Research & Service

Dr. Ronald Waldman

At a special Mailman School of Public Health Grand Rounds on March 1, 2010, Dr. Ronald Waldman, MD, MPH, Professor of Clinical Population and Family Health and Professor of Epidemiology at the Mailman School, discussed the U.S. response in Haiti.  Dr. Waldman, who served as Coordinator of the U.S. government Medical and Health Emergency Response in Haiti, had just returned from the country where he has been working closely with an inter-agency team to advance relief efforts and the health sector response.

The following are excerpts from his talk.

According to the Haitian government, the more recent numbers are 230,000 deaths and 604,000 displaced in Port-au-Prince. 598,000 fled Port-au-Prince and are overrunning the health systems in the countryside throughout the country. So this is more than a Port-au-Prince problem – it’s a problem affecting services available throughout the countryside.

These numbers are difficult to digest and comprehend – and unprecedented in my lifetime.

Destruction of Federal Buildings Impedes Recovery

The Presidential Palace
Photo Credit: J. Schwieger

The Presidential Palace is an important national symbol in Haiti and [its destruction] had an effect on the spirit of the population. Another important symbol was the cathedral where the archbishop was killed by the earthquake.

[Narrating a montage of photographs picturing destroyed buildings] This is what the ministries and the seat of government look like – the Supreme Court, Ministry of Foreign Affairs, Ministry of Planning, Ministry of Women’s Affairs, Ministry of Environment, Ministry of Culture and Communications, Ministry of Public Works, Ministry of Health... There is no physical seat of government anymore.  

The roads are filled with rubble so it’s hard to go from one place to another. We’ll meet with the Ministry of Health, but first they have to make calls to figure out survivors, where they can get together and have a meeting. People have to decide where they’re going to go and how they’re going to get there.

The physical destruction of the seat of government is not going to go away and it will be a long, long time before those buildings are built back.

Psychological Impact

Everybody in Port-au-Prince is extremely shaken – and when I say everybody I mean personnel in every single embassy, the diplomatic community, in every private sector organization, factory or whatever - everything across the board was destroyed. People lost everything.

It's sometimes easy to forget that the people you work with have suffered loss of family, loss of friends, loss of everything they own. And yet you expect them to get up early in the morning and work all day alongside you. They understand the urgency far more than any of us coming from the outside.

Food & Water

Food actually hasn’t been a problem in Haiti. At the very beginning, in the first days there were people cut off from their food supplies and a lot of anecdotes about someone not being able to get something. But actually the food operation has been quite impressive and got together very quickly.

Nearly 3 million people received food very early on of 2-week or 4-week rations. The distribution is now being broadened to include staples of the diet like oil, salt, beans and rice in one month quantities.  There’s the occasional incident, but food has not been a source of great concern.

Same for water supply. Consider that Haiti never really had a very modernized water system and had depended on trucked water from the beginning. It wasn’t too hard to put that truck system run by the private system back in place provided you got the funding and cleared the rubble from the road.

Shelter - A Different Story

Overview of camps
Photo Credit: M. Choi

There is very little indoors now in Port-au-Prince; everything is outdoors. One of the big debates was why couldn’t the international community just bring in tents and set them up.

The relief experts were very reluctant to do that and insisted that the right approach was to hand out plastic sheets [which were] developed specifically for these kind of relief interventions. The sheets are totally waterproof as opposed to tents which are water resistant.

With tents – you need land to pitch them. They’re nice and good and a lot of people can get in one, but tend to become implanted where they are. Not easily moved from one place to another by a family. Whereas plastic sheeting is very flexible, lightweight, waterproof, and very easy to move; you can fit it to the space you need. They’re a good technological improvement than what used to exist.

The goal is to distribute two plastic sheets to everyone who needs it by the first of April. They have finished about 2/3 of first distribution. It’s an ambitious schedule with a long ways to go.

Health

I’ve never been anywhere where there were so many injured survivors. In the tsunami they either drowned or they were alive and relatively fine.

Everywhere you went people were hurt. Some had lacerations that were relatively superficial but still pretty bloody. Some people were trapped with spinal cord injuries or brain injuries that needed immediate and emergent care. Those trapped for days suffered from pressure ulcers which got very nasty very quickly.

It was well and good to have so many doctors coming down offering their assistance but there wasn’t time to get the facilities up and running to absorb those doctors. Not to mention that the hospitals that were not yet certified to be structurally sound.

Within a week the health cluster which is managed by a couple of people from the WHO – was trying to coordinate the needs of maybe 300 organizations ranging from professional highly skilled organizations to smaller groups that spring up out of a seriously good intent and generosity, but need guidance. The whole system gets a bit clogged up with people and organizations that need to be managed.

The US Naval ship Comfort was an enormous asset – this is a complete hospital. But as big as it is – it has a few negative points. For one thing – it’s in the middle of the water, so you need to transport patients back and forth. But the upshot is that this ship saved numerous lives by being there. And by being in the harbor it was a very visible symbol of goodwill not only of the U.S. but of the international community.

How to Assess Impact

Photo credit: J. Schwieger

All of these numbers that we put out in these reports talk about supply but not about consumption. How much is available on a per capital basis to the people who need it. It’s really hard to try to get people doing assessments to get them away from how much we pushed out there to actually look at how much water people had for their own use. Those numbers can be very different and lead you down a primrose path.

You see what’s going better, what’s going not so well. You know what the priorities are and where a particular intervention is lagging. More pressure and more attention gets paid to that sector and the performance improves dramatically. That’s what’s happening in shelter and in the sanitation area where the relief effort was lagging somewhat.

Five-Year Plan?

There are many competing priorities for what needs to be done… and everybody has an idea.

It needs to be carefully studied and implemented in concert with the Haitian government. The most import question is what does the Haitian government want the health system to look like 5 years from now?

If you know that, you have a clear vision of where you are going and everything you do now can be a building block to that vision. If you don’t have that it makes it very difficult to decide what’s a better or less good thing to do.

We don’t want to end up with a health system in Haiti that resembles the one on January 11th. Goals should be much more ambitious. Haiti has the worst health parameters in the western hemisphere. I don’t think there’s any reason or any justification at all for the international relief community to aim for the bottom. The goal needs to be much more ambitious, but it’s going to take a lot of effort to achieve those ambitions.