©, Haiti, 2010

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE:

CHOICES, OBSTACLES, ACTIVITIES AND FINANCE

Issued in July 2010, six months after the earthquake on 12 January.
Covers the reporting period up to 31 May.

Published by
Médecins Sans Frontières
July 2010www.msf.org

Médecins Sans Frontières is an international humanitarian organisationthat brings emergency medical care to populations in over 60 countries.

2

EMERGENCY RESPONSE AFTER
THE HAITI EARTHQUAKE
contents

Executive Summary

5

Introduction: One Million Under Canvas

6

A History of Vulnerability

9

Day Zero11

Emergency Choices

13

Work and Witness

17•

Surgery and Rehabilitation

17•

Primary Health Care

19•

Specialised Services

20•

Water, Sanitation and Shelter

22

At a glance: MSF Assistance in Figures

25

Donations and Spending

26

Future Plans

29

Annex: Overview of Locations and Activities

31

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 3

© Julie Rémy

4

EXECUTIVE SUMMARY
Six months after the earthquake that devastated Haiti on 12th January 2010, this report describes the evolution of MSF’s work during what is the organisation’s largest ever rapid emergency response. It attempts to
explain the scope of the medical and material aid provided to Haiti by MSF since the catastrophe, but also to
set out the considerable challenges and dilemmas faced by the organisation. It acknowledges that whilst theoverall relief effort has kept many people alive, it is still not easing some of their greatest suffering.
MSF had been working continuously in Haiti for 19 years prior to the earthquake, providing a wide range of
medical care from maternity services to physiotherapy and mental health programmes. From this long term
involvement, the organisation knew that the health system was out of reach for the majority of Haitians. There
was a lack of trained medical staff across many disciplines, from physiotherapy to psychiatry. The country was
totally ill-prepared to deal with the medical consequences of such a calamitous natural disaster.
The earthquake destroyed 60 per cent of the existing health facilities and 10 per cent of medical staff were
either killed or left the country. MSF had to relocate services to other facilities, build container hospitals, work
under temporary shelters, and even set up an inflatable hospital. With over 3000 Haitian and international staff
working in the country, MSF currently manages 19 health facilities and has over 1000 beds available at various
locations. The organisation has provided emergency medical care to more than 173,000 patients between
January 12th and May 31st.
MSF was overwhelmed by the generosity of people around the world providing financial support for theorganisation’s response in Haiti. By the end of May, MSF had received over 91 million euros specifically for
emergency relief there. Well over half of this money – some 53 million euros – was already spent in the first
five months following the disaster. Our current budgets foresee that around 89 million euros will have beenspent on direct assistance to the earthquake victims by the end of 2010.
Six months on, the medical provision for the majority of citizens has been significantly improved in general andsome poor people who were unable to access healthcare prior to the disaster are now able to recieve care.
However, the sustainability of this situation depends on continuing international commitment and the questionof ensuring quality remains. Shelter remains the most urgent need, with reconstruction moving at a very slow
pace and the rainy season compounding the misery. Poor Haitian people are entirely used to limited comfort
and resources but MSF staff there report that frustration and anger are rising because too little has changed in
the living conditions since the quake.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 5

© Kadir van Lohuizen/Noor

Introduction: One Million Under Canvas
The disaster in Haiti was such an intense blow toa poor and densely packed urban population thatit presented new challenges of scale and complexity on every level for the relief effort. Although
MSF was in the country before the earthquake
hit, the organisation was stretched to its limits by
the urgency and extent of the medical needs. The
organisation’s financial resources were generously
augmented by millions of individual donors, but
the sudden pressure on its medical, technical andmanagerial staff was unprecedented.
The report sets out the ways in which those people, the Haitian and international staff, struggled
to answer the challenges thrown up by the earthquake. They know that the response could neverbe sufficient, that even the core medical action in
the early days was overwhelmed by the suffering.
And that the wider need of the Haitian people forthe restoration of some dignity and hope to theirlives has been painfully slow to be realised.

6

The dust laid down by the thousands of buildingsthat were crumpled and split by the huge tremors
in January has now been washed into pools andgulleys in the streets of Port-au-Prince. The rainsthat were the next threat to the survivors havebeen falling for weeks and the predictable miseryfor the hundreds of thousands without homes is
now relentless. And it will likely get worse as whatis expected to be a bad hurricane season looms
on the horizon.
Many people who escaped from the falling buildings six months ago are still too afraid to seek shelter in the ruins. They remember the after-shocks
and have heard the scientific gossip about more
quakes to come. They huddle under the flimsiest tarpaulin or tent, chase and recover themwhen they get blown away, and stay with their
new neighbours in the straggling city settlements.
From the air, Port-au-Prince has ragged lakes of
tarpaulin blue. There is protection against the sunand showers but not tropical downpours or cy-

clones. The relief effort has kept the people alive
but it is not easing some of their greatest suffering. The conditions of life are raw and levels offrustration are increasing.
The level of violence in Port-au-Prince is a permanent concern. Before the earthquake, MSF wastreating people with bullet wounds and victims ofsexual violence in Martissant and Trinité. Beyond
these important medical needs, the generalised
insecurity requires special attention. However,
MSF’s medical data do not show an increase in
the number of victims of violence after the earthquake. The overall figures for five months show
2,147 patients treated for violence related trauma
and another 264 for gunshot wounds.
HealthToday, the medical provision for the majority of
the citizens has been substantially improved since
the quake and in some respects is better than
before it. Numbers of poor people who before
the disaster were effectively excluded from thepublic and private systems are now able to get
attention. The range of medical care in new, temporary structures and in some of the surviving
hospitals and clinics is substantially greater andnearer to the people, although issues of quality
remain. The concern is that so much of this depends on a continuing international commitment
and there are real questions about its sustainability. The Ministry of Health has a plan for the next
18 months that has free care for some vulnerable
groups at its core. But all this needs external funding and the reconstruction of lasting facilities. The
private sector, which has always been significant
in Haiti, was badly hit too and is struggling to recover. The other constraint is the lack of trained
professionals. The earthquake destroyed 60 per
cent of the health facilities and 10 per cent of the
medical staff were either killed or left the country.
Haiti has always exported talent and those who
survived the quake are still heading abroad.
Food and water
The availability of food and water has also improved substantially since the quake, although formost people it is still less secure than in their lives
before. The massive World Food Programme
distributions were effective and although there isconcern whether they reach all of the most vulnerable groups in the communities, MSF has notseen evidence of growing malnutrition. The water issue is less clear because the free distribution
in the first three months has been changed to acharge system, which complicates non-charging
relief distributions like MSF’s and puts a strain on
so many people without jobs and income. The
concern here is that this is not something that
MSF specialises in, it is not a core medical activity and the organisation’s resources are being
stretched because of the lack of response fromother providers.
Sanitation and shelter
Similar concerns apply even more forcefully tothe sectors of sanitation and shelter. In sanitation provision there have been improvements
since the dire conditions shortly after the quake,but in some communities like Cité Soleil or thecamps of Carrefour Feuilles, MSF is one of very
few organisations with a presence. MSF is playing
a role with latrines, waste disposal and hygiene
provision in many other parts of the earthquake
affected area, which often goes well beyond thestandard work at the medical facility and the surrounding community. At the same time there are
big challenges that are not being resolved by thewider relief and reconstruction effort. There isjust one waste dump for the city, which is full to
overflowing. No alternative has been decided on
and the rainy season is compounding the problems of access and pollution. Large parts of thecity are at sea level, so latrines should be emptied very regularly. They are not. In the camps,
the inadequate provision adds to the likelihoodthat heavy rains will wash sewage through theliving areas.
By far the biggest threat to people’s living conditions is the failure to provide any substantial, robust shelter. Sheeting and tents were never anything more than a very temporary solution. They
have a life expectancy of around six months. MSF

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 7© , Haiti, 2010

Never enough
MSF has focussed a very substantial part of its global resources on Haiti in the last six months. The
peak of that emergency phase activity was aroundthe two-months mark, when some 350 international staff were working there. They were needed
because it took longer than usual to find and recruit
all of the Haitian staff to run the massively expanded
medical projects. At its peak in March there were 26
separate facilities – a number that included hospitals,
rehabilitation centers, and general medical centers.

