Haiti Earthquake Relief, Phase Two — Long-Term Needs and Local Resources

출처 :

Volume 362:1858-1861		May 20, 2010		Number 20

http://content.nejm.org/cgi/content/full/362/20/1858

A month and a half after January’s devastating earthquake in Haiti, the National Organization for the Advancement of Haitians, a U.S.-based nonprofit organization with a division dedicated to improving health care in Haiti, sent in teams of U.S. physicians and other health care professionals, primarily of Haitian descent, as the acute phase of disaster response was ending. As part of this group, I worked in a makeshift hospital in Tabarre, a section of northeast Port-au-Prince.

As a first-generation Haitian-American and an internist, I expected to be prepared for the situation I was walking into. Haiti was a country I knew, I spoke the language, I understood the people, and by this point I had been watching the disaster on television daily for over a month. I knew that with the threat to life no longer minute to minute but week to week, the long-term recovery phase was beginning. According to my relatives in Haiti, the initial shock was passing. Dead victims had been cleared from the streets, families were either reunited or mourning their losses, the roads were somewhat drivable, and food and water were slowly making their way to survivors. Yet when I came face to face with the disaster, I realized that the media hadn’t even begun to capture the extent of the devastation. Seeing Haiti through a framed television screen had given me only a snapshot of destroyed buildings, misplaced families, and stories of loss and survival.

When you’re on site, there is no television to turn off, no place to avert your gaze, no way to avoid hearing endless conversations about loss and devastation — and fears about worse to come. Nor could I turn off the unrelenting heat, or the airborne dust from the rubble of destroyed buildings, or the smoke rising from burning bodies, wood, and rubber. As I looked around, not a single standing building interrupted my line of sight in any direction. Every street was spilling over with masses of displaced people, many of them young children, stuck in a strange purgatory with no place to stay and no place to go.

I soon saw that the Haitian people were paralyzed by fear. In the middle of the night, while coworkers and I were asleep inside a small home that had survived the earthquake, a minor tremor (measuring 4 on the Richter scale) knocked me out of bed. Immediately, people were screaming in the streets, afraid that “the next big one” was upon them. Neighbors yelled frantically, telling us to get out, that they could hear the building cracking. The next thing I knew, I was sleeping in a tent — the most secure and comfortable option. At that point, my only solace lay in focusing on what I could control — what little I could offer as a physician.

View larger version (37K): [in this window] [in a new window]   Postoperative Care for a Young Amputee. Helene Garcon, a medical student, examines a boy who lost both of his legs below the knees after being trapped in the rubble of his collapsed home after the earthquake. Courtesy of Marie Berjorie Cadet.

 
At our makeshift hospital, we were past the heroic stage of rescuing bodies from the rubble and performing emergency lifesaving surgeries. Now the delayed effects of the earthquake, which affected an estimated 1.4 million people, were manifesting themselves. Inconsistent wound care and rehabilitation for trauma victims and amputees resulted in a multitude of patient visits for infections, disabilities, and complications from delayed treatment, such as gangrene and sepsis. The dust and smoke in the air led to respiratory illnesses, including severe asthma, flares of chronic obstructive pulmonary disease, bronchitis, and pneumonia. According to the World Health Organization (WHO), respiratory infections are now the main cause of illness, followed by trauma or injury, diarrhea, and suspected malaria.¹ Crowding and poor sanitation in rapidly growing tent settlements were creating or exacerbating medical problems, particularly in children. Mobile clinics from Tabarre provided targeted, large-scale treatment of postoperative infections and therapies for outbreaks of lice and scabies in orphanages. Before the earthquake, diarrheal illness accounted for 17% of deaths in children under the age of 5 years. Now, in addition to the already contaminated water supplies and poor sanitation, the rainy season will increase the risk of acute respiratory infection, diarrhea, and waterborne and vectorborne diseases, including dengue, typhoid, and malaria. In anticipation of this onslaught, the WHO is undertaking large-scale vaccination campaigns and tasking mobile health clinics with identifying outbreaks quickly in order to limit the associated morbidity and mortality.

In addition, the chronic diseases that patients had been ignoring since the earthquake were rearing their ugly heads. Several patients arrived after having interrupted their treatment for tuberculosis or HIV, with no records of their previous regimens. Large numbers of patients — some who had had no regular health care before the earthquake and others whose care had been interrupted — now presented with acute manifestations of their uncontrolled chronic diseases, in the form of hypertensive emergencies, strokes, seizures, and diabetic ketoacidosis. Although many medications were available, donors had provided a supply of drugs that generally were not targeted to chronic health problems. In Tabarre, despite the fact that we limited each patient to only 10 to 15 pills at a time, the medications in highest demand — such as basic antibiotics, asthma inhalers, and hypertension and diabetes medications — became scarce, while boxes of others, such as intravenous amiodarone, remained untouched.

