Report of Danielle Laraque MD and Wiener Leblanc, MD /AMHE Relief Pediatric group

Danielle Laraque, MD, President APA, AMHE member and Wiener Leblanc, MD, Section of Pediatrics, AMHE
A devastating earthquake measuring 7.0 on the Richter scale hit Haiti on January
12, 2010 at 4:53pm in the afternoon. The epicenter was near the densely populated capital of Port-au-Prince and the impact was felt there, in Petit Goave, Jacmel, and
Leogane. The immediate responders were the Haitians with the international community joining forces over the ensuing few days. The United Nations, numerous sovereign countries and a multitude of non-governmental agencies and a contingent of AMHE physicians from the diaspora responded. The small organization of the Academic Pediatric Association – an organization of about 2000 academic generalists -partnered with the AMHE (Pediatric Section) in completing a needs assessment near the end of the acute period of the disaster entering the recovery phase. Listed below are the activities of this needs assessment which took place between February 20th and March 1st and preliminary recommendations based on direct observations, meetings with multiple physician and hospital groups, site visits to camps, and discussions with families and a few Haitian people.
Saturday, February 20, 2010
Departure:
Took off from Morristown, NJ in the airplane of Honeywell due to the efforts of Robin
Solomon (Board of Trustees at Mount Sinai) and Ernest Benjamin. Marc Arena, my son,
accompanied me to the private airfield at 7am in the morning –the flight took off at 8:15 – on board were two pilots, Kelly Reed from Honeywell, his assistant Benjamin
Rosanvallon, a Haitian family medicine physician going to Petit Goave, Tania Desgrottes, Susan Fassig of Operation USA, another Haitian physician, Steve Texas with Partners in Health (PIH), James R. Wilentz, and a cardiologist from Lenox Hill Heart and Vascular Institute of New York. Two fully filled suitcases of children’s toys, paper and crayons, comfort kits and other things , four boxes full of medicine (3 from Mount Sinai), were accommodated on the plane. We arrived safely in Haiti by noon. [picture] Right to left: Steve Texas, Tania Desgrottes, Danielle Laraque, Susan Fassig, Kelly Reed, James Wilentz, Benjamin Rosanvallon.
Initial Observations of Conditions in Haiti:
Toured the city of Port-au-Prince and the surrounding communities of Delmas, Petion-
Ville and others. The devastation is rampant. The centre-ville is almost completely
demolished including the National Palace, the majority of the ministries, the faculties of the University, the Cathedral, St Francois Hospital and the General Hospital (HUEH).
Also affected are the surrounding pharmacies and laboratories around the General
Hospital. The Champs Mars is a tent city. [See attached article from Nouvelliste
summarizing the extent of the losses and destruction].
Sunday, February 21, 2010
Worked at the General Hospital (HUEH) most of the day. Delivered the three boxes of
medication to Marlaine Thompson, the administrator for the General Hospital. Met
briefly with Dr. Alix Lassegue, the CMO of the General Hospital who escorted me to the
Pediatric section. With the exception of one part of a building at the University of Haiti, General Hospital (HUEH) called General Hospital, all the clinical work had been
transferred to tents. The majority of the pediatric tents were staffed by the Swiss Red
Cross pediatricians. Later in the day I met Dr. Eveillard and another attending physician, staff of the pediatric department. My communication with Dr. Jessy Coliman Adrien, department chair, prior to my arrival in Haiti confirmed that she would not be in the country at the time of my visit but I was to meet with her staff. I was assigned to work with Dr. Chery Anne Eluourde (a second year pediatric resident). I met also with two other residents. Each described the status of the hospital and their personal circumstances. The NICU and pediatric intensive care units were no longer functioning. No outpatient services were rendered in the pediatric section this day. The tents, arranged by age: infants, older children and adolescents; maternity; outpatients; had a census of about 20 each of severely ill children – inclusive of newborns with jaundice (probably Rh incompatibility), sepsis, status epilepticus, respiratory distress, congenital heart disease among others. Oxygen, antibiotics, selected blood work, IV access, blood transfusions were possible. There was no access to a laryngoscope, glucometer, no meds on site. Parents were responsible for bringing bloods to the general laboratory. If reagents were not available, the parents were responsible for locating a laboratory outside and paying for the tests. Dr. James Wilentz was able to be reached and did portable, bedside echocardiograms on two children – one with probable VSD, the other was difficult to diagnose (no small transducer was available) but clinically had Tetralogy of Fallot in the midst of a “tet spell”. Children who had suffered trauma and were stable were housed in some of the other tents. Physician coverage extended only to late afternoon/early evening.
