Saturday, February 20, 2010

Change We Can Believe In

Many people maintain the assumption that Americans are complacent and stupid. Seeing the crazy things that happen in this country on a daily basis, it is hard to argue with that sometimes. But Americans know when they are being threatened and know when they are being lied to. They abhor hypocracy (usually) unless they are in love with the hypocrite. Once committed to an idea or an ideal they are frequently unmoved by fact or reality. But all notions, ideals and belief systems have tipping points. All of them. Actions have consequences but so do inactions. It is time we put honor and dignity back in our lives, hold each other accountable and educate ourselves to the sometimes bitter truths of common sense and a plain talk. Cheers

Saturday, February 13, 2010

The Bombing Of Dresden

Today, tomorrow and Monday mark the 65th anniversary of the bombing of Dresden. On those days RAF BomberCommand and Divisions of the USAAF VIII Bomber Command bombed Dresden unleashing a firestorm that consumed 15 square miles of the center of the city and killed between 18 and 25 thousand people. Even more controversial than the nuclear bombings of Hiroshima and Nagasaki, this remains one of the most inexplicable acts by the Allies during World War II. Some have argued it was a legitimate strategic target, an industrial and communications center that the Russians wanted destroyed to assist their offensive into Germany. Many have doubted thay assertion.

What is important here, I believe, is the myopia imposed by hindsight and revisionism. One must always put the act within the context of the thinking of the commanders "on the ground" at the time such decisions were made. To judge now, even based on the historical record, deprives the advocate and the critic of the contextual thinking. In other words, we will never know what was truly going on "inside their heads" 65 years ago. One can only guess. Any answer could be the right one.

Thursday, February 11, 2010

Haiti, a rock in the sun

Will Durant once said, civilization exists by geological consent, subject to change without notice.

At 4:53 pm ET, an earthquake of 7.0 magnitude started approximately 10 miles southwest from Port-au-Prince, Haiti. It lasted anywhere from 35 seconds to a minute. Geologically speaking, it was the result of the release of energy 6.2 miles below the earth’s surface from the Enriquillo-Plaintain Garden fault system, the subduction zone between the Caribbean tectonic plate and the North American one. This same fault system produced the major earthquakes of 1751 and 1771, both of which destroyed Port-au-Prince. At least 200,000 people have been killed, 196,595 injured and 800,000 to a million people displaced with extreme damage suffered in Port-au-Prince. The good news, if any, was that the earthquake occurred on land and not the ocean which might have resulted in a tsunami. (The 2004 Indian Ocean earthquake and resulting tsunami was of 9.0 to 9.3 magnitude. Also by way of reference, the 1906 San Francisco earthquake was 7.8 and the Alaskan earthquake of 1964 recorded a magnitude of 9.2, the second strongest earthquake ever recorded in the world.)

The Cathedral in Port-au-Prince. The stained glass was intact.

As I had done in the past for 9-11 and Katrina, I got online and volunteered my services as a general and thoracic surgeon with several agencies, private and governmental. In my case, one can only witness so much tragedy and suffering before one is moved to help. After waiting several days without response, I gave up the pursuit, assured that somewhere my name was on a list. Tuesday, one week after the earthquake, my operating room circulating nurse, Mike Vandervort, an old hand in Haiti from mission work in years past, told me he was leaving for Haiti in three days. I told him I would like to go and within a matter of an hour or two I was on the roster to go. This would be at the behest of OMS, One Mission Society. To my surprise, the next day my wife, Debbie, said she would like to go also. And so it was the four of us, Mike, his wife Dawn also an RN and Debbie and I were on a trip which ultimately landed in Cap Haitian on the northern coast of Haiti.

After we landed in Fort Lauderdale on the first leg of our trip one of the luggage porters asked where we were going with all of our supplies, 23 boxes and packed luggage with donated supplies. Airtran had flown it down from Baltimore gratis. I told him we were headed to Haiti. In broken English he explained that he was from Haiti also and his wife lived in Port-au-Prince and he had not heard from her since the earthquake. He did not know if she was dead or alive. He gave us his contact information as well as information about his wife. Dawn noticed the address was the same street as the Villa Ormiso, the Mission’s Villa. We told him we would find out what had happened to his wife and family.

Cap Haitian was unaffected by the earthquake except to note the huge influx of displaced persons, surviving family members and refugees, that had streamed north from the earthquake zone. This placed a big burden on the resources of Cap Haitian. Importantly, it afforded us an opportunity to see what Haiti was like before the earthquake. It was my first trip to a Third World country. Haiti is more destitute and impoverished than I could have possibly imagined. It is hot, crowded, dirty and smells. But it is also a place of raw, almost primitive beauty where people make due, live for today and smile a lot.

