Ophthalmologists step up to assist Haiti earthquake relief effort

Ophthalmic outreach to Haiti following the Jan. 12 earthquake was an overwhelming experience for those involved, both immediately after the disaster and a month after the quake. Language barriers proved a challenge, food was hard to find, and clean water was scarce.

“It was a life-changing experience for me. I’ve been around for a while … [but] this 1 week was truly life-changing. It was unbelievable,” OSN Oculoplastic and Reconstructive Surgery Board member, Charles B. Slonim, MD, FACS, said.

Physicians operated and cared for patients in tents, existing hospitals and open-air sites. Surgical conditions ranged from state-of-the-art to dire. In some surgical environments, physicians worked in high heat and humidity without air conditioning. At times, some operated without suction. In other operating theaters, they had necessary equipment and ideal conditions.

Justin Townsend, MD, from the Bascom Palmer Haiti Relief team, examines a boy with traumatic optic neuropathy. Image: Shane T

Dr. Slonim performed oculoplastic surgery in Haiti in mid-February as part of the University of Miami’s Bascom Palmer Eye Institute-Project Medishare relief efforts. He and other ophthalmologists treated open-globe injuries, crush injuries and ptosis. They also saw head injuries that caused droopy lids and optic nerve damage.

Early responders treated initial injuries, while physicians who arrived later, including Dr. Slonim, treated infections and pre-existing problems. They also performed secondary repairs.

Other ophthalmic issues in Haiti included lost eyeglasses, difficulty with surgical follow-up and pre-existing ocular disease that required medical therapy.

The earthquake, which measured 7.0 on the Richter scale, was centered about 15 km southwest of the country’s capital, Port-au-Prince. It killed an estimated 300,000 people, according to the Haitian government; an independent assessment estimates that about 100,000 died.

Ophthalmic-related volunteers have been caring for thousands of survivors in city hospitals and medical field tents at the airport. U.S. and international ophthalmic groups and institutions have responded by sending ophthalmologists, medical support personnel and medical supplies to the country. The American Academy of Ophthalmology created a Task Force on Haiti Recovery, which is working in concert with the Pan-American Association of Ophthalmology, Bascom Palmer and the Association of Haitian Physicians Abroad.

Initially, the need for materials and supplies far outweighed the need for ophthalmologic manpower, Michael W. Brennan, MD, former AAO president and leader of the AAO task force, said.

“We realized quickly that materials and supplies were more important than eye surgeons, and we assembled a number of people to make calls to industry and solicit contributions,” Dr. Brennan said. “We’ve got some donations lined up, and we have some materials on the way.”

Dr. Brennan visited Haiti in early February to facilitate partnerships with the Haitian Society of Ophthalmology and assess short- and long-term eye care needs. Mildred M.G. Olivier, MD, a task force member, also visited Haiti at that time. Dr. Olivier, a Haitian-American who has visited the country many times, said she was overwhelmed by the devastation and the incredible need for medical supplies, food and clean water.

Mildred M.G. Olivier

“I think in terms of the infrastructure, I knew it was always fragile,” she said. “But there was nowhere in your entire mind that you could think that something this huge would happen to Haiti.”

Ophthalmology organizes

The AAO task force was formed in late January to spearhead ophthalmic relief efforts and help rebuild Haiti’s medical infrastructure. The group is also collaborating with the Haitian Ophthalmology Society, U.S. Agency for International Development, International Medical Corps and other groups.

Bascom Palmer has joined forces with the Haitian Ophthalmology Society and other ophthalmic groups from the region, Richard K. Lee, MD, PhD, said. Dr. Lee is organizing the collaboration.

“It’s really a concerted effort,” Dr. Lee said. “We went off on our own to begin with, but now we’re part of a larger group throughout the U.S., then linking up with Caribbean, Haitian and Puerto Rican groups. The whole Pan-American organization is a part of all this through the PAAO.”

The AAO and PAAO are joining forces to provide portable eye units, supplies and equipment to ophthalmologists in Haiti. These items will help Haitian ophthalmologists re-establish their practices, Dr. Lee said.

