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By Julia Moline

When you read an article or hear a story or see firsthand how hard it is to manage information after a disaster, it’s tempting to think that if only we had the right systems, all of our problems would go away. Technology can achieve amazing things. We can use aerial imagery to allocate response teams; we can trace tweets to find people trapped in a building; we can share information with people all over the world over computers and mobile devices. So why can’t we make this work?

The first hindrance is money, which can be a large barrier for non-profits. There are also number of issues that technology itself cannot address. These challenges are especially pronounced in areas that bring a lot of different kinds of responding groups together, including anywhere voluntary aid meets government response.

1. Different groups need systems for different reasons. In-kind donations management is a good example of this—it makes sense to have a single system that allows donors, beneficiaries, and decision-makers to see what’s needed and what’s available. Systems like the National Donations Management Network are built to help meet various needs through selective user access, multiple data filters, and custom reports. But as the system continually expands to meet more needs, it becomes less intuitive for the average user.

2. Database skills are not a given. The people who respond to disasters range from extremely tech-savvy grassroots organizations like Occupy Sandy to retired first responders with decades of field experience but little knowledge of technical systems. Most of the government and aid workers who get involved fall somewhere in the middle, so they need training (or instructions) on how to use a new technology or database. Often the system only goes part of the way toward accomplishing their tasks. Without the skills or the confidence to make the system work for them, aid workers often resort to simpler systems or even manual methods.

3. Frustrations with systems lead people to develop workarounds. In a high-pressure response environment, you only have time to do the minimum to get your job done. So spending time entering data or trying to run a report seems like a waste. Instead, you start printing out the individual records you need and handwriting your notes. Or, you don’t completely give up on the database, but you start to enter your information in the comments field instead of trying to track down all of the places you’re supposed enter data. Or, you just pick up the phone and have a conversation with someone. So you get your task done right now, but when your shift is up, the next person doesn’t know where you logged everything. And when his shift is up, you don’t know where his stuff is. You want to fall back on the system, but by this point, its information is outdated, and you have to figure out who has the information you need.

4. Sometimes, people just don’t want to share. Organizations can be territorial or suspicious of each other’s ulterior motives. It can be unclear who is responsible for keeping certain information up to date. And sometimes, people just don’t get along (especially when the environment is tense and the stakes high). So even when a system has the capacity to collect and synthesize data from a lot of different sources, some people might not want to use it, because they don’t want to grant others access. If enough users start to feel this way and stop using the database, it will no longer hold enough information to make it worth others’ time.

That is not to say that we should give up on developing technological systems for response. On the contrary: we have an obligation to continue to develop and improve our systems so that we’re best able to respond to disasters. But to do so without recognizing these challenges would be a waste of technology and a failure of development. We must develop systems with an emphasis on user-friendliness and intuitiveness, implement data management goals into planning programs, and make a concerted effort to train responders on basic data management principles.

Technology alone isn’t going to “fix” emergency management. But if we’re deliberate about making technology a part of the way we prepare for disasters, we can go a long way toward a more efficient, effective response.

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Muck Out

 

By Julia Moline

When a house floods, it doesn’t just fill with water; there’s dirt, household chemicals, and, often, raw sewage in the mix. In the response world, this toxic brew is known as muck. To clean a flooded home, it’s not just a matter of getting the actual muck out, though.  You have to remove all damaged furniture and finishes, clean all surfaces, and dry everything out to prevent mold growth. On top of all of that, you have to document damage for insurance purposes.

In an event like Superstorm Sandy, which had such widespread impacts, muck outs are a case study in the challenges of disaster response and recovery. They are deeply personal and a challenge of scale, at once slow going and a race against time.

I spent a few days working with the New York City Donations Coordination Team in the aftermath of Sandy. Coming in looking to learn something about how response works, and with a background in flood mitigation and flood damage-resistant materials, I was fascinated by muck out coordination efforts. It was becoming clear that muck outs would be the next major need, particularly as a cold front approached and shelter space began to run low. As coordination proceeded, I noticed four themes emerging that spoke to larger challenges of emergency management in general.