8

Following the consolidation of some of these facilities and a shift in priorities, MSF now manages 19
health structures. MSF also runs 16 operating theatres and has more than 1100 beds available at its various locations. Overall, since the earthquake and up
to 31 May, MSF has provided medical care to morethan 173,000 patients and performed over 11,000
surgical operations.
This report records some of the thinking that went
into choices made around strategy and deployments. It contains testimony from staff and patients
who have seen the different faces of MSF’s work.
It sets out the ways in which MSF is spending thegenerous donations it received from so many people around the world and it sketches some of theways that the organisation is committing itself to the
future of medical action in Haiti. But first, this report
looks at the past, the long history of MSF in Haiti andwhat it tells us about the fragile condition of everything even before the disaster.

© Julie Rémy

itself distributed significant quantities of tents but
some form of reconstruction should have begun inJune and July so that people would then be able tomove into at least semi-permanent shelters. Verylittle of this has happened. Decisions about land allocation have been very slow. The tents are starting
to deteriorate and the rain is exposing the problem.
Even without a hurricane, the wet season will beenough by itself to complete the misery of the people caught in the open.

A History of Vulnerability
When MSF began its continuous presence in Haiti in 1991, the emphasis was largely on rehabilitation of hospitals
and health facilities that were crumbling and unsanitary. The work was accompanied by training for surgeons andanaesthetists. There was some direct medical action through surgery and a considerable amount of water andsanitation provision around the hospitals but the majority of MSF’s engagement was in supporting a very underresourced and fragile health system. There were also periodic emergency responses to floods and hurricanes.
That began to shift after 2000 when the first attempts started to reduce maternal mortality in one of the healthdistricts. This marked the beginning of what has been an ongoing commitment to maternity and obstetric care.
But the big evolution of MSF’s work happened as the country descended into political turmoil and violence in the
middle of the decade.
In 2004, MSF opened a surgical project in Port-au-Prince that is still running in a new setting of Trinite Trauma
Centre, the only comprehensive emergency treatment facility in the country. Wound treatment became vital for aconstant stream of casualties from street fighting. MSF was located at the heart of the violence in the capital whenother organisations had left. Between 2005 and 2007, MSF worked in Choscal hospital in the slum of Cité Soleil
as fighting went on between armed gangs and the UN peacekeeping forces. The lack of emergency care in the
public health sector and the surge in violence led to the establishment in 2006 of the Martissant emergency roomand mobile clinics in that slum area of the capital. In the following year, MSF increased its capacity to work with thevictims of sexual violence when it opened the Pacot Centre. That facility also provided rehabilitation with physiotherapy and psychological care.
At the same time, extreme levels of maternal mortality combined with frequent sexual violence brought MSF todeliver emergency obstetric services in the Jude Anne hospital in Port-au-Prince and later on in Maternite Solidarite. New peri-natal services were also started, along with voluntary testing and counselling for HIV.
And Haiti’s frail infrastructure is constantly exposed to savage natural disasters. In 2008, the northern city of Gonaives was flooded by a hurricane and MSF worked there for several months in an 80-bed hospital and running mobile
clinics in the camps where people had to subsist in temporary shelters.
The main lesson of those 19 years work in the country was that for the majority of Haitians, the health system wasalmost out of reach. In Port-au-Prince, many of the poor have been highly dependent on MSF’s free emergency
services. Fees charged by the public and private health facilities made care unaffordable for most people. Public
hospitals and clinics were often plagued by management problems, strikes and shortages of staff, drug and medical
supplies. Patients could be turned away because the hospitals were full and they had to abandon treatment when
they ran out of money.
One of the clearest statistical indicators of this poverty of care is in the life expectancy for women. It is estimatedat 58.8 years. And with maternal mortality at 630 deaths per 100,000 – 50 times the rate in the United States nextdoor – giving birth can be more than hazardous.
The shocking truth of MSF’s experience as a major medical and humanitarian organisation in Haiti is that even
without the risk of violence, Haiti’s people are exposed to life threatening suffering and neglect. The country could
hardly have been less well-placed to deal with the huge additional demands that a natural catastrophe would placeon its medical resources.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 9© , Haiti, 2010

© Julie Rémy

10

Day Zero

Dr Hans Boucher, the Haitian medical director
at MSF’s Maternite Solidarite Hospital in Portau-Prince, was one of the first to respond to thequake.
“I was in my office when the computer screen suddenly
fell to the ground. All of sudden I saw the building shake.
When I got outside, I saw the walls crumble, crushing carsin the courtyard and that’s when I understood the wholebuilding was collapsing. I noticed then that a lot of people
were lying on the ground. So I called another doctor over,and both of us went over to check on these people lying
on the road. That’s when we realised they were all dead.
They were the street vendors who were working in front of
the hospital grounds. Then I went back into the hospital
to evacuate the other patients. 70 or 80 patients needed
to be evacuated so we got them all out – it took us one
hour and a half to get all the patients evacuated from thebuilding.
We had them lie down on mats in front of the hospitalwhere the logisticians had quickly set up three tents toshelter the patients. We treated the injured who arrived
at the hospital gate. We spent the entire night treating
people, bandaging them, we were working as quickly as
possible because there were so many injured people in thefront courtyard of the hospital.
When I realised what was happening, the first thoughtthat crossed my mind was that my children must be
dead, because at the time of the earthquake (5 pm) mychildren are usually home. I was wondering if I had thecourage to go home to find out what had happened tothem. There was no way to reach them because all thephone lines were down. So I had to make a choice at thatpoint: I could stay and help the injured who were pouring
into the hospital compound or go home not knowing who
I would find.
The event was so intense, I cannot say I was not thinkingof my family, but we saw so many injured people arriving
at the hospital that we had to care for them. Fortunately,around 7 pm, a colleague came to inform me that he hadseen my wife and children and that they were alive andokay. So I continued to work until midnight, and then I
went home to check up on my family. A few hours later
I went back to the hospital where I continued to care forthe patients and with my colleagues. We spent the night
keeping an eye on them, knowing that tomorrow would be
the beginning of much more medical work to treat those
who had been wounded.“

Dr Hani Fares was in his MSF office, without any
medical facilities, in another part of town. He is asurgeon and a medical coordinator for MSF.
“For a whole minute it felt like the ground was moving onwater. I was alone in the office, and I think the first thing
in my head was that it had to be an earthquake. Maybe
it’s because I’m Egyptian, and we had an earthquake in
Cairo in 1992, so I recognised the feeling. So I got myself
out of the office fast and went outside, where I found theother staff.
People began to arrive on foot at the office, more andmore of them, and I had to decide what to do with themall. That’s when I first heard the rumour that many of
the hospitals in Port-au-Prince had collapsed. We started
to get the picture, and realise: yes, it’s big; in fact it’s acatastrophe.
My problem was that I didn’t have any drugs to give them.
But I went next door and found some boxes with justenough drugs in there to help me, and I took them backto the office.
Then I started to see patients, pregnant women with a lotof fractures; serious wounds; head trauma; open fractures.
Initially I covered the wounds with antibiotics, and gave thepatients painkillers to relieve the pain - I had found some
injectable diazepam and morphine and antibiotics in thebox of drugs. The Haitian colleagues were an enormous
help to me. During those first two hours, they were really fantastic: they were all afraid, and worried about theirchildren and families, and yet not one of them left – all ofthem stayed and helped me.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 11

I think we had eight people who died. Most of them there
were serious head trauma cases. One frustration was when
there were cases of subdural hematoma – when blood pools
under the scalp. With a small machine you can make a holein the bone to let the blood out and save the patient, but I
didn’t have the machine.

