Haiti, Aid, and Rehabilitation

A few weeks ago, I was invited by my department at work to talk about Haiti and they left it open for me to say whatever I wanted! I assumed that the rehabilitation department would prefer that I talk about my therapy experience, but I couldn't give up the opportunity to educate myself - and my colleagues - a little bit about the earthquake aid debacle. I was inspired by Jonathan Katz's The Big Truck That Went By, and wanted to include historical and recent context for why the recovery effort has been so stagnant and difficult. Then I talked about therapy and orphans, too.

Thanks Virginia Mason for inviting me to share my story!

Full text after the break.

My name is Rachel Prusynski. For those of you whom I have not met, I’m a physical therapist in the inpatient PMR department here at VM. Today I’m going to talk about my experiences in Haiti and try to make it relatable to all of you by focusing on some of the therapy work I’ve done there, but since I have a captive audience for 40 min or so, I’d also like to touch on some important things about Haiti and all of the international aid after the earthquake in an attempt to explain some of the context of the challenges Haitians are facing in rebuilding their country.

To start off with why I got involved in Haiti in the first place, On January 12, 2010 I was on Christmas break of my first semester of PT school and visiting my best friend from college, Molly, who was in Haiti volunteering for an organization called Our Little Brothers and Sisters.

 Molly’s organization started in Mexico in the 50’s and goes by NPH, which is the acronym for “Our Little Brothers and Sisters” in Spanish. Today, NPH is raising 3,600 children in 9 countries, where the kids become family for life and receive an education as far as they are able to go.  Molly worked for one of the many NPH outreach programs in Haiti called Kay Germaine, an outpatient clinic and school for children from the community with disabilities. Molly split her time between clinic and classroom and took children into the therapy pool.

So back to January 12, 2010. At 4:53 PM, Molly and I had just come back from the market and I had gone up to the top floor of the 6-story Father Wasson center, an NPH building where Molly lived, housing volunteers and administrative offices, when the violent shaking started. It didn’t stop until our entire building pancaked to the ground.

After a few hours of being buried and in and out of consciousness, I was eventually rescued by three Haitian strangers, driven to the US embassy, and began a journey of medical procedures, frantic calls to Molly’s cell phone, helicopter evacuations, and flight negotiations until I arrived in Florida a few days later. While in transit, I learned that Molly had been found, buried two floors below me, and the NPH helpers who had come to dig her out had been too late. Two others in the building survived, but Molly and Ryan, a visitor sitting right next to me when the shaking started, did not. A week after the earthquake, I was back in class.

I wish I could say that fighting with the U.S. government to fly me home for less than $11,000, or enduring aftershocks while the US embassy shuddered, or getting stitches without anesthesia were the hardest parts of my earthquake experience. But losing Molly, surviving while the medical student next to me did not, and returning to a full PT course load while wanting more than anything to be back there, doing something – anything – to be useful to this country lying in ruins, was much harder.
I don’t have a perfect recipe for getting over PTSD and survivor’s guilt, but what helped was getting involved – and staying involved – with the organization Molly loved.

I started by sponsoring a child in the NPH orphanage where Molly worked. My godson Kervenson survived the earthquake and lost his parents, and we welcomed him and dozens of children orphaned by the quake into the NPH family. I’ve returned to Haiti every winter since the earthquake, comforted by finally being surrounded by people who understood even more acutely what was lost that day.
I started a young professionals board here in Seattle to fundraise in support of the work of NPH and have been privileged to use my growing therapy skills in a meaningful way through ongoing therapy teaching trips (more on that later).

I also started a scholarship fund in Molly’s honor at our alma mater, and found a donor to fund a 4-year full-ride scholarship for Jean Francois, who grew up in the NPH orphanage where Molly worked.
Before I highlight the accomplishments of NPH in Haiti and talk about our therapy work, I wanted to contrast their successes with the failures of traditional aid in the earthquake recovery effort.

But first, the Earthquake damage. At a magnitude of 7.6, In 34 seconds of shaking from the epicenter in Leogane, outside of the capitol of Port-au-Prince, up to 316,000 people died. This equates to 10% of the population of the capitol, 17% of all government employees, and most public buildings, including the Presidential Palace and National Cathedral.

