HAITI, STILL IN THE TIME OF CHOLERA: An epidemic becomes endemic

By: Ambereen Sleemi

In January 2010, the small island of Haiti was devastated by a massive earthquake that hit the capital city of Port-au-Prince in the late afternoon of a busy workday. As the nation tried to grasp the scope of the tremendous loss of life and damage to infrastructure, another tragedy hit. This time, it was not the overt physical assault of the earth moving. It was the microscopic insidiousness of Vibrio cholerae the bacteria that causes cholera, spreading through the community at breakneck speed, ultimately infecting 1.2 percent of the population—over 700,000 individuals—and killing 8,700. Five years later, cholera is still a threat to Haiti’s most vulnerable populations, with over 10,000 new cases reported in the first three months of 2015. Although it is less deadly, it is now endemic—a fact of life in modern day Haiti, even though the country never before had a recorded cholera outbreak.

Dr. Karine Severe is an internal medicine physician with GHESKIO, the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections, a health center set up in the early 1980s to battle the enormous AIDS epidemic that ravaged Haiti. The center has evolved over the decades to become a comprehensive health facility, rising to meet the health challenges of the underserved and impoverished.  GHESKIO has become ground zero in the fight to keep the post-earthquake cholera epidemic from engulfing Port-au-Prince. Dr. Severe has a ground-level view of how the cholera epidemic established itself in her home country. Yet, despite the herculean challenges this impoverished island nation has faced, the epidemic came to Haiti by means that were not inevitable.

In the aftermath of the Haitian earthquake of early 2010, local and international officials struggled to deal with the many known hazards of post-natural disaster events: the human injuries and trauma, the physical environmental disruption, structural and engineering challenges, as well as the loss of the ability to provide civil and public works, including water, electricity, banks and healthcare.  The months that followed were crucial in recovery and rebuilding.  Thousands of volunteers and billions of dollars poured in to help.

The first reported case of cholera in mid-October 2010 stunned many, as it had never made it to the shores of Hispaniola—or at least had never been documented. Theories about its introduction included a rise in water salinity and temperatures because of the disruption of the environment from the earthquake. The epicenter of the first reported cases was near the Artibonite River, which provides the only source of water to thousands of Haitians. Among the thousands of volunteers who came to help were U.N. troops who were harboring the cholera bacteria, Vibrio cholerae.  Investigations and evidence since the outbreak have implicated the U.N. troops as the source of the cholera organism in Haiti, with poor management of the base camp’s sewage removal system as the mechanism for the contamination and spread.  The U.N. has yet to take official responsibility for the cholera outbreak. For Haitian physicians trying to navigate the horrors and trauma of a massive natural disaster the magnitude of Haiti’s earthquake, the additional strain of a potentially lethal infectious disease outbreak was overwhelming.

A HAITIAN DOCTOR'S STORY

Dr. Severe is proud of the fact that she was born and raised in Port-au-Prince. She graduated in 2004 from the Haitian Medical School of Notre Dame University. Afterwards, she attended L’Hôpital Universitaire Justinien and completed residency training in internal medicine. She stayed on as chief resident of internal medicine from 2007-2008.  She originally went after a fellowship in gastroenterology, but in 2009, after completing her internal medicine training she came upon the opportunity to work at GHESKIO Centers and has been there ever since.

At GHESKIO, she began working with HIV patients and stayed in the infectious disease department.  “I love the GI tract, but was not so familiar with ID (infectious disease). I learned a lot here.” She was better equipped than most as the lead clinician when the virulent cholera bacteria began to invade and destroy its host’s intestinal tracts, leading to the severe intestinal pain, cramping and the classic, tell-tale rice water diarrhea.

When the earthquake struck Haiti in January 2010, she had just left GHESKIO and was driving home. Fortunately for her, neither her home nor her family, were hurt.  However, like all Haitians, she knew many friends who had lost family and loved ones.

She and her colleagues immediately saw massive trauma injuries including crushed limbs, head wounds, and they worried about common infectious diseases that thrive in post-disaster conditions. GHESKIO is located close to one of the largest slums in the metropolitan area of ort-au-Prince, not too far from the presidential palace.

“The day of the earthquake, we had been invaded by the inhabitants of this large community. More than 7,000 people had occupied our space. We had quickly helped organize this new community by providing health care, realizing surgical cases with the support of the disaster medical assistance team. Prevention of infectious diseases such as diarrheal diseases, tuberculosis, was very important and this had necessitated the significant mobilization of our community unit,” says Dr. Severe.

As the center and staff tirelessly cared for the thousands of wounded, sick and displaced people, thousands of foreign workers and volunteers entered the country, bring their skills, and unfortunately, their diseases.

WHEN CHOLERA CAME

Approximately 10 months after the earthquake, reports of cholera surfaced in the Artibonite region, north of the capital. “When cholera started to appear in the rural Artibonite Department, we knew that its arrival in Port-au-Prince would be only a matter of time, knowing the precarious and unsanitary conditions in which most of the population is exposed, particularly after the earthquake,” Dr. Severe says, recalling the urgency at the time.  “It was Dr. Jean William Pape , our founder and director, who warned that we didn’t need to be worried about the refugee camps, they had potable water. The fear will be in the slums, the Cité du Dieu or City of God.”  The Cité du Dieu is a large Hatian slum located close to GHESKIO. Just after the opening of the cholera treatment center (CTC), the first of the metropolitan area,  “People came in very dehydrated, hundreds of them,” Dr. Severe says.

