Tuesday, March 9, 2010

Haitian notes from Alan del Castillo

Dear Nestor:

As you requested, this is a description of my eight days in Haiti. It was hard experience and I had to write about it.

Our plane, loaded with 7 medics and 700 boxes of medical supplies, lands in Port-au-Prince at 5am. None of us really knows what we're going to find or do there.
An hour on the dark tarmac, of hellos and quick exchanges of info with those returning on the same plane to San Juan, the relieved greeting the anxious, and then a 15 minute ride thru dusty streets. We soon see the first of hundreds of collapsed and twisted homes, piles of rubble, refugee camps (some neat rows of tents, others ram shackled crowded clumps of plastic awnings and sheets), and people walking on the streets, even though twilight has only just begun to shed an eerie glow over this city wakening to the 38th day of the nightmare that began on Jan 12. One in fourteen died, one in four is homeless.

For now, the promised Puerto Rico Hospital lies on the (formerly green) lawn of Haiti's National Laboratory, a solidly built and undamaged structure shared with the US CDC in Delmas 33, a run down neighborhood, even before the quake. A refugee camp, one of the down-scale versions, lies directly across the street, and the state hospital La Pe, staffed until this week by Canadians, Cubans and Koreans is 2 doors down.

Our “hospital” was set up by a Belgian disaster team on Jan 14, and ceremoniously handed over to PR on Feb 2. It consists of 5 large white tents which can sleep up to 20 patients or act as clinics or even an operating room if properly equipped (which it is not), several small tents for staff, a large cement warehouse for storage of meds and equipment, and a tall metal roof with no walls which provides shade for a rudimentary kitchen and tables for staff meals. A pile of refuse lies a few meters from the tents: cans, plastic bottles, and debris mixed with urine and the feces of patients who have no latrines to use. Only the staff has the privilege of using the laboratory’s toilets and shower.

Our “hospital” now has 10 female patients, mainly amputees, some recovering from skin grafts, some of which were operated weeks before in our hospital when better equipped, (but never with air-conditioned operating room, the sweat of the surgeons dripping into their wounds in the saunas/ tents well stoked up by mid-morning). Some 50 – 80 outpatients arrive daily, some amputees for wound debridement, some for skin infections, fevers, diarrhea and dehydration, high blood pressure, anxiety, weakness, eye infections (from the constant rubble dust which permeates the city), malaria, some to take advantage of the first free medical care they have ever received, and some to ask for money, water, food, or, the most sought after item, a tent. We can give very little, and only with the utmost discretion for fear of creating a small stampede to receive any of these items.

You might ask what a psychiatrist would do in such circumstances- I did, often, when deciding whether to go. I only knew that I would remove my regular hat and wear whichever was needed and within my ability. And though my Creole was rusty, I read parts of a Creole Bible (no, I haven’t gone all preachy – but it is the only Creole text I own) in the week before leaving and I knew I could talk to people enough to communicate interest and concern. So at times I served as interpreter, at times as primary doc in the clinic (checking in with my colleagues the most basic questions – it’s been 20 years since I touched a patient, clinically speaking), delivered water bottles, answered questions from the nurses, administered malaria quick-tests, or connected iv saline or blood bottles. I often just hung out with the patients, some of whom gave me their terrible stories.

Nicole Jeremy 39, was hanging up washing on the roof of her 6 storey apartment building when the earth began to shake. One minute later the entire structure collapsed sideways and sent her flying with it. Miraculously she did not fracture a bone. But a water deposit landed on her and did severe skin and soft-tissue injury requiring much grafting. Less miraculously, she lost her 2 children, her home with all belongings, and was left with only the clothes she was wearing.
“The Good Lord didn’t want me to go” (I censure my immediate question of whether He wanted the children to go) “but I still don’t know whether this is just a bad dream or if it is reality”.

