Crisis in Haiti Commentary

Thirteen days after the 7.0 quake devastated Port-au-Prince and the surrounding region, the initial phase of “search and rescue” is clearly over.  That is not to say that the occasional “miracle survivor” will not be pulled from the rubble, but those situations will be rare and random.  Reports are that the medical situation for adults and children remains horrendous, in spite of large numbers of physicians now in country.

• Children at Extreme Risk
• Extraordinary Disconnects Remain Between Scale of Disaster and Resources Available
• Consequences of Profound, Pre-Existing Poverty on Impact of Earthquake Will Undermine Relief and Recovery Efforts

Most striking – and insufficiently reported on – are the disconnects between the scale of the disaster and the combined resources that have been brought to bear from around the world.

• With hundreds of thousands of people buried, some alive, under the wreckage of Port-au-Prince and surrounding communities, as of January 22 (10 days following the earthquake) only 132 people had actually been rescued by all urban search and rescue teams – including thousands of rescue specialists - sent from the U.S. and many  other countries around the world.
• With the vast majority of rescue and relief efforts being focused on Port-au-Prince, assessments of damage and casualties in outlying areas of Haiti affected by the earthquake are just beginning. These areas include Jacmel, Petit Goave, and other communities.
• Medical treatment – including surgery – provided by all nations and agencies may account for a small percentage of total need.
• Resource to care for and provide nutrition, vaccinations, mental health support, and needed medical care for some 400,000 children among the surviving one million displaced persons is not currently imaginable under current conditions.

Here are current principal concerns that must be addressed simultaneously:

• Extraction of bodies and clearance of rubble need to proceed rapidly. “Rescue” from the rubble is now over. Every effort to identify victims must be made and clearance of rubble will help open roadways and establish venues for survivors to get care and support.  These venues may be in or near the Capital or even in neighboring Dominican Republic.
• Establishment of safe, temporary locations for survivors who are now “internally displaced persons” within Haiti.  These locations will need to focus on security, nutrition, safe water, sanitation, healthcare, day care, mental health support, and resumption of education for children.
• Supply and distribution logistics need to be better coordinated and managed. Materials headed to Haiti via ship, air transport, and overland from the Dominican Republic are now in abundance from a massive multi-national, international effort. Backlogs of needed supplies at the airport and other staging centers must be rapidly and effectively distributed to wherever needed.
• Coordination of international relief efforts remains challenging at every level. Maximizing the role of the Haitian government is essential, even as it is still trying to regain its footing and control.  Physical destruction of the Capital adds to a sense of social and political uncertainty which much be addressed rapidly, while understanding that getting vital supplies to survivors is of paramount importance.
• Appropriate medical care will mean the difference between life and death for hundreds of thousands of Haitian survivors going forward.  The immediate death toll from earthquake trauma is still unknown, though estimates range from 150,000 to 300,000 early fatalities.  Almost all survivors will need medical attention, including care for on-going chronic conditions, emotional trauma, vaccinations, and so forth.  At the more serious end of the medical care spectrum will be care of non-fatal injuries sustained during the initial days of the disaster, including persistent wound infections, poorly managed or unmanaged orthopedic injuries, or other surgical or advanced medical conditions.  
• Effective public health practices, already visible throughout the affected region include assurance of safe water, stabilizing food supplies, immunization programs, and monitoring for water-borne and other post-disaster related issues.  Few of these programs are up to speed in relationship to the sheer scale of the challenges being faced at the moment, nor do they seem to be necessarily organized for the growing problems likely to be seen in the weeks and months to come.
• Appropriate sheltering of survivors is one of the most daunting challenges to be faced in the coming weeks.  Providing safe shelter for 1 million displaced individuals in a disaster-devastated country that had already been among the poorest in the world is an overwhelming challenge. Temporary camps must be developed that are able to withstand persistent aftershocks, provide a sense of general stability, access to vital services, security, school and social service access, and other basic staples.  Significant rains are possible in Haiti from late April through July, ending coincident with the onset of “hurricane season.”  Flooding, mudslides and substantial storms are therefore serious threats to earthquake survivors in the spring and summer.  Rapid development of sufficient numbers of appropriate shelters or safe permanent housing is an extremely high priority for Haiti and the international relief community.

Given the enormous amount of work being done on all fronts, there are at least 10 large – almost imponderable - issues that will continue to dominate strategies, short- and long-term, as Haiti and the international community do whatever is needed to create a functional and resilient healthcare system.

1. Who is in charge of resource allocation and development of recovery strategies especially around healthcare and public health needs?
2. Logistic and operational capacities are both limited and bottle-necked, so how will priorities be determined with respect to focus on survival needs (safe water, food) vs. ongoing attempts at further rescue?
3. How long will international resources be available to continue providing food, water, and shelter to a totally impoverished nation that has just experienced one of the worst disasters in modern memory?
4. How long and how open-ended is the U.S commitment to these efforts, and at what level?
5. How will secure housing be developed for 1 million internally displaced Haitians?
6. How and where will Haitian adults and children who have received life-saving surgical care be followed-up?
7. How will primary healthcare be provided long-term to surviving Haitians?
8. How will the health, well-being, and safety of Haitian children (orphaned and non-orphaned) be secured?
9. Will the international community assist in assuring an acceptably stable public health system in Haiti?
10. What lessons will be taken from this mega-disaster to make sure everything possible is done to help resource-poor nations develop the infrastructure, economic stability, and resiliency necessary to mitigate great disasters likely to strike anywhere in the years to come?

Director, National Center for Disaster Preparedness Columbia University Mailman School of Public Health & President, Children's Health Fund
(212) 535-9707
ir2110@columbia.edu           
Twitter account: IrwinRedlenerMD