Haiti Earthquake, January 2010

Haiti suffered a massive 7.0 magnitude earthquake on January 12, 2010. Below is expert commentary by Dr. Irwin Redlener.

As Haiti recovers, give children special attention

Published in USA Today, February 10, 2010

Given the extraordinary destruction wrought by last month’s earthquake in Haiti, few will be surprised if this catastrophe is recorded as one of the deadliest natural disasters in recent history. But what is not well appreciated is that this disaster could disproportionately impact children, not only those who perished in the initial shocks but also those who will not survive what is likely to be a cruel aftermath.

Before the quake, as many as 380,000 children living in shelters were placed there out of economic desperation; families could not afford to care for them. Now, many more children displaced by the earthquake will literally have no surviving family members, further swelling demand on social service agencies throughout the country.

Kids at risk
As the U.S. and other countries plan to help Haiti get back on its feet, emphasis should be placed on enhancing that nation’s resiliency, which will mean dealing with the needs of its children. The unusual extent of child casualties will be driven by several factors:

About 50% of the Haitian population of 9 million is younger than 18. Even more striking is the fact that children 14 years of age and less make up more than 38%.
Everything about a natural disaster puts children at greater risk. A comparatively small chunk of dislodged ceiling would injure an adult, but it might well kill an infant or small child. Water deprivation will lead far more rapidly to dehydration and shock in an infant than it would in an adult.
Some seriously injured children have survived the initial trauma because they were among the few to get surgical attention provided by international medical teams. But, access to follow-up care could be an overwhelming challenge. Compounding concerns, the Ministry of Health at one point asked physicians not to provide medical care that can’t be sustained in Haiti.

Long-term needs
Between 1 million to 2 million Haitians will be “displaced” for the foreseeable future. This means a minimum of 400,000 to 800,000 children will be in temporary shelters for months or years. But the rainy season is coming in May, followed by hurricane season in June. Families in tents or other flimsy shelters will be at grave risk.

What about the psychological impact? Grieving over loss and trauma carries the potential for long-term consequences for every Haitian, especially the countless children.

Then, Haiti’s chronic problems must be addressed head-on. For decades, Haitians have experienced a seemingly intractable state of poverty, accompanied by malnutrition and high rates of acute and chronic illness. More than 50% of Haitians live on less than a dollar a day, and more than 60% of its young children have nutritional anemia.

Despite the efforts of international agencies and non-governmental organizations, chronic illness abounds, and access to clean water, medical care, and sanitation remains a significant challenge for Haitians, particularly children.

This is why the recovery and rebuilding of this fragile nation must begin and end with a central focus on the immediate and long-term needs of children. If there is to be a glimmer of hope for Haiti, it will be because the international community understands that the capacity to rise from the ashes of catastrophe is directly related to the health, well-being, and potential of its youngest generation.

Beyond Search and Rescue

Posted January 25, 2010

Key Messages:

One Million Haitians Displaced by Disaster, Three Million Affected; Children at Extreme Risk
Extraordinary Disconnects Remain Between the Scale of Disaster and the Resources Available
Consequences of Profound, Pre-Existing Poverty on Impact of Earthquake Will Undermine Relief and Recovery Efforts

Thirteen days after the 7.0 quake that devastated Port-au-Prince and the surrounding region, the initial phase of “search and rescue” is clearly over. That is not to say that the occasional “miracle survivor” will not be pulled from the rubble, but those situations will be rare and random. Reports are that the medical situation for adults and children remains horrendous in spite of the large numbers of physicians now in the country.

Most striking – and insufficiently reported on – are the disconnects between the scale of the disaster and the combined resources that have been brought to bear from around the world.

With hundreds of thousands of people buried, some alive, under the wreckage of Port-au-Prince and surrounding communities, as of January 22 (ten days following the earthquake), only 132 people had actually been rescued by all urban search and rescue teams – including thousands of rescue specialists – sent from the U.S. and many other countries around the world.
With the vast majority of rescue and relief efforts being focused on Port-au-Prince, assessments of damage and casualties in outlying areas of Haiti affected by the earthquake are just beginning. These areas include Jacmel, Petit Goave, and other communities.
Medical treatment—including surgery—provided by all nations and agencies may account for a small percentage of total need.
Resource to care for and provide nutrition, vaccinations, mental health support, and needed medical care for some 400,000 children among the surviving one million displaced persons is not currently imaginable under current conditions.

