FEEL-GOOD DIPLOMACY

The Baltimore Sun

PORT-AU-PRINCE, Haiti -- The massive white ship that appeared one morning in the city's polluted harbor was wondrous on its own, but few Haitians could have dreamed of what was inside. There were nurses and surgeons, X-ray machines, cases of clean bandages and medicines. And, most incredibly, there was hope.

Within sight of the city's squalid waterfront slums, the Baltimore-based hospital ship USNS Comfort dropped anchor to dispense free medical care, its ninth stop on a 12-country tour of South and Central America. As word of its arrival spread, thousands of would-be patients swarmed through the city's dusty streets to line up at the Comfort's makeshift clinics, patting their swollen bellies or raising their children into the air each time the Americans came near.

"I think God has made these people come," said Wilton Milford, after the ship's crew gave medicine and vitamins to his malnourished 10-year-old daughter.

The ship and the crowds it drew revealed the possibilities of the $25 million Latin American effort, part of a nascent Bush administration initiative known as "medical diplomacy." They also exposed the weaknesses of a mission conceived more for its symbolism than its substance.

During the four-month tour - which made its first stop in Belize in June and its last in Suriname in early October - the Comfort's military and civilian medical teams treated hundreds of patients whose lives were improved and, in some cases, even saved by basic medical care that would have been otherwise unavailable.

Yet when it sailed away, the ship often left a wake of frustration and unfulfilled potential, its doctors and the patients they left behind grousing about an agenda dictated by public relations and politics.

For all the good it accomplished, the mission appeared to break some cardinal rules of humanitarian medicine, according to doctors who specialize in public health.

It didn't always tailor services to the specific needs of the countries it visited, for instance, arriving at each port with essentially the same mix of medicines, equipment and specialists. And it failed to maximize the ship's greatest asset - its hospital. Anchored off countries that, in some cases, lacked simple medical supplies and even clean sheets, the Comfort rarely used any of its most sophisticated medical equipment, such as its CT scanner and X-ray machines.

The Comfort is designed to respond to military emergencies and can treat as many as 1,000 casualties at a time. For this mission, however, just four of the ship's 12 operating rooms were put to use. It carried seven surgeons and 14 public affairs specialists.

In press releases and news conferences, Navy officials kept a running tally of the patients treated - ultimately reaching 98,000. Most received services such as free eyeglasses, vaccines or fluoride treatments, which did not require a doctor or nurse.

The ship's staff performed roughly 100 surgeries in each port - 1,170 in all - but because of limited coordination with local hospitals, meager provision for local follow-up care and insufficient time to oversee recovery, doctors were forced to turn away scores of relatively simple surgical cases.

In Haiti, more advanced planning and an investment of two or three more days might have enabled the ship to offer services such as cardiac care or prostate surgery - procedures that doctors who have worked in Haiti say could save hundreds of lives.

Physicians on board described the profound effect they were able to have on many patients in the region, some of whom needed only vitamins or water to be restored to health. But they also complained of a barnstorming schedule that all but assured they could make no lasting effect on public health in the region. With an itinerary prescribed by the State Department and the White House rather than the ship's medical specialists, the Comfort's full value as a hospital never came close to being realized.

"There's a lot of medical need down here - simple stuff, really - that we can't take care of because we're not here long enough to get into it," said Navy Cmdr. Timothy F. Donahue, a urological surgeon from the Bethesda Naval Hospital. "It's frustrating for all of us."

Esmold Maxi knows firsthand. For two years, the 12-year-old had hobbled around Haiti's crumbling streets with a bum leg, cast off by a state health system that lacked the skills and equipment to help him, and which his family couldn't afford anyway. Then, somehow, he was sitting on a soft bed inside the Comfort.

Hugging his left knee, which had been locked at a tight angle and infected since an accident in 2005, the boy pondered his changing fortunes. "I want to run and play, and follow my friends again," he said. "I have been sad for a long time."

When the Comfort's crew first examined Esmold and began to cut off the ratty cloth dressing wrapped around his knee, the boy screamed for them to stop. For a moment, they thought he was in pain but then realized he was trying to save his only bandage.

His knee, with its tendons and ligaments fused tight from healing improperly, would have been fairly easy to fix in the United States. The Comfort's doctors knew this was probably his last chance to walk again. But the surgery was too complicated to do quickly, and his recovery would have to be closely managed - an impossibility given their schedule and the limited medical care in Haiti. The doctors took him into surgery anyway, figuring they could at least clean and treat his persistent infection and perhaps graft skin over his wound. They didn't have time for anything else.

