altIn a matter of months, two major seismic disasters affected the Region: in Haiti, at least 200,000 victims died in a magnitude 7 earthquake (January 12), while in Chile a magnitude 8.8 earthquake on February 27 killed “only” 521 persons. The striking difference in impact illustrates, among other things, the critical importance of poverty in disaster risk reduction. As noted by Richard Olson in his commentary on 5 April  in Magazine, “Development levels matter, but so do governance capabilities, because together they determine vulnerabilities”.

Although there are lessons to be learned from all sectors, this editorial focuses on health sector issues in Haiti.

Lessons on prevention

Safe hospitals is a goal that has been adopted by all countries, Haiti included. Retrofitting all existing facilities is a challenge everywhere but is often presented as an unrealistic goal in a poor country. The total capital losses to health services are proof enough of the cost-benefit of risk reduction, even in Haiti. Now, there should be no excuses for very strict enforcement of building codes during reconstruction.

Hospitals are not the only critical facilities. It seems that little attention was given by Haiti’s Civil Protection Agency and the United Nations to the vulnerability of their own headquarters. The loss of key UN staff and installations seriously affected immediate response to the disaster. PAHO requires that an assessment of structural vulnerability be carried out before renting or acquiring new facilities in a country. The resilience of the new additions to the PAHO office in Haiti shows the wisdom of this requirement, while severe damage to PAHO’s old building points to the need to extend this practice to its existing facilities.

Lessons on preparedness

No country is ever fully prepared for major disasters. Reality is always different from projected scenarios and catastrophes will continue to take us by surprise. Nevertheless, training and planning should shorten the duration of confusion and chaos. How useful and relevant international and, in particular, PAHO investment has been in preparing the health sector requires careful, objective evaluation. The issue will not be to identify what went wrong, but what would have been worse without this investment. Again, preparedness is a relative issue.

Health sector preparedness in the Caribbean cannot be limited to the national level. It should assume a Caribbean-wide dimension since the health resources of any single country are quickly overwhelmed.

Lessons on the response

In Haiti, the initial medical response was provided by local agencies, mostly NGOs, forces from the UN Stabilization Mission in Haiti (MINUSTAH), and a strong contingent of Cuban doctors. The additional external health response was extraordinary but suffered from the same shortcomings observed in other large disasters: inevitably late (the country was on its own for at least 3 to 4 days) but with a rapid buildup. Quantity and visibility are not always matched by appropriateness and effectiveness.
Coordination and information were significant issues that did not get the required attention. In particular, PAHO/WHO personnel responsible for coordinating the UN Health Cluster were not up to the task of guiding over 300 health actors. Information on unmet needs and on who was doing what in the health sector was lacking. Decision makers tend to forget that disaster management is primarily a matter of information management. Shipping supplies and teams without data and prior consultation is a recipe for chaos, a natural element of major catastrophes.

Although much, and even too much was done on the short-term relief side, the mass media kept focusing on unavoidable local gaps, providing a somewhat dark picture of the international community’s performance. This contributed to an overflow of less than appropriate assistance.

Obstacles to response seen in the 2004 tsunami and other major earthquakes were also present in Haiti, including:

  • Bilateral official assistance was generous, operationally effective, and highly skilled in search and rescue and medical care. However, the first priority, understandably, was for their many nationals missing or trapped in hotels, residences, or offices or wishing to evacuate. Actual availability of external resources to assist Haitians was delayed and limited.
  • Caribbean assistance was coordinated by the Caribbean Disaster Emergency Management Agency (CDEMA), which Haiti joined recently. Effective support, including medical personnel, was provided through the hub in Jamaica. However, CDEMA’s lack of logistic and financial resources rapidly hampered what should have been a massive neighborhood response. Part of the funding assigned to logistic support of bilateral teams from developed countries would have been more effective technically and socially had it been applied to support this Caribbean response.
  • A survey by Handicap International shows that the distribution of injuries was similar to that observed in other earthquakes, with one major exception: an abnormally high number of amputations.  It is premature to determine the cause of this anomaly but one can only wonder whether foreign teams unfamiliar with the social conditions of an amputee in a developing country might not have adopted a more conservative approach to their treatment. Emergency teams interviewed in past disasters have cited the number of field amputations as a measure of their effectiveness under extreme conditions.
  • Medical evacuations may be a necessity when local facilities are utterly inadequate. The response in Haiti suggests that clear medical criteria were lacking. Returning stabilized patients to Haiti now poses a difficult issue for the host countries. For example, the long-term care needs were not taken into account at the time that victims of spinal cord injuries were arbitrarily selected for referral.  A triage strategy to determine who can benefit most from evacuation is needed.

PAHO/WHO, in consultation with its Member States, has developed a series of guidelines on field hospitals, dead bodies, donations, logistics management, etc. How realistic and effective are those guidelines, and how well were they complied with in Haiti? In severe disasters with intense media attention, such as the tsunami or the Pakistan earthquake, compliance is generally poor. Haiti is no exception: the guidelines do not seem to have “guided” most of the response.

In part, public demand and pressure from the mass media for rapid and visible action are not conducive to reflection and evidence-based decisions. But there are also extreme situations when strict compliance to guidelines is impractical or counterproductive. Guidelines should call for flexibility but definitely not for a free-for-all response in disregard of the basic disaster management principles.

A few preliminary conclusions

The experience and lessons from Haiti are highly perishable. The humanitarian community has a short memory and a remarkable capacity to repeat the same errors. If no formal evaluation and dissemination of this experience are carried out, the losses in Haiti will not help other Caribbean countries to be in a better position to face the next massive urban earthquake. That such an event will occur is not speculation, but certainty. Place and date are unknown.

It is time also for PAHO and WHO to review their guidelines on the use of foreign field hospitals and the management of dead bodies to make their application more practical in extreme situations.

The more exposed a country is to daily emergencies and crises, the less inclined it is to prepare for the rare catastrophic events. In addition to their short memories, countries ignore warnings and recommendations. In 1990, Haiti organized a conference on natural disasters and the recommendations for action were submitted to the Prime Minister at the time. Only in recent years, with the support of international donors, have prevention and preparedness returned to their place in the priority list of the national authorities. Far too late, however, to have made a significant impact on this catastrophe.

This earthquake has demonstrated that risk reduction is not a luxury for the poorest countries but a critical condition for their emergence from poverty.

Sophisticated health response will always come late! Neighborhood (i.e., Caribbean) response must be respected, strengthened, and supported by donors. The forthcoming Caribbean Regional Public Health Agency (CARPHA) includes preparedness for public health emergencies as a core function. If a massive earthquake is not a public health emergency, what is it? CARPHA should play a lead role in preparedness not only to traditional outbreaks but to all type of health crises.