stanford medicine


Valley of hope


Valley of hope

A report from one of Haiti’s few working hospitals

“Is this your first visit to Haiti?” the attending doctor, Cynthia Racine, asked me. A Haitian-born, U.S.-trained physiatrist who works at a hospital in Brooklyn, Racine arrived as a volunteer at Hospital Albert Schweitzer two weeks after the earthquake. “And today is your first time in the hospital?” She raised her eyebrows. This isn’t like the hospitals you are used to, those eyebrows said.

I took a deep breath, swatted at a mosquito and followed her into the wards.

It was early on a February morning, a month and a half after the devastation of the 7.0 magnitude earthquake. Already the tropical heat was blasting and a wet blanket of humidity hung in the air.

I’d arrived in Haiti the night before to report on this small 80-bed hospital in the Artibonite Valley, relieved to have missed the horrors of Port-au-Prince in the days following the quake, the dead bodies left to rot in the heat, the looting. My flight was only the second to arrive from New York after the re-opening of the airport. The cracks were still visible in the airport walls, the tarmac crowded with military and U.N. trucks and the white tents of aid agencies.

After a three-hour bumpy truck ride past the capital’s tent cities and into the barren terrain of the Haitian countryside, I arrived at the town of Deschapelles, and this 54-year-old hospital started by the Mellon family of Pittsburgh with wealth from the family business, Gulf Oil.

Word got out quickly that the hospital was undamaged after the quake. In two days, its patient load swelled from 80 to 800. Within weeks, thousands of refugees had come to the Artibonite Valley to stay. By the time of my visit, the patient load had dropped but was still twice the hospital’s normal capacity.

We wound our way through the wards — through post-op, then pre-op, then the neonatal ward and, finally, pediatrics — each a small room crowded with patients and their families. People cooked meals in the corridors; through the hospital windows you could see them doing the laundry in an outdoor courtyard, draping dresses and sheets to dry over dusty bushes.

A young man seated on a stretcher in the hallway lifted his amputated leg high for the doctor to examine as we walked past. He looked calmly from the oozing open wound to the doctor, who shook her head, no. He was not ready to leave yet.

I took another deep breath.

The earthquake victims were scattered between the burn victims — mainly children who had fallen on the open fires that many Haitians cook over. The hospital’s other patients included a man who had lost toes from diabetes, a malnourished child hugging stick-thin legs, a motorcycle accident victim with a broken neck who spasmed uncontrollably.

Only the complicated earthquake cases still remained — those with the deepest wounds, the crushed bones, the severed spines. The amputees whose stumps hadn’t healed well.

As we continued winding our way through the wards, it was the strength of the Haitian people that struck me most. The single mother of five singing soft lullabies to her baby boy in her arms, sitting by her 19-year-old daughter lying in a bed paralyzed. A 5-year-old boy helping his horribly burned 2-year-old sister move her arms and legs in circles for physical therapy.

The air grew heavier and my knees weakened as I struggled to catch my breath.

At the end of the hallway, an adolescent boy near my son’s age allowed the physical therapist to move his burned arm up and down, up and down. He smiled bravely to hide the guttural moans of pain that filled the room. And I turned away to hide my tears.

I’d been told repeatedly the Haitians were a resilient people. They’re survivors. Two days after the quake, the hospital ran out of pain relievers. Within a week the antibiotics were gone. Limbs were amputated with no pain relievers at all. And still, no one complained.

“They’ve had so much thrown at them, they just get up and go,” Racine told me with a shrug as she moved on to the next patient.

The operating rooms had finally thinned out. The amputations were over. The stunned and somewhat giddy staff, sleep-deprived and deeply moved, had a moment to pause and plan.

What next?

One night after my tour, at the end of another long day, I found the managing director of the hospital, Ian Rawson, at home at his dining table in front of a sewing machine. Reading glasses balanced on the tip of his nose, he squinted down at the curtain he was hemming, a curtain that would give amputees privacy while being fitted with their new prostheses.

Providing limbs to amputees had become a new focus for the hospital. So at the end of a long workday, he pulled out the sewing machine and threaded a needle.

For weeks after the earthquake, Rawson’s day started before dawn and stretched late into the night. Reporters and aid workers, volunteer surgeons from Harvard, anesthesiologists from MIT, Project Hope workers and physical therapists from around the world had rotated through his home, next to the hospital. The work had slowed somewhat when I arrived, and finally near the latter part of February, he had some time to reflect.

