Abstract

Haiti’s earth­quake caused untold num­bers of new dis­abil­i­ties across the age spec­trum, from infants and chil­dren to elderly indi­vid­u­als. Ampu­ta­tions, spinal cord and brain injuries, com­plex mul­ti­ple frac­tures, and other mas­sive trauma will leave resid­ual impair­ments, pre­cip­i­tat­ing press­ing needs at both indi­vid­ual and soci­etal lev­els. Short-term pri­or­i­ties include clin­i­cal sta­bi­liza­tion, wound heal­ing, and sur­gi­cal revi­sions of sub­op­ti­mal repairs. After­ward, in the near term, com­pre­hen­sive reha­bil­i­ta­tion must com­mence to ensure the best pos­si­ble func­tional out­comes. Even before the earth­quake struck, Haiti had few reha­bil­i­ta­tion pro­fes­sion­als and lit­tle capac­ity to man­u­fac­ture essen­tial assis­tive tech­nolo­gies, includ­ing pros­the­ses and wheel­chairs. While inter­na­tional orga­ni­za­tions are assist­ing to fill these gaps, ulti­mately reha­bil­i­ta­tion pro­grams and assis­tive tech­nolo­gies will need to fit the spe­cific demands of Haiti’s cul­ture and rugged nat­ural phys­i­cal envi­ron­ments. As Haiti rebuilds its pub­lic and pri­vate spaces, ensur­ing acces­si­bil­ity to per­sons with dis­abil­i­ties will be crit­i­cal. Ulti­mately, one pos­i­tive legacy of Haiti’s earth­quake could be the emer­gence of social atti­tudes, pub­lic poli­cies, and phys­i­cal envi­ron­ments that more fully accom­mo­date dis­abil­ity across the lifespan.

Dis­abil­ity Def­i­n­i­tion and Implications

Accord­ing to the World Health Organization’s Inter­na­tional Clas­si­fi­ca­tion of Func­tion­ing, Dis­abil­ity and Health (ICF), dis­abil­ity is an “umbrella term for impair­ments, activ­ity lim­i­ta­tions or par­tic­i­pa­tion restric­tions” result­ing from “a dynamic inter­ac­tion between health con­di­tions (dis­eases, dis­or­ders, injuries, trau­mas, etc.) and con­tex­tual fac­tors,” includ­ing the social, atti­tu­di­nal, and phys­i­cal envi­ron­ments (1). The ICF explic­itly rec­og­nizes that exter­nal factors—physical, social, and atti­tu­di­nal environments—can exac­er­bate or mit­i­gate dis­abil­ity. Fur­ther­more, by con­cep­tu­al­iz­ing dis­abil­ity as a con­tin­uum, ICF empha­sizes the uni­ver­sal­ity of dis­abil­ity and its rel­e­vance to “all peo­ple … at dif­fer­ent times in their lives” (2).

The ICF’s frame­work pro­vides a roadmap for address­ing dis­abil­ity, for both indi­vid­u­als and pop­u­la­tions as a whole (3). Responses must include not only treat­ments of injuries and indi­vid­u­als’ health con­di­tions but also alter­ations of phys­i­cal, social, and atti­tu­di­nal envi­ron­ments to allow per­sons with dis­abil­i­ties to par­tic­i­pate as fully as pos­si­ble in their homes and com­mu­ni­ties. Haiti rat­i­fied the United Nations Con­ven­tion on the Rights of Per­sons with Dis­abil­i­ties on 23 July 2009 (4). Nonethe­less, even before the earth­quake, Haiti had lit­tle to offer per­sons with dis­abil­i­ties. As else­where in both the devel­oped and devel­op­ing world, Haitians with dis­abil­i­ties had fewer employ­ment oppor­tu­ni­ties, lower edu­ca­tional lev­els, and worse poverty than nondis­abled per­sons. Steep, moun­tain­ous ter­rain and treach­er­ous, unpaved streets impeded the mobil­ity of per­sons with impaired walking—even those few who owned wheel­chairs. No spe­cial­ized reha­bil­i­ta­tion hos­pi­tals existed, and few reha­bil­i­ta­tion pro­fes­sion­als prac­ticed in Haiti.

