Dan Khodabakhsh doesn't require a whole lot of sleep. It's perfectly normal, in fact, for the 33-year-old doctor to work a double shift bandaging up drunks and pulling bullets from teenagers in the emergency room of UCLA's Harbor Medical Center before driving home, scarfing down some takeout, and setting the alarm to wake up five hours later and do it all over again. Every other month or so, Khodabakhsh changes the routine: Instead of going home, he drives to the airport, hops a red-eye to Miami, transfers to Port-au-Prince, and heads directly to some ill-lit clinic in some dusty Haitian town. But one morning last December, stepping out into the chaos and glare of Toussaint Louverture Airport, he was told by his supervisor that he would be skipping the clinic and traveling instead to the city of Les Cayes. The country's nascent cholera epidemic had begun to migrate south, and it was moving fast.
Arriving at the coastal city's main hospital, Khodabakhsh didn't know where to look first. The makeshift Cholera Treatment Center consisted of two tents erected in a low-lying area, and the previous night's rainwater was pooled around the legs of its few rickety cots. Bedless patients slumped against a short concrete wall running the length of the tents, awaiting the handful of doctors and nurses wading through the water. The pharmacy and triage areas were flooded, drums of liquid cholera waste were accumulating in the back, and the tents were sweltering--not exactly ideal conditions for victims of a disease that kills by draining the body of fluids.
Within 72 hours of his arrival, Khodabakhsh and his Haitian colleagues had treated more than 200 patients in that cramped space. Between scrambling to find more cots and cut holes in them (a plastic bucket placed beneath each would catch the bodily waste), meeting with community leaders who had ridden down from the hills on donkeys for lessons in hand-washing and administration of oral-rehydration solutions, and hounding UNICEF for additional supplies, Khodabakhsh was sleeping about four hours a night. Looking back, he says today, that was probably the sanest part of that particular stint with International Medical Corps (IMC), the nongovernmental organization with which he regularly works. The next few days involved barricading himself in a hotel room while outside an angry mob fired shots in response to unhappy election results; being evacuated by machine-gun-wielding UN soldiers; traveling the streets in what felt like slow motion as the military vehicle he was in navigated around dozens of flaming tires; and eventually being helicoptered back to the capital.
That kind of madness is all in the line of duty for the volunteers and employees of IMC, who began arriving in Port-au-Prince less than 24 hours after the deadly earthquake of January 12, 2010. A week later, while reporting from the grounds of the University Hospital there, I met IMC nurses, orthopedic surgeons, and emergency-room doctors who were doing everything from amputating limbs and delivering babies to organizing supplies and designating makeshift wards with taped-up signs handwritten on sheets from yellow legal pads. The organization had already become the go-to agency for coordinating the hundreds of volunteers who had descended from around the world on the 700-bed hospital, known as HUEH. On subsequent trips to the country, I spent time with other IMC volunteers, each of whom was as personable and efficient as the last. Though you've probably never heard of it, IMC is in fact one of the most unusual NGOs on the planet. Its history begins with an idiosyncratic effort to help Afghan tribesmen. Its business plan, largely unchanged for 27 years, is conditioned on its obsolescence. But in many ways, IMC is--or should be--a model for other NGOs. The organization's cadre of international and local staff are playing an enormous role in the rebuilding of Haiti. And if all goes well, IMC will leave the country with a medical infrastructure that's far better prepared for the next, and unfortunately inevitable, natural disaster.
Like Khodabakhsh, the founder of IMC was an emergency-room physician at UCLA. Back in the early 1980s, Robert Simon, then in his mid-thirties, learned that the Soviet invasion and occupation of Afghanistan had killed, jailed, or exiled all but 200 of the country's 1,500 doctors. So he began making trips, solo efforts to bring medical care to its civilians. Told by one humanitarian agency after another that its mandate didn't allow it to work in Afghanistan, Simon founded IMC in 1984, setting up a medic training center in the relative calm of neighboring Pakistan. That same year, he sold his Malibu home to finance the clinics he was building. With the help of a grant from the U.S. Agency for International Development, or USAID--which at the time was focused on countering the Soviets--he recruited locals from underserved areas of Afghanistan, trained them for nine months, and then sent them back to their communities with supplies, medications, and skills to set up clinics. By 1990, IMC had graduated more than 1,000 health-care workers who had helped establish 57 clinics and 10 hospitals throughout rural Afghanistan.
