Shelter from the storm: Volunteer nurse monitors a three-year-old girl with two broken legs in mobile operating room in Leogane. Photos courtesy of Patrick Adams.
Shelter from the storm: Volunteer nurse monitors a three-year-old girl with two broken legs in mobile operating room in Leogane. Photos courtesy of Patrick Adams.

Healing and Helping

In the wake of Haiti’s devastating earthquake, an alumnus discovers the enduring resilience of the country’s residents—and the ongoing efforts of the Duke community to respond to their needs.
Writer: 
June 1, 2010
 
I left for Haiti five days after the earthquake. I flew into Santo Domingo, hitched a ride to a small port town six hours south, and managed to make it aboard a Dominican Navy ship, the Tortuguero, ferrying food, water, and medical supplies to Jacmel, a city of 40,000 on the country’s picturesque southern coast.

Up till then, news accounts, and the bulk of relief efforts, had focused almost entirely on the devastated capital, Port-au-Prince, approximately fifty-five miles to the north. Jacmel, like much of the rest of the affected area, had been largely ignored. Fifty percent of the buildings were damaged or destroyed. An estimated 3,000 people were buried under the rubble. And those hospitals still standing had exhausted their reserves of medicines and supplies.

As a freelance journalist, I travel often. But I had never been to Haiti. I wanted to find out what was going on, and I wanted to wade in from the shallow end. Jacmel, long the country’s top tourist destination, renowned for its friendly people and low crime, seemed like the best place to start. I packed a week’s worth of food, a stock of antibiotics, some clothes, some cash, and a tent and hoped for the best.

The first people I met in Jacmel were Nick and Gwenn Mangine, a young, hip missionary couple from Clayton, North Carolina. And I was lucky I did; I had planned to make camp that first night on the beach by the port. But the Mangines insisted I pitch my tent in their front yard, alongside them and the nine Haitian kids they were caring for, all of whom were sleeping outside for fear of the aftershocks.

The Mangines had come to Haiti nine months earlier with their three biological children to run the Haitian Children’s Home, a refuge for orphaned and abandoned children on the outskirts of town. After the quake, though, they’d been thrust into the role of relief worker: The United Nations’ World Food Program wanted their help with distributing MREs, and the Red Cross needed their warehouses to store medical supplies. But it was the day the mayor put them in charge of Jacmel Airport that the Mangines understood how large a role they were to play. “We’ve become airport administrators,” Gwenn told me the day I arrived. “We’re directing planes where they need to go, handling the flight manifests, checking passports. Because, basically, there are flights coming in, and there is no one else to do this.”

For the first three weeks, I helped the Mangines and a half-dozen other volunteers run civilian-aid operations out of the airport, which had also become headquarters for Operation Hestia, the Canadian Forces’ humanitarian relief effort. All day, as Sea Hawk helicopters and Hercules transport planes thundered overhead, we conducted needs assessments at the clinics around town, found tents and tarps for incoming medical teams, and reported on the U.N. cluster meetings, where, in time, representatives of all the major agencies met to coordinate their activities and identify gaps.

On one of my first days in Jacmel, I helped a Dominican Red Cross team set up in Pinchinat, the city’s soccer-stadium-turned-refugee camp, where an estimated 5,000 displaced persons had congregated after the quake, many of them refugees from Port-au-Prince. U.N. peacekeepers patrolled the sea of makeshift huts—assembled with sticks and bed sheets and scraps of tin fished from the rubble—while aid workers with Save the Children built the wooden frames for the camp’s first latrines.

Life goes on: Girls jump rope in Jacmel’s soccer stadium, where some 5,000 displaced people congregated after the earthquake.

Life goes on: Girls jump rope in Jacmel’s soccer stadium, where some 5,000 displaced people congregated after the earthquake.