Here are current principle concerns that must be addressed simultaneously:

Extraction of bodies and clearance of rubble need to proceed rapidly. “Rescue” from the rubble is now over. Every effort to identify victims must be made, and clearance of rubble will help open roadways and establish venues for survivors to get care and support. These venues may be in or near the Capital or even in the neighboring Dominican Republic.
Establishment of safe, temporary locations for survivors who are now “internally displaced persons” within Haiti. These locations will need to focus on security, nutrition, safe water, sanitation, health care, daycare, mental health support, and resumption of education for children.
Supply and distribution logistics need to be better coordinated and managed. Materials headed to Haiti via ship, air transport and overland from the DR are now in abundance from a massive multi-national, international effort. Backlogs of needed supplies at the airport and other staging centers must be rapidly and effectively distributed wherever needed.
Coordination of international relief efforts remains challenging at every level, though maximizing the role of the Haitian government is essential, even as it is still trying to regain its footing and control. Physical destruction of the Capital adds to a sense of social and political uncertainty, which must be addressed rapidly while understanding that getting vital supplies to survivors is of paramount importance.
Appropriate medical care will mean the difference between life and death for hundreds of thousands of Haitian survivors going forward. The immediate death toll from earthquake trauma is still unknown, though estimates range from 150,000 to 300,000 early fatalities. Almost all survivors will need medical attention, including care for ongoing chronic conditions, emotional trauma, vaccinations, and so forth. At the more serious end of the medical care spectrum will be care for non-fatal injuries sustained during the initial days of the disaster, including persistent wound infections, poorly managed or unmanaged orthopedic injuries, or other surgical or advanced medical conditions.
Effective public health practices, already visible throughout the effective region, include ensuring safe water, stabilizing food supplies, immunization programs, and monitoring for water-born and other post-disaster related issues. Few of these programs are up to speed in relationship to the sheer scale of the challenges being faced at the moment, nor do they seem to be necessarily organized for the growing problems likely to be seen in the weeks and months to come.
Appropriate sheltering of survivors is one of the most daunting challenges to be faced in the coming weeks. Providing safe shelter for 1 million displaced individuals in a disaster-devastated country that had already been among the poorest in the world is an overwhelming challenge. Temporary camps must be developed that can withstand persistent aftershocks and provide a sense of general stability, access to vital services, security, school and social service access, and other basic staples. Significant rains are possible in Haiti from late April through July, coinciding with the onset of “hurricane season.” Flooding, mudslides, and substantial storms are, therefore, serious threats to earthquake survivors in the spring and summer. Rapidly developing sufficient numbers of appropriate shelters or safe, permanent housing is an extremely high priority for Haiti and the international relief community.

Given the enormous amount of work being done on all fronts, at least ten large—almost imponderable—issues will continue to dominate strategies, short—and long-term, as Haiti and the international community do whatever is needed to create a functional and resilient health care system.

Who is in charge of resource allocation and development of recovery strategies especially around health care and public health needs?

Logistic and operational capacities are both limited and bottle-necked, so how will priorities be determined with respect to focus on survival needs (safe water, food) vs. on going attempts at further rescue?

How long will international resources be available to continue providing food, water and shelter to a totally impoverished nation that has just experienced one of the worst disasters in modern memory?

How long and how open-ended is the U.S. commitment to these efforts, and at what level?

How will secure housing be developed for 1 million internally displaced Haitians?

How and where will Haitian adults and children that have received life-saving surgical care be followed-up?

How will primary health care be provided long-term to surviving Haitians?

How will the health, well-being and safety of Haitian children (orphaned and non-orphaned) be secured?

Will the international community assist in assuring an acceptably stable public health system in Haiti?

What lessons will be taken from this megadisaster to make sure everything possible is done to help resource poor nations develop the infrastructure, economic stability and resiliency necessary to mitigate great disasters likely to strike anywhere in the years to come?

