Even as aid trickled in Thursday to earthquake-ravaged Haiti - and estimates emerged of as many as 50,000 dead and countless more gravely injured - experts feared the country was on the brink of a public health disaster that could persist for months.
While relief workers hoped to provide food and water and to confront the most pressing of immediate medical needs, from antibiotics to bandages, disaster response experts say what remains ahead could be equally daunting: rebuilding from scratch a public health system that was fragile at best before disaster struck.
"Haiti had almost no public health infrastructure, and now it's all gone," said Dr. Thomas Kirsch, an emergency physician and co-director of the Center for Refugee and Disaster Response at the Johns Hopkins Bloomberg School of Public Health. "Haiti is an ongoing chronic disaster with a high infant mortality rate and life expectancy that is horrendous. Thousands die every year needlessly. They have no margin for error. This event removed what few resources they had already."
As President Barack Obama promised $100 million in aid to the quake-ravaged country, the U.S. Department of Health and Human Services has activated the National Disaster Medical System and the U.S. Public Health Service Commissioned Corps. More than 250 troops are in the process of deploying to Haiti and thousands more could assist in the coming days. Hopkins hopes to send a team of public health professionals to help in the relief effort.
The ramifications of the lack of food, water and shelter are even greater than the medical problems, said Kirsch.
Clean water, a luxury even before the disaster, is scarce. With survivors foraging for whatever basics they can find from local stores, the situation will only grow more dire - and fast, he said.
"The likelihood of a large outbreak of diarrheal disease - it's going to happen," said Kirsch, who has experience responding to Hurricanes Katrina, Rita and Andrew, the Sept. 11 terrorist attacks, and California wildfires. "There's almost no water available. Certainly, people are working on this, but this is paramount."
Without water, the threat mounts for other diseases such as malaria and dengue, which are transmitted by mosquitoes, he said. When the infrastructure established to keep those diseases in check crumbles, outbreaks are likely. The same is true with measles, which can surge in crowded conditions.
And that covers just the physical ailments. No one knows how the devastated nation will cope with the mental health aftershocks.
With the capital's major hospitals reduced to rubble, Haiti will need a new primary care delivery system, with emergency and internal medicine care to treat people with chronic illnesses such as diabetes and basic infectious diseases, Kirsch said. In the short term, emergency teams will need to provide a bridge to the primary care system until the older system can be brought back - however long it takes.
But that poses great challenges for local medical professionals and organizations with ties to Haiti. They are still trying to assess the damage to their programs, not to mention the possible casualties.
Three senior staff members of IMA World Health, a Carroll County-based aid group, had been missing since Tuesday's earthquake, but the organization reported overnight on its Web site that they had been found safe. The three, including president Richard Santos, were at a meeting in the Hotel Montana; it ended minutes before the five-story building collapsed.
Also pulled alive from the wreckage was Ann Varghese, who lives in Baltimore and works as IMA's program officer for Haiti, and Sarla Chand, vice president of international programs and a New Jersey resident.
"We're ecstatic. That all of them were found alive in the rubble is just miraculous," said Douglas Bright, vice president of IMA World Health in New Windsor.
He had projected a sense of optimism Thursday.
"We are going over everything we know and contacting other relief organizations to make sure we have not missed any bases," Bright said. "We are calling continually our office [in Haiti], the families of our people here and every contact number we have."
Five Haitian employees of the organization were still missing, however, including a doctor who ran IMA's local office. None of the Haitian staff members attended the meeting; they worked out of a small building in Petionville outside the capital.
Dr. Abdel Direny ran the office, aided by a pharmacist, bookkeeper, general assistant and driver. IMA set up a Facebook page, Haiti IMA World Health, with photos of all eight.
Other Baltimore-area organizations were still working Thursday to gather information about their staffs in Haiti. As of late Thursday, an HIV prevention and treatment program in Port-au-Prince run by the Institute of Human Virology at the University of Maryland School of Medicine was missing 15 members of its staff of 20, including doctors, nurses and lab specialists.
Dr. Guesly Delva, an infectious-disease fellow with the Institute of Human Virology, had hoped once his training is complete in a year to return to his native Haiti to join the program. For now, though, the toll of the catastrophe has hit him personally as well as professionally. Since the earthquake, he hasn't heard from his mother, cousins and classmates scattered throughout Port-au-Prince and his native Gonaives, about 100 miles north of the capital city.
"I'm still semi-numb; in disbelief," he said. "For now I'm just trying to keep busy. I can't watch TV. I turn it on and I turn it back off."
The program and others like it provide a lifeline for a nation ravaged by HIV/AIDS. In recent years, infections have stabilized and the program was poised to partner with the local medical school to establish a residency program in infectious diseases and HIV care to train local doctors, said Delva.
Now, all that's up in the air. "Right now we're just trying to identify what kind of losses we may have had," he said. "It's a little bit hard to say, beyond that."
But it's clear that much of the program's work has been derailed. "This is going to set us back to ancient times," Delva said. "A lot of things are going to have to be restarted. God forbid if we lose some of those people who we were already training and providing care."
Jhpiego, an international health nonprofit in Baltimore, had yet to locate two Haitian employees and a consultant. The organization, which has provided maternity care, family planning and HIV/AIDS counseling services in Haiti for 15 years, expressed hope that all of its staff members would be found alive.
"We call ourselves the Jhpiego family," said Leslie Mancuso, president and chief executive. "When you think about family members in a situation like this, you're worried. It's a hard time for us."
The organization plans to send a team to Haiti to offer newborn and infant care and help other public health organizations and the government rebuild the health care system.
The needs will be vast. Before the earthquake, Haiti had just a small number of public health workers trained to take care of pregnant women and teaching about family planning. Mancuso said she hopes to replicate the organization's efforts from the 2004 tsunami, during which aid workers renovated midwife practices and schools.
"Let us all remember, the emergency is critical, let us all support each other," Mancuso said. "But it's critical that we realize that the difficult part will be looking at this as a long-term issue. How do we help the country to help itself?"
Engaging people locally to help rebuild the public health infrastructure is key, said Kirsch.
"It's really lovely to sweep down there and be rich Westerners to help," he said. "But if you do that you are marginalizing them and the long-term impact on the local economy is huge. We need to engage the locals so they can support their families. The money we spend on shipping a doctor on a plane from Baltimore to Haiti, for a $1,000 plane flight, you could employ a Haitian doctor for three months."
The heavy lifting will come in the months and years ahead.
"Rebuilding is critically important," said Kirsch. "In a month, all the reporters will disappear and the [nongovernmental organizations] will pull out, and yet the devastation to the public health care system will go on for decades."
The Associated Press and Baltimore Sun reporters Scott Calvert and Mary Gail Hare contributed to this article.
How to help These locally based relief organizations have launched appeals for earthquake relief:
P.O. Box 17090
Baltimore 21203-7090
800-736-3467
IMA World Health
P.O. Box 429
New Windsor 21776
877-241-7952
Lutheran World Relief
P.O. Box 17061
Baltimore 21298-9832
800-597-5972
World Relief
7 E. Baltimore St.
Baltimore 21202
800-535-5433