Civil-Military Medical Response to Haiti Earthquake May Be Viewed as Model for Disaster Relief

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By Matt Pueschel,
FHP&R Staff Writer

The U.S. government interagency response to Haiti after the devastating Jan. 12 earthquake has drawn praise from health policy leaders for its speed and coordination, raising the possibility of it being referred to as a model for best disaster relief practices.

"For disasters this was the best civil-military coordinated response I've seen, and most of the lessons learned are refinements, not necessarily huge mistakes," said Dr. Lynn Lawry,

Senior Health Stability/Humanitarian Assistance Specialist for FHP&R's International Health Division (IHD). Dr. Lawry traveled to Haiti in the immediate aftermath of the quake to assist with interagency medical relief coordination under the auspices of the nongovernmental organization, International Medical Corps (IMC).

The disaster scene was overwhelming. "You drive down the street, and you have to go under telephone poles and through neighborhoods where not a single building was standing," said Dr. Lawry, who was in Haiti for 10 days to provide technical assistance for the relief effort. "There were four or five bodies burning in the street that were found in the rubble. What else can you do with them? There were too many. It was pretty horrific."

DoD and NGOs work together on disaster medical relief in Haiti  after Jan. 12 earthquake. (photo courtesy of International Medical Corps)

In addition to helping with NGO coordination and facilitating flow of medical supplies from DoD to NGOs, Dr. Lawry participated in nightly U.S. government interagency health meetings that were led by the U.S. Agency for International Development (USAID) at the U.S. embassy in Port au Prince. The meetings included representatives from DoD, the Department of Health and Human Services, the State Department, Department of Homeland Security, the Federal Emergency Management Agency, the Centers for Disease Control and Prevention, and the Haiti government.

Dr. Lawry, who worked for NGOs for 16 years before she joined DoD in 2007, was part of a medical relief team composed of several IMC volunteer emergency physicians and nurses from Stanford University Hospital and Columbia University Medical Center that traveled to Haiti to help staff the university hospital in Port au Prince on Jan. 17. "The scene was apocalyptic," Dr. Lawry and her colleagues wrote in a paper that appeared in the online edition of The New England Journal of Medicine Feb. 24

(http://content.nejm.org/cgi/content/full/NEJMp1001555). "Approximately 800 victims were within the hospital compound, most of them outdoors...an internal medicine ward was packed with patients with crush and other severe soft tissue injuries, amputations, open and infected fractures, compartment syndromes, hemorrhagic shock, and other conditions threatening to life and limb...a single operating room with a few tables was staffed by overworked surgeons who amputated limbs and debrided infected tissue. The morgue was overflowing and approximately 40 bodies were stacked near the medical ward. For the next two days, we practiced continuous battlefield medicine."


Dr. Lawry, who provides policy guidance and research for IHD through a Henry Jackson Foundation grant at the Center for Disaster and Humanitarian Assistance Medicine, said the university hospital was supported by many NGOs. "I could work out non-patient issues while they were doing direct care," she said. "I knew who to call."

The hospital was secured by the 82nd Airborne Division, and Dr. Lawry served as a liaison to DoD when the NGO doctors needed certain supplies. "I pointed out where there were big NGO issues that they can help out with," she said. "I brought in the Army Civil Affairs guys, and we pointed out what we needed and they got us an extra generator and clean instruments. On behalf of IMC, I was able to help the hospital with many NGOs, and to make sure the 82nd Airborne would let local NGO staff in. And when other NGOs used up the water and food supply, I got more from the military for the hospital. I did a great deal of (facilitation of) movement (of patients and supplies)."

Although Dr. Lawry was funded for the trip by IMC, her consulting role for DoD enabled her to help with both sides. "I think it was being able to be on the ground with NGOs and coming back to the interagency coordination meetings to give the on-the-ground experience and assessments," she said. "Many weren't (seeing what was happening in the field)."

According to the NEJM article, when the Navy's hospital ship Comfort arrived on Jan. 19, the hospital's most critical patients were transferred by Navy helicopter to the ship's operating rooms and beds. "If we had not been able to transfer patients to the Comfort, many more lives would have been lost," the authors wrote. "The support of the U.S. military was unequivocally integral to the success of the medical mission. The military supplied us with critical equipment and supplies...we saw consistent professionalism, competence, and compassion in the American soldiers."