“The packets are for mobile use, but we are looking into getting more substantive supplies and equipment to help the Haitian ophthalmologists start treating patients,” he said.

In addition, during a trip to Haiti in early February, Dr. Brennan met with staff from the Navy hospital ship USNS Comfort. The vessel was dispatched to Haiti after the quake to provide vitally needed surgical facilities. Terence McGee, MD, and Kristen Zeller, MD, were the two Navy ophthalmologists who managed most of the serious initial ocular injuries.

Experiences on the ground

Ophthalmologists mobilized and headed to the earthquake zone within days of the disaster. James T. Banta, MD, an ocular trauma specialist from Bascom Palmer, was among the first American ophthalmologists to arrive in Haiti. Currently, ophthalmologists are serving solo 5-day tours of duty at the University of Miami field hospital, which is located at the airport, Dr. Lee said.

Initially, volunteers faced various challenges related to transportation, food and living quarters.

“There were literally planes that took off and arrived in Haiti but had to be turned around because they could not land or there was no space for them to park a plane,” Dr. Lee said. “So the first logistical problem was trying to get people and supplies in and out of the airport.”

Lack of food and water initially was a problem, but conditions have improved significantly since the first few days and weeks, he noted.

“Now there’s food there, whereas before there was plenty of food but it was all snack foods. You could have all the granola bars you wanted as long as all you wanted was granola bars,” Dr. Lee said.

Dr. Olivier assisted at the Haitian Community Hospital, where language was a major issue. In addition to English, Dr. Olivier speaks French and Haitian Creole. She interpreted for Haitian patients to medical teams from countries including Sweden, Hungary and China.

“As I was going around, I was saying to the patient, ‘Are you OK, are you in pain, is there anything we can do?’ And they would say sometimes, ‘Yes, I’m in pain.’ I would say to the nurse [in English], ‘He’s in pain.’ And she’d say, ‘Well the pain medication is right there, next to his head.’ I would say [in French or Haitian Creole], ‘See these little pills in this little plastic baggie? These are your pain pills,’” Dr. Olivier said. “But how much of that could you do? Then we started getting a whole team of translators. Sometimes it was 8-year-old translators. Sometimes it was someone who had medical training.”

Charles B. Slonim

Dr. Slonim performed surgery in three different environments: the USNS Comfort, the state-of-the-art U.S. Navy hospital ship; the University of Miami’s tent field hospital; and the University Hospital of Haiti in downtown Port-au-Prince.

The University Hospital of Haiti’s operating conditions were by far the most challenging, he said.

“The operating rooms had been moved to a very crude, open-air, non-air-conditioned, poorly staffed and poorly supplied building. The morgue was on the other side, and the eye clinic for the university hospital was two blocks away,” Dr. Slonim said.

Patients received preoperative care at the eye clinic, walked two blocks to the operating area and underwent surgery there. One patient assisted in draping her own operating table, he said. The only light source was a borrowed camping light.

“We had to use a fan not only to keep me cool, but to keep the flies off the surgical wound,” he said.

Arrival view from helicopter, tent city amid destroyed homes.

A military presence — here, the 82nd Airborne Division — was invaluable to NGO presence. Images: Brennan MW

At the Haiti Embassy, meeting with U.S. Navy physicians from Comfort. From left: Michael Brennan, MD, U.S. Navy Capt. Colleen Gallagher, (nurse practitioner), Italo Subbarao, MD, (AMA Disaster Relief), Kathleen Casey, MD, (ACS) and Terence McGee, MD.

The Haitian Palace that was destroyed by the quake. Images: Brennan MW

Pediatrician attending to her patients in plaza tent clinic/hospital/commune at base of destroyed neighborhood, wearing T-shirt from her NGO supporter, International Medical Corps.

Patients seen in the operating room. Images: Brennan MW

The Bascom Palmer Haiti Relief team at Fort Lauderdale airport hangar. From left to right: Tom Shane, MD, Tom Johnson, MD, Richard Lee, MD, Ashlee Vainisi, RN, Manuel Paz, nurse anesthetist and BPEI Chairman Eduardo Alfonso, MD.