Madelene Lazare 34, had her arm trapped for a few hours before her sister and neighbors were able to free her. But it took days to get medical attention and in the end she lost her right arm just below the shoulder, as well as her husband, and now has 2 children to feed (10 and 12). To add insult to her injury, her wound wasn’t healing. Every 2 days Felix, the surgeon, would ‘milk’ it of a cupful of pus. He finally decided to explore the wound further ( meaning open it up, expose masses of red flesh and shove fingers and tools in to probe), and found a huge piece of gauze, the size of a small kitchen cloth, that had been left in during her amputation and had begun to adhere to the bone. This was (obviously) intensely painful. Her sister, a nurse working with us, had been by her side throughout the rescue, amputation, and recovery. This was now too much to bear and she left the tent sobbing. It was only the second time she had cried since the quake.

Ofelie Delmas 29, had her leg pinned down by a fallen wall in her home and lay for 2 days in a small dark space, her ceiling hanging so near to her head she could touch it. With every replica it sank closer and closer towards her. She tried to shake her leg free until she had torn skin and muscle and exposed bone. Her husband and neighbors were ready to cut off the leg then and there but she did not believe she would tolerate or survive it. Her husband finally found a rescue team with equipment, and 2 hours later the wall was lifted and she was released, but her leg was lost. Her recovery was now complicated by severe anemia but she was transfused and was doing better when I left. She too lost her home but not her 8 year old or her wonderfully dedicated husband. He lost his photography workshop and has one camera left.

Another patient at the clinic came every two days for wound cleaning. Her right arm was cut just below the shoulder, her left one above the wrist. She and her husband asked me for a tent. I had to suggest the Red Cross, three bus-rides away and they cannot afford the fare. One morning she sees an acquaintance at the clinic who asks her how she’s doing. She replies “Pa pli mal” (Not too bad).

One night we transfer Ofelie to the Hospital La Pe. That means 4 of us put her on a stretcher and carry her down the unlit street and into the unlit emergency room, staffed by Cuban doctors wearing miners’ head-lamps.

The next morning, having checked in on her, I pass a small group looking at a gorgeous baby cuddled in a sheet on the walkway. “Is she sick?” I ask the lady next to me. “No, she’s dead”. Her tearful father then kneels and takes some photos, and her uncle has an outburst of wailing and shouting, a ‘crize’. “If my mother had been here this would not have happened!” he screams. With no further ceremony, another man places her in a wooden coffin, bangs and nails in the lid, and carries it away on his shoulder.

I joined an American nurse to visit her school, funded by Norwegians. They have 120 primary students and, since the quake, 600 family members living under awnings around the school. They feed 200 a day and distribute food for 500 more. They asked me to give a talk to a group of mothers who had requested someone to help explain their and their children’s reactions to the events. My focus was to explain some changes often seen in people’s thoughts, mood, and behavior after a disaster, and to reassure them that they were not going crazy, that most of their reactions were normal and would go away with time, in this case a very long time. Their questions, some impossible to answer, others impossible to answer honestly, included these.

‘How will we ever lose the fear?’

‘How will we forget?’

‘What can we do to stop thinking about all this?

‘What will we do in our tents when a hurricane comes?

‘Will a larger quake create a giant hole in the earth and swallow us up?

After winding down, I announce I have a ‘ti cado’ (small present) for them, and play a couple of songs for them on my pocket ocarina. It brings smiles and applause, to me worth ‘anpil lajann’- a lot of money. Two days later, a similar session with the Haitian staff of the British Merlin Hospital down the road and another with the nurses in our set-up.

Elide Darnais left Haiti to study medicine overseas and moved to Puerto Rico to practice internal medicine. He had not been back in 30 years, but arrived a few days after the disaster and stayed for 6 weeks. He flew back to San Juan with us to request indefinite leave from his hospital. He now plans to build a new hospital there and, with his apparently limitless energy, this may not take him long.

John Estimable is a foul-mouthed surgeon, on his third tour in Haiti since the quake. He has worked on unimaginable injuries. He is thorough and thoroughly human in his interactions with patients. I watched him one night, moved, as he helped a delirious and wasted old man who lay on a cot, alone, soaking in his own vomit. John bathed him with wet-wipes, wrapped pampers around him and dressed him in dry scrubs. A Caribbean male Florence Nightingale. Here’s to you John, and keep swearing as much as you like.