Interestingly, this damage is in contrast to a much stronger magnitude 8.8 earthquake in Chile a few months later where only about 525 people died, or even the 2001 Seattle earthquake with zero deaths at a magnitude of 6.8.

I think it’s incredibly important to understand why, since we can’t predict damage based solely from earthquake magnitude, Haiti’s earthquake was so destructive in terms of human life and infrastructure.
From a simple structural standpoint, there are building codes in Haiti but they are not enforced. In 2008, the mayor of Port-au-Prince estimated that 60% of the city’s buildings were unsafe. With the damage from a particularly devastating 2008 hurricane season that wiped out 70% of Haiti’s crops in a country already 97% deforested, together with U.S. policies of subsidizing American rice and lobbying Haiti to reduce import tariffs, many rice farmers went bankrupt. So many of the earthquake deaths can be attributed to over-crowding in the cities as rural farmers were forced to flock to the city to find work.  
But why aren’t building codes enforced in the first place? The answer to that question is multi-factorial, but it boils down to a bankrupt government without the money to bankroll law enforcement much less an organized emergency response effort. Haiti’s entire budget in 2009 was $1 billion, one-fourth the size of the budget of the City of Seattle. It’s hard to collect taxes when 80% of Haiti’s population lives on less than $2/day. But what most people don’t understand is this bankruptcy and resulting political instability has perhaps as much to do with outside forces as corruption or any problem within Haiti itself.

So let’s go back in time. Haiti became independent in 1804 and is the only country ever to become independent through a slave revolt. As reimbursement for its plantation owners’ losses, France forced Haiti to pay an indemnity in return for France’s recognition of Haiti as a sovereign state.  Once France’s most wealthy colony, Haiti quickly became insolvent when over 100 years after independence, in 1914 Haiti was still using 80% of its government budget to pay back their debt to France. Haiti did finally pay off the indemnity, but the total ended up being the equivalent to $22 billion today. Remember, a year’s budget for Haiti is $1 billion.

In addition to a 19-year U.S. occupation of Haiti in the early 1900’s, the U.S. also backed the early regime of the Duvalier dictatorships since we considered the up and coming candidate Francois Duvalier, AKA the notoriously brutal Papa Doc, as an ally against Cuban communism in the Caribbean. It turned out that his son Jean-Claud pocketed over $800 million in mostly aid money during his 15-year rule.  The U.S. has also had a hand in forcing 5 of Haiti’s presidents out of office– in total only 9 presidents have had a full term since the country’s independence in 1804. Finally, before the earthquake, even with a less corrupt elected government finally in place, only 3% of aid to Haiti actually went to the government and instead went to private NGOs and foreign government contractors, further weakening the power of the government to help its people via vital services like building code enforcement. 

So after Haiti lost so much on January 12, 2010, how did the rest of the world respond? With initial generosity. The number most sited is that the world gave $16.3 billion to Haiti after the quake. At a UN donor conference in March, over $9.28 billion was pledged by foreign governments to help Haiti recover, and the Interim Haiti Recovery Commission, chaired by Haiti’s Prime minister and Bill Clinton, was formed to help spend the money. That $9.28 billion was in addition to $3.1 billion in private pledges from people all over the world. In fact, 50% of American households gave generously after the quake.

But where did the money go? This is where things get tricky, and unfortunately, a bit deceptive. Initially, $16.3 billion seems like a lot to spend. And, given Haiti’s lack of progress in the last four years since the quake, I often get questions about why the recovery hasn’t been more successful given the outpouring of financial support. My reply is that that money was never really Haiti’s to spend. And there are a lot of unfortunate reasons why. First of all, almost $2 billion was in the form of debt relief, which was already being negotiated before the quake. While important, it’s deceptive to include that money as earthquake recovery funds for Haiti. Most importantly, very little of the actual recovery money ever landed in the hands of a Haitian person, and much of it never actually left the donor countries. Overall, 93% of that money in the first year went to the UN or other donor country NGOs, so the benefits from aid worker salaries and equipment and contracts ended up being a sort of kickback to the donor countries themselves. In total, only 2 Haitian organizations received any of that funding.