Imme­di­ate Needs

The wounds that dis­abled count­less Haitians were dev­as­tat­ing. Data sys­tems do not exist for count­ing and cat­e­go­riz­ing injuries, but the Hait­ian gov­ern­ment esti­mates that 6000 to 8000 per­sons lost dig­its or limbs (5). Many had com­plex com­pound frac­tures, spinal cord or brain injuries, exten­sive burns, or other mas­sive trauma. Clin­i­cians on the USNS COMFORT, anchored off Port-au-Prince, treated crit­i­cally injured per­sons of all ages, many of whom had hor­ren­dous injuries. Open wounds left bones and soft tis­sue exposed. Life-threatening sep­sis and gan­grene were com­mon, and some­times the physi­cians rec­om­mended ampu­ta­tions to save lives. But some patients refused ampu­ta­tion, hop­ing for recov­ery and explain­ing that they pre­ferred risk­ing death over the cer­tainty of los­ing a limb. Peo­ple who refused treat­ment some­times died shortly there­after. Oth­ers left COMFORT after treat­ment, return­ing to unsan­i­tary liv­ing con­di­tions and putting sur­gi­cal wounds at risk.

A United Nations sit­u­a­tion report from Haiti (dated 25 Feb­ru­ary 2010) indi­cated that 1.2 mil­lion peo­ple needed shel­ter (6). The 1 March report described heavy flood­ing from recent rains and wide­spread unsan­i­tary con­di­tions, with only 13% cov­er­age by latrines in tar­geted areas and 40% of those in need hav­ing emer­gency shel­ter mate­ri­als (for exam­ple, tar­pau­lins, tents) (7). Per­sons with dis­abil­i­ties, espe­cially out­side Port-Au-Prince, had not yet been reached by aid agen­cies and had crit­i­cal imme­di­ate sub­sis­tence needs (6). These indi­vid­u­als risked infec­tions and addi­tional wounds that could exac­er­bate their impair­ments or even cause death.

In the earthquake’s imme­di­ate after­math, numer­ous field facil­i­ties pro­vided essen­tial care, some­times of uncer­tain qual­ity. For the first few weeks, ampu­ta­tions, debride­ment, and frac­ture reduc­tion took pri­or­ity (8). Now, the empha­sis turns to wound care and clo­sure. Unless ampu­ta­tion sites heal prop­erly, per­sons might not obtain max­i­mum ben­e­fit from pros­the­ses. Imme­di­ate med­ical sta­bi­liza­tion of cer­tain gravely injured patients remains prob­lem­atic. In par­tic­u­lar, find­ing facil­i­ties to care effec­tively for per­sons with spinal cord and brain injuries has been dif­fi­cult. Crit­i­cal albeit basic assis­tive tech­nolo­gies are in short sup­ply. Clin­i­cians on board COMFORT could not find enough wheel­chairs for patients they dis­charged from the ship. On shore, Haitians requir­ing ambu­la­tion aids some­times could not find even canes or crutches.

