Starting from Scratch
2010; Elsevier BV; Volume: 55; Issue: 5 Linguagem: Inglês
10.1016/j.annemergmed.2010.03.018
ISSN1097-6760
Autores Tópico(s)Cardiac Arrest and Resuscitation
ResumoApocalyptic language has been devalued in the United States in recent years, to the point where newscasters and headline writers could describe a large snowfall in the Tidewater states as a “snowpocalypse.” But the earthquake that struck Port-au-Prince, Haiti on January 12, however moderate on the Richter scale (7.0), had medical and social consequences that were decidedly nonmetaphoric. The response to this national scale emergency illustrated how tightly any country's medical infrastructure is interwoven with its broader physical, political, and economic fabric.Haitian civic institutions, concentrated in a vastly crowded capital city and headquartered in buildings that were neither designed, constructed, nor maintained in ways that could survive strong tremors, failed utterly. The national palace, ministries, police stations, hospitals, schools, hotels, food stores, and other critical centers were reduced to rubble. By the time relief arrived from nongovernmental organizations (NGOs), quasipublic organizations, the US military, and other sources, the fault lines in Haiti's public health system had been exposed every bit as deeply as those between the Caribbean and North American tectonic plates.The combination of poverty, weak governance, and an absence of emergency planning led to conditions that even seasoned relief workers found unfathomable. The populace was already inured to malnutrition, high maternal and child mortality, and high rates of tuberculosis and HIV; some now gave way to abject panic. Two weeks of aftershocks in the 6.0 range exacerbated the general disorder: a building safe to occupy in Port-au-Prince is now a rarity, and at least 1 million displaced persons (estimates range up to 1.7 million) must obtain shelter, medical care, and basic subsistence services in hygienically challenged tent cities as the spring hurricane season approaches.Lower Magnitude, More DamageHaitians and members of the international Haitian diaspora immediately began planning for national recovery. United Nations secretary-general Ban Ki-moon vowed to “help Haitians ‘build back better.’ ”1Ban Ki-moon. Remarks at launch of revised Haiti Flash Appeal, UN News Centre, February 18, 2010. Available at: http://www.un.org/apps/news/infocus/sgspeeches/statments_full.asp?statID=730. Accessed March 21, 2010.Google Scholar Their endurance and spirit in the face of adversity have profoundly impressed volunteers from abroad.At a February 24 conference held by the UN Association of Haiti on reconstruction in key sectors (medical care, education, finance, and culture), boisterous audience responses testified to Haitians' loyalty, energy, and determination. Looking to other small, cohesive nations such as Israel, Singapore, and South Korea as economic models, panelists brainstormed about ways to leverage efforts by the Association des Médecins Haïtiens à l'Étranger (AMHE, the Association of Haitian Physicians Abroad), the Fonkoze microfinance network, Haiti's vibrant musical community, global NGOs such as the Clinton Foundation and the Open Society Institute, and perhaps even a conjectural “Friends of Haiti” congressional caucus. Haitians are well aware how little their government officials to date have led them to expect; they also treasure their unique culture and envision its eventual self-sustenance.But Haiti's ill fortune was compounded 3 days after the UN conference when an 8.8-magnitude temblor struck the coast of Chile. The South American nation is at the opposite end of the economic spectrum from Haiti and was better prepared on every level. Yet even the most resilient nation requires international aid after such an event, and the Chilean quake inevitably dilutes the global pool of available relief resources.Chile has a reasonably well-developed emergency medical system; after major quakes every few years through much of the 20th century (including the 9.5-magnitude Valdivia quake in 1960, the largest recorded in the history of instrumental seismology), the nation also maintains the strict building codes adopted during the Salvador Allende regime.2Tapia Gutierrez P. Seismic hazard and countermeasures in Antofagasta, Chile.Bulletin of the International Institute of Seismology and Earthquake Engineering. 