I want to highlight an example how misleading the $16.3 billion number can be by breaking down some of the more wasteful parts of the $465 million spent by the U.S. Department of Defense for Haiti relief. I’m not saying that some of these functions were important to Haiti in the days after the quake, but much of the money was spent evacuating U.S. citizens and paying for aid workers’ hotel rooms, many of which weren’t in Haiti at all. Some even more bizarre numbers are $50,000 for elevator maintenance in a country with about 12 total elevators, $18,000 for a jungle gym (that goes for less than $6,000 online), $194,000 for video equipment, over $4,000 for a deep fat fryer, and over $11,000 for medals and ribbons. Even if this was essential equipment for Haiti’s recovery, which is a stretch, I want to point out that none of this money was spent in Haiti and served to benefit the U.S. economy instead.
16. Finally, even if the Haiti relief money had actually been earmarked for contracts or organizations in Haiti, most of it still hasn’t arrived. At the end of 2010, over 90% hadn’t been delivered. This is somewhat understandable since a good chunk of it was to be used for longer-term development rather than emergency relief. But at the end of last year, less than half had been delivered, and the U.S. has delivered less than 1/5 of the aid we promised.

Overall, less than 1% of the global funds promised after the earthquake actually went to the Haitian government itself, including nothing from the U.S. directly to Haiti’s government.

So who is really to blame that Haiti hasn’t made progress? It’s a tricky question, but I hope I’ve illuminated for you that aid promised wasn’t aid delivered, and even aid delivered did not reflect the priorities of the Haitian people and largely served to benefit the donor countries while we could pose as generous benefactors.

So if all of that weren’t disappointing enough, onto an issue that crosses the line from upsetting to pretty infuriating. Our director in Haiti calls the earthquake and the cholera outbreak the “twin tragedies” of 2010. Since the cholera outbreak started in October 2010, over 640,000 cases have been documented with over 8,000 deaths. What makes the cholera outbreak the finest example of aid gone wrong is that it was brought to Haiti by a contingent of UN soldiers from Nepal. The UN peacekeeping mission has been in Haiti since it arrived in the wake of a coup in 2004, and has had a string of controversies such as rapes and abuses of Haitians by UN soldiers, but the cholera outbreak is certainly the worst. Multiple independent studies – included one ordered by the UN itself – have confirmed the Nepalese soldiers as the source and proved that the Nepalese base was improperly disposing of its human waste into the Artibonite River. Most upsetting of all, especially after personally having spent time holding buckets and replenishing fluids for Haitians suffering from such a debilitating and dignity-robbing disease, is that the UN refuses to take responsibility. When a group of 5,000 cholera victims and families submitted a legal claim to the UN for compensation, the UN invoked immunity under the 1946 UN convention. According to the UN, this claim wasn’t even “receivable.”

While the UN did recently begin developing a cholera-reduction plan, they have yet to take responsibility or fess up to being the outbreak’s source, all the while continuing to spend $650 million a year on the peacekeeping mission, with $0 spent so far on treating cholera or helping victims’ families.
So the job of cleaning up this mess is left to private NGOs and Haitians themselves. Cholera is the gift that keeps on giving. Our cholera hospital started as tents and is now a permanent building where we have treated over 20,000 people, and we know this disease isn’t going away. Once introduced, cholera stays in the water supply as long as poor sanitation exists, and in Haiti where there is no sewage system, that means the foreseeable future. But, for those with proper access to healthcare, cholera isn’t fatal. It’s a nuisance; like a bad case of food poisoning. It costs our organization just $22 to rehydrate someone with cholera, which makes the 8,000 deaths even that much more tragic. With a $22 treatment unaffordable for many in Haiti, cholera is truly a poor person’s disease.

So that’s the bad news. Now you know a little bit more about what the Haitian people are up against, but I’d like to shift gears to some good news and some pictures of cute kids. I like to think of the organization I work for and its successes as kind of a beacon of hope in the muck of misguided top-down aid approaches.

