What it takes to provide medical care in Haiti (podcast)

ELIAS: Hello and welcome. I'm Elias Primoff and on today's episode, we're taking a closer look at Haiti through a humanitarian lens. 

Haiti is facing a deepening humanitarian crisis, one that hasn't gotten the attention it deserves. In the capital, Port-au-Prince, violence between armed groups and the police has intensified, spilling into residential neighborhoods and putting civilians in harm's way.

At the same time, the already fragile health care system is being pushed to the brink. 

This didn't happen overnight. Years of political instability, poverty, and repeated emergencies have left communities extremely vulnerable. And the current violence is only making things worse. Today, we'll talk about what this means for people trying to access health care and how our medical and humanitarian teams are continuing to respond, even as insecurity makes their work more dangerous and difficult.

To help us understand what it takes to deliver medical care in this environment, I'm joined by Tirana Hassan, CEO of Doctors Without Borders USA, who was recently in Haiti meeting with our staff and hearing directly from patients.

Tirana, thanks so much for being here. 

TIRANA: Thanks for having me.

ELIAS: First of all, Tirana, Haiti was your first project visit as CEO of Doctors Without Borders USA. Why was it important for you to go there personally? 

TIRANA: I mean, there are two things. One is that I felt it was really important as I took this role to connect with our projects. Our work in Haiti is one of our oldest projects, but it's also very close to the US, and there's a lot of connection between Haiti and the US. 

[Secondly,] the projects in Haiti are huge. MSF is one of the most significant providers of health care in Haiti. And particularly around providing support — both medical and psychological — to survivors of sexual violence. 

ELIAS: That's a good point that I want to come back to you later about, our kind of special connection here in the US to Haiti and to the Haitian diaspora as well. Going back to your visit to Haiti, [did you fly] into Port-au-Prince?

TIRANA: It sounds like that's an easy thing to do, Elias, but it's a lot more complicated right now because of the insecurity. The airport is actually closed in Port-au-Prince, which is Haiti's capital. So, you arrive in the north of the country, in Cap-Haitien.

We have an MSF base in Cap-Haitien, and that's our hub to be able to coordinate all of the staff and the logistics that passes through the country there. 

That's where you wait for a helicopter, which is run by the UN [United Nations], and depending on the weather, and if the stars align, that helicopter will arrive on time and then it's a quick ride into the capital. 

ELIAS: What was your impression coming in from Cap-Haitien on a helicopter arriving in Port-au-Prince? What did you see?

TIRANA: Cap-Haitien to Port-au-Prince is a very short ride, and you cover a lot of the country and you can see that there's an abundance of potential in Haiti.

And it's really being dampened and curbed by the insecurity we were talking about. People have been consolidating in Port-au-Prince for a while, because that's the area that you are most likely able to get services and things are functioning. Increasingly, we are seeing people moving out of the city because of insecurity.

But when you approach Port-au-Prince, you are really struck — or at least I was — by how densely populated it is. You look down and see how close together all of the houses and the shelters are once you get into that city area. And then once you get into the MSF projects, you see what that means for people in real life, because a lot of the residents of Port-au-Prince are living in areas which are controlled by armed groups and they're often displaced.

And that displacement means that you'll move from your house to some sort of temporary living situation, which is often just a room in an abandoned school or building. An entire family can be living there. When you connect those two, when you look at it from the air, you can feel that pressure that the community, our patients, are living through.

ELIAS: Once you arrived and you made your way to an MSF project, what were you seeing?

TIRANA: I'm glad you asked the question, because it is quite striking. Where we have our base, where our offices are, and where we do a lot of coordination and administration work is an area of Port-au-Prince which is relatively safe, and life goes on as normal. 

I vividly remember seeing the things that you would expect to see: people dropping their kids to work, sitting in traffic jams, the chaos of gridlock, people on their way to work. And then slowly, as you get to the areas where our clinics and our hospitals are, often areas which are more insecure and prone to outbreaks of violence between security forces and the armed groups, things start to peter out. So, you go from watching this intensity of life to it just slowly diminishing — fewer people on the street, fewer businesses are open. 

And because there have been skirmishes in those areas before, some of the roads will actually be blocked, either be blocked by rocks and tires on the street, and you really get a sense that you have entered a different kind of area. It's a little bit eerie. 

ELIAS: Yeah. Haiti is so geographically close to the United States. But conversely, for a lot of Americans, I think they hear about Haiti, they hear about what's going on there, and even though it has this proximity it still sometimes feels very far away.

From your perspective, why is Haiti such a critical place for Doctors Without Borders to be working right now? 

TIRANA: Well, the Doctors Without Borders projects in Haiti have existed for a very long time. We have a really, strong connection to the country that predates the [2010] earthquake, even. But it's the same reason that we work in a lot of places. This is where the needs are. 

There are very few basic services when it comes to health care that are available to the general population. And for us as Doctors Without Borders, that is key. We are driven by one thing. Where there is a need for urgent medical, medical services, humanitarian response, that's where we are.

And in Haiti, there isn't a sanitation system that is functioning currently. So the garbage piles up in front of the maternity hospital that MSF runs. This is in an area that is controlled by armed groups. And as a result, very few services exist.

