Health Challenges Facing Haitian Responders

Haiti is in agony; the earthquake has destroyed its buildings, homes, lives. But with regard to health care, there wasn't much to destroy in the first place. Even before the quake hit the capital, leaving its hospitals "abandoned or destroyed" the country's medical infrastructure was in shambles. Three fourths of the population had no access to any kind of health care as of 2008, according to the International Crisis Group. There are no emergency wards to speak of in the country, and only one doctor for every 3,000 citizens, compared with seven docs per 3,000 people in the U.S. Private hospitals charge fees that put decent medical care out of reach for everyone but the Haitian elite, and public clinics, according to an April report from Doctors Without Borders (Médecins Sans Frontières, or MSF), "are often plagued by management problems, strikes, and shortages of staff, drug, and medical supplies."

It's no surprise, then, that despite Haiti's recent strides toward a more stable society, the country had what MSF's operation director called in April an "immediate public health crisis" long before the quake. Life expectancy is 61 years (Americans, on average, live to 78), and out of every 100,000 pregnant women, 630 die young of complications, a rate 50 times greater than it is in the U.S. Haiti's infant mortality is the worst in the western hemisphere, at 60 deaths per 1,000 births, compared with U.S. rates of 7 per 1,000. A third of babies are born underweight. Malnourishment, according to MSF, is "endemic." Almost 4 percent of people have HIV, compared to 0.3 percent of the U.S. population. In the slums, there's open sewage; everywhere, there's undrinkable water and the malaria-bearing mosquitoes that breed in it.

The earthquake has added traumatic injuries and their aftereffects to Haiti's litany of woes. Irwin Redlener, director for the National Center for Disaster Preparedness at the Columbia University Mailman School of Public Health, says the most immediate concerns will be severe head and chest injuries, but that doctors will also have to carefully manage all wounds, even small ones, to avoid infection and septic shock, a challenging task in hastily constructed tent clinics that may be running short on antiseptics. Any survivors pulled from the rubble in the next 24 hours are likely to be weaker than those rescued yesterday; they will be dehydrated, especially with temperatures in Port-au-Prince topping 90 degrees.If victims are also suffering from "crush injuries" after being struck or trapped under falling debris, they will be at risk of kidney failure—damaged muscles release proteins that are toxic to the organs—and in need of extra hydration to prevent it. But sterile saline may be hard to come by in a country where most people don't have access to clean drinking water under normal conditions.

By Friday night, doctors will have to give up on treating newly found survivors—there probably won't be any more—and start thinking about the long-term health effects of the disaster. Acute injuries that aren't effectively treated, especially broken bones that are set improperly or not at all, may end up crippling patients for life. Blows to the head can cause a permanent decline of cognitive function. And even survivors who don't outwardly appear to be injured may suffer long-term consequences of the earthquake, says Redlener: "It's highly likely that we're going to see a lot of patients who survive this trauma and then have exacerbations of existing conditions like diabetes and asthma, or who develop stress-related medical disorders like coronary artery disease and hypertension." Mental health issues and post-traumatic stress disorder, which can set in any time in the six months or so after a diaster, will be "absolutely overwhelming," he says, especially since many aid workers don't speak Haitian Creole and won't be able to communicate well with the people they're trying to help. These ailments might sound like small worries to some in the developed world, but for Haitians, who already struggle under so many other burdens, they may be too much to bear.

How will aid workers avoid this second wave of health catastrophe? Doctors Without Borders is reporting that its ad hoc clinics are overwhelmed, and the aid that is now pouring in from countries around the world has yet to reach most of the people who desperately need it, since there's no central authority directing it. Redlener, a close observer of government responses to disasters and the author of Americans At Risk: Why We Are Not Prepared for Megadisasters and What We Can Do, notes that the beleaguered Haitian government "couldn't coordinate that kind of effort even under ideal circumstances." No other government will be able to either, since no relief team from any one country has the right to tell the other teams what to do, and the U.N.'s headquarters in Port-au-Prince has been decimated.

Still, the earthquake may have leveled homes, but it did not level hope. Some aid workers believe that good will improbably arise from Haiti's disaster because the quake will present an opportunity to rebuild the country's institutions, including its health-care system, stronger than they were before. "It's a chance to start over," says Redlener. It has happened in other countries: Five years after the catastrophic 2004 Christmas tsunami in the Indian Ocean, despite a relief effort that has been "dogged by graft," many Sri Lankans are faring well, and the recovery there is now considered by some to be "a model of how to respond to nature's calamities." It has also happened in the U.S.: Some parts of Louisiana and Mississippi now appear to have better primary care than they did before Hurricane Katrina.

But Redlener says the success stories are the exception. Most of the time, "the world does not have a very good track record of rebuilding better." Like Haiti, Iran and China were rocked by earthquakes, and their recovery was not nearly as successful as Sri Lanka's. And, Redlener adds, Haiti's well-being now substantially depends on the largesse of a world that is "still reeling from the general global recession." It's possible that, once the rubble has been cleared and the news reports die off, "the majority of the relief efforts will close up shop and go back home, and then Haiti will revert back to its usual state of extraordinarily inadequate access to care." The world must see that it doesn't.