View larger version (40K): [in this window] [in a new window]   Emergency Room at a Field Hospital. An open structure at a small amusement park has been converted into an acute care facility. Courtesy of Dominique Bayard.

 
Public health problems affecting women, ranging from sexual violence to a lack of obstetrical care, were also exacerbated by the earthquake. We treated women and girls as young as 12 years of age for newly acquired sexually transmitted infections (STIs). Many women reported being the victims of forced sexual encounters in the tent settlements. Though these reports are unconfirmed, increasing numbers of reports by health care workers of STIs and sexual violence have led to an official WHO investigation and a targeted assessment of women’s health care needs.^2,3

Ultimately, it became clear to me that the most important resource for the ongoing relief effort is the one most threatened by the earthquake: the local people. Though I had not been back to Haiti in 15 years and was there for only 2 weeks, the local people were what enabled me and my colleagues, both emotionally and logistically, to provide care to more than 800 patients a day. Local volunteers — who constituted about half our staff, though they could easily have been devoting time to their own recovery instead — spent every day, sunrise to sunset, making it possible for us to provide care. They triaged patients, organized the physicians, distributed medications, and rose to any necessary task. Patients were grateful that the Haitian diaspora was returning to help. Despite their own loss and tragedy, they would laugh at my American-accented Creole and tell me how proud they were of me for coming back. Neighbors living in tents in their backyards cooked a full breakfast and dinner for me and several coworkers every day. In exchange for our provision of a 2-week proverbial Band-Aid, the people helped, encouraged, and took care of us. While international volunteers come and go, the local people will remain the backbone of the recovery process, and integrating them into international relief efforts will be vital.

The road to recovery will be long, and with the rainy season beginning, circumstances will get worse before they get better. Six months after the 2005 earthquake in South Asia, a similar pattern of respiratory infections, diarrhea, infectious disease outbreaks, poor sanitation, and insufficient shelter persisted and worsened despite a strong initial relief response.⁴ In Haiti, the initial response has also been strong, and we have learned from previous disasters what to anticipate in the months and years to come. Clear insight into the changing medical needs, together with the collaboration of the strong-willed Haitian people, will drive an effective effort to rebuild Haiti and, I hope, make it stronger than ever.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

Dr. Bayard is an editorial fellow at the Journal.

This article (10.1056/NEJMp1003839) was published on April 14, 2010, at NEJM.org.

References

1. Pan American Health Organization. Haiti health cluster bulletins — earthquake, January 2010: update, March 10, 2010. (Accessed April 13, 2010, at http://new.paho.org/disasters/index.php?option=com_content&task=view&id=1108&Itemid=1.) 
   
2. UNICEF. Haiti emergency response update: March 17, 2010. (Accessed April 13, 2010, at http://www.reliefweb.int/rw/RWFiles2010.nsf/FilesByRWDocUnidFilename/MDCS-83PC9M-full_report.pdf/$File/full_report.pdf.)
   
3. United Nations Office for the Coordination of Humanitarian Affairs. Haiti earthquake situation report #30. (Accessed April 13, 2010, at http://www.reliefweb.int/rw/RWFiles2010.nsf/FilesByRWDocUnidFilename/VVOS-83PQ24-full_report.pdf/$File/full_report.pdf.)
   
4. Brennan RJ, Waldman RJ. The south Asian earthquake six months later — an ongoing crisis. N Engl J Med 2006;354:1769-1771. [Free Full Text]

아이티 어린이 보호하기

[뉴잉글랜드저널오브메디신(NEJM)] 2010년 2월 17일자

아이티 대지진으로 23만명이 사망한 가운데, 어린이들은 대재앙에 직면에 있는 상황입니다.
이 article은 1월 24일 아이티로 긴급 파견된 하버드 대학의 François-Xavier Bagnoud Center for Health and Human Rights팀이 9일 동안 아이티 정부 및 지방정부 관료 등 여론주도층, 인도주의 구호활동가, UN 기구와 비정부 기구의 대표 등을 인터뷰하고, 현지 진료소나 병원, 거주지, 고아원 등을 방문하여 조사한 결과를 NEJM에 발표한 내용입니다.

아이티 인구 9백만 중 어린이가 거의 50%에 육박한다고 합니다. 대지진이 발생하기 전에 고아원에서 살고 있던 어린이가 35만명으로 추정된다고 합니다. 부모가 있으나 가난이나 실업 등 경제적 이유 때문에 고아원에 맡겨진 어린이도 상당히 많다고 합니다.