Visited St. Francois de Salle Hospital in centre-ville. Most of the hospital had been
destroyed, but the Catholic Relief Services had numerous tents attending to trauma
victims adults and children. They had a functioning laboratory with access to most
reagents. A much needed serum sodium level was run for the child at the General
Hospital with dehydration and status. Met with Guestly Delva, MD – a Haitian-
American Medicine/Pediatrics boarded physician from the University of Maryland,
trained at Tulane Medical Center.
Young boy with his father, at his age oblivious to his injuries and his missing arm.
Inquired about the process for referring a child for intensive care or surgical intervention. Received email communication from Terri-Ann Bennett, the new CAO at UM-Medishare field hospital. She outlined the process to send patients to the US through the NDMS Medical Review Board. [see attached file] The priority is for directly related disaster surgical or medical conditions. Once approved, the board is reported to take care of documents, flight and accepting hospital. Submissions must be emailed by 3pm and are reviewed every 48 hours. The USS Comfort a Navy Ship Hospital from Southern Command also had an ICU on board. Learned later that St. Damien did also have a waiting list for children needing cardiothoracic surgery.
Received word that Dr. Wiener Leblanc’s flight had been cancelled and he would be
arriving Monday evening.
Other observations:
The nursing school is adjacent to the pediatric tents and has been completely demolished, entrapping and killing the 300 or so nursing students inside whileattending courses.
Residents:
The pediatric residents described being homeless, having inconsistent access to food, working 7-7, seven days a week. Not all residents have returned to work. Attending coverage is reported to be rounds in the morning. Identified needs included emotional and economic support, lodging, mentorship, equipment, clinical teaching. Observations of the course over the week were that residents were very affected by the constancy of death for the children in their care. The Swiss Red Cross physicians made periodic rounds. There was no access to any social services for the families or staff. The sister of one resident is a SW and plans were made to meet with her.
Meeting with Dean of the University of Quisqueya;
Met with Dr. Genevieve Poitevien, Dean at Quisqueya who recommended that I visit the mobile clinics and also meet with the medical students. This meeting was arranged for Wednesday, February 24, 2010 at 8:30am.
Aftershocks
An aftershock measuring 4.7 awakened us at about 4:40 am of February 22, 2010. We
slept the rest of the night outside in sleeping bags. Later that day at about 10am another was felt and patients and their parents screamed and were clearly unsettled by the quake. This recurred the following night twice at about 1:30am.
Monday, February 22, 2010
Returned to HUEH and learned that several children from the babies ward cared for on
Sunday had died. Surprisingly, the child with the tet spell was sitting up and off oxygen. The child in status was still decerebrate but with sedation had stopped seizing. Her father and other family members were at her side.
Worked at the General Hospital in the outpatient tent with pediatric resident Clifford
Massilon. There was a constant stream of patients outside the tent. I admitted a 12 year with an acute abdomen who later died with confirmed typhoid. Acutely ill patients, children who had suffered trauma during the quake came back for persistent pain and complications, newborns being cared for by relatives came for nutritional support, and so on. There was little access to milk or nutritional supplements from the World Food Program. In the inpatient tent, American physicians from Chicago, Rush assisted in the care of an infant with congenital abnormalities and respiratory distress who died within a couple of hours. Hospitalized children included those with amputations. Delivered 15 pairs of children and youth crutches to the HUEH. Spoke with Dr. Pierre-Pierre, Chief of Orthopedics. Also delivered a suitcase of comfort kits, diapers, crayons, paper, toys to the General Hospital, pediatric department.
The social worker came to the hospital, met with the father who had lost his wife during the quake, who was caring for an 8 week old with congenital heart disease and had two children 3 and 5 being cared for by friends. He wished assistance to return to the province. SW later met with Dr. Eveillard who spoke to her about the overwhelming
need for her services. The obvious concern was for a paid position and to continue her profession. Something would be worked out.