12© Julie Rémy

I’m a surgeon, so there were a lot of things I was able todo, and a lot of patients I could save, but afterwards I kept
asking myself whether perhaps there was more I could havedone. Maybe I could have saved some limbs. But then I think,
I simply didn’t have the time. When we went outside, anddown into Port-au-Prince, we found a dead city. There werelots of collapsed houses, cables fallen down, streets blocked,
and then hundreds of people, all sleeping outside. Some ofthem were praying, or singing, others were crying.”

Emergency Choices
As those first terrible hours were unfolding, the initial connections were being made with the wider MSF network
outside the country and the emergency managers who would have a vital part to play in steering the overall response.
This section of the report looks at the way that response was handled, the strategic choices that were made and thefactors that challenged the effectiveness of MSF’s work.
As the news broke, the 19 years of history in the country were among the most important assets for the organisation.
They allowed for a much more rapid, better informed reaction and the battered teams in the country were the basefor the medical action. But the first hours were still clouded by poor communication because contact between theteams on the ground was limited.
The patient’s account of the sexual assault and thedoctor’s observations are recorded in a document
Inthe MSF offices in the USA and Canada late that Tuesthat can be used as evidence in court and help convict
dayafternoon and in Europe in the early hours of theperpetrators.

morning of the 13th January, staff were trying to interpret the patchy information about damage levels andthe impact on MSF facilities. The first decisions that day
were based on experience of earthquakes elsewhere
and the certainty that Haiti’s limited medical capacity
would have been completely overwhelmed. There wasword that MSF’s hospitals were badly hit and that staff
were struggling to rescue patients and colleagues. Many
staff could not be accounted for and one international
staff member was trapped under the rubble of theirhouse. The final toll was that four Haitian colleagues
were killed, along with four more who had worked
with MSF until shortly before the quake.
Quick decisions were taken about supplies and extra
staff. It was clear that the top priority had to be materials for surgery, along with the extra surgical teams, andshelter materials to rig new facilities by the damaged
hospitals. A whole inflatable hospital was rushed to an
airport in France to add operating theatres and beds.
Medical needs were brutally obvious: life saving surgery
and wound care. The plan was to get pairs of surgeons
and anaesthetists to rotate and work around the clockin as many theatres as could be reclaimed or erected.
On that first day, estimates of the numbers of injured
were rising fast and medical orders for dispatch were
multiplying. MSF had a plan for emergency responses
to widespread violence in Haiti and it was being rapidly
adapted to this massive disaster.
Landing rights
The pressure was mounting on the logistics staff tocharter planes and find routes into Haiti. The first teamfor reinforcing MSF staff already in the country arrived
An 8 year-old girl, raped by her father, receives
48
hours toaftertheHIV/Aids
earthquake
but
there were serious
medication
prevent
and othersexually
struggles
get landingslots
thea blooddamaged and contransmitted to
infections.
The nurse
alsoindoes
test, to check whether the girl had contracted HIVfrom a previous assault.

gested airport at Port-au-Prince. In the first 6 days, outof 17 flights with vital supplies and staff that MSF intended to reach Port-au-Prince, 9 cargo and two passenger planes were diverted, usually to the neighbouring
Dominican Republic. The consequence for the patientswas that many of the medical staff and their supplies had
to come by road, which added around 36 hours to thejourney. Half of the inflatable hospital with its 100 beds
and three operating theatres had to come that way. MSF
protested publicly to the US authorities who were running the airport and access did improve but there wasreal concern about the impact the diversions had on theemergency care that was so urgently needed. Even so,some MSF planes did arrive early on from the logisticalbase in Panama and the Santo Domingo transport hub
was soon consolidated as an additional access point.
Operating space
Restoring and expanding surgical care was the key forthe staff on the ground, who were searching for newbuildings in the first few days that could be used for
operating theatres. One was identified in Carrefour
hospital, where the theatre could function, although
the patients were kept in tents outside on the street
because everyone feared new tremors. Another teamre-established MSF in Choscal hospital in the slum areaof Cité Soleil where it had worked some time before.
The choices were not always able to be made on thebasis of clear information about alternatives. Further
down the street there might have been an even better building but the teams took what was good enough.
In Choscal, the decision was made as much because
MSF’s strong reputation in a potentially dangerous area
allowed the organisation to work in a community thatmight not otherwise have seen aid workers. In anotherlocation, beside the collapsed Trinite hospital, MSF surgeons were working in a container. Nobody thoughtthat was best practice because hygiene conditions were
EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 13

hardly as they should be in operating theatres but thealternative was not to treat seriously injured people.
Staffing issues
On the staffing side, the impact of the quake on the Haitian staff was particularly difficult. Many of them had lostfamily members or homes but still carried on working.
More international staff were also needed to come in to
replace the exhausted workers during the first week.
Recruitment internationally was dramatically successful as hundreds of people put themselves forward as
emergency cover. The limitation for the organisation
was more in the managerial challenge of handling theswelling teams and the multiplying project locations.
Beyond the capital
Outside Port-au-Prince, the decision was taken early on
to head for some of the other badly affected towns.
Within the first week, MSF was in Leogane to the westof the capital and even closer to the epicentre of theearthquake. The team set up a central surgical unit andran mobile clinics along the road to Grande and Petite
Goave. In Jacmel, to the south, another hospital was
identified. But here the first journeys had to be madeby helicopter because the road was so badly damaged.
That resource continued to have value to search for remote communities whose restricted access to healthcare had become even more limited and who had seenno aid even two or three weeks into the emergency.
Mobile clinics and deliveries of household items andshelter were then organised.
Everything is a priority
One of the constant challenges for the management of
the work was in trying to anticipate and plan for the
emerging health needs. To begin with they were obvious and overwhelming. And one of the preoccupations for the medical staff was the need to find specialist
treatment for complex cases like spinal injuries, cranial
surgery or multiple fractures. The solution was to referthem to hospitals in Santo Domingo by helicopter. In theearly days in Port-au-Prince, the normal MSF practiceof outreach into the communities to find new patientswas sometimes suspended as they were coming in suchgreat numbers to the hospitals and clinics. The standard
local security procedures of a ban on night driving weresuspended for the first two weeks because of the clinical pressures.