Yet there were no doctors in sight, and as the Red Cross team made its way through the camp, a crowd started to gather. There was an elderly woman holding an infant that was too weak to cry and a small boy, naked from the waist down, with his head wrapped in blood-stained gauze. There were children with hair bleached by kwashiorkor (a disease caused by malnutrition) and others with festering wounds that wouldn’t heal. And everywhere, I was told, the invisible trauma of mental distress. Never before had I so wished I had the power to heal.

But I didn’t, and instead I fetched chairs and tables from a nearby school and helped the doctors and nurses set up a tarp to work under as patients lined up for the chance to be seen. Mothers, traumatized by the earthquake, explained that they couldn’t breastfeed their malnourished babies. And children suffering from gastrointestinal infections, one of the leading causes of illness owing to the lack of clean water, complained of cramping stomachs and diarrhea. Scabies and other skin infections were common in the camp, and cases of malaria and dengue fever were already on the rise, far ahead of the rainy season.

Still, life went on. Women prepared meals over charcoal fires, while children chased one another through the corridors of tents or played games in the open spaces. Boys flew kites and kicked soccer balls, and girls jumped rope, singing and cheering as each waited her turn. And just as the stakes were pounded into the ground and the tarp went up over the tables, the rain came down, pouring on the people in line, who stood there in spite of it.

While volunteers assisted Haitian health-care workers in Jacmel, Partners In Health (PIH), a Boston-based nonprofit organization, had taken a lead role in relief efforts in Cange, a small town about 100 miles to the northeast. Cofounded in 1987 by Paul Farmer ’82, a Duke trustee and U.N. Deputy Special Envoy to Haiti, PIH serves the country’s poorest and most-marginalized populations. In the process, PIH, which is staffed almost entirely by Haitians, has strengthened local capacity and vastly improved the control of chronic infectious diseases, serving as a model of care for organizations in resource-limited settings around the world.

Indeed, as Tracy Kidder, Farmer’s close friend and biographer, observed in a recent editorial in The New England Journal of Medicine, Zanmi Lasante, the Haitian branch of Partners In Health, had been the largest health-care provider in rural Haiti before the earthquake, with close to 4,000 Haitian employees—approximately 90 percent of its staff—operating out of twelve medical facilities across the province. “After the quake,” Kidder wrote, “[ZL] became (temporarily, at least) the largest and one of the most important in the entire country.”

“We are in uncharted territory,” Farmer told an overflowing audience at Harvard Medical School in early February, describing Haiti’s devastation as an “acute-on-chronic” affliction—evident, at last, to the entire world. In an effort to support Partners In Health as it navigated the unknown, Duke University Health System (DUHS) dispatched a fourteen-member team of health-care professionals, the first of three to date, to provide emergency surgical services and care for people with chronic infectious diseases, such as HIV/AIDS and tuberculosis.

Triage and treatment: At a rural hospital on the outskirts of Jacmel, volunteers saw a steady stream of patients

Triage and treatment: At a rural hospital on the outskirts of Jacmel, volunteers, such as nurse Cecile Noel, saw a steady stream of patients in varying degrees of distress.

 

“My first impression was one of total amazement,” said Ian Greenwald, chief medical officer of the DUHS Preparedness and Response Center and the team leader in Cange, as he recalled walking into the Partners In Health chapel, which had been converted into a hospital ward. “The Haitians were incredibly calm and brave in the face of so much suffering and so many unknowns.”

Greenwald and his team spent a total of ten days in Haiti, making do without much of the equipment at their disposal in Durham. But for many members of the team, the professional challenges paled in comparison with the emotional impact of the experience. “The sheer number of patients with limb loss, particularly in children, was not something we’re used to,” said David MacLeod, the team’s anaesthesiologist. “Each day, going around the ward and doing dressing changes for children who had lost part of their arm or leg—that, for me, was probably the most striking thing.”