Today, IMC has more than 4,000 employees--including doctors, nurses, drivers, logistics people, and security detail--and thousands of volunteers in more than 25 countries. (Simon, now 62, is chairman of the IMC board and continues to volunteer in the field.) It has responded to such emergencies as famine in Somalia, ethnic cleansing in Bosnia, the earthquake and tsunami in Japan, and the conflict in Libya. It is among the few humanitarian agencies still on the ground in Darfur and Iraq. Most important, the organization encourages its trainees to return to their native communities to serve, using skills they never would have developed without IMC. This commitment to empowering locals--the whole teach-a-man-to-fish thing--is what distinguishes International Medical Corps from such better-known NGOs as Doctors Without Borders.
Its chief tactic for leaving behind a lasting footprint is equally unusual. IMC engages at every level of society, from the grassroots to the ministerial. Agron Ferati, its director of program development, explains this as "understanding priorities, working with communities, and giving them the skills necessary to do the job on their own." Haiti's so-called Republic of NGOs has received, and has often deserved, much criticism in the wake of the earthquake--for bypassing the national government, for example, and for providing little accountability to the people it's supposed to be serving. IMC has mostly dodged the scolds. Rather than setting up a parallel system of health care, Ferati, a Kosovo native, met regularly with the minister of health and the head of HUEH (the hospital) during his tenure in Haiti as IMC's country director. In every place where IMC works, the organization recruits some 96% of its field-based staff and health professionals from the local community.
"When Simon created International Medical Corps," explains Nancy Aossey, the CEO of the organization since 1986, "the whole idea was to figure out new and better ways of doing things. He used to say, 'Three steps forward, one step back: Nothing wrong with that.' We take risks and learn from our mistakes. We can only do better and overcome obstacles that others haven't been able to overcome if we maintain that attitude and that can-do culture."
On an oppressively hot day in April, Ross Donaldson meets me at IMC's Haiti headquarters, in the quiet Tabarre neighborhood of Port-au-Prince. A 36-year-old with cropped sandy hair and pale blue eyes, "Dr. Ross" (Khodabakhsh goes by "Dr. Dan") is also an emergency-room doctor at UCLA. He first volunteered with IMC in 2008. Dressed in a short-sleeved dress shirt and chinos, the Midwesterner is all boyish earnestness, but Donaldson is hard core, a martial artist with near fluency in both Chinese and Spanish and proficiency in Arabic. He has lived in Iraq and China, and he nearly died from a strange, Ebola-like virus while studying infectious diseases in Sierra Leone. His email signature features 10 lines of credentials.
In January, based on a proposal written by Donaldson, the Clinton Bush Haiti Fund awarded IMC a $1.56 million grant to establish an emergency-medical-care system. As he leads me around IMC's open-plan work space, the young doctor explains that some 5.8 million people worldwide die every year as a result of injuries. That's 32% more than the number of fatalities from malaria, tuberculosis, and HIV/AIDS combined. And yet in many countries, including Haiti, few people have been educated in emergency care or basic concepts like triage. Haiti's paramedics are poorly trained, and there are few ambulances. In the cities, patients arrive at hospitals in the back of a pickup truck or clinging to the driver of a moped; in rural areas, there is often no care at all.
"For too long," says Gary Edson, CEO of the fund, "the global community has focused its efforts on post-disaster recovery and reconstruction and not enough time and energy on pre-disaster preparedness. If we do things like what IMC is trying to do, we will be better prepared the next time, and we'll mitigate the human toll of these disasters."
As it does in all its locations, IMC is working to put itself out of business in Haiti. Ferati's meetings with local officials and UNICEF executives often revolved around the details of turning over IMC's programs to the Haitian government. In Iraq, where IMC arrived in 2003, the organization's staff has dwindled from more than 1,400 down to 400 (with just a handful of expats). The longer it stays in a country, the more IMC's work moves toward the development of sustainable community projects. It has helped create more than 300 small and medium-size businesses like bakeries and car-repair shops in Iraq, for example--a process that involved scores of town-hall meetings where locals identified "pressure-point projects" that were likely to have lasting impact.
In Haiti, IMC has a 2011 budget of $18.9 million (its total 2011 budget is $180 million). The organization employs 311 locals and 16 expatriates, but those numbers are beginning to shrink. Ferati wants IMC to pack up for good in three to five years, though it will only leave when it feels that the country has truly reduced its reliance on foreign medical care workers. Haiti's weak government and deep poverty meant that its medical system was in a shambles before the earthquake, its best doctors having fled the country for better conditions and wages elsewhere. In many ways, the influx of free care post-quake only exacerbated the situation. "Doctors from Texas and Cuba come in and intimidate the local physicians," explains Ferati. "There are plenty of Haitian doctors and nurses, and they don't have jobs. We want to empower local physicians, since they're the ones who know the system best."