You don't have access to clean water. The rubbish that has been accumulating for years has now reached the height of about a perimeter fence. We know from the type of illnesses that are coming into our clinics that those poor conditions translate into real health consequences. 

I went to a mobile clinic that we run once a week. And it's an extraordinary operation. It's a four-car convoy that goes down into an area that is controlled by the armed groups.

Our colleagues have essentially packed a mini clinic that they can get out of the car and into a church that we use in 40 minutes and set it up. The cases that were coming in, people flooded it. 

There were a couple of hundred people sitting in the pews of the church where the team was doing the triage (deciding and allocating people where to go and which services that they need.)

There were a lot of people in one corner, and I asked one of our colleagues and what's happening to these people? They said, well, these are all the people that are just coming to access soap and treatment for scabies. Because there's no access to clean water, because displaced people are living in crowded conditions in encampments.

They end up having a lot of skin conditions, and other health consequences. And it's without having an MSF mobile clinic that goes to that area, they would never have access to any kind of medical care.

ELIAS: We think and talk about this a lot as MSF, and we work often in conflict settings where people are at risk of injury or death because of violence. But I think a lot of people don't necessarily understand the depth and the breadth of the effects of conflict on everyday life. So we talked earlier about the airport being closed on and off. But the impact of insecurity and violence on infrastructure, basic services, and things as simple as water and sanitation are really dire and something that I think a lot of people don't consider. 

Another aspect of conflict that MSF teams often respond to is sexual violence. And I know that our teams have noted growing rates of sexual violence in Port-au-Prince. You visited MSF's Pran Men’m clinic in Port-au-Prince during your visit, which is one of very few places in Haiti where survivors can receive comprehensive treatment.

Why is it so important for MSF to be providing this kind of care in Haiti? And what was your experience visiting that project? 

TIRANA: I'm really glad you asked. For survivors of sexual violence in Haiti, there are very few services that are available. And one of the things we see is that, as you mentioned, the actual rate of sexual violence is climbing year on year and it's changing.

We recently did an analysis of what we've been seeing when it comes to sexual violence. Not only are more people coming, [but there are] very disturbing patterns that are beginning to emerge, including the fact that they were, more often than not, more than one perpetrator. On average, there were three perpetrators involved in an assault.

Another very disturbing trend was that this sexual violence wasn't just being perpetrated against young women and girls, although they do make up the vast majority of our patients. Increasingly, we're seeing older women between 50 and above, and 80, being targeted, and surviving sexual violence. 

The project of that clinic was incredibly unique. It's not like anything I have seen in two decades of doing this work and working specifically with survivors of sexual violence. And the thing that made it very special was it is [open] 24 hours in a context like Port-au-Prince. This is incredibly important because one of the things that we heard from survivors was that they struggled to get to our facilities.

And when it came to survivors of sexual violence, it was even harder because they were often living in the same neighborhoods as the perpetrator.

That meant sometimes that if the perpetrator was a person who was arming a checkpoint that they had to pass every day, survivors were hesitant to want to cross that checkpoint to be able to get to our clinic.

And so [patients] would come at all times of the day and night. And in particular, the project coordinator of Pran Men'm was telling me about one day when a group of girls, all of whom had been survivors of attacks of sexual violence, banded together because it was safer and more discreet for them to look like they were just going out to do something as a group.

But what they were actually doing was of creating an image so that they could pass easily without suspicion, and they all arrived at our clinic at the same time, and we were able to provide care for them. 

Pran Men’m offers comprehensive care. So that's really quite unique. People and survivors can arrive and get the medical treatment that they need. But they're also able to access social workers and psychologists who can provide and assist in the healing process, beyond the injuries that they may have faced.

We have this inpatient clinic that essentially means that survivors can arrive, get the service they need, and then there is an outpatient clinic. For patients needing follow-up care, they can go there for any sort of sexual reproductive health needs that they may have. And then there's a third service that is run out of the clinic: a 24-hour hotline for survivors. 

Now, even though our clinic is in Port-au-Prince, a survivor can call from anywhere in the country, and there is going to be a qualified midwife, or one of our MSF staff, who is going to be at the end of that phone and be able to talk to that survivor and make a referral, even if they patient is not in the capital.

One of the challenges we face, though, is because of the current situation in Haiti, there are very few places to receive our patients if they need to be able to find emergency accommodation, so that they don't have to go back to being proximate to perpetrators.

We do have some fantastic partners in Haiti that we are able to make referrals to, but the numbers just aren't greater than the resources. 

ELIAS: I think it's also worth noting here that the majority of people who are started these projects are Haitian themselves and often from the communities where they're working, which adds an important dimension to making sure that we're meeting people where they are and giving them the care that they need.

TIRANA: Our Haitian colleagues are living in communities which are affected by these escalations in violence, [and] many of them have also been displaced. The realities of working and living in a conflict is acute for our colleagues. And every day they continue to show up.

One of the things that I took away from this trip was the time that I spent with our Haitian colleagues, particularly in the Tabarre hospital, which is, a particularly special project that MSF runs: It is the only burns center in all of Haiti.