Clin­i­cal Reha­bil­i­ta­tion and Assis­tive Tech­nol­ogy Needs

Fol­low­ing imme­di­ate med­ical sta­bi­liza­tion, reha­bil­i­ta­tion must begin with the goal of max­i­miz­ing patients’ ulti­mate func­tional out­comes. For instance, after ampu­ta­tion wounds heal, per­sons must per­form phys­i­cal ther­apy to keep the mus­cles around the ampu­ta­tion site strong and pre­vent con­trac­tures in antic­i­pa­tion of fit­ting and using pros­the­ses. Inter­na­tional med­ical aid orga­ni­za­tions have begun staffing selected Hait­ian facil­i­ties with reha­bil­i­ta­tion pro­fes­sion­als, but the avail­abil­ity of these essen­tial clin­i­cians remains spo­radic. Patients will require inter­dis­ci­pli­nary teams, includ­ing physi­a­trists, phys­i­cal ther­a­pists, occu­pa­tional ther­a­pists, and experts in such assis­tive tech­nolo­gies as mobil­ity aids, pros­the­ses, and orthotics to address their needs (4). Psy­choso­cial sup­ports are also essen­tial to ensure max­i­mum ben­e­fit from these inter­dis­ci­pli­nary services.

Per­sons who under­went emer­gency ampu­ta­tions in the field imme­di­ately after the earth­quake may need reop­er­a­tions by ortho­pe­dic sur­geons to ensure opti­mal out­comes. Even under the best cir­cum­stances, fit­ting per­sons with pros­the­ses and max­i­miz­ing mobil­ity is chal­leng­ing, despite sub­stan­tial progress in pros­thetic tech­nolo­gies (9). In recent years, upper– and lower-limb pros­the­ses have improved con­sid­er­ably, with advances in socket fab­ri­ca­tion and fit­ting approaches, com­po­nents, sus­pen­sion sys­tems, power sources, and elec­tronic con­trols. New pros­the­ses and fit­ting tech­niques accom­mo­date even high lev­els of limb ampu­ta­tions, improv­ing patients’ func­tional abil­i­ties. These advances are espe­cially ben­e­fi­cial to indi­vid­u­als with mul­ti­ple limb ampu­ta­tions, the sit­u­a­tion of many Hait­ian earth­quake amputees. Prob­lems with cur­rent pros­thetic tech­nolo­gies do remain, notably with achiev­ing com­fort­able socket fits, align­ing pros­thetic limbs for max­i­mum func­tion­ing, and repli­cat­ing nor­mal gait and other phys­i­cal maneu­vers (10).

How­ever, few Haitians with ampu­ta­tions before the earth­quake had the ben­e­fits of new—or even older—prostheses. A 2001 inves­ti­ga­tion found only 3 full-time stores pro­vid­ing pros­the­ses in Haiti, and all offered insuf­fi­cient ser­vices due to lack of sup­plies and poorly trained per­son­nel (11). Only one quar­ter of 164 Haitians with ampu­ta­tions inter­viewed for the study had ever had a pros­thetic limb. In geo­graph­i­cally iso­lated regions, pros­the­ses were vir­tu­ally nonex­is­tent. In postearthquake Haiti, the need for pros­the­ses will sky­rocket, but the man­u­fac­tur­ing capac­ity does not yet exist. Fur­ther­more, repli­cat­ing the pros­thetic indus­try of devel­oped nations might not work opti­mally in the devel­op­ing world, where tech­no­log­i­cal sophis­ti­ca­tion might not be as crit­i­cal as other fac­tors, such as dura­bil­ity, sim­plic­ity, ease of man­u­fac­tur­ing, light weight, and cul­tural accept­abil­ity (12). With so many Hait­ian infants and youth also affected, pros­the­ses must con­sider the spe­cial needs of devel­op­ing and grow­ing bod­ies (13). Sup­ply­ing equip­ment to chil­dren who might rapidly out­grow and no longer use it can raise finan­cial ques­tions in the devel­op­ing world (12).