After several days in Cange, the Duke team moved to the Partners In Health facility in Port-au-Prince, where a broader spectrum of cases—everything from fevers and abdominal pain to gunshot wounds and crush injuries—presented new challenges. “Even then, some people came in with fractures that hadn’t been seen by a doctor since the earthquake,” recalled Katie Sligh B.S.N. ’06, a clinical nurse. “It was three weeks out, and they were just now making their way to a hospital.”

According to Greenwald, many fracture wounds had become infected by the time patients could be seen. “But amputating was always the last resort,” he said. Greenwald added that while limb loss is a big deal anywhere, amputees in Haiti often face severe discrimination, and that the loss of an arm or leg represents a major economic burden on top of the mental and physical trauma of the event itself. “It was utilized only when the situation was truly life-over-limb,” he said.

I mentioned to Greenwald that in my conversations with trauma surgeons in Leogane and Jacmel, I’d heard over and over again about Haitians’ remarkable resilience and seemingly superhuman stoicism, and I asked him whether he had encountered the same. “Absolutely,” he said. “Collectively, their pain threshold was just incredible. Throughout our time there, our team was awed by how a patient’s perception of pain seemed to be, in some ways, a social phenomenon.”

Cameron Wolfe, an infectious-disease specialist with experience in a number of post-conflict and disaster zones, including Timor, Ethiopia, Malawi, and Rwanda, was no less impressed. “The one thing that was the same throughout all of those places was that resilience of the local population,” he said. “Rarely did any effort from our team go without a thank you or a smile, and that was striking to me, given the number of people who had lost not only a limb but often family members, a home, and a livelihood, as well.”

All hands on deck: names of medical workers taped to clinic door in Leogane

All hands on deck: names of medical workers taped to clinic door in Leogane.

Wolfe added that while the Duke team did its best to address short-term threats to health such as tetanus and sepsis and other secondary infections associated with postoperative care, it’s vector-borne and enteric diseases—malaria, dengue fever, and diarrhea—that could ravage displaced populations during and after the rainy season. “That threat is very real,” he said, adding that Haiti’s baseline rates of childhood malnutrition and chronic infectious diseases were already some of the highest in the Western hemisphere. “Tuberculosis and HIV control is a problem in Haiti at the best of times,” he said. “While there’s a concerted effort to minimize the spread of those diseases, there will inevitably be some breaches.”

In early March, an investigation by the Joint United Nations Program on HIV/AIDS (UNAIDS) revealed a very large breach, and one that could have significant ramifications for population health over the months and years to come: Of the 24,000 HIV-infected Haitians taking anti-retroviral treatment before the quake, less than 40 percent had been able to access treatment in the seven weeks since.

According to UNAIDS, that was due in part to the fact that the vast majority of HIV-infected patients had been displaced and continued to live in overcrowded tent cities, all but cut off from health-care institutions. Moreover, given that close to 80 percent of camps lacked any kind of management or security infrastructure, the overcrowded communities provided an atmosphere conducive to sexual violence and the STDs that could sweep through in their wake.

On a rainy afternoon in early March, about five weeks after the quake, I met David Walmer, a physician and associate clinical professor of medicine at Duke, in the Delmas neighborhood of Port-au-Prince, where he had just arrived on a flight from Durham.

The founder of Family Health Ministries (FHM), a multi-ethnic, faith-based nonprofit organization dedicated to the health and education of women and children in the developing world, Walmer was making his first trip to Haiti since the quake, and he had agreed to show me FHM’s clinic in Blanchard, a ten-minute drive from the airport.

Built in 2006 with support from Duke Chapel, a longtime FHM partner, the Blanchard Family Health Clinic was the only one of three FHM clinics in Haiti to survive the earthquake unscathed. A volunteer medical team was to begin working there in a few days, and Walmer had brought along the supplies they would need for the thousands of patients they would treat over the next six weeks. “I also just needed to see it all,” he said. “With my own eyes.”