1999; 33: 97-116Google Scholar Damage, displacement, and disorder at both sites have been severe, but more of Chile's buildings withstood the shock, and the death toll at this writing (early March) is in 3 figures.At the Haitian capital, in contrast, physical and social structures were both unprepared. Mortality estimates have ranged between 100,000 and 230,000 (the latter figure being the government's official estimate as of mid-February). With inadequate search-and-rescue operations leaving unknown numbers of bodies buried beneath collapsed buildings, a final count of 300,000 is conceivable. Physicians who responded to Haiti's needs and worked in the tent cities, particularly those familiar with the local situation before the quake, believe that many of these casualties were preventable.Desperation Before the DisasterErnest Benjamin, MD, chief of critical care in the department of surgery at New York's Mt. Sinai Hospital and a native of Haiti, took a 27-person multispecialty team to Port-au-Prince the day after the earthquake, using connections to the local organization Partners in Health (also known by its Kreyol name Zanmi Lasante) to help bypass bureaucratic obstacles that delayed some other volunteers' arrival where they were needed. In public meetings and private interviews alike, he speaks knowledgeably and frankly of his homeland's capabilities and challenges.Slave Revolt, Papa Doc and VodouHaiti's Historical Context and the Dangers of Media Sensationalismby WILLIAM B. MILLARD, PhDSpecial Contributor to Annals News & PerspectiveOften lost in the media portrayals of devastation and lawlessness in Haiti, is the rich history that has created a unique culture, a great source of pride among the island's inhabitants.“The most respectful thing one can do before going to Haiti,” says Joia S. Mukherjee, MD, MPH, attending physician at Brigham and Women's Hospital and Massachusetts General Hospital and medical director of Partners in Health, Paul Farmer's quasipublic organization with extensive experience in Haiti, “is to understand a little bit about the importance of [Haitian] history, and how history has resulted in Haiti's political marginalization.”Haitian culture has certain aspects that are easy for the commercial media to sensationalize (eg, the tonton macoute thuggery in the days of the Papa Doc/Baby Doc Duvalier dictatorship, or the vodou religion, a syncretic mix of Roman Catholic intercessory prayer and assorted West African Fon, Ewe, and Yoruba beliefs). News reporting about the earthquake and its aftermath has missed few opportunities to skew the nation's external image to emphasize degradation, governmental irresponsibility, and gunplay. These portrayals not only distort the picture but erode the natural empathy that is inseparable from both philanthropy and medical care.History supports the exuberant pride that Haitians show toward their country. Ernest Benjamin, MD, chief of critical care in the department of surgery at New York's Mt. Sinai Hospital and a native of Haiti, readily recounts the nation's experience and achievements since Columbus's landing in 1492. He says that knowledge of this background is indispensable for a nuanced view of Haiti's current circumstances. Haiti is the only nation born of a successful slave revolution; in a prolonged struggle from 1791 to 1803, Haitians ousted the French under Napoleon Bonaparte, Dr. Benjamin notes, even as Napoleon sold the Louisiana Territory to the US to pay for this and other wars. The price Haiti paid for beating Europe's largest army and advancing the worldwide antislavery movement was a series of crippling embargoes, blockades, and threats of invasion and reconquest.The new nation struggled to develop adequate leadership under conditions of geopolitical isolation and financial constraint; as Dr. Benjamin says, “we have always had dictators, from the moment we became independent until now.” In 1825, the half-French military ruler Jean-Pierre Boyer agreed to pay France 150 million gold francs1Ordonnance de Charles X.http://www.haitiforever.com/windowsonhaiti/act3.shtmlGoogle Scholar, 2Miller C.L. The French Atlantic Triangle: Literature and Culture of the Slave Trade. Duke University Press, Durham2007Google Scholar, 3BBC NewsG7 nations pledge debt relief for quake-hit Haiti.http://news.bbc.co.uk/2/hi/americas/8502567.stmGoogle Scholar, 4Klein N. Haiti: A creditor, not a debtor.http://www.thenation.com/doc/20100301/klein?rel=emailNationGoogle Scholar, 5Varadarajan T. Why Haiti's earthquake is France's problem.http://www.thedailybeast.com/blogs-and-stories/2010-01-14/why-haitis-earthquake-is-frances-problem/Google Scholar (the equivalent of over $20 billion today) to indemnify slaveowners for their losses, in return for King Charles X's recognition and withdrawal of warships from the harbor. “This is the first time in history when the vanquished get paid for losing,” comments Dr. Benjamin. By the time Haiti finally discharged this debt in 1947, economic bondage and underdevelopment had become chronic. Still, Haitians supported Simón Bolívar financially, militarily, and through sanctuary during Latin America's independence struggle against Spain. “Haiti in the past was always on the side of fighting against inequality,” Dr. Benjamin says, “fighting against injustice and colonization.” Perhaps significantly, one national symbol of these ideals, the statue Le Negre Marron by Albert Mangones (The Black Maroon, or Neg Mawon in Kreyol, with one leg set loose from a broken chain), has survived the earthquake intact, even as the nearby presidential palace crumbled.