1. Government-NGO coordination. The real work of rebuilding can’t happen until homes are clean and dry, but the government doesn’t have the resources to muck out each of the tens of thousands of flooded homes.  Formal partnerships with VOAD groups1 can help provide the needed assistance; a number of those have the resources and experience to help with large-scale muck out operations. Groups such as Team Rubicon and the Southern Baptist Disaster Relief have experience from previous floods and understand what’s needed. Local organizations with access to large numbers of volunteers can be additional resources, even though they may lack training and experience. This convergence of organizations and resources presents an opportunity and challenge that, if managed well, can lead to a successful and empowering response.  Managed poorly, it can lead to duplication of efforts, disenfranchisement, and, worst of all, inability to help disaster victims. 

2. Rapid action, the right way. After a disaster, you try to act as quickly as possible to get life back to normal. With muck outs, however, up-front speed might not always translate to time savings or better results in the long run. It’s tempting to skip some of these steps, or to only take the first step of getting the muck out of the house. If a house isn’t allowed to dry fully before reconstruction begins, moisture can lead to long-term mold problems that can require years and thousands of dollars to fix. If damage is not documented, the insurance reimbursement process can be prolonged. Doing these things all at once can save a lot of time and money. It’s more important to take the time needed to do the job right, rather than focusing on doing the job fast.

3. Data collection and situational awareness. To ensure that every area in need is covered, to avoid duplication of efforts, and to provide necessary follow up with homeowners, tracking and mapping is a critical step in a coordinated muck out effort. Because no single organization has the capacity to meet all of the needs, mapping also helps to ensure that each area is covered. Still, few organizations can spare the people to canvas needs and collect enough information to create a meaningful, complete dataset, and this is a significant issue that needs to be addressed.

4. Supplies and logistics. Having the people to do muck outs isn’t enough; cleaning supplies, personal protective equipment (gloves, goggles, etc), hammers and other tools are needed in bulk. Although volunteer efforts and donations are necessarily managed separately, close coordination is required to make sure that volunteers have the resources they need to do what they show up to do.

These four themes are common to all areas of disaster response and boil down to a few key elements: personnel, process, plans, and products. Each of these elements must be present for a successful response. When failures in response occur, looking for improvements in each key area can help to improve response. For instance, a map of affected areas will do no good if there is no coordination among government and not-for-profit organizations. Truckloads of personal protective equipment (PPE) and cleaning supplies will not solve anything if there is no way to get those supplies to muck out volunteers. And thorough action plans will not be successful if there is no mechanism for training and information sharing.

New York City is one of the best-equipped cities in the world for such large-scale coordination challenges, and will hopefully be able to learn and improve its own processes. As Sandy recovery continues for the months to come and winter approaches, we are sure to see new relationships forming, new information flows, and innovative data collection and tracking techniques.

1Link to: http://www.nvoad.org/

By Hisham Bedri

I recently attended the USAID Higher Education Solutions Network (HESN) launch event in Washington DC as part of the MIT delegation. As a belt-way outsider, I always thought USAID and government agencies were distant ivory towers–untouchable by peasants like myself, however this event changed my perspective on USAID. During the event, professors and students from the HESN universities (composed of MIT, UC Berkeley, Duke, Michigan State, William and Mary, Makerere, and Texas A&M) had the chance to meet the leadership of USAID and learn about their renewed commitment to harness the power of science and technology for international development. What was it like to be in the National Academy of Sciences building and the National Press Club next to the top USAID officials and administrators? Remember Willy Wonka and the Chocolate factory? Yeah, It was like that.

