Six months after the earthquake that devastated the country, Haiti remains a nation whose people are on fragile ground. With much of the infrastructure destroyed and the capital city of Port-au-Prince devastated, life is still far from normal.

However, for some of the nation’s healthcare leaders—those that provided much-needed care during the country’s darkest hour—there exists a glimmer of hope. They are working to transition from the environment of emergency care that developed following the earthquake to a global health village that could provide better care for the nation’s poorest citizens than they could ever receive prior to the disaster.

Jean Pape, MD, has been working to improve the health of Haiti’s citizens for 30 years, and has been a grantee of NIH for two decades. A Haitian physician, Pape graduated from Weill Cornell Medical College in 1975 and returned to Haiti in 1979. He visited the campuses of NIH last month to provide an update on the health situation in Haiti, and the role his organization—Groupe Haitien d’Etude du Sarcome de Kaposi et des Infectieuses (GHESKIO) has played prior to the disaster and during the recovery.

Creating an HIV Infrastructure

The poorest country in the western hemisphere, Haiti’s health situation was “no less than a catastrophe,” Pape declared. With 2.3 physicians for every 10,000 citizens, getting care to those Haitians who need it has never been easy.

Pape’s first work began in 1980 and was on infant diarrhea. Haiti was experiencing a very high infant mortality rate, where 40% of children with diarrhea would eventually die. “With the introduction of oral hydration therapy, we were able to bring down the mortality to 1% within a year,” Pape stated. The effort cut the infantile mortality rate in the country in half.

While treating children, he began to see adult patients with intractable diarrhea who presented with a number of other symptoms. These turned out to be Haiti’s first diagnosed AIDS cases. Pape, along with a number of other clinicians, formed GHESKIO, which in English means the “Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections.” Formed in 1983, the organization was recognized in 1987 by the government of Haiti as an independent non-governmental organization on the same level as the Red Cross. “We partnered with the minister of health from day one, as well as local aid societies and medical institutions, with continuous support from NIH since 1983.”

From 1982 to 1989, GHESKIO worked to define the disease, seeking to understand the modes of transmission, the cofactors, and the natural history as it differed from other parts of the world. Pape and his colleagues began looking at models for prevention and the introduction of highly active antiretroviral therapy (HAART).

Over the last 20 years, GHESKIO has worked to create an infrastructure of HIV/AIDS care in Haiti from the ground up. The organization has done extensive studies on AIDS treatment, as well as TB, which is frequently present in AIDS patients. It also serves as the Haitian government’s research and training center for HIV/AIDS: educating physicians, nurses, lab technicians, and other health workers on prevention and treatment for patients with the disease.

GHESKIO is housed on two campuses—a three-acre campus in downtown Port-au-Prince and its Institute of Infectious Diseases and Reproductive Health near the US embassy. This put GHESKIO not at the center of the earthquake, but at the center of the human devastation that immediately followed.

The Immediate Aftermath

The scenes of downtown Port-au-Prince following the earthquake were broadcast all over the world. Pape stated that the situation was worse before the television cameras managed to get to the city. “There was no one in charge. There was a collapse of all authorities. The country was isolated. There was no communication by phone or radio during the first week. The airport was severely damaged, as were the ports. There were 300,000 dead and unaccounted for, representing 15% of urban Port-au-Prince.”

Many of the major buildings in the city were rubble, including the palace, the parliament, major hotels, and three of the country’s four medical schools. Approximately 70% of the homes in the city were destroyed, leaving 1.2 million people displaced. With nowhere to go, the people began filling up the public spaces—any place that was free of the rubble. This included GHESKIO’s main downtown campus, which found itself home to 7,000 displaced citizens.

The campus had also suffered from the earthquake. The administrative building was unusable, according to Pape. “My office was six feet lower than it had been before the quake.”

Two clinics on campus were still usable and though the other GHESKIO site was damaged, the lab located there was still intact.