“Haiti is not a poor country in my view; it's an impoverished country,” says Dr. Mukherjee. “It's been very much political forces that have impoverished Haiti. If you look at its neighboring countries that didn't have the similar political history, they're much wealthier than Haiti, more second-world countries.” The United States, still half a slave nation during Haiti's early decades, feared that Haiti's example would catalyze a revolt on its own territory and refused to recognize Haiti's independent government until 1862. American-Haitian relations have had a mixed legacy, Dr. Benjamin says, weighing occupation from 1915 to 1934 and support for a succession of dictators against good works in the public health sphere. “Most of the hospitals… were built by the U.S. military during that occupation, and they had fairly good public hygiene and a sanitation system, which we really have to give credit for. I think it has always been an ambiguous type of relationship.”If Haiti is on balance more a creditor nation to the developed world than a debtor, as these volunteer physicians and others agree, health care and associated forms of emergency aid remain decisive ways Americans can add their weight to help restore balance. Those who have already answered this call advise new volunteers not to go it alone.Paul Auerbach, MD, MS, professor of surgery in the division of emergency medicine at Stanford University and a member of an International Medical Corps mission to the University Hospital, said the best method is to work through a reputable agency, either governmental or nongovernmental, that is familiar with the situation in Haiti and has the means and the methods to support the person who wants to help.Emergency physicians in this setting, he adds, are often called on to apply skills extending well outside their customary comfort zone. As some have discovered in other disaster scenarios, honing one's professional abilities in settings like Haiti is beneficial for everyone involved.6Ali R. In search of miracles: a physician volunteer at Ground Zero. Ann Emerg Med. January; 39:5-8.Google Scholar It will be a considerable time before the uphill short-term work of providing adequate living conditions is succeeded by the long-range labors required to establish a credible Haitian public health system with full emergency care. “This is not a recreation of the health system,” Dr. Auerbach summarizes; “they need to create the health system.”In disasters affecting developing countries, he says, “the first thing to remember is that the countries cannot fend for themselves. They don't have any infrastructure to do it. Even before the disaster, they are already in a state of disaster.” Haiti's national budget, he points out, is lower than that of Mt. Sinai Hospital. With a population of 10 million people, 80% live below the poverty line, and 54% live on less than a dollar a day.3Human Development Report OfficeUnited Nations Human Development Report, 2007/08 Fighting Climate Change: Human Solidarity in a Divided World.in: Palgrave Macmillan/United Nations Development Programme, New York, NY2007: 239Google Scholar Unemployment, though difficult to measure, is around 60%, and illiteracy 44%; 46% of Haitians lack access to potable water.The World Bank defines Haiti as a “low-income, chronic-food-deficit country,” capable of producing only 43% of its nutritional needs. Rural-to-urban migration has also drastically inflated the capital demographically. “Port-au-Prince was built for about 150,000 people,” notes Benjamin's colleague Jean Louis Dupiton, MD, an intensivist at Elmhurst Hospital in Queens, “but before the quake it had anywhere between 3 and 3½ million.”For Haiti's medical infrastructure, surge capacity was not even an issue, because the capacity simply to handle the population's pre-existing demands was absent. The University Hospital (Hôpital de l'Université d'État d'Haiti) in Port-au-Prince, the nation's largest public health facility, was recognized before the quake as a source of excellent training–and of a prominent brain drain of Haitian physicians and nurses to the U.S. after their year of mandatory service–but it has long operated on inadequate funds and supplies. “Ninety percent of the budget of that hospital is to pay for salary,” says Dr. Benjamin. “That means there's really no money left for functioning.” Nurses might go 3 months without a paycheck, and physicians “work mostly in private” at separate clinics serving a wealthy oligarchy, in some cases rendering their hospital appointments nominal rather than full-time.Law enforcement is likewise minimal, with “only 9,000 policemen for 9 to 10 million people,” says Dr. Benjamin. “A lot of them died in the quake; a lot of those who did not die lost everything [and] were not in the mood to assist in anything. The government was completely nonexistent” when