Dr. Jean-Paul Dixmeras - War Surgery in Port-au-Prince, Haiti

Dr. Jean-Paul Dixmeras, a surgeon from Paris and a member of the Board of Directors for the French section of MSF, recently returned from providing emergency surgical care in the Haitian capital of Port-au-Prince. MSF is trying to address the needs of civilians injured in the waves of violence that have wracked the city's most impoverished neighborhoods.

Like any area where there is conflict, the pattern of clashes is very uneven. Patients are received every day, but there are waves of violence. – Dr. Jean-Paul Dixmeras

When MSF called me up at the end of December 2004, I was sure it was in order to send me to Sri Lanka in the aftermath of the tsunami since I had already been on four missions in that country. In fact I was to go to Haiti, where MSF was starting a surgical program. I took a plane on December 31st. In the beginning I was skeptical. I had come for an extremely short period of time (10 days), I knew that the program had just been launched, and I wondered whether I was only there to unpack crates, instead of using my expertise as a surgeon for operations.

I quickly realized I was wrong. The day I arrived in Haiti's capital of Port-au Prince we received a 25-year-old woman - a bullet had cut through her abdomen. We spent four hours in the operating room trying to save her, but unfortunately she died. It was like that every day after that, with standard gunshot wounds affecting the entire population.

This young man was at the wheel of his car when he was shot twice, once in the right shoulder and once in the chest. The bullets exited his left side, puncturing both lungs. He was lucky, however, because no vital organ was injured beyond repair. Photo © MSF

Like this 18-year-old kid, shot point blank with a bullet in the sternum.

Urban Fighting

MSF reinforced its presence in Haiti with an emergency intervention after Tropical Storm Jeanne in 2004. Following that intervention, some MSF volunteers conducted an assessment around the island, which had been impacted by successive natural disasters - floods in March of 2004, and Tropical Storm Jeanne in September - but also by intense political instability. The team noticed an unexpected degree of violence, a situation of urban fighting, with a large number of people being wounded by gunshots who had no access to treatment.

The violence is concentrated in Port-au-Prince, a city of 2 million people, many living in extreme poverty, and it particularly affects civilians who are trapped by fights between armed gangs - both pro- and anti-Aristide - and the police When clashes erupt, all the residents of these neighborhoods are at risk. We treated many women and children who had been shot in the back. These were not stray bullets, or accidents. They had been shot at deliberately as they fled trying to find shelter.

Public Hospitals Overwhelmed, Private Clinics Too Expensive

The Haitian health system is absolutely unprepared to cope with such a challenge. In Port-au-Prince there is only one functioning public hospital, which is completely swamped. Because of impoverishment and recent political events, it is no longer being supplied. So patients cannot be treated unless they bring their own materials and medications. Besides this, many doctors only work in private practice because they earn almost nothing at the public hospital. So the hospital uses only partially trained students, who are currently out on strike against this system.

The clinic run by MSF has the only operating room equipped for major surgery in Haiti that offers free services. The complete surgical team is comprised of many specialists, including orthopedic, thoracic and maxillo-facial surgeons. Photo © MSF

At the same time, the small clinics in the private sector work on a purely for-profit basis. The few existing surgeons, who I presume are sufficiently qualified, move from one establishment to another with their doctor's bag and their equipment, and charge for a package that includes the intervention and post-op care. When there is a serious fracture, osteosynthesis using external fixators [ed. Note: externally attaching rods to the bone with screws] costs between $1,000 and $2,000, depending on the establishment. A caesarian in a fairly inexpensive establishment is $200 and even a simple cast is expensive. In this country, where average per-capita income is estimated at around $380, very few people are able to access this type of medical care.