Some of the challenges encountered in the civil-military collaboration included initial confusion on what types of patients to transfer, and field litter ambulance locations and transfer times that could have been better communicated. "One of the biggest problems was the 82nd Airborne didn't have communications with the Comfort, so we had no way to call ahead, plus the Comfort couldn't have control of air space," Dr. Lawry said. "There were triage issues trying to get messages back and forth about triage problems."

Dr. Lawry also said at times there were children waiting at the university hospital for their parents, who had died in some cases, so she had to help the hospital locate local orphanages to care for them. Family members also got separated at times, such as when a baby was separated from her mother just three hours after birth. "The baby was on the Comfort and the mother was at the hospital," she said. "We reunited the mother with the baby on the Comfort. I (also) helped the Comfort liaison with local (civilian) social workers in areas so they can get patients off the ship and back home."

But Dr. Lawry said just minor refinements could be made to the mass casualty coordinated response. She said it would be helpful to have civil-military patient discharge planning up front and a mutual understanding of how humanitarian assistance works and that USAID is in the lead. Concealed weapons carry should also be emphasized to soldiers when they enter or secure civilian hospitals. Military, USAID and implementing partner briefs should also be unclassified so they can share them, sit in on each other's presentations and coordinate better. DoD's informational briefs were unclassified during the response, which was a huge help, Dr. Lawry said, although some of USAID's presentations were for official use only.

However, these issues were understandable in the face of such an extreme disaster. "I don't think anybody expected the disaster to be as severe as it was," Dr. Lawry advised. "They did the best they could with the huge numbers of patients being dropped off. I don't think anybody expected the numbers of severe injuries. It was just an overwhelming number of casualties. Next to Rwanda, it was the second worst I've seen."

DoD and IMC provide medical relief following the Haiti  earthquake. (photo courtesy of IMC)

Intersection with DoD Response

In the early morning of Jan. 12, Lt. Col. Joshua T. Stevens, USA, Commander of the 98th Civil Affairs (CA) Battalion (Airborne), was notified by the 95th active duty CA Brigade to begin planning for possible participation in DoD's Humanitarian Assistance/Disaster Response (HA/DR) operations in Haiti following the 7.0 magnitude earthquake that struck the greater Port au Prince region. Four days later, Lt. Col. Stevens deployed 20 members of his battalion CA Planning Team to form the core of the Joint Task Force (JTF) Haiti Humanitarian Assistance Coordination Center (HACC), which was aimed at meeting the CA mission planning requirements for HA/DR as outlined by DoD's Southern Command. After being stood up, it evolved into a 30-person cell that included Army and Navy CA, Department of State and Federal Aviation Administration representatives. "We chose to deploy a number of healthcare professionals to include the battalion surgeon, brigade environmental science officer and brigade veterinarian," Lt. Col. Stevens said.

About half of the HACC's members operated from the U.S. embassy in Port au Prince acting as DoD's interface with USAID's Office of U.S. Foreign Disaster Assistance, which served as the lead U.S. federal agency for the Haiti disaster response effort. This included participation in the nightly embassy meetings with Dr. Lawry and the various U.S. government agency representatives.

The HACC's other members worked at the U.N. Logistics Base, partnering with the United Nations Office for the Coordination of Humanitarian Affairs (U.N. OCHA), the U.N. Stabilization Mission in Haiti, partner nation militaries and the international humanitarian community within the U.N.'s cluster system, which includes civil-military teams focused on particular pressing issues such as health, food, water, electricity, agriculture, and shelter. "The HACC's healthcare professionals began to collaborate with a wide range of healthcare professionals working initially to provide and coordinate trauma/emergency treatment," Lt. Col. Stevens said. "The HACC established collaborative partnerships with a number of nongovernmental organizations (NGOs), private volunteer organizations, and international organizations, focusing support on both emergency and interim care."