it was needed most. “The state administration does not have a long history of caring for the people,” he summarizes, by all accounts understating the case. “People have always fared for themselves.”Dr. Dupiton, a graduate of Mt. Sinai's critical care fellowship and a fellow volunteer alongside Dr. Benjamin, expands on the background conditions. “There's no private industry, not much of it to speak of; there's no health insurance system. Health [care] is free, but there's no access, because there's no health to speak of.” Patients must provide their own supplies, “even the syringes,” he reports. “If you need it, you have to buy it, and if you cannot buy it, then obviously you won't make it.” Disaster planning and emergency medical services (EMS) do not exist in Haiti; patients needing emergency care are taken to hospitals by family or friends or do not arrive at all.Limited facilities are not the only obstacle to care. “There's a small emergency room in the general hospital; there are several private emergency rooms; but there's not an emergency medical system,” says Joia S. Mukherjee, MD, MPH, attending physician at Brigham and Women's Hospital and Massachusetts General Hospital and medical director of Partners in Health, Paul Farmer's quasipublic organization with extensive experience in Haiti. “Often the fees for such services are too exorbitant to really apply to poor people. Similarly, most surgery is in the private sector, and you could pay up to $30,000 US just for a simple gallbladder surgery.” With poverty closer to that of sub-Saharan Africa than neighboring Caribbean countries, but a higher cost of living owing to the reliance on imported goods, she says, Haitians carry an abnormal economic burden.Paul Auerbach, MD, MS, professor of surgery in the division of emergency medicine at Stanford University and a member of an International Medical Corps mission to the University Hospital, was unfamiliar with Haiti before arriving and found conditions alarming.“The medical infrastructure in Haiti was lacking a lot of what we take for granted in the United States: EMS, prehospital care, trauma care. . . . I'm not aware of any hospitals in Port-au-Prince that are in good condition. The Hôpital Albert Schweitzer is in good condition, but [it's] further out from the epicenter” in Deschapelles, north of the capital in the rural Artibonite department.4NationMasterAdministrative divisions of Haiti.http://www.nationmaster.com/encyclopedia/Administrative-divisions-of-HaitiGoogle Scholar Working at the University Hospital site, Dr. Auerbach and his colleagues did not directly witness criminality, though the lack of social cohesion makes reports of violence plausible: “The gap between the people that are most well off and least well off in Haiti is as dramatic as it is anywhere in the world. . . . You wouldn't expect, after a catastrophe of this nature, the social problems to improve.”Dr. Auerbach has high praise for the Haitian community leaders, physicians, and patients he encountered, along with the US military and the NGOs. “Every country has its leaders and inspirational people, and Haiti is no exception,” he says. “The patients were remarkable: they were to an individual appreciative, gracious, and helpful to us and to the family members, and doing so in the worst imaginable circumstances.” He attributes the calamitous consequences to a scalar mismatch between damage and resources. “There was not an internal Haitian infrastructure capable of dealing with a disaster of this magnitude without a tremendous amount of external support–but I would challenge any country, regardless of its political stability, to manage something of this magnitude, in which the entire city structurally collapsed. I don't know any society that could handle that without external support.”Missing FoundationsDrs. Benjamin and Dupiton also emphasize the vulnerability of Port-au-Prince's residential architecture. Haiti was in some respects the perfect model of an unregulated society, with no zoning, planning, building code inspections, or other mechanisms of public accountability. “You want to build a house, you build it anywhere you want,” reports Dr. Dupiton. The magnitude, speed, and severity of the destruction indicate the critical role of building quality in a city's ability to withstand disaster conditions.A visual presentation that Dr. Benjamin gave for colleagues after returning to Mt. Sinai shows the shoddy construction standards prevalent throughout Port-au-Prince. Houses of unreinforced concrete, initially built on shallow foundations at single-story height, were expanded to accommodate new residents with second, third, and fourth stories of cement blocks and cheap concrete, using dirt rather than sand or gravel as aggregate. These materials contributed weight but not strength; nothing gave each new level rigidity but four half-inch steel rebar corner poles. Dr. Benjamin follows these images with an aerial photo