Posts Tagged Artibonite River
[An eye-opening, first-hand account of the epidemic from Connie Ghiglieri RN, who left it here as a comment on my last cholera update. Posted here with permission, for which I am grateful: it is very difficult to get first-hand,on-the-ground information from Haiti unfiltered by media or aid agencies. Very slightly edited.]
I just spent two weeks at the cholera treatment center in Hinche. I am a RN from Arizona. Here is what I wrote to a friend to describe my experience:
I am in Hinche. . .working at a cholera treatment center. . .Cholera is a very dark hell, plain and simple. Not like anything I have ever seen or could have imagined. . . and thus far we have been able to keep things under control and have not lost many, which is a small victory but an unrelenting battle. . .there is not a moment to breathe. . .it is just work and sleep and sometimes eat.
Never have been in a situation where the urgency to perform is so damn constant. Keeping people hydrated is the key, they come in often close to death and look like they are dead except that they are puking and shitting volumes. IVs are such a challenge to keep going and patent. Their clotting factors must be way off, have to constantly restart them. Then keeping them drinking when even tho they often end up vomiting what they have just taken in, and keeping them clean. . .oh the inhumanity. . .there is no dignity involved in this disease other than the compassion that we feel, and them saying an occasional quiet merci, or just making eye contact. . . but for the most part they are too sick to really care.
Most of our patients are on cots that are soaked with liquid cholera (looks like rice water. . . sort of. . .that’s being generous ) and bleach, with a bucket alongside to use if they can. . .We try to keep a plastic barrier between them and the cot. . .yeah not entirely successful, the rest are on the wooden MSF cholera beds. . .wooden benches covered with plastic with holes cut in them with a bucket underneath. Pretty much everyone is naked and then covered with whatever we have, mostly plastic surgical gowns. . .and at night they are freezing. We used to diaper most patients when they first came in because they are too weak to use the buckets, yes adults. . . but we have run out of those, so you guessed it. . .naked. . .what I would give for a pamper. . .We too wear plastic surgical gowns as barriers. . . and gloves. . . at all times, I probably change my gloves at least 50-60 times in a shift. . .not kidding. . .I wear rubber boots and I wash my hands several times a night with a clorox solution…and do not get my hands near my face. . .for any reason.
Hard not to touch people skin to skin, but I just don’t do it. The best I can do is give the patients back rubs with lotion…but rarely have time for that. We try to clean people with baby wipes, but I’m not sure there are enough of those in the world for this disease. . .we run out every day. The smell is. . .well, it is distinct and now I am used to it and am sure I will recognize it anywhere. . .right now it is just what it is and I don’t think about it. I actually don’t think about much except checking IVs, keeping them going, keeping people drinking, keeping them clean, keeping the tents as clean as possible and then hydrate. . .checking IVs, drinking, clean. . .hydrate. . .IVs, drinking, clean….simple, simple, simple yet exhausting. . .BUT when you see someone go from death to life in a matter, sometimes, of hours. . .it is all good and for a moment you remember life really is beautiful. . .and then you take a breath and . . .hydrate. . .IVs, drinking, clean. . .
The news of it spreaking rapidly in Haiti is the worst possible. I don’t want to leave.
The latest report of the MSPP (Ministère de la Santé Publique et de la Population) on 16 November 2010 states there have been 49,418 cases of cholera and 1186 deaths since the outbreak began. MSPP has begun reporting “cas vu” — “cases seen” — as compared to previously reported “hospitalizations”, numbered now at 19,646. (It is a bit of a mystery to me why the “cas vu” figure is not being more widely quoted.) If we assume the “cas vu” figure represents the 25% of cases that have a clinical presentation, approximately 200,000 people have been infected thus far. This is a bit more in line with James Wilson’s estimates (see below). The hospital mortality rate is 3.9%, and MSPP is reporting a “general mortality” of 2.4%. This last probably is not a reliable figure. Cholera promptly treated has a mortality rate of 1-2%. I will defer to James Wilson’s thoughts on the number of cases at Haiti: Operational Biosurveillance. His comments:
- Conservative estimates therefore suggest 75,000 cases of cholera in Haiti to-date, the majority of which were subclinical.