Assisted by Michaelle Saint-Natus passed by Food for the Poor. Then visited the
Buddhist Compassion Relief Tzu Chi Foundation and International Medical Association camp. Met with physicians there and one of the administrators Rene Li. There were two pediatricians seeing non-acute children in a partially covered area. Basic history, vitals and brief examinations were possible. The services provided local care to the surrounding community. Any acutely ill children were referred to the General Hospital. This group discussed that the acute phase of this disaster will conclude March 27th and then transition to the intermediate phase with a focus on latrines, followed by long term planning for permanent housing and schools. Up to this time all schools remained closed. The Lycee Francaise will open 3/1. Seventy percent of schools have been destroyed in the affected area.
Met with Edith Hurdicourt one of the Board of Trustees from Hopital de la Communaute. Similarly to other private hospitals, they had responded to the disaster by opening their doors to everyone. They had expanded their OR capacity from 2 OR to 4 and did hundreds of surgeries. There were no pediatricians reported to be working there at this time, a stated need. There were preliminary discussions on the development of a public-private model to continue to address the needs of the population.
Scheduled to meet with Dr. Claude Surena, member du Conseil d’Administration, le
Groupe Sante Plus. He is responsible for Disaster Response coordination for health
services. The coordination effort asks all international organizations wishing to work in Haiti to obtain an accreditation from the Ministere de la Sante (Ministry of Health) in
Haiti. The procedure for this is detailed on the web at One Response.
Tuesday, February 23, 2010
Wiener Leblanc able to come in this morning via Santo Domingo. We visited the
GHESKIO Center and met with Dr. Bill Pape who also accompanied us to the adjoining
camp which formed on the grounds of GHESKIO immediately after the earthquake. The
camp of over 6000 included about 1500 children under the age of 5. This tent camp
ground demonstrated muddy grounds and the beginning of digging of ditches in
preparation for the rainy season which would surely aggravate current health conditions. Daily rounds are made and four triage questions on the presence fever, cough, diarrhea or rash are used to standardize referral for clinical evaluation in the adjacent medical facility. All children in the camp have been immunized with the basic immunizations consisting of DPT polio, MMR. There is no access to hepatitis, pneumococcal, meningococcal or Hib vaccination. Nutritional efforts are complemented by the efforts of UNICEF. The GHESKIO center is well equipped for HIV and TB care and this has continued in all their sites. Identified needs include coordination with hospital administration in the adjoining field hospital and concerted efforts at infrastructure building including a well organized trauma system. Efforts at community organizing have been difficult. Mental health for sexual assault victims and those affected by the quake (patients and clinicians) and environmental interventions are needed. At GHESKIO Center also met with Henri Ford, MD Chief of Pediatric Surgery at LA Children’s, USC; Vanessa Douzier, MD (pediatric ID trained physician from McGill), Francine Noel (head of the pediatric clinic) and another Haitian pediatrician who staff the HIV pediatric clinic. Delivered comfort packs to the pediatric clinic. Danielle Laraque and Jean William Pape at GHESKIO in the refugee camp site.
GHESKIO refugee camp
Right to left: Danielle Laraque, Henri Ford, Vanessa Rouzier, Wiener Leblanc at GHESKIO. Meeting with HPS and AAP representative Marlene Goodfriend Initial meeting had been held by the HPS Executive Committee and M. Goodfriend on
Sunday, February 21st. Laraque and Leblanc representing APA/AMHE were invited to
the Tuesday meeting held in a tent outside of the Haitian medical association. Presented at the Tuesday meeting were the results of the discussion on Sunday and plans for support of the identified pediatric workforce. [See summary by Goodfriend].
Wednesday, February 24, 2010
Met with the staff at University of Quisqueya in Turgeau with the aim of speaking to a
medical student representative and going on the mobile clinic Van to the four camp sites cared for by the physicians and students at the University. The School of Medicine has been severely damaged. On the campus there were 3 tents attending to children and adults. Malnutrition was evident. Visited two camp sites. The mobile van/clinic is a van that is then equipped with available medical equipment and drugs. Dr. Poitevien was particularly interested in discussing ideas for providing medical care with a well equipped mobile clinic. We visited two camp sites (that day the driver was not available for the mobile van, so we took our own truck): one site was on the rocky hill top -with approximately 400 children. There were small stores that had been set up and some cinder block houses had survived; the second was affiliated with a Catholic church. Met with “Sister Brandon” who has been in Haiti for 47 years and is Canadian. The convent was not damaged. On the site there was a clinic in open air attended by a Haitian born physician living in France and a student from Quisqueya. The physician Tour of duty was to finish at the end of the week and there was an identified need for replacements. Met with Sr. Marie-Pierre Saint Amour who has a BA in psychology from Ottawa University and was holding sessions with the children as a group [see pictures] where they were encouraged to talk and to draw. The group meets regularly, 3 times/week. The parents were able to go to work during this time. We delivered two bags of crayons, paper, comfort packs, a sphygmomanometer.
