Raymonde Ulysse was certain her daughter was going to die.
Fourteen-year-old Daphcar Laurent, whose left leg was amputated after a wall fell on her during Haiti's earthquake in January, had developed a life-threatening infection.
So when a group of U.S. doctors named Team Ange arranged to transport Daphcar to Philadelphia for emergency treatment, Ulysse made the heartbreaking decision to leave two other children behind so she could accompany her ailing daughter.
Only after they boarded the plane did Ulysse, 38, begin to believe her daughter would be OK.
Daphcar and several other seriously ill and injured Haitians who were airlifted out received the immediate care they needed. But the aftershocks were not over.
In a country they didn't know and hampered by a language they did not speak, the patients and relatives were moved from house to house, sometimes stranded without transportation or documentation, left to navigate a system without the help of the doctors who brought them here.
Team Ange - the loose-knit humanitarian group that physicians Katie Gollotto and Julia Helstrom-Coupet formed after the earthquake - believed it had fulfilled its obligations.
"It makes me sad things didn't turn out the way we intended them," Helstrom-Coupet said.
Still, said Gollotto, "we would not change our decision to bring them here, because that's why they're with us today."
In September, seven months after leaving Haiti, the evacuees moved into two homes in Germantown when an international medical-aid group, Partners in Health, intervened in response to concerns about the patients' well-being from Philadelphia-area Haitian Americans.
Today, the evacuees are doing well. But their stories illustrate the complexity of giving aid, and how the distance between good intentions and good follow-through can be as great as the miles between Haiti and Philadelphia.
"To not provide any additional support for them puts them in an impossible situation," said Naomi Rosenberg, Partners in Health's Philadelphia representative. "When nobody feels a sense of responsibility, you always run the risk that bad things can happen."
After the earthquake left hundreds of thousands injured, doctors from around the world, including private-practice physicians Gollotto, 32, of Medford, and Helstrom-Coupet, 33, of Harleysville, wanted to help.
"We knew we had to respond in some way," Gollotto said.
And they did. In the Haitian city of Jacmel, Gollotto and other volunteers spent long hours in difficult conditions treating the wounded. They decided that 20 of them, children included, would die without elaborate medical care.
So Team Ange sent nine patients plus their caretakers to Philadelphia-area hospitals, including Shriners Hospital and Thomas Jefferson University Hospital, and to the children's hospital at Geisinger Medical Center in Danville, in Montour County. Another child and her caretaker were flown to Shriners Hospital in Cincinnati. (Of the 18 evacuees Team Ange brought to this region, two have returned to Haiti.)
Even as eight of the Haitians in Philadelphia quietly talk of problems they experienced here, they said through an interpreter that they were thankful for the lifesaving care from Team Ange.
"I was suffering a lot, and those people were there to help me," said Wilner Pierre, 29, whose back was broken during the earthquake.
Dr. Marc Altshuler, director of Jefferson's Center for Refugee Health, worked with Helstrom-Coupet as she made arrangements for the patients to come and be treated.
"She was absolutely phenomenal," he said. "The amount of work and time she put into it was over and above what most people would have done."
But some who came to know Team Ange evacuees are less charitable.
"The whole thing was a mess," said physician Moise Anglade, who hosted two of the evacuees on short notice. "You bring these people here, and, basically, you have no idea what you are going to do with them?"
Gollotto and Helstrom-Coupet, who had worked in Sri Lanka after the 2004 tsunami, said their priority was to save lives. Helping evacuees live in America was not their job.
"We're physicians who brought them here for immediate care," Gollotto said. "We don't pretend to know social work."
No aftercare help
In August, an interpreter, a Shriners social-service worker, and a Haitian American who befriended the newcomers contacted Rosenberg. They were worried about the evacuees, some of whom were still being treated. (Boston-based Partners in Health sponsors other earthquake survivors in Philadelphia.)
"They told me they thought the families might be living in conditions that weren't good," Rosenberg said. "It was unclear how they were living and who was taking responsibility that their daily needs were met. . . . These people came with nothing."
When Rosenberg got involved, the evacuees had been through a lot:
The second host of Jean Nichodeme Pierre, 42, and son Odilson, 9 - still on medication after surgery at Geisinger for tuberculosis of the hip - "began to feel we were a burden," Pierre said. After a cordial start, the host wanted the two out immediately.
Previously, Anglade, a Haitian cardiovascular fellow at Geisinger, agreed to host the Pierres as the young patient was about to be discharged. Team Ange had little contact with them during the month they stayed at his house, Anglade said, including when he had to leave them to attend an out-of-town conference.
There were documentation problems, too.
"At the hospital they were asking us for papers," Pierre said. "When they asked me how I got here, I did not have anything to show."
Wilner Pierre, paralyzed and in a wheelchair, was soon to leave Magee Rehabilitation Hospital in Center City with nowhere to go. Homeless shelters and nursing homes were being discussed as possible options for him.
For three of the more than six months he was hospitalized, Pierre said, he didn't see his mother, Elmise Touissant Douse, 50. Douse, who accompanied him from Haiti, didn't know how to travel from the Northeast home where she was staying and, for much of the time, no one arranged transportation.
Four months after Daphcar left the hospital, her pregnant mother checked in. (Ulysse didn't know she was expecting until after she arrived here.) Diagnosed with preeclampsia, Ulysse delivered three months premature. The baby, Lovintz Jean Baptiste, immediately went into neonatal intensive care.
"He could not breathe," Ulysse said of her 1.7-pound son.
Team Ange members were not at the Albert Einstein Medical Center for Ulysse's emergency C-section - they had no idea she was pregnant or where she was living.
