Earthquake victims from the south came in buses, piled into pickups and jammed into cars, driving almost 90 miles to find any care they could – even at Haiti’s poorest hospital.

Justinian Hospital doctors, nurses and residents worked through the first weekend treating 130 patients from Port-au-Prince, the capital city destroyed by the Jan. 12 quake, which killed an estimated 200,000 people.

Additional Photos

Nate Nickerson, executive director of Konbit Sante, looks over medical supplies in a store room at the Justinian Hospital on Tuesday, January 19, 2010. The store room for the supplies and staff to inventory the supplies that are donated is one way Konbit Sante provides ongoing support to the Justinian Hospital. 2010 Press Herald file photo/Gregory Rec

With sparse resources, they helped men, women and children who had broken bones, amputated limbs and crushing emotional and psychological truama.

And members of the Portland-based Konbit Sante worked alongside them. Haitian nurses and doctors from the nonprofit were there, even a Portland volunteer who teaches English as a second language.

But as important as the all-hands effort was, it may not have been possible without the work done by Konbit Sante over the past decade.

Justinian doctors and nurses were able to work in operating rooms without fear of a blackout, thanks to electrical upgrades made by Maine electricians; children were treated in a pediatrics unit supported by two Konbit Sante-funded attending physicians; and the opening of a Konbit Sante supply depot gave the hospital access to vital materials donated to the organization.

Even so, scraping together enough to respond to the disaster has been difficult.

At a hospital with no operating budget, medical and Konbit Sante officials knew they’d have to work together. That’s especially true now, because the situation in Cap Haitien was becoming more difficult, not less.

Through last week, victims continued to pour in. The hospital ships off Port-au-Prince were filling up fast, and plans were to more aggressively send victims north, said Nate Nickerson, executive director of Konbit Sante.

Public power in Cap was set to be cut to three hours a day, meaning the hospital would have to rely on generators and an increasingly limited gas supply to power critical systems.

”This is another opportunity to stick it through and demonstrate this isn’t a superficial relationship,” said Nickerson.

That hasn’t always been the case in this impoverished nation, where doctors and volunteer groups often come and go as money runs out or a short-term project ends.

The earthquake may be the latest crisis, but the reality is that the need for medical care here was stunning before it, even on an average day.

”It’s a different set of challenges this time, but people here are used to dealing with incredible challenges all the time,” Nickerson said.

”These are bigger.”

PEELING THE ONION

In recent days, Konbit Sante has secured medical supplies – X-ray films and anesthesiology materials, for example – from the Dominican Republic, and a shipment of gasoline for generators, as well.

Specialists, such as orthopedists and emergency trauma physicians, who have worked with Konbit Sante in the past are on their way to Cap Haitien to help their Justinian colleagues with the overflow of patients from Port-au-Prince.

Konbit Sante has secured the donation of needed instruments from Portland’s Orthopedic Associates; a doctor coming from Atlanta will carry them along.

Nickerson’s days and nights are spent trying to coordinate stateside aid efforts, sitting in Konbit Sante’s tiny office, bent over a laptop that has questionable Internet access. A lot of time is spent just trying to head off overzealous efforts to flood the hospital with volunteers and supplies the system may not need or be able to support.

Hospital officials, somewhat overwhelmed by medical volunteers who show up without notice, have asked Konbit Sante to coordinate their efforts.

And there’s also a lack of coordination among local government, the United Nations and other nongovernmental organizations. They are parallel bureaucracies that don’t mingle much. The problem with that becomes evident when a disaster strikes, making coordination  next to impossible.

Nickerson has been talking with officials, trying to gently get them to prepare for an influx of refugees from Port-au-Prince. With the collapse of the capital, the centralized government has been wiped out. Regional officials who have never made decisions – or had resources to do so – now find themselves forced into that role.

Many don’t believe there will be a surge in victims and refugees, as Nickerson does. Part of that may be the unprecedented scope of damage from the earthquake; it’s hard to fathom.

And part of it may be the cultural split between northern and southern Haiti. Many believe that refugees from the south would resettle in that part of the country, rather than come north.

Nickerson has come to Cap about 35 times in the last decade, and every time he learns something new, like peeling back the layers of an onion.

”The thing of it is, I have no idea how big an onion it is,” said Nickerson.

FISHING TOGETHER

Konbit Sante has worked to help Cap Haitien’s health officials strengthen its public medical system, through Justinian Hospital and a clinic at Fort Saint Michel, one of the city’s poorest neighborhoods.

The nonprofit funds 26 jobs at the Justinian and the clinic. Via the clinic, it provides outreach workers who make their way through neighborhoods carved out among garbage dumps to help mothers of young babies. Amid the refuse, they vaccinate children and teach mothers about breastfeeding.