Wheel­chairs have also been scarce in Haiti, where road­ways are fre­quently unpaved and inac­ces­si­ble. Many newly dis­abled Haitians, espe­cially those with spinal cord injuries and mul­ti­ple ampu­ta­tions, will need wheel­chairs. But wheel­chair tech­nolo­gies will require extra dura­bil­ity and other fea­tures to oper­ate in Haiti’s rugged ter­rain, upon rocky or debris-strewn road­ways, and sandy or muddy sur­faces. Com­pli­cat­ing mat­ters, per­sons unable to self-propel man­ual wheel­chairs will need power wheel­chairs for max­i­mum inde­pen­dence. Not only do power wheel­chairs require elec­tronic cir­cuitry and con­trols, they also need reli­able bat­ter­ies and steady power sup­plies for recharg­ing. Import­ing wheel­chairs from abroad is prob­a­bly the only option to meet the imme­di­ate wheel­chair needs while Haiti devel­ops its own wheelchair-production capacity.

Long-Term Needs

Clearly, the needs of Haiti’s newly dis­abled cit­i­zens are enor­mous. For indi­vid­u­als, min­i­miz­ing dis­abil­ity and pre­vent­ing deaths from earth­quake injuries may require years of ongo­ing surgery (8). At the soci­etal level, responses will require con­certed efforts from local Hait­ian author­i­ties as well as inter­na­tional aid agen­cies, inter­na­tional health care pro­fes­sional orga­ni­za­tions, and assis­tive tech­nol­ogy devel­op­ers and providers. Over the long term, Haiti’s med­ical edu­ca­tors must begin train­ing cadres of inter­dis­ci­pli­nary reha­bil­i­ta­tion pro­fes­sion­als to staff inpa­tient and out­pa­tient facil­i­ties. Pros­thetic, orthotic, wheel­chair, and other assis­tive tech­nol­ogy indus­tries must develop cul­tur­ally accept­able and eco­nom­i­cally sus­tain­able capac­ity within Haiti, with dis­tri­b­u­tion links even in remote regions.

As Haiti begins rebuild­ing its cities and towns, every aspect of that new phys­i­cal environment—both pub­lic and pri­vate spaces—must con­sider and accom­mo­date the needs of per­sons with dis­abil­i­ties. This process must involve Haiti’s newly dis­abled cit­i­zens in shap­ing poli­cies and deter­min­ing rebuild­ing plans. Experts in acces­si­ble design from the United States and other coun­tries should pro­vide essen­tial con­struc­tion advice. Expe­ri­ence from the devel­oped world indi­cates that build­ing struc­tures that accom­mo­date the needs of per­sons with dis­abil­i­ties from the out­set is less expen­sive than ren­o­vat­ing later and may add lit­tle, if any, addi­tional con­struc­tion costs (14). Mak­ing the struc­tural envi­ron­ment acces­si­ble and accom­mo­dat­ing needs in other ways will ulti­mately improve the qual­ity of life for all Haitians with dis­abil­i­ties and allow them to con­tribute to their own and their country’s future.

Arti­cle and Author Information

• Note: Dr. Ronan worked for 2 weeks as a civil­ian vol­un­teer with Project Hope on the USNS COMFORT out­side Port-au-Prince, Haiti, after the 12 Jan­u­ary 2010 earth­quake. Dur­ing this time, he served as part of the Navy’s Rapid Assess­ment Team.

• Poten­tial Con­flicts of Inter­est: None dis­closed. Forms can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0561.

• Requests for Sin­gle Reprints: Lisa I. Iez­zoni, MD, MSc, Mon­gan Insti­tute for Health Pol­icy, Mass­a­chu­setts Gen­eral Hos­pi­tal, 50 Stan­i­ford Street, Room 901B, Boston, MA 02114; e-mail, liezzoni@partners.org.

• Cur­rent Author Addresses: Dr. Iez­zoni: Mon­gan Insti­tute for Health Pol­icy, Mass­a­chu­setts Gen­eral Hos­pi­tal, Har­vard Med­ical School, 50 Stan­i­ford Street, Room 901B, Boston, MA 02114.

• Dr. Ronan: Depart­ment of Med­i­cine, Mass­a­chu­setts Gen­eral Hos­pi­tal, Har­vard Med­ical School, 50 Stan­i­ford Street, Room 901B, Boston, MA 02114.

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