Senior Advisor to President Obama on Science and Technology John Holdren and USAID Administrator Rajiv Shaw at USAID HESN Kickoff Event

Senior Advisor to President Obama on Science and Technology John Holdren and USAID Administrator Rajiv Shaw at USAID HESN Kickoff Event

Just as Charlie walked through a factory filled with magic and whimsy, I was walking through one of the epicenters of international development in the world. This is where policy is made. These are the people who make the hard decisions. USAID opened its doors allowing us to meet its top officials, and gave us knowledge of its inner structure and capabilities.

The best take-away from the trip was meeting university professors, students, USAID officials, and other honored guests, all of whom were passionate about international development and science. I was surprised to see so many development labs and such a strong commitment to appropriate technology. There is a growing interest among engineers and scientists to focus their efforts on developing regions and emerging markets.

During our time together – shuttling between offices, eating meals, and participating in a science fair – there were plenty of opportunities to “geek out” and discuss research in depth with peers. I particularly enjoyed discussing geo-spatial analysis with researchers at the College of William and Mary and food security and conflict with researchers at Texas A&M. In addition to informal socializing, I was very interested in the work presented during the science fair. While a lot of impressive research was shown, I think first prize goes to UC Berkeley’s iPhone based microscope for its simplicity and potential impact on remote medical diagnosis.

There was also debate, particularly about how to approach global challenges within engineering education. There is a need for more engineers with skills, passion and the ability to work across conventional fields. Some argued that it is time for a new field: “development engineering and sciences,” while others believe in changing our traditional engineering and science curricula to incorporate the concepts of sustainability and development early. No matter the solution favored by individuals, it was evident to everyone that change was coming.

Difficult questions were posed and facilitated in round tables by Washington’s young leadership. I had the opportunity to meet Presidential Management Fellows (PMF), Presidential Innovation Fellows (PIF), and American Association for the Advancement of Science (AAAS) fellows. These young people are rising stars within the government and are a driving force for HESN – providing organizational backbone as points of contact for universities and finding ways to connect research with USAID needs.  Meeting this group of young people contrasted with my prior vision of government as a clunky, uninspiring machine. This is not your grand-dad’s government; seeing the inner-workings of USAID made me believe that change is possible and that there is serious hope for the future.

MIT crew at HESN kickoff event in front of National Academy of Sciences building

MIT crew at HESN kickoff event in front of National Academy of Sciences building

USAID’s new commitment to science is an important change to the world of international development. International aid and development has become a dynamic field with huge changes in philosophy since the 1960’s. What was once an avenue to give assistance and show compassion (through in-kind donations and investment) has become a specific mission to make lasting and serious change. Officials at the agency were very excited about the use of mobile technologies, geo-spatial analysis, and statistical evaluation for the sake of development goals like healthcare and food security. Furthermore, USAID is playing an active role in crowdsourcing solutions to development problems. The office of Innovation and Development Alliances (IDEA) has organized hackathons and open-data challenges to address development issues. This is exciting because USAID is embracing new opinions and hearing new voices.

I’m impressed by this new commitment because we are taking an appropriate approach to science and technology. Technology by itself is not the silver bullet that will save the world. Often there is a great deal of excitement surrounding newly designed products that turn out to be ineffective in the field. Unless a product is designed with culture, supply chains, and sustainability in mind, products deployed in the field will probably fail. Rarely do we hear when a development product or project fails or learn from our mistakes. The silent failure of products holds back the revolutionary power of technology in international development. USAID is acutely aware of this effect and is combatting it in its new commitment by including programs (such as CITE) to evaluate technologies across multiple platforms, including technical feasibility and supply-chain robustness, and produce easily accessible reports to inform designers about results.

USAID plays an important role in international development and international relations for the US. This new commitment to science and research partnership is very exciting. If humanity can engineer a way to the moon, ending poverty should also be achievable. This partnership is a giant leap in the right direction.

Hillary Clinton on HESN: http://www.youtube.com/watch?feature=player_embedded&v=hhXGKeGoX_s

Where does MIT play a part in this?