Tom Shane, MD, conducts vision screenings for patients at the University of Miami Haiti field hospital. Images: Shane T

More than 140 patients were screened in one day at the makeshift eye clinic in the University of Miami field hospital.

Tom Johnson, MD, takes a moment to comfort an orphan of the Haiti earthquake. Images: Shane T

One example of the devastation in Haiti.

Mildred M.G. Olivier, MD, performing surgery in the OR. Images: Olivier MMG

Charles B. Slonim, MD, changes the dressing on a surgical patient with an orbital fracture on the surgical ward of the University of Miami/Medishare hospital tent.

Patients recover in the pediatric ward in the University of Miami/Medishare hospital tent on the airport property. Images: Slonim CB

Dr. Slonim, left, performs an orbital exenteration at an operating room converted from a storage building adjacent to the earthquake-damaged University of Haiti hospital in downtown Port-au-Prince.

One of Dr. Slonim’s many patients was this 8-year-old boy who survived a building collapse with head and orbital trauma. Images: Slonim CB

Existing needs in Haiti

Before the earthquake, the need for medical assistance in Haiti was already great, Dr. Olivier said. Haiti is the poorest country in the Western Hemisphere, with 80% of the country’s more than 9 million people living below the poverty line. Fifty-four percent of Haitians live in abject poverty, and many Haitians are underserved medically, with limited access to medical care.

The Haitian Ophthalmological Society had 50 members before the quake. One Haitian ophthalmologist died in the earthquake. Approximately six or seven ophthalmology practices were destroyed, and several ophthalmologists lost their homes.

“Patients who normally would have normal care, they were falling into a situation where the only care they had was the non-government organizations that were down there rendering care,” Dr. Slonim said. “You take seven or eight ophthalmologists out of the picture when there are only 50 in the whole country, you start to lose your capabilities of eye care.”

Dr. Olivier has been studying glaucoma genetics in the country’s population since 1993, and she said the country has a 10% to 15% incidence of glaucoma. Haitian ophthalmologists have minimal experience with laser and do not do a lot of filtering surgery, and medication, although imperative for glaucoma treatment, is not a long-term solution. Delivering enough medication to Haitian glaucoma patients could prove difficult in the coming months, she said.

“Already, the infrastructure was stressed in certain areas, especially for the underserved,” Dr. Olivier said.

Haiti also has the highest prevalence of HIV in the Caribbean and Latin American regions, according to the World Health Organization. Haiti has the most severe AIDS epidemic in the world besides Africa and the greatest burden of HIV in the Western hemisphere, the WHO said.

While in Haiti, Dr. Slonim operated on Haitian children who were HIV-positive and had tuberculosis. Knowing that those children would most likely not receive adequate follow-up care was devastating, he said.

“I think that bothered me the most – that with these kids, we’re trying to save their lives or their sight and they’re HIV-positive and they’re TB-positive, so how much longer could they possibly live under those circumstances without [medical care]?” he said.

Addressing long-term needs

Rebuilding the physical infrastructure and developing human resources will pose significant challenges, Thomas Shane, MD, said. Dr. Shane, from Bascom Palmer, volunteered in Haiti in late January.

“That’s going to be the challenge going forward, re-establishing both the clinical space and the operating room space, as well as replenishing the skilled people that are needed to use them,” Dr. Shane said.

Bascom Palmer will have a presence in Haiti for several months, but that presence cannot be sustained indefinitely, Dr. Lee said.

“The big issues right now, I think, are getting the Haitian ophthalmologists up and running so they can take care of things locally. We can’t have a continuous presence there,” he said.

Outreach efforts need to focus on persistent, pre-existing ocular conditions, Dr. Lee said.

“I think a significant amount of that is an underlying need to begin with. This is a very underserved country,” he said. “I think some of those things are going to be key in terms of low-tech, high-yield things that we can do for the Haitian people.”

Bascom Palmer volunteers are building upon a foundation of medical outreach established in 2009 when faculty and residents taught their Haitian counterparts how to treat glaucoma, Dr. Shane said.

“Going forward, now that the acute injuries are taken care of, we will go back through those routes to establish a more lasting eye care setup,” he said.