After we arrived at Cap Haitian we had a lovely dinner with Haitian friends of Mike and Dawn. .

Saturday we spent a pleasant day with the missionaries, the same mission Mike and Dawn had lived at for eight years. Later, other members of our contingent arrived. While there, we had to fill out insurance forms required by the Mission to underwrite the risks incurred by those of us entering the earthquake zone. In addition to contact information there was the disquieting request to name the place where we would want to be interred. Mike wrote “where I drop”. Debbie and I wrote a more realistic location. The next day, Sunday morning, we all, along with luggage, supplies, and Haitian translators, got on a truck and went down Carrefour. It was a long, bumpy, dusty eight hour trip to Port-au-Prince. The pot holes would easily swallow a small automobile and how the axle was not ripped from the chassis I will never know. Debbie, because of her bad back and me, presumably because I was the oldest member of the party were afforded the luxury of riding in the cab. The folks in the back, sitting on narrow benches and on luggage were in short order covered with a choking, tenacious dust. The road was a bone jarring combination of ruts, craters and foot-high speed bumps. It is the main north-south highway connecting Port-au-Prince and the north coast of Haiti. The only semblance to a highway is that there are occasional sections which are paved. It is their I-95. We passed many small towns and villages. They all appeared the same. One or two room cinder block and cement hovels all quite similar. Invariably, there were small, slightly clad children, old women, chickens, goats and the occasional prized cow or hog tethered to a bush or tree trunk. The women were sweeping dirt off of the dirt. Laundry drying on lines strung between tree limbs or simply flung over bushes. We waved, they waved back.

As we approached the suburbs of Port-au-Prince we began to see toppled hovels with fallen walls. Initially, we thought this was evidence of earthquake damage. No, we were told, this is how Haiti normally looks. People milled around looking distracted for the most part, going about the activities of daily life. This was how they normally look.

Not long after arriving at the mission’s villa in Carrefour, a western suburb of Port-au-Prince, we saw some young Haitian men surfing the net on their laptop computers. I asked Mike if he thought they might be able to locate the porter’s wife and family or perhaps contact them by cell phone. They took her phone number and were able to contact her immediately. It turns out that after the earthquake Haiti had changed its international exchange. It was a simple matter to correct this and after we advised his wife of her husband's concern she promptly called him. We counted this is our first miracle.

Later that afternoon, before dark, we unloaded our luggage and went up the hill to Daquini to the abandoned home that would be the site of our clinic. The home had a commanding view of the Bay where we could easily see a small flotilla of naval vessels swinging at anchor and of course, the USNS Comfort. I found it reassuring to have a completely self-contained tertiary medical center a short helicopter ride away. I asked Gavin McClintock, an emergency room physician from Northern Ireland and the head of the mission’s activities on the hill, what contingency plans he had to evacuate a critically ill patient off the hill and he replied “none.” This was not reassuring. We set up the pharmacy in the shed used for lawn care materials and pitched the five tents, donated by the Rotary Club International, that would serve as our clinics and, it turned out, our operating room.

The next morning we drove up the hill. As we approached the gate to our clinic we noted that both sides of the path were lined with patients. When they saw us putting together the clinic the evening before, word must have traveled quickly. They parted ways as we drove into the clinic. No rush, no disorder. Patience is the Haitian way.

Patients outside the gates to the clinic.

In the meantime, I went to the Hospital Adventiste to offer my services as a surgeon. I met with the ostensible chief and he said the place was crawling with surgeons because coming to Haiti was suddenly, the ‘sexy’ thing to do and, while he appreciated my offer, there was little work for me. An abundance of medical help was apparent getting the patients to it and it to the patients was the problem. This is why our little tent clinic on the hill was so sorely needed.

We started seeing patients immediately Monday morning. The patients all had a story to tell. Many were refugees from Port-au-Prince, displaced by the damage to their homes and neighborhoods. They lived in a tent city which grew by the hour on the side of our dusty hill.

Most had simple problems like belly aches, most often related to intestinal parasites, headaches, aches and pains, scabies and general anxiety manifesting as somatic complaints. Virtually all got treatment for worms. Most left with acetaminophen, ibuprophen and an oral cephalosporin.
The clinic pharmacy

Debbie and I in the dispensing area of the pharmacy. I am pouring anti-scabies medicine into little bottles between cases.

