Haiti: The International Response

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By Morgan Stanfield

"Mwen malad anpil."-I am very sick.

"oupe"-amputation

"enfimite"-disability

These words are now far too commonplace in the Haitian Creole tongue. The Republic of Haiti was ailing even before the catastrophic January 12 temblor laid waste to the nation's capitol-80 percent of its population lived in poverty, its people had endured decades of crushing political corruption, and its formerly lush landscape was almost entirely deforested. Now, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) estimates that some 300,000 Haitians were injured in the earthquake, 230,000 people died, and 1.2 million were left homeless. Some 600,000 of the sick and the well live side by side in the flimsiest of makeshift shelters-bedsheet-draped fences of rubble in many cases. And as the downpours and mud of the rainy season approach, these makeshift, sewage-strewn camps could also be left in ruin. People with long-term or permanent disabilities abound; the United States Agency for International Development (USAID) estimates that the earthquake created between 2,000 and 4,000 new limb amputees, and many times that number have other mobility injuries. And this, lament Lisa Iezzoni, MD, and Laurence J. Ronan, MD, in a March 15 article in the Annals of Internal Medicine, is in a country in which disability is considered a curse upon families and dooms many individuals to a life of dependence, isolation, and shame. The Inter-American Development Bank estimates that the cost of rebuilding from the earthquake will range from $7.2 billion to $14 billion, in a nation in which the median income is less than $3 per day.

However, for all of that, there is no reason that the country's collective voice need speak the dreaded Creole phrase, "Moin pap refe"-I will never be well again. Haiti has a tremendous, underused resource-its people. In a January 25 New American Media article, Haitian-born PhD student Marc Péralte Dandin described them as "a resilient people, still eager to positively contribute to human affairs...an honorable people; a people who notice not the ruins of its national monuments but that the flag that flew over them did not perish under the rubble." These are the people who created their nation through what may have been the only successful slave uprising in world history. They live in a culture rich in art and music, built on tightly knit families and startling generosity. And Haiti is not alone-the international outreach effort since the earthquake has been immense, and the partnership between nongovernmental organizations (NGOs) and the Haitian people could lead to not only a recovered nation, but to a Haiti in which people with disabilities are far more socially integrated and independent than ever.

"If Haiti responds comprehensively to the needs of its newly disabled citizens, these efforts could eventually produce positive transformative changes that would benefit all Haitians at some point in their lives," Iezzoni and Ronin write. "This comprehensive response will require involvement, commitment, and creative short- and long-term thinking from multiple sectors of Haitian society, including healthcare, as well as the numerous international agencies poised to help."

Bringing People Together

A man is lying in the hospital garden outside of University Hospital, Port-au-Prince, because there is no space inside. His son tries to keep him cool by fanning him with a piece of cardboard. Two of this man's children died in the earthquake and another lost an arm. ©ICRC/M. Kokic/ht-e-00449

Less than three weeks after the earthquake destroyed Port-au-Prince, the World Health Organization (WHO) rallied the involvement, commitment, and creative thinking of both Handicap International (HI) and Christian Blind Mission (CBM), in cooperation with Michel A. Pean, MD, the Haitian Secretary of State for the inclusion of persons with disabilities, asking them to lead the coordination of the international effort to aid the Haitian injured.

"At the moment, there is an uncertain number of organizations on the ground that wish to assist the country and do P&O care," Heinz Trebbin, HI's orthopedic/rehabilitation technical support consultant for Haiti, told The O&P EDGE. "There are about 20 organizations that expressed an interest in setting up P&O workshops in the country.... The best parts are probably the excellent and highly motivated groups and people who are trying to help the country right now and which give their professional services in a very challenging climate and general conditions. The other positive feeling is about the people in Haiti, who have been very welcoming and warm in their contacts with the large amount of foreign volunteers and professionals serving their country right now."

