Montreal Serai

February 18, 2010

For Elisa Zlami, the burden of her fractured leg just got heavier, literally. The day before, Marc, an ortho-tech at the General Hospital in Port au Prince, came immediately to her tent, “Post Op 3″, after I asked him to ”do something” about Elisa’s old split cast that was causing her pain. Haiti’s earthquake snapped her shin bone in two, and left an open wound that has finally healed. 

 Marc expertly rewrapped her leg in a new plaster cast. Despite a day of drying, the new cast must weigh 20 lbs. Yet her leg still hurts along the fracture point. A summoned orthopedic doctor inspects Elisa, and tells her the pain should go away, and Elisa need not stay in the hospital. But Elisa has lost her home and her family too.

A few weeks after the earthquake, Rea is desperately trying to get food for her community of children and their families from the school she ran before the earthquake. It now is a community center and clinic. Baz, an American medic, has told her that there might be food from the UN. But it is very confusing. The Italian Navy is also promising food in a few days. The prospect of being able to participate in that food distribution system seems daunting for Rea, whose English is not very good and whose Italian is nil.

Pediatric patient, HUEH

A new French doctor, Michelle, breezes into Post Op 3 and cuts away the dressings from Mrs. Wintour’s heel. Mrs. Wintour’s wounds are now green with infection. I changed her dressing two days ago and there was no green then, so daily dressing changes are now mandatory. Better nutrition is essential too, since malnourishment is preventing healing.

At the sprawling, busy United Nations compound, there are no hungry people. Not many are Haitians either, who are being stopped at the gates while whites like me are waved through. I have no business there really; I am wandering around looking to book a flight to Miami. I see many cheerful foreigners working for NGOs, governments, militaries and businesses, because Haiti is now a boomtown. The opportunities for aid and development work are enormous thanks to the disaster and the millions or billions of dollars being pledged. Foreigners, especially Americans, are flocking to Port au Prince to pursue this offshore opportunity. Many are earnest, believing sincerely in their humanitarian mission. Of course, the thousands of mostly U.S. soldiers didn’t exactly come by choice.

When deposed popular Haitian President, Aristide told the UN in 1991, “Everyone must have a place at the table,” he was referring to Haiti’s hungry dispossessed. But it is the international community that has invited itself to feast. Little has changed since Columbus first colonized Haiti, including blaming the Haitians for their poverty.

Shanti town across from port in Port au Prince

Post Op 3 tent is a small community where Elisa and Mrs. Wintour live with 18 other patients, their families and friends. The young girl who often tends Elisa is a friend, the healthy sister of another girl living outside the tent, who also has a painful broken leg. Food brought in by the families to supplement the meager daily hospital meal is often shared. Nearby, the Haitian Adventist hospital sponsored by US Adventists and an evangelical food mission provides two large vegan meals a day with food mostly bought from the neighbouring Dominican Republic.

I asked Mr. Abelard, Elisa’s older neighbour in the next bed, to make sure Elisa gets to X-Ray. He knows how the informal system works – you flag down someone walking by in Transport, hand them your paper note saying “Radiograph – jambe droit”, and they put you on a stretcher and carry you to and from X-Ray.

Emmanuel has extensive injuries, including an amputated right arm, and is fighting an infection to hip and leg wounds that have been repeatedly surgically cleaned. He also has two sisters jealous of his neighbour, Mrs. Wintour’s new experimental mechanical wound suction device that aspirates draining fluid from her foot wound into a corrugated blue squeeze bottle. The sisters want one for Emmanuel. The device is being developed by a Boston medical team who work with Partners In Health based here in Haiti. Kristine, their engineer, thinks when the kinks are worked out, they can provide the molds for the plastic bottles to businesses in third world countries that can stamp out bottles for a few dollars. They hope each system will cost less than $75. In the U.S., a more efficient electrical system called a Wound Vac costs $25,000; its manufacturer made $1.4 billion from it in 2008. The next day, Emmanuel gets the blue bottle wound suction for his hip.

Shekhar, an Edmonton Red Cross volunteer called me the other night after assisting with food distribution that day. He can’t understand why food distribution is run so badly in Haiti. After all, Shekhar and the international agencies have done this successfully around the world. The Haitians are prepared to do anything they can to help. Those of us who have had the good fortune to hang out with Haitians or wander around Port au Prince’s poor neighbourhoods, remark to each other how kind and gracious these Haitians have been to us. This is in contradiction to their sinister portrayal by our media and governments.