14

The surgical priorities did begin to shift though from lifesaving to limb saving. Doctors in the emergency facilities had always been faced with very difficult decisions
about how to save badly damaged limbs and amputations were sometimes necessary to preserve the lifeof the patient. The second wave of surgical cases saw
arms and legs which had infected wounds but where life
was less immediately at risk. By then the surgical capacity was significantly expanded with the presence of theinflatable hospital with its three operating theatres.
That phase of the medical work had been preceded by
an explicit strategy of consolidating specialist provision
for dialysis for crush injuries and to expand emergency
obstetric care. This had always been an MSF core activity and it became a major part of the life saving capacity.
Psychological services were also very much integrated
into the medical provision, initially as part of trauma
care for badly injured people but increasingly as an outreach activity that dealt with the widespread symptomsof shock and bereavement in the communities.
Beyond medicine
At the same time as the medical work was being refined and elaborated, there were parallel efforts to fillsome of the large holes in the provision of water, sanitation and shelter. These are normally support activities
for MSF medical projects, which involve creating theappropriate working conditions in the hospitals andclinics and providing for the patients. But in Haiti, theneeds beyond the hospitals were huge and potentiallydamaging to the health of the surviving people. There
was a real tension for MSF as its resources could havebeen pulled in all directions. The focus had to remain
on securing the medical services for the patients but
substantial work was done even so in camps and thefacilities. Water trucking, setting up bladders and starting to construct latrines was a significant contribution tobasic welfare in the settlements. Constant monitoring
was going on to identify any signs of disease outbreak or
epidemics, which are so much more likely in crowded
conditions. Fortunately, such outbreaks are comparatively rare in Haiti.
The next level of provision, distribution of shelter andnon-food items like hygiene and household kits, wasmore problematic. The needs were – and still are – sooverwhelming that MSF’s contribution to meeting them

could never be very satisfactory. Even so, the project
managers did push the boundaries of MSF’s core medical action and organise distributions. But MSF has been
disappointed in Haiti with the overall commitment toget shelter in particular to the people.
Secondary and primary
The medical needs were certainly shifting by the second
month and hospitals had filled up with patients recovering from their injuries. Other emergency medical teams
were preparing to leave and MSF was pushing for new
facilities to take the patients. That meant a shift to longer term care with an emphasis on physiotherapy as partof the recovery process. Moreover, the wider move inthe second phase of the medical work was to reinforce
the provision for non-earthquake related conditions andchronic illnesses. Violence related injuries needed frontline care and there was growing provision for paediatriccases. So even more hospital beds had to be freed andnew ones created for longer-term patients. All of thiswas a confirmation of the fundamental choice for MSF
that it would concentrate on its strengths as a providerof quality hospital care, which was not guaranteed fromother sources.
At the same time, there was a determination to work in
the communities to deliver primary care. Clinics in thesettlements were dealing with wound dressing and minor ailments. The flow of patients to the hospitals was
re-balancing to the “normal” medical work with respi-

ratory infections, road accidents, sexually transmitted
infections and chronic conditions like TB and HIV infections. By the third month there was also a consolidationof some of the medical facilities, with adjustments totake account of other organisations’ work and in response to the Ministry of Health’s needs. The staffing
patterns were becoming more conventional for an MSF
intervention. Recruitment of Haitian staff had greatly increased and the international component stabilised, sothat the ratio came back to a historical 10:1. The earlier
tendency for staff to overwork with long hours and few
breaks was calmed and greater efficiency establishedwith better staffing numbers per ward and clinic.
Reflections
MSF emergency managers have been looking backat the achievements and the frustrations of the earlywork. They feel that their preparations and plans forevents like this were pushed to the limits. The capacity
to respond was demonstrated but it was also close tobeing swamped. The financial cost of flying such a highproportion of the vital material was very high and at
the beginning even that was compromised by the airport problems. But the scale of the disaster was exceptional. MSF had dealt with natural disasters where thefatalities were as high but in this case there were far
more injured survivors. The nature of the buildings, thedepth of the quake and the way people lived delivereda particularly cruel level of suffering. Experienced MSF
workers were universally shocked by it.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 15

© Tristan Pfund

16

Work and Witness
SURGERY AND REHABILITATION
Emergency Surgery
In the 20 days following the earthquake, MSF surgeons worked around the clock, carrying out over 1,300 surgicaloperations. Just over one tenth (140) of those operations were amputations, and they were always the last resort in
the effort to save the life or limb of the patient.

Paul McMaster is a surgeon who reached Haiti
less than a week after the earthquake struck.
“When we started surgery we didn’t have electricity in thehospital. The team rigged up a couple of lights in a tree.
We were working off two makeshift operating tables in the
courtyard and we just went from one patient to the next.
Those first few days we didn’t have water or food for thepatients - or indeed for the teams working.
These were brutal wounds. They were deeply infected after three or four days when people were still being brought
out. The surgery isn’t very complex, but it’s a very, almost
primitive and brutal surgery of removing dead and damaged tissue and amputating limbs. The decision you haveto take surgically is whether you can preserve that limb
or whether it must be removed. It can be a very difficult
decision at times and amputation is clearly the last resort
you want to turn to. But when a person has been crushed
for days in a building, the tissues have been severely damaged, and the great dangers are overwhelming infection
and septic shock setting in.

that the infection was still raging, and they became extremely concerned that it would spread to the rest of
his body and threaten Jerry’s life.
“The wound was very near the groin, so if the infection
went above it there would have been very little we could
have done to save him. We knew we had to amputate if
we wanted to keep him alive,” remembers Dr. Karin Lind.
Reconstructive surgery and rehabilitation
Reconstructive surgery is not just about aesthetics:
it can help limit infection and restore mobility. In thedays after the earthquake many patients arrived at MSF
facilities with drastic loss of tissue, both muscular andcutaneous. To limit the risk of infection and preserve
patients’ limbs, the teams administered skin grafts andcarried out scar control.
In the less severe cases they were able to use a technique that involves taking a piece of skin from a healthy
part of the body and applying it to a superficial wound.
This allows new skin growth to occur after two or
three weeks.

For us individually, it’s always different things, but for me
it’s always the children, I think. Having to amputate thelimbs of children who have already been deeply traumatised by their experiences is always hard to do. There isoften a feeling of helplessness, or wanting to do more. And
so the emotions and the feelings are very strong.”

For more severe tissue loss or necrotised wounds(notably severe burns), it was necessary to apply reconstructive grafts. Once the acute phase has passed,
other techniques are used to restore mobility andphysical function.

Seven year old Jerry was trapped under the rubble
when his house collapsed, and emerged with a severe
open fracture to his femur. MSF put Jerry on antibiotics straight away to keep infection at bay and an MSF
surgeon performed a complete cleaning of the wound.
However, a few days later the doctors discovered

Most of these methods were taught in the University
Hospital of Haiti before the earthquake, but many Haitian surgeons were unable to use them due to lack ofequipment. Since the earthquake, local MSF teams haveworked in partnership with their Haitian colleagues toreintroduce these techniques into the operating thea-