MIT was awarded the USAID partnership for its IDIN and CITE programs. The brilliant minds at D-Lab, Department of Urban Studies and Planning, and the Humanitarian Response Lab have drafted these two programs to fill a gap in innovating for interanational development. The first part of MIT’s propsal is IDIN, a global network of innovators sharing ideas and best-practices. The second part of MIT’s proposal is CITE (Comprehensive Initiative on Technology Evaluation). These two initiatives are critical for USAID’s technology transfer and innovation efforts.

 

In-Kind Donations

By Julia Moline

A few days after Superstorm Sandy struck New York, a call came into the city’s Office of Emergency Management (OEM) that a woman was on her way into the city with an 18-wheeler full of donations from her church group. She needed to know where to bring her haul.

This wonderful and well-intentioned gesture created a big challenge for OEM. First, wind damage, debris, and transit issues had resulted in massive traffic congestion. Second, there was no clear place to bring large quantities of donations—warehouse space was in short supply. Third, there were no trained people available to sort the donations and bring them to afflicted populations.

After a catastrophic disaster, people want to do something to help. It’s only natural—how can you sit at home and watch story after story of families who lost everything without wanting to, well, do something? So people text to donate $10, celebrities host telethons, and…community groups organize drives. And that’s where things get complicated.

When a disaster strikes on as large a scale as Sandy, it is incredibly challenging just to figure out three basic logistics questions:

  1. What do the organizations responding, sheltering, and canvassing need?
  2. Who has what these organizations need?
  3. How are those resources going to be transported from the donor to the recipient?

To have any kind of timely response, it is imperative that these transactions be conducted in understandable units, for instance pallets, containers, or truckloads. If I know that a shelter needs five pallets of water, I can get them five  pallets of water and know that their need has been met; but if I start sending them one case or a few cases at a time, it becomes impossible to track whether they have enough. More than that, if I send a shelter with critically low water levels a truck full of some water, some clothes, and some other stuff, I may be doing more harm than good; not only do they likely not have the capacity to sort what I sent, they have no place to store things that can’t be used immediately, and they either have to keep everything on the truck (which means the truck isn’t available to transport new shipments) or take up valuable shelter space with piles of unnecessary stuff.

If this concept isn’t planned, it rapidly becomes obvious to anyone managing the logistics of response. Unfortunately, it is not obvious to well-intentioned bystanders. So unsolicited donations flow in, most of it unsorted. “Mystery bags” of clothes, blankets, and who knows what else are dropped off at shelters. Truckloads of donations from church groups in the Carolinas and the Dakotas arrive without specific destinations. And responders, whose goal is to match resources to need, get diverted into making sure those donations don’t choke their logistics network.

This is not to say that the outpouring of support and the desire to help aren’t appreciated; in a lot of cases, these kinds of efforts are the only ray of hope for people whose lives are destroyed. And giving something tangible, not just money, contributes to the much-needed feeling that an entire country is coming together to help its vulnerable citizens.

The response world’s challenge, then, is this: How can we direct in-kind giving to encourage and maximize outside assistance without disrupting critical response work?

New York City came up with several innovative ways to try to strike this balance. First, as much as possible, individuals were encouraged to give money rather than items. This message was relayed through a number of channels, including the city’s service website (link to: nyservice.org), Twitter, not-for-profit partners, and OpEds like this one by Jose Holguin-Veras (link to: http://www.dallasnews.com/opinion/latest-columns/20121106-jose-holguin-veras-avoiding-a-post-sandy-disaster.ece).

Second, individuals looking to donate were directed to their local Salvation Army or Goodwill store. Why? Unlike response organizations, these two groups have the local capacity already in place to receive, sort, store, and transport unsolicited gifts. Where donations are not immediately useful for affected people, they have the ability to turn things like golf clubs and tuxedos into revenue that can later be used to aid response and recovery efforts. And, because those organizations also have the capacity to separate different kinds of donations, donors have the satisfaction that their contribution did its part. If I contribute food, my food goes to a shelter; if I give something like golf clubs, they go to Goodwill.