I happened to have been in Washington when the quake struck down Haiti. I’m not a bad schmoozer, so with a little luck and effort, I found myself connecting with people and agencies that were to be some of the players in the emergency medical response.

Food lines for women, Place St-Pierre, Pietonville

Last week, Christine, a trauma surgeon in Washington told me that I should tell the director of the General Hospital that if he wants medical materials, he should go to the US A.I.D. web site. “Like a bridal registry,” Christine texted. I presented the message to Director Dr. Lassegue, who responded skeptically, “Oui, perhaps something will come of it.”

Many experienced in disaster response, label the beginning organization “a cluster fuck”. I bumped into David, a young tattooed American at the UN campground walking to a health-cluster meeting. David griped that the scheduled meeting times were often changed, and tended to be useless because the decisions had already been made overseas.

Like so many of the people sharing the Post Op tents, Elisa’s losses are more profound than her wounds. It’s not their crooked or missing limbs that will be their biggest impediment. It is the prospect of trying to make a home and a life out of their shattered country that again is being occupied – and is now run by a coalition of a post-coup regime, foreign governments, militaries, religious charities, NGOs and aid agencies – all under the umbrella of humanitarian relief.

Three weeks after the quake, the French-run Handicap International organization set up shop at the hospital with a plain green military tent and a team of about a dozen French physical therapists and Haitian trainees. The French will leave eventually, but they understand that the work must continue with the Haitian staff. This model has yet to be adopted by most aid agencies that have no plan to sustain their programs without their presence.

Most charitable aid to “take care of Haiti’s poor” spends little actual money inside Haiti. We long to hear announcements that there will be substantial aid for Haiti’s peasant farmers to provide credit and resources to plant sustainable crops for local consumption, and to help Haitian businesses produce essential local goods.

Back at the trauma ward, we have to figure out who will be operating on the patients now that after a month, the Red Cross Norwegian orthopedic surgeons have left to another health facility, and the Medecins du Monde surgeons are leaving this weekend. The rapid turnover of many volunteers is maddening. In the operating room, I ask the Haitian surgeon in charge, who says, “When you need a surgeon, just come in and grab one of us.” Sounds like a plan.

The staffing at least during the dayshift at the hospital is much better now than three weeks ago when I first arrived. Many more Haitians are able to work. Even the Israelis just sent in a half dozen Mogen David staff, while they are still busy blocking medical aid to Gaza after destroying hospitals and ambulances there last year.

Diana is an American nurse running a clinic inside a tent community of 2,500 homeless and hungry people. Talking with worker at the airport where supplies are being delivered, she found out that his friend has a quadriplegic child who needs a wheelchair with a head support. With the help of a Mr. Fix-It friend, Diana presents the worker a retrofitted wheelchair with a headrest, and drives back to the tent community with four pallets of food. But two weeks later, Rea still has not been able to tap into a food pipeline for her community.

The informal networking ways of getting things done described above can only work on an international scale if the Haitian people are included and are allowed to be masters of their destiny.

International businessmen are urged take advantage of the new manufacturing climate in Haiti. Foreign aid earmarked for security will also revitalize Haitian security forces who historically have been its death squads, attacking labour and community organizers who might reduce profits from such sweatshops.

The Toussaint Louverture Airport was being run by the US Military when I arrived yesterday evening, despite the handful of Haitians who stamp our passports before we walk out onto the tarmac. Homeland Security’s immigration police and border agents then check our passports as we board. Three weeks previously when I arrived, no one asked for my passport – in fact, no one asked me for any identification or professional license during my entire stay. On the tarmac are Canadian soldiers, RCMP officers, CIDA aid employees and diplomatic personnel waiting to board their military transport plane to Ottawa. There is also a tent for the US soldiers, and the US State Department processing civilians for their humanitarian transport to the U.S. in military C-130s. 

The aid response is not so confusing after all. The Montreal Meeting of international donors, the Davos Forum, the Clinton-Bush Haiti Fund, US A.I.D., the UN, and the various security forces in Haiti all seem to be navigating the humanitarian response ship to further their interests in Haiti. Most NGOs and religious missions have found a niche to plug into.

Humanitarian aid is perceived as just and moral. But until Haitians like Elisa, Mr. Abelard, Mrs. Wintour and Rea are permitted at their own table and given the chance to build a sustainable infrastructure, so-called aid becomes another weapon to exploit these good people who liberated themselves from slavery, and are still paying the price.

February 9th, 2010

Slande flew out of Miami two days after the Haitian earthquake struck. She is a nurse at a Ft Lauderdale nursing home, and her home country was devastated. “Well, I had to come” she explained.  Slande went immediately to work at the HUEH or public General Hospital in downtown Port au Prince, as it is known by most.