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 17

tres, using the new equipment sent into the country. In
the future the teams will therefore be better able to deliver patient care to victims of violence, road accidents
and burns, who are now replacing earthquake victims in
the hospital beds. Overall, some 11,421 patients went
through MSF’s rehabilitation programmes.
Doctor Maria Adele Dammacco, a specialist inreconstructive and aesthetic surgery, joined theemergency teams in Port-Au-Prince in February.
“In Port-au-Prince, patients leaving hospital are going to livein very difficult conditions, and the risk of infection is high.
Plastic surgery, amongst other things, can reduce the risks.
For instance a simple skin graft will allow a superficial wound
to close more quickly than if it were left to heal completely
by itself. In a situation where tens of thousands of people
were injured at the same time, it is a real bonus to be able
to make post-operative care easier.
I do not think the aesthetic question is trivial or exclusively
for the rich, it is a question of status as well as appearance.
In many countries people afflicted by aesthetic handicaps
are excluded from society. By repairing their faces one gives
them a chance to regain their place in their community.”
Physiotherapy
For many of the types of injuries sustained during earthquakes, physiotherapy is vital to recovery and rehabilitation. Patients with lower and upper limb fracturesand breaks, pelvic trauma and compound fractures all
require physiotherapy to ensure they regain as much
mobility as possible, recover muscle tone and avoid
muscle atrophy. Physiotherapy also helps prevent medical complications such as deep vein thrombosis and pulmonary embolism.
Initially MSF, in partnership with Handicap International,
was providing post-operative physiotherapy to fresh
trauma cases. By the beginning of June the nature ofpatients’ injuries had changed, so that only about half ofcases were directly related to the earthquake - mainlycomplicated orthopedic issues. The other half were18

largely due to road accidents and burn injuries.
There were few physiotherapy services available in
Haiti prior to the earthquake, so finding trained physio
staff has been a major challenge. Many auxiliary medical staff had to be trained from scratch. Much of thenecessary equipment has been sourced locally: parallel bars, weights and extension machines have all been
made with local material. An exercise bike machine wasmade by simply suspending a normally bicycle by theback wheel.
MSF is now providing physiotherapy in a number of inpatient and outpatient facilities, both in Port-au-Prince
and other devastated cities such as Leogane.
Gilles Lavigne is a physiotherapist who arrived in
Haiti a week after the earthquake.
“The treatment includes massage, exercise, working on
mobility. It’s very important you start treating burn patients very quickly after the accident to prevent muscle
shortening. If a patient has had a skin graft you have to
massage around the scar to keep the skin elastic. We havebrought in special thermo-plastic splints for the treatmentof burn victims. The special splints keep the hand or arm ina good position and ensure the scar is able to heal properly.
We have to make a unique one for each patient.
I remember one patient - a little three year old girl called
Anelka. She asked her mother, ‘Mummy, mummy give me
my legs – I want to play with the other kids!’ Her motherasked me if it would be possible to give her crutches and I
said no way – I knew I’d never be able to find anything fora three year old. So I made some for her myself and she
tried to walk with them. I said ‘Oh my God, I’m sure she’ll
fall down, she’ll never manage’. But two days after that
she walked very quickly with these crutches. Now she has
an artificial leg. But the problem for kids is that you haveto change their artificial limb every three months because
they grow so fast.”© William Daniels

PRIMARY HEALTH CARE
The earliest forms of this most basic contact between
patient and medical professional after the disaster werein the hospital reception units and clinics that dealt withthousands of the more minor injuries. As the MSF presence expanded and the number of facilities increased,these outpatient departments touched on ever wider
parts of the city, as well as the towns in the affected
area. Mobile clinics went out into the settlements tofind people who were not travelling to the hospitals.
The primary health care clinic, a familiar model frommany countries and refugee camps where MSF works,
is important for several reasons. One of the first procedures is a check up when a new patient registers. Weight,
height, temperature, blood pressure, a urine test, andnutrition measurements are all taken. This allows MSF
to identify major health problems among the communities and monitor for potential disease outbreaks such as
measles, meningitis, typhoid and whooping cough.

At first, patients were coming with injuries to be
dressed, four or five hundred a day to each clinic. Today
this number has dropped drastically, down to an average of around 70 a day. Many of the health problems
reflect the extremely poor living conditions: respiratory
infections, skin infections and diarrheoa. Recently there
have been more cases of violence and sexual violence,
although these may simply have not been reported previously. In the five months after the disaster, 212 patients were treated following sexual violence.
The services offered at the clinics are generally basic
consultations, ante- and post-natal care, vaccinations, ahome visiting feeding programme and referral to mental health services or hospital when necessary. There
are also still people coming to the clinics who failed toreturn for follow up care after surgery, who now haveinfections needing medical attention.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 19

Dr Emmanuel Bélimaire divides his time between
Delmas 24 and Champ de Mars, one of the largest
camps for displaced people in Port-au-Prince. Primary care clinics in both places were establishedby MSF.
“Infections and intestinal parasites are the most common
complaints we see. Sometimes we also give guidance on
the basics of hygiene because it is necessary for a patient
to change their habits.
Pregnant women may be screened or referred to specialised
centres if there are complications. Newborns are given special attention with screening for conjunctivitis. The organisation also offers vaccinations and monitors for epidemics
such as measles, malaria, tuberculosis and tetanus.”

SPECIALISED SERVICES
Maternal and Obstetric health care
Even before the earthquake, pregnant women in needof maternal health care were at risk in Haiti. The earthquake severely damaged or destroyed up to 60 per
cent of health facilities in Haiti, including the old MSF
maternity hospital. As a result, MSF started providing
support to the Ministry of Health maternity hospital,Isaïe Jeanty, which had not been damaged in the earthquake, providing human resources, drugs and obstetrics expertise. As well as treating pregnant women withmedical complications such as eclampsia and malaria,
the centre offers neo-natal and post-natal services anda blood bank. The latest figures show that MSF helped
to deliver 3,752 babies in its facilities.
Dr Gessie Delusma is an obstetrician-gynecologist
currently working in the Isaïe Jeanty hospital.
“Pregnant women were already vulnerable, but now their situation is even worse. They have even less access to health careand health education, and their living conditions are poorer.
Mothers who have lost their husbands and other family members live in tents with their children. Those women face great
difficulties actually staying in the hospital and delivering.
I have always been careful to talk with my patients and to
explain to them what is happening. Patients without mucheducation need to be able to understand the information theyget. I saw a patient recently who came in with her mother.
She presents with a molar pregnancy and needs to be treated,20

otherwise she could develop cancer. This girl must come backto the hospital for her treatment, so it is crucial that I take thetime to explain properly why.”
Roseline, 34, was five months pregnant when theearthquake struck. She delivered her first baby at
the Isaïe Jeanty maternity centre in May.
“When the earthquake happened I was afraid I would lose
the baby as I ran outside the house. I was so scared forhim. Afterwards, I talked to the baby inside me and explained to him what happened.
The pregnancy went well but the birth was a bit difficult. I
had a lot of pain and I needed a c-section. I knew that theservices would be free here, that’s why I came. It all finallywent well, and here is Angely, my first baby.
Life was pretty cool before. When I look at the past, I
think that we used to be free. My life is totally different
now and much harder. Our community life has changed.
Some people died. Some left. We used to live much more
all together. Today, everyone goes their own way. But I amvery proud to finally be a mother. We thought that life wasdone. But no, we take it back, step by step.”
Burns
Haiti lost its only specialized treatment unit for severeburns when MSF’s La Trinité Hospital was destroyedby the earthquake. Re-establishing this unit became apriority, especially given the dangerous living conditions
faced by earthquake survivors.
By late March, a new dedicated unit had been set up under canvas within the Saint-Louis Hospital compound.
The unit includes three tents and thirty beds for severeburn patients, both children and adults.
Dr. Rémy Zilliox, a plastic surgeon and burn specialist started working in the burn unit just after
it opened.
“Burns are increasingly frequent and severe now because
lots of people are living in even more dangerous conditions.
All aspects of family life take place in just one, often very
cramped space: family members sleep, play and cook in
the same area.Women and children are often burned because a pot of boiling water or oil tips over, or a candle sets
fire to a blanket. Men are mostly burned when handling
flammable products, primarily fuel containers. I’ve also
seen electrical burns, which are particularly serious.