In a supporting role to this effort, DoD worked by, with and through many NGO and host nation medical experts. Among these were IMC, the University of Miami Hospital, Project Medishare, the Harvard Humanitarian Initiative, Project Love a Child, and St. Damien's. "The primary purpose of these relationships was to assist lead agencies in establishing a network of highly capable medical professionals initially capable of patient exchange, and ultimately capable of patient decompression from the USNS Comfort," Lt. Col. Stevens advised. "The HACC was able to leverage its horizontal and vertical integration with U.S. government agencies, the U.N. and the international humanitarian community to provide these dedicated professionals with the necessary tools to enhance their respective capability and sustainability."

John Dunlop, of USAID's office of military affairs, said the military helped to get medical supplies out faster in Haiti. Former assistant secretary of defense for health affairs Dr. S. Ward Casscells said there were many USAID personnel in Haiti working with the Pan American Health Organization and U.N., and the civil-military coordination worked very well. "I've never seen anything that has worked as well as Haiti has worked, with all the different disasters I've seen," he said.

Furthermore by serendipity just a few weeks prior to the disaster, Dr. Lawry had edited and updated a new guide for DoD to work more productively with NGOs in the field (http://www.fhpr.osd.mil/intlhealth/news.jsp?newsID=130). "We put it on the DoD (Haiti disaster relief) coordination site and we got a lot of feedback quickly that it was really helpful," she said. "The (civilian) U.S. government side liked it, too."

Lt. Col. Stevens said the HACC's ability to work within the host nation and humanitarian medical networks was enabled by daily interactions between the HACC surgeon and U.N. health cluster. "This interaction provided the JTF a more complete understanding of the priorities, capabilities and challenges within the international humanitarian community, as well as the approximately 2.5 million Haitians affected by the earthquake," he advised. "The HACC was also fortunate enough to develop a relationship with Dr. Lawry, (and) through relationships established by a series of Civil Reconnaissance patrols for the purpose of conducting healthcare capability assessments at area 1, 2 and 3 clinics and hospitals."

A U.S. soldier from the 82nd Airborne provides security  outside a relief distribution point in Port au Prince, Feb. 26. (photo by  MCC Robert Fluegel)

These patrols resulted in the HACC identifying and fostering a number of key relationships with both host nation and international medical professionals that led to faster delivery of JTF and NGO resources in response to prioritized demands. Dr. Lawry said part of her role was to make the handoff of care smooth between DoD, NGOs and local providers. "I think I was able to keep people from doing harm and to think more about a long-term, internationally acceptable coordinated process," she said. "I think there are policy implications, but it needs to be done with the whole of government because the interagency response worked very well. There also could be lessons learned and discussed for the interagency (coordination process)."

Rabih Torbay, Vice President of International Operations for IMC, said he hopes the positive NGO and DoD interactions in the Haiti earthquake relief effort, from the ground on up to the headquarter levels, will be viewed as a model for future disaster responses. "The civil-military collaboration in Haiti has just been fantastic," he said. "Our interaction with Civil Affairs was mainly at the university hospital and they came in at the right time. They would do anything we asked and got us anything we needed."

That included the generator, fuel for the generator, MRE (Meal, Ready to Eat) food rations, helping with medical evacuations, and stabilizing security in and around the hospital. Torbay said Lt. Col. Stevens' response from Civil Affairs "was just fantastic" and the civil-military effort and coordination was definitely one of the better ones in recent times. "Absolutely, and we've had good cooperation (before), such as (following) the (Indonesian) tsunami and the Pakistan earthquake," Torbay said. "But this is by far one of the best interactions."

Although there are challenges with any emergency, Torbay said in Haiti's case they stemmed more from incomplete communications early on between all of the players overall, such as search and rescue teams, FEMA and Haitian authorities, but not necessarily between NGOs and the military. In the early days, he said disaster assistance response teams did not know where some of the healthcare facilities were, but CA helped with that as the mission went along. "Relating with the military, there were very minimal challenges," Torbay advised. "We had their (phone) numbers and email addresses and we could reach anyone at any time. They respond almost immediately (to our requests for assistance). Our dealing with the military was very good, but I heard the same thing from other NGOs, as well, who had the same impression. It was a really excellent response from the military."

