Genyen tout yon sosyete ki pou change.
(There is a whole society to be changed.)
— Haitian Proverb
It is no exaggeration to say the forty-five second, 7.0 earthquake that rocked the capital of Haiti on January 12th and reduced hospitals and clinics to rubble set the country on a trajectory back to a medical stone age. Forty-five seconds.
The earthquake destroyed the health care infrastructure in Port-au-Prince and shut down basic services critical for the delivery of health care: the electrical grid, transport, water and sanitation systems. The country didn’t have much of a health care system to topple. Haiti lacks modern medical resources: state-of-the-art hospitals and clinics; sufficient numbers of trained nurses, doctors and other medical staff; medical devices, diagnostic technology and medicines.
Haiti is a medical backwater, an island trapped in a time capsule where disease, disability and death stalk impoverished Haitians year after year. About 80 percent of Haitians live in poverty (on less than a $1 day) and 54 percent live in “abject poverty.” No one should die of tuberculosis: medicines to cure the disease have existed for half a century. Yet in Haiti, over 5000 a year die and rates of TB infection are increasing. HIV/AIDS is considered a chronic disease treated by a cocktail of anti-retroviral drugs. But not in Haiti − over 7000 die every year. AIDS is the leading of cause of death for those between the ages of 15 to 49. TB and AIDS are the infections of inequality and unremitting poverty.
Dozens of foreign non-governmental organizations (NGOs) have provided medical care to Haitians for decades. Haiti has become a “medical missionary’s mission.” Thousands of committed and compassionate nurses and doctors travel to the island to offer medical services and then fly back to the developed world. Paul Farmer, a physician and anthropologist at Harvard University, has brought attention to poor Haitians dying from curable diseases. The organization he founded, Partners in Health, has offered basic medical services to Haitians for 20 years. In his groundbreaking book, Infections and Inequalities, The Modern Plagues, Farmer explains how the social determinants of health collude at every turn to debilitate and kill.
Haiti needs a permanent, modern health care infrastructure that can respond to the medical needs of all Haitians and is organized and staffed by Haitians themselves. To be sure, medical charity for Haitians is an important example of solidarity and support for the sick and poor, but it’s no substitute for a free, national, indigenous health care system.
Medical personnel the world over rushed to aid the victims of the earthquake. First responders, typically a seasoned group of medical providers, were astounded by the degree of devastation, the number of deaths and the damage done to hospitals and community clinics. They were confronted by a cacophony of screaming, crying and moaning from Haitians crushed and trapped under piles of concrete and to the sight of bleeding, dying and dead men, women and children lining the streets. The word “traumatic” can’t begin to describe the sounds and scenes of human suffering that went on for days and weeks. Tears are supposed to be cathartic, but could anyone shed enough to wash away the tragedy of 200,000 lives lost?
Haitian medical personnel were killed when workplaces crashed down on them. Democracy Now reported from the General Hospital campus in Porto-au-Prince the entire class of second-year nursing students was buried inside their classrooms. Dr. Evan Lyon outlined the medical catastrophe at the hospital: only four working operating rooms, no anesthesia, no narcotics, running out of antibiotics, operating by daylight and flashlight, using hacksaws to amputate limbs, thousands of dead bodies stacked everywhere and no refrigeration in the morgue.
Two things could transform the horror into hope ¾ freeing people from the wreckage and providing medical care to survivors. Rescue and medical teams were stymied in these two tasks at every turn. The press reported daily on the “logistical nightmare” at the airport and on the lack of coordination of relief efforts on the ground. Five flights carrying inflatable hospitals and physicians from Doctors Without Borders were rerouted to the Dominican Republic. In the United States, the RN Response Network (RNRN) signed up 12,000 nurses within a week of the quake, but the RNs weren’t able to get to Haiti until early February. These delays in medical care were unconscionable and resulted in more deaths.
Why, when natural disasters strike from Hurricane Katrina in New Orleans to the earthquake in Porto-au-Prince, is the United States incapable of planning and organizing a rapid, coherent and consistent response? Why is there so much chaos, the logistics a “nightmare” and medical resources and personnel to save lives delayed or denied access? After all, the medical needs of survivors of trauma of every type are well known. No organization understands psychological and physical trauma — how to inflict and survive it — better than the U.S. military.
In an article in the New England Journal of Medicine, Atul Gawande, M.D., titled Casualties of War – Military Care for the Wounded in Iraq and Afghanistan, explains how quick access to medical care “determines whether or not someone dies.” The military learned how to decrease soldier mortality; create Forward Surgical Teams (FSTs) positioned directly behind troops instead of miles away. Think of them as modern, mobile “M*A*S*H” units on meth minus Hawkeye and Houlihan. Gawande describes them, “…small teams consisting of just 20 people: 3 general surgeons, 1 orthopedic surgeon, 2 nurse anesthetists, 3 nurses, plus medics and other support personnel.” The FST sets up a troika of tents called Deployable Rapid Assembly Shelters that function as mini hospitals. They are stocked with state-of-the-art medical technology to resuscitate and operate on up to 30 patients at a time. Once stabilized, soldiers are moved to the next level of care — combat support hospitals. They are portable facilities too, and provide more complex medical care within 24 to 48 hours of being assembled. The next stop is a hospital in Kuwait, Spain or Germany and the end of the line is transfer to a VA hospital in the United States. Gawande notes, “The average time from battlefield to arrival in the United States is now less than four days. In Vietnam it was 45 days.” This meticulous level of coordination of care is a remarkable human achievement and has resulted in a mind-blowing 90 percent survival rate! It is proof positive effective and timely medical care can be delivered in the most dangerous and difficult circumstances.