Trebbin and Thomas Calvot, HI's disability and emergency advisor, can list a variety of major challenges the international team faces in coordinating O&P care in the country:

  • There is no reliable estimate of the number of people who need O&P care in the country.
  • The O&P responses of different groups and nations, though enthusiastic, have developed in a very uncoordinated way.
  • The groups providing care have "very unequal experience" with working in underdeveloped nations and emergency situations, and some have never previously been involved in O&P.
  • It is unclear how many organizations are only doing emergency work and how many are seriously considering staying for the long-term.
  • Some groups, including the Haitian authorities, have conflicting views about the best ways to establish O&P services.
  • Some organizations seem more concerned with gaining publicity than with finding culturally appropriate solutions.
  • The international community has shown overwhelming enthusiasm for providing prosthetic devices, but orthotic care is far more needed.
  • Geographical and technical coordination is a constant problem.

Sustainability

A patient on an operating table at the Norwegian Rapid Deployment Field Hospital on the grounds of Port-au-Prince University Hospital. ©ICRC/M. Kokic/ht-e-00510

The biggest challenge the HI teams face is likely to be sustainability. Trebbin projects that Haiti's poverty will make it very difficult to create a sustainable solution, and "only a united mid- to long-term approach may lead to a certain degree of sustainability."

Isabelle Urseau, head of HI's Rehabilitation Technical Unit, says, "We can't just make what we'd like to see-we have to do what will be the most appropriate for people and the country now and in the future. 'Emergency-rehabilitation-development' is a continuum of care we have to consider globally as soon we start to do something.... The point is to be sure that somebody will ensure the continuity and the resources.... One of our principles is capacity building and training-professionals, trainers, managers-through local partnerships. It's the key element in building accessible and sustainable services."

Fortunately, many of the O&P groups serving in Haiti now are working harmoniously, some directly under the auspices of HI and some peripherally. Following are details on just three of the major new O&P initiatives in Haiti.

The International Team

A patient receives treatment at the Norwegian Rapid Deployment Field Hospital on the grounds of Port-au-Prince University Hospital. ©ICRC/M. Kokic/ht-e-00503

HI is working in coordination with groups including the Haitian government, CBM, Healing Hands for Haiti International Foundation (HHH), the International Committee of the Red Cross (ICRC), and USAID. Calvot says, "During an emergency response, HI usually adopts an approach that looks for complete coverage of the needs of the vulnerable persons...[including] persons with injuries, persons with disabilities, older persons, persons with chronic disease, and other categories." With this goal, HI has developed or expanded a relative bounty of services in about 20 different Haitian hospital sites:

  • Providing 300-400 temporary prostheses and an uncounted number of orthoses since the earthquake.
  • Establishing a fully operational O&P clinic in Port-au-Prince, with nine CPOs and six HHH assistant O&P technicians.
  • Establishing seven disability and vulnerability focal points (DVFPs), also known as "antennas," which provide information about services, simple wound treatment, mobility recovery advice/physiotherapy, and mobility devices.
  • Providing physical rehabilitation at hospitals after surgery and other treatments.
  • Hiring local staff; 42 community workers have already been added to the payroll.
  • Establishing a logistical platform for transportation and storage of humanitarian goods.
  • Distributing temporary shelters and non-food items.
  • Monitoring coverage of the vulnerable population's basic needs and how they are being responded to.
  • Providing ongoing care and support, including psycho-social support, to vulnerable persons and their families.
  • Preparing specialized long-term care for severe injuries such as amputations, and capacity-building activities for local health staff.

Al Ingersoll, CPO, of Winkley Prosthetics and Orthotics, Golden Valley, Minnesota, will be working in Haiti on behalf of USAID for the next year. He reported to the OANDP-L listserv that "after hearing that up to 20 different organizations are currently open or in planning stages, we [members of the international effort] decided to visit the operational facilities in or near Port-au-Prince. Five labs are now completely operational in Haiti, with three in Port-au-Prince. A national plan for P&O education has been drafted and is being reviewed."