On the main campus, a tent city quickly sprang up. It was here that the US military and HHS volunteers collaborated with GHESKIO to set up an acute field hospital. “We had to provide care to the growing number of refugees, we had no walls to prevent them from coming,” Pape said. GHESKIO set up a TB hospital and TB evaluation procedures for other hospitals and tent cities.

“The people at HHS and the 82nd Airborne did a beautiful job,” Pape said of the field hospital. “They saved thousands of lives.”

Helicopters choppered patients with severe needs to the USNS Comfort, and brought patients from the ship to GHESKIO’s TB lab for evaluation.

A major problem physicians had to deal with was that once a person was operated on they had no home to go back to. They went back to the tent city. “We noted that 30% of the people who came back after surgery needed another operation either because of malunion or nonunion,” Pape declared. “We don’t know about those who did not come back; we didn’t know what was happening at the other hospitals.”

GHESKIO’s staff also had to deal with their own grief. Besides the many family and friends lost to the earthquake, GHESKIO lost four employees, including their best laboratory technician and head of their TB lab.

While all this was going on, GHESKIO still had to manage the research and HIV/AIDS treatment work it had been doing prior to the earthquake. A hold was put on research projects, to stop enrollment and training, which Pape said eventually resumed in April. “We concentrated on patient care to make sure that HIV and TB patients had enough drugs. We provide an extra two weeks supply of medication, so we knew they were okay for two weeks.”

By March 11, GHESKIO was able to account for 94% of patients (13,000) who were on HAART through GHESKIO, and knew they were taking their meds.

Global Health Villages

In the weeks that followed the earthquake, GHESKIO and international aid workers helped make the tent city habitable. Potable water, sanitation, food, and eventually schooling were all provided, along with the vast healthcare efforts that were required. Eventually the tent city was moved to a new location—land that belonged to the Haitian prison system, and which is located on higher ground.

The new tent city is more orderly and organized. Solar panels provide energy at night, and there are even televisions, allowing those living there to watch the World Cup, and letting GHESKIO broadcast public service messages to the entire camp.

The move has allowed GHESKIO to clean up their campus and begin thinking about the future. With NIH support, walls have been built around the property, though there is still considerable damage to buildings. In the near-term, a maternal health school, primary school, and vocational school will be built on the campus. Also, GHESKIO has expanded its TB lab capabilities. “We used to be able to do 150 [patient tests] a day,” Pape said. “Now it’s 300 a day, and we plan to increase it to 600 a day.”

The organization, which provides HIV/AIDS care to 52% of the Haitian patients who need it, is almost back to the patient level it saw before the earthquake. It is also moving forward on four ongoing research protocols, with enrollment efforts faring very well.

But the long-term goals are most exciting. The new focus of GHESKIO is to transform the tent cities into model global health villages. The goal is to provide potable water, sanitation and latrines, along with a basic healthcare package, that focuses on disease prevention through health education and vaccines. This includes a focus on major diseases, such as HPV and dengue. “Haiti probably has the highest rate of cervical cancer in the world,” Pape explained. “And 60% of Haitian children are exposed to dengue by the time they are two years old.”

While the GHESKIO tent city has been moved, many more need to be relocated to higher ground before the hurricane season comes and with it the danger of flooding. “When that happens, people will be trained as plumbers, masons—they will be trained to build houses themselves,” Pape declared.

What was a tragedy can provide an opportunity for the citizens who, prior to the earthquake, were the country’s poorest. “Tent cities offer a unique opportunity. In the past, those were the people that nobody would attempt to see. We have to make sure that those people are taken care of.”

This includes focusing on what GHESKIO does best—HIV prevention and treatment. One of the projects Pape is working on currently is a model of care that starts with HAART on day one of HIV diagnosis. “Our biggest concern was whether people could take it. Can you start treatment the same day you tell them [they are HIV positive]? Would this be too much? In fact, it’s a relief for them. You give them a red carpet; you take them by the hand. They are very happy with this situation. And our adherence rate has been very, very high.”

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