Year after Haiti quake, agency asks how far it can go

By Stephen Smith
Globe Staff / January 11, 2011

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PORT-AU-PRINCE, Haiti — A lanky, square-shouldered man, his bearing courtly, presides over a water jug, carefully twisting its spigot so the ill and those who treat them can cleanse their hands.

Once inside this field clinic, established amid a congested tent settlement by the Boston-based charity Partners in Health, patients receive a booklet that serves as their medical record and a plastic sheath to protect it. Everybody is seen. No one is charged.

Before the earth parted last Jan. 12, most of the patients who flocked to this makeshift medical ward in a place called Camp Dadadou had never seen anything quite like it. They were accustomed to this city’s main hospital, where resources are scarce, care uncertain, and patients provide their own bandages and pills.

But the earthquake, which struck a year ago tomorrow, left little untouched, transforming not only Haiti but also Partners in Health, an agency born in the nation’s denuded countryside more than two decades ago. The charity has expanded at unparalleled speed, both on its familiar turf and in the cacophonous and chaotic capital city, where it has established a beachhead for the first time.

“Here, in Port-au-Prince, you learn not to expect much,’’ said Madeline Tresmutus, a 25-year-old who came to the Dadadou clinic with an infection and a pounding head. “But my sister came here, and she told me the help is very honest. And it’s free.’’

With thousands of bodies and minds shattered and the emergence of a lethal cholera epidemic the Partners in Health workforce in this country, constituted almost exclusively of Haitians, soared from roughly 4,400 before the catastrophe to 5,500 now. Fueled by donors who showered it with $89 million, Partners in Health hired mental health specialists, recruited amputees to visit the limbless, and sheltered forsaken children. And, in its most prominent bricks-and-mortar expansion ever, it is building a $15 million, 320-bed hospital in the hills north of Port-au-Prince.

So much growth so fast has sparked soul searching, even trepidation, at an aid agency that as recently as eight years ago worked in just one bucolic village, Cange, and scavenged for donations. Much as Haiti stands at a crossroads, so, too, does Partners in Health.

Will it remain for the long haul in the capital city, where it sees 7,000 to 10,000 patients a week in camp clinics? And how will it sustain the post-earthquake expansion as interest in Haiti wanes and generosity flows elsewhere?

The answers to those questions will resonate across a country whose medical system was fractured even before the earthquake: Partners in Health plays a singular role, collaborating with the cash-strapped Ministry of Health to treat more patients than any group in the country.

“You could sit somewhere far away and say: ‘Do we really want to do this? Do we want to grow this way? Do we have these resources?’ ’’ said Dr. Paul Farmer, the charismatic Harvard University professor who was among the founders of Partners in Health. “But when you get in the field and you look around, you say, ‘God, what else can we do?’ ’’

Hospital struggles
A man, so skeletal his rib cage etches a road map on his chest, sits naked under the sun. A relative bathes him on the frenetic grounds of Haiti’s University and Educational Hospital, the government-run medical center that stands as a metaphor for the nation’s frayed health care system.

Around the corner, a woman uses a can for a toilet. Outside the remains of the pediatric ward, a young mother holds fast to her 2-month-old daughter, sharing a patch of jagged sidewalk with other patients, faces sullen. Something’s wrong with the baby.

“They let us sit here all day, say nothing, and just leave,’’ said Geraldine Marcean, estimating she had made seven trips to University Hospital seeking care for her child, each time returning home by foot, a two-hour trip. “They keep saying tomorrow, tomorrow, tomorrow.’’

The hospital’s yearly budget of $5 million is consumed by meager staff salaries. Massachusetts General Hospital spends more than that every day.

University Hospital has just four operating rooms (it had a dozen before the quake). It has no intensive care unit. It relies on the good will of other governments and charities to pay for some services. It is a hospital as sick as its patients.

“We are working in very difficult conditions,’’ said Dr. Alix Lassègue, the hospital’s executive director, who wears a starched white coat and an air of resignation. “We work with the number of personnel that we have, and we struggle with the money that we don’t have.’’

The Ministry of Health, which operates the hospital, is so broke that it came to Partners in Health early in the fall pleading for cash to buy gasoline for the generators at the ministry’s provisional headquarters in Port-au-Prince.

The government also approached Partners in Health and its Haitian affiliate, Zanmi Lasante, when it became evident that the medical needs of the displaced were going unattended in the tent settlements that rose spontaneously after the calamity. The Boston nonprofit group agreed to open four clinics, even in one of the biggest, most fearsome camps, Parc Jean-Marie Vincent, estimated to house 50,000 and patrolled by armed United Nations forces.

Camp Dadadou has about one-tenth as many residents but many of the same medical woes. There are malnourished children, people with skin infections, cholera cases. One day in November, the clinic ambulance had been sent for servicing, so one of the brightly hued jitneys that ply Haiti’s roads, known as tap-taps, was hired to ferry patients needing to go to a hospital or a cholera treatment center at Parc Jean-Marie Vincent.

“You have to adjust to the situation; you have to have new ideas,’’ said Dr. Anany Gretchko Prosper, the Haiti-born physician who runs the medical operations of Partners in Health in Port-au-Prince. “The priority is to keep the patient alive.’’

The clinic treats babies, children, pregnant women, adults, the mentally troubled. A pharmacy dispenses drugs; a lab performs tests.

But the staff works in a clutch of steamy tents, with no prospect of anything more permanent. When Partners in Health approached the government about erecting a more substantial structure, Haitian officials demurred, wary of anything that suggests the tent camps are enduring fixtures.