The health schools and universities have been decimated, structures collapsed and nurses, doctors and their teachers dead in hundreds, records of previous education gone with the chance producing, at anytime soon, a group of professionals to replace them. The same is true for all schools.

800,000 refugees are thought to occupy most of the open spaces in and around the city, only a minority having the luxury of a mosquito-proof, water-proof tent. They can be easily identified on Google-Earth, and the ones I saw were far more congested than what I saw on Google on March1. Thousands of houses and offices, even those with no apparent damages, are eerily empty, as only the most desperate run the risks of further tremors bringing down even the most innocent looking of homes.

I walk by a woman sitting on the pavement, thin, gaunt, and dirty with a lost stare. I ask her what she needs, no response. People passing by tell me she’s crazy and a small crowd forms around us. Someone says she’s been like that since she lost a son 3 years ago. Psychotic and abandoned before the quake, she has little chance of help now.

A Taiwanese engineer walks in to our grounds with a sense of urgency. In broken English he tells me is looking for anti-HIV meds. He has just stuck himself with a needle on the ground and is terrified. I find a bottle of retro-viral meds and he leaves, grateful and only slightly relieved.

We ‘visit’ the Hotel Montana, where all sorts of foreign workers, international pilots and consular staff stayed. All guests and employees died, 112 so far recovered. We have to wear hard-hats. An 8 storey building is flattened, surrounding restaurants and clubs collapsed and tilted. A US team seeks for the safest approach to two more bodies spotted that day, the whiff of putrefaction in the air.
The Haitian government is fast returning to the usual ways. It has officially declared the emergency to be over on March 12. On my last evening in Haiti we make a mad dash to a hospital across the border in Dominican Republic 1 ½ hours away, to load our ambulance with medical supplies donated by Puerto Rico. Having been assured by officials on the Haitian side of the border that we’d be let thru after closing time of 7:00 PM, we return at 9 to find new staff.

We are now told we will not be allowed in until customs opens next morning. Three doctors in scrubs and an ambulance full of supplies stuck in the no-man’s land between the two border posts on a Saturday night, and our flight home leaves at 8:00 AM next day. The Haitian official makes his case even more plainly by wrapping a thick chain around the gate and locking it with a big padlock. We don’t know if he’s waiting for money, or proving to others how powerful he is, or both. Other officials who had initially refused our passage try to convince him to back down. After 45 minutes of anguished waiting, he concedes.

As we ready to board our flight home, after a week of sweaty work, officials in the airport ask us for a $40 US departure tax. I don’t know if it is my shit-fit in Creole or other forces that convince them we are a humanitarian flight and are exempt. As if any foreigner in Haiti right now is a tourist.

A Canadian epidemiologist takes me with her car and driver to see downtown Port-au-Prince on my last afternoon. I am stunned by the wreckage of the large and small, colonial and new, public and private, the elegant and the shoddy. Some are pan caked, others tilted at bizarre angles, others with walls and floors dangling precariously, some of the hanging pieces offering treacherous shade to street vendors. Thousands of corpses must still be buried under it all. I am reminded of photos of European cities after WWII bombings.

It’s impossible to conceive the sum of traumas they have been thru – loss of loved ones, limbs, homes, belongings, jobs. Not to mention schools and universities, teachers and colleagues, documents, whatever sense of normality their lives had before. Not to mention the terrifying waits for rescues, surrounded by the stench of corpses, the uncertainty of who had survived and who would survive the injuries, and now the prospect of long-term existences under awnings that bake you in the day, wet you when it rains and provide no escape from malaria and dengue-ridden mosquitoes that make restful sleep impossible. The continuous replicas keep the fear alive, even though their awnings and sheets now pose no dangers. The real danger they now face is the future.

Editor's note:
To avoid identifying the patients and personnel Dr. Alan del Castillo met in Haiti during his missionary activity he sent me made-up names to publish in this blog.