It is also interesting to note that both Salvation Army and Goodwill developed voucher systems for disaster victims. The vouchers allowed people to purchase what they needed rather than what donors thought they wanted.

Third, VOAD groups (link to: http://www.nvoad.org/) like the American Red Cross managed large-scale corporate donations through their well-established infrastructure. Large-scale, unsolicited in-kind donations (such as the bounty of a church donations drive) and trucks (including the one that was en route in those first few days) were intercepted before they got to the city so that the goods could be sorted and redirected as appropriate without interfering with operations in the city. This eliminated the need for massive donations warehouses like those that popped up after the Joplin, MO tornadoes last year. It also cut down the potential for disaster capitalists to sell donations that the city didn’t want.

New York City continues to struggle with in-kind donations—from club DJs with weekend drives to individuals cleaning out their closets continue to send “mystery bags” to shelters and other sites that don’t have capacity. As response turns to recovery and the flow of generosity decreases, the need to manage existing donations will increase. Building on lessons learned from Hurricane Sandy and earlier events like the March 2011 Japanese earthquake/tsunami and the 2010 Haiti earthquake, the disaster response community can move forward with innovative approaches to the logistics of in-kind donations that will make a difference when the next disaster strikes.

By Dr. Jarrod Goentzel

The mammoth logistics effort needed to help New York City cope with the ravages of Hurricane Sandy is a story that will unfold over the coming months. But there is one logistical subplot that may surprise those active in the response and the public at large: the race to reopen the city’s schools.

Amid the turmoil brought on by Hurricane Sandy, bringing New York’s schools back on stream may not seem like a critical priority.  But as I witnessed firsthand last month in New York, and in other contexts such as Haiti in 2010, returning the education system to normalcy is a vital, and perhaps underestimated, logistical step on the road to recovery.

Unused emergency supplies await pickup as a shelter is transitioned back to a school

Unused emergency supplies await pickup as a shelter is transitioned back to a school

Amidst the chaos post-disaster, children need the routine that is imposed by school timetables. And having kids under the care of teachers frees time for weary parents to focus on disaster recovery.

But the challenge is far more complicated than inspecting and cleaning classrooms.

On October 28, more than one day before Sandy arrived in New York, the city mobilized 76 shelters, mostly in public schools. A few days after the storm passed, city leaders decided to consolidate the network into 15 core shelters, including four special “warming centers” where citizens could manage the dropping temperatures. The goal was set to transform most shelters back to their primary role as schools by Monday morning, November 5.

This transition required a huge logistics operation, one of many managed by the New York City Office of Emergency Management (NYC OEM). Ample supplies of critical items such as blankets, cots, food, hygiene products, and water – which had been successfully deployed prior to the storm – had to be shipped from 61 locations scattered across the city back to a warehouse for redeployment as speedily as possible.

NYC OEM workers repalletize water

Workers repalletize water

The age of some of the buildings posed a number of unique logistics problems. For example, many old-style school doors have steel posts positioned narrow enough to make it impossible for pallets to pass. Full pallets of supplies such as water had to be manually disassembled so the items could be carried out of the building. Once outside, they had to be repalletized before being loaded on the trucks.

This work required many hands, so logistics personnel drove to the schools to do the heavy lifting. That required them to burn gasoline – a scarce commodity in the storm-torn city. As a result, an additional logistics challenge was organizing this operation while keeping fuel consumption to a minimum.

Planning required coordination with staff at the schools, to estimate the quantity of supplies remaining in each building for labor and truck assignments and to ensure access for the around-the-clock operation. Further complicating plans, efforts were made to redeploy supplies directly to the remaining shelters, using impromptu “crossdocks” to avoid unnecessary trips to the warehouse.

Despite the scale of operations required over the weekend, the logistics operation was a success. All shelter supplies were removed by Sunday night, some 12 hours ahead of schedule. Dozens of former shelters were able to open their doors for school children on Monday morning.