Such shortcomings are common for aid missions, particularly shoestring operations in which under-funded volunteers try to balance endless needs with limited resources. But for a $25 million mission from the United States government - one hailed as a show of force against the blight and disease of Latin America - doctors who specialize in humanitarian medicine said they would have expected more.

"The one-size-fits-all kind of mission, for 12 different countries, is not a very reasonable approach," said Dr. Gilbert M. Burnham, co-director of the Center for Refugee and Disaster Response at the Johns Hopkins Bloomberg School of Public Health.

"If the ship is a resource that's available and that the government is willing to use down there, why couldn't they plan this as an intervention that makes sense instead of just using it as a public relations tool?" said Dr. Henry B. Perry III, former director of Haiti's Albert Schweitzer Hospital, a community medical center 90 miles from Port-au-Prince.

Navy officials say that the Comfort's trip will be the first of many, and that any perceived deficiencies will be considered when the next mission is planned. Most agree, for instance, that the designated five-day period in each port was not long enough to conduct the kind of advanced care the ship is best equipped to provide.

"The experimental character of this voyage is to go into as many ports as we could and sort of test the waters in each of those places," said Adm. James G. Stavridis, commander of the U.S. Southern Command, which is responsible for military operations in Latin America. "When we get a better sense of the needs and responses, then we can target packages to come in afterward to do the kind of follow-up and longer-term care that we really want to be involved in."

Visibility a key

Bush adviser Karen Hughes said the Comfort's successes and failures will be evaluated and considered when future missions are planned - efforts that are already under way.

"The goal is to make the ship as operational as possible," said Hughes, State Department undersecretary for public diplomacy and public affairs.

Hughes initiated the Comfort's medical diplomacy mission after a trip to Latin America in 2006, and says publicity was a central goal from the beginning. Although the president considers Latin America a focus of his administration and has overseen a near-doubling of annual assistance to the region to $1.47 billion, she said the commitment seemed lost on people who live there.

"Almost to a person, we were told that because of the media's focus on Iraq and Afghanistan, Latin America thought that the United States was ignoring them," said Hughes, in a recent interview with The Sun. "And yet, we're more substantially engaged there than we ever have been before."

Officials knew from missions that the Comfort's sister ship, the USNS Mercy, conducted in the Pacific after the 2005 tsunami that humanitarian medical care can have a positive effect on public opinion. In Indonesia, for instance, American approval ratings hovered around 15 percent in 2003, but polls conducted after the Mercy mission showed a jump to more than 40 percent. With that experience in mind, the administration dispatched the Comfort to Latin America not just to provide medical care but "to do so in a very visible way," Hughes said.

"The ship is something that not only can improve people's lives but that says, by its presence, 'America cares,'" she said.

Each country handled announcements of the ship's arrival differently, but in Haiti officials said almost nothing in advance, relying on the radio and word of mouth. Dr. Jacques Pierre-Pierre, medical director of the main government hospital, said patients arrive at his door every day asking for one of the Cuban doctors assigned to his facility. He expected plenty to come asking for the Americans.

He was right. As in most ports, the Comfort's arrival here attracted throngs of would-be patients drawn by the capabilities and reputations of American physicians, or by the prospect of free care.

Michel Schneider, a 14-year-old Haitian with a painful tooth, rode a series of three ramshackle buses to arrive by 6:30 a.m. at a clinic that the Comfort's crew established at the state hospital in Port-au-Prince. Five hours later he was sitting in a dentist's chair.

"Everything is good," Schneider said afterward in garbled English, smiling and rubbing his jaw.

Immacula Marcelus, a 62-year-old woman with cloudy vision, heard about the Americans from a friend with a radio, and waited all morning before being invited inside to select a pair of glasses. She took a pair for nearsightedness and a second pair for reading - one for church, one for sewing, she said - and beamed as she showed them off to people around her.

"Look at me. I'm a very lucky woman," Marcelus said. "Now I will have a boyfriend."

Each day the Comfort spent in port, its doctors, dentists and crew members gathered at their temporary clinics to find lines extending beyond sight. In some countries, the crowds continued to gather days after the Americans had sailed away.

"It's been, probably, the most incredible and rewarding experience of my life," said Air Force Sr. Master Sgt. Steven Foster, a site leader for one of the ship's clinics in Haiti.

For the ship, the mission was a rare opportunity to be useful.

Ideas, not missiles

Ever since it was converted from an oil tanker into a floating hospital in 1987, the Baltimore-based Comfort has sailed the world in search of a purpose. The ship typically waits idle in Canton until called on by the Pentagon. Deployed to New York after the 2001 terrorist attacks, to the Gulf Coast after Hurricane Katrina and to the Persian Gulf for two wars, the 1,000-bed facility in each case arrived either too late or too far from the action to be of much use.

