Dr. Wendy Lai was accustomed to watching women deliver babies in unusual places. Since arriving in Port-au-Prince in September 2008, the 33-year-old family doctor had seen mothers give birth in the stairwells, the bathrooms, and on the ground outside Jude Anne, the maternity hospital operated by the Dutch section of Médecins Sans Frontières. But even Lai was surprised when a guard fetched her one Friday in late October to say a woman had delivered “dans le carrefour” — “in the intersection.”
Before Wendy Lai arrived in Haiti, she worked in a Toronto hospital doing low-risk obstetrics. That meant uncomplicated vaginal deliveries in a well-equipped facility, with a gynecologist always available as backup and lots of experienced labor nurses to assist. Her job in Haiti was a world away. The mother who gave birth in the intersection was among the lucky ones; at least she was within a short walk of free, high-quality medical care, a rarity in this Caribbean nation of nine million. By any measure, health care in Haiti is a disaster, particularly for women and children. The country has the highest infant mortality and maternal mortality rates in the Western hemisphere. For every 1,000 babies born here, about 60 won’t see their first birthday (compared with five or six in the United States, Canada and the UK), and about five mothers will die, a rate at least 50 times that of developed countries. While a wealthy minority can afford good quality care in Port-au-Prince’s many private clinics and hospitals, as many as 70 percent of the population has no access to health care at all. Not surprisingly, the life expectancy of a baby born in Haiti today is less than 61 years, ranking it number 181 among the world’s 224 countries. Those are numbers that MSF is hoping to change.
Maternal care in Haiti is supposed to be free. In March 2008, the country’s health ministry launched a program called Soins Obstétriques Gratuits, designed to provide every expectant mother with four prenatal consultations, delivery in a public hospital — including a caesarean section if necessary — one postnatal visit, and any necessary medications. Under this program, public hospitals are expected to give care for free and then submit a claim to the World Health Organization for reimbursement. A year after it debuted, MSF found that many women were indeed able to deliver for free, but they were still being asked to pay for drugs, and in a country as poor as Haiti, even a $5 regimen is hopelessly unaffordable.
It’s little surprise, then, that expectant mothers flooded Jude Anne as soon as it opened in March 2006. By the time Lai arrived two-and-a-half years later, the 65-bed hospital was averaging more than 50 deliveries a day, with the busiest days approaching 80. The overcrowding was particularly acute in October 2008; during that exhausting month, three of the five government-run hospitals were on strike, including Isaie Jeanty, the public maternity hospital. “One day when I was on my way to work the driver had the radio on,” Lai says, “and I heard the Minister of Health telling the public not to go to the general hospital because there was essentially nobody working there. I remember the moment I found out the maternity hospital was on strike, too. One of our gynecologists came to find me because he was working in triage that day and he said, ‘Isaie Jeanty is closed and I don’t know what I’m going to do. I’ve got patients I want to transfer, but there’s nowhere to send them.’ He said he felt like he was going to have a heart attack. It was horrible.”
The other reason for the dramatic increase in deliveries during October is rather less mundane than work stoppages. Like many Caribbean countries, Haiti celebrates Carnival in February or March, a three-day extravaganza of music, parades, costumes, dancing, and uninhibited sex. Nine months later, a wave of Carnival babies arrives. When Lai first heard the story of Haiti’s reproductive peak, she thought it was an urban legend. But when she tested it on a pregnancy wheel — a tool that can be used to determine a baby’s due date based on a woman’s last menstrual cycle — she discovered that the math works out. “For someone who’s ovulating during Mardi Gras, their last menstrual period would be around the first week of February. I fiddled with the pregnancy wheel and looked at the expected due date for a full-term pregnancy, and lo and behold, it fell bang on in October. February and March are pretty quiet at the hospital, and in April and May we start seeing spontaneous miscarriages and people who’ve tried to induce an abortion. Women will also start to come in with the complications of early pregnancy, such as ectopic pregnancy. Around the summertime we start seeing the premature babies, and then in October, everyone is delivering all over the place.”