I had the opportunity to actually go through the hospital, speak to patients, and talk about the work with our Haitian colleagues. 

I was speaking to one of our patients who had very serious burns all over his body. He was working in a bakery, and was attaching a gas tank and changing the tubes on a gas cylinder and it exploded. He had been in the [center] for months. And what he talked about was not just the quality of care and the fact that he would not have survived if he had not been brought to the MSF hospital. After spending that length of time, he talked about how important it was to have relationships with our staff.

He said, “One of the things that I appreciate so much about being here is the doctors sit with me every day. The staff are wonderful.” And that's the quality of care aspect, right? Our colleagues are not just providing  the highest quality medical care, or physiotherapy to help him be able to move his joints and be able to rehabilitate and leave the hospital and go back home. There is a lot of psychological healing that has to happen as well. And that hospital has, both in the outreach and the inpatient services, social workers and psychologists that are available to provide that service throughout the healing journey. 

We also have community health workers who basically play a liaison role as well. I had the opportunity to sit and meet with a group of our community health workers who do this liaison work, and they are the people who are able to identify patients that might need to be referred to the hospital.

They're also able to give us information about the conditions, the security situation, how the population and the community are being affected by escalations in violence, for example. They're also able to tell us when there are disruptions in water delivery because there's no access to clean water in many of the areas where we work.

Those teams play a really critical role in a number of ways. They build trust with the community, they help us make sure that we're tailoring our services to meet the needs of the community, and they're able to tell people what's available because not everybody will know. 

ELIAS: Right. Here in the US, Haiti is often discussed through the lens of migration. And those who are following the news may be aware that there's a current legal challenge to what is called Temporary Protected Status for Haitian people living in the US. 

I think based on what you saw on the ground, it's important for audiences here in the US to understand what people are facing inside Haiti today. What are they up against, and what are the causes that are leading them to travel to places like the United States? And why is Temporary Protected Status important?

TIRANA: To cancel Temporary Protected Status from one day to the next would mean, essentially, that 350,000 people would have to move back to Haiti.

And the assumption is that Haiti is safe and functioning and they can return. I think that that is reality that everybody wants to see, but is not the reality on the ground. What we have seen in the years that we have been there — and particularly in the last few years — is that insecurity, particularly in Port-au-Prince, in the capital, is pervasive.

The statistic that's quite often stated is that 80 percent of the capital is controlled by armed groups. There is not a justification that feels reasonable from what we have seen as Doctors Without Borders to make the assertion that Haiti is a safe place for people to return.

As I was saying before, there are not [enough] basic services available to the population, and what is available is already taxed. Sending back 350,000 people would only put more pressure on that. And then there is just the reality of the violence; There are bouts of insecurity where there is shooting and fighting between armed groups and security forces.

People are often injured, during those there's a lot of what is referred to as balles perdues, which are stray bullets, basically, because where the skirmishes take place are in very densely populated areas and so there are people everywhere. We have high levels of sexual violence. And then there's the issue of displacement.

All of that together is the reality that a lot of people in places like Port-au-Prince are living through on a daily basis. And it is just a difficult case to make that Haiti is currently safe enough for people to return. 

ELIAS: This was your first visit to an MSF project as CEO of MSF, Doctors Without Borders USA. I'm curious to hear what has stayed with you the most about this experience, not just as CEO, but as a human being. 

TIRANA: Well, I'm both CEO and human being at the same time, so it'll be an easy question to answer.

But, I was so proud to work for MSF. When I looked at the projects, I think the work that we are doing in Haiti is MSF at its best. There is a great need for the level of care and the quality of care that is being provided. Everything from the trauma hospitals through to the sexual violence clinics, is really of a standard that is exceptional.

I was really heartened by that, as well as by the resilience and the care of the patients that we spoke to, and the resilience of our colleagues who are working in incredibly difficult circumstances. We could spend a lot of time talking about all the challenges that Haiti faces, and they are very real.

What I saw was extraordinary: examples of courage, integrity, commitment and care. That just gives me faith in humankind. 

ELIAS: Tirana, thanks so much for joining us today, and for sharing your experiences. You provided a lot of really important depth and nuance and detail. And I know that for supporters, for people who follow MSF’s work, understanding intellectually that this work is happening is important and meaningful.

But I also know that anybody who has seen an MSF project in action is moved, and really understands the impact and the power of this work. Being able to hear it from you firsthand is a great opportunity. Thanks so much for joining us. 

TIRANA: Thanks for having me. 

Haiti is experiencing a severe humanitarian emergency driven by conflict between armed groups, which control the majority of Port-au-Prince. Displaced people have limited access to food, water, and medical care.

In Port-au-Prince, MSF provides care at its Cité Soleil hospital, the Orezon clinic, Tabarre Hospital, and Pran Men’m Clinic for survivors of sexual and gender-based violence.

Breaches of security makes movement dangerous — MSF staff navigate armed checkpoints and active conflict zones to reach patients. Health facilities have been attacked, and many Haitians have no alternative source of care.

The humanitarian response remains critically underfunded. MSF operates independently and does not accept government funding. We rely entirely on private donations.