The shortest lineups for care at this city's single, overwhelmed hospital are at an unmarked white tent pitched in the parking lot and lined with 12 recycled sports stadium seats, half of which are often empty.
Leaned next to the entry flap is a small canvas painted with a cartoon character juggling his crutch and cast, an illustrated attempt to remove the mystery from the unconventional type of medicine - absent needles, pills or hospital beds - offered inside.
Diagnoses here are made with the hands, usually after they've felt out things like neck flexibility, spine curvature and vertebrae spacing; prescriptions come in the form of orders to complete daily repetitions of exercises that sound foreign to most Haitians, such as seated clams and pelvic rolls.
While they rhyme off these lists, the physiotherapists staffing what passes for a rehabilitation clinic right now in Jacmel are wondering in the back of their minds when the trickle of broken people finding their way to the tent will morph into a flood.
Haiti's national dearth of rehabilitation and physiotherapists - there are only about 12 in the country - has set off alarms among teams of foreign medical experts who, in recent weeks, have been conducting cross-country assessments to measure the massive need for long-term treatment. Neither specialties are viewed in high esteem in Haiti, yet an estimated 4,000 to 6,000 people who lost limbs in January's debilitating earthquake are in need of physiotherapy and rehab as they struggle to cope with deformities that will affect them for life. That includes a critical mass of victims who survived with spinal cord injuries in the quake and are newly paralyzed from the waist down.
Local doctors are at a loss as to their treatment. At one clinic in Milot, a tiny northern hospital near Cap Haitien set up for maternity patients, doctors accepted 19 spinal-cord patients from Port-au-Prince after medical aid groups begged for help from facilities with open beds. A group of therapists from the Toronto Rehab Institute who recently visited the patients witnessed firsthand how the lack of understanding among local medical staff - and among patients who have no idea what kind of help they need - is creating nightmare scenarios for patients who should be celebrating their unlikely survival.
"Some [paralyzed]patients had 10 days worth of stool completely backed up. Same thing with the bladder," said Mike Landry, a physical therapist who is also an adjunct scientist at the Toronto Rehab Institute.
Complex spinal cases are daunting even in the developed world, let alone for physicians working in a country where rehabilitation and assisted-living facilities are non-existent. And, to make matters worse, patients who are stable enough to leave hospital after surgery often have no place to go but a tent.
"We've never had to deal with this kind of thing in the global health arena," said Dr. Landry, who recently completed a fact-finding mission across Haiti's devastated regions. "I've seen a lot of scenarios that are devastating, including Rwanda. But this is among the worst I've ever seen: the absolute lack of infrastructure, the lack of human resources. This is uncharted territory … for everybody."
Dr. Landry has been working with several other international organizations trying to meet rehab needs, and estimates that Haiti currently has the largest proportion of disabled people in the world. Making the country's situation more unique is the fact that a huge swath of those disabilities are quite dire: the post-quake foreign emergency response was rapid enough to save huge numbers of people whose injuries would have been fatal had the disaster been less geographically accessible to top-flight rescue teams.
While the fact that so many people were saved is a victory, the struggle is that hundreds are grappling with complex disabilities, such as paralysis, in a country that struggles to treat even the most common medical afflictions, such as diabetes.
"The Haitian country is not well-designed for people with spinal injuries," Dr. Landry said. "You can't use a wheelchair on most sidewalks - if there is a sidewalk."
Nor does the nation, with its 12 physiotherapists, have the human resources to treat them.
"It is undoubtedly the largest supply/demand imbalance that I have ever seen," Dr. Landry said. "If we're not there, there is very little rehab going on."
Indeed, rehabilitation experts have spent more than a decade working to build up capacity here, led by the non-government aid organization Healing Hands for Haiti, which has been working in Port-au-Prince since 1998. The earthquake destroyed most of their facilities, leading the organization to partner with a collection of individuals and foreign therapy groups working to build up capacity, including several Canadians.
"To get physiotherapy on the map here has taken a lot of work," said Shaun Cleaver, a native of Niagara Falls, Ont., who has been working independently in Haiti to train physiotherapists for several years. "Doctors often see us as unnecessary. But we're sitting at an important point in history here."
The Canadian Physiotherapy Association is working to seize it: Last week the group sponsored travel for two Haitian physiotherapists to attend an international membership conference. Their hope is that supporting Haitian therapists will motivate them to build up the profession and lobby doctors to recognize the validity of rehab therapies.
"We need to scale up the capacity of Haitian health providers to deal with this," Dr. Landry said. "If we can raise awareness of rehabilitation now … it will have a powerful impact on people."Report Typo/Error