Today, patients in Iraq and Afghanistan are ably treated by land-based medical teams inside the war zones, so the Comfort is more often considered a candidate for scrapping than for combat. Its use as a symbol - particularly in a region where countries such as Cuba and Venezuela are competing for goodwill - might be the most valuable role the Navy has found for it.

Such missions are the central focus of a new national maritime strategy unveiled by the Navy, Marine Corps and Coast Guard this month, calling for less emphasis on warfare at sea and a greater concentration on preventing violence. The Mercy's effect on public opinion was so profound among Muslims in Indonesia and Bangladesh that officials in the Pentagon have come to believe that humanitarian aid might be more effective at deterring radical extremism than the threat of arms.

"When you see this great big white ship with a red cross sitting off your coast, it is a symbol. It sends a signal to these countries about what the United States is trying to do for them," said Navy Capt. Robert Kapcio, who served as the Comfort's mission commander and the top military officer on the ship. "They have to know this huge white ship was not cheap to send down there."

"This is a part of the world where we're not launching Tomahawk missiles, we're launching ideas," said Stavridis. "We, the United States, need to show that we're a reliable partner to these countries, and to be able to take an incredible symbol like the Comfort and sail it through the area is just extraordinary."

Selected for the Latin America mission because of its conspicuous profile, the 900-foot ship often proved ill-suited for its primary mission of establishing teams of medical specialists ashore, however, because of the cumbersome and time-consuming task of moving crew members to land and back.

Too big to fit into most ports in the developing world, the Comfort was frequently forced to anchor miles out to sea, often in rough and unprotected waters. Medical teams spent as much as four hours each day ferrying back and forth on buses, helicopters or boats.

Initial plans to move medical teams ashore using the ship's floating pontoon platforms proved unworkable because they were unstable. The Comfort eventually settled on a plan to use the ship's lifeboats to move passengers on and off, though maintenance crews had to pay close attention to the motorized winches that lowered and raised the boats, which weren't designed to handle the strain and occasionally overheated.

The logistics were frequently awkward and sometimes dangerous. At exposed anchorages in Guatemala and Peru, the ship had to engage its main engines and swing around perpendicular to the wind each time a medical team needed to get on or off, because the wind and chop would have been too harsh otherwise. The Comfort also carried two Navy helicopters, which could be used to ferry relief workers or patients to and from the ship. But their flight hours were limited by Navy regulations, and in several ports their schedules were restricted, because they were needed to shuttle government officials and other dignitaries on and off the ship.

"We tried everything we could, but the truth is the ship just isn't designed for this kind of thing," said Ed Nanartowich, the civilian merchant seaman in charge of the vessel's operations. "Ideally, you'd have a smaller ship. Or no ship."

Before the Comfort left Baltimore, Navy officials said the ship would also be available to respond to hurricanes or other humanitarian disasters that might occur in the region. But when an earthquake struck Peru and a hurricane hit Nicaragua, both within an easy sail, the ship stayed on its scheduled route.

"Nicaragua in particular desperately needed aid, and the Comfort could, conceivably, have offered assistance," said Larry Birns, director of the Council on Hemispheric Affairs, a liberal think tank that specializes in the Americas. "Was it on a humanitarian mission or a political mission?"

According to Nanartowich, publicity was so important to the mission's success that in the Colombian port of Bahia Maliga, Kapcio, the Navy commander, ordered the ship to anchor a mile off the coast, largely to meet the expectations of the media waiting on shore. Nanartowich refused, citing the port's narrow channel and dangerous cross-current, and Kapcio backed down, but not before taking the disagreement up with Navy officials in the United States.

"The political pressure has been just incredible," Nanartowich said. "They don't want to disappoint the television cameras."

Fulfilling, frustrating

Nowhere was the missed potential more apparent than in the ship's surgical ward, and perhaps nowhere was surgery needed more than in Haiti.

When it sailed into Port-au-Prince, where the public hospitals look less like medical facilities than dark warehouses for the sick and dying, the Comfort elevated the level of surgical care to a height the general population had never known.

For five days, the doctors, nurses and technicians worked marathon shifts, wheeling one patient in while the doors had barely stopped swinging from the last.

They repaired hernias and undescended testicles, performed hysterectomies and cleft-lip repairs, removed growths, reconstructed scars and changed lives with procedures considered almost pedestrian by American standards. Many called it the most fulfilling medical experience of their lives - and some, one of the most maddening.