taken shortly after the quake, showing dense clouds of concrete dust blanketing the city. The resemblance to New York's Ground Zero in the days after September 11 is unsettling. “When you see that,” comments Dr. Dupiton, “you know there is destruction all over, which you don't see in Chile.”Although Haiti does not have Chile's obvious seismic vulnerability, Drs. Benjamin and Dupiton point to the island of Hispaniola's pattern of major quakes every few decades (sometimes clustering a few years apart), along with more regular hurricanes, as grounds for taking disaster preparation seriously. The last major local quake, an 8.1 epicentered across Haiti's eastern border in the Dominican Republic, occurred in 1946, too long ago to be prominent in the collective memory of a nation with a life expectancy of 61 and a median age of 20.5Central Intelligence Agency World Factbook.https://www.cia.gov/library/publications/the-world-factbook/geos/ha.htmlGoogle Scholar “We have a history of earthquakes, but Haitians behave as if that had never happened,” says Dr. Benjamin.Speed, Supply Chains, and SequenceWith limited medical, logistical, economic, and infrastructural resources available, Haiti's minimal public health sector was rapidly overwhelmed. The conditions after January 12 were exactly those that modern triage strategies (START,6Kahn C.A. Schultz C.H. Miller K.T. et al.Does START triage work? An outcomes assessment after a disaster.Ann Emerg Med. 2009; 54: 424-430Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar SALT,7SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association.Disaster Med Public Health Prep. 2008; 2: 245-246Crossref PubMed Scopus (49) Google Scholar or others) are designed to prevent. If the 6 critical hospital substrates in a disaster are the physical plant, personnel, supplies and equipment, communication, transportation, and supervision or managerial support,8Schultz C.H. Koenig K.L. Noji E.K. Disaster preparedness and response.in: Rosen P. Emergency Medicine: Concepts and Clinical Practice. 4th ed. CV Mosby, St. Louis, MO1998: 326Google Scholar the systems operating at Port-au-Prince proved insufficient on most levels. International relief efforts brought personnel to the tents of Port-au-Prince more promptly than supplies, and the absence of coordinated management and communication precluded approaches that might have worked around the severe deficiencies in the physical plant.Drs. Benjamin and Dupiton point out that the lag time for any international relief effort responding to disaster in a developing country, typically at least 3 or 4 days for most NGOs, exceeds the “golden period” of approximately 72 hours when many survivors must be found, evacuated, and treated to minimize casualties. “Somehow food and water delivery is never early enough for the people who are suffering,” Dr. Benjamin adds. “A lot of people would have been saved if there was a way for international help to be present very early on.”Damage to Port-au-Prince International Airport's control tower delayed access to the country; with the US Air Force assuming control of the undamaged landing strip, military flights sent in expectation of civic unrest initially took priority over relief flights, leaving some supply planes sitting on the tarmac, and a first-come, first-served policy meant that the sequence of arrivals had little to do with the urgency of the needs for different types of cargo. (Oddly if not infamously, a missionary flight sponsored by a Hollywood-connected and notoriously litigious psychological cult, promulgating what one medical official calls “apocalypse voyeurism” and “some kind of bizarre touch therapy [with] no scientific basis,” was reportedly permitted to land before several Médecins Sans Frontières [Doctors Without Borders] flights bearing medical supplies.9Mackey R. Jan. 21: Updates on the crisis in Haiti. The Lede: New York Times news blog, Jan. 21, 2010.Google Scholar)Resources that might have been useful were omitted from the response. Dr. Benjamin suggests water transport: the shipping port at Port-au-Prince was damaged, but ports at Saint-Marc, Gonaives, and Cap-Haitien were operational, as were roads north of Port-au-Prince. “It boggles the mind,” he says: “we have 2,500 flights that are awaiting clearance, while Haiti is at the most 3 days by boat from Miami. A lot of the international help could have been diverted to other port cities in the country. . . . Somehow, somewhere, something did not click.”Dr. Benjamin knew before traveling to Haiti that broad-spectrum antibiotics would be at a premium. Since the 2001 anthrax scare led US hospitals to stock up on ciprofloxacin, he says, “I told the pharmacy we need a lot of antibiotics, and they gave me 5,000 doses of Cipro.” However, Dr. Dupiton adds, “there [weren't] any antibiotics for babies. . . . We'll know next time to bring, also, suspension for kids.” Considering the limited local supplies, he says, “we need a lot