- In some areas of Haiti, we have confirmation that in-patient statistics are under-reported by as much as 400%. In many areas of Haiti, we are documenting outbreaks that are not being accounted for in the official statistics. We therefore estimate the upper bound of estimated case counts to be 250,000.
- Although PAHO [Pan-American Health Organization] projections use an attack rate of 2% of a total estimated Haiti population of 10 million to estimate 200,000 total clinically apparent infections, the true community load will be closer to 800,000 if subclinical infections are counted.
- We err on the side of over-estimating because this is a “virgin soil” epidemic and expected to aggressively spread throughout the country and across the border into the Dominican Republic.
He adds, “We are now pursuing answers to the question of uptake by indigenous zooplankton and spread along oceanic currents that pass west of the Gonave Gulf, which is where the Artibonite River discharges, north and west along the northern Cuban coastline and north to the waters east of Florida.”
A couple of more posts of interest from James Wilson. First is a post which points out the spike in mortality from initial contact until a clinic adjusts to treatment.
Secondly, he sardonically refuses to use the term “disaster” to describe the bureaucratic obstacles in the provision of desperately needed medical supplies. “It should not be this difficult,” he says, “to save lives from an easily treated disease.” He goes on:
Aside from the eye-opening account from St Louis du Nord, we have report this morning of one of the major NGO HEAS partners stating they use an average 8 liters of IV fluid per critically ill patient. Here is a direct account from a donor in New York today: “No idea where these supplies can be purchased [in Haiti]-we just airlifted almost 40,000 lactated ringer solution bags in from NY and in just a weeks time, more than half have already been used”. This is an example of “light” medical supply usage.
As another example of the logistics challenge, we have discovered an ominous, persistent indicator over the last couple of weeks: the slow degradation of grid level responsiveness to emergency requests for assistance. These emergency requests may be viewed here in the HEAS public portal, where there is little ambiguity that people are dying because of lack of medical care. In short, we are seeing the entire response community- both personnel and materiel- is insufficient to save all of these lives. To-date, the HEAS has not been funded appropriately to even provide the most basic support despite multipleemergency requests to the Clinton Foundation, USAID, and CDC. The entire community continues to struggle onward, but many of us feel we will move from calling this a “disaster” to a “catastrophe”. The sight of random corpses in the streets of Port au Prince and Cap Haitien points to this.
In short, the same political interference and bureaucratic challenges observered post-quake are being observed here and now in the middle of the cholera disaster / catastrophe. And we are losing an untold number of lives daily because of it. The word “accountability” becomes a strong… and bitter… pill to swallow. And it is to all of our chagrin to consider the words of one senior US government official who advised us on November 10th,
…we think [the cholera epidemic] can be managed effectively, as the response has been good in Haiti, and the GOH with our help has gotten out ahead of the curve, and are working hard to stay there…This is not to say that 1,500-2,000 or so deaths from cholera a year in Haiti for the next several years is acceptable, and we hope to get the mortality rates down well below that. But this is not in the same league as the earthquake either, so I think you can turn off the alarm bells.
As has been widely reported, sometimes violent protest has broken out in Port-au-Prince, Cap-Haïtien and other places, reflecting frustration over the continuing epidemic, and above all, the continued presence of MINUSTAH in Haiti. From Cap-Haïtien, Ansel Herz:
While many expected demonstrations to continue in commemoration of Haiti’s independence struggle, the streets were quiet. No further confrontations were reported. I walked around downtown Cap on my own, trying to find an Internet connection to send out a radio story.
I’m asking everyone I meet here – from local journalists, vendors, men at the barricades, to a local magistrate – if these protests were organized by a gang or political group.
The unanimous answer is no – people are fed up with UN peacekeepers and the cholera outbreak is the straw that broke the camel’s back. The magistrate said he understands and respects the people demonstrating, but he wishes the barricades weren’t impeding the transportation of medical supplies to fight cholera in his commune, where people are dying in the street.
As the head of MINUSTAH warned that “every second lost” because of protests means more suffering and death from cholera, the anti-UN demonstrations continued in Port-au-Prince on Thursday.