The hospital was in as bad a shape as the surrounding neighbourhood. The five story nursing school annex collapsed, killing many – reports of between 100 – 500 nursing students died. Inside the hospital, many sections were damaged. “But the courtyard was intact, and that is where the injured and the dead were brought. It was too much! We had nothing then. People were lying outside in the boiling sun during the day. The entrance to the X-ray department was crowded – because it had shade”.

“Yeah, we treated them of course. People came in with open fractures, dirty, flies, untreated. It was really bad”, Slande says wearily. “There were no tents. People were dying too”.

Over the last few weeks, the destroyed hospital has turned into a functional hospital with large 10 -20 bed size tents serving as specialized wards crowded in the courtyard, there is a mixture of HUEH staff and international organizations providing health care. Food is minimal for the patients, and none for the staff, but there is plenty of drinking water. Essential pain medications, antibiotics and wound dressing supplies are generally in adequate supply. The operating room is functioning, and the x ray department has two machines running.

Three weeks later, Slande is now running between 50 patients in three trauma tents. She cleans their wounds and changes their dressings; make sure they get their pain medications and antibiotics, and puts out fires. She coordinates with the irregular and rapidly changing staff. Slande is of course very popular, not just because she is a friendly, excellent, dedicated nurse, but because she is speaks the three languages that operate here: Creole, French and English. Her past experience as an Emergency Room nurse prepared Slande “only a little bit” she confesses, to the overwhelming demands here.

Jeanne is 26, pretty and has a large shoulder bandage at her shoulder where her right arm used to be. Being tended by her younger sister, and two children she survived the traumatic crush injury to her arm, but now finds herself among the hundreds of amputees.

She has a note from her surgeon dated Jan. 30th, stating she needs to return for surgery February 10th, and her wound needs to be cleaned and dressed daily. But Jeanne can’t read much English, so when I approached her on Feb 2nd, she is convinced that the doctor wrote that her wound dressing will be changed next on Feb. 10th. My French is good enough to explain to her what the note says, and to warn her that wounds like hers’ must be cleaned daily to prevent deadly infections. Her French is good enough to understand me. Jeanne refused nevertheless.

Slande doing the dressing of Jeanne's wound, while Jeanne's son is looking on from behind

I asked a Haitian doctor to lay it out for her. If Jeanne gets a serious wound infection, she will die. He did. She refused. The next day, Slande made it clear to her what the deal was, and reassured her that we would give her pain medications before doing the dressing change. Fear of pain, we thought, might be the underlying reason for her obstinacy. Jeanne agreed. But Slande got caught up with other patient’s wounds and needs, so Jeanne who lies at the far end of the ward, didn’t get her dressing changed that day.

When Slande cleaned Jeanne’s wound of Feb. 4th, she said it looked “really bad”. “Really bad” means it’s infected. We made sure Jeanne was on appropriate antibiotics. I asked Slande if the dressing change was painful, and she said, not really.

The next day, Slande changed the dressing again- Jeanne readily agreed- and the wound improved significantly. This is more a testament to Jeanne’s age, than our treatments. Young people can heal that much quicker. (Photo is from Feb 7th, after 3 dressing changes).

Our wards are little communities. There is no privacy between the beds or cots. Most of the patients have family members staying with them all the time, there is a buzz of conversations and activity throughout the day. The families are essential – feeding, cleaning their kin, and advocating for them. They clean the mess on the grounds too.

 Occasionally the cacophony of various evangelical preachers and prayers. By my second day, enough patients or family members know me by name to call for me. Usually their needs are basic: pain medications (which they rarely ask for); when will I get around to changing their wound dressings; but mostly it is to say Hello. In fact, all the foreign staff are shaking their heads about how little we are asked to treat anything – especially the pain which must be considerable. Bone pain from fractures, even amputations, are considerable. But most of our patients are getting by with the occasional Tylenol or ibuprophen. We use narcotics for a few.

C.M. and E.F. are two Haitian nurses who come in for the night shift. They work for the HUEH hospital, yet like all the medical staff, haven’t been paid in four months. “The government is broke”, they explain. Pierre, a Miami accountant who is back in Haiti helping with logistics after being gone for 25 years, is like me, astounded. “Why do you come to work then?” he asks. “This is typical for Haiti” replies E.F., “no one gets paid here”.

