MSF surgical team at work in Port au. Photo © MSF

Civilians Caught in Haiti's Waves of Conflict

One bullet came to rest under Charles'* left jaw after ripping through the right side of his neck. Another bullet shot through Robert's chest and lodged in his ribcage next to his aorta. Yet another tore into 9-year-old Pierre's leg, exploded in fragments and broke his femur in two.

These were just a few of the victims of Haiti's continuing unrest recovering from recent gunshot wounds at MSF's trauma center in Port au Prince, where politically motivated violence has wracked the city in waves since September 2004. By the end of March 2005, MSF surgical and medical teams had treated more than 1,000 patients – nearly 250 for gunshot wounds – since the project opened at the 42-bed St. Joseph's Hospital in late December 2004.

The Changing Nature of the Violence

A crowded street in Haiti. Photo © MSF

For months, intense fighting was confined to several of the capital's vast, densely populated seaside slums, or "quartiers populaires." From visits to the city morgue, MSF estimated that 100 people were killed each month from September to December 2004 as armed bands supporting and opposing exiled President Jean-Bertrand Aristide actively fought in the streets. Hundreds of homes were burnt to the ground in Cite Soleil and Bel Air, and many people fled the areas to stay with family or friends elsewhere in the city.

Today, the conflict is more sporadic and diffuse, spreading unpredictably into other parts of the city. Intense political jockeying among many groups in Haiti – members of the transitional government, the small but powerful business community, pro- and anti- Aristide forces, the Haitian National Police (HNP), and the former military – points to a likely continuation of conflict for the coming months.

When asked, people living and working in the most affected areas of Port au Prince say they have never experienced such insecurity and they see little reason to hope for a better situation in the near future. While no one can predict when the levels of violence will rise or fall, it is fairly certain that another brutal chapter of unrest in Haiti will be written.

Treating Gunshot Victims

Surgeon James Smith reviewing a patient x-ray. Photo © MSF

Dr. James Smith is a 27-year-old general surgeon from Ireland who arrived in Haiti in mid-January. It is his second mission with MSF.

With gunshots, there are some victims that never get to a doctor because the person dies instantaneously – maybe a major vessel or the heart was hit, something that kills them straight away. Then there are wounds that would kill someone eventually, but more slowly, maybe their bowel or liver is perforated and there is slow bleeding – something where if you operate, you can actually do something to stop them from dying. Then there are patients who could have serious debilitating problems from the gunshot wound such as a broken bone. And finally you get cuts and grazes and nicks from stray bullets which you clean up to prevent infection.

We see about 3 gunshot victims a day, maybe 1 or 2 a day with fractures where we have to bring the patients into the operating theater to clean it up. About twice a week we need to do a laparotomy. When a patient has been shot in the chest, the chest fills with blood or the lung has collapsed, you need to put a chest drain in. Between 50-60 patients come in every week to get their dressings changed.

I most remember one patient who died. His brother came in a few days earlier, with quite a big hole blown into the back of his chest. We closed that up and put in a chest drain because his lung had collapsed. Then about four days later his brother came in shot with exploding bullets in the chest and abdomen. So much liver was destroyed he just bled out.

I was in Guinea before, working as the surgeon in a District Hospital. I saw elective cases as well as consultations. I think I saw only 3 gunshot wounds the whole time I was there, which is a lot for a district hospital.

A Haitian physician working for MSF

X-ray of a patient whose arm has been fractured by an exploding bullet. Photo © MSF

We have a lot of injuries caused by fragmentation bullets. Like the patient you saw upstairs, he had a huge injury just from where the bullet hit him. Usually there is a small entry wound and a small exit wound. These bullets, though, they explode inside the abdomen of the patient and cause a lot of internal injuries. Fragmentary bullets are used by everyone – it seems they are using ammunition for a war, not for a city.

We had violence before, a lot of violence. But the kinds of gunshot wounds we have now are different. We used to see 38 caliber bullets. They don't cause many internal injuries. Now, it is something that explodes inside. We had a lot of crime before. Everyday we would receive one or two gunshot wounds. Now we have 3 or 4 or more. It was mainly crime then, but now we have more political violence. It's not directed like a persecution, but affects everybody in the country.