The Haitian Amputee Coalition

A Haitian Red Cross volunteer gives first aid at Place Jeremy, Carrefour Feuille. The tent and medical supplies were provided by the International Committee of the Red Cross. ©ICRC/M. Kokic/ht-e-00530

The Haitian Amputee Coalition was founded in the first weeks following the earthquake via an ambitious effort by the Hanger Ivan R. Sabel Foundation, Physicians for Peace, the Harold & Kayrita Anderson Family Foundation, and Donald Peck Leslie, MD, of the Shepherd Center, Atlanta, Georgia. It created an O&P and rehabilitation center on-site at the Hôpital Albert Schweitzer (HAS), an undamaged local hospital located 60 miles north of Port-au-Prince in the town of Deschapelles.

According to Hanger Prosthetics & Orthotics, a division of Hanger Orthopedic Group, Bethesda, Maryland, the facility is already functioning, thanks to shipments that brought in 13,000 pounds worth of equipment and donations of more than $500,000. It will be staffed by clinicians from Hanger and Physicians for Peace, as well as local professionals.

"It will be staffed by teams of prosthetists who will rotate in one- to two-week intervals from now on," says Jay Tew, CP, lead prosthetist and first resident clinician for the project. "On top of that, we'll be identifying patients who are interested in helping out and we'll start training them. The ones who do well, we'll train them in technical skills to a bit higher level, and we're considering bringing some to the States to train them at the SPS labs. If they do well from there, we would like to see them be trained to be clinical prosthetists. Eventually, the goal will be to have a sustainable prosthetic rehabilitation clinic on-site that can be run and manned by Haiti's own people. They will always have our oversight and assistance available, but I think it's a great opportunity not only to help but to educate, and to create something that will be of permanent benefit to the country."

Mission of Hope

The ICRC has set up two first-aid posts in Belaire, one of Haiti's most violent slums. The ICRC's relations with the local population allow the organization to operate in the area with relative safety. The post will be run by Haitian Red Cross volunteers. ©ICRC/M. Kokic/ht-e-00520

Mission of Hope, a U.S. Christian ministry that has primarily focused on providing meals (more than two million served in post-earthquake Haiti at the time of this writing), shelter (more than 1,000 tents distributed), and emergency medical care (to more than 2,000 patients), is now planning to create what it deems "a self-sustaining center of excellence in Port-au-Prince for providing life-changing artificial limbs." The clinic would provide surgical reconstruction, O&P care, health education, and rehabilitation. According to Kasey Guentert, PTA, the group hopes to have the clinic opened by the end of the year.

Plans for the Future

Ingersoll emphasizes that each step in developing a long-term O&P plan for the country needs to be taken deliberately. He told The O&P EDGE that an early goal will be to get Healing Hands for Haiti's (HHH's) trained Haitian technicians back to work.

"It really helps in the healing to get people back to work," he says, adding that in the first weeks after the quake, the HHH technicians who were working "were able to focus for eight or 10 hours a day, which really took them away from the reality of what was going on around them." A second goal is to coordinate the various O&P projects, starting in Port-au-Prince, and then moving out into the countryside, where many of the injured have migrated. A major element of the coordination process will be to bring the various O&P projects under the auspices of the Haitian Ministry of Health.

To provide O&P care in the country, he says, organizations must be nonprofit in nature and be registered with the Haitian government. "It's an effort to try to keep everyone from just showing up and duplicating [efforts] and stepping on each other's toes," Ingersoll says. "I'll be working very closely with the Haitian Ministry of Health to...help them figure out who's working where and what they're doing and how they can help support them. Second, I'll be coordinating with all the different organizations that want to set up labs and bring in personnel, making sure that they're not all set up next to each other."

Trebbin also listed prospective interventions HI is pondering, including material care and training. They include providing definitive prostheses and ongoing care, supporting the preparation and implementation of training programs for O&P and physical and occupational therapy, and researching and developing the most appropriate O&P technologies and materials for Haiti.