Wendy Lai’s Haiti mission was her second with Médecins Sans Frontières. Born in Newfoundland, she earned an undergraduate degree at McGill University in Montreal and attended medical school at the University of Western Ontario, graduating as a family doctor in 2003. Though she studied sciences at McGill, she didn’t originally intend to become a doctor. “Most people decide on medicine pretty early. A lot of doctors will say they have always wanted to be a doctor since they were a little kid, but that certainly wasn’t the case for me.” When Lai was in high school, she was active in social justice and human rights. As the editor of her school newspaper she also learned the power of advocating for people by bringing their stories to a wide audience. “Even though my undergraduate degree is in biochemistry, I was thinking I would become a human-rights lawyer. As my undergrad wore on, though, it occurred to me that I could use medicine to get at the same kinds of issues. Being a doctor doesn’t mean you have to be in some suburban practice, treating hypertension and whatnot. I realized it could be an interesting way to provide something real and concrete to people, and to get to know their stories really well.”
Lai knew that a mix of medical expertise, a passion for social justice and a willingness to shout from the rooftops is at the heart of MSF’s work. Curious about the organization, she decided to ask for advice from someone who knew MSF as well as anyone. James Orbinski, the former president of its International Council and the man who accepted the Nobel Peace Prize in 1999, worked in the same Toronto hospital where Lai was doing her residency. Orbinski, also a family doctor, had joined the group in 1992 and been at ground zero for some of the world’s worst humanitarian crises: the famine and civil war in Somalia, the Rwandan genocide and the refugee crisis it spawned in neighboring Zaire, and the 9/11 attacks in New York. “When I was seriously thinking about this,” Lai says, “I wandered down and asked, ‘So James, what’s it like?’ He is a very philosophical person, so the answer he gave me was a good one. I’m not sure it was the answer I was looking for, but it was accurate. He said, ‘It’s like nothing you’ve ever done before. You will find yourself doing things you didn’t know you could.’”
MSF usually requires doctors to have two years’ experience after their residency, but the recruiters were impressed enough with Lai that they accepted her with only one. In August 2006, she shipped off to Shabunda, a region of South Kivu in the Democratic Republic of the Congo. About 15,000 to 20,000 people live in this remote, densely forested area that can be reached only by landing a small plane on a tiny airstrip. As Orbinski had warned, it was like nothing else Lai had experienced. Some MSF efforts are highly specialized, targeting malnutrition, treating a cholera outbreak, or providing trauma surgery in a war zone. Shabunda, on the other hand, had everything. “There was a general hospital in town where we did obstetrics, surgery, internal medicine. We had a pediatric ward, we did tuberculosis, malnutrition, HIV. When I was there we had a measles epidemic, so we were doing a vaccination campaign, too. We were also supporting half a dozen primary health clinics out in the bush, several hours’ travel, so we would send a mobile team into the jungle on motorbikes.”
As in most MSF projects, the organization’s role in Shabunda was not to run the whole show but to support the work of local health authorities. One of the public’s biggest misunderstandings about medical humanitarian aid is the belief that it’s done largely by doctors and nurses from developed countries. In fact, while these foreigners — or “expats” — attract the most interest in the West, the work in the field is done mostly by locally hired medical and nonmedical personnel, called “national staff.” (In 2008, MSF had almost 22,000 full-time national staff positions in its projects, compared with about 2,000 positions filled by expats.) In some cases, expat doctors and nurses do little hands-on work, concentrating on supervision, training and administration.
Indeed, a project’s success often comes down to the caliber of its national staff. Even in countries where medical training is suspect, local health workers can be the organization’s greatest asset. “National staff understand not just the local political context, but the medical context, too,” says Lai. “I certainly learned a lot from the national staff in Congo. Malaria is rampant in that part of the world, and what do I know about malaria? Not a lot. I had the basic theory, but when it comes to the variety of ways in which malaria can present itself, I had no experience with that. Tuberculosis, typhoid fever, measles — same thing. National staff are much better at diagnosing and treating those things than I am.”
At the same time, many MSFers admit that differences in culture, skill level and attitude can drive a wedge between expats and national staff, sometimes compromising the entire project. In Africa, and in Haiti, a long colonial history has made people suspicious of foreigners who act like they know best and want to change local practices. “Certainly there was that tension in Congo, where I often felt like I couldn’t push too hard or say too much, because they didn’t want to hear it, and they didn’t put much value in the perspective that I had to bring,” Lai says.