One of the largest causes of visual impairment in Haiti is untreated refractive error. Autorefraction is ideal for measuring eyeglass prescriptions because technicians do not need extensive training and patients do not have to give subjective responses. Dr. Shane and colleagues have shown that autorefraction and inexpensive, pre-made glasses can improve vision from 20/60, the threshold for not being able to drive, to a strong average of 20/25.

In developing countries such as Haiti, small-incision extracapsular cataract surgery is performed in lieu of phacoemulsification because of budget limitations.

“It’s been shown to be the best way to do cataract surgery in the developing world,” Dr. Shane said. “We’re not bringing anything new to that procedure.”

Dr. Brennan was optimistic that a modernized, improved medical infrastructure will emerge from the ruins. Long-term efforts must be focused on reconstruction, technical improvements and continuing medical education, he said.

“I see [the communities] having a chance now to restore a more sophisticated [system],” he said. “I think that organized medicine could do an awful lot to help reconstitute that, and I’m talking about the long term. Most important, we need to engage our Haitian ophthalmology colleagues.”

Dr. Olivier was also optimistic about Haiti’s future, pointing to the devastation after Hurricane Katrina in New Orleans and how quickly humanitarian efforts there rebuilt the area. However, Haiti lacks the infrastructure that New Orleans had before the hurricane, she said.

Long term, the country will need the assistance of many experts, including planners, engineers and the medical establishment.

“I think the future can be bright. But it’s like when you’re in that pathway where you can go right or left, and one might be a good road and one might be a bad road. I think that’s where we are right now – the crossroads,” Dr. Olivier said. “A lot of it depends on Haiti, and a lot it depends on how people are going to try help Haiti. How much do they want to try to help Haiti? We’ll have to see.”– by Erin L. Boyle and Matt Hasson

How to give

To give directly to an ophthalmic outreach effort in Haiti, Bascom Palmer Eye Institute has established the Bascom Palmer Eye Institute Vision for Haiti Relief Fund.

Funds can be given in three ways:

1. Make a donation in person. Bring a check or credit card to the Marketing and Development Offices on the 4th floor of Anne Bates Leach Eye Hospital, 900 NW 17th St., Miami, FL 33136.

2. Make a donation by mail. Mail your check or credit card information for the “Bascom Palmer Vision for Haiti Relief Fund” to: Bascom Palmer Eye Institute, Marketing and Development Department, 900 NW 17 St., Miami, FL 33136.

3. Make a donation online at https://www6.miami.edu/campaign/gift/onlinegiving.html?unit=19. To ensure your funds go to relief efforts, in the comments section please type, “Bascom Palmer Vision for Haiti Relief Fund.”

Donations can also be made to the AAO’s effort in Haiti through the Foundation of the American Academy of Ophthalmology’s Disaster Relief Fund. For more information, go to http://www.aao.org/haiti. – by Erin L. Boyle

What should physicians know about doing safe and successful ophthalmic outreach volunteering after natural disasters in countries around the world?

• Michael W. Brennan, MD, can be reached at Alamance Eye Center, 1016 Kirkpatrick Road, Burlington, NC 27215; 336-228-0254; e-mail: mbrennan1@triad.rr.com.
• Richard K. Lee, MD, PhD, can be reached at Bascom Palmer Eye Institute, University of Miami, 900 NW 17th St., Miami, FL 33136; 305-326-6000; e-mail: rlee@med.miami.edu.
• Mildred M.G. Olivier, MD, can be reached at Midwest Glaucoma Center, the Doctors Building One, 1575 N. Barrington Road, Suite 110, Hoffman Estates, IL 60194; 847-882-5848; fax: 847-882-3060; e-mail: molivier@midwestglaucoma.com.
• Thomas Shane, MD, can be reached at Bascom Palmer Eye Institute, University of Miami, 900 NW 17th St., Miami, FL 33136; 305-326-6000; e-mail: tshane@med.miami.edu .
• Charles B. Slonim, MD, FACS, can be reached at University of South Florida Eye Institute, 12901 Bruce B. Downs Blvd., MDC 21, Tampa, FL 33612; 813-974-2064; fax: 813-974-5621; e-mail: cslonim@health.usf.edu.