Written by Adam O. Goldstein, MD, MPH
This week’s New England Journal of Medicine has three articles on the Haitian cholera epidemic, and radio and newspaper stories are awash in stories blaming the cholera outbreak on U.N. workers from Nepal who passed cholera through infected feces to surrounding villages. I just returned from a medical mission to Haiti, and these media stories inflame already fragile spirits across Haiti, arise passions against most foreigners at a time when outside help is needed more than ever, and obscure the immediate steps needed to save thousands of lives from cholera in the coming month. Plenty of time will exist after lives are saved to assign blame and ask the favorite media questions.
Times are truly desperate in Haiti right now. Eleven months ago, the earthquake killed 250,000, injured 300,000, and left over 1 million homeless. This earthquake hit a country already suffering from severe poverty, corruption, little economic development and even worse infrastructure for basic needs, such as safe housing or clean water. Haiti often ranks at the bottom, 147 out of 147 countries, in the Water Poverty Index. Experts predicted that cholera and other transmissible diseases would hit Haiti, and the only question was when, not if. The start of cholera in October was depressing but not unexpected. When Hurricane Tomas hit Haiti last month, causing flooding and worsening of living conditions, particularly severe for the more than 1,300 displaced-person camps in the country, fragile Haitian public health could not prevent the spread of cholera.
What I saw in Haiti several weeks ago, however, was a public health and NGO health care system that has rapidly mobilized to take advantage of available expertise and resources to treat affected Haitians with cholera, quickly and reliably lowering the death rate with established public health principals of isolation, disinfectants, and oral and IV rehydration, in facilities spread out regionally across affected areas. These cholera treatment camps surely saved tens of thousands of lives. At the same time, few resources are going into solving the problems that caused cholera to emerge, such as establishing nationwide access to clean sanitation and water.
What is needed immediately is a comprehensive plan to reduce cholera transmission (and improve sanitation and potable water) across Haiti, and unfortunately, in neighboring Dominican Republic, where cholera is gaining a footprint. In addition to cholera treatment centers, government officials, NGO’s and UN workers and World Health Organization officials, including those from USAID, should agree and implement a comprehensive plan. A few ideas:
1) Establish in the next two weeks 1,000 smaller, more mobile cholera treatment centers across the country, in addition to larger, regional centers. Cholera treatment centers still rely on Haitians bringing people to the centers- for many in rural Haiti, they cannot get to such centers quickly enough because of poor or any roads and great distances. Thus, smaller, more mobile, centers, need to be set up and distributed more widely, utilizing community health workers and any trained health care personnel- a thousand centers across the country educating and providing oral rehydration salts, water-purification systems, water filters and instructions about hygiene and hand washing.
2) Provide antibiotics to affected family members of cholera victims, or those with diarrhea, that present to all treatment centers. Several safe and relatively inexpensive antibiotics (doxycycline, or azithromycin) are effective in treating the cholera strain circulating in Haiti. Working with pharmaceutical companies to make these antibiotics widely and quickly available to affected family members will prevent new infections and cut in half the severity of existing infections. A win-win will occur, and limiting antibiotics to affected patients and close family members will decrease worries about resistance. Children and pregnant women are most at risk for cholera severe adverse outcomes.
3) Provide country-wide vaccination, starting with those at highest risk, such as family members of all affected patients, and extending outwards.
4) Establish a Haiti Home Health Corps (HHHC), utilizing native workers, starting with community health workers already trained, but also tripling the number of trained workers that can deliver basic health care delivery, such as vaccinations, antibiotics for affected family members, and education on sanitation. People are desperate for jobs and there is plenty to do.
5) Push access to safe water country-wide. I am not an expert, but those experts exist. Let all Haitians know the water plan, both short and over the long term,
I learned when I visited that Haitians are incredibly spiritual, kind and optimistic. Health care leaders across the world, and in particular in Haiti, need to develop and communicate a comprehensive cholera eradication and treatment program in Haiti that will give all of us reason to remain optimistic moving forward.