To be sure, a war is different than an earthquake, the number of injured in Haiti is dramatically higher, but the acuity is not. Instead of mobilizing and prioritizing the arrival of FSTs, medical equipment, medicine and adapting the knowledge gleaned in war (as sick as that is) to triage and treat the injured in a full-on attempt to save Haitian lives, the U.S. military prioritized flights carrying soldiers, high-ranking officials like Hillary Clinton (the airport was shut down for 3 hours because of her arrival) and the media. Currently, 20,000 US troops occupy the ports, Louverture International Airport and Porto-au-Prince. President Obama appointed George Bush Jr. to assist humanitarian efforts in Haiti. As if the idiot ex-president who flew over the inundated New Orleans after hurricane Katrina with a perplexed smile on his face could coordinate disaster relief.
Just 600 hundred miles away — 1 hour and 22 minutes by commercial flight — is the United States of America: The richest country on earth with the largest, most technologically advanced health care infrastructure staffed by millions of health care workers. Surgeons operate with Da Vinci robots (surgery is a science and an Italian art), dialysis machines cleanse blood, a new class of injectable drugs called biologics have transformed the lives of millions with auto-immune diseases, the United Network for Organ Sharing (UNOS) coordinates the harvesting and sharing of thousands of organs – kidneys, livers, lungs, hearts – and delivers them to hospitals in all fifty states by a fleet of helicopters.
Alongside this embarrassment of medical riches is an embarrassment of medical poverty and medical apartheid: 50 million uninsured Americans, 45,000 die every year from lack of access to health care and a disproportionate number that perish are African-American.
The state of Florida is in the midst of an unprecedented fiscal crisis and a health care system meltdown: 4 million Floridians have no health coverage. Families USA reports 797,000 of the uninsured are children. The medical disaster in Haiti ran pell-mell into the health care crisis in Florida. Hundreds of critically injured Haitians have been evacuated by military C-130s to the state, but flights were suspended for four days in January. In an article in the New York Times, Dr. Barth A. Green, co-founder of Medishare for Haiti, warned the suspension of flights could be catastrophic for patients and added, “They need a degree of expertise and facilities not available anywhere here [Haiti] or on the Naval hospital ship Comfort.” A surgeon predicted 100 of his patients would die if military flights weren’t restarted. The flights were halted after Republican Gov. Charlie Crist sent a memorandum to Kathleen Sebelius, the secretary of Health and Human Services, warning the health care system was reaching a “saturation point,” and asking the federal government to pick up the bill (in the millions) for Haitian’s medical care. The governor said, “We are trying to make sure we don’t over burden Florida and I think that it’s important that we don’t.” An article in the South Florida Sun-Sentinel reported, “The day Crist made his request, with 136 Haitian evacuees hospitalized in Broward, Palm Beach and Miami-Dade counties, a state health task force member formally requested that victims be sent north – in part to make sure Miami emergency rooms are ready for the Super Bowl.”
Most Haitians flown to Florida for medical care aren’t legal residents. They can apply for Medicaid but only if granted a temporary status called “humanitarian parole.” To date, 34 patients have been given “humanitarian parole” according to Matthew Chandler, a spokesperson for the Department of Homeland Security. Governor Crist wants to bypass the parole process and force the federal government to activate the National Disaster Medical System. Under that system, the complete cost of providing care for patients regardless of legal status is covered.
The federal government should activate the National Disaster Medical System. Immediately − for the entire country.
The national medical disaster playing out in Haiti has its doppelganger in the United States. Thousands of Haitians are standing in line for medical care and so are Americans. Remote Area Medical (RAM) is a charity organization committed to providing health care in developing countries. But now over 60 percent of missions are based in the poorest areas of the United States and wherever RAM goes thousands of people line up for medical, dental and vision care. The tag-line on their website reads: Pioneers of No-Cost Health Care.
In rural Virginia RAM set up on fairgrounds. Workers bleached the area clean of horse manure, registered patients in a barn, then examined and treated 2500 people over three days in animal stalls full of hay and mud. In urban Los Angeles the digs were clean and modern − the Forum concert arena − but the queues were longer. Dentists and optometrists treated patients on the floor of the mega-stadium, mammograms and gynecological exams were performed under the bleachers. The all-volunteer medical staff treated up to 1,500 patients a day for 8 days.
Shards of concrete crushed thousands of Haitian limbs and created an instant generation of amputees. The number of amputations performed has reached 4000. Dr. Deane Marchbein, an anesthesiologist with Doctors Without Borders, observed, “I imagine that not since the Crimean war have surgeons seen and amputated so many limbs, perhaps the Civil War in the United States…” The United States has generations of amputees from the “Diabetes War” which we are losing. Diabetic foot ulcers/infections are the number one cause of lower extremity amputations. From 1980 to 1996, the number of diabetes-related lower extremity amputations increased from 36,000 per year to 86,000. Almost 80 percent of amputations are preventable with tight control of blood sugars, uninterrupted access to insulin and consistent medical follow up. Diabetic amputations disproportionately afflict poor, uninsured people of color who live in a high blood sugar hell.
All over the globe poverty and the pursuit of profit join together to produce millions of preventable deaths and disability. An ocean may separate Haiti from the United States but the struggle to make health care a human right in both countries — one poor, the other rich — unites us.
*I wrote this article in loving memory of Howard Zinn and in solidarity with the people of Haiti.
HELEN REDMOND is a medical social worker in Chicago. She can be reached at: firstname.lastname@example.org