NPH has been in Haiti since 1986. I am proud of a lot about NPH, but most of all I am proud that we employ over 1,600 Haitians and there are only a handful of foreigners in leadership positions. We are a Haitian organization. We are three hospitals (including the cholera program), two clinics, thirty schools, three orphanages, and many other community outreach programs.

I want to touch on some of the programs I’ve worked most closely with and then focus on the rehabilitation piece that you thought this presentation was about.

NPH Haiti started as all NPH homes do, with the original St. Helene orphanage in the cool mountain town of Kenscoff, where we have 400 children, including a house full of children and adults with disabilities that stay with us their entire lives.

Slowly we started growing as the need in Haiti became more apparent and diverse. Our director, Father Rick, soon realized after founding the home that Haitians needed a doctor more than a priest, so he went to medical school and then opened St. Damien’s pediatric hospital, a free 120-bed facility with the country’s only pediatric oncology program, a new maternity ward after the earthquake started to meet the need when the state hospital collapsed, and my most and least favorite room - where we house abandoned children who are left at the hospital. Many of our abandoned children have disabilities. But many do not.

After the earthquake, we built a new orphanage out of left over shipping containers and called it Angels of Light. Originally a day camp with food and education for children in the tent cities, the Angels of Light program has grown into two permanent orphanages, housing 200 children, including our babies! Who were Orphaned or endangered in the earthquake.

We also built a permanent school for our children plus 600 external students from the nearby tent cities.

The programs closest to my heart are our robust set of programs for children with disabilities, including the Kay Germaine elementary school where Molly worked, the pediatric clinic where our staff is composed of Haitian technicians trained by foreign volunteer physical therapists, and the adult outpatient neurological clinic housed in the same building.

Finally, in addition to our cholera hospital, after the earthquake we realized that we were uniquely poised to address the gaps in health care for adults after so many hospitals and medical programs were damaged.

We started the St. Luc adult hospital in left over shipping containers in the spring of 2010. Now we have three large permanent structures and a dozen or so small semi-permanent buildings to make up the St. Luc campus. The Mayo Clinic sent down teams every few months to help train staff, including therapy techs, and St. Luc now treats over 120,000 patients per year in their main hospital and new small hospital in the slum of Cite Soleil.

So this is where my actual rehabilitation work comes in. Once the adult hospital was up and running, the Haitian staff started to see a lot of patients with CVA or other infections and wounds involving deconditioning, and they recognized the need for an acute care therapy team to help with initial mobilization and family training. NPH is very uniquely poised in Haiti because, miraculously, there can be continuity of care between acute and our outpatient PT center at Kay Germaine (although inpatient rehab is sadly missing).

The Mayo Clinic started sending down PTs as part of their medical teams to train two Haitian staff members as PT technicians. There are no therapy programs at all at any of the universities in Haiti, so our therapy techs Dimitry and Sofanie went to high school but haven’t really done any formal college or medical education.  

Dimitry and Sofanie got a bit of training at the outpatient center prior to moving over to St. Luc, but they’ve largely learned through the traveling Mayo teams and myself. The last two times I’ve travelled to Haiti, I’ve spent a week to ten days with Dimitry and Sofanie, splitting time between classes, lab demos, and patient care. I developed a written curriculum starting with basic anatomy and patient handling, and collaborated with the visiting Mayo Teams to reinforce their education and pick up any loose ends from their previous visits. We worked on developing forms for documentation, refined the referral process to the outpatient clinic, I taught mini lectures on everything from “what is the brain” and stroke signs and symptoms to basic range of motion and DME, simple contraindications to therapy and other safety information, skin protection and positioning, and finally we did hands-on practice for transfers, exercises, and family education. I also collected equipment from generous professors and family members to help provide the techs with blood pressure cuffs, textbooks, and gait belts, and Mayo contributed supplies as well.