In her Shabunda project, most of the hospital staff were employees of the Congolese health ministry whose salaries were being topped up by MSF. “There was a power imbalance, because we were bringing in the drugs, we were trying to insist on protocols, and there was this question of neo-colonialism. I understand that, but it made the work very difficult. One of the struggles I had was trying to get the nurses to take a full set of vital signs two or three times a day. They would take a temperature and wouldn’t do anything else — no pulse, no blood pressure, no respiratory rate. I know blood pressure is harder because you’ve got to find a cuff, but pulse? I failed at it. I was there nine months and I still wasn’t getting a full set of vital signs. When I left I didn’t feel I had accomplished much. I was exhausted and stressed, and I felt like I had done the most difficult thing I had ever done in my life, but I don’t know what has really changed there.”
The dynamic was much different during her work in Port-au-Prince. Lai found the Haitian medical staff were well educated, and they fully embraced Western medicine. “If I say ‘evidence-based practice’ to the doctors in Haiti, they get what I’m talking about. We can talk about research. It’s a little difficult, but we’re speaking the same language.”
As 2008 wore on it became obvious to everyone that Jude Anne was simply too chaotic to function as a maternity hospital. It wasn’t just that it was too crowded. One of the most common complications of pregnancy in Haiti is preeclampsia, which made up about a quarter of the caseload at Jude Anne. The treatment for preeclampsia, a condition that is potentially life-threatening for both mother and baby, includes rest in a calm and quiet environment. The hospital, situated on a busy street amid the incessant honking of car horns and powered by rumbling generators, hardly fit that description. When it became clear that MSF was going to need a new hospital, they looked to Lesli Bell.
Less than a quarter of MSF’s field workers are physicians, and almost half are nonmedical staff, including project coordinators, financial coordinators and administrators. Then there are the logisticians — rhymes with magicians, Wendy Lai points out — who are routinely asked to do the impossible. On a given day they may be expected to fix a generator, install a satellite phone, track down hard-to-find medications or, in the case of Lesli Bell, take an empty warehouse and turn it into a fully functioning hospital.
Bell, the logistics coordinator for the Haiti project, knows something about building hospitals, though her career path was different from most MSF logisticians. She was born and raised in Bermuda, spent time in the US and Canada, and later moved to Australia, where she currently lives. (Bell is also unusual among MSF veterans in that she has two teenaged children, with whom she keeps in touch through email and Skype while on mission.) She earned a degree in fine arts, spent 10 years as a professional photographer and is an accomplished wildlife painter who has done contracts for Earthwatch and Greenpeace. “When I was doing a painting job for Greenpeace in Australia, I started doing logistics and realized I was good at it,” says Bell, who has also worked for Oxfam. Her first MSF mission in the Democratic Republic of the Congo included overseeing the construction of a new health center. She also built a cholera treatment center in Congo-Brazzaville, and just before arriving in Haiti she helped start a domestic and sexual violence project in Papua New Guinea. But opening a new project is one thing; moving an existing hospital that’s chock full of very sick patients is rather more difficult.
“I was told that the project was an emergency obstetrics hospital, that it was very crowded, and that I need to find a place for twenty more beds,” Bell recalls during a smoke break at one of the MSF houses in Port-au-Prince. “So from the airport on my way here, I stopped at the hospital just to have a look. First of all, I couldn’t get through the gate because there were hundreds of people, patients, families, standing outside. Then I came into the waiting room, which was actually an outdoor area with a tin roof, and it was complete chaos — women in labor screaming, yelling. A baby was born in a woman’s hands right in front of me. She was sitting on a bench, stood up, and the next thing you know she had a baby in her hands. I couldn’t believe it. There were babies being born on the floor, on staircases, everywhere. I couldn’t even get up the stairs to see the other levels. The nurses were running all over the place. The beds were all tightly packed one against the other, and nurses were reaching across three beds to give medication to a patient against the wall. I realized there was no way I was going to fit twenty more beds anywhere in that building. So I decided to look for another building.”