PAHO evidently has the same talking points as MINUSTAH:
“Every hour that the efforts of medical and relief workers are obstructed means more deaths of Haitians from cholera,” said Dr. Mirta Roses, PAHO’s Director. “We understand the frustration of many Haitians with the tragic situation that has developed as a result of systemic poverty, the January earthquake and now the cholera epidemic. But relief and medical workers are as critical to saving lives as rescue teams were after the earthquake.”
However, according to PAHO in their updated situation report (17/11/10) the unrest has had a real impact:
Civil unrest since November 15 has slowed several activities of the response to the outbreak. In the northern city of Cap Haitian prevention and treatment supplies are were not delivered in last three days. WHO/PAHO cholera training was postponed, as well as an Oxfam initiative to chlorinate water for 300,000 people. A nearby World Food Programme (WFP) warehouse was looted and burned. In Hinche, six MINUSTAH personnel and a number of bystanders were injured, according to the MINUSTAH.
Given the amount of suspicion that MINUSTAH brought cholera into Haiti, finding the exact source takes on a new importance. Alas, it might also be impossible.
This suggests it entered Haiti in a single “event” — not necessarily an infected person, but possibly. People often can carry cholera with no symptoms and in a country with chlorinated water and good sewage, the bacteria in their waste quickly get destroyed.
Other potential sources include imported food, especially seafood, or a boat or ship’s bilge water. With tons of aid pouring into Haiti for months, it may be impossible to track down who or what carried it in.
Public health officials will try. They want to prevent such outbreaks in the future and finding the culprit will help experts come up with ways to prevent it from happening.
But what if it does turn out that a U.N. trooper carried it in? Riots already going on in Cap-Haitien and protests in Port-au-Prince [ID:nN18144494] could worsen and other countries may be reluctant to accept U.N. aid when they need it the most.
And what if health experts are unable to find the source? Will anyone believe them, or will suspicious residents call it a cover-up — and resist public health advice that could help stem the epidemic?
If some other aid organization turns out to be the source, again, not only could Haitians resist more help, but other countries may become warier of letting these non-governmental organizations help in the case of disasters.
Stupid headline of the day: “Poor sanitation could worsen Haiti cholera outbreak, CDC says.”
I will post the next update Sunday, or sooner if events warrant. For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.
Praecipio International (HEAS)
On the ground, good sources of information and of course needing donations:
[UPDATE: minor word changes for clarity]
According to MSPP (Ministère de la Santé Publique et de la Population — PDF), as of 6 November 2010, there have been 544 deaths and 8138 hospital cases from cholera. Total deaths are divided between 309 hospital deaths and 235 deaths in the community. This represents a hospital mortality rate of 3.8%. Cholera promptly treated has a mortality rate of 1-2 % The total number of cases in the community is unknown. James Wilson at Haiti: Operation Biosurveillance estimates over 50, 000 persons have contracted the disease, either subclinically (75%) or actively (25%). He writes: “Any claim of containment or control of this epidemic should be treated with skepticism.” People infected with Vibrio cholerae continue to shed pathogens for two weeks after initally contracted the disease.
Disturbingly, Wilson also reports, via Samaritan’s Purse, a cluster of 47 new cases of cholera in Cité Soleil. Further outbreaks are noted in Gros Morne, Grand Bois, north and east of St-Marc respectively, and suspected cases in Mole St-Nicholas and St-Louis-du-Nord, both of which are in areas most directly affected by Hurricane Tomas.
Via HaitiLibre, yet more misery and an increased risk for contamination, a consequence of Tomas:
The Artibonite River, likely initial vector of cholera, may overflow. Already heavily loaded by the rains brought by the hurricane Tomas, and at the limit of the flood, the river Artibonite could get out of its bed during the day following the opening of the valves of a hydroelectric dam on the River.
United Nations representative said that the engineers were forced to open the valves of a dam on the river, whose level of the reservoir was too high, to allow water to escape and reduce the pressure on the structure.
It was asked the people living on the banks of the river infected with cholera to evacuate their families and livestock. The health situation is bad enough, but the overflow of contaminated river could contribute to spread the cholera and to worsen the situation considerably.
In the course of the day, the area should be flown to locate and assess potential flooding.
On the ground, good sources of information and of course needing donations:
[Cross-posted at Sister Sage's Musings]