As chief of reproductive endocrinology at Duke Medical Center and director of the Duke Fertility Center, Walmer has spent much of his career helping couples in the U.S. realize their dream of becoming parents. But ever since his first trip to Haiti seventeen years ago, the North Carolina native has also been an enduring presence among underserved communities in the developing world, particularly poor Haitian women, who tend to be the most vulnerable to disease.

“We conducted several focus groups last year with women in Leogane,” he told me as the van rumbled over rutted dirt roads, past the American military base and a herd of bone-thin cattle prodded along by a sinewy man in a straw hat. “One of their top priorities was reducing maternal mortality. And they actually formed a women’s group to educate others about the need for cervical cancer screening; they’re extremely invested in this. So we’ve tried to determine how we can use the resources we’ve got to make the biggest possible impact.”

It was that sort of resourcefulness, combined with a clear understanding of the Haitian context, that led to the development of the “CerviScope,” a portable, inexpensive, battery-operated diagnostic tool Walmer invented for use in settings with limited resources. In the developed world, the devices, called colposcopes, are used to detect abnormal cells in the cervix that signal infection by human papillomavirus (HPV), the primary cause of cervical cancer, which can be treated if caught early.

Falling down, getting up: Ob/gyn Delson Merisier in front of what remains of his house.

Falling down, getting up: Ob/gyn Delson Merisier in front of what remains of his house.

Indeed, in the U.S., where routine screening is widely available, cervical cancer accounts for just over 2 percent of all cancer deaths. Across the developing world, however, a dearth of colposcopes ensures that poor women lack access to screening and that most infections with HPV go untreated. The result is that, every year, cervical cancer kills approximately 230,000 women worldwide, roughly the same number of people killed in the Haiti earthquake, according to the most recent estimate by the Haitian government.

Still, despite the fact that most, if not all, of those cancer deaths could be prevented, it’s the sudden, seconds-long snuffing out of life that, for better or worse, arrests our attention and moves us to act—to break with our normal routines and to help out however we can. Indeed, when news of the quake reached the Duke campus, the response was massive and immediate, an outpouring of support—financial, technical, and professional—far exceeding any such effort in the past.

There was the Haitian Student Alliance’s flex-point fundraiser, which brought in $32,000 for the Red Cross, and “Save Haiti Saturday,” an athletics-department initiative benefiting Project Medishare for Haiti. Duke law students raised $1,595 for Doctors Without Borders, while students at the Sanford School of Public Policy raised $2,300 for Mercy Corps. And with the help of Duke staffers, dozens of area restaurants participated in “Dine Out Durham,” raising more than $10,000 for both Partners In Health and Family Health Ministries.

And that was only the fundraising. There was also a variety of other, non-monetary initiatives—from law professor Guy Charles’ development of a nonprofit agency to support the rebuilding of schools to Romance studies professor Deborah Jenson’s creation of a Creole language course for relief workers to the volunteer program REMEDY’s packing and shipping of 400 boxes of medical supplies to FHM clinics.

Hardy Vieux ’93 was born in Brooklyn, but he spent his childhood in Port-au-Prince, in the downtown home of his maternal grandmother, not far from the presidential palace. “We used to play near the palace as kids,” he told me over the phone from Washington, where he works as a lawyer with the firm Blank Rome. “When I saw the pictures in the paper that evening—that’s when it really hit me.”

The president-elect of the Duke Alumni Association, Vieux was in New York for a Duke meeting when the quake struck—exactly six weeks before a planned visit to the city in March. “I had already bought my ticket,” he said. “I hadn’t been back since 1995, and I was really looking forward to seeing family and friends.”

Mangine of Haitian Children’s Home feeds dehydrated infant in Jacmel’s largest

Mangine of Haitian Children’s Home feeds dehydrated infant in Jacmel’s largest refugee camp.

It was two days before Vieux or his parents heard anything from their relatives in Haiti. Then came the bad news: “We lost family on my mother’s side,” he said. “But we also got news that many others had survived.” One cousin, he said, had a very close call: “He was in a restaurant, and he punched through the window to escape as the ceiling came crashing down. He cut up his leg on the glass, but he was okay.”

