Physical Therapists in Post-Earthquake Haiti: Seeking a Balance Between Humanitarian Service and Research

On January 12, 2010, a devastating earthquake measuring 7.0 on the Richter scale occurred in the small Caribbean nation of Haiti. Much of the instantaneous human and structural destruction that resulted from this massive earthquake was broadcast widely via media sources, and the world immediately responded. Within hours of the event, emergency medical teams joined the large number of nongovernmental organizations (NGOs) already operational in Haiti, and humanitarian aid began to flow into the capital of Port-au-Prince by land (through the Dominican Republic), air, and sea. More than 6 months following the event, many of the details remain “preliminary”; however, we know that at least 220,000 people died, making this earthquake one of the largest single-day casualty counts in history.1,2 Even though the number of fatalities is staggering, it is believed that mortality rates would have been higher if the international community had not responded so quickly. Physical therapists from around the world have become part of the global response in Haiti. Although there are far too many individuals and organizations to mention here, collectively they have placed their personal and professional lives on hold in order to contribute to the global humanitarian efforts in this devastated country. These physical therapists are an inspirational group of caring people who have made, are making, and will make important contributions in Haiti. They also have indirectly helped to propel physical therapy into the mainstream of humanitarian aid and relief (Fig. 1). Jamie Young, PT (left), and Tess Devji, OT (center), help a patient stand for the first time since the earthquake. (Photo Credit: Lisa Carnie) I have been fortunate to be involved as part of Toronto Rehabilitation Institute's (TRI) humanitarian response in Haiti. The TRI has been working with partners from Healing Hands for Haiti at a spinal cord rehabilitation unit that emerged in the post-earthquake phase. Three main sites in Haiti agreed to admit people with spinal cord injuries following the earthquake: St. Boniface Hospital in Fond-des-Blanc, Medishare/University of Miami project in Port-au-Prince, and Haiti Hospital Appeal (HHA) in Cap-Haitien. The Toronto Rehabilitation Institute has been providing direct care and education to HHA for a number of weeks, and, in this editorial, I use some of these experiences to highlight and argue 2 concepts. Preserving life clearly was the primary mission in the aftermath of this natural disaster, but the lives saved translated into a large population of people who will live with major lifelong disabilities. Relatively low mortality rates engender higher morbidity rates, and an estimated 300,000 people were injured during the earthquake. Estimates indicate that 2,000 to 4,000 people survived with amputations, more than 200 survived with spinal cord injuries (SCI), and thousands had fractures.3 From a rehabilitation perspective, one of the important outcomes of this earthquake is that it created a sizeable cohort of people with disabilities—which added to the already large number of Haitians living with disabilities. Even prior to the earthquake, from both a societal and a structural/architectural perspective, Haiti was a rather hostile environment for people with disabilities. The utter destruction that this earthquake caused in the affected zones has made accessibility and housing an even more critical issue (Fig. 2). Collapsed and collapsing buildings define the landscape of Port-au-Prince. (Photo credit: Landry) I do not suggest for a moment that the decision to preserve life was incorrect; on the contrary, I admire and applaud the fine work of others in the acute phase of the disaster. Rather, I am signaling that the preservation of life—which results in a corresponding growth in cohorts of people with disabilities—demands the moral and ethical accountability of the international community to also provide appropriate rehabilitation services to ensure some level of quality of life for individuals in the post-earthquake period. Prior to the earthquake, for example, very few people in Haiti lived with SCI; however, due to lifesaving interventions after the earthquake, about 200 people with SCI have survived. Because of low prevalence rates prior to the earthquake, few settings in Haiti provided spinal cord rehabilitation; furthermore, the Haitian health care provider community had very little experience with such complex injuries. In fact, after the earthquake, a Haitian nurse colleague asked an insightful question: “What kind of earthquake happened in North America for you to develop all this expertise with these patients?” This question created a powerful context for our work. Spinal cord rehabilitation in North America began when soldiers returned home from World War II with SCI. We in North America have been developing expertise in the treatment of spinal injuries for close to 65 years; in Haiti, they have been developing their skills in the weeks since January 2010. I contend that if the global community intervenes to preserve lives following disasters, the nature of these situations creates a moral imperative to provide direct rehabilitation services and to train local providers to manage the complex outcomes. It may seem premature to suggest the necessity for a research agenda, given that much suffering continues (almost unabated in some cases) across Haiti. However, questions must be asked in order to more fully understand the effects of the Haitian earthquake. There are 2 primary areas of scientific inquiry that, in my opinion, must be conducted in this context. The first line of inquiry is related to more fully exploring the types of injuries that occurred as a direct result of the earthquake. For example, establishing the clinical profiles of people who survived the earthquake and sustained SCI would provide important insights into the etiology and mechanism of injuries that occur in a disaster of this type. Given our experience with the HHA, we suspect that many of the people who survived with SCI are young (under 30 years old), have very few comorbidities, and have low thoracic or high lumbar lesions. We hypothesize that few individuals with cervical injuries survived and that only the healthiest could withstand the lengthy process of being triaged and subsequently transferred between multiple facilities across Haiti in the effort to reach appropriate care. The patient profile is likely to be different in Canada or the United States, and a comparative analysis would identify important differences and could be used to prepare for future emergency responses. For instance, prior to assessing Haitian patients with SCI, we assumed that pressure ulcers would be a priority area; however, upon our arrival, wounds (mostly stage IV) were being well managed, whereas bowel and bladder care was lacking—resulting in a vastly different clinical picture than we expected. Data to clarify these questions and observations could yield essential information to create an evidence-informed framework to consider for current and future emergency humanitarian rehabilitation responses. The second line of priority inquiry is related to discharge planning for people who survived the earthquake but who now live with major disabilities. Discharge planning in Haiti has been complicated by the destruction of the infrastructure—from individual homes to facilities—and by the absence of many family members who have been displaced themselves or who died during the earthquake (Fig. 3). As of press time, the NGO community involved in long-term planning for SCI is considering options and strategies ranging from discharging patients with tents, constructing independent and integrated homes in a community, or creating large facilities that would house groups of people with disabilities. The latter option often is met with particular disdain and can elicit the suggestion that “institutionalizing” people in large centers would set back the global disability movement. Given that there is no one solution that is ideal or even appropriate in all settings, the empirical assessment of the each of these options (and others) would provide an evidence base to draw upon in future planning. Severe infrastructure damage has complicated discharge planning, especially among people with mobility impairments. (Photo credit: Landry) Overall, the context and consequences of the Haiti earthquake can be used to generate useful and meaningful research, and the findings of that research in turn can be used not only to effectively plan future development in Haiti but to facilitate this process in other countries that will experience natural disasters in the years ahead. Evidence-based or evidence-informed research following natural disasters must include the investigation of clinical interventions and also must reach into system planning at the local, regional, and international levels. Ultimately, it may be our role as global citizens to first work in solidarity with Haitians, but we must then share important lessons learned so that we can improve emergency response. In doing so, we can search for some deeper meaning of the tragedy in Haiti, honor the immense loss of life, and give tribute to those who now struggle to regain their lives while living with disabilities. I propose that it is of paramount importance for physical therapists (and all health care professionals) to seek a moral and ethical balance between providing humanitarian services and engaging in research to more fully explore the health care outcomes of natural disasters. Unlike some of our past attempts as a global community, once we find this balance, we must then be prepared to deliver on it.

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