Dr. Lawry added that the HACC was helpful as the lead civil-military coordinator.

Interagency Progress on Partnering

USAID representative Ambassador Lewis Lucke, the U.S. Special Coordinator for Relief and Reconstruction in Haiti, said he's seen USAID lose many staff, resources, clout and effectiveness over the last 30 years to the point where the agency had less than 1,000 foreign service officers and 8,000 staff in 2001. "That is unbelievable to me, but there were 300 new foreign service officers hired last year and the tide is turning," he said. "We don't have (DoD's) numbers...but when combined the skills of the two agencies become a formidable partnership."

It is a partnership that seems to be improving. Lucke said the civil-military effort in the early Iraq reconstruction days, for example, was needs-based and USAID was not at the tip of any organizational sphere there. "Many people had not heard of USAID," he said. "In Iraq, we got many things right eventually, but it took a while."

Meanwhile IHD, which focuses on developing policy for Military Health System support to stability missions like those in Haiti, Iraq, Afghanistan and other stressed areas, viewed DoD's early response in Haiti as pivotal in lending itself to help with security, logistical support and specialized essential services backup. DoD's approach to Haiti was also a self-correcting one, in which it actively sought to correct its course and apply lessons learned on the spot if needed.

Torbay said the number of casualties was really high in the aftermath of the quake and the IMC doctors were working around the clock, sometimes 24-48 hours nonstop with little rest. IMC had teams of doctors and nurses on the ground 22 hours after the quake struck, rotating in and out for 2-3 weeks at a time. "There was a time when we were seeing 1,000 patients a day in the hospital," he said. "CA personnel helped with moving patients while doctors operated, amputated and (treated), in addition to helping out with medical (tasks). CA rolled up their sleeves and helped. They stabilized some of the patients, performing some of the basic procedures, wound dressings, administering IVs, they would do whatever they could do. Especially with the number of patients inside and outside of the hospital, we had to move patients around and we couldn't have done it without them."

Looking Ahead

Ambassador Lucke called the Haiti earthquake a "disaster of biblical proportions," with over 230,000 people killed, hundreds of thousands injured, 1.2 million people displaced, 600,000 people living in makeshift camps and 15 of 16 government ministries leveled. Haiti also lost half its GDP, and it only had 30 percent employment even before the disaster.

But Lucke said the civil-military partnership is working and has helped provide Haitians with access to clean water at a 50 percent higher rate than before the disaster, 59 health facilities have reopened, displaced families now have access to portable shelters, and food has been distributed across the affected population. They are working with dozens of NGOs, and new IDP camps and sanitation projects are being prepared. "I pray we beat the rains on drainage and canals and the challenge is to decide if the international community is to restore Haiti or improve it," he said. "The U.S. administration has said it will stay the course, but that is up to Haiti. The way forward for Haiti is difficult to predict. Historically they have had weak services and government, but it is up to the Haitians on how they want to proceed. There is so much rubble, for example, it will take 1,000 trucks in 1,000 days to remove the rubble alone."

Amb. Lucke said DoD worked well and responded quickly to provide food, water and commodities at the outset of the disaster through the airport and port, and that showed the Haitians that they are supported. "The Haitians were traumatized, so the fact that was provided so quickly helped," he said. "The Haitian people are full of life and hope, and maybe are more resilient than anyone, but they shouldn't have to be."

Radiology assessments of patients on USNS Comfort during Haiti   medical relief mission.

Dr. Lawry said vodou, which is practiced widely in Haiti, may also have a role in the population's recovery in terms of how it relates to healing practices, health promotion, spirituality and harmony with the environment, and particularly, in the context of the earthquake, how the trauma and inconsistent burial of victims may affect them emotionally. "I think (Haitians) have resilience," she said. "That's not to say they won't have issues. All NGOs and all U.S. government personnel need to integrate local, traditional beliefs in helping people get better because it is a healthcare system, not just a religion. It has a role in everybody's eyes."