At first there was little support for the idea of starting from scratch. “Everybody was saying don’t even bother,” says Bell. “People have been looking for buildings for years and have never found anything. I wanted to try anyway. So I put an ad in the paper and told everybody on our staff that we were looking for a building. Then one day a man came to the office and said he owned a building that used to be a UN warehouse, and he thought it would work as a hospital.” When the MSF team went to have a look, their first thought was that the building was too big. “But Wendy Lai and I sat down with a spreadsheet and started to play around, imagining all the different departments on each floor, and once we fit everything there wasn’t any extra space. And it was just a lot more humane.”
The renovations were complete by January, and then came the task of figuring out how to move an entire hospital. “I said let’s close Jude Anne for forty-eight hours, put everything in trucks and drive it to the new hospital — it’s only about six minutes away — and then open up the new building,” Bell remembers. “And the medical team said, ‘Do you know how many people are going to die in that forty-eight hours?’ There was nowhere else to send our emergency cases. So, over the course of many meetings, we drew up a timeline and worked through how we were going to do it.” The overall plan was to dramatically reduce the number of patients admitted to Jude Anne in the days before the move. “We tightened our admissions criteria so we had fewer patients than normal, and for transfers we were doing only the absolute emergencies. As the beds emptied, we slowly moved them over to the other hospital.”
There were inevitable setbacks — at one point four of the five refrigerators failed, rendering a stock of medicines useless — but otherwise the move went remarkably smoothly. The MSF team shuffled between two hospitals for the first two weeks in February 2009, and the last patient left Jude Anne, perhaps inauspiciously, on Friday the 13th. The next day the team officially opened the doors of its new building, which they christened Maternité Solidarité. “Ladies and gentlemen,” Wendy Lai wrote in her journal, “I think we’ve made a hospital.”
The overcrowding at Jude Anne highlighted an important MSF principle: the organization must be careful not to duplicate the health care system of the countries in which it works. By admitting even the most routine pregnancies at Jude Anne, MSF risked undermining the services of the public hospitals in Port-au-Prince. In March 2009, with Maternité Solidarité in full swing, MSF decided it had to narrow its admissions criteria and accept only emergencies and high-risk pregnancies. As a result, the new hospital now delivers some 400 babies a month, less than a quarter of what Jude Anne handled during the peak. “If she’s not delivering right now, we think we can get her five minutes down the road to the public maternity hospital,” says Wendy Lai. “Even the women from the slums — unless they are complicated, we are going to refer them. I often found myself saying to the staff, ‘Look, she needs medical care, but she doesn’t medical care from us.’”
It was not a popular decision with patients and their families, Lai admits. “Some got angry and belligerent. Sometimes we would try to transfer patients and they would make their way back, because they really wanted to stay. But that’s part of trying to look at the big picture, the longer-term goals of what are we doing there. I knew if we accepted every patient, soon we were going to be doing 1,200 deliveries a month again. And that’s not what we are there for. MSF has been criticized — and I think anyone who does aid work can be criticized — because what we are doing can impede the development of a sustainable system. But that can be a difficult trade-off.”
Fast forward two months. It’s just after 7 a.m. on a May morning and the roosters are still crowing outside the barbed-wire walls that encircle Maternité Solidarité. Dr. Veronika Siebenkotten has just greeted her Haitian colleagues, some of whom are who are finishing the night shift. Siebenkotten, a German-born gynecologist on her second mission with MSF, has taken over from Wendy Lai, and her rounds this morning provide a glimpse of the types of high-risk pregnancies the team treats every day.
Siebenkotten approaches a woman with an extraordinarily high blood pressure of 240/160, a textbook case of preeclampsia. For reasons no one understands, this condition is more common and more severe in Haiti than almost anywhere else. Preeclampsia occurs in late pregnancy and can cause severe headaches, blurred vision, swelling and a dangerous spike in blood pressure. If left untreated, it can lead to seizures (eclampsia) or another dangerous and aptly named condition called HELPP syndrome, which can affect blood clotting, the liver and the kidneys. Both complications are potentially deadly. The only effective treatment for preeclampsia is to get the baby out as soon as possible, either by inducing labor or by C-section. The medical team explains to Siebenkotten that the unborn baby is dead (it would be stillborn later that night) and the woman has been slurring her speech and unable to move her legs, both signs of a possible stroke. “We have seen several women who have been blind for days, or even a week, and you would think they had suffered the consequences of high blood pressure and would never get any better.” Siebenkotten has learned, however, that neurological symptoms sometimes improve after a few days. But when they don’t, treatment by specialists and long-term follow-up simply aren’t an option in Haiti, except for the wealthy. “The doctors sometimes want us to send these patients to an ophthalmologist, but what benefit would that have? What it is the point when, if you diagnose something, you can’t do anything about it anyway?”
