A Sobering Meeting With the WHO

25 May, 2010

Ever since I arrived in Haiti I’d wondered how the medical efforts of all the NGOs and Haitian hospitals were being coordinated. After spending the morning seeing patients at a clinic at the Ste. Croix “tent hospital” I found out.

The wall of the Ste Croix Hospital
 SOS: 180 Dead

We were invited to go to the biweekly meeting of the Léogâne area WHO “health cluster.” It was held in a big tent on the grounds of the regional UN headquarters. The big UN site was bordered by cinder block walls topped with several layers of razor wire. Very serious looking UN soldiers from Sri Lanka wearing blue helmets, combat fatigues, and machine guns stood at the entrance. We exchanged our IDs for UN badges and walked through the compound. The grounds were filled with tents of various sizes and little pre-fab offices. A row of white satellite dishes pointed up to the sky like huge, gaping mouths. We found the tent, and settled in on folding chairs arranged in a rough circle. There were 10 or 15 other people.

The head of the Léogâne Health Cluster, a Haitian physician and new WHO employee, welcomed everyone and took a quick poll which established that more people spoke English than French. So the meeting was conducted in English. He began by apologizing for the absence of the representative of the Haitian Health Ministry, who was supposed to be conducting the meeting. (The next day he told me that he’d called the man daily over the previous few days to remind him, most recently at 11 am that morning for the 3 pm meeting. When he called the representative afterwards to see why he hadn’t shown up the man said something like, “Oh, sorry, I guess I forgot.”)

We learned that about half the medical NGOs registered in Léogâne were represented at the meeting; the other half were unaccounted for. Furthermore, it was estimated that no more than half the NGOs working in the area had registered with the WHO at all--maybe they weren’t even aware of the existence of the Health Cluster. It didn’t take a rocket scientist to figure out that under these circumstances, meaningful coordination of health care resources wasn’t going to happen. The truth is, each NGO was operating semi-autonomously.

The WHO doctor summarized the current state of play: The seasonal rains were just starting, making it impossible to run mobile clinics in some remote locations. Not a single facility was providing dental care in all of Léogâne. Virtually none of the NGO field hospitals, and almost none of the few standing Haitian hospitals had working laboratories, and the very few that did were charging for their services. Many patients who had had emergency surgery for fractures following the earthquake had not achieved satisfactory bone union and would need new surgery for internal fixation. But the nearest facility able to provide this surgery was many miles away and waiting lists were very long. In fact, there was only a single X-ray machine in the entire region, operated by the Japanese Red Cross. They could only accept emergency cases.

Then each NGO gave an update on its activities. Some were focused exclusively on reproductive health and domestic violence, others on childhood nutrition, still others on lymphatic filariasis. Several doing mobile clinics had already run out of key medicines.

The WHO doctor summarized the combined epidemiology report based on information supplied by some of the NGOs. Unfortunately, he said, he had data for only five medical categories—several key diagnoses such as sexually transmitted diseases and PTSD could not be collected. Why? Because WHO was not allowed to change the collection forms without the approval of the Health Ministry. He had sent the Ministry a proposed revised epidemiology form many weeks ago but they hadn’t yet approved it. Not surprisingly, the current statistics were not particularly useful—almost 60% of the cases fell in the category, “Other.”

He also repeated a previous request that NGOs conducting mobile clinics provide the GPS coordinates of each of their sites so that a map could be constructed that would reveal both unnecessary overlap and gaps in coverage. To date almost no one had complied, and at this meeting not a single NGO could supply the requested information.

Copies of an undated and unsigned letter from the Ministry of Health were passed out which ordered all medical NGOs to register with the Ministry or leave Haiti within 30 days. Several NGOs reported trying to meet all the requirements of the letter, but said it was virtually impossible because the relevant office was often closed, and even when it was open, when they went to  register they were told to come back in a month. As I understood it, most NGOs were in fact operating without having satisfied the Health Ministry’s requirements. Nevertheless, it seemed unlikely that they would be kicked out of Haiti, if for no other reason than bureaucratic inertia. It also emerged that the government had recently imposed an import tax on many items being brought into the country by health-related NGOs, such as computers and medical equipment. The tax specifically included medicines that were to be distributed without charge.