All were given reassurance and an opportunity to convert from voodoo and black magic to Christianity. It was not long before the ER docs were convinced many of the patients were suffering from post-traumatic stress disorder. This was entirely understandable considering what had just happened. Many, in fact most, people related the loss of a child, spouse, parent, brother or sister. They seemed to share a collective grief.
Our waiting room.

I immediately started seeing neglected wounds on arms and especially legs. Some were infected and required debridement of necrotic tissue. Many people who saw us off at home figured I would be doing a lot of amputations from crushed and badly mangled extremities. This was not the case. By the time we arrived all of the limbs requiring amputation had only been removed or the patient had expired.
A cinderblock fell on this leg.

She cut her foot trying to escape her collapsing home

Other issues requiring surgical attention started to appear. A two-year-old boy was brought to us by his mother. He had suffered first and deep second degree burns over his right arm, shoulder and chest. This had occurred when he fell into the family campfire. Before arriving at the clinic someone, probably a voodoo doctor, had covered the burns with gentian violet. He was covered with a thick, dried, purple crust. I gently picked this off and found that the burns were already healing quite nicely. We gave him a tetanus shot and some antibiotics and pediatric analgesics and advised him to return daily. We saw him the next day, picked at the gentian violet again and were pleased with his progress. We never saw him again.

The next most memorable case was that of a two-week old little boy named Daniel who appeared dead as his mother handed him to me. He was critically dehydrated, lethargic and did not move. It turns out that his mother had tossed him out the window when the earthquake started. She and the rest of her family got out before the building collapsed. From what we gathered in the translation from Creole to English she was advised not to breast-feed baby if it was crying. This admonition resulted in the rapid dehydration of this infant. His eyes were glazed over, he had virtually no skin turgor, and his anterior fontanel was completely hollow. We had no intravenous fluids available so I started to feed the baby a solution of water and brown sugar reduced to sweeten our morning coffee. The baby wasted little time sucking down the fluids. Finally one of our nurses pulled out some Propel which we also mixed in water and fed this to him as well. Several hours later we convinced the mother to resume breast-feeding and he took to the breast with great abandon. She brought the child back everyday until we left and each day he showed further improvement. He was a survivor.

Debbie getting to know Daniel a little better

Once word got out that there was a surgeon in the clinic all manner of minor surgical issues appeared. It wasn't long before we had numerous lipomas, sebaceous cysts and a large congenital nevus of the face and a chondroma of the ear to remove. These minor procedures were performed under the most primitive conditions using nothing but local anesthesia. We sterilized our instruments between cases with bleach and rubbing alcohol. In each case the patient was very happy to lose a disfiguring lesion. (We later learned that they returned for follow up visits and suture removal. All wounds were healing very nicely without infection.)

Congenital Nevus, before


On several occasions after arriving in Carrefour we experienced after shocks. While it awakened many, caused panic among the nurses sending them screaming into the night. I managed to sleep right through all the excitement. One particularly severe tremor occurred during breakfast. It registered 4.6 magnitude. Again panic with everyone heading for the door. I continued to eat my pancakes. The night before I had a long chat with an American contractor who happened to be a structural engineer. His inspection told him the building was earthquake proof. I felt rather smug, grinning at my own bravado. No one else thought this was funny.

One afternoon a UN truck arrived at our gate. There were boxes of food donated by Walmart of Mexico. Each contained a bad of noodles, rice, sugar and cans of tuna and meat. Each was meant for one family. Within minutes a crowd of several doze people arrived seeking food. The tent city, we were told, was populated by over a thousand families. Perplexed and uncertain what to do, the Haitian driver, asked me through the fence what he should do. I had no easy answer for him and not wanting to start a riot, he turned the truck around, still loaded with the parcels, and left.
The UN food truck

The last day we were at the mission, after breakfast, I was approached by the one of the drivers and manager of the villa, Winkney. He asked if we could immunize his children, his nieces and nephews and the children of the cooks in the kitchen. I said we had long since run out of tetanus toxoid and that I was sorry. He and I were both aware of tetanus, lockjaw, which was affecting so many injured Haitians. Interestingly, we had heard rumors that the American doctors had never seen such cases and did not know how to treat it. That was when the second miracle occurred. Delivered to the clinic that morning had been several multidose vials of tetanus-pertusis and diphtheria immunizations. Winkney, for the first time in our stay there appeared at the clinic to attend to some chores. I asked Winkney how many doses he needed. Twenty. Dawn tucked two vials into her backpack and twenty syringes. After dinner we had an inoculation party. Unfortunately, more kids showed up than we had immunizations. A dozen or more had to be turned away.
The “Inoculation Party”

Post-Party group picture. Winkney is on the far left.