Wiener Leblanc, Sister Marie-Pierre and the Haitian children showing their drawings. Medical student Claude Emmanuel is at the end.
Visited - L'eglise St. Louis [see picture] While the church had been destroyed the
adjoining land now housed several tents for acute care of children and adults and an
outpatient clinic for wound care, other acute illness evaluation, and nutritional
assessment. Dr. Marone, an expert in nutrition, had partnered with the International
Medical Corps and was assisted by two Haitian physicians who reside in the camp after their house was destroyed during the earthquake. Nurse practitioners practitioners from IMC also helped. Mean arm circumference and active identification of malnutrition was a clear focus of this clinic. Also on site was access to a well organized pharmacy, nutritional supplement for children 6-35 months (Plumby) and those 36-60months and pregnant and lactating women –high energy biscuits - Ready Use Therapeutic Food (RUTF, RUSF). This supply was provided through the World Food Program. Dr. Marone is affiliated with the Ministry of Health. Identified needs include pediatricians and other physician services.
Nutritional supplements provided by Dr. Marone’s clinic.
Visited Centre Diagnostique Technique Informatique (CDTI) – a state of the art private
hospital that had ultrasound and CT capability prior to the earthquake. Met briefly with
Dr. Reynold Savain who explained that the ultrasound was functional but the CT (the
only in the island) had been damaged. There are several OR in this hospital and at the
outset of the disaster the hospital had been “handed over” to the team of Colorado
surgeons who responded to the disaster. Hundreds of surgeries had been performed –
approximately 250 amputations of which about 50 were on children. We met a little girl
–who had lost a leg and her mother described that she was injured – crush injury on the 12th and then her foot was amputated on the 17th when there was vascular compromise and necrosis. There were several tent clinics predominantly for trauma patients. Physical therapy was available and the therapist spoke to us of the need for “stump shrinkers” to assist in the preparation for prostheses. She emphasized the urgent need for physical therapists in the rehabilitation phase of this disaster.
Child at CDTI post amputation of her right leg.
Thursday, February 25, 2010
Returned to the General Hospital (HUEH). Worked with Dr. Leblanc. We shared a
small tent to see the endless stream of patients lined up early in AM –from those acutely ill (e.g. jaundice with diffuse edema and hepatomegaly), to those returning for review of laboratory studies, newborns and malnourished children. Access to basic equipment was difficult (e.g. thermometer, child size sphygmomanometer, pulse oximeter). Triage occurred prior to coming the tent and included patient demographic, weight, and a chief complaint. There was no access to nutritional supplements. No immunizations were given. Clinic had not been set up as yet. Referrals were possible to cardiology and the one neurosurgeon at USS COMFORT. A new hospital, Hopital Sacre Coeur de Turgeau with a well equipped in renal dialysis, had been destroyed by the quake. Delivered the 5 pairs of adult crutches and Dr. Leblanc made sure that the orthopedic service received these. Met with Dr. Chery Eluourde, the pediatric resident again. Gave her a Harriet Lane and when asked she requested Harriet Lanes for the 18 other residents. Most had lost everything when they evacuated the building.
We left the Pediatric Clinic at the Hospital early afternoon to meet with Dr. Claude
Surena in his office, to obtain an overview of the coordination efforts of PAHO/WHO
and the Ministry of Health. We discussed the need to access statistics to review current status of children and inventory of services available at the various sites. Discussed disaster-related priorities and non-disaster related priorities. Vulnerable groups were identified as women, children, amputees and affected population. Discussed the need for a nationwide trauma system, an idea spearheaded by Dr. Barth Green of UM and Dr. William Pape before the earthquake. Dr. Surena spoke of the need to resume discussions. Asked about the nutritional and vaccine programs and the organization of mobile clinics. Discussed briefly access to USS Comfort for surgical interventions, Medishare from the Jackson Memorial Hospital, Miami, and the process for referral of children for cardiac care and surgery.