Fluent in Creole, his first language, Vieux figured he could be of help to an organization that might have him along. He eventually got in touch with Kathy Walmer, FHM’s executive director, whom he’d learned about through Duke’s Haiti Relief website.

Walmer, a pediatric nurse practitioner, was preparing to take the first post-quake medical team to the clinic in Blanchard, and she welcomed Vieux along. “Sixteen of us met up in Miami,” he recalled. “And we arrived at the clinic that night.” In the days that followed, Vieux tracked down family and friends in Port-au-Prince, and found that all of those who had survived were now displaced, their houses, as well as the one he grew up in, damaged or completely destroyed. “It was a difficult week,” he said. “But at the same time, it was heartwarming to see such selflessness in action and so many Americans helping out on the ground. As a Haitian-American, it made me extremely proud.”

For Kathy Walmer, the trip was exhausting. The Blanchard clinic saw 1,508 patients, “a one-week record that I do not care to break in the near future,” she wrote on the FHM blog. Walmer also went to Fondwa, a mountain village on the road to Jacmel, where FHM has a school. “The school is a total loss,” she told me afterward. “Fortunately, though, the kids had gone home by the time the quake hit.”

On one of my last days in Haiti, I joined Delson Merisier, an adjunct professor of medicine at Duke and FHM’s head ob/gyn, for an afternoon in Leogane, the epicenter of the earthquake. Ninety percent of the town’s structures had been affected, and piles of rubble lined the streets, the smell of dead bodies still strong in the places the Canadian soldiers had yet to reach. Merisier showed me into FHM’s satellite outpatient clinic, where he’d delivered a healthy baby moments before the second floor came tumbling down on the first.

“I was standing right here with the patient,” Merisier said, as we entered a blue room with a single crack dividing the ceiling into halves. “Her husband was there, next to the bed. So I picked up the patient, and I told the husband, ‘Run!’ And he ran—but he left the baby! We got outside, and I said, ‘Where’s the baby?’ He said, ‘I left it inside!’ I said, ‘Why did you do that?’ He said, ‘I don’t know!’ So I ran back in.

“Everything was moving—the walls, the ground, the tables, the chairs—back and forth, back and forth. It was so hard to stay up. I kept falling down and getting up and falling down.” Merisier told the story with his whole body. When he said the ground moved, he lifted his arms up and down and bent his knees. And when he said he was standing in a certain spot, he put his foot down hard, as though he needed to convince me that it all really happened, that it wasn’t a dream.

Miraculously, Merisier and his wife, who is also his head nurse, survived unharmed, along with their three kids and the baby he had just delivered. Their house, however, did not. Showing me through what had been his living room, Merisier stepped carefully over tangled rebar and chunks of concrete and stopped at the edge of a gaping hole. A pair of goats stared down from atop a felled wall, and a hen scuttled by. Merisier paused and bent over to pick up an egg hidden in a pocket of rubble.

“Nobody ever said, you know, ‘You need to be careful, an earthquake is coming.’ Nothing like that—no warning,” he said. “Then it came, and we lost everything.” Merisier shook his head and gave a small laugh, as if to say, “What can you do but keep going?”And that he has. Days after the quake, Merisier, one of Leogane’s two resident ob/gyns, was back in the shattered clinic, delivering babies. “But this time I was careful,” he said. “I put the bed right next to the entrance in case we had to escape.” Before I left, Merisier drove me by the ten-acre site of what will someday be the Leogane Family Health & Research Center. Construction had been planned to occur in phases—lasting up to ten years—as funds became available. But after the earthquake, which toppled the area’s only other hospital providing surgical care, the Walmers began lobbying USAID for an out-of-cycle grant, hoping to build it instead in just two years.

“It’s going to be right here,” said Merisier, stopping the truck. In front of us, rows of banana trees stretched as far as the eye could see.