It also helps identify and fill specific needs.

Konbit Sante built a pediatric outpatient clinic at the hospital, for instance. Maine electricians have upgraded parts of the wiring system to maintain critical operations, even during blackouts. Konbit Sante secured donations from Maine Medical Center in Portland to equip a neonatal intensive care unit.

The general model of doing this type of work in Haiti involves foreign groups ignoring government officials and essentially setting up operations and running them with foreigners.

Konbit Sante takes a different approach, by partnering with hospital and health ministry officials, asking them what help they need and then coordinating efforts stateside to meet those needs. It has offices right on the grounds of Justinian and is seen as part of the system.

”When tough things happen and you have a depth of relationship and a depth of experience, it allows you to sit as people together to try to solve what can start to be viewed as a common problem,” said Nickerson.

Local officials appreciate that difference in approach because it shows respect for Haitians, said Dr. Jean-Gracia Coq, medical director at Justinian.

The hospital has received help in the past from numerous NGOs, said Dr. Marie-Carmelle Leconte, who is in charge of the hospital’s operating room and of anesthesiology.

The NGOs would do a short-term pilot program and then would be gone, she explained.

”With Konbit Sante, this is a permanent relationship,” said Leconte.

The model brings to mind the old saying about giving a man a fish or teaching him to fish, but Nickerson discounts that as arrogant. It assumes, in this case, that the Haitians don’t know anything about health care.

”It’s more like, ‘I know about fishing, and you know about fishing, and this is a really tough pond to fish, so let’s work together,’ ” said Nickerson.

There are several initiatives at the Justinian that will move forward, though the earthquake has likely delayed one of them.

The U.N. has approved funding of an expansion of the Justinian’s emergency room, which has been a priority of Coq’s since he arrived here in 2007. Konbit Sante worked to find funding and secured it through the U.N., Coq said.

”The country faces this kind of emergency,” he said. ”We could better manage if we had it.”

The funding was just approved; the office that approved it was razed in Port-au-Prince, all the workers there killed. The fate of the project is unknown.

More immediate is the damage Justinian Hospital suffered in the earthquake and its continuing aftershocks. Although there was relatively little damage, medical residents at the hospital say there are cracks in the walls – some that have widened – in their living quarters at the hospital and they are afraid to sleep inside. They have asked for tents, but none are available.

Konbit Sante is working with Maine Med and Dr. John Devlin there to set up a diabetes treatment program at the Justinian. Devlin, an endocrinologist, is on Konbit Sante’s board and has been to the Justinian several times.

”We are a pioneer in the country with the project,” Coq said.

Maine Med got the grant, said Nickerson, to improve care of this serious health problem.

”It can be as complicated to manage and as fatal as HIV, but nobody pays attention to it here,” Nickerson said.

‘THE PEE OF A MOSQUITO’

When you look at the problems of Haiti – even without the earthquake – they seem insurmountable.

Poverty is apparent throughout the interior of Cap Haitien. The hospital has no budget to work with; its main supporter is a tiny nonprofit from Maine.

People wait for hours for surgery because doctors have to sanitize the one set of orthopedic instruments they have between operations. Family members wave flies away from patients lying in hospital beds.

Many die here, and the entire hospital knows when that happens as the patient cries over and over again in a singsong – ”Amwa, amwa, amwa,” Creole for ”Help me.”

Get away from the hospital and its relatively middle-class neighborhood, and the poverty increases exponentially. In neighborhoods like Petite Anse and Fort Saint Michel, families live among garbage and pools of contaminated water, because no one else will. No one will kick the poorest from those places.

There’s nothing like it in this hemisphere, said Nickerson.

Even with the flood of aid coming into the country because of the quake, individual scenes illustrate the depth of need.

In Cap Haitien, the city has arranged a running loop of up to 10 buses between Cap Haitien and Port-au-Prince to ferry people north. At the local gymnasium where the buses tend to drop off injured patients around midnight, a single Haitian nurse helps what has been up to 500 people at one time, said Nickerson, who was trying to coordinate volunteers to assist her.

At the same time, Nickerson is hearing that the medical ships have been filling up quickly and officials in Port-au-Prince will be much more aggressive about transporting people north. An influx of patients at Justinian is becoming more likely.

The Haitians are big on proverbs, Nickerson said, and one applies aptly to the work that Konbit Sante does. It translates, essentially, to ”Even the pee of a mosquito raises the level of the river.”

”Sometimes the issues and problems here are overwhelming, and you just think you can’t do anything. But on the same hand, the problems and issues are so massive that it’s amazing what a little group of people and a little bit of resources can do, what an incredible difference it can make in that kind of setting.

”It’s kind of a paradox we live with.”

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