A few beds away, a woman recuperates after having miscarried the night before. The medical team believes the woman has a partial molar pregnancy, where the placental tissue fails to develop into a viable fetus. While in most cases the condition is not immediately life-threatening, molar pregnancy can lead to complications and can later develop into cancer. “She going to need to come for follow-up, because you have to check her for two years. You have to do a curettage on the uterus to make sure everything is out,” Siebenkotten explains. But again, it seems unlikely that a woman with so few resources will be able to go through these steps. “Is she going to come back? Is she going to understand what is happening to her? If it becomes malignant, who is going to pay for the medication? Is it going to be detected in time?”
Siebenkotten turns to follow the soft cries of an infant and finds mother and baby both looking healthy. As it turns out, however, this mother is HIV positive. MSF does not run an HIV program at Maternité Solidarité, but mothers who carry the virus are included in the newly tightened admission criteria. “The idea is to give them an opportunity for safe delivery that will lower the probability of transmission from mother to baby. We give them antiretrovirals just before the delivery, or during the delivery. We can also give medication to the newborn, at least the first dosage, and try to make sure the mother will go to one of the follow-up programs that are available.” In a worst-case scenario, Siebenkotten says, more than 40 percent of mothers with HIV will pass the virus along to their child, but she estimates that the number here is less than 10 percent.
Severe anemia is another chronic problem at the hospital. Hemoglobin, the iron-rich molecule that transports oxygen through the blood, is measured in grams per liter, and the normal range in women is about 120 to 160. By comparison, it’s not uncommon for patients at Maternité Solidarité to have levels in the 40s, or even lower. Siebenkotten has learned that aggressive treatments she would not have thought pregnant women could tolerate, such as administering high doses of diuretics to prevent heart failure and pulmonary edema, are sometimes necessary in a hospital with an inadequate supply of blood for transfusions.
The next woman Siebenkotten visits is 27 weeks pregnant and has had severe bleeding as a result of placenta previa, which occurs when the placenta forms in the lower wall of the uterus and blocks the cervix. As the pregnancy progresses, the placenta detaches, causing hemorrhaging. “If this woman was in Germany, we would keep her in hospital for a couple of months,” Siebenkotten says. “Here, if the bleeding stops and the risk of it recurring is not too high, we tell them to take rest, and not to do hard physical work. But I have no idea how they can put that into practice. Who is going to help them carry the water and all of that? I don’t know.”
In a modern Western hospital, a mother with placenta previa may have an emergency C-section, and the baby would likely do just fine, even if born weeks before full term. But in Port-au-Prince, most women have no access to an incubator or neonatal intensive care, even at Maternité Solidarité, which has only a heartbreakingly small pediatric ward where nurses do what little they can for their tiny patients. “They give them oxygen, they give them IV medication. But these kids get infections they can’t deal with because their organs are still too immature. In the end, only the strongest survive. This is a big problem for the parents: they reject these kids. They don’t want to take them home, because they would have to feed them with a syringe for twenty minutes every two hours, and many women don’t have the capacity to do that. They have to struggle with other things in order to survive.” Siebenkotten says the mothers often do not choose a name until it is clear the baby is out of danger, something she observed while working in Africa as well. The pediatric ward is the loneliest place in the hospital. “Sometimes I want to go in there and sit with the babies, but I can’t. You have to give yourself some distance.”
While hundreds of babies draw their first breath at Maternité Solidarité every month, many also breathe their last. MSF’s job doesn’t end in the delivery room; part of its role is supporting grieving women through its mental-health program, which runs out of a small first-floor office with a sign on the door in Creole that reads Sikologé.
