The Exclusive Business of Disaster Relief
May 3, 2011
Global Health Fellow, USAID and Professor of Clinical Population and Family Health, Columbia University
Following the Haiti earthquake of January 12, 2009, a variety of factors contributed to the atmosphere of ultimate chaos that reigned for the first few months of the relief effort. First and foremost were the circumstances of the disaster themselves – a major seismic event occurred in close proximity to the shoddily constructed capital city of the country, resulting in 230,000 deaths, hundreds of thousands of injuries, the literal (not to mention the functional) collapse of the government, and the abrupt end of whatever semblance of ‘normal’ life had previously existed. Major population movements both away from and towards the shattered city were impossible to track. Whatever health care facilities remained standing were absurdly and obscenely overcrowded, under-staffed, and inadequately supplied.
Despite all this, two things worked remarkably well. First, food distribution. A combination of agencies including the World Food Programme, USAID’s Office for Foreign Disaster Assistance, and US Department of Defense forces working together with Menustah (the UN military contingent that had been on-site prior to the earthquake) devised a workable system of vouchers and established a network of distribution sites that were secured and made functional in record time. Food availability, the lack of which could have provoked major outbreaks of civil unrest, never became a problem. Second, a breakdown in public health never occurred. For reasons which are not completely understood, but which probably have a lot to do with good luck, the world did not witness the “disaster after the disaster” – a public health collapse caused by large numbers of people living in crowded conditions with inadequate shelter and essentially no sanitation facilities. No important epidemics of diarrhea, respiratory illnesses, vector-borne diseases such as malaria and/or dengue, or other important communicable diseases were detected. On the public health front, things remained relatively calm and under control from January until October, when the much-publicized and discussed cholera outbreak occurred. Although more could have been done to restore both public and private sector activity, including more rapid removal of rubble from the earthquake area, more rapid resettlement of the large displaced population, and more rapid rehabilitation of the health system and other vital societal functions, this six month relative lull in action allowed relief efforts to concentrate on providing intermediate-term care for physical rehabilitation, some repair of damaged facilities, and the matching of available resources (human, material, financial) to the new needs of clinics and hospitals.
Two things from the negative side of the ledger are also worth mentioning. The descent upon Haiti of hundreds of groups and thousands of people coming to ostensibly provide assistance to the beleaguered population had the undesirable effect of contributing to the chaos. While many of those who arrived were motivated by a laudable generosity of spirit, a selfless desire to help the unfortunate, and even, in many instances, a desire to put appropriate skills to good use, the inexperience of many of these newly-created “NGOs” slowed the ability of experts in international disaster relief to get organized, to rationally order priorities, and to provide appropriate supplies to the places that needed them most. Haiti – a country whose health services were already dominated by the presence of NGOs, both large and small, both competent and other – was newly deluged with groups from around the world. It is not clear why, in situations where one of the most important commodities is the good judgment that comes from long and hard-earned experience, the early days of large relief scenes tend to be dominated by the presence of young, idealistic, disaster ‘rookies’. If these people were working under the aegis of experienced organizations they could make a major contribution in both the present and the future; many, however, come either unattached or under the banner of NGOs that have formed overnight, that are under-resourced and under-equipped, and that have not taken the time to carefully consider whether or not they can actually make a useful contribution. Over 350 organizations were registered in the official “health cluster” – the coordinating mechanism of the UN relief operation – far too many to allow for the dissemination of any but the most superficial information. There are times, I find, when the most appropriate answer to the frequently posed question “we just got here last night – where can we go to help?” is blunt: “home”. Emergency relief, especially in the health sector, needs to become a more exclusive business, more the domain of experts than of volunteers. When so many lives depend on an efficiently operating system and when skilled personnel with adequate support are at a premium, some sort of licensing or certification should be required by the authorities. But no such system is in place and emergency relief remains, to an excessive degree, a business where amateurs are made welcome.
The other problem that arose in Haiti is more nuanced and has to do with the nature of the injuries that resulted from the earthquake and the level of care that was provided. In addition to the inexperienced providers mentioned above, highly-skilled teams of crack emergency medical professionals quickly arrived on the scene. These included a slew of orthopedic and neurological surgeons who worked under the auspices of the US Department of Health and Human Services, the US Department of Defense, the public and private sectors of many other countries from around the world, a variety of major academic institutions and all of the most professional and experienced NGOs . The medical teams worked heroically, treating patients for injuries that could not have been treated successfully in pre-quake Haiti, given its state of poverty and under-development. But that was the problem. The new level of care that became available within weeks was far higher than what could be maintained. Patients who had suffered serious spinal cord injuries and severe head trauma who might not have survived were it not for the surge of external support, now required long-term rehabilitation and support that was simply not available. Hardly any of the organizations that provided the life-saving interventions were in a position to provide the long-term follow-up that became necessary. In other words, the rush to save lives in the immediate was undertaken (heroically) with insufficient regard for the longer-term consequences. Unfortunately no studies exist that document these consequences. Triage is one of the basic principles of emergency medicine, especially in situations of mass casualties, but based on what I saw, I do not feel it was it was applied well in Haiti. The power to decide who should live and who should die is something no one wants, but is, nevertheless, a function that had to be exercised in the horrible circumstances of post-quake Haiti. Guidelines for the provision of an appropriate level of care should be put in place prior to the next major disaster.
Some things went right with the health sector response to the Haiti earthquake, and some did not. The magnitude of the catastrophe brought out the need to fix lingering problems with the existing humanitarian assistance architecture. In emergency response, many of the decisions that need to be made will be difficult and not politically popular, but the focus needs to be unwaveringly and unflinchingly on providing those in need with the best possible care, not with giving those who are willing to provide that care the best opportunities to do so.
Ronald Waldman was coordinator of the United States government health sector response to the Haiti earthquake.