Humanitarian aid work, especially in crisis or conflict situations, is not easy work. It exposes you to a side of human nature and reality that we are shielded from in our privileged modern day lives. The extremes of poverty and illness burrow deep into your heart and mind, staining your naive morals with a dark splash of cynicism. Hopelessness and chaos inevitably infect your spirit like a live virus, tormenting you with powerful thoughts of defeat and despair. Unlike what most people think, humanitarian medical aid work is not a glamorous feel good job filled with Kodak moments of happy smiles and hasty recoveries. Not every patient we treat returns back home into the arms of exultant family members and a better life. Not every day is filled with toasts and high-fives over the outstanding work that was done. Of course, there are wonderful success stories which emerge from hard work and determination, and these are the moments when I feel like I did my part. However, they are often overshadowed by the anguish and frustration of wishing that there was more that I could do and the injustice of so many people living in poverty and deprivation. This is why, after a long and grueling medical mission, I cringed when I returned back home and people asked me the question, “How was Haiti?”
It’s really the worst question to ask any humanitarian aid worker returning from the field. “How was Haiti?” “How was Afghanistan?” “How was Sudan?” Sometimes I feel like putting aside all of my manners and replying with a sarcastic, “Haiti was just lovely thank you. And you? Can you pass me the salt please?” I know that people aren’t asking this question with any ill intentions, but from my own experience and from discussing this with other aid workers, it’s simply a horrible question to ask. How is one supposed to reply to that; with a one word answer or a whole recap of the traumatic experience? As if the intense experience of witnessing poverty, death, starvation and disease wasn’t hard enough, this type of disconnect with the people back home makes return and reentry even more difficult. Would you ask a friend battling cancer, who was just discharged from the hospital after an unsuccessful surgery with post-operative complications, “How was the ICU?”
This medical mission to Haiti was a particularly challenging one, right from the beginning before I even left the US. 2 days before my planned departure, I received news that one of the nurses on ground from the team that we were replacing, had died unexpectedly. This devastating news shocked all of us, and for a moment it weakened my determination and motivation to go. It’s not uncommon for aid workers to get injured or die in the field, as aid projects are often conducted in unstable and destitute environments. Death from disease and road accidents, and even kidnappings and executions are rampant. One of the aid organizations that I worked with had to temporarily close down their projects in Afghanistan and Somalia due to such atrocities. Even while I was in Haiti, 2 aid workers from another medical organization were kidnapped from a small town west of Port-au-Prince. Luckily, my team remained healthy and unharmed during our month, but the incoming team that replaced us suffered a big blow from their first day in Haiti. One of the nurses fell and broke her leg, necessitating medical evacuation back to the states for surgery. We all go into this well aware of such risks, but we still go because we believe in the work.
I arrived in Haiti after the immediate post-earthquake crisis of treating acute crush injuries had plateaued. Many earthquake victims suffered orthopedic problems due to fallen rubble, like fractures, compartment syndrome and lacerations. Emergency limb amputations were being performed under sub-optimal conditions due to the fact that everything had been destroyed in the earthquake. Temporary hospital tents and tarp were set up in whatever space could be scavenged in lieu of the concrete medical facilities which had been reduced to powder. Along with the buildings, the earthquake also took with it all functioning medical equipment, medications, and even hospital staff. Every working hospital and clinic in Port-au-Prince had collapsed with the earthquake, and there weren’t any buildings left that were usable.
Over 200 international aid organizations responded to the 7.0 magnitude earthquake and descended upon this tiny island nation with aid workers, equipment and numerous other resources. I was amazed to see some sophisticated tents, 2 stories high and sturdy as hell, set up by various medical groups as their new hospital grounds. All types of medications and anesthetic equipment were shipped over to perform complex surgical procedures. Still, many victims who couldn’t access these facilities were treated in the acute crisis phase with life-saving amputations often without any type of anesthesia or proper post-operative care. The situation was desperate in the first week following the earthquake, as chaos and improper coordination caused a delay in foreign aid workers being able to enter the country.
My month in Haiti was split between 2 projects in 2 different locations. The first half was spent in Leogane, the city closest to the epicenter. The drive out to Leogane was a haunting one, as we whizzed past replaying landscapes of crowded IDP (internally displaced persons) tent camps and demolished concrete houses. Not a single building in the area was spared in this earthquake, and there was rubble and garbage everywhere on the streets. Road traffic was dominated by hefty 4×4’s displaying NGO stickers of organizations from all over the world. Every partially intact building or large tent facility was clearly labeled with NGO flags and signs- the foreigners had moved in and taken over all operations in the country. It was a lively international scene of expats from all over the world. We shared a campground with Americans, French, Dominicans and Canadians, where tents of all sizes and shapes crowded the small grounds next to an old factory that we now used as a warehouse to store medical supplies. Even though we lived frugally, with limited electricity from a gas-run generator and bathing water from a local well, our camp life in the expat quarters was luxurious compared to the harsh reality of living in an IDP camp for millions of displaced Haitians.