Psychosocial programs are a relatively recent addition to MSF’s suite of activities. Only in the mid-1990s did the organization start adding psychologists and counsellors to its medical teams. In Port-au-Prince, the mental-health program is run by Monika Osvaldsson, who is doing her first mission with MSF. After studying psychology in her native Sweden, she worked in South Africa in 2000. “I was interested in what happens in a society, psychologically, when you make a complete change of the rules and values,” says Osvaldsson, who speaks flawless English with a Swedish accent and the delightful hint of a brogue, the legacy of an Irish former boyfriend. Her work in Sweden had focused on accident victims, people who had attempted suicide, and other long-term counselling. Here at Maternité Solidarité, her role is to supervise two young Haitian counsellors, Djénane Jean-Charles and Delano Jean, in supporting women who have lost their babies or experienced a traumatic delivery.
“What we do here is talk the women through what has happened and their thoughts and feelings about it. Putting words to what has happened is often a great relief to people. Sometimes there are things they just don’t know about, like how preeclampsia works, and we can explain it to them and increase their understanding.” Osvaldsson admits it’s not something that comes naturally to many of the patients. “We are caring for a group of people who have a low level of education; they are living in slums and they’re not used to being taken care of. They are not used to people asking them a lot of questions about their private lives, especially if you are a white person. So many of them are reluctant to talk about their feelings, though they are very open in other ways; they are friendly and happy to talk to you, and they will share a lot of things, but there is a clear limit, and we have to work around that to create a feeling of safety and confidence. It’s about respecting the limits of the patient. It’s an intricate process that happens between two people. If they feel I am responding in a good way to what they’re saying, then they feel they can trust me and take more risks.”
While some of the patients speak French, Creole is their first language, and here Osvaldsson has to lean on her Haitian colleagues. “I rely very much on Delano and Djénane, because they can pick up on all of the subtle signals that I don’t understand. There are signals during a consultation that come down to when we should move on, and when we should press.” She’s also aware of the dangers of criticizing local practices, even if they have potentially dangerous consequences. For example, many women use herbal concoctions during pregnancy that may be harmful to the baby. “I’m not very well versed in the culture of Haiti, so I need help from Delano and Djénane to explain this to them in a way that is not going to offend them. It’s difficult to have that discussion if you are a foreigner, because they see you as someone from the outside who doesn’t belong here, and now you are telling them they shouldn’t do this, which is their culture.”
Other cultural differences are more troubling. “I have had women say that their husband shot at them, and they are talking to us about what they can do to keep the marriage together. I’m not sure that many women in Sweden, if their husband was shooting at them, would spend time thinking about how they were going to make the relationship work.” Sometimes women are abandoned by their husband when a baby dies, leaving them to grieve the loss of a child and a marriage. Osvaldsson’s patients have also included children of children: the youngest mother she’s counselled was 11 years old.
Osvaldsson admits these girls and women need more than counselling. “In the slums I would like to give them clean water, sewage, housing and jobs. What am I doing talking to women? But I know we are helping people here. I know we are giving them something, relieving something that hurts. You can make a connection with patients.”
When Jude Anne opened in Port-au-Prince, MSF was already working in other parts of what was then a brutally violent city. After president Jean-Bertrand Aristide was exiled following a coup in 2004, the UN deployed a Brazilian-led peacekeeping force deployed to stabilize the country. With some 7,000 troops and 2,000 police on the ground, the Mission des Nations Unies pour la stabilisation en Haïti (MINUSTAH) has been fraught with controversy from the beginning, with many Haitians accusing the soldiers of massacring civilians during their crackdowns on gang activity, particularly in Cité Soleil, a notorious slum in Port-au-Prince. Between December 2004 and April 2005, almost a third of the patients admitted to MSF’s three medical centers in the capital were treated for gunshot or machete wounds.
It took two years to finally hold the election that would choose Aristide’s successor. In February 2006, voters elected René Préval as their new president, and the situation cooled off briefly. But violence in the capital resumed that summer, and in July MSF treated more than 200 gunshot victims. MINUSTAH and the Haitian police finally managed to get the area under control by early 2007, and in December of that year MSF handed over its hospital in Cité Soleil to local authorities. The organization started discussing whether it was time to wind down its other Haiti projects and move on.
