthquake, influenced by the opinions of my Haitian neighbors and coworkers, had been one of the heavily armed, resource-intense activities that seemed to have little apparent relevance to the day-to-day needs of the largely peasant farmer population. For these predominantly peaceful, highly rural parts of the country, the struggle of day-to-day survival in the face of severe poverty and serious food insecurity was greater than the largely urban issues of kidnappings, gang violence, and common crime. The inequity of a $601.58 million budget for stabilization in a place with such pressing development needs was flagrant. In 2008, many of our neighbors, the rural poor, questioned the effectiveness of MINUSTAH when the response to a series of four tropical storm and hurricane force rains was slow and inadequate despite the fact that MINUSTAH had resources that could have been faster mobilized to help. In post-hurricane Gonaïves on September 6, 2008, the same day that UN and other sources reported that “access to
Gonaïves remains virtually impossible,” a PIH four-wheel drive vehicle traveled the road to the flooded city to transport supplies. The trip was repeated the next day, uneventfully.

We did have some positive interactions with MINUSTAH, including help transporting an X-ray machine one day while we were stuck in the road. Some volunteers from the forces participated during their free time in our community activities, but other community activities promised by the local battalions of MINUSTAH, such as repairing the latrines in a primary school, were not fulfilled. The breadth of PIH's collaboration with MINUSTAH expanded positively and significantly in 2009, when a Brazilian military MINUSTAH engineering core participated in the design and construction of a bridge, donating bridge parts to the government of Haiti.

Waiting on the runway that day, I considered the kindness of the MINUSTAH soldier who had accompanied us from the driveway, and the pain on the face of his commander who had been attempting to rescue colleagues at the nearby UN headquarters. However, in the context of this massive disaster, it was not just my personal perspective on MINUSTAH that was important. All humanitarians had a right to think cautiously about a military presence and to wonder in what context they would act.

I returned to Haiti four days after that initial departure and quickly got back to the tasks at hand, working frantically with a team of colleagues on a series of new projects: providing assistance at the general hospital and developing healthcare services at some of the spontaneous settlement camps. Things remained chaotic, but we were slowly getting our own communications lines in order and assigning each team member a specific task. Our interface with the U.S. military was now an almost everyday occurrence. The USNS
Comfort
, a U.S. Navy medical treatment vessel, arrived the same day that I returned. Docking two miles off the coast of Haiti, it served as a much-needed tertiary referral hospital for the most severely injured. A Brigham and Women's Hospital junior doctor, one of our residents in Global Health Equity, arrived to join our team. Handing him a cell phone, I asked him if he would manage our patient transfers. “Do you need me to call you about them?” he asked. “Only if you need
my help,” I replied. Days later, I overheard him calling out GPS coordinates for a helicopter landing zone near our own main hospital in Cange. Despite this being his first working trip to Haiti and with almost no Creole or French skills, he not only had quickly started coordinating our own transfers of patients, but had also figured out how to leverage the goodwill and determination of the U.S. military stationed at the General Hospital and was organizing military helicopter flights for evacuations. At the General Hospital, all but one of our staff reported positive experiences with the U.S. military, describing their willingness on an individual level to do whatever they could and attempts to make their own “big machine” of an organization flex to accommodate the shifting humanitarian needs.

Military involvement in humanitarian activities has become increasingly common since the end of the cold war. Nonmilitary humanitarian actors (typically aid agencies and nongovernmental organizations but also others) must fulfill their role to decrease human suffering by providing services with impartiality. In situations of conflict or violence, association or perception of an association with any one side can prevent those who want to help from gaining access to victims and can also endanger staff. One set of guidelines
^b
for interactions of nonmilitary agencies with military agencies in conflict notes: “The most important distinction to be drawn is whether the military group with which humanitarians are interacting is, has become, or is perceived to be a party to the conflict or not.”
^c
Association with military, even if the particular task of the military at that time is to provide support or to reduce human suffering, can have serious consequences for aid organizations.