The project in Leogane concentrated on running mobile clinics to reach hard hit areas. Collapsed streets and bridges made transportation difficult, isolating remote villages even further from medical help and resources. Here, in these small quaint villages that were affected by the tragedy, was where I encountered my first slew of unbelievably sad and upsetting stories. Every patient that we saw had a tale to tell of the legendary few minutes when the earth violently rumbled on January 12th and swallowed villages, people, livestock and buildings whole. One young woman came with a malnourished and weak baby wrapped in tattered blankets. Just before the house collapsed, the baby’s mother threw the baby out through the window in a desperate lifesaving move before being crushed, along with the other family members, under heavy concrete blocks. This young woman, a very distant relative of the family, who became an orphan herself, took on the role of caretaker. There were many problems though- she couldn’t breastfeed the baby, and she had no money to buy infant formula. She didn’t even have money to feed herself. Caretaker and baby were both malnourished and poor. We gave her diapers and cans of infant formula, along with medications for the horrible diaper rash that the baby had, but with no money or shelter, what was to become of this new family unit? What were we doing handing out temporary band-aids to grave situations if we couldn’t guarantee a secure future for anybody? Although our presence and care undoubtedly made an impact to these people in need, I couldn’t help but feel like our efforts were futile. This is why many aid workers leave the field and go into public health and foreign policy.
Skin infections dominated clinic visits, as practically every other child presented with a severe case of scabies. Poor hygiene in crowded and dirty living conditions subjected every vulnerable human to a slew of dermatologic diseases, and my heart ached each time I handed out tubes of medication, knowing that these remedies would only hold for so long. Even if these horrible rashes cleared up with my prescriptions, the slum life would inevitably manifest on their skin in a couple of weeks. What we were doing was important, but what really needed to be done was to remove everybody from the crowded camps that had scarce latrines filled with putrid feces, and get them into houses with clean potable water and sanitation facilities. But this was going to take years, maybe even decades. As much as the people of Haiti felt helpless, we did too.
Trips to local orphanages left me with a mixed feeling of hope and sadness. Some of the children in these facilities were orphaned by the earthquake, but the majority were already there before the disaster. My naive eyes were jolted to a reality that in Haiti, many children in orphanages still have living biological parents who had no choice but to give them up due to extreme poverty. This is a common and accepted practice in Haiti, which is the poorest country in the Western hemisphere. They’re better off here than being sold off as slaves, the orphanage coordinator told me, and I silently wept for the hundreds of child slaves who were desperately surviving on the dirty streets of Haiti, stripped of their innocence and happiness. The reality of life in developing countries, so vastly different from our own defined by creature comforts, always hits my conscience with a painful thud.
What was to become of these children and their future, if 3/4 of Haiti’s schools were now in ruins due to the earthquake? How can they be expected to lead Haiti into a brighter future if they can’t even get a proper education? These children were starving for games and activities. They needed stimulation, just like any child deserves. It was fascinating to see their eagerness and fervor as they all played with the balls, hula hoops and balloons that we brought. Their eyes lit up as they grabbed the paper and crayons we provided and drew pictures and scribbled words with ferocious intensity. For the first time since the earthquake, they were able to just be children.
At times we crossed rivers, climbed tall mountains and rode mules and donkeys for hours under the beating sun to reach remote villages. These long and treacherous journeys wore us down both physically and mentally. Long hard days weren’t easy, but it was nothing compared to what the people of Haiti had gone through. It was this determination that kept our adrenaline going every day.
Although we were tending to patients in dire need of medical attention, it was quite apparent that the majority of cases were not directly related to the earthquake. The immediate crisis phase of life saving procedures and amputations had passed, and we were now treating chronic problems that had gone untreated simply because of the inefficient health system in Haiti. After all, even before the earthquake, international medical organizations were running several hospitals in the country to augment the feeble national health care system.
This sparked a huge debate among our team every day. Non-native doctors and nurses were now running the show in Haiti, and NGO clinics had completely replaced any existing Haitian medical system. People were flocking to these clinics to take advantage of the opportunity to see the ‘good white doctor’ and get medications for free. And now that the crisis phase is over, many of these foreign organizations will inevitably pack up and leave very soon. Then what? Who is responsible for laying out the long term blueprint for rebuilding the health care system, and who is obligated to see it through? Much of my previous humanitarian work involved teaching and training of local practitioners to help establish a more competent and internally-run system. It didn’t make sense to me that we were coming in, passing out medications, and leaving.
But Haiti was different. This was a natural disaster of unprecedented proportion, the worst that all aid workers have ever witnessed. The one that claimed more than 230,000 lives and displaced more than 1 million people. How can we start the process of education and training to the few Haitian doctors and nurses who survived the quake, who themselves have become homeless and were still grieving from the death of family members? One of the Haitian doctors that worked with us, Dr. Spencer, was living with his family under a sheet of tarp when he hired him. He was the only survivor in his neighborhood. Carol, a Haitian nurse who worked with us, told us that the nursing school she graduated from had completely collapsed. Classes were in session when the earthquake hit, and the entire 2nd year class of nursing students and the professors conducting the class, died. How do we rebuild this country that has literally lost everything?
