Alternatives to Traditional Ambulances: Lessons from Haiti's Earthquake
The majority of Haiti's poorer neighborhoods are not ambulance-friendly, requiring access to be made on foot.
In the five-plus years since the 2010 Haitian earthquake decimated much of Port-au-Prince’s already fragile healthcare system, the nation has been making a concerted effort to implement a formal emergency medical services (EMS) system, primarily in the metropolitan Port-au-Prince area. Thanks to strong support from leaders at both the governmental and community levels and an influx of new equipment, creation of a functioning prehospital system is now a public health imperative. But despite all the effort and assistance, not a lot of progress is being made.
I’ve been directly and indirectly involved in multiple initiatives to improve EMS capacity in Haiti, and I’ve witnessed many of the struggles and obstacles that the government, local healthcare providers, and international partners have been working hard to address. Over the past five years several valuable lessons have emerged about how effective, sustainable EMS systems should – and shouldn’t – be designed in countries with limited infrastructure or discretionary funding.
Left: This map from the United States Geological Survey shows the earthquake's far reaching impact. Right: A poor neighbourhood in Port-au-Prince. Most buildings have collapsed or sustained significant damage. Image: UNDP.
Pre-Earthquake EMS in Haiti
Prior to the earthquake, the nation’s EMS system was virtually non-existent, with the majority of available emergency response services coming from a range of international and local partners with variable coverage and effectiveness. The ambulance services that did exist were fractured and non-uniform, largely restricted to community- or hospital-level efforts that lacked needed support and a smattering of ambulances used largely for inter-facility transfers and owned and operated by private organizations, including the Red Cross, United Nations, and Doctors Without Borders, among others. Public access numbers were either non-existent or had limited resources to dispatch, and the individual numbers you could call varied according to the organization that they connected to. Whatever anecdotal evidence may exist, it can hardly be said that the few ambulances on the road prior to the earthquake constituted an EMS system capable of delivering timely emergency care to the estimated 3+ million people living in greater Port-au-Prince.
The Second Disaster: International Aid
Despite the best intentions, things only got worse after the earthquake. In 2011, the government of Brazil donated 35 ambulances to Haiti - independent of the Brazil-led U.N. peacekeeping forces in Haiti that had a few of their own ambulances already. For some people, this effort was a failure before it even started. The list of obstacles faced by CAN/116 staff in ensuring that the 35 ambulances could provide timely emergency response was long. Problems included a hastily drafted implementation plan; a business model dependent on external aid; a lack of cooperation from existing ambulance providers; maneuvering for funds among multiple international partners; insufficient funding needed to operate, maintain, repair, and fuel the vehicles; a reliance on vehicles that were largely unsuitable for widespread deployment in a congested, urban metropolis with poor infrastructure; and, perhaps most importantly, no prior experience in managing municipal EMS systems in a sprawling metropolis. When cholera struck, a seemingly herculean task suddenly turned for the worse, making the whole effort somewhat quixotic.
The Third Disaster: Cholera
To help manage the outbreak of cholera, a new, separate emergency response hotline (*300) was launched. While based on well-intentioned and seemingly rational advice, the new number not only duplicated the challenges that 116 was already facing, but it also created a direct, yet inadvertent competitor to CAN/116, and diverted much needed funding, attention and resources away from the official EMS provider., The problem was compounded when it was announced that the public should report all suspected cholera cases through *300 in order to access emergency transport, as well as to find public health education about cholera prevention and treatment. This dual role of response and outeach essentially turned *300 into a hybrid 311/911 hotline devoted strictly to cholera, and took a lot of wind out of 116’s sails. This bifurcation of services and objectives may have seemed like a logical short-term solution to a horrific threat, and Haiti’s efforts to stem the cholera outbreak have produced excellent results. But the duplication of inadequate services laid out in stark detail the many problems associated with the development of EMS systems in resource-limited settings.
And herein lies the fundamental problem: Because Haiti doesn’t have a legacy of experience to draw from in the development, operation and improvement of comprehensive emergency medical systems that meet their specific needs, Haitian policy makers are obliged to seek assistance from foreign consultants who have the requisite experience. However, the only solutions foreign experts have been able to offer, to date, are those that have succeeded in affluent countries and/or communities with good roads and the money to cover the costs of such services and their high overhead. (Dial 1298 for Ambulance in India is a good example of how this model works in developing countries.) This is why the donation of 35 ambulances (and then many more) to a municipal service in a poor country charged with providing services to all who request them, regardless of their ability to pay, will never succeed. In Port-au-Prince, for example, over 70 percent of the urban population lives in slums that are inaccessible by road, so even if you had all the ambulances, staff, and equipment a western model would prescribe, they still wouldn’t be able to reach most of the population.
Left: In areas where ambulances can’t reach, locals are often on their own. Here, a door is used to transport a woman in labor. Right: This chair was used to transport victims of Cholera to medical services. Photo: David Piet/via Trek Medics Int'l.
In order to develop, manage and sustain emergency medical systems in resource-limited settings, they must first be designed at the local level with direct input from the community. They cannot be imported. If a Haitian living at the top of a hillside shanty in Port-au-Prince has an acute medical emergency, there are no roads to for the ambulances to provide door-to-door care. But the patient still has to come down the hill in order to get care, and every day, local community members are carrying the sick and injured down these pathways using primitive yet innovative solutions, and communicating by mobile phone all the way. This is where the development of a system should start, and at Trek Medics we’ve been able to leverage the same technology (Twilio) that powers communications for apps such as Uber to connect victims/patients with nearby first responders. Ad hoc, informal systems and innovative methods for delivering emergency medical care in the poorest communities are plentiful and effective, and they recognize a simple truth that senior government officials, policy-makers and expert consultants seem to have a difficult time coming to terms with: the ambulances aren’t coming any time soon.
Jason Friesen, MPH, EMT-P is a licensed paramedic and the founder of Trek Medics International, a nonprofit organization that develops emergency medical systems in communities that don’t have them, and recipients of a Global Impact Award seed grant from Google.org. Jason has worked for large and small nongovernmental organizations on three continents and received his master’s degree in public health from Columbia University while commuting from Haiti.
Photos via Trek Medics Int'l.