She exaggerates; clearly, some Haitians are getting paid very well. They drive nice cars, and live in big houses, with servants and gardeners. But one aspect is clear about this extremely poor country, there is little money for public services like health care or education. Which is why the patients appear very happy to have this foreign health care all of a sudden?

Not only are the staff here because we want to be, but we bring in tons of free medications and supplies that previously, they would have had to pay for, even at the public hospital. Yet, this is creating a black market too – the supplies and medicines disappear. Desperate people may be taking them, or common criminals. The patients go without, as their donated supplies are now for sale on the streets. Haiti has long been a country where the poor are grievously exploited – and this influx of relief aid without accountability and justice, is not going to change the corrupt economic system.

Emanuel is a young man with wounds on all four limbs, including a high right arm amputation has not been having much relief in the last two days. Three nights ago, one of his sisters assisted me with the wound dressing changes, while I instruct the other squeamish sister to “not look”. Previously, her natural reaction to her brother’s pain during a wound cleaning forced the doctor to stop.  I told him I was going to medicate him well with analgesics before I began. Emanuel got 10 mg of morphine, but to my surprise, he was wide awake when I began the dressing change. So I sprayed lidocaine anaesthetic on his wound, and even injected a few cc’s into the necrotic area. It worked fine. The squeamish sister stayed calm, the other sister assisted with holding E.S. leg up and unwrapping dressing supplies, and Emanuel felt nothing as I removed a patch of dead tissue from his calf.  Last night when I did his dressings, he refused extra medication, took deep breaths, and did fine.

One consequence of 1 million homeless is that a bed in a hospital tent is a bed for someone without a home. I have had to play the bad sheriff, this morning telling a man with a finger wound and a limp, to leave, because he snuck in and spent the night in one of our beds, despite his children pleading. But our beds are for people much worse off than him. Where can he go? To a crowded camp with a mixture of homemade tents and fancy Red Cross tents. The situation was difficult before, and now it is just overwhelming. We all hope that the Haitian people will be able to take over the services the international volunteers are providing, and rebuild a better country.

Scott Weinstein, RN

February 4, 2010

Hi, Very quick message because I’m borrowing a computer. I’ve been working the post op ’ward’ of 3 tents w 50 people at the very busy HUEH hospital in Port au Prince – mostly fractures and amputations. There are probably several hundred in patients and just as many ‘out patients’.   We are trying to save their limbs and lives with the materials and medications we have. It is very busy, and not as coordinated as I hoped it would be. Part of the problem is that there are teams from everywhere who don’t have similar systems and styles. Lots of turnover, unreliable transport, etc…   But folks are trying hard and doing good work. The Haitian nurses and staff are invaluable to the rest of us, especially the non-French or Creole speakers. I would say that Haitian and French or Creole speaking RNs and MDs are still very much needed. We are seeing still a lot of trauma, plus acute and chronic medical issues, and peds. Babies are being born and, yes, patients are also dying. I can’t say everyone is getting adequate care because of the holes in our supplies personnel and equipment.   X-ray is now available. MSF just opened a 200 bed rehab hospital. We are mostly in tents, it’s hot humid, but plenty of drinking water. The patients have their families with them which is the only way they will get most of their daily care.   Again, I am choked up about how little the people here expect from us. They rarely ask for pain meds, despite their fractures and amputations. The people are very resilient.

Best, Scott

Jan 31, 2010 

Hi,
 
Roger & I walked around for an hour today in crowded Pietonville which has the rich and lots of poor, and 4 hours in crowded downtown which is all poor in tents and shanties. We went by the port, the national palace camps and by Cite de Soleil. The worst thing that happened to me was a sunburn. Downtown which is flat is really pummeled by the earthquake, a lot of houses down. Shanties on hills collapsed too.
 
But everyone was very nice. Very busy, but safe all around. No fights, no yelling, other than hailing ‘tap-taps’.  It helps to be white guys. Very little hustling even – less than a NYC street. In a shanty town, an orange wholesaler gave us free oranges, because it was too complicated to sell individual ones. This was so unlike the fear propaganda that is drummed into our heads, which is why we didn’t see any other white person on foot the whole time, except one guy with his young Haitian girlfriend. We didn’t see much in the way of soldiers or police either.
 
There appears to be a lot of food for sale in the streets & sidewalks, but most is non caloric, most is fruit. I saw very little rice, no corn, some potatoes, sugar cane, a little wheat, some beans & oil. I saw no one actually eating…, and not a lot of people buying. We saw no food aid at all, on the streets or in the camps. We hear rumors of food aid now for sale in the stores…
 
In the camps, we put a sling on a young girl with a possible fractured arm and gave her some Tylenol. She was afraid to go to the hospital because she thought it would cost, and they would amputate… So we had to dispel that myth.
 