Lt. Col. Stevens said that as conditions in Haiti improved and healthcare transitioned from emergency/trauma care to interim care, the HACC began to look for methods of enabling the creation of a codified emergency patient referral program. "Establishment of such a network appealed to the JTF as it would serve to establish sustainable host nation and U.N. patient referral capabilities, subsequently reducing dependence on JTF transport capabilities," he advised. "The HACC was fortunate enough to begin a working relationship with IOM-Health (the International Organization for Migration--Health Division, an NGO working closely with U.N. OCHA)."

The HACC facilitated several key introductions for IOM-Health with USAID, DoS, DoD and NGOs, and IOM-Health accelerated the networking of crucial capabilities for the establishment of a robust patient referral network. "By the time I left, the emergency was winding down, coordinating mechanisms were set up, and it had definitely moved to long-term reconstruction issues as opposed to emergency response," Dr. Lawry advised. "Now it's moved to large groups of displaced persons, (who are at risk of) water-borne diseases, (and there are) sanitation (issues). Some of the Haitian hospitals are starting to come back online and asking for help from NGOs. About 70 percent of the clinics in rural areas were assisted by NGOs (prior to the disaster) anyway."

Lt. Col. Stevens said in early March that the relationship the HACC has enjoyed with healthcare professionals within the U.S. government, government of Haiti, and international community has been quite positive. "Members of the U.S. Army Civil Affairs community had not seen or participated in this level of collaborative partnering in any previous HA/DR operation and were exceptionally impressed with the collective skill, professionalism and dedication of the many NGO doctors, nurses and support staff working tirelessly for the people of Haiti," he said.

According to Southern Command, as of April 21 more than 2,000 U.S. military personnel continue to support operations to provide relief and care to more than three million Haitians who were affected by the earthquake. DoD is currently focused on mitigating the effects of bad weather on displacement camps in Port au Prince, supporting efforts to relocate displacement camps to transitional resettlement sites, and preparing to transition efforts to NGO and international relief agencies as their capacity grows.

Torbay said an IMC core emergency medical and logistical response team is still there, and the NGO continues to rotate teams of 45-50 physicians and nurses into Haiti. "Most are at the university hospital, but some are also at mobile clinics outside of Port au Prince in the coastal area and epicenter of the earthquake," he said. "It's more primary care now. A lot of health infrastructure was destroyed. Our doctors and nurses are providing care in tents and (temporary) structures. A lot of people are living in tents. We are also staffing the emergency ward at the university hospital. In addition to basic health issues, there is some follow-up care being provided to those who had surgeries initially."

More than 100 countries and 500 NGOs have contributed to the Haiti earthquake relief effort overall. At the height of the mission's response, more than 20,000 U.S. troops, 20 ships and 130 aircraft were in Haiti to help. The Comfort's medical crew alone treated 871 patients and performed 843 surgeries onboard the ship over the seven weeks it was in Haiti, including more than 540 critically injured earthquake survivors within the first 10 days. The Comfort's medical crew included DoD physicians and supporting volunteer experts from the Orthopedic Trauma Association, Project Hope, Operation Smile, National Nurses United and Johns Hopkins Emergency Medicine, among others. "Overall, U.S. military medical professionals saw thousands of earthquake survivors and military surgeons conducted nearly 1,000 surgeries," according to Southern Command. "U.S. forces also helped move thousands of pounds of medical aid to various distribution points."

DoD has further delivered 2.6 million bottles of water, 2.2 million food rations, 17 million pounds of bulk food, and 149,000 pounds of medical supplies.

Torbay said it will be some time before the healthcare system is restored. Many of the nursing schools also collapsed during the disaster. The relief effort will evolve into training Haitian doctors and nurses. "As an organization, IMC will be there for the next few years, for service provision but also training nurses and physicians," he advised.

Torbay said IMC will further focus on putting good systems in place to prepare for future disasters. "What to do in the event of a hurricane, earthquake or flood, and what to do with first responders," he said. "We're looking at training a core group of first responders in Haiti, with a pre-positioned health infrastructure, looking at what to do in a contingency plan. We'll be focusing on health, but also looking at the bigger picture."

For more information about the military and U.S. government-wide Haiti earthquake relief effort, please go to:

http://www.southcom.mil/AppsSC/factFiles.php?id=138, http://www.usaid.gov/helphaiti/, and International Health.