But a series of events conspired to keep MSF in the country. When the price of beans, rice, fruit and other staples skyrocketed in early 2008, the desperately hungry population resorted to eating sun-baked cookies made from mud. The food crisis came to a head in April, and thousands of Haitians rioted in the streets, burning tires, looting stores and exchanging gunfire with UN troops. A doctor in Martissant, a slum neighborhood in the capital where the Belgian section of MSF runs an emergency hospital, said it was difficult to go anywhere without having stones thrown at you by angry mobs. In September, hurricanes Gustav, Hanna and Ike hammered the northwestern coastal city of Gonaïves, causing flooding and mudslides that killed more than 800 people. Then, on November 7, a three-story school in Pétionville collapsed, crushing at least 90 people to death, many of them children. About half the survivors were treated at Martissant and at Trinité Trauma Center, another MSF hospital in the capital.
The flooding in Gonaïves was an opportunity for MSF to get involved in the kind of work its adrenaline junkies thrive on. When the disaster happened, Massimiliano Cosci had just begun his job as head of mission for MSF-Belgium, whose Martissant hospital was then handling some 8,000 patients a month. Cosci, an Italian with nine years of MSF experience, has worked in some pressure cookers, including the Second Liberian Civil War and in South Sudan, where he was once trapped in a small plane as a rebel soldier leveled a Kalashnikov at the pilot. Here in Port-au-Prince, he found his role as head of mission — MSF’s top administrative position in the field — decidedly less exciting. “To be in the office writing reports and making telephone calls…” His voice trails off and he shakes his head. “Then, three weeks after I got here, there was the emergency in Gonaïves, and I jumped into a helicopter and I was in the middle of the mess again. It was great. That’s what I like.”
With a team of seven others, Cosci arrived to find about 80 percent of the town under several feet of water. “The people were living on the roofs. We could not reach most of the town because there was too much water, and we could not go with the car, so we used the helicopter.” MSF organized three lines of intervention. First, they sent mobile clinics (small, lightly equipped medical teams that travel from place to place) to reach the people trapped by the flood waters. They also provided clean drinking water for over 150,000 people to help prevent diseases related to flooding, such as cholera. Finally, they set about building a new hospital to replace the one that had been completely destroyed. “We took an old factory that was about six thousand square meters and built walls inside with wood and plastic sheeting, and we turned it into a hospital with surgery, pediatrics, outpatient department and emergency room.” The water took weeks to completely recede from the town, and it left behind a sea of mud, but at the end of 2008, MSF handed over the hospital to the Ministry of Health.
While there’s no questioning Cosci’s compassion for the populations he’s worked among, he fully admits he loves being in the middle of the action. “When I go back to Italy now, my friends are all married with kids, so my problems are so far from theirs. They say, ‘Max, you do all of these exciting things, but I always do the same job and nothing ever changes in my life.’ And I say, ‘It’s true, nothing changes in your life, but you have created a family, you have stability and this is what I don’t have.’ But I’m not jealous of them, otherwise I would not do this job. I don’t need the stability in my life — I cannot stand stability. It’s something that scares me more than a bombardment. So I think this is one of the reasons why I am still with MSF, because MSF is feeding me exactly what I need.”
Like most MSF veterans, Cosci has many quibbles with the organization, but even after nine years he insists they are the most “clean and honest” NGO, especially when it comes to responsible spending. He was in charge of the €2.6 million the organization budgeted for the five-month intervention in Gonaïves, and when he prepared the financial statements, only €9,500 — that’s 0.36 percent of the budget — was unaccounted for. Cosci says the shortfall was almost entirely due to the team simply forgetting to record perfectly legitimate expenses, but headquarters in Brussels was angry with him for the lapse. “That is the way it should be. This is what I love about MSF.”