“We’ve redefined ourselves as a result of this tragedy,” says Rawson, referring to the hospital and its staff of 15 doctors and 50 nurses. “None of us who were in the middle of this will ever forget it.”

In the weeks and months following the quake, as a panicked country buried its dead and tried to care for its injured, a plan to save Haiti had begun to emerge, resting on the policy buzzword “decentralization.” With the capital city of 3 million in a country of just 8 million virtually destroyed, Haiti’s survival depended on building the infrastructure of the countryside, agreed both the Haitian government and the international community.

As just one small hospital, in one small, poverty-stricken valley, the task of opening its arms to the rest of the country appeared daunting. As one of only four surgical hospitals functioning in the entire country, Hospital Albert Schweitzer was struggling.

But Rawson remained hopeful. “We’re not rebuilding Haiti,” he says over and over during my weeklong visit, repeating the words he’d heard many times at meetings of aid organizations and government officials. “We’re building Haiti.”

I knew a little about the hospital’s history when I arrived in Haiti, about its reputation for stability and excellence in a country where the health-care system has little of both. These qualities inspired the Stanford community to donate $370,000 to the hospital following the quake.

“It was pretty clear to us, this was the place that needed health care the most.”

“The hospital has been there for 50 years,” says Michele Barry, MD, Stanford medical school’s senior associate dean for global health, who fondly remembered a residency early in her career there. “It will be there for 50 more years.”

But I wanted to hear the story firsthand.

Seated on the couch in his home, Rawson told me the story. His mother and stepfather, Gwen and Larimer “Larry” Mellon were so inspired by a 1947 Life magazine article on the medical missionary to Africa, Albert Schweitzer, and his philosophy of “reverence for life” that they became disciples of a sort. After searching for the place in the world where they could relieve the most suffering, they leased an abandoned Standard Fruit Co. banana plantation from the Haitian government and began building Hospital Albert Schweitzer while Larry finished medical school at Tulane University. Medical school, which Larry started at 39, was part of the plan. And Gwen studied to become a laboratory technician.

The family had traveled to the Yucatan and Peru searching for the right place for their hospital. But the overwhelming need for health care in the Artibonite Valley, a patient base of 185,000 with not a single doctor, drew them in instantly. They founded the hospital 54 years ago, years before Paul Farmer — made famous by Tracy Kidder’s book Mountains Beyond Mountains — founded his own small hospital just a few hours north.

Valley of hope

“It was pretty clear to us, this was the place that needed health care the most,” says Rawson, 70, who first traveled to Haiti with his family when he was 10 years old. Three years ago, he retired to the area with his wife, Lucy, after a career as a senior manager at Allegheny General Hospital in Pittsburgh. His mission in retirement: to continue his family’s legacy.

“My mother would say, ‘Haiti chose us,’” says Rawson, who has a PhD in medical anthropology from the University of Pittsburgh and served as president of the Hospital Council of Western Pennsylvania.

The hospital has made a tremendous difference in the valley. The Mellons’ emphasis on community-based primary care has resulted in a virtual eradication of tetanus. Typhoid has been greatly reduced. The valley is now almost free of blindness caused by vitamin A deficiency and outbreaks of measles. Life expectancy has increased from 30 to 53 years. Diarrhea, pneumonia, AIDS and TB are no longer death sentences. Daily it continues its battle with malaria, malnutrition and typhoid, saving countless lives. It’s seen patients through hurricane devastation, AIDS epidemics and outbreaks of antibiotic-resistant tuberculosis.

But still, the hospital had never seen anything like the disaster headed its way Jan. 12.

Rawson was driving Haiti’s back roads, headed home to Deschapelles on Jan. 12 when the earthquake struck at 4:53 p.m.

“Suddenly the car veered to the left side of the road and went into a ditch,” says Rawson. “I thought I’d broken a tie rod or had a senior moment.” The country folk started pouring out of their homes, wailing and waving their arms, a blur of brightly colored clothes. Rawson realized then that there’d been an earthquake, a tremblement de terre, but he had no concept of just how bad. He drove on.