We were provided with two Groupe Sante Responsabilite Sectorielle in Haiti –Disaster
Relief reports. The latest update dated February 9 and 19, 2010 [see attached]
summarized current efforts. Assisting and monitoring of HIV/AIDS, waste management,
vector control, sanitation, protocol for reproductive health, assessment of nutrition,
distribution of hygiene kits, and female rape survival were outlined. In addition, we were referred to the UN Cluster meetings which covered the following areas: Health Cluster Meetings and specific meeting times, usually 2-3 times/week [see attached]:
. General health
. Mobile clinics
. Hospital group
. Information group
. Health Sub-cluster in Leogane
. Health Sub-cluster in Jacmel
. Mental Health and Psychological Support group
. Vector control group
. Epidemiology group
. Injury Rehabilitation and Disabilities group
Late in the afternoon, we visited the Hopital de L’Espoir (a children’s hospital – which
now housed adults and children) where we met the director (her wish is to build a NICU) and an AMHE Neonatologist in a tour of duty for 2 weeks. We also visited an orphanage sponsored by the Director of the hospital. [see pictures]. There is a section for normally developing children and a section for disabled children – many with cerebral palsy and other with MR/CP and other diagnoses. We met an 8 year old whose parents had left him there after the earthquake – he had a well healed 15cm semilunar scar extending from his forehead to the left parietal area. As he walked away he had a slight limp – we called him back and noted some mild-mod swelling of the anterior tibial area -healing fracture perhaps that had not been set. The orphanage building housing the normally developing children was damaged by the quake so they stayed in tents outside. Shelter Box tents were airy and spacey but not the kind equipped with running water or other facilities. We ended the day with a visit to St. Damien, Petit Freres and Soeur, a well equipped children’s hospital established through Italian donations. Met with Mr. Phadour, the administrator for the hospital. He outlined that in the acute phase of the disaster, now nearing an end, approximately 500 surgeries had been performed. This children’s hospital had converted to care for adults and children alike. The current census was slightly above the baseline of 150, at 200.
Friday, February 26, 2010
Dr. Laraque was to return to NY but the flight was cancelled.
Dr. Leblanc was scheduled to work at the General Hospital to help the resident staff with the tremendous influx of infants and children registered at the Pediatric Clinic. Worked there until the last patient was seen in late afternoon. In the meantime Dr. Laraque: Visited APAAC, Association for the Prevention of Alcoholism and other Chemical Dependencies and met with the Director Gaetane B. Auguste. There is a teen group there as well. They own their building and have seen an upsurge of patients affected by the quake and struggling with mental health and substance use problems. This is not unexpected and certainly was witnessed after 9/11. The center also has space that used to be utilized for inpatients, that is now vacant and can be rented out.
- Phone conference with Dr. Poitevien, Dean at Quisqueya to review visit to Quisqueya
and the mobile clinic sites on Wednesday. She summarized the following needs and
possibilities:
1. Expansion of a well equipped mobile clinic to continue the community outreach
efforts begun by Quisqueya to bolster the community pediatrics focus of the
school of medicine.
2. Physicians and nurses to team up with students who are providing medical care at
the four sites. There is an urgent need for a pediatrician now.
3. Availability through the school of medicine of dormitory rooms to house volunteers from the US and the provision of two meals per day by the school of medicine in support of the volunteers; stays of 10-15 days per volunteer are preferred; transportation is provided with a driver to the sites. Since volunteers are matched to Haitian trainees who do speak English, translation is available.
4. Teaching through coupling of more trained physicians with 5th year medical
students.
5. Visiting professorships for didactic sessions at the school
6. Research focusing on nutrition, malaria, psychological support for disaster victims would be welcomed. She discussed that the school had just begun a program where they had 25 children per site for a total of 100 children come to the university campus and provided two meals to the children, cultural activities and didactic sessions on sanitation. She stated that she welcomed a focus on psychological and emotional support. The site run by the Catholic Church had been one of the few to display attention to the psychological needs of children and may well serve as a model for intervention. Psychological support of clinicians is also needed.
Saturday, February 27, 2010
Worked (Dr. Leblanc) at Dr. Marone’s camp site in the yard of the Church Saint Louis Roi de France seeing infants and children and helping with the immunization program at the site.