For victims of severe burns, the 24 hours following the accident are crucial. Emergency surgery must be performed
within six hours of the accident happening and they require very regular care for three weeks to a month. They
are initially treated in the emergency room of the hospital,
where specially trained doctors decide whether to set up a
resuscitation infusion. Burn patients lose a lot of water, salt
and micronutrients.
Next, we determine whether the patient needs emergency
surgery, which usually involves a tracheotomy or escharotomy - an incision in the burned area. A tracheotomy is required when the lungs or mouth have been burned, whichmakes it difficult to take in oxygen.”
Five year old Walderson suffered third-degree burns to
his right leg in April. His mother was cooking in theirtent while Walderson was playing with his twin brother.
His trousers caught on a pot of boiling water and 12 percent of his body was scalded. He was admitted to theSaint-Louis burns unit, where he received emergency
surgery and remained as an inpatient for over a month.
“He had blisters on his skin and he was in pain,” his father
explains. “Fortunately, his mother snatched him up rightaway. He used to go to the operating room and receive histreatment under anesthesia, but now we just change his
dressing every other day.”
Mental health
Dealing with the ‘invisible wounds’ – the psychologicalconsequences of the disaster – quickly became a vital
part of MSF’s response. Not only were people mourning
the death of loved ones, the fear of re-experiencing theearthquake was aroused with every aftershock. Many
were also extremely anxious about their own injuries,
and were particularly scared of having to lose a limb.
MSF started to provide a broad range of mental healthsupport, from group counselling sessions with psychologists to one-on-one consultations with psychiatry
professionals for those who developed acute psychiatric distress. Over the last few months, MSF has given
psychological support to more than 80,000 Haitians.
Most patients that had individual sessions presented
with physical complaints such as cardiac palpitations,pain or flashbacks.
By June, psychologists were providing support not
only to individuals who were direct victims of theearthquakes but also, increasingly, to those who canno longer bear their dire living conditions. People are
extremely anxious about the future, with no hope insight for an improvement in their lives. Marital, family
and socio-economic problems have reappeared and areexacerbated among people who have lost their social
standing or who find themselves forced to raise theirchildren alone.
MSF offers therapy sessions including relaxation techniques to help reduce anxiety. This strategy works
much of the time, but if patients have psychiatric complications, such as mania or delirium, they are referred
to a psychiatrist.
Before the earthquake, Haiti had only a few facilities
that could treat patients with severe psychiatric illnesses. Today there are less than 10 psychiatrists in all ofHaiti. There are still only limited opportunities to referindividuals who require hospitalisation and increasing
numbers of seriously ill psychiatric patients are today
seeking help from MSF.
Dr. Maryvonne Bargues, a psychiatrist, leads a
19-person MSF mental health team in Port-auPrince that includes 13 Haitian psychologists.
“Four months after the earthquake, many people remain inwhat I would call a state of ‘complete confusion of land andbody.’ Most of my patients are afraid of being swallowed upby the earth. The earthquake is literally in their body andthe noise is always present. They have major sleep disorders. They live in a constant state of fear and continue tohave flashbacks. In April alone, I saw 70 patients who werein a state of acute delirium, confused and unable to think
clearly. Many have stopped speaking and eating. After twoor three weeks of sessions, they improve.
There are also people who are grieving deeply and who suffer from depression. Many patients tell me, ‘We will never
get through this.’ Living conditions are horrific and many
people think that things will not change. Their houses aregone. In the best of circumstances they have a tent, whichis almost a luxury. The people in the camps are living incrowded, unsafe and violent conditions.
We work both within MSF’s medical facilities and in thecamps. I see each of my patients at least once a week. Ifthey are in an acute state or delirious, I see them every
other day. We also hold group psycho-social sessions, targeting people of the same age, such as children.”
EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 21

WATER, SANITATION AND SHELTER
So many people lost almost everything in the quake thatthe basic needs for survival were very pressing in thefirst few days. MSF was focussed on the medical andsurgical priorities and the first concern for the waterand sanitation specialists was to make the hospital areas
safe for the patients. That always involves ensuring highstandards of cleanliness and waste disposal.
But that rapidly expanded to the people who were in
the area. Karline Kleijer, one of the emergency managers in Port-au-Prince, says the reaction is instinctive.
“You see it because you are working in a hospital in the
middle of a big camp and you just have to take care of thepeople in it.” At the same time she acknowledges that
all of this had to be related to the medical work andthe facilities because otherwise all of MSF’s resources
would have been diverted away.
Outside Port-au-Prince, MSF also started going intosome of the small camps and communities and built
22‘sanitation areas’ which consisted of a latrine, a shower
and a wash area. There were hygiene distributions ofsoap, toothpaste and toothbrush. Then there werehousehold kits of cooking materials and sheets for shelter and tents. There are still camps with very poor provision and the latest MSF work is in Aviation camp andthose around Carrefour Feuilles in the capital, wherewater and sanitation support is underway.
MSF has been significantly involved in shelter delivery
but the organisation remains very concerned about thelack of progress overall. It delivered 26,971 tents andover 35,000 hygeine and households kits.
Paul Jawor is a water and sanitation specialist who
went as part of the emergency team.
“Haiti had trouble with water and sanitation before theearthquake, so when the earthquake happened it looked
like the perfect storm of disasters all at the same time.

© Katrijn Van Giel

Everyone was talking about cholera, which was interesting
because there is no cholera in the country! But they did
have incredibly bad sanitation issues in the camps. The‘flying toilets’ as they are called – basically defecating intoa plastic bag and throwing them into the waste system
was a huge problem because there was no waste collection, so it gets thrown in the lake or into the street.

it was linked to the medical work.

So we made basic cubicles, with a frame and plastic sheeting around the outside and we used a slurry vacuum pumpto get the waste out into a 3000 litre tank on a pick-up,
which we then drove out of town to the dump area.

Siliana is one the 45,000 displaced people living in
the Golf Club Camp in Port-au-Prince.

In the city it was clear that you could get lost among thehundreds of thousands who all needed help. So MSF would
do something very simple, which was to put a protractor
on the map with its point on the health centre that wewere working in and I drew a circle. And I said the firstpeople we’re going to influence are within it because these
are the people who will be coming to the health centre, so

We’re now moving on to the next stage with putting in water towers and other more permanent ways of water provision other than trucking, which has been the basic model.
And there’s the challenge of keeping the latrines above thewater table and the floods with the rains now.”“I came here on January 13th with my mother, my daughter, my three brothers and my cousin. I received plastic
sheeting but these things do not last long. With the rain
falling for weeks the water gets inside… Do you understand that? We have to wait until it stops to put our beds
back and sleep. Six people are sleeping in this little space.
This is how we live and this is not easy.”

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 23

© Frederic Sautereau24

AT A GLANCE: MSF ASSISTANCE IN FIGURESThe earthquake in Haiti on 12 January left immense numbers of people in need of urgent medical care and relief. MSF
staged the largest natural disaster response in its history. This table gives some of the key operational data for the period
up to 31 May.