Something we as parents take for granted, ‘getting baby’ shots for our kids, is a luxury for these people. It broke our hearts.

In just 4 days on the hill, the clinic saw 1104 patients.

There were several reasons why the damage was so severe and widespread. The cinderblocks were poorly made and were not allowed to cure sufficiently to acquire strength, barely a step above mud bricks. The cement mix was diluted by excessive amounts of sand to make it go further. Minimal re-bar was used to support the structure and there is no foundation. There are no building codes in Haiti. No one could afford to build a home, no matter how austere or primitive, if they had to comply with anything resembling building codes.

Haitians are very proud, resourceful and resilient people. Their gratitude for our services was plain to see. One elderly woman after having a large disfiguring sebaceous cyst removed from her chest wall walked through the camp, hugging every white person she saw. Haitians always seemed to be walking somewhere. Cell phones were ubiquitous. There was the occasional mp3 player. Motorbikes laced in and out of traffic with suicidal abandon often carrying several people at once. I once counted five adults hugging each other on a motors-scooter like slices of bread in a loaf. Rarely saw anybody smoking. For Haitians, seeing a doctor was a privilege and they came to us in their finest clothes. Even little Daniel, near death was dressed as if he were about to be baptized.

As we left Port-au-Prince we had the chance to drive through the earthquake zone in the central part of the city. The damage was staggering. Buildings collapsed and were knocked down like dominoes. Some of the wreckage had not been touched and no doubt still contained bodies. The Presidential Palace had simply imploded leaving the once elegant rotundas cocked to the side. The cathedral was a ruin as if bombed from the sky.
The Presidential Palace

Lastly, at the end of our stay, Mike and Dawn stayed another week, Debbie and I tried to leave Haiti. The first day we got on a standby list and none of the little trans-Caribbean airlines that service Cap Haitian had available seats. Discouraged, we got up at 5 AM Sunday morning and went to the airport to be first on standby. After waiting around for several hours it was getting increasingly clear we would not get out then either. Late morning, a Navy Blackhawk helicopter landed to off-load some supplies. I ran out to the crewman and asked if it were possible to get a lift to Port-au-Prince airport to get a flight out. He checked with his superiors and we were taken aboard. What had taken eight or nine hours by truck took us about 45 minutes by chopper. We refueled on the back end of the frigate USS Underwood before finally arriving at the airport. We were taken into custody by some State Department officials and waited in a tent. Turns out we had two choices. Fly to Miami in an Air Force C-17 cargo plane without certainty when we might leave if at all or we could get on a United 767 that had been chartered to bring in supplies. It would be deadheading back to Chicago. If we wanted to go along we could then make our own arrangements to get home. It was a no brainer. We boarded the 767 and the crew treated us like returning heroes, which of course we were not, but it felt good to be heading back to the US. We caught a late flight from O’Hare to Dulles and finally got home at 3 AM, nearly 22 hours after leaving the mission.

The Navy Seahawk I flagged down.


It is difficult to image abject poverty on the scale we saw everywhere in Haiti. People in our country living at or below the poverty level would live like royalty in Haiti. The history and politics of Haiti are complex and not easily understood. Haitians, in their slavery, ousted by armed revolt, the forces of Napoleon. It may have been the high-water mark for Haiti. Crippling reparations to France and a general disdain for a free, independent black state in the Western Hemisphere doomed them and the Haitians, it is said, never got over being slaves, dependant on their slave masters. Everyone with whom I discussed Haiti, its current situation and history said it ran better when it was under the control of the Duvalier’s. They were not benign dictators by any means but there was a central authority and an army and the Haitian people, for the most part, got along pretty well. Democracy was a dismal failure under Aristide. The extent of corruption at every level of government is mind-numbing. There is no controlling authority. The worst thing that happened to Haiti, I was repeatedly told, was the disbanding of the army. Everyone fortunate or clever enough to get an education or the opportunity leaves Haiti and does not return producing a permanent, crippling brain drain. Simply put it is a country devoid of infrastructure and its best and brightest.

Looking around, I found it difficult to know where the endpoint is after this disaster or who will know it or when it might arrive. But for a brief time we did our best.
The Happy Campers. Dawn and Mike are to our left.

The Haitians have a saying which describes their predicament, their poverty and isolation: The rock in the cool water knows not the pain of the rock in the sun.

For corresponding pictures go to my Facebook page Wes Harden III