As leaders, we sometimes have to follow

Lisa R. Roberts | 04/26/2019

Helping out in times of disaster is no excuse for paternalism.

As leaders, we sometimes have to follow

Unwillingness to invest in building relationships makes short-term volunteers particularly prone to causing inadvertent harm.

This may look like an article about Haiti—and it is—but it’s more than that. My primary purpose is to discuss how nurses can best respond to calls for help following a natural disaster in any country. As a researcher, I focus on nursing interventions and public health programs to address the needs of vulnerable populations. Haiti provides an excellent example of what nurses on humanitarian missions should and should not do when natural disasters strike.

On the island of Hispaniola
Haiti is globally known as a low resource country fraught with natural disasters. In fact, it’s the poorest country in the Western Hemisphere. Corruption and high unemployment rates (41%) account for 59% of Haiti’s population living on less than $2.42 per day (the national poverty line), and 24% living in extreme poverty, defined as living on less than $1.23 per day. High maternal mortality rates (359 deaths per 100,000 live births), high infant mortality rates (46.8 deaths per 1,000 live births), very high risk of infectious diseases, and recent natural disasters contribute to Haiti’s higher than expected death rate of 7.6 deaths per 1,000 population.

Because of its geographic location, Haiti is the fifth most natural disaster-prone country in the world. In 2004, the island experienced extensive flooding. In 2008, four fierce storms hit within two months, and a massive earthquake in 2010 brought destruction yet again. Recent estimates indicate that more than 300,000 people were killed and approximately 1.5 million left homeless after the earthquake. As a result, the population of Haiti was particularly vulnerable when Hurricane Matthew hit in 2016.

The main health concerns following natural disasters are infectious outbreaks such as diarrheal diseases (including fatal cholera), acute respiratory infections, and infections resulting from wounds and injuries. Additionally, loss of shelter increases risk for vector-borne diseases (from exposure to mosquitoes and rodents) and infections associated with human and animal waste.

In the years following the earthquake, the international response brought more funds to Haiti than other countries have typically received. Some speculate that Haiti has more nongovernmental organizations (NGOs) per capita than any other country in the world, creating parallel states that function like government but are not part of the government, a situation that may not be best.

With less than one hospital bed per 1,000 people, Haiti lacks the infrastructure to adequately respond to healthcare needs created by natural disasters. NGOs do provide important acute emergency relief. However, the unintended negative effects of relying too much on them include poor quality of care, inadequate utilization of existing facilities, and exacerbation of the country’s brain drain when Haitian healthcare providers emigrate elsewhere after working with NGOs (Seager, 2012). Nevertheless, established organizations such as Baptist Haiti Mission are well known and respected throughout Haiti for the consistent work they do, including provision of healthcare and relief work in times of disaster. 

Baptist Haiti Mission and Hôpital de Fermathe
Baptist Haiti Mission was founded in 1948. Two years later, a hospital was established, the same year a paved road to the mountain campus, located 12 miles southeast of Port au Prince, was completed. The hospital quickly gained a positive reputation as wounds healed quickly and patients survived pneumonia (Anderson, 2010), and soon the need for a larger facility was obvious. Known as a place where no one is refused care, regardless of ability to pay, the hospital has continued growing to meet the needs of surrounding communities. 

As leaders, we sometimes have to followToday, Hôpital de Fermathe (Hospital of Fermathe) is an 80-bed, full-service facility that collaborates with the local Ministry of Health. The ministry pays some of the aides and nurses, sends a dentist three days a week, and supplies an orthopedist and urologist four times a month. Additionally, many medical students from Université Notre Dame d’Haïti in Port Au Prince come to the hospital for training, and nursing students also come from several schools. Hospital facilities include two operating rooms, maternity services, a lab providing outpatient testing and inpatient support, a radiology department, a pharmacy, an eye clinic, and a dental clinic. Additionally, an on-premises office of the United States Agency for International Development (USAID) provides family planning services, an immunization clinic, and a vaccination program.

Serving more than 10,000 patients a year, Hôpital de Fermathe is the only hospital available for a rural population of approximately 150,000 people. Fifteen nurses provide patient care; six to 10 of them, working eight-hour shifts, staff the hospital in a 24-hour period. The head nurse functions in an advanced practice capacity, running the emergency room in addition to her administrative duties. 

The hospital also has three clinics in remote communities, run by nurses. When the care requirements exceed a clinic’s capacity, nurses provide referrals. Patients often arrive at a clinic with burns and wounds that are badly infected, gastrointestinal illnesses, malnutrition, and respiratory infections. Although these primary care clinics are not staffed by advanced practice nurses, the nurses who work in these locations often function in advanced capacities in the absence of other healthcare providers. Intermittently or in extenuating circumstances, the hospital collaborates with NGOs and volunteers to provide eye care and medical camps in areas where there are no established healthcare facilities.

