As soon as the shaking stopped, the first wave of misery began.
For badly injured victims of Haiti’s massive earthquake and the crews who rescued and treated them, the early days have been all about survival.
“From a patient’s point of view, you’ve got about 48 hours,” said Dr. Jerry L. Mothershead, a Norfolk, Va., emergency room physician and a disaster response consultant. “A few might make it longer.”
But in the days and weeks ahead, public health experts say Haiti can expect new rounds of health problems to emerge and worsen, challenging even the best efforts of a global humanitarian response.
Thousands of deaths likely will be added to the estimated toll of 50,000 as infections from untreated or poorly treated injuries set in, said Dr. Thomas Kirsch, co-director of the Johns Hopkins Center for Refugee and Disaster Response. Victims crushed beneath falling buildings and other debris would have required the skills of entire trauma teams in a developed nation. In Port-au-Prince, medical crews are running short on staff, pain medication and bandages.
“Haiti has no surge capacity at all,” said Kirsch, who is also the national physician adviser for the American Red Cross and a veteran of hurricanes and the Sept. 11 terror attacks. “The issue now is the lack of resources.”
Even as foreign medical crews begin to make their way into the capital city hit hardest by the magnitude-7 quake, more basic problems loom in a nation that has long struggled with poverty and hunger, said Dr. Curtis E. Cummings, an associate professor in Drexel University’s School of Public Health and an expert in public health readiness.
“A destroyed infrastructure means no clean water or food,” he said. “There are already high levels of diarrheal disease, respiratory disease and malnutrition. Bad will go to very much worse.”
Mild illnesses pose deadly threat
Outbreaks of cholera, dysentery and other illnesses are expected to skyrocket. With people congregating in refugee-like conditions, mingling at aid sites, contagious diseases will spread rapidly. Even simple illnesses like colds and flu — including the H1N1 swine flu, now the dominant strain — could threaten immune-compromised people.
“Those are the things in refugee camps that nail people,” Mothershead said. “What they need is water, plastic sheeting and moving the porta-potties away from where the people are.”
After the 2004 tsunami in Indonesia, acute cases of diarrheal illness in Thailand nearly doubled from the previous year, according to a report in the Journal of the American Medical Association. Wound infections jumped, including a scourge of hard-to-treat drug-resistant infections. And some people developed a disabling or deadly type of pneumonia called "tsunami lung," caused by swallowing saltwater.
Earthquakes pose different dangers. Tens of thousands of victims in Haiti have suffered crush injuries, which harm victims not only through the initial trauma, but also later, when damaged muscles pour toxins into the bloodstream, often leading to kidney damage.
The situation is especially dire for children, who make up an estimated 40 percent to 50 percent of the Port-au-Prince population. They're smaller and more vulnerable to injury than adults, but they also suffer faster from dehydration, blood loss and shock. Their immature immune systems also make it harder to fight back against illness and infection than adults, health experts said.
In the meantime, medical teams on the ground will continue to grapple with the aftermath of early triage, which postponed treatment for those whose injuries may have been serious, but not life-threatening.
Victims with arm or leg fractures, for instance, wouldn't have been a top priority, Cummings said. But the untended wounded remain ripe for infections and shock and they're more vulnerable to other illness.
It’s a no-win choice for health workers who have to make hard decisions about who gets care — and who doesn’t.
In a catastrophic situation, doctors will exclude “expectant” patients — people they know are going to die — and they’ll defer care for survivable injuries. That reserves life-saving effort for the worst injured with the best chance of surviving.
“We have only so many resources. We have to look at who we can save here,” said Cummings.
Rescuers and public health officials shouldn't spend much time worrying about the health risk of the corpses piling up on the city's streets, Cummings added. Contrary to common belief, dead bodies don't spread disease, especially when they've likely died of trauma and not infection.
"They're just not the problem people think," he said.
Intervening in a disaster of such magnitude — whether it’s a massive earthquake in a country of nearly 9 million, the series of hurricanes that slammed Haiti last year, or the tsunami in Indonesia — is not for the inexperienced, Kirsch and Mothershead emphasize.
Help is needed, but it must be the right kind
Volunteer crews of doctors, nurses and other health workers are clamoring to fly to Haiti, motivated by compassion, adrenaline or even a sense of adventure, said Kirsch.
“You take all these rich Westerners who want to fly down there and help,” Kirsch said. “They become more a burden than they are help.”
Organizers on the ground in Haiti are calling for trained surgeons with experience in battlefield or disaster conditions. Medical crews with little training in working in developing nations would do better to send money — and stay home, Kirsch said.
In past catastrophes, Kirsch saw well-meaning volunteer medical crews show up, only to become overwhelmed by rugged demands of the job and the lack of resources for their own comfort.
“The best way to help is to give money to the experts who know what the needs are," he said. "That’s the way you help the world.”
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