Total

Haitian staff

2,807International staff

209

Operating theatres

16

Number of beds

1,187

Patients treated

173,757

Surgical operations

11,748

Patients treated: post operative care

11,421

Patients treated: bullet wounds only

264

Patients treated: other violence related trauma

2,147

Patients treated: other trauma

44,717

Patients treated: psycho social and mental health

81,735

Psychological consultation

20,652

Psychological education

61,083

Patients treated: deliveries

3,752

Patients treated: sexual violence

212

Relief kits distributed

35,350Tents distributed

26,971

Number of fixed sites

19

Number of mobile clinics

3

Litres of water distributed per day in cubic meters

723

Latrines built

880

Showers built

415

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 25

Donations and Spending
Following the earthquake, MSF initially developed fundraising activities and the generosity of people around the worldin response to the tragedy that befell Haiti has been overwhelming. While the MSF medical relief effort was immediately shaping up to be massive in volume, the total of funds donated to MSF by the public specifically for this emergency threatened to eclipse what MSF could foresee to spend. Striking the right balance so early on was complicatedby the fact that it took weeks for the real scale of needs to become clear as well as to guage what other organisations
would bring in terms of practical emergency assistance.
MSF takes the expectations of donors seriously and decided to discontinue active fundraising for the victims of theearthquake in the days following the disaster. While MSF continued to welcome donations, pro-active earmarked
fundraising for Haiti was put on hold. Instead, MSF called upon donors to continue to support the organisation for its
current and future emergency work in general.
As of 31 May, four-and-a-half months after the earthquake, MSF had received around 91 million euros(1) earmarked for
emergency relief in Haiti, and had already spent nearly 53 million euros on assistance to the Haitian population. MSF
foresees to spend around 89 million euros in Haiti until the end of the year; remaining earmarked funds will support
MSF’s ongoing commitment to the victims of the earthquake in 2011 and beyond.
At a glance

Rounded totals

Spent until 31 May

53 Million euros

Donated for Haiti until 31 May

91 Million euros

Projected budget until 31 December

89 Million euros

Examples of activities
Among the large scope of MSF activities in Haiti, as of May 31, more than 11 million euros have been spent on surgical care for significant numbers of Haitians injured in the earthquake. At least 4 million euros were spent on providing
maternal health services, which were already extremely limited before the earthquake struck. Roughly 8.5 million
euros (2) were spent on shelter and related items in an attempt to improve living conditions for some of the hundredsof thousands of people whose homes and livelihoods were destroyed.
MSF also invested substantial means in other medical and relief activities, including primary care, mental health support, and provision of water and sanitation.
Examples of major MSF activities

Estimated costs up to 31 May

Surgery and post-operative care

More than 11 Million euros

Maternal health care

More than 4 Million euros

ShelterMore than 8.5 Million euros

Some caution is warranted regarding the quoted totals as fluctuating exchange rates, mainly between the US dollar and the euro, have impacted
the calculated totals in euros. The calculations are based on the average monthly rate for currencies other than the euro.
(1)(2)
These figures only include the direct costs related to this work; as some investments are shared between a variety of medical activities, the realcosts are higher than the quoted totals.

26© Julie Rémy

Categories of spending
Operating such emergency health programs requires a range of investments. Given the devastation in Port-au-Prince
and beyond, including the near-total destruction of many health centres and hospitals, nearly 30 per cent of MSF’s
expenditures as of 31 May were devoted to logistics, such as the rehabilitation or construction of medical facilities,
and ongoing maintenance of health structures including water and electricity provision. Without this investment, medical staff would not be able to operate. A further 16 per cent of MSF’s expenditures have been attributed to medical
materials and supplies.
Because of the large number of essential emergency workers and vast amount of relief goods brought into Haiti, transportation accounted for 23 per cent of the total spending to date. At one point, the MSF team totaled over 3,500 Haitianand international emergency personnel – many of them doctors and nurses, but also logisticians, administrators, drivers,
and project coordinators. At the end of June, MSF still has more than 3,000 staff on the ground, well over 90 per centof them Haitians. The costs related to employing personnel accounted for 28 per cent of the money spent.(3)MSF is immensely grateful to the millions of people around the world who have helped finance the organisation’s massive relief work in Haiti.

(3)

These rounded figures, totaling 97 per cent of expenditures, are very close approximations of total expenditures to date.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 27

© Katrijn Van Giel28

FutureThe broad range of MSF’s work listed above is constantly re-shaped to meet new needs and, in some cases,
reduced ones. It is already clear that MSF will be making a very substantial commitment to Haiti in the years tocome. There are uncertainties around the speed of reconstruction and the extent to which other organisations
will still be providing elements of care. There are concerns about the continued physical exposure of so many
people in Port-au-Prince and about political and criminal violence which always risks being increased by frustration and despair about the slow improvement in living conditions. All of this has reinforced the urgency of MSF’s
planning and provision for all kinds of new emergencies; outbreaks of violence, disease, nutritional crises andfurther natural disasters.
The immediate challenge though for MSF has been to create some more robust medical facilities to replacethose damaged in the quake and the tented structures that have coped up to now. In Port-au-Prince, the inflatable hospital known as Saint Louis, along with the Tabarre rehabilitation centre, are expected to be replacedwith a new hospital next year, that will be an MSF emergency medical and surgical hospital. Martissant hospitalwill continue into 2011 and Choscal is also likely to operate as an emergency room. Another container hospitalin Delmas 33 will be dedicated to obstetric care for the next three years, while support will continue to the
Ministry of Health maternity hospital of Isaïe Jeanty. Paediatric care will also continue in 2011 in Carrefour Paediatricand Bicentenaire hospital, which will provide trauma care and surgery too. Primary health care services,
including mental health and sexual violence programmes will be provided through next year in the deprived
Carrefour area and in the new slums of the Airport zone.
Outside the capital, MSF will continue to support the hospital in Jacmel with a range of medical specialties
through this year, although the hope is that the Ministry of Health will then be able to resume its responsibility
there. In Leogane, a container hospital of up to 200 beds will become operational in the next few weeks to replace the current tent structure and until others can provide these services. MSF will work there on obstetrics,
surgery and paediatrics.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 29

© Bruno Stevens, Saint-Louis / Delmas 31

30

Annexe – OVERVIEW OF LOCATIONS AND ACTIVITIES
Hospitals and Surgery
In Port-au-Prince
Bicentenaire: Since January 25th, MSF has been running a hospital and provided emergency care in a former dental
clinic. An average of 350 people seek care in the emergency room every week. This facility provides surgical, paediatric, obstetric and mental health care. It has two operating theatres and an inpatient ward with an 80 bed capacity.
Carrefour Orthopaedic and Trauma Hospital: Around 20 major and 110 minor surgical operations are performed every week in this 120-bed surgical and post-operative hospital, which has four operating tables, a standard
X-ray machine, and one of the few C-arm x-ray machines in the city. Orthopaedic surgery, including external andinternal fixation, skin grafts, and muscle flaps are being performed and post-operative care and rehabilitation provided. The hospital is also functioning as an emergency trauma hospital for the Carrefour area. Rehabilitation care
is offered to patients in collaboration with Handicap International and psychological care is provided to patientsand families. The hospital also as an outpatient department for wound care treating around 100 patients per day.
Carrefour Paediatric Hospital: This new hospital, located next to Grace Camp, started activities at the end of
May. It has a paediatric emergency room, a paediatric ward with 40 beds, and another of the same size for severely
malnourished children.
Choscal Hospital in Cité Soleil: MSF is working in this Ministry of Health hospital and was initially focused onearthquake-related trauma. Currently two operating theatres are functioning for major surgery, and one for minor
surgery. MSF also works in the emergency room and the maternity and paediatric wards. Medical and psychological care is provided to victims of sexual violence. The hospital has a 100-bed capacity. It now operates as a general
hospital which serves a slum community living in extremely precarious conditions. Psychological care continues for
all patients and their carers.
Isaïe Jeanty / Chancerelle, Emergency Obstetrics Hospital: MSF is working in collaboration with the Ministryof Health in this 85-bed hospital, providing maternity, neo-natal and emergency obstetric care. In May, 588 deliveries, including 120 c-sections, were performed. At the moment this is the main referral hospital in Port-au-Prince
for complicated births and eclampsia cases. In the next few weeks, MSF is going to build a flat-packed container
hospital with a capacity of 130 beds, which will become a referral and training centre for neo-natal and obstetricalcare. The partnership with the Ministry of Health in Isaïe Jeanty will continue.
Martissant 25: This emergency, outreach and stabilisation centre (operated by MSF since 2006) with a capacityof 40 beds, sees approximately 100 new patients per day, around a third of whom need immediate care. Pediatriccare as well as internal medicine and maternal services are provided.
Saint-Louis Hospital / Delmas 31: Medical and surgical activities are ongoing in a 250-bed-capacity inflatable
hospital, which includes three operating theatres, one specially designed to treat patients suffering from burns. It
replaced MSF’s La Trinitée hospital, which was destroyed by the earthquake. Saint Louis also operates as a general
hospital, complete with paediatric and medical emergency capabilities. This includes medical and surgical followup, physiotherapy and psychological care. Almost 3,000 surgical operations have been performed since January 25.
The bed occupancy rate is around 90 per cent.
Outside Port-au-Prince
Jacmel: Since the hospital was badly damaged in the earthquake MSF has provided full inpatient services under tents
in a facility with 81 beds. In May, construction was completed of new 77-bed capacity wooden structures which now
house the maternity, paediatrics, emergency room, surgery, internal medicine and mental health services.
EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 31