Arriving within days of the disaster to assist the NYC OEM logistics team where needed, I was surprised that my first role focused on reverse logistics. I was tasked with “demobilizing” at a time when many people were still in need. But I quickly learned that sometimes the mantra of logistics professionals – having the right goods at the right place at the right time – means getting supplies out of the way…so the kids can come back to school.

By Dr. Jarrod Goentzel

Six months after the earthquake that devastated Haiti and galvanized the international community, lessons are emerging about striking the right balance between faster and better crisis responses, and how both objectives can be met.

Last fall we began a project with Partners In Health (PIH), a Boston based NGO, to identify how the organization’s healthcare supply chain in Haiti can be scaled up. PIH is known for focusing on better, demonstrating that “allegedly untreatable” diseases can in fact be treated in impoverished settings. It is also focused on the long term by involving the community and working with the public sector to strengthen systems. While PIH had extensive experience in Haiti, having provided health care in the Central Plateau north of Port au Prince since the mid-1980s, the earthquake challenged PIH on two fronts: it was not a disaster relief organization and it had no previous operations in Port au Prince. This organization needed to become faster to meet the needs of injured Haitians by establishing mobile clinics in a city where it had no existing capacity.

Previous PIH experience did prove useful in establishing emergency health services.  According to Kathryn Kempton, Director of Procurement for PIH, “We were able to act faster because we had already tackled some parts of the ‘better’ by having a solid formulary, well trained local staff, experience with mobile clinics, and some logistics procedures in place, all in the Plateau.” Still, it was difficult to be both faster and better in setting up the supply chain to support new mobile clinics in the informal settlement camps.

The Cement Warehouse

The day we visited the new PIH warehouse in Port au Prince – an old cement warehouse converted overnight into a medical facility – it was uncomfortably warm and far too humid for effectively storing pharmaceutical products. The majority of the warehouse was well organized, with medical supplies in one room, pharmaceutical products in another, a small dispensary in the corner to effectively serve the mobile clinics, and an electronic pharmacy management system tracking the stocks. However, we did notice some expired medicines stacked against a wall next to a room of surgical equipment that no one had the skills to understand, and hundreds of water bottles piled haphazardly just outside the door.

Faster clearly ruled the choice of warehousing. It simply wasn’t an option to wait until climate-controlled and better-secured warehouse space could be found in the capital city; supplies were flooding in from around the world and they were urgently needed to treat those injured in the earthquake. The supplies reflected what was available rather than what was needed, such as equipment that was too specialized for emergency needs. PIH tried to screen every item before shipment to Haiti, but the sheer volume of donations and the need to respond quickly made this very difficult. Shifting priorities made the task even tougher. Ultimately, the faster solution was to accept everything (necessitating a large warehouse) and sort out what was useful as demand materialized. In the circumstances, opting for faster rather than better was a good tradeoff, since most of the products will be used fast enough that the shorter shelf life does not matter for current purposes. And, as the managers told us, this warehouse – with its ad-hoc inventory – is not a long-term solution: it was the best they could do on short notice.

Looking Forward

The central question now for PIH is how to transition earthquake response resources into a better long-term system for healthcare in Haiti. Though successful in meeting urgent needs, the emergency effort departed from their typical approach in scaling up operations. Kempton reflected, “Had we had tools or just some guidelines/parameters for how to set up rapid response systems that can evolve into longer-term solutions, it would have been an enormous help.”

At MIT, we are focused on developing such guidelines and tools using insights from both commercial and humanitarian supply chain methods. In a classic application of commercial supply chain methods, students modeled the PIH supply chain to show how they could scale up operations within existing facilities simply by changing ordering policies from annual to monthly or even quarterly. Another research project shows that there are insights to be gained for commercial logistics from humanitarian organizations who are experts in building supply chains quickly for emergency response. Supply chain design techniques like mathematical optimization may provide better solutions but require more data and time than are available in a disaster response. To be faster, humanitarian logisticians use their experience and intuition to make decisions. We observe decision-making during humanitarian logistics training exercises to formally document some of these heuristic approaches. We are developing tools, including a shipment planning tool for the UN World Food Programme, that should improve results by combining models that are better with intuition that is faster.