They felt displaced
After the 2010 earthquake, many medical teams from humanitarian organizations and churches came to help. Teams of 30 to 40 healthcare providers were typical, and they took over the hospital while they were there, providing hundreds of orthopedic surgeries. Haitian health professionals who ordinarily manage and staff Hôpital de Fermathe felt displaced by the visiting teams. As one Haitian nurse explained, “When their community needed them [their local nurses] most, they were sometimes relegated to providing translation for foreign team members, rather than providing care as health professionals in their own right.” Some felt that the foreigners, who sometimes interacted disrespectfully with the locals, did not understand or take the context into account and disregarded the knowledge and experience of local health professionals.

While Haitian health professionals and other staff members acknowledged the need for additional resources and helping hands in the wake of natural disasters, they expressed a desire to work shoulder-to-shoulder with teams that come to help, rather than teams from other countries taking over. One worker expressed a sense of relief when the teams left, and, despite the heavy burden of caring for patients still recovering, the local Haitian team was once again running the hospital. They also noticed that foreign health professionals generally do not return to help during epidemics that often follow natural disasters.

Nursing education in Haiti
Nursing shortages plague Haiti’s healthcare system, and the proliferation of private schools poses a challenge to establishing curriculum standards. Both factors affect the ability of the Haitian nursing workforce to deliver quality care. Nursing education in Haiti is provided by five public schools, five major private nursing schools, and more than 400 small private nursing schools.

The public schools provide a three-year diploma program with a focus on training nurses for hospital service. Graduates of these programs sit for a national exam before being registered as professional generalist nurses. Of the five major private schools, a few provide four-year programs that offer specializations in midwifery and HIV care. However, the large number of small private schools has made regulation of education difficult, despite steps taken to strengthen reconnaissance, which is similar to accreditation. Quality nursing care is dependent on well-trained nurses, retention, and continuing education, which present challenges as well as opportunities for the growth of nursing in Haiti. 

Building capacity with respect
Using an asset-based approach, foreign healthcare professionals, including nurses, can help build local capacity in a manner that respects Haitian healthcare professionals (Seager, 2012). Local nurses and other healthcare providers are well versed in delivering care in resource-poor environments and are trained to recognize and treat common health problems in the local context—and, they know the Haitian healthcare system. Identifying these and other resources and working together to address problems empower Haitian nurses and other local healthcare providers while avoiding paternalism.

Volunteer professionals should take care to avoid voluntourism (volunteer tourism), which often does more harm than good. Lack of time and unwillingness to invest in building relationships, combined with the human tendency to put one’s own interests first, make short-term volunteers particularly prone to causing inadvertent harm. At its worst, voluntourism promotes use of unqualified or underqualified volunteers, leading to actions that would not be taken in their home countries and resulting in poor-quality care. Despite good intentions, unless voluntourism is carried out in partnership with local professionals and reputable organizations, the good it accomplishes may be overestimated while significant issues are disregarded and local initiatives and solutions are undermined. At best, voluntourism might be described as cultural exchange.

A more meaningful healthcare response to natural disasters is providing money and resources and developing long-term relationships. Even the initial physical response is often best provided by local volunteers. Foreign volunteers make more meaningful contributions by engaging in longer commitments, asking how they can help, and doing only what is asked of them. Whether the volunteers are students intending to participate in service-learning projects or seasoned professionals, they should prepare by learning the political, social, economic, and cultural history of the population they will engage with. Gaining cultural competency through stories, continuing education, and workshops supports cultural sensitivity. Embracing successful collaborative models for community partnership also increases the probability of volunteers doing more good than harm. Volunteers willing to come alongside Haitian healthcare professionals and serve respectfully and humbly can be useful in building capacity or providing services not otherwise available.

When natural disaster strikes
When Hurricane Matthew hit Haiti in October 2016, there was a spike in cholera, homes were lost, and livelihoods were destroyed. Baptist Haiti Mission and other NGOs collaborating with the government quickly reversed the tragic trend. Haiti is a resilient country, despite having had more than its share of natural disasters, grueling poverty, and poor infrastructure, which affect everything from safe drinking water to healthcare access. Indeed, would any country fare better when subjected to a continual cycle of natural disasters?

When natural disaster strikes—in Haiti or elsewhere—the immediate environmental safety needs are frequently followed by health issues often related to environmental factors and communicable diseases. This situation requires swift response from health professionals, both near and far. Nurses who respond from other nations can play an important role in reducing a disaster’s horrendous impact. Working alongside local nurses who are familiar with local knowledge and resources, nurse volunteers from outside the country can help build much-needed capacity among local nurse leaders.

It is important to recognize the essential contributions of local nursing leaders and follow their lead while providing support through a reputable organization. Capacity building might include sharing expertise in evidence-based practice, continuing education, disaster management, or organizational leadership. The expertise you have to offer will be valued most when shared in a respectful, collegial manner. RNL

Lisa R. Roberts, DrPH, MSN, RN, FNP-BC, CHES, FAANP, is a professor and research director at Loma Linda University School of Nursing in Loma Linda, California, USA.


Anderson, M. (2010). Beyond all this: Thirty years with the mountain people of Haiti. Durham, NC: Light Messages.

Seager, G. (2012). When healthcare hurts: An evidence based guide for best practices in global health initiatives. Bloomington, IN: AuthorHouse.

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