When he arrived home, he first checked the hospital for structural damage. Everything was intact. But the cell phone towers were down, and he has no TV, so it would be hours before news of the devastation and loss of life 60 miles away in Port-au-Prince began to trickle in.

At 8 p.m., the pickup trucks, the colorful tap taps that serve as taxis, started arriving, continuing through the night and into the next day and the next. Families and neighbors loaded their injured into the backs of these trucks and drove the three hours north from Port-au-Prince to the Artibonite Valley.

They used the front doors of their destroyed homes as stretchers and prayed the injured would survive the journey. But sometimes it was too much, and cries would arise from the family at the shock of the loss of their loved ones.

“In the back of the truck are one or two people, their legs or arms covered in bandages or clothes,” Rawson wrote in a blog he started the day of the quake. “Security staff rush out to the truck with a backboard or a gurney and bring the patient inside to be triaged by the emergency team.”

With the arrival of each new truck, the reality of the devastation caused by the quake began to sink in. The radio news reported that the National Palace had collapsed, that hundreds of thousands might be dead, that hospitals had crumbled, that the international airport was closed and medical crews from around the world were desperately trying to get into Haiti to help.

It took one week to run through three months’ worth of supplies. As the days passed, Rawson’s blog grew increasingly desperate. The injured waited in line for surgery for days, weeks sometimes, but didn’t complain. When a patient began to smell like rotting meat, the gangrene had set in, and he or she was moved ahead in line.

Jan. 13: “Two school buses filled with patients just came to the door,” Rawson wrote. “We sent to St. Marc to buy a dozen more beds and mattresses in the market. We are all exhausted. I haven’t left the hospital for two days except to take a shower and change. And I have been lucky — others have just stayed through.”

Jan. 17: “Overnight, several patients have died, of a combination of their injuries and sepsis,” Rawson wrote. “We have run out of antibiotics. We have never had enough pain medicine, and the usually stoic patients are now succumbing to days of unrelieved pain….”

Jan. 18: “Many of our patients have been in our hallways now for days, patiently waiting for help. We have become good friends and I appreciate their forbearance when I explain why they have not yet had their much-needed surgeries. Their pain is becoming more intense, but they always respond with a smile.”

Several days after my arrival in Haiti, I crowded into the back seat of Rawson’s car with the members of a newly formed mobile rehabilitation team from his hospital to travel to Farmer’s hospital, Zanmi Lasante, two and a half hours farther north, in the town of Cange. With estimates of the number of amputees in Haiti reaching as high as 4,000, prosthetics care and rehabilitation services were in great demand.

Just a week earlier, Hospital Albert Schweitzer had become the site of a prosthesis factory and rehabilitation lab. Prosthesis producer Hanger Orthopedic Group Inc. had set up the factory at its own expense, shipping in 13,000 pounds of fabrication equipment and machinery. Hospital Albert Schweitzer was prepared to teach amputees from across the country to walk again.

When Farmer called Rawson about the need for prostheses for his patients, a mobile team was set up — a perfect example of the future coordination of services that Haiti will need more of in the future, Rawson says. Hospital Albert Schweitzer’s prosthetics team would serve the patients at Zanmi Lasante as well.

The miles of open countryside rolled past: women with baskets of fruit and laundry balanced on their heads, children bathing naked in streams, huts with corrugated metal roofs, donkeys, goats. Vendors along the roadsides sold rocks and charcoal and sugar cane laid out in neatly organized piles. Pickup trucks, top heavy with passengers and loaded down with luggage and an occasional strapped-on mattress, passed by as refugees from Port-au-Prince headed out of town looking for homes out in the country.

I’d seen the first amputee fitted with a prosthesis kicking a soccer ball around the rehabilitation lab the night before.

Almost every family in the Artibonite Valley was housing friends or relatives newly homeless from Port-au-Prince, Rawson told me.

The limited infrastructure that once existed in Port-au-Prince completely disappears in the countryside. There are no public services. No waste-removal systems, no running water, no electricity. As in most of the country, garbage is piled up, squirted with gasoline and lit on fire. As the miles rolled by, the concept of “decentralizing” Haiti grew more overwhelming to me.

Why would all those Haitians who had once escaped the poverty of the countryside, migrating to Port-au-Prince for the opportunities of city life, return to the country to live for good? How could a government criticized for its inability to run its own country be able to build new homes and schools and clinics out here?