In post-earthquake Haiti, the U.S. military mission was officially humanitarian. Reflecting President Obama's “whole of government response” to the crisis,
^d
the U.S. military worked under the direction of the U.S. agency for international development (USAID). The choice of military actors to assist in humanitarian assistance was controversial, but in pragmatic terms, the budget, human resources, and logistics assets of the U.S. military are well beyond those of USAID. At the height of the U.S. military footprint, some twenty-two thousand troops were in Haiti or offshore providing assistance, compared to some hundreds of USAID civilian workers—many of whom were seconded from other nations' programs.

At the time of the earthquake, the deputy commander of U.S. Southern Command had been in Haiti. I believe that his personal determination to relieve human suffering set the conditions for his command of Joint Task Force Haiti. For the most part, the troops that he led displayed respect and diligence in their pursuit of supporting the victims of the earthquake. He and his team became a familiar site at a huge temporary settlement camp in Port-au-Prince where my Haitian colleagues and I spent many hours and days during the subsequent months. Haitian community leaders, themselves survivors living in the settlement camp with almost fifty thousand other people, from whom I regularly take my cues, were and are avid fans of the assistance from U.S. military. One day, several of them called me aside and said with glee about the U.S. troopers:
Gade Doktè Louise—bòt yo sal.
“Look, Dr. Louise: They got their boots dirty.” So often, people offering help (so-called humanitarian actors included) are not willing to get into the grimy part of the work.

Political and military motivation should be separate from humanitarian assistance. By definition, humanitarianism requires impartiality, which is not possible if aid is delivered as a tool to sway opinions, to win support, or to advance one ideology over another. As an organization that partners first and foremost with the poor,
PIH look to those we serve for legitimacy and also to determine what is in their best interest. Paul Farmer wrote in 2003:

In truth, no one group or individual has a monopoly on humanitarian actions or goals. The sheer devastation of the earthquake, the flattening of infrastructure, logistics capacity, and medical care, and the loss of key leaders in governmental and nongovernmental sectors required a huge, multifaceted effort. In the face of such catastrophe, we could not afford to ignore military assets. If military cannot by definition be humanitarian actors, they can surely accomplish humanitarian tasks. In Haiti in those first weeks and months, we needed and I welcomed all who came with a humanitarian task in mind, a determination to help achieve the common objective of saving lives and reducing suffering, and a willingness to get their boots dirty.

T
he Haitian State University Hospital, l'Hôpital Université
d'Etat d'Haïti
(HUEH), is known in Port-au-Prince and beyond as The General Hospital,
Lopital Jeneral
. It is the largest public hospital in Haiti and the nation's most important medical institution. The national medical and nursing schools occupy the same campus, with roots reaching back to the era immediately following Haiti's independence in the first years of the nineteenth century. Until 2002, when the initial class of physicians graduated from Haiti's first private medical school, Notre Dame University, the State University was one of very few providers of physician education in Haiti. Generations of Haitian medical professionals proudly claim HUEH as their alma mater despite the fragile infrastructures of the hospital and university, which have weathered many storms, including political change
,
military unrest, rapid urbanization, hurricanes, and continuous financial stress.

Lopital Jeneral
is often the only facility available in the nation for medical specialty referral and care. It is also, sadly, a hospital of final resort for the destitute sick and dying. Among the rich and the poor, the general consensus is that anyone with means would seek care at
another center before going there. HUEH is at once a proud national teaching hospital, an essential referral hospital, and a physically and financially poor facility where clinicians struggle to provide quality compassionate care under crippling conditions. Those who work in Haiti have long been witness to this struggle. The devastating earthquake that rocked Haiti on January 12, 2010, revealed the conditions at the hospital to a worldwide audience.

Everyone has seen photographs of the crumbled domes of the previously grand National Palace.
Lopital Jeneral
sits one block behind the National Palace. At the moment of the earthquake, two-thirds of the hospital was destroyed. The surgical hospital, emergency room, and main operating suites were rendered unusable; all pediatric facilities and half of the internal medicine wards were destroyed; the lab and its equipment were reduced to rubble; and the chronically understocked pharmacy was left in shambles. The State University School of Nursing collapsed while the second-year students sat in a lecture, killing nearly the entire class, along with several of their professors. Perhaps 125 to 150 people died in this one building alone.