Earthquake in Haiti Will Be An Unprecedented Catastrophe For World’s 4th Poorest Nation: Coordinated, Phased International Response Critical to Maximizing Survival in Days and Weeks To Come

Posted January 13, 2010

The full effects of a massive 7.0 earthquake focused on Port-au-Prince in Haiti are still undetermined although fatality rates well in excess of 100,000 are likely given the extent of the catastrophe and the widespread destruction of buildings throughout the Capital.

Two factors will exacerbate the consequences of the disaster and have the potential to push fatality rates to unprecedented levels:

First, the wholesale destruction of infrastructure, particularly health care facilities, will markedly affect Haiti’s ability to treat survivors, even with a significant influx of external aid from the international community. Loss of electricity, water, sanitation and transportation capacity will significantly hamper rescue and response efforts, as well.

Second, profound pre-existing poverty and deprivation in Haiti that have been the nation’s reality for decades pose special levels of population risk that exacerbate the consequences of a major disaster. Some 80% of Haiti’s population live in poverty and the nation’s economic capacity is extremely limited. Malnutrition and chronic diseases are rampant. This translates into much higher pre-disaster risk and diminished ability to withstand acute shortages of food, water and medical care.

Response phases to a disaster of this magnitude are as follows:

Search and rescue with provision of life-saving emergency medical care, including major surgical intervention when necessary.

Control of social order.

Shelter, nutrition and general care for all survivors.

Assurance of clean water and food for survivors and responders.

Prevention and management of secondary injury related to dangers consequent to massive rubble accumulation, downed power-lines and other factors.

Control of public health hazards and infection.

Recovery

It should be noted that these phases will overlap, of course, with multiple response fronts open simultaneously.

Initial Medical Challenges will be overwhelming. Individuals with severe head and chest injuries are highly acute emergencies. Timeliness of care could not be more important, but quality of medical and surgical response is also critical. Crush injuries also must be treated rapidly to avoid kidney failure from release of toxic proteins from damaged muscles. Prevention and control of wound infection will be substantial objectives of initial care.

Coordination of Responders is a challenge in every large-scale disaster – and will be critical in Haiti. Mobilization of assets from governments around the world, the United Nations and a large number of international and national relief organizations, individual volunteers and enormous outpouring of materials is inevitably chaotic. The more these multiple independent assets can be coordinated, the more effective will be the distribution and deployment of efforts to save lives. Who and how these efforts will be coordinated is unclear at this time.

Recovery will be a painful and very prolonged task that will likely require years of work in every sector. As with any major disaster recovery, it is hoped that the goal will be to “rebuild better” in ways that may give some hope of improved conditions, enhanced infrastructure and economic opportunity for survivors.

Mental health challenges in Haiti will be extraordinary. Terrible loss, social disruption and persistent fear for personal safety, condition of loved ones and future uncertainty will fuel acute and chronic emotional stress and, eventually, post-traumatic stress for survivors. Children may be particularly affected.

Individuals providing rescue and relief in the short term and ongoing will themselves be subject to severe emotional stress and PTSD. Furthermore rescuers and responders in all sectors will also be exposed to physical, hazard-related dangers as well as risk from infection or other public health concerns.

All of these issues must be addressed preemptively and effectively as part of the immediate recovery efforts.

Children will be a particular risk throughout all phases of the response and recovery. They are more at risk from serious trauma, dehydration, shock, and infections than adults tend to be – particularly in a chronically undernourished state. Children are also less able to avoid hazards and require adult protection, which may or may not be available. Children are also prone to significant emotional trauma – short and long-term – which will need to be managed as swiftly as possible under the circumstances.

Children also require specialized medical providers to manage emergency, surgical, post-operative, and long-term care needs. Such providers were virtually non-existent in Haiti prior to the disaster and are not likely to be significant components of incoming response teams.

U.S. Response is extensive and comprehensive. President Obama’s statement, as well as subsequent statements from the Department of State, Department of Defense and U.S. AID make it clear that this country will mount an extensive, highly coordinated and on-going effort to assist in the disaster response. Much of what will actually be done by American governmental organizations will have been informed by mistakes and missteps in the response to previous disasters, including the 2005 Hurricane Katrina response efforts in the Gulf region. Although agencies responding to international disasters differ from lead organizations working on response to domestic catastrophes, it does suggest the possibility of more effective response to domestic disasters in the future.

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