of IV fluid, things you'd never think of; pain medicine, tetanus shots, because those people have dirty wounds. . . . All things you would never think about, but those are the first things, because if you bring them to bear early, then probably you can make a difference.”Bright spots amid the chaos included the logistical support and supplies provided by the American armed forces, which greatly expanded the range of care available in the nation by sending the medical ship USNS Comfort to Port-au-Prince's harbor on January 20,10Auerbach P.S. Norris R.L. Menon A.S. et al.Civil-military collaboration in the initial medical response to the earthquake in Haiti.N Engl J Med. February 24, 2010; (online only) (Accessed March 21, 2010)http://content.nejm.org/cgi/content/full/NEJMp1001555PubMed Google Scholar and by the Norwegian Red Cross, which Dr. Benjamin credits as the first significant donor of tents. Israeli logistics experts and Cuban physicians, who have had a volunteer program in Haiti for a decade, come in for frequent commendation. Potable water shortages and dehydration were especially problematic during the first few days, but the Red Cross, Operation Blessing, and other groups responded to this need. Dr. Mukherjee says that “water has been, I think, an undersung success story. . . . I didn't see anyone die of dehydration, which is quite shocking, given the temperatures and the fact that the water systems were destroyed.”“Even the Dominicans,” Dr. Benjamin says, wryly recounting the longtime adversarial relations between the two nations sharing Hispaniola, “have been really unexpectedly nice to us.” The Dominican Republic opened its borders rapidly for relief traffic and sent firefighters with a water station and purification supplies.“Whatever organizations are going to respond to disaster need to be capable of moving swiftly and mobilizing the appropriate numbers of individuals rapidly,” comments Dr. Auerbach. “We found that some of the NGOs such as the International Medical Corps, Partners in Health, and Doctors Without Borders were able to do this effectively. The military was certainly able to do this effectively, and the support we received from the military was outstanding. . . . The military needs to be an integral part of disaster response.”Earthquake EpidemiologyAt a field hospital with a 100-bed intensive care unit, set up by the Red Cross at the soccer stadium in the western residential commune of Carrefour, senior medical officer Alin Stoica, MD, has observed changes in the patterns of presentations since the early stages. Surgeons were the specialty most in demand at the outset, given the huge number of orthopedic injuries.“We notice that we get less and less patients with earthquake-related trauma or something like that,” says Dr. Stoica. “Most patients coming now are car accidents or shotgun wounds, but mostly are pregnant women [or women with] gynecological problems.” Malaria cases, he notes, have remained relatively steady. As the rainy season strikes, many fear that poor sanitation around the tent cities will lead to skyrocketing rates of diarrheal diseases, but so far Dr. Stoica has seen “a normal parade of infections for this period.”Working in quarters that often compared unfavorably to a battlefield MASH unit, early responders had to make difficult but expedient triage calls. With “less than a dozen orthopedic surgeons in Haiti practicing on a regular basis before the earthquake, and only a handful working in the public sector,” says Dr. Mukherjee, “there was really no orthopedic capacity in the immediate aftermath of the earthquake. Because of that, many people who could have had their limbs saved had amputations.”Along with massive problems with infected amputation sites requiring follow-up procedures, Dr. Mukherjee describes neurosurgery as another of Haiti's important unanticipated needs, but she notes that the University of Miami's neurosurgery chairman Barth A. Green, MD, director of Project Medishare for Haiti, established a large, well-staffed tent facility at the airport. As the acute emergency gives way to chronic conditions, rehabilitation, prostheses, and physical therapy for the severely injured population will strain the capacity Haiti's small number of providers. The existing elevated rates of HIV and tuberculosis are another long-range risk factor, Dr. Mukherjee notes, in part because of a likely rise in “transactional sex: women who are trying to feed their kids and end up having to have sex to negotiate getting food or safety.” She is concerned that many children under 5 are living in camp conditions, subsisting largely on rice rather than a complete protein diet, will be vulnerable to “surging rates of kwashiorkor.”Partners in Health has been working in Haiti for over 25 years to provide community health services, says Dr. Mukherjee, and its local knowledge continues to be a substantial asset. At th
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