And the clinic lacks the full complement of social and economic services that are the hallmark of Partners in Health in the countryside, where the diseases of poverty are treated, as well as their festering causes. Internally, the charity is grappling with its long-term presence in Port-au-Prince.

“Some people inside of PIH, like me, we think that if we stay in Port-au-Prince, we have to implement the full package,’’ Prosper said, citing surgical and orthopedic services as examples. “We cannot continue to give health care under a tent. At midday, it’s [more than 100 degrees] inside, you understand?’’

Quake fuels growth
As Port-au-Prince crumbled a year ago, the battered and bleeding fled by the thousands northward, bound for the healers known as “Dr. Cange,’’ the medical workers of Partners in Health.

The legend of the organization had long ago spread beyond its birthplace in Haiti’s Central Plateau. When Paul Farmer and the other founders arrived in the 1980s, they devoted themselves to treating the poorest of the poor, and those were rural peasants. Through most of its existence, the charity’s resources were so taxed treating tuberculosis, AIDS, and malnutrition that there was little money left for more specialized services.

“Five years ago, they had only one psychologist for all of the Central Plateau,’’ said Tatiana Therosmé, a Partners in Health psychologist whose diminutive stature belies an iron will.

The outpouring of donations after the quake brought a wave of new workers. The charity hired 40 mental health workers, bringing to 65 the number it has in Haiti. It also established a physical rehabilitation department.

The money pledged to Partners in Health is benefitting not only the disaster’s immediate victims. Esther Balthazar hails from a finger of land jutting into the Caribbean, far from the quake’s epicenter. That’s where missionaries from Cange discovered her, incontinent, inconsolable, barely able to communicate.

“My head was shaking,’’ Balthazar, 28, remembered. “Inside, my brain was very hot.’’

The missionaries told her: We know where you can get help.

Therosmé counseled Balthazar, who was placed on a standard psychiatric drug, Haldol. That was in February. By the fall, Balthazar was off the medication, back to school, and extending the universal gesture of welcome in Haiti, the offering of a chair.

The need to repair broken bodies was evident in the days after the quake, too. Mike Shelove Julmiste, trapped in her Port-au-Prince house for a dozen hours before clawing to survival, was ferried to Cange. Doctors told her they couldn’t save her leg.

“I cried, and I cried, and I cried,’’ she recalled. “Paul Farmer came and talked to me and said, ‘You’re going to walk again.’ I believed him.’’

And so she did, mastering a prosthetic leg in a matter of weeks. Then, Partners in Health hired her to counsel and console other amputees. She talks to them on the phone and accompanies them to a workshop where a US company builds limbs.

The charity has also ended up running a home for abandoned children. The children — nearly 50 in all, many developmentally and physically disabled — had lived in squalor, closeted away on the rambling campus of University Hospital before the earthquake. They were desperately malnourished.

With the pediatrics building damaged and the staff dead or overwhelmed, hospital administrators asked Partners in Health to take care of the children.

The charity found a partner in Operation Blessing, the relief organization founded by televangelist Pat Robertson. Operation Blessing paid $350,000 to buy a quaint country estate just north of Port-au-Prince and pledged $450,000 more to build dorms and cover maintenance.

Partners in Health promised, in return, to care for the children for the rest of their lives at the home, known as Zanmi Beni (the name translates to Blessed Friends).

One November noontime, a toddler scampered raucously across a courtyard festooned with fruit trees. His name is Steff. There were peals of laughter.

When he arrived at the estate a few months earlier, he couldn’t even walk.

Looking to future
Partners in Health has a 30-month plan to spend $135 million here. It has already used $51 million to treat patients at existing facilities, run tent clinics, respond to the cholera epidemic, and provide other medical, social, and economic help.

The burst of generosity after the earthquake yielded a long roster of individual, corporate, and foundation donors that the charity intends to tap to sustain the Haiti expansion, which it expects to be permanent.

Scaling up so rapidly poses formidable challenges, even for an organization that has repeatedly defied doubters, veterans of other aid agencies cautioned.

“Growth is hard to manage,’’ said Nate Nickerson, executive director of Konbit Sante, a small aid organization based in Maine and Cap-Haitien, Haiti. “And fast growth is really hard to manage.’’

Charities flooded with donations, Nickerson said, must balance contributors’ desire to see problems fixed swiftly with the mandate to use aid wisely.

There is also a more deeply rooted concern about whether transformative growth will eat away at the organization’s mission-driven ethos: Can its high-minded idealism of attacking poverty, not just illness, survive when it has little time to inculcate that philosophy in new workers racing from one bedside to the next?

“One of the biggest challenges is staff and making sure you hire the right staff and making sure that as this new staff comes in, they maintain the culture of the agency,’’ said Sean Callahan, executive vice president of overseas operations for Catholic Relief Services, which doubled its Haiti staff from 300 to 600 in the past year.

Ophelia Dahl, executive director of Partners in Health and one of its founders, acknowledged that the expansion of the past year “clearly does place some stresses and strains on an organization that, really, we still like to think of as a large family.

“The culture of the organization, I would like to say, has not changed except, perhaps, it’s a little bit more impersonal than it used to be,’’ she said.

Farmer, whose quest to heal the world’s poor has been widely chronicled, said the charity will not decide its future alone. It will consult with entities such as the William J. Clinton Foundation, started by the former president, and the Haitian and American Red Cross.

“The anxiety is free floating and all around,’’ Farmer said as he traveled from Haiti to Rwanda, where Partners in Health also works. “We will succeed. It’s just going to be tough.’’

Stephen Smith can be reached at