In Mountains Beyond Mountains, I’d read Kidder’s description of Farmer’s hospital, an oasis of hope in perhaps an even more destitute spot than the Artibonite Valley. But when we drove into the town, it looked just like one more forlorn stretch of the highway, the hospital hidden behind a high wall.

Valley of hope

This was the rehab team’s first trip to Zanmi Lasante. Jay Tew, a prosthetist, newly arrived from Lafayette, La., who works for Hanger, and Sean Cleaver, a physical therapist on Hospital Albert Schweitzer’s staff, originally from Canada, planned to measure the limbs of five amputees and form five plaster casts to take back to the prosthetics workshop. From each cast, a technician would make a mold to create a plastic socket — the part of the prosthesis that fits over the stump. Last, a technician at a workbench would assemble the limb, complete with tennis shoe or flip flop or work boot attached.

Eventually, the patients from Zanmi Lasante would travel to Hospital Albert Schweitzer to be fitted with their custom-made prostheses, and the physical therapists would teach them to walk again.

I’d seen the first amputee fitted with a prosthesis kicking a soccer ball around the rehabilitation lab the night before amid the cheers and laughter of amputees waiting their turn.

“Does it hurt?” Tew asked a 16-year-old girl in a tube top, both her legs amputated below the knee. He was pulling a white prosthetic sock over her stump in preparation for making the cast. Cleaver knelt next to the two of them, translating Tew’s southern twang into the native Creole.

She nodded yes, her eyes wide with fear.

Within a month, back at home, I’d see this same girl on an MSNBC news show, walking around the hospital, laughing and joking with Tew, proudly showing off her two new legs.

A month after I return home from Haiti, I’m jogging on a treadmill staring out at the lush rolling hillsides of Northern California through pouring rain. When my cell phone rings, a halting voice comes through:

“This is Jean, remember me?” It’s an aspiring priest from Zanmi Lasante who lost his arm in the earthquake, trapped for 24 hours beneath rubble. He’d told me in halting English of his fear that he’d never become a priest because he could no longer raise both arms to properly celebrate the Catholic mass. “I’m going to France,” he says, through static. “A bishop is paying my way. Don’t forget about me. Please send money.” Then the line goes dead.

Images of Haiti run through my mind. Sidewalk markets in Port-au-Prince built upon piles of rubble between block after block of tent cities. Haitians selling pineapples, cell phones, charcoal. A young boy skinning a pig in a gulley by an open-air market in Deschapelles. Schoolchildren in neat uniforms crowding around my camera. Truckloads of Haitians fleeing the capital searching for a place to live.

The boy with burns in the hospital, smiling through his pain.

Hospital Albert Schweitzer has undergone a transformation in the months since the earthquake. It’s fitted nearly 300 amputees with new prostheses. On average, 35 percent of its patient base regularly comes from outside the Artibonite Valley. As one of the only functioning surgical hospitals in Haiti, it plays a key role in coordinating services, and its leaders talk to Ministry of Health officials and various hospital administrators on a daily basis. The goal of decentralization is still a good one, Rawson believes.

“The world has changed for us,” says Rawson. “There are new attempts to integrate health-care services across the country. We’re being called upon to do things we’ve never done before.”

But what he wants people to know most about the earthquake was the incredible perseverance of the Haitian people, Rawson says.

“What I remember mostly of those weeks after the quake are the faces of the patients. Moving them to the operating room. Helping to clean them. To get them ready for surgery. To look into their faces and to see how little people here complain about their obvious pain and anguish. Every patient has gone through difficulties in their lives. They learn they can get through it. That the pain will pass. It’s absolutely incredible.”

Media reports in the United States about Haiti have dropped off dramatically in the five months since the quake. The fevers and nausea that followed me home have completely disappeared. I woke up once in the middle of the night, the week after I returned, tears on my cheeks. But now I sleep just fine. Perhaps I complain a bit less, and appreciate my life a bit more. I hope so.

“When will you be coming back?” the staff asked me when I left the hospital. It’s the same question they ask everyone who visits for the first time, full of good intentions, then returns home to hot water, overstocked grocery stores and weekly garbage service — never to return.


More stories and images from Haiti are available on the School of Medicine's Scope blog.


E-mail Tracie White






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