It isn't terribly glamorous work. The day after meeting Donaldson in Port-au-Prince, I accompany him on a training round at an IDP (internally displaced persons) camp clinic in the town of Petit Goave, where he sits in an airless tent and listens as a young Haitian physician, Dr. Charlene Louis, consults with some 50 patients. (The camp is home to about 400 families, but Donaldson suspects that many of the day's patients don't actually live there.) Among the cases is an 8-year-old boy complaining of itching, whose body is covered in tiny pale spots. Louis lifts his shirt and asks several questions, as Donaldson leans in to hear the translator and nods with approval, occasionally interjecting a question of his own. Louis diagnoses scabies and writes a prescription for lotion. The seven others sharing the boy's living quarters will also need to be treated, she explains, as will the tent itself.
Khodabakhsh is pure drive, like Donaldson. En route to one training session, he taps away steadily at his laptop even as we bounce over the rutted country roads, compiling statistics for yet another grant proposal. Soft-spoken and with a mild, lopsided grin, he may not be as intense as Donaldson, but his dedication is no less fierce. He confesses that he and his girlfriend of one year recently broke up because he was never around: In the two years he's lived in his Santa Monica, California, apartment, he's never turned on the stove; the fridge has nothing but "hot sauce and maybe some spoiled milk."
But Los Angeles is far from his mind on this cloudless spring morning. Khodabakhsh introduces himself to some of the few dozen doctors, nurses, firefighters, and volunteer Scouts of Haiti who have assembled in a building adjacent to the flattened hospital in the southern town of Jacmel. On the lesson plan today: first response and disaster preparedness.
"Let's say this person was at Carnival and got hit in the head with a bottle," he begins, pointing to the anatomically correct plastic bust on the table in front of him. "Now he's unconscious. What are you going to do?" He tips back the bust's head. "Make sure the person has a way for the air to get in and out of his lungs."
The first people IMC seeks out, Khodabakhsh explains to me, are the first responders to disasters. In Haiti, these are usually the scouts (men and women mostly in their twenties and thirties) and the firefighters. IMC brings them together for trainings, confident that they will pass on what they learn. Today, some 20 scouts are in attendance, dressed in neat khaki uniforms with scarves knotted loosely around their necks.
"People think this program is really good," says Cuban-trained Robert Gilles ("Dr. Robert"), who has been translating the day's demonstration into Creole. "But they always want us to do more." Still, he says, "the system we're trying to bring is something that will be left for the country. I think it will be here for 100 years."
The following day, dressed in his trademark blue scrubs and Old Navy cargo pants, Khodabakhsh prepares for a triage drill in the driveway of the emergency building, one of the few parts of the hospital still standing after the quake. Under the shade of a flowering tree, he lays out bright green, blue, and red plastic tarps to designate different sections of a triage ward, and uses his Stanley pocketknife to cut up bedsheets for bandages. Eventually, some 40 people show up, many of them guys in tight navy blue Corps des Pompiers (firefighter) T-shirts. Khodabakhsh uses lengths of toilet paper to wrap a volunteer's leg, scribbling with a red marker to denote wounds, and then ties up the leg with pieces of cardboard and some strips of sheet. "I don't usually carry a stretcher with me," he says, "so we need to learn how to make one." Taking a pair of 8-foot-long two-by-fours and a plastic tarp, he demonstrates how to fashion something sturdy. The day before, he used plastic bags as a stand-in for surgical gloves. Even if first-aid kits were plentiful, he explains later, they'd eventually get used up, or the gauze would go moldy in the humidity. The idea is to make everything as sustainable as possible. A half-hour into the drill, Khodabakhsh is so drenched with sweat that his shirt has taken on a new shade of blue. He directs the group to practice their patient-evaluation and bandaging skills on one another. "We need this," Macdonald Duplan, the city's 36-year-old fire-department chief, tells me once they disperse. Revved up by their new knowledge, the volunteers make their way over to lunch. While waiting (and waiting) for the caterers to arrive, the tough firefighters in their wraparound sunglasses huddle arm-in-arm and break into an impromptu version of Hot or Not, erupting in raucous laughter and applause--and effortlessly attaining the kind of team-building nirvana that corporate America would kill to achieve.
"Do you know about the three Ms?" asks Chessa Latifi, an IMC program officer who is also Donaldson's girlfriend. She's sitting beside the pool of the IMC guesthouse where she lives in a gated Port-au-Prince neighborhood. Your average expat aid worker, she explains, falls into one of three categories: mercenary, missionary, or misfit. They are the adrenaline-seekers, the do-gooders, the people who can't function in normal society. These are mere stereotypes, of course, but there's no denying that the global aid worker is a unique breed, characterized by a subtle territorialism and been-through-it-all bravado.