Leogane: Again, this has been a tent hospital with a 130-bed capacity, initially on the existing St Croix hospital site,then moving to Chatulet. There are emergency services, maternity, obstetrics and gynecology, general surgery, general medicine, including paediatrics and neonatology. Physiotherapy and mental health care are integrated. MSF has
started to build a container hospital on the same Chatulet site, which will have a capacity of up to 200 beds. The new
hospital is expected to be ready between mid-July and mid-August and will provide the same range of services, plus
radiology and laboratory facilities.
Rehabilitation
Although a full range of post-operative care is offered in all MSF-supported structures where surgery is performed,
some sites in Port-au-Prince have been specifically dedicated to welcome patients after surgery.
Sarthe: Opened in February as a post-operative centre in a converted soft drinks factory in the Sarthe area with a potential capacity of up to 300 beds. At present, 130 patients are receiving wound care and more specialised orthopaedicor reconstructive surgery. Handicap International physiotherapists are working in collaboration with MSF to advance
rehabilitation and patient adaptation to prosthetics. Mental health care is also provided.
Tabarre: 100 bed capacity under tents. It was designed to take patients and their carers transferred from Saint-Louis
Hospital. It replaced MSF’s post-operative centre in Delmas 30, which was closed in April.
Lycée des Jeunes Filles, Champs de Mars: This site was functional as of February 1st and held an average of an
80 patients for post-operative and medical care, mental health care, and physiotherapy. Closed in March, all patientsrequiring further treatment were referred to other MSF facilities.
Ministère du Tourisme, Champs de Mars: Site opened on February 22nd with an average of 40 patients hospitalised and receiving post-operative and medical care, mental health care and physiotherapy. It was closed in April andpatients were referred to other MSF facilities.
Mickey crèche, Christ Roi road: Opened January 19th with an average 60 patients. Closed in April.
Promesse: 50-bed capacity, which closed its doors at the end of May.
Primary Care
Aviation Camp: MSF teams are installing latrines and showers in a camp that is currently home to 40,000 displaced
people. Several mobile clinics have begun providing basic health care, ante-natal consultations and community mental
health services in May, averaging around 110 consultations a day.
Carrefour Feuilles: Tented clinics are run in two sites—Carrefour Feuille and Tapis Rouge—close to four camps
where 20,000 displaced people are living. Between 200 and 250 consultations are carried out daily. The team does
wound dressing and vaccinations and provides clean water, sanitation, and mental health services. Work is also startingin four camps near the MSF hospital of Bicentenaire to provide water and sanitation services, as well as psycho-social
care to the people there.
Ministère du Tourisme, Champs de Mars: An outpatient department conducting approximately 3,000 consultations a month.
Delmas 24: A health centre opened in February with some 2,300 consultations in the following month.
Mickey crèche, Christ Roi road: Around 3000 consultations a month, closed mid-April, including reproductive
health (ante-natal care, family planning, treatment of sexually transmitted diseases), mental health and physiotherapy.

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Petionville Golf Club camp: Basic health and ante-natal care, rehabilitation (in collaboration with Handicap International), routine vaccination and psycho-social counselling for a camp of an estimated 45,000 people. Around 160
consultations daily.
Saint-Louis / Delmas 31: Next to the inflatable hospital, a 24-hour service cared for over 50 victims of sexual
violence in May. There is also an outpatient department, with around 3,000 consultations a month and ambulatory
program (for patients leaving the hospital or the emergency room and needing regular dressing or other follow up),with 1,600 consultations a month.
Sarthe: Alongside the post operative centre in the former soda factory, there is a health clinic offering basic healthcare for the surrounding population.
Shekina Clinic, Waney 87: Basic health, antenatal and postnatal care, as well as mental health services. Receives
around 95 patients per day.
Village Grace IDP camp: A health centre for a camp of 10,000 displaced persons and the surrounding urban area.
Some 230 patients are seen daily, plus 120 women a week in the ante-natal and post-natal service.
Outside Port-au-Prince
Leogane, Chatulet: 1,000 consultations per week in the outpatient department. This includes reproductive health(antenatal care, family planning, treatment of sexually transmitted diseases), mental health care and physiotherapy.
Duffort Health Centre in Leogane: 400 outpatient consultations per week in a temporary health centre.
Distributions
MSF has completed its distributions of tents, targeted at the thousands of people living in areas surrounding its medical
facilities. Distribution of basic necessities such as kitchen utensils and hygiene kits is still going on in a wide range oflocations both inside and outside the capital. In total, MSF has distributed 35,350 non-food item kits and 26,971 tents
in: Ecole Saint Louis, Delmas 33, Delmas 24, Tabarre, Sarthe, and Cité Soleil in Port-au Prince; in Carrefour; on the
coast west of Carrefour in Petit Goave and Grand Goave; in Leogane and in Jacmel. Tents and basic necessities werealso recently distributed to about 200 families in remote villages of the Léogâne region.
Water and Sanitation
MSF has joined other organisations working in the water and sanitation sectors in a number of locations both insideand outside Port-au-Prince. Overall, 1,269 cubic meters of water are distributed per day and 880 latrines and 415
showers have been built. MSF is also cleaning and emptying latrines to help guarantee minimal hygiene conditions forpeople living in makeshift camps.
Evaluations and plans
MSF has conducted assessments in areas outside Port-au-Prince to identify potential emergencies. Recent missions
have covered, among other areas, Gonaïves, Port-de-Paix, Cap Haïtien, Fort-Liberté, Saint-Marc, Belle Anse, Thiotte,Jérémie and Les Cayes. MSF teams also assessed the area along both sides of the border with the Dominican Republic,
as well as in Santo Domingo. There was a clear lack of public health services. The cost of health care in private andsemi-private structures is an obstacle to people’s access to healthcare, even for medical emergencies.
MSF is preparing to meet an increase in needs for emergency treatment related to the arrival of the rainy season anda possible worsening of the medical situation in Port-au-Prince and throughout the country. Additional medical andlogistical supplies have been ordered to increase the capacity to respond to the needs that arise.

EMERGENCY RESPONSE AFTER THE HAITI EARTHQUAKE 33

34© Julie Rémy

www.msf.org© Julie Rémy

Published by
Médecins Sans Frontières
July 2010