It seems they were well prepared.  With the Ministry of Health and support of NGOs such the Centers for Disease Control, UNICEF, and the Red Cross, they were able to build the cholera treatment center equipped and organized as recommended by the World Health Organization. The staff, medical, and non-medical personnel, were quickly trained and were from diverse health care facilities nationwide. When asked about specific efforts made, Dr. Severe notes that the most important steps were mobilization of community health workers and trying to convince the Ministry of Health to help in all aspects: “We were afraid of people dying and people were scared to seek care.”

At the time, the actual origin of cholera was unknown, but the poor sanitary conditions and the difficulties accessing potable water were contributing factors.  Allegations surfaced that U.N. peacekeeping troops imported the bacteria, and anger began to rise.  At this point, Dr. Severe feels that the U.N. should have respond by “being very supportive. In all aspects.”  There is little anger in her voice as she returns to what needs to be done at this moment. “We continue with the sensitization despite the decrease of funds. At GHESKIO, we try our best to maintain our CTC opened with a minimum staff.  We’ve made great efforts for mobilization, sensitization, and to decrease stigmatization. Patients come in earlier with mild to moderate degrees of dehydration.”  Improvement of sanitary conditions and access to potable water are priorities.  She is clear about international relief efforts, stating that outside help and aid can best be used to strengthen the existing Haitian health systems.

Dr. Severe outlines the needed steps to prevent another catastrophic outbreak. “Train people for care, with education and mobilization. We know how to provide care—rehydration, quickly and as soon as possible. Start with oral rehydration.”

“Then, of course, prevention of new cases,” she says. GHESKIO and Partners in Health, an NGO active in Haiti, began a study with the cholera vaccination.  They started with 100,000 people in a pilot project here and gave out information. “Since July, the Ministry of Health with UNICEF is now providing vaccine to areas with higher prevalence,” says Dr. Severe. She led a census conducted to see what barriers existed to get the vaccine.  “Ninety to ninety-one percent agreed to take the vaccine.”

Just this past month, the preliminary results returned promising findings.

I asked Dr. Severe if she had gotten the vaccine.  She paused and quietly laughed, “No, but I must have so many antibodies after caring for many people, just from my job.  I was the first to do the cadaveric examination on cholera’s first victim here in Port-au-Prince.”

BILLIONS IN AID

International governments reportedly pledged about $15 billion in aid. The actual amount donated was over $9 billion from global private and public donors. It is estimated that only 1 percent actually went to the Haitian government.

“Aid money had definitively played a key role in the response to the earthquake at least at the beginning. But at this point, it is very difficult to provide an informed opinion knowing that we have not been able to have access to all documents report the use of these funds,” says Dr. Severe.

I asked her if she was able to dictate where the funds would go, who would get most of the money?  She wouldn’t claim to know the best place to put these funds, but her opinion was to give it to the Haitian government, in particular the department of public works, to create an infrastructure of clean water and sanitary conditions.

“If you take what happens all over the world, we need to focus on health systems. But,” she pauses, “with the NGOs, I feel the approach is by the book no matter where you are. But the answer may be different for India, for Tanzania and for Haiti.  Same as the situation in West Africa,” she says, referring to the Ebola outbreak there.  Tailoring a public health response to a specific place and culture is of paramount importance, but she’s not convinced that all who help believe in this approach.

THE IMPENDING RAINY SEASON

We walk from the main clinical building to the heavy canvas tents set up near GHESKIO’S entrance.  The roadway is filled with puddles of rainwater from the recent downpours.  The tent is staffed with a head nurse and a few others.  Until recently, one large tent was plenty, with cots lined up along the sides, each with hooks for intravenous hydration, a mainstay of therapy.  GHEISKO added a second tent with a similar layout in the last few weeks.

“About the treatment center, it had been fairly stable, only one to two patients a day, but in the week, the number of patients and call for referrals has steadily increased. We’ve started to increase our staff and are preparing for an influx of cases. This increase in numbers coincides with the start of the rainy season here in Haiti. This is when we brace for more cholera cases,” Dr. Severe says.

Cholera has a seasonal spike with rainy season that has just begun. V. cholerae, the culprit, thrives in unclean water.  Just as we were talking outside the main treatment tent, an ambulance pulled up and a few more patients step out for evaluation and treatment.

“We have a zero death policy from cholera here,” says Dr. Severe. “If you make it here for treatment, you won’t die from cholera. You may die from something else, but not cholera.”

In January, a U.S. judge ruled that Haitians affected by cholera could not sue the United Nations since it has legal immunity. When asked about the ruling, Dr. Severe responds that cholera is still present, but reduced, as is the international support. She added, “(A) significant peak can be noticed at any moment knowing that the precarious sanitary conditions which prevail now are far from being improved and international support by donors underwent a major decline since the last two years.”

A POSTCARD FROM HAITI

I returned to Haiti a little over a month ago.  On a Sunday drive out of Port-au-Prince, up to the town of Mirebalias, we stopped by the grounds that housed the Nepali U.N. Peacekeeping Mission, next to a stream that emptied in the to Artibonite River. The large metal gates were locked, the grounds deserted and a lone sentry stood watch in a tower at the entrance.  He was in civilian clothes, a large gun draped across his chest.  Hired by the local mayor, he kept looters and vandals out.  “The troops left in early February,” he says in Creole.  He opened the gates, inviting us to walk around for a few minutes. As we left, he pointed to the stream, running only meters away from the compound walls.  Several families were doing their Sunday wash, as kids and cows played in the clear water.

Edited by Dana March; originally published in The 2x2 Project on April 29, 2015