Despite the tremendous surgical capability the ship brought to the region, many patients were turned away because local health systems weren't equipped for follow-up care and the ship's schedule didn't allow for enough recovery time onboard. Some patients selected for surgery found themselves discharged into the uncertain treatment and unsanitary conditions of the local hospitals, while others were sent home with no post-operative follow-up.

"We can't take on any big chest cases, or bowel cases, because the recovery takes too long and local facilities aren't equipped for it," said Cmdr. Frazier Frantz, a pediatric surgeon from the Portsmouth Naval Hospital and the chief surgeon on the mission. "We all wish we could do more. These aren't complicated cases."

About 100 patients in each port were brought out to the ship for surgery. Lined up with their family members in orange life preservers, they stepped onto the steel deck with nervous glances and entered into a foreign world of beeping machinery and sterile conditions. In Haiti, where half the population lives on less than $1 a day, they were the lottery winners. Thousands more like them were left on land.

For six hours, Yolande Jean waited outside the clinic that the Comfort set up in Haiti's main state hospital, crouched next to a bin of rotting garbage in a line that never moved. When a white man finally emerged onto the street, she rushed over excitedly, tapping her temple and yelling to him about fuzzy vision and the painful lump in her eye.

Her pleas were lost in a swarm of voices, however, as limping men, glassy-eyed children and women with swollen bellies all rushed forward to describe their ailments and shout out their names. The frenzy briefly spilled into the street and blocked traffic, before word spread that the man was just a visitor, not a doctor.

"Please, tell them to come outside and find the people who are suffering the most," said Jean, 51, before plodding off to resume her wait along the wall.

"Tell them we are still here," urged Madechelon Orvil, a 77-year-old woman with a debilitating pain in her ear. "I'll sleep here if I must."

Few ever made it inside, and many who did could not be helped, because their conditions were too severe for the ship's timetable and resources to accommodate.

Donahue, the urological surgeon from the Bethesda Naval Hospital, described a patient whose swollen prostate kept him from urinating - a problem correctable with relatively routine surgery.

"I saw half a dozen people in the same situation - young guys, sometimes, with urethral strictures that would be easy to fix - but we couldn't do surgery, because we're not here long enough to manage their recovery," said Donahue. "If we had another three days or five days, we could."

The doctors on land faced similar frustrations. Ten-year-old Wilka Milford was brought in by her parents, because she was lethargic and weak and hadn't gained any weight in two years. Dr. Coleen Kivlahan, a volunteer working with the civilian relief agency Project Hope, determined that the child was anemic and had been eating dirt.

Kivlahan prescribed vitamins, walked with the family down the hall to the American team's pharmacy to procure a three-month supply - two months more than patients were generally allowed - and urged the family to give the girl meat and green vegetables, which she knew was unlikely.

The girl's father, Wilton Milford, was elated. "I know they are good doctors, because they are American," he said.

But Kivlahan, a specialist in family medicine, was distressed that she could offer only a temporary solution. Like previous patients - a severely dehydrated infant, a malnourished mother who ate the muffin she was offered and its paper wrapper, too - Wilka was likely to get sick again once her supply of American assistance ran out.

"It's one thing to sweep through here and say, 'Let's do surgery, let's fill cavities,' but are we really making a difference?" asked Kivlahan, a former director of the Missouri Department of Health. "On a one-to-one level, of course, we are. But from a public health standpoint, we haven't solved anything."

At one clinic in suburban Port-au-Prince, Cmdr. Jeff Cleary, a pediatrician from Portsmouth, Va., sat behind a desk with a stethoscope and a box of tongue depressors and worked his way through a train of wide-eyed mothers and children.

It was the crew's last day in Haiti, and the complaints were pretty much the same - itching, coughing, lethargy - and so were the diagnoses: scabies, respiratory infections, perhaps malnutrition. To each mother, Cleary smiled and handed a prescription for an antibiotic, anti-fungal cream or whatever he thought would help, which they could take to the makeshift pharmacy dispensing free drugs from the ship's supply. Each consultation, conducted through an interpreter, lasted about five minutes - longer if the parents asked Cleary to diagnose their problems as well.

"In the states, I'd examine them, maybe order some lab work, then ask them to come back in a few days," Cleary said. "Here, I just give them what we have and hope I'm right."

After a few hours, the pace diminished. Crew members shut down the clinic early to prepare for a visit by U.S. Health and Human Services Secretary Michael O. Leavitt, who was due to arrive shortly with the Haitian health minister.

The Haitians hanging on the gate outside, waiting to get in, didn't know the clinic had closed, however. In a brief exchange heard over the radio, the American and Haitian security teams decided not to tell anyone outside, saying they didn't want the dignitaries to arrive without a crowd on hand.

robert.little@baltsun.com

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