The tension between “faster” and “better” is likely to recur in the years ahead. It’s worth our while to invest in solutions now, while lessons are fresh, to enable a faster AND better response next time.

by Erica Gralla

Port-au-Prince, Haiti – Wednesday, Jarrod and I had the opportunity to visit Cange, where Partners in Health (PIH) began its first clinic. To convey just how inspiring that is, Mischa (who has a masters in public health) told us it was like visiting “Mecca” for public health. If you’ve never read Mountains Beyond Mountains, or heard of Paul Farmer, perhaps now is a good time to start.

Jarrod has been working with Partners in Health to examine their supply chain in Haiti, which was already stretched near its limit before the earthquake. Of course, the earthquake changed all that, as donations of money and medical goods poured in faster that PIH could handle them (though the money is never enough for the need in Haiti, it seems), and the supply chain expanded many-fold overnight. Katherine, PIH’s point person for all things logistics, came down to Haiti to assess the situation, lend assistance, and bring Jarrod and I on a logistics-oriented visit to Zanmi Lasante (the Kreyol name for Partners in Health).

My global health friends would perhaps have found our “tour” slightly disappointing – we saw mainly warehouses, boxes, and the storage rooms of pharmacies. For me, this is fascinating stuff – and it should be for you, as well! Because without a steady supply of pharmaceutical products and medical supplies, health systems stop functioning.

Our first stop was Saint Marc, a relatively recent addition to PIH’s network of clinics. The reason for our stop was a brand-new warehouse, built into the back corner of the clinic compound, with gleaming walls and high ceilings. An SUV was pulled up to the entrance, being loaded with boxes for a journey to another clinic. Inside, boxes were piled on boxes, since shelves had not yet been ordered, but the space did not feel particularly crowded (a good thing). Jarrod wanted to measure the warehouse, and since there was no tape measure, he used dollar bills and a camera to get the dimensions of the square floor tiles. This type of making do, ad-hoc creativity is a key element of many supply chains I’ve seen in developing countries. So we fit right in. We saw the paper-based system used to keep stock records, then headed back to the clinic to see the pharmacy. Drugs stocked in the warehouse are sent to the pharmacy weekly (or as needed) to be stored in plastic containers and dispensed to patients. Finally, we wandered the clinic compound a little, while we waited for the driver to pull up the car. Zanmi Lasante pays a lot of attention to landscaping and the environment of the clinic, and in Saint Marc the landscaping was very much in progress. The warehouse was recently constructed, another building was going up near the pharmacy, and trees were being started all over the compound.

Next, we visited the outpatient clinic in Saint Marc, a short drive away. Here we saw another pharmacy, but in this case (perhaps because the main warehouse was not on-site), the pharmacy back room doubled as warehouse. Boxes were stacked to the ceiling, though drugs were organized and accessible. Drugs are dispensed to patients through something like a barred window, though the “bars” are really a nicely worked artistic design.

Finally, we headed toward Cange, the original clinic now grown into a “Sociomedical Complex”, including a full-service hospital, plus blood bank, schools, and other social enterprises. The roads have apparently improved in recent years, and it wasn’t until the last stretch up the side of a mountain (overlooking the lake created by the big dam –  if you remember your Mountains Beyond Mountains) that we hit bumpy dirt road. I’ve heard from several people that “there’s Haiti, and then there’s Cange.” I don’t think I can judge the truth of this statement, since my experience of Haiti has mainly been shuttling between the US Embassy and the UN Log Base through a recently destroyed Port-au-Prince. Not exactly the standard Haiti. But I can see why it might be true. Much of Haiti appeared (to my eye) empty and barren, where Cange is covered in tall trees. There’s an atmosphere that I can’t quite put a name to, but it comes from the kids and adults and doctors and managers and everyone else you find in this ‘sociomedical complex’. The school, the hospital, the church, and the koi pond (!) beckoned, but our first stop was… the warehouse!

