An estimated 300,000 people were injured by the massive earthquake that rocked Haiti in 2010. Patients suffering from crush wounds, compound fractures, amputations, and other serious injuries flooded into facilities supported by PIH and its Haitian sister organization Zanmi Lasante (ZL).
To address the special needs of these patients, PIH/ZL launched an ambitious program to provide short- and long-term rehabilitation services. After hiring and training specialized staff, purchasing unique equipment and procuring prosthetics, PIH/ZL was soon providing rehabilitative care to hundreds of patients. This included preparing staff to accompany 136 patients with amputations through a partnership with Hanger International and l’Hôpital Albert Schweitzer. This program is managed by one of the first PIH/ZL patients to receive a prosthetic, Shelove Julmiste.
“Rehabilitation is the indivisible comrade of medical and surgical services in comprehensive trauma care,” says Dr. Koji Nakashima, Director of PIH/ZL’s Rehabilitation Services. “If emergency medical and surgical services save lives, it is rehabilitation services that save livelihoods, transforming dependence into dignified independence. This was clear from the first patients who found themselves alive but wheelchair-bound in a country of boulder-strewn roads and shanty houses clinging to eroded hillsides.”
Over the course of the past two years, PIH/ZL’s staff of clinicians, nurses, rehabilitation technicians and rehabilitation community health workers – some of whom suffered amputations themselves as a result of the earthquake – have delivered care to hundreds of patients throughout central Haiti. This team, led by Dr. Nakashima, Dr. Andree LeRoy, Rehabilitation Program Advisor, and Megan Brock, DPT Rehabilitation Program Coordinator, are developing a community-based, integrated rehabilitation program to serve as a model for and answer to the Haitian Ministry of Health’s call for comprehensive, dignified care for Haitians with disability.
The team currently provides ongoing, daily rehab care in the community to roughly 24 patients. At the same time, they manage the long-term health needs of 136 patients with amputations. In total, the team accommodates 1,500 inpatient encounters and 550 outpatient visits annually. More broadly, PIH/ZL has trained 10 community health workers (CHWs) to provide long-term, daily support (accompaniment) to people with disabilities, including case finding in local, often rural, communities.
PIH/ZL’s program brings hope to those affected by the earthquake, while creating a rehabilitative healthcare initiative long needed in rural Haiti.
A long-needed intervention
Even before the earthquake, the majority of Haitians living with physical disabilities lacked access to medical or rehabilitative services.
Like other woman in rural central Haiti, Lelan spends her days taking care of her family – cooking, cleaning, and tending to her children. But for her, having suffered paralysis after contracting spinal tuberculosis, each chore is infinitely more difficult.
She couldn't walk. Instead, she would lie on her back and drag her body across the dirt floor of her family’s small hut. When it rained, the ground turned to mud. Because she could only move about 20 feet at a time, she was literally cut off from her community.
Lelan’s situation was far from unique. In 1989, the Pan-American Health Organization estimated that approximately 7 percent of Haitians – roughly one of every 14 people – was living with a disability.
And then the earthquake struck.
Post-earthquake estimates suggest that upwards of 300,000 Haitians were injured as a result of that catastrophic event, bringing the total number of Haitians living with disabilities to nearly one million. With fractured bones never set, amputations, spinal cord injuries caused by falling debris, and various other disabilities, thousands of Haitians will require specialized ongoing rehabilitation.
PIH/ZL’s rehab team also has the capacity to work with patients with rehabilitation needs unrelated to the earthquake, including survivors of car accidents and strokes. Functional capacity is also maximized through the provision of rehabilitation equipment. Lelan – the mother suffering from infection-related spinal paralysis – received a specially-designed wheelchair just a few months after the earthquake, the result of a partnership among PIH/ZL, the Walkabout Foundation, and Whirlwind Wheelchair International. With this chair and the strength Lelan gained with therapy, she has now gained the mobility she desperately needed to get around her home. In early 2011, PIH/ZL was able to distribute wheelchairs to 250 other Haitians living with disabilities.
Providing rehabilitative care in rural Haiti
PIH/ZL’s rehab team uses a multidisciplinary, team-based approach to patient care. Once a patient’s needs are understood, a customized team of doctors, nurses, physical therapists, rehabilitation technicians, and community health workers provides each patient with comprehensive, integrated rehabilitation services.
Upon entry into the program, the team works with patients and their families to complete a comprehensive assessment, formulate an individual rehabilitation plan, and teach them about their condition. Each person is assigned a specially-trained rehabilitation CHW at the onset of his or her therapy, who provides continuity across inpatient, outpatient, and community care.
While CHWs meet with patients on a regular, often daily basis, an interdisciplinary mobile rehabilitation team also regularly travels to each patient’s home to provide critical monitoring and adjustments to individual care plans. These small teams meet regularly with patients in hour-long sessions to conduct evaluations, continue rehabilitation and community reintegration, and have meaningful conversations with patients and their families.
After a rehabilitation patient graduates out of the intensive need program – ideally after a one-year period, depending on the severity of the injury – he or she will continue to be accompanied as appropriate by a CHW for as long as necessary. This complete array of services is currently offered across several communities in the Central Plateau and is in development in the Lower Artibonite.
PIH/ZL is committed to offering dignified care to Haitians with disabilities. This care extends beyond the hospital or clinic where advocacy, individualized accompaniment, environmental modifications and psychosocial support are key if these individuals are to regain the strength and confidence to fully reintegrate into their communities.
Believing that public sector strengthening is critical to building back better in Haiti, PIH/ZL has partnered with Spaulding Rehabilitation Hospital, MASS Design Group, Shelpley Bulfinch Architects, Partners Harvard Medical International, The Institute for Human Centered Design, and Massachusettes General Hospital Institute of Health Professions to develop plans for the first universally accessible rehabilitation center in the public sector in Haiti.
Budgetary constraints have delayed construction, but not before plans had been completed and ground broken for a 6,750-square-foot, two-story facility, on the grounds of Hôpital St Nicolas, located in the northern city of St Marc. The plans call for a facility that will serve as a model for accessible design and a nexus of disability advocacy through rehabilitation, education, and vocational training in a dignified space integrated into the public health care system. In the future, the Center for Excellence in Rehabilitation and Education will house specialized training in the PIH/ZL rehabilitation services model for eight rehabilitation technicians over nine months who will then be hired to reinforce and scale up the program.