Finally, plans were announced for a big health fair to be held on Haitian Mothers’ Day. The theme was pregnancy prevention--there would be talks on birth control, and lots of condoms would be distributed. Though the plans were presented very seriously, I chose to think that the organizers recognized the irony of holding a pregnancy prevention fair on Mothers’ Day. I had to find something to laugh about!

Last Clinics

26 May, 2010

We went on mobile clinics to pretty little villages—Mellier, Casale, Mattieu, K Simillien. As with the previous clinics, there were wounds, fevers, and lots of chronic disease. Most disturbingly, there were so many patients with symptoms dating from the earthquake. The stomach ache or palpitations or dizziness or headache was almost always associated with horrific loss—of property, family, friends. Gently I tried to help the patients establish a connection between the losses and the symptoms. I said that these were normal, didn’t mean there was necessarily anything wrong with their bodies, and encouraged them to talk about their feelings with family and trusted friends. I referred many to a new post-traumatic stress disorder clinic at the Doctors Without Borders hospital.

Haitian health care workers will need to learn a lot about how to care for these patients, and Haitians will need to learn to be mutually supportive to help deal with the incredible trauma that was collectively experienced. This isn’t a problem that will go away any time soon. Children who lived through the earthquake, many of whom lost parents and siblings, all of whom suffered psychological if not physical trauma, will be affected for the rest of their lives. Perhaps they will come to be known as “the earthquake generation.”

Back to Port-au-Prince

29 May, 2010

The drive from Léogâne took over three hours because of traffic, earthquake damage to the roads, and the rains which have begun in earnest.


Here are two photos of the presidential palace, which we passed by on the way to the guest house in Port-au-Prince. A Haitian physician friend, who now works for the WHO in Leogone, said he was in the Dominican Republic when the earthquake occurred. He got a call from the US about an hour later, and went on Facebook where he saw pictures similar to these. He said he thought the pictures had been “Photoshopped”—he didn’t believe they were real. Then he saw the same photos on CNN, and raced across the boarder to Haiti to see his family, and to help out.

As is evident, absolutely nothing has been done to clear away the rubble, much less reconstruct the palace--it stands exactly as it did on January 12th. This is a poignant metaphor for the discouraging situation in Haiti, now approaching five months after the earthquake.

Two days ago was our last mobile clinic. We drove over muddy roads (the rains have finally begun in earnest) and across swollen rivers to a tiny village near the base of a mountain. We set up in the dirt under a big mango tree, next to a sugar cane field and across from a raggedy banana grove. Little bleating goats clambered over our equipment as we unloaded it and small jet-black pigs, like self-guided torpedoes, cruised around the periphery, grubbing for food.

Part way through the clinic it began to rain hard, and everyone rushed into a tiny single-roomed building with a tin roof, rousting the alarmed goats who had taken cover there. We managed to set up our interview tables and chairs and relocate the three big rolling bags of medicines that made up our pharmacy and began treating patients again while those waiting to be seen huddled under cover of the roof. In a low-budget imitation of a three-ring circus, we listened to hearts and lungs, pulled men into a slightly secluded corner to examine hernias, dressed wounds, gave babies ORS (oral rehydration solution) and handed out pills and condoms while children cried and goats bleated in time to the rain on the roof.

The last patient I saw in the increasingly steamy little room was a 53 year-old man who complained of three years of headache and belly pain, the two most common complaints of Haitian patients. I got the details, did my examination, and began to explain to the patient (via my translator, Conception) that I didn’t think these represented anything serious, but that I’d give him some medicine that might help, as well as worm medicine which we give routinely. The opaque discussion in Creole between translator and patient took a lot longer than usual. At one point Conception’s face lit up and he said something like, “oh, aha!” More discussion, then in answer to an apparent question, he showed visible disappointment.