Sunday, February 28, 2010
Dr. Danielle Laraque departure for New York.
Dr. Wiener Leblanc stayed in Port-au-Prince.
Visited a temporary campsite in Petion Ville and started an “impromptu” clinic for the
children. Saw children with: Tinea Capitis, bronchitis, anemia (pale looking), borderline malnutrition, psycho-somatic complaints (age 9 and above) and one case of sexual abuse (8 year old girl) transported t Hopital de La Communaute Haitienne for further evaluation.
Monday, March 1, 2010
AM: Visited the Pediatric Section at the Hopital de la Paix, a University Hospital under
the Department of Health.
Met with a Haitian Attending Physician (Medecin de Service), a Cuban MD and a
resident from a private medical school making inpatient morning rounds. Only
physicians available to see admissions and clinic patients. Three other pediatricians
attached to the hospital have already left the country. The Nursery and NICU are closed for lack of medical and nursing staff.
In the Pediatric Clinic, a long line of patients was waiting.
PM: Dr. Leblanc Departure for Florida.
Summary Recommendations from Haiti needs assessment:
The acute phase of the disaster relief in Haiti is coming to an end and with this the
anticipated departure of many NGOs. There are many intermediate and long term needs. Uniformly, public and private hospitals and specialty hospitals responded to all disaster victims, adults and children alike. New opportunities to create a public-private partnership in building the health care infrastructure for Haiti was discussed by a number of parties. In addition, a uniform regionalized system of disaster and trauma care is being discussed. Intermediate and long term needs identified include:
1. Pediatricians volunteers to complement the efforts of the Haitian physicians
2. Support for trainees, medical students and pediatric residents through coupling of
these trainees with trained physician volunteers
a. Mentor attendings in inpatient and outpatient settings at HUEH, Quisqueya, Hopital de la Communaute and others
b. Long-distance support ideas
c. Didactic materials
3. Coordination of efforts of AMHE, APA, HPS, AAP, PIH and the multitude of sites that need assistance.
4. Remain abreast of the discussions on cross university collaborations on the development of a nationwide trauma system.
5. Access to statistics on pediatric health care capacity was not readily available in a
structured way and would help identify needs and sites – mapping of these sites would assist our efforts
6. Better knowledge and dissemination of the coordinating efforts of the UN clusters
7. Nutritional efforts – was unable to meet with UNICEF contacts in Haiti – malnutrition of children, many of whom have lost mothers and live in dire circumstances is a major priority
8. Vaccination efforts need to be embedded in the current activities. This was evident in some sites but not uniform.
9. Focus on both disaster related and non-disaster related issues such as:
a. Care of disabled children
b. Physical therapy and preparation for prostheses for amputee children
c. Mental health services for children
d. Mental health support for trainees
e. Mental health support for other clinicians
f. Return to school a priority – a major concern being that if children are not in school this creates a vicious circle and security risk for and limits their parents’ ability to access work.
10. Centre de Reference for acute treatment of severe malnutrition (Centre mobiles
under WHO/OMS, PAHO, and UNICEF) do exist as well a program for prevention.
11. Additional assessments of areas not reached via this trip
Planned Actions:
1. Summary report to circulate, inform and facilitate collaboration
2. Conference call, March 5, 2010, with Richard Mollica at Partners and Paula Madrid to explore mental health interventions in support of clinicians. Clarify other mental health efforts in Haiti going forward.
3. Planned call with AMHE
4. APA Global Health debriefing call set for March 9, 2010
5. Mount Sinai Global Health debriefing meeting March 10, 2010
6. Explore with Joseph Boscarino (senior researcher) project idea on compassion fatigue and intervention in support of Haitian health care professionals.
7. Explore support for mobile clinic idea with Irwin Redlener
8. Immunization coverage and expansion discussions (L. Cooper)
9. Coordinate efforts with AMHE, AAP, HPS for volunteer physicians
10. Work on ROR Haiti
11. Explore evidence-based interventions from international experience (Olness article)
12. Explore use of “Return to Happiness” program from UNICEF with Quisqueya
University and others.
13. Mail 20 Harriet Lane Handbooks to residents at HUEH (J. Coliman Adrien)
14. Continue to expand the action list based on re-evaluation of needs
15. Plan a return trip to Haiti to solidify and maintain connections.