Confronted with such a hospital system, MSF led an investigation in the more troubled neighborhoods of Port-au-Prince. A few humanitarian organizations had opened dispensaries with some 50 beds each. This allows them to provide treatment on-site in areas where victims can't easily leave the neighborhood, but these centers don't have the capacity to do complicated surgery

Rehabilitating a Hospital Near The Most Affected Areas

We identified a private establishment, Saint Joseph Hospital, near Cité Soleil. By the end of December we had the premises, and all its existing staff and equipment, fully up and running. To strengthen the team we were able to recruit a Haitian orthopedic surgeon, as well as four general practitioners for emergency service who between them ensure that there is 24-hour patient intake. We also found an oral/maxillofacial surgeon, a generalist surgeon, a neurosurgeon, and a radiologist on site. All of them agreed to work with us for negotiated fees. For vascular surgery, which is essential in this type of context, foreign surgeons like myself would take turns. All in all the foreign team consisted of nine people: a surgeon, an anesthetist, a surgical nurse and a circulating nurse, the head of mission, the administrator, and the field director-but two logisticians as well.

After having taken over the hospital our first job was to restore it to working order. Because it was in very bad shape. We counted 6 respirators, but none were working. None of the 4 operating tables were intact. The ambulance hadn't been in service since 2000 because its license wasn't valid. And we had other unpleasant surprises: the sterilization system didn't function, there was no water faucet in the operating room and a single faucet for the surgical unit, no waste treatment (officially it was taken to the public dump, which was already not so great, but in fact it often ended up in a gutter near the clinic), no surgical gowns and practically no instruments, etc. The generator, which was supposed to take over in case there was a power outage, was defective. We had to operate by the light of our surgical headlamps! In fact, before we even had the time to start repairs, we were immediately confronted with a flood of wounded persons. We couldn't leave these people untreated, so we had to cut them open very quickly.

At the same time we went to work trying to fix up an operating room worthy of the name. Our Belgian colleagues at MSF and the Red Cross lent us autoclaves to sterilize the equipment; we only managed to use half of them because the MSF logistics base sent a kit with enough equipment to treat 300 wounded. In order for us to work it wasn't enough just for surgeons to be there. The equipment had to keep pace, and the post-op care, as well.

When we got to the hospital there were only fifteen individual rooms, so we quickly doubled the intake capacity by furnishing a large ward. And the goal was to reach a total of 60 hospital beds by converting the former chapel on the top floor of the clinic. But we couldn't do anything beyond that.

We were going to have to focus our work or we would have trouble with overcrowding right away. We had come there primarily because of the violence, so we set to work on caring for all victims of firearms and bladed weapons. The second priority would be the treatment of everyday accidents and trauma that wasn't being provided elsewhere. There are victims of car-accidents or domestic accidents. For example, because the population of Port-au-Prince lives in extremely unstable conditions, on two occasions we accepted people wounded in mudslides, one of which was a 16-year-old kid whose head had been crushed by rocks and was in a coma. But we wanted to try to avoid handling gynecological-obstetric interventions, such as caesarians, ourselves, and we found referral hospitals to which we could direct patients with such needs. The idea is to work in partnership with the dispensaries run by the Red Cross, the Sisters of Calcutta, and the Brothers of Bangladesh. They are set up in the heart of the neighborhoods where the clashes are taking place, but they aren't equipped to perform complicated surgery. So if they send us wounded, we operate on them and provide the immediate post-op care, but we send patients back to them for more extended follow up care.

Irregular Waves of Violence and Extreme Urgency

Like any area where there is conflict, the pattern of clashes is very uneven. Patients are received every day, but there are waves of violence.

Because the hospital where we are set up is very near to the zones where clashes are taking place, we get the patients very quickly. It is rare that one is in such direct proximity to the zone, with the risks this poses to the teams' safety. People arrive with gunshot wounds, they are in a state of shock, and they have to be operated on immediately. These are extreme emergencies. From the perspective of working conditions, this mission reminded me of the first missions I was on with MSF in Sudan more than 20 years ago. In terms of the context it reminded me of Somalia, with the same phenomenon of clans-perhaps even more unstable. Finally, these 10 days completely erased any doubts I had about the usefulness of a project in Haiti. Both the level of violence and the inadequacy of the health care system fully justify MSF's presence.