Ulysse and her daughter were placed in the same home with Yclane Pierre, 36, and her daughter Fania Mathieu, 15, who also had to have her left leg amputated. After Team Ange helped them get the food stamps, cash, and Medicaid benefits the evacuees were entitled to through their humanitarian-parole status, the women briefly lost that assistance when they couldn't provide proof of residence at the home of host Therese Patterson.
Patterson did what she could to help her guests. She drove the girls to occupational and physical therapy at Shriners, and Ulysse to prenatal visits at Einstein. She bought supplies, including two queen-size beds for each woman and daughter to share.
Patterson thought that their stay would be short - not five months - and said Team Ange never made good on promised financial help.
No such promises were made, Helstrom-Coupet and Gollotto said. The group held a fund-raiser in March and solicited money for months through a "Donate Now" page on its website, now defunct. But everyone who worked with Team Ange was a volunteer, they said, and money went to projects in Haiti.
Helstrom-Coupet said she tried to connect with Haitian organizations in Philadelphia to assist with the evacuees, but "they were so overwhelmed at the time." Eventually, Bernard Sejour, a Lutheran Children and Family Service caseworker, helped.
Physician Kent Bream, a University of Pennsylvania professor who works in global health and teaches courses on medical volunteerism and aid, said that, ideally, doctors who bring patients to the United States could rely on the broader community to take over after emergency treatment is complete. But "because our society doesn't recognize communal responsibility for that, we need to depend on the rescuer to complete the circle." He believes that responsibility lasts up to a year.
"We knew our group had significant limitations - we organized on the fly," Gollotto said. "The priority was to get them here and to deal with the rest later."
A Haitian American woman whose Facebook page name previously was listed as Kathy Ontopp Jean-Baptiste (she declined to confirm her name or be interviewed for this article) arranged much of the evacuees' housing for Team Ange with relatives and other Haitians in the area.
Although the doctors kept tabs on the evacuees during hospital stays, Helstrom-Coupet acknowledged she and Gollotto lost track of the families when the two lost touch with Kathy, who had traveled to Haiti with Team Ange as an interpreter.
Gollotto and Helstrom-Coupet said they told the evacuees in Haiti that Team Ange would not be responsible for them once patients were medically stable, and offered them tickets home after their hospitalization. The evacuees do not recall being told Team Ange had airfare for them.
Partners in Health often sent patients home to Haiti soon after surgery in the United States, Rosenberg said. But not anymore, not since the earthquake, with more than one million people still homeless, the country's infrastructure in shambles, and, now, a cholera outbreak.
"Before we can send someone home, we need to know we won't be sending them home to die."
When vulnerable victims of crises are taken out of their country, they require more than medical care - housing, food, money, and transportation basics must be met.
Who is accountable for tending to those needs?
Humanitarian-relief experts say the onus rests primarily with the group that takes people out of their home country - in this case, Team Ange.
"The individual wanting to help is so important," said Carol Bellamy, former head of UNICEF and World Learning, an education and development group.
But, she said, "it's so naive to assume you can just bring some people who have never left their country . . . [and] all of a sudden they're going to fare well in this environment."
The responsibility - moral if not legal - extends beyond "as soon as they're on the road to recovery, it's bye-bye," said Joel Charny, vice president of humanitarian policy and practice at InterAction, a U.S. alliance of international nongovernmental organizations.
People may need help during months of recuperation, or, seeing the problems still gripping their homeland, while they figure out the next phase of their lives.
Peter Van Arsdale, director of the humanitarian assistance program at the University of Denver, understands the doctors' single-minded impulse to deal with those in the worst condition.
"It's triage, to their credit," he said. "Of course, the good doctors follow up, too."
No one followed up with Roseline Hyppolite, 11, whom Team Ange brought to Shriners in Philadelphia for surgery on a hip injury. Her father, Lionel Hyppolite had lived in Naples, Fla., since 2004, and in May, came to take his wife and daughter back with him.
When an Inquirer reporter called late last month, Roseline had seen a doctor in Florida only once, her father said, to get shots so she could go to school (though she hadn't gone to class yet). Because she is having trouble walking, Hyppolite said, he planned to have her hip examined.
Lack of foresight since the earthquake has not been unique to Team Ange.
In Florida, as U.S. agencies rushed to help in the earthquake's aftermath, many Haitians were given humanitarian-parole status for up to two years, while others were issued visitor's visas requiring them to go home after six months. It was not uncommon for a child to get one type of visa and the parent to get the other, said Yolanda Coto, senior attorney for the refugee-services program in Florida's Department of Children and Families.
Of the 53 children Gov. Rendell personally accompanied from Haiti to Pennsylvania in January, 12 remain in a foster-care facility near Pittsburgh as U.S. and Haitian officials sort out their family status in Haiti, said Kenneth Wolfe of the U.S. Department of Health and Human Services' Administration for Children and Families. The rest were released to adoptive parents.
In Philadelphia, one of the biggest questions looming over the evacuees is whether they will return home, a journey that humanitarian-parole status requires them to make unless they apply to stay longer. Some said they would like to stay; others want to go home.
For Daphcar and Fania, with their prostheses, life in Haiti would be hard. For paralyzed Wilner Pierre, it probably is impossible.
If the evacuees try to stay in the United States, Partners in Health, which covers their current expenses through its own funding and donations from two Philadelphia nonprofits, would help them make the transition to living independently, said Ted Constan, chief program officer.
Although the evacuees are increasingly able to do more for themselves, a nursing aide visits daily. All, including the baby who was discharged last month, have transportation for doctor's appointments and are accompanied by Rosenberg, the aide, or the caseworker to advocate on their behalf. The children, now vaccinated, are in school.
"Now," said Jean Nichodeme Pierre, "I feel like I'm living."
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