PORT-AU-PRINCE, Haiti - Fourteen-month-old Abigail Charlot survived Haiti's cataclysmic earthquake but not its miserable aftermath. Brought into the capital's General Hospital with fever and diarrhea, little Abigail literally dried up.
"Sometimes they arrive too late," said Dr. Adrien Colimon, the chief of pediatrics, shaking her head.
The second stage of Haiti's medical emergency has begun, with diarrheal illnesses, acute respiratory infections and malnutrition beginning to claim lives by the dozen.
And while the half-million people jammed into germ-breeding makeshift camps have so far been spared a contagious-disease outbreak, health officials fear epidemics. They are rushing to vaccinate 530,000 children against measles, diphtheria, tetanus and whooping cough.
"It's still tough," said Chris Lewis, emergency health co-ordinator for Save the Children, which by Tuesday had treated 11,000 people at 14 mobile clinics in Port-au-Prince, Jacmel and Leogane. "At the moment we're providing lifesaving services. What we'd like to do is to move to provide quality, longer-term care, but we're not there yet."
In a report issued Monday, the United Nations said the Haitian government estimates 212,000 people were killed and 300,000 injured in the quake. The number of deaths not directly caused by the quake is unclear; U.N. are only now beginning to survey the more than 200 international medical aid groups working out of 91 hospitals - most of them just collections of tents - to compile the data.
At Port-au-Prince's General Hospital, patients continue arriving with infections in wounds they can't keep clean because the street is their home. The number of amputees, estimated at 2,000 to 4,000 by Handicap International, keeps rising as people reach Port-au-Prince with untreated fractures.
Violence bred of food shortages and inadequate security is also producing casualties. Dr. Santiago Arraffat of Evansville, Ind., said he treats several gunshot wounds a day at General Hospital.
"People are just shooting each other," he said. "There are fights over food. People are so desperate."
Nearly a month after the quake, respiratory infections, malnutrition, diarrhea from waterborne diseases and a lack of appropriate food for young children may be the biggest killers, health workers say.
Part of the problem is ignorance. Abigail's mother, 20-year-old Simone Bess, waited a week after her child fell ill to bring her in, Colimon said.
Colimon ushered Bess into an adjacent tent when it became clear the Swiss doctors trying to hydrate and keep her child breathing would fail. Bess screamed in agony and crumpled to the paving stones when she heard.
"Please give me my child!" she wailed. "My one and only child. Tell them to do something for her! Tell them to wake her up!"
Twenty yards away, the child's father, James Charlot, curled up against a wall, shaking with grief.
A shortage of medical equipment and spotty electrical power - service has been restored to about 20 per cent of Port-au-Prince - have worsened the medical emergency.
A respirator might have saved Abigail, Colimon said. But the hospital has none. Nor does it have electrocardiogram machines. The sweltering heat inside the pediatric tent may also have been a factor.
"This whole tent - all (the infants inside) are dried up because it's so hot in there," said Willow Walsh-Hughes, of Draper, Utah, a nurse who hugged and stroked Bess as her child's life slipped away.
The wire-thin Bess had stopped lactating after the quake, Walsh-Hughes said. Because breast-feeding is the best way to avoid infant diarrhea, a mother's ability to lactate can determine a baby's survival.
At another General Hospital tent, Farah Paul, 16, held her acutely malnourished daughter Roselande. Doctors said the wan-looking, 4-month-old baby was coughing and not gaining weight.
Paul said her breast milk dried up the day of the quake, even before she learned that her sister, mother and aunt had been killed in the disaster. Doctors said Paul had given the baby porridge and bananas, food the child could not digest.
Acute child malnutrition is only expected to worsen until the summer harvest in August, said Mija Ververs, a UNICEF child nutrition expert.
Ververs said that while shock and trauma can cause a mother to stop lactating, it is a myth that hungry women can no longer breast-feed.
"Little infants are like parasites in a way. No matter how little the mother gets herself, she is always able to nourish a child," Ververs said.
She noted that breast-feeding provides the best nutritional chance for babies in a crisis such as Haiti's and protects against disease by helping them build immunity. Powdered infant formula is a terrible idea, doctors say, because mothers living in tent camps have limited access to clean water and are unable to sterilize bottles.
Forty-seven per cent of Haiti's population of more than 9 million is under age 18. The Caribbean country has the Western Hemisphere's highest birth rate and its highest child and maternal mortality rates. Haiti also has the hemisphere's highest malnutrition rate - with some 17,500 children under age 5 acutely malnourished even before the quake, according to UNICEF.
At a Save the Children clinic west of the capital, about 30 people stood in line for help. Camp residents subsisting in part on plantains from an adjacent grove said two adults and five children died of starvation there last week. A clinic doctor, Nermie Augustin, said she was seeing a lot of infants with diarrhea.
A mother of five, Janina Desir, said her children were barely getting one meal a day.
"Since this morning all they've had was coffee - and a tiny portion of bread," she said. "No milk."
An official from a major field hospital said the case of 10 American Baptists charged with kidnapping for trying to take 33 children out of Haiti without permission was impeding the evacuation of critically injured youngsters to the U.S.
"Pilots are very reluctant to take off from the United States and take back children without the proper papers," said Elizabeth Greig, chief administrative officer for the University of Miami-Medishare Foundation. "That fear has been exacerbated by the kidnapping case, and now they're just paralyzed."
The evacuation of eight critically injured children in all has been held up, Greig said. None of them are orphans, she said, but obtaining identity papers after a catastrophic quake can be impossible.
She said she could not say with confidence whether any children have died as a result.