It’s certainly not a perfect system and it would be lovely if the technicians would be able to get more formal education, but the fact that there is an acute care therapy program in the first place at a hospital in Haiti with cement walls, a tin roof, a few IV poles, and intermittent electricity is pretty outstanding. I still have a lot of goals for the technicians and the Mayo Clinic has stopped sending therapists down, so I hope to continue to help develop their skills in the coming years. My next project is writing a short stroke education book in Creole with important information for patients and families in an attempt to decrease the negative impact of the lack of follow-up care for patients after strokes. Many of them live too far to get to our outpatient center or cannot afford transportation. I hope to have it written and printed for my next visit in January. If anyone knows a free or cheap printer let me know.

I want to end by highlighting a few hard learned lessons from this teaching work that I feel are valuable for anyone interested in doing international volunteer work. I call this my soapbox slide.

Be sustainable. What I love about teaching in Haiti is that my work carries forward. I’ve been so impressed by Dimitry and Sofonie in their ability to retain what they were taught year to year, ask intelligent follow up questions, turn around and teach the families how to care for their loved ones with strokes, and provide excellent patient care. Teaching Haitians to do this job is the gift that keeps on giving long after I fly home.

Number two, which is related, is how important it is to do work that empowers or educates local people. I get pretty frustrated by mission groups that travel to a country, spending hundreds or thousands of dollars on airline tickets to go build a church or school or work on a project that could have employed dozens of local people and maybe taught them some useful skills.  I’m also suspicious of NGOs with all-white or western staff members. This is not to say I wasn’t one of those high schoolers in the matching t-shirts on a plane to Mexico back in the day. Personal enrichment and growth are important, but it’s important to recognize that traveling as a volunteer often benefits us more than we could ever hope to give back. Unless you have a unique skill to impart when you travel to volunteer abroad, don’t underestimate the local people by assuming that we as Americans automatically have something to offer them with our presence. Often, they could do way more with the money from our plane ticket than we can achieve in a week or two on the ground. This is something I struggle with every time I get on that plane.

Third, on that same vein, I did get in a bit of an e-mail argument with a Mayo Clinic therapist who was reluctant to teach the technicians how to take blood pressure because they never had physiology education. Our technicians are in fact quite intelligent. Their brains are the same as ours, and it turns out they had no problem grasping the concept once we did a quick class about blood pressure and practiced performing it. We as students had to learn these skills at some point too. Again, formal education isn’t always all it’s cracked up to be. Any of us who have slept through a general bio lecture can attest to that.

Number four. Be adaptable and flexible and humble. An example I can give is documentation. The importance of thorough and detailed evaluations and documentation is drilled into our heads in school. But I had to let go of that a bit upon the realization that the medical record system is totally different in Haiti. Of course it’s important to keep track of our patients, but the technicians often didn’t have time to write up detailed notes, didn’t know all the terminology and tests anyways, and didn’t really see the value in it when the doctors never read their notes (so maybe the system in Haiti isn’t that different after all). Instead of focusing on teaching so many assessments and tests to help with documentation, we compromised by developing a shorter form that would help with continuity of care when the patients go to our outpatient center. And in the end, the technicians got to spend more time seeing all their patients and educating their families. We had to focus on patient care and doing it well. The system in Haiti has yet to develop to the point where therapy documentation is even on the radar. Maybe someday when there is3 formal therapy training at the university level and therapists in all the hospitals, it will be more feasible. But sometimes our idea of what’s best just isn’t best practice elsewhere. We need to look at the big picture and practice humility.

Lastly, on a more philosophical note, I want to quote a recent essay by Phil Garrity, an employee for Partners in Health, another impressive NGO that works in Haiti, “so we easily fall into the trap of making systems and machines out of countries, communities, and individuals—broken devices that only we can fix.” Haiti may be a bit broken after the earthquake and because of many tragedies and unwelcome negative forces from the outside, but Haitians themselves are not broken. The earthquake aid debacle showed us the dangers of thinking of ourselves as the fixers. We certainly haven’t earned that title. When I travel to Haiti, I am not there to fix them. I started my Haiti journey by being broken. I went back to Haiti a year later still fractured and torn apart, but over the years this work and these kids and my patients and my students have fixed me, not the other way around.