Remaining Steadfast

These plans should be heartening to see. According to a March 11 New York Times editorial titled, "Haiti, Two Months Later," every aspect of aid in Haiti is still insufficient to the overwhelming need, and "large swaths of the earthquake zone remain untouched by aid." However, the story emphasizes that despite their century and a half of political and economic oppression, "Haitians are eager to help themselves. Refugees are forming settlement councils and electing representatives to collaborate with the nongovernmental organizations. They are building homes themselves, clearing rubble themselves, burying the dead themselves, organizing security brigades themselves."

Laura Wagner, a U.S. social researcher who was trapped inside an earthquake-shattered Port-au-Prince house for several hours after the earthquake, sums up the situation in a February 1 Salon.com article titled, "Haiti: a Survivor's Story." She writes, "I am telling you two things that seem contradictory: that people in Haiti are suffering horribly, and that...suffering is not some intrinsic aspect of Haitian existence. It is not something to get used to."

Morgan Stanfield can be reached at

Component Recycling vs. Appropriate Technology: Are They Compatible?

Dozens of groups around the world have sponsored recycled-limb drives to benefit Haitian earthquake survivors. Some proudly state in their promotional materials that all donated limbs will be shipped directly to Haiti, so that all parts can be used. However, some experienced aid workers suggest applying sensitivity and discretion when considering sending used componentry to any developing nation.

A working group of 34 organizations supported by Landmine Survivors Network (LSN) and the Swiss Cooperation for Development considered this question in a June 2004 paper titled, "A framework for a common approach in setting up prosthetic and orthotic projects in developing countries." The paper states, "What better way to make use of medical materials and equipment than to ship them off to low-income countries for re-use? In the world of prosthetics and orthotics, however, this activity can be very problematic. While the material may come from a great variety of devices, the components are seldom interchangeable. And unless the technical personnel have been given the specific training needed to work with each technology, there is a risk that components are misused and that the quality of the devices will be poor. There is also the concern that the supply may not be constant, which means that individuals with state-of-the-art recycled devices may later on have to accept using very basic devices or-even worse-get no devices at all. Besides, recycling can create negative image issues, since the implicit message is that what industrialized countries throw away should be good enough for those in low-income countries."

Isabelle Urseau, orthopaedic advisor at Handicap International (HI), has developed the following series of questions for groups who have collected limbs for donation. The answers can help determine where each limb should go and to whom.

  • Is there actually a need, corresponding, for example, to a supply forecast or an expected order?
  • Does the merchandise being sent correspond to a technology that has been mastered or is in the process of being integrated into an explicit development strategy, without creating dependence on a product which one might not be able to replace by an alternative solution?
  • Has at least one technician been trained on the imported technologies?
  • Can the shipment be done under satisfactory conditions and within satisfactory time limits?
  • Is the beneficiary in a position to bear or share the cost of shipment and other pertinent expenses?

For now, Al Ingersoll, CPO, who will be working in Haiti on behalf of USAID through mid-2011, says that HI currently recommends that the minimum standard for limbs used in Haiti be new limbs fabricated according to the International Committee of the Red Cross (ICRC) polypropylene-limb model, or limbs fabricated of Endolite Atlas componentry. "New and gently used 30mm" is another option, he says. HI does not recommend use of the Jaipur-foot technology, and it requests that components in the United States be donated through the Prosthetic and Orthotic Component Clearinghouse (POCC) run by the U.S. member society of the International Society for Prosthetics and Orthotics (U.S. ISPO). On a personal note, Ingersoll adds that after many years of working with Haitian amputees, he feels strongly that it is entirely reasonable and very important that those supplying cosmeses and sockets use only skin tones that are a reasonable match to Haitian's dark skin.

For more information about POCC, visit www.usispo.org. Instructions for manufacturing ICRC polypropolene-based limbs can be downloaded at www.icrc.org/web/eng/siteeng0.nsf/htmlall/p0913?opendocument