"OK, Conception, I said, let me in on what’s going on!"  He smiled a little self-consciously. “Well. This man told me that the cause of his stomach ache is that a woman who doesn’t like him put a charm on him three years ago.” What? “You know, a charm. What she did was take some of her poop, put it out in the sun to dry, then ground it up. Then she sprinkled some of the poop powder into his food or into something he drank, he’s not sure which. That started his stomach aches.” Really? “Of course! But it’s so sad, this man’s mother is dead.” Yes, I said, that is sad. But why did you mention it just now? “Well only a person’s mother can counteract the charm. If she were alive she would give her son some of her urine. Or wash her vagina with a little water. And give it to him to drink. That would make the charm go away.” It would? “Of course!” Is it only the mother who can supply the urine or the washings? “Of course.” Oh, I guess that’s because they are from where he came from when he was born? “Of course.” Wow. Do you really believe this stuff? “Of course.” I finished writing the prescription for antacids, with very little hope that they would make a difference.

Goodbye to Haiti...For Now

30 May, 2010


As I mentioned in an earlier post, almost all commerce occurs on the streets, sometimes right under severely damaged buildings. On one busy road I saw a big chunk of concrete hang threaten-ingly from a twisted rebar, right over crowds of passing people. This seemed to be a metaphor for the tropical sword of Damocles that has been hanging over the heads of the Haitian people ever since the earthquake. Sadly, it won't disappear any time soon.

The waiting room at the airport was a milling rainbow of T-shirted volunteers. There were the gray HODR people, the yellow Baptists, and the green “Mission Adventures 2010” folks. The back of the green shirts listed the locations of all the mission trips planned for 2010; they were an exact echo of  those rock band “World Tour” T-shirts. We talked to a few of the rainbow people: they had generally been in Haiti for a week and their experience had been ‘awesome.’ They had cleared rubble or built a church or repaired a school. Some were texting on their iPhones.


There were some free-ranging volunteers too. A well-dressed woman went around introducing her 13 year-old son as well as an apparently famous rap singer (Haitian or American, I wasn’t sure which) who I’d never heard of. She said her son’s bar mitzvah was in a few weeks and she wanted to give him a taste of "the real world" before then. She handed out little rubber “I support Haiti” bracelets and offered to take people’s pictures with the rapper. I declined.

Finally there was a boarding call for our flight. As we trundled down the aisle of our plane we passed the rapper and the mother and the bar mitzvah boy all sitting in first class.

As uncomfortable as the airport scene made me, I don’t pass judgment on any of these people who had come to help the Haitian people. Our mere two and a half week stay seemed barely long enough to allow us to learn the ropes and become at all effective; a single week seemed almost pointless. But who was I to say? Even if the bar mitzvah boy didn’t singlehandedly change Haiti, he may have himself been changed. Or he at least might raise the consciousnesses of some of his friends as he described what he saw in Haiti during his bar mitzvah speech. Maybe the gray-shirted girl texting on her iPhone was telling her boyfriend that she’d decided to get a degree in public health rather than go to business school. And surely there’s value for the Haitian people to know that people care about their plight. Haitians had written on one of the green T-shirts with a black marker: “Good Travel, Miyou,” God bless you, Yves,” and “I love you.” This connection has got to be worth something.

In Miami we cleared customs and boarded a flight to Orlando. Then there was a long layover before the next flight to Seattle so Elise and I decided to treat ourselves to lunch. At Ruby Tuesday the cheerful waiter asked, “So you folks on vacation?” No, not exactly, Elise said.



The plane from Orlando to Seattle was full. Many of the passengers, of course, had been to Disney World so the overhead racks were crammed full of Disney booty. As the plane rose into the clear blue sky a little girl a few rows behind us hugged her stuffed Simba tight and said, almost in a trance, “bye bye Mickey ...bye bye Goofy...bye bye Bambi...bye bye Ariel...”

I closed my eyes, and felt the weariness of the last few weeks settle in. As the engines roared, all I could think about were the people I’d met and the patients I’d tried to help. I took a deep breath and thought, bye bye Chanté...bye bye Lissa...bye bye Azacca...bye bye Wilkenson.”