The “depot” has two floors, with pharmaceutical products stored in the climate-controlled rooms upstairs, and medical supplies downstairs. This warehouse felt distinctly more “seasoned” than the new one in Saint Marc, with a proven system of organization, yet a feeling of being strained almost to its limits. Nevertheless, it functioned well. Most supplies go through Cange, and are distributed from here to the other clinics. Boxes were piled to the ceilings around the outside of the warehouse, waiting for distribution to a clinic when needed, while unboxed medical supplies were stored on shelves for use in Cange. PIH uses an electronic medical records system to track stock. I attempted to learn about it from a very patient woman, using my one-and-a-half semesters of French. Katherine translated where necessary. This time, when Jarrod wanted to measure the warehouse dimensions, someone had a tape measure, so I followed him around writing down dimensions while the PIH staff looked on in bemusement (or, that’s what it seemed to me!).

After our warehouse visit, we got to see the rest of the complex. The hospital is extremely impressive, with two operating rooms, staffed at the moment by a team from the US. We saw women making “Plumpy Nut”, a peanut-based supplemental feeding product aimed at children. We saw the blood bank, patient rooms, an art center run by a woman from North Carolina, and the Friendship House, where guests can stay. Finally, the last stop on our tour: the koi pond! Along the way, we met a number of fascinating and dedicated people who contribute in very different ways to making Zanmi Lasante in general and Cange in particular as amazing as they are.

Our last stop was a PIH agricultural warehouse, which is currently housing some overflow medical goods (donations after the earthquake overwhelmed the dedicated medical warehouses). Finally, we drove back to the hotel. It had been a long, hot day, and we dropped our things off in our rooms, loaded up on bug spray, and headed back to the outdoor tables by the pool, ready for a cold beer. Or so we thought. Katherine asked for one brand, and they didn’t have any. She asked for another, then another, and finally any beer at all. They didn’t have any. At all! They had Bailey’s and vodka and whiskey, but no beer. (And in places where one should be suspicious of ice, beer is really the way to go.) We ordered cokes and lamented. Until, twenty minutes later, someone from another table got up, walked behind the bar, opened the fridge, and pulled out a can that looked suspiciously like beer.  We waited to confirm our suspicions; ten minutes later, again. Was the restaurant hiding beer from us? Had they brought their own beer? Was there some sort of misunderstanding? Was this some sort of test, to see whether we wanted beer badly enough to take it ourselves? The suspense was too much. We had to ask. Impolite to say the least, we walked over to the beer-laden table and inquired. Turned out they had brought it themselves. They were also a team from University of Georgia, with a bit of overlap in interests. We exchanged business cards, and they offered us beer. Mission accomplished! (And a good thing too, since we met some interesting people!)

The following morning, we drove back to Port-au-Prince, down a beautiful paved road (it wasn’t always this way). Our last stop was the PIH warehouse in Port-au-Prince, which they acquired just for the earthquake. It’s not a long-term solution, but at the moment it is piled high with all things useful and mysterious. Donations (of goods) after an earthquake are more often useful than not, but sometimes people donate what they have without thinking of what PIH might actually need. This can be a problem if there is limited storage space and limited capacity to look through the donations and understand their use. There were piles of pain relievers and beds and bottled water, but also an entire wall of expired medicines and mysterious surgical equipment no one had the skills to understand. They planned to have a surgeon from the US come down to the warehouse for two full days to sort through the surgical equipment and figure out what might be useful and what to discard.

PIH faces an interesting challenge here. They are generally a health care organization, which has ramped up (amazingly well) to deal with a major emergency in Haiti. How will they manage the assets (donations, warehouses, people) they have acquired for the earthquake when things return to “normal”?