As a humanitarian aid group that concentrates on life-saving work, MSF never wants its projects to endure for long. Many do last for years, of course, often because the populations would have nowhere else to turn if MSF were to leave. But famines end, wars are settled and normality usually returns. When that happens, countries need a functioning, locally managed health system, and that process is something MSF is simply unable to provide. With the brutal violence in Port-au-Prince finally under control, for example, MSF’s Trinité Trauma Center entered what the aid community calls the “transitional phase.” The situation was no longer an acute emergency, but the Haitian government was clearly unwilling or unable to maintain the same quality of care that MSF provides. Patients were still coming to Trinité instead of public hospitals that should have been able to care for them, a situation that makes MSF the de facto health ministry. But if the organization were to leave to deploy its resources in other parts of the world, what would they leave behind?
Reflecting on the situation in the spring of 2009, Brian Phillip Möller admits he’s frustrated. Looking tired in his office at Trinité as a generator rumbles outside the window, the head of mission for MSF-France says the string of disasters — both real and perceived — seems ongoing. While he hopes to turn the hospital over to the government or another NGO by the end of 2010, he doesn’t expect the handover to go smoothly. “There is always going to be something. This year in Port-au-Prince, I find there is a great deal of alarmism, especially since we announced our closure. You will hear things like, ‘The Carnival is always violent, there will be thousands of people in the streets, there are going to be knives and guns, there’s going to be sixty dead and hundreds of wounded!’ And in the Carnival that has just passed? One person died, and all of the wounded were treated immediately on site, no problem. Then April arrived and it was, ‘Senate elections, it’s going to be a disaster!’ So we prepared, and practically nothing happened. Some problems in the provinces, but the big catastrophe and violence that people were expecting just didn’t appear. Now people are talking about hurricane season again. Once we start preparing for things that may or may not happen, then I think it’s time to question our relevance and our impact.”
Möller is not suggesting that the medical needs in Port-au-Prince are no longer pressing; a walk through Trinité quickly puts that notion to rest. In the post-op area, a group of patients recuperates from badly broken bones — one is in traction, with a sand-filled bleach bottle serving as the weight — while in the burn unit a little boy lies face down, exposing a grotesque wound on his buttocks. It’s an upsetting scene, but it’s also a common sight in any trauma hospital, and not an indicator of an acute crisis. Möller, a New Zealander who trained as a trauma nurse, did an earlier mission in Haiti in 2006 during the height of the violence, and things were radically different. “It was really hot then; we were looking at a situation that was practically civil war. Teams were working seven days a week, twenty-four hours a day. But things are a lot calmer now, so our work has changed. Now violence comprises about twenty percent of the work. Most of the surgery we are doing now is for domestic and industrial accidents, followed closely by road accidents. We’re doing a lot of stuff that is necessary, but it’s not really our mandate. About eighty-five percent of the cases that present to our emergency room get ambulatory treatment; they have their wounds sutured and dressed, and then they leave. So most of the work is not life-saving, and it could be done at any small clinic. But they come to us for two reasons: because the quality is good, and because it’s free.”
A similar debate is happening at Maternité Solidarité, where Soins Obstétriques Gratuits, the program to provide free maternal care, promises to allow MSF to wind down its operations and turn things over to the government. The organization hopes the city won’t need a hospital for obstetric emergencies if the public hospitals can handle these cases as their capacity improves. But the team knows they will have to hand over the responsibility gradually. As one of them says, “To just close the project down at the end of 2010 would be criminal.”
Brian Phillip Möller has the same concerns. “If you take the three MSF sections here in Port-au-Prince — the Belgians, the Dutch and the French — we have a combined budget of about fifteen million euro per year, and if you put it all together we’re running what amounts to a large public general hospital. For us it’s no longer tenable.” But it’s also clear that the people don’t want MSF to leave. “When we announced our closure, there were threats to block the road to the airport: they said they’d create a catastrophe so we would have to stay. MSF is well known, well liked and well respected here, and for sure, when we leave we are going to leave behind a vacuum. If we leave next year, what we going to do with these patients? Where will they go?”
Möller’s voice takes on an edge as he describes one the patients at his health center. “She’s a 26-year-old quadriplegic who needs two hourly turns, constant toileting, ongoing care, and her only caregiver is an aunt who is seventy-five and has just been diagnosed with liver cancer. The aunt has been given to the end of the year to live, and when she dies, this young woman will have no one. She is currently living in the slums, in a shack, sitting on a cardboard box. It’s tragic. I hope we will find solutions for these people.”