At the hospital, I took a photo of 4 guys with the US 82nd Airborne armed with M16s guarding a cart of patient’s food being distributed! It was so ridiculous, because others were distributing food by themselves.
 
Certainly, the Haitians are resilient, and also self sufficient. I imagine they don’t expect people to help them.
Best,
Scott
 

Jan 30, 2010

Hello All,  
 
I can only write about my very limited impressions over 2 days here, so take what I write as having an very narrow perspective.
 
Port au Prince in the four neighbourhoods including downtown that I’ve been through is teeming with people, buses and cars. It really seems like any crowded city in an under-developed country. Unlike abandoned New Orleans when Americans were barred from returning to their damaged neighbourhoods, and also they felt unable to return without electricity, water and sewage, this is not the case here.
 
People appear very industrious, and a lot of small businesses and street vendors are operating.  I am aware that small business, schools and churches are now functioning in a public relief mode – helping people with food, water, medical and other essentials. Everyone I have spoken too has been polite and friendly. Haitian French is very easy to understand, and many Creole speakers understand my French.
 
Most of the streets are cleared of rubble. I would estimate that about 5 – 10% of the buildings have collapsed, but a lot more are structurally damaged to the point that people do not feel safe to live in them.
 
Every town square and park is teeming with the new homeless, thousands. There are also people camped out on the sides of streets.  Yet, I was prepared for the odor of decomposing bodies or food, and it is no longer present in the areas I have been.
 
The airport is down to 40 flights a day from 120 last week according to an Air Force soldier I spoke to there upon arriving. The Air Force and the FAA control it. Immigration did not even ask me any questions or stop me before I left the building.
 
Medicine/Medical
 
I visited and spoke with the director of the main hospital yesterday (HUEH/General), a very kind and welcoming Dr. Lassegue. He notes that the trauma period of medical care is over, and medical needs are post op care, wound care, and chronic illnesses.
 
There are still shortages of essential medical materials and medicines on the ground – analgesics, anesthetics, antibiotics, and regular meds for the usual chronic diseases. (I sent in another email, their staff and material/medicine needs).
 
The hospital itself is a combination of medical tents outside, and some services inside. There are many Haitians working and volunteering there, plus a good compliment of international teams. It appears very well organized and staffed. I note a busy, but focused and calm atmosphere, despite the improvisational nature of the services. They are doing it all from Labour and Delivery, neo-natal, pediatrics, trauma, OR, medical, ER, mental health and triage.
 
Many patients are on simple beds or cots. Few have running IV’s, and probably few have pain meds. Remarkably, people seem awfully stoic and quiet. I heard no complaining or yelling (less so than our hospitals!). Patients often had their family there – especially the kids. Everyone was polite who I spoke with and let me take their photo when I asked.
 
Outside the hospital, the medical needs are wound care, and regular illness. I noticed very few internationals medical people besides my acquaintances from the US and Medecins Sans Frontiers. Of course, sanitation, drinking water and food in the new homeless camps is essential.
 
Problems:
Food, water, money & armed troops.
 
Food is simply not being distributed adequately to those who need it the most. Yet there is both food in the restaurants and stores for sale, and I believe food in the warehouses that the UN and the International bodies are controlling. I was in a store today to change money and the shelves were full. It seems horrible to think that many are going hungry or even starving, but across the street, if they had money, they could eat their fill. Food in Haiti is expensive because most of the essentials are imported. Their agriculture is more geared for export crops like fruit.
 
I keep hearing about security concerns for the teams distributing food, but my strong impression is that there is a lot of ill prepared teams and paranoia about crushes & violence. If food can be distributed safely around the world in other emergencies, it could be done here too. Frankly, the streets are busy, but I have yet to notice any threatening behavior. Like the hospital, people seemed focused and calm. A business association I was visiting today was busy distributing water, and there are no armed guards with their operation.
 
Because of the class divisions in Haiti, those that have money will not go hungry unlike those without who are dependent of food aid and distribution.
 
Drinking water is in short supply like food.
 
There are pockets of US soldiers around the downtown that are noticeable, and I have heard comments from Haitians about them. Since there seems to be no general security threats, people are wondering why they are here. My lame answer is that is what the US does best; send troops, because it has no civilian emergency corps. But they would be more helpful if they were not carrying around M-16s, but had medical supplies or food.
 
 
Best,
Scott