아이티 정부에 등록된 고아원 수는 350군데 정도인데 미등록된 시설을 포함하면 거의 2배(700개) 정도가 될 것이라고 합니다.

아이티 대지진은 그렇잖아도 열악하기 짝이 없는 아이티의 어린이 건강과 인권을 더욱 악화시켰음은 더 이상 말할 나위가 없겠지요.

Published at www.nejm.org February 17, 2010 (10.1056/NEJMp1001820)

출처 : http://content.nejm.org/cgi/content/full/NEJMp1001820

Haiti has long had difficulty in protecting its children from harm. The earthquake that struck the country on January 12 destroyed much of the capital, Port-au-Prince, as it killed many government officials and United Nations (UN) workers and left as many as 230,000 people dead and many thousands injured. In the wake of this sweeping disaster, the plight of Haiti’s children has acquired new and terrible dimensions.

On January 24, we went to Haiti as members of a team sent by the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University to conduct a multisite rapid assessment of child-protection needs in the post-earthquake environment, where it was already evident that children were at grave risk of abandonment, abuse, and trafficking. The focus was on the current systems and practices for identifying and caring for unaccompanied children and for tracing those who had been separated from their families and reuniting them with parents or guardians. Longer-term interventions to promote the welfare, rights, and safety of this population were also examined.

In 9 days, we interviewed more than 25 stakeholders in Haiti, including government officials, local staff members, humanitarian aid workers, and representatives of domestic and international nongovernmental organizations and UN agencies. We visited field hospitals, clinics, shelters, and orphanages, along with observing risk-assessment practices and participating in meetings of UN “clusters” (groups focused on individual service sectors).

Children constitute almost half of Haiti’s population of 9 million. Before the earthquake, an estimated 350,000 children lived in “orphanages,” yet only 50,000 of them had no living parents.¹ Desperately poor families have often felt compelled to place children in residential care facilities, only to return later and find that they have been given away for adoption. Throughout the world, many families have historically relinquished their children when they reached a tipping point due to unmanageable birth rates; parental death, disability, or unemployment; physical insecurity; displacement; or natural disasters.² In pre-earthquake Haiti, many families had already reached such a crisis.

Local officials estimate that there are about 350 registered orphanages in the country and about twice as many unregistered and unregulated ones. Even most registered institutions do not meet international UN guidelines. A related long-standing threat to child protection has been the common practice of sending children away as restavèks (Creole for “stay with”) to live with others in exchange for work. An estimated 150,000 to 500,000 restavèks work essentially as unpaid domestic laborers, with little or no access to education or recreation and subject to physical, mental, and sexual abuse.³ The restavèk situation and the practice of institutionalizing children reflect the extreme destitution of Haitian families. Thus, the earthquake occurred against a background of economic extremity driving family separation, aggressive trafficking networks, inadequate law enforcement, and a growing global demand for adoptive children.

Parents died and families were splintered as a result of the earthquake. In the rush to provide emergency care, injured adults and children were often scattered, taken to the nearest available health care facilities, and sometimes transferred, without records, to other centers. This situation prevailed for a month, during which time little, if any, demographic or registration information was collected at sites of care or settlement. Critical early opportunities to record, identify, and trace children and families were lost. The lack of data has impaired all aspects of child-protection efforts.

Irregular settlement adds further risk. By January 31, there were 1.1 million Haitians in need of shelter in Port-au-Prince and the surrounding communes, living in 591 documented improvised settlements — some of which, like the Petionville Club, hosted as many as 100,000 refugees.⁴ Children and young people in these dense settlements are easy targets for organized crime, violence, and sexual exploitation.

This disaster has imposed a massive socioeconomic burden on a country that was already struggling with poor governance and an impoverished population. Stripped of all assets by the earthquake, a growing number of families are parting with their children. Given Haiti’s unregulated borders, weak law-enforcement practices, and insufficient numbers of international monitors, traffickers face few deterrents. There is growing consternation among child-protection workers about the lack of financial and human resources for protecting Haiti’s vulnerable child population, which is estimated by some at 1 million.⁵

View larger version (77K): [in this window] [in a new window]   A Young Boy Walks Alone on the Road after the Earthquake in Port-au-Prince. Photo courtesy of Tim Williams.