No wonder, then, that the 26-year-old Latifi was sheepish about bringing me back to this fancy house, which she shares with various other IMC staff and the random passing volunteer. (She has since left Haiti and IMC.) Nicknamed "Miami Vice" for its tropical neon style and swank faux-leather couches, the house has a flat-screen TV and a drinks cart loaded with Barbancourt rum. Of course, the place does lose power regularly. At the organization's house in Jacmel, I slept in a room that had a sprawling bathroom complete with an elevated Jacuzzi. The thing didn't come close to working, though, and my vanity crawled with ants. The monster chandelier and heart-shaped pool mired in green slime contributed to the overall effect of a mansion owned by some African dictator who fled frantically as rebels closed in. These disconnects aptly capture the schizophrenic nature of the IMC worker's life. These people tend to dying infants and navigate rivers of shit by day; can you blame them if they enjoy a custom-cooked meal or a few drinks at night?
Part of the need for release can be attributed to IMC's security policy. Employees are forbidden from driving, for example, and are not allowed to walk in downtown Port-au-Prince. IMC recently eased up on its curfew in Haiti, which previously had been an adolescent-enraging 7:30 p.m., but employees are still required to sign out when leaving their homes and offices.
Then there's the stress of reentry to the U.S. When Donaldson goes home, he says, he doesn't talk about his life in Haiti or Iraq (where he lived through bombings and tended to sundered bodies). "It's too hard," he says, invoking the scene in The Hurt Locker where Jeremy Renner stands paralyzed before the cereal boxes. "People have no idea."
Given the difficulties inherent in such a life, you have to wonder why some do it at all. Most, including Donaldson and Khodabakhsh, will tell you it just feels right to serve. But others are more conflicted. "Yeah, right," laughs one IMC veteran over dinner in Port-au-Prince's Quartier Latin. "Help? If we really wanted to help, maybe we should all go home."
And sitting there in the chic restaurant amid middle-aged French women sipping champagne and military contractors attacking $26 steaks, you do have to wonder how much good all the outsiders are accomplishing. I had heard that fewer Haitians are eating at the restaurant lately, thanks in part to the fact that an IDP camp has sprung up across the street. But it is also because the expats have driven up the prices.
"At the end of the day," says Ferati, "everybody is grateful for what the NGO community has achieved over the last 40 years in Haiti." He adds, "They might have created a dependency, but that dependency can turn around in a day if the government becomes more responsive to community needs."
IMC continues to push for that turnaround. Marie Antoinette Toupuissant, a 41-year-old Haitian nurse who recently completed a month-long training with Donaldson at HUEH, didn't hesitate before declaring that there would be far fewer deaths if an earthquake were to hit the capital again. Since completing the course, she had already used her new knowledge of mouth-to-mouth resuscitation twice, one time to revive an infant. "I feel like I'm part of a cycle," says Toupuissant, who finished the training at the top of her class. "Haiti is being rebuilt now, and I'm a part of that."
On my last day in Les Cayes, I tour the Cholera Treatment Center built by IMC to replace the disaster that had confronted Khodabakhsh back in December. Funded by USAID and at the time overseen by Zach Zanek, IMC's local program coordinator, the $30,000 facility is so immaculate it seems more suited to Stockholm. Zanek and Augustin Innocent (who was then in charge of the center's doctors) lead me through the triage tent and wards, where Haitian nurses replace IV drips and play-act with the children, and local women in gray IMC coveralls methodically scrub patients' clothing. Beaming like two proud fathers, Zanek and Innocent direct my attention to the neatly stocked pharmacy and the elaborate water- and waste-treatment systems. The whole site, they explain, was raised a meter off the ground, so flooding would no longer be a problem. Innocent estimates that more than 3,000 lives have been saved there.
Now, though, Zanek is moving on. Most of IMC's expat staff have removed their belongings from the local guesthouse, and he plans to fly out later in the week, to be replaced by an Iraqi-born IMC doctor and a skeleton expat staff. "The business of business is to stay in business and grow," says the Clinton Bush Haiti Fund's Edson. "The business of a not-for-profit should be to solve the problem and get out of the way."
Of course, there's still plenty to be done in Haiti. Tens of thousands remain homeless; the country ranks 146th out of 178 countries on Transparency International's scale of perceived corruption; and cholera is now endemic, likely to surge with every rainy season. And though his first several months have been bumpy, many are still hopeful that their new president, former Carnival singer Michel Martelly, will find a way to steer the country in a different direction, one where the aid worker isn't such a common sight. With luck, the Donaldsons and Khodabakhshes of the world will move on, taking their can-do drive to some other bleeding corner of the planet, and feeding something in themselves along the way. "This is all about hope," says IMC CEO Aossey. "We believe in the potential of people. We believe we can find a way to unlock potential, regardless of the political environment, anywhere in the world. I mean, look," she adds with a laugh, "we try to be realistic. But we are always hopeful."