These thoughts consumed my every waking hour as I took a propeller plane to Les Cayes for the second half of my medical work at the Bonne Fin surgical hospital. Due to the remote location on the southern part of the island, this area wasn’t affected by the earthquake. This longstanding surgical hospital, equipped with sophisticated operating room facilities (for a developing country, that is), served as an optimal referral center for complicated orthopedic cases that were untreatable in Port-au-Prince. The rooms were overflowing with trauma victims who were directly affected by the earthquake. Here too, I met many courageous people who all had a story to tell.
Josephine, an 8 year old girl, was trapped under the rubble when her house collapsed. For 18 hours she couldn’t move, as her right leg was wedged under a heavy piece of concrete. There she lay for hours on end, unable to even move her head away from the horrific sight that was directly in front of her. Her pregnant mother’s lifeless arm was almost within reach, and she could see the back of her sister’s head in the distant rubble, but it never moved and she never heard a reply when she called out to her. Her other sister was nowhere to be found. Her father, who was away for work, was still alive and he made it back in time to pull her out of the rubble. She survived, but eventually had to get her gangrenous right leg amputated. She suffered other open fractures which got infected and had to be cleaned in the operating room daily. Every day was a repeat cycle of more procedures and more pain. These were the stories that haunted every patient we treated, and these were the reasons why we were busy performing many surgeries every day.
Despite the modern facilities at this hospital, it was still nothing compared to hospitals in the US. With almost every patient that we treated, it was obvious that they would have had a better chance of recovery if they were treated in the US. Take one of our head trauma patients, for example. It was apparent that this young man, who suffered a severe blunt blow to the head from the fallen rubble, had a skull fracture with cranial bleeding. How did we treat him? With observation and intermittent sedation for extreme agitation. In other words, we watched him die. If we had neurosurgeons and neurosurgical operating rooms, this guy may have had a chance at meaningful recovery with a good quality of life. Ventilators and heart monitors in ICU rooms would have made his post operative recovery smooth. A CT scan would have helped to give us a diagnosis. Even if his injuries were inoperable, oxygen would have helped to ease his agonal breathing in the final stages of his painful life. A touch of morphine would have decreased his suffering to make a comfortable transition into the afterlife. But we barely even had enough morphine for those who needed their fractures reduced. With limited resources, we were having to make decisions on which suffering patient deserved things the most. This responsibility was one of the heaviest burdens of the job. Who are we to call the shots and decide who deserves what? Every evening I crawled back to my bed, completely exhausted, with an uneasy feeling in my chest.
Still, miracles do happen, and we performed many life-saving operations and nursed people back to good health. We even managed to evacuate 2 Haitian girls to a university hospital in Texas to get specialized operations for their complicated fractures. This is what makes the work worthwhile, and this is the joy that feeds my motivation to keep going. A simple smile from a child is all it takes to make my fatigue disappear.
Humanitarian aid work is not only physically challenging, but psychologically, emotionally and mentally challenging as well. It’s impossible for all of this tragedy and pain to not have an effect. When you see a child, whimpering with pain from an injury and lying helplessly on the bed in front of you, how can your heart not feel his pain too? When you see a child dying from starvation and malnutrition, how can the inconceivable misfortune not rip your heart out of your chest? Yet, we must put aside our emotions in order to concentrate on our work. There’s simply no room or time for emotional wavering when the emergency room overflows with critically ill and dying patients. After a while, when you’re overwhelmed with the sheer volume of patients who keep coming one after another on a day which never seems to end, your heart starts to numb. These repressed feelings, which take a back seat during a medical mission, often come flooding out uncontrollably upon return back home. Many aid workers go through a severe depression and have difficulties with re-entry back into their society; a type of post-traumatic stress disorder. It took me around 2 weeks of contemplation and reflection in a state of withdrawal before I was ready to be myself in front of my family and friends. So after witnessing great tragedy, loss, destruction and disease, and after coming face to face with unjust atrocities and having to operate on gruesome traumas whose bloody images still haunt me to this day, how do I answer the question, “How was Haiti?”
“It was an interesting experience”, I say quietly, as I run through the images of crying children and suffering patients, and fight back my tears as I fake a smile.
For an even more interesting insight into the life and the mind of a humanitarian aid doctor, go see the Doctors without Borders documentary called ‘Living in Emergency’, which is going to play in theaters nationwide on June 4th. This documentary was shot in my hospital project in Liberia right before and after my 7 month duty there, so it accurately depicts my personal experience in Liberia while I served with Doctors without Borders. Many of the doctors filmed in the documentary are my colleagues with whom I worked with in Liberia. It’s a riveting and raw look into the intense life of a doctor in the field.
This is the New York Times article about the film:
http://www.nytimes.com/2010/05/30/movies/30doctors.html
TOMOSTYLE 