 
The restavèk phenomenon and unregulated “orphanages” pose challenges to the placement of unaccompanied children. Although international standard practice is for orphans to be promptly returned to their relatives or communities, the restavèk option and severe poverty make community-based solutions problematic. Many aid workers feel compelled to consider institutional placement as a safer interim solution. But safe institutions are hard to come by. We encountered several hospitals where unaccompanied children whose treatment was complete were not being released for lack of a safe discharge plan (though in the first few weeks after the earthquake, many unaccompanied children had been discharged to the street). Representatives of orphanages visit camps and hospitals daily, and there is no effective mechanism for distinguishing safe residential care facilities from fronts for trafficking.

Adoption is sometimes seen as a viable alternative in the face of destitution. Experience from past disasters and conflicts, however, suggests that adoptions in the immediate wake of such crises carry a high risk of permanent removal of children who are not actually orphans — a practice that inevitably inflames latent nationalist sentiment in the affected region. The fields of child human rights and child psychology place great emphasis on maintaining the integrity of the family unit, where children have the best chance of being raised in a loving, intimate environment. There is great need now to provide care for thousands of children, including those with medical and other postoperative needs, and in some instances temporary protection status or adoption across borders might be acceptable. But a much better system for tracing children and protecting borders must first be implemented, to reduce the risk that children will be torn from their own families who, given the means, would nurture and care for them.

Improved family-tracing procedures, border control, effective scrutiny of international adoptions in line with the Hague Convention on Protection of Children and Cooperation in Respect of Intercountry Adoption, and more stringent oversight of orphanages are urgently needed to forestall further abuse. We believe that all aid workers, including voluntary health care professionals, should receive training in child-protection norms and be sensitized to the prevalence of child abandonment, abduction, and trafficking. Child-protection basics, including identification procedures and record keeping, reestablishment of educational opportunities, creation of child-friendly spaces (set up specifically for children in crises to address their physical and psychosocial needs in a stable, trustworthy environment), and health interventions, must be ramped up rapidly. Additional steps must be taken to strengthen local governmental and policing institutions charged with child protection, specifically the Ministry for Social Welfare and Research and the Brigade for the Protection of Minors.

View larger version (76K): [in this window] [in a new window]   Personnel from Haiti Social Services and the United Nations Children’s Fund Visit with Displaced Orphans in One of the Many Tent Cities in Port-au-Prince. Photo courtesy of Brett Nelson.

 
A sustained strategy must be developed to mitigate the distress and insecurity of affected children. The challenges of tracing and family reunification must be addressed through streamlined data-acquisition systems, heightened public awareness, and community-driven monitoring initiatives. Attention to child welfare and disability-related needs is essential, even as economic strategies are found to enable families and communities to achieve a reasonable standard of living. A common refrain heard among aid workers is that to ensure safe childhoods, families must be given a fair chance to be economically viable — which requires investments in health, education, vocational skills, sustainable livelihoods, microfinancing, and improved agricultural practices.

A senior aid worker spoke for many seasoned responders when he said, “We must be firmly committed to this notion of building back Haiti better. We must not accept the restavèk phenomenon as the inevitable. We must build a society free of restavèks. Children belong in their communities.” This goal will be difficult to achieve. Yet, as the UN’s special rapporteur recently remarked, “The human security of every child is of utmost importance to the sustainable development of a society based on human rights and [is] a precondition for sustainable peace.”³

An imaginative, bold solution is required. Recovery from an earthquake is always complex and slow, but Haiti’s children should not be made to wait and suffer. One million vulnerable children are a very large share of Haiti’s future and of ours.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (S.B., J.L., T.P.W., B.D.N .) and Harvard Medical School (B.D.N.) — both in Boston; and the Division of Emergency Medicine, Weill Cornell Medical College, New York (S.B., J.L.).

This article (10.1056/NEJMp1001820) was published on February 17, 2010, at NEJM.org.

References

1. Lederer E. UNICEF warns against Haiti child smuggling. The Associated Press. February 9, 2010.
   
2. Panter-Brick C, Smith MT, eds. Abandoned children. Cambridge, United Kingdom: Cambridge University Press, 2000.
   
3. Shahinian G. Report of the Special Rapporteur on contemporary forms of slavery, including its causes and consequences — addendum: mission to Haiti A/HRC/12/21/Add.1. New York: United Nations, September 4, 2009. (Accessed February 16, 2010, at http://www.unhcr.org/refworld/type,MISSION,,,4ac0c6b42,0.html.)
   
4. International Organisation for Migration. Improving conditions for displaced in Haiti’s spontaneous settlements. Press briefing note, January 25, 2010. (Accessed February 17, 2010, at http://www.iom.int/jahia/Jahia/media/press-briefing-notes/pbnAM/cache/offonce?entryId=26872.)
   
5. Sequera V, Fox B. 1 million children vulnerable. The Associated Press. January 27, 2010.