Treating Victims of Sexual Violence

Olivia Gayraud, a French emergency nurse, has been the field coordinator for the trauma center in Port au Prince since October 2004. She started with MSF in 1998 and has worked in Abkhazia, Democratic Republic of Congo, Ivory Coast, Uganda, Afghanistan, East Timor, Burundi, Madagascar, and Sudan.

Now, we have treated about 20 patients from extremely violent sexual attacks. You can't imagine. The youngest ones have been 10 years old. Many of them had one of their parents killed before being kidnapped, and it's always many men, between 4 and 10. The rapes are very, very brutal, and the women and young girls are afraid that if people find out they went for help that they will be killed.

If they seek treatment within 72 hours of the rape, we can prescribe antiretrovirals (ARVs) for HIV prophylaxis and antibiotics for prophylaxis against sexually transmitted diseases (STDs). If they don't come within the first 72 hours, we can only give them the prophylaxis for STDs.

It's important for us to network with other groups, stressing the importance of the first 72 hours, because after, it's too late. We have to continue to let people know, especially in the hardest hit areas like Bel Air and Cite Soleil. But it will be difficult – a lot of community groups don't exist anymore because of the insecurity. Community workers can't work anymore because of the violence. It's just too dangerous.

It's hard to imagine the situation getting any worse, because since September 2004 it has already been the worst many people here have ever seen. They say it was never this bad before – with Aristide or the coup d'etat in the 90s. We'll see what happens, though. Especially before the November elections – there are groups that don't want the elections to happen.

Some people in Port au Prince know there is violence but they only hear about it on the radio and feel like it is very far away. They may change part of their routine – maybe they don't go to the center as often as they used to. It's more the people living in the center – simple people, very poor people – who are affected.

Voices of Those Caught in Port-au-Prince's Ongoing Violence*

Charles, 33 years old
On the first day of Carnival, Sunday, I was near my house sitting at a restaurant listening to music. A friend came in and yelled to run because there would be problems. I didn't have time to get away, and got shot in the leg by the rat pa kaka [note: Creole term for “rats that are still-living”]. They just robbed a store and ran off and didn't want anyone to bother them so they were just shooting everywhere. My two friends were shot, but they died. I came to the hospital.

It's getting worse because nobody can talk about the rat pa kaka doing such things. If you tell the police, they can exterminate your whole family, so everyone is afraid to talk. The police aren't sure who is in a gang and who is not, so they think everyone who lives in an area is a gang member or collaborator. So even if I tell the police, the police may think I am a gang member.

I'm not working now and I have a family to support. My wife gave birth 6 months ago to a baby girl, our first child. So if this would stop, maybe I could find a job.

Robert, 9 year-old boy.
I was shot by the police. Everyone was running, I was running too. The police car came up starting shooting all over the place, and I got shot in the leg. This was in January. I think the police were shooting because the rat pa kaka were in the neighborhood.

Madeline, Robert's 22 year old mother
I've been in the hospital with Robert for a month. When I left Bel Air, it was really bad. Every time there was shooting, many people would die. I don't think it will get better and a lot of people have left the area. I will never go back.

Florence, mother of another young boy who was recovering from a gunshot wound
I was in front of my house and I saw a lot of men coming down the street. I didn't see any guns but I was suspect. I told the children to get inside, and was helping my son jump over the wall, but he was shot in the leg. We left Cite Soleil in November because we had so many problems – they stole things and burned my house near the market. My daughter has her own house and still lives in Cite Soleil. She says they are shooting every night.

Pierre, 20 years old
I am originally from Jacmel, in the southeast. I was walking on the street, looking for a friend in Post Marchand so we could go to Santo Domingo, when I was shot by the police. There was a girl with me at the same time but she died. I didn't know what happened. They were just shooting, shooting all around. The situation is terrible. If I could leave the country, I would.

Cheryl, 24 years old
I was in the street with my boyfriend and another couple on Valentines day. Two men with firearms stopped us, my boyfriend and the other guy ran, but my girlfriend and I couldn't get away. They demanded money and jewelry but we didn't have anything, so the men wanted to rape us. The police came, and when the two men saw them, they shot me in the stomach. The situation in Haiti is very dangerous. At 6 pm you have to stay home, you can't go out. Even if you don't have any problems, you can be a victim of violence at any time. I wish it would stop but it just gets worse and worse. It wasn't like this before.

*All patients' names have been changed