Archive for category Battered Nation Syndrome

Says Blatchford, First We Shoot All The Nurses

I actually did a double take, and my jaw dropped, slightly when I read this:

It’s why, where I used to think that before I got really old I’d get me a gun so I could shoot myself, I now wonder if I won’t instead turn the weapon on some officious hospital executive, wanker bureaucrat or brute of a nurse.

Yes, it’s Christie Blatchford in her latest National Post column, taking her Canadian-health-care-is-the-Fifth-Horseman-of-the-Apocalypse shtick to new heights. It’s pretty tiresome, and a bit tasteless, given the high rates of violence nurses experience.

One also gets impression that Blatchford’s knowledge and experience of nurses and nursing runs in a straight line from Cherry Ames, Student Nurse to Nurse Ratched in One Flew Over the Cuckoo’s Nest to Annie Wilkes in Stephen King’s Misery. Funny how a self-proclaimed straight-shooting iconoclast ends up reinforcing predictable cultural stereotypes.

But let’s assume Blatchford’s hostility and ignorance isn’t willful. Maybe she really knows squat about nursing. I am willing to have her shadow me for a day in my emerg, under two conditions: first, she works the entire 12 hour shift, and second, she sits when I sit. Seriously, Christie, email me.

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The Most Useless Form on the Planet

Imagine this: you’ve had the shift from hell, no beds, every other patient is moments away from seeing Jesus/Allah/Buddha and to top it off, the department is down three nurses, another nurse is transporting the multisystem trauma downtown, and you feel really think working conditions were unsafe for both you and more importantly, your patients. So you go to your unit union rep — in the case of most Ontario nurses, from the Ontario Nurses Association — and she says, No problem. Just fill out this document, the Professional Responsibility Workload Form, in either Official Language, in quadruplicate, and all will be well.

Oh, I forgot. Here’s page 2:

So it’s 0730, you’re coming off nights from the shift in which you thought you might finally go postal, and you’re union rep is telling you to fill out this form. The chance of it getting completed? Is zero too high an estimate? Here’s a hint: there’s a four-page guide on how to effectively fill out the form.* And if the form is actually filled out? The union (I think) is supposed to meet with  management to discuss the (completed) form, but in truth I have never heard of any outcome of such a meeting, or if in fact such meetings exist. One suspects when the union raises workload issues with management — encompassing such items as competency, patient safety, you know, important things — management says, “It is what it is,” and with a nod and a wink the union goes off to collect its membership dues. In short, we’ve filled out these forms for as long as I’ve been a nurse, and nothing has ever changed as a result.

It seems, to me anyway, that the Professional Responsibility Workload Form is a classic example of appearing to address an issue, while in fact doing absolutely nothing. Doing so lets both the union and managers off the hook for the deteriorating quality of nursing work life. I don’t think I am being unduly harsh. There is a distinct lack of accountability and transparency around these forms, and it’s symptomatic of a general complacency within ONA’s leadership about issues affecting front line nurse. Given that ONAs 57,000 members each pay nearly a thousand dollars annually in dues, you think someone would come up with a better process to watch workload issues.

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*The statement on the top of the guide made me laugh out loud:

“ONA members indicate it is important and worth the work to complete Professional Responsibility Workload (PRW) Report forms.”

I am not very clear which ONA members the union leadership was speaking to. Not anyone, I’m guessing, from an emerg.

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New Contract Beats Up on Ontario Nurses

On 3 June 2011, an arbitration panel handed down the new contract for the majority of Ontario hospital nurses. The panel was set up when negotiations between the Ontario Hospital Association and the union, the Ontario Nurses’ Association broke down. This is a pretty routine procedure when the union contract comes up for renewal, because in Ontario, nurses are considered “essential workers” and don’t have the right to strike. I’m fairly sure this wouldn’t interest many or even most of my readers — even nurses — except for a obnoxious new contract clause, buried deep in the arbitration award:

Effective April 1, 2011, no sick pay benefit is payable under HOODIP for the first fifteen (15) hours of absence for the sixth (6th) and subsequent period(s) of absence in the same fiscal year (April 1st through March 31st).

English translation: if you have six or more absences because of illness (as opposed to days, it must be noted), your employer will punish you for being sick by docking you fifteen hours of sick pay for each absence.

It is true that nurses have among the highest absentee rate among any employee group, and this clause is an attempt to remediate the situation. It is also true that high absenteeism is for reasons unique to nursing. These are the smartly dressed white elephants you see standing in the corner that the hospitals and the union both ignore: we’re exposed to infectious disease, high stress levels, poor morale and horrendous working conditions. We all know about it, and nothing is ever done but pass the blame to nurses. I can’t see how punishing nurses for factors out of their control is even remotely helpful. It’s a little like starving a child, then beating her when she takes a bite of cake.

Even aside from these generic issues, one can easily see circumstances where the heartlessness of this clause will affect individual nurses. Supposing you had an illness which required specialized treatment over a period of time, such as chemotherapy, which required you to take an occasional sick day. According to the union and the hospitals, too bad for you. We are now, they are saying, going to flog you financially for contracting cancer.

It’s disgusting.

The union will probably say, “Well, it was an arbitrator’s award, it was out of our hands.” This only partly true, at best. The arbitration panel doesn’t pick contract language out of thin air. Both the hospitals and the union make submissions in the arbitration process based on their bargaining positions. Clearly, this little piece of horizontal violence was on the table beforehand. How vigorously did the union contested the hospital’s position on this at negotiations? Who knows. I respectfully suggest, however, that ONA put this clause at the top of its list when new negotiations start in a couple of years.

Unfortunately, ONA has calculated, probably correctly, that the pushback from front line nurses over this clause will be minimal. We can do very little about it, and in any case, there is a huge disconnect between front line nurses and the union leadership — which you would think would be a cause of concern. In its news release, all ONA could offer was some anodyne mush from ONA’s president, Linda Haslam-Stroud. The bash-the-nurse clause was mentioned not at all. “The agreement,” said Haslam-Stroud, “addresses the priority issues of the front-line registered nurses and allied health professionals – the backbone of health care.”

Uh, huh. How about working with the hospitals to fix some of the root causes of absenteeism, instead of tacitly supporting a policy which punishes them?

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A Medication Error Leads to Suicide

A nurse commits suicide:

Kimberly Hiatt, 50, a longtime critical-care nurse at [Seattle Children’s Hospital], took her own life April 3. As a result, the state’s Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant’s death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt’s mother.

“She absolutely adored her job” at Children’s, where she had worked for about 27 years, said Crum. “It broke her heart when she was dismissed … She cried for two solid weeks. Not just that she lost her job, but that she lost a child.”

Is it just for a nurse to be fired for a medication error, even if lethal? Most hospitals do have procedures in place to deal with such errors, aimed at discovering the root causes of mistakes in order to improve patient safety. A key part of this process is to encourage nurses to report medication errors and even near-misses without threat of retaliation or disciplinary measures, but instead to offer education to strengthen skills and critical thinking. The hope is that in doing so, flaws in the process of drug administration can be easily identified and corrected.

Unfortunately, such an arrangement requires a certain degree of trust between management and the front line. When I worked in the U.S., management decided to implement a “No discipline, no retaliation” policy for medication errors. When the ED manager was asked if there actually would be no discipline taken for medication errors, she laughed and told us it would be “situational.” You can guess how successful the new policy was. Once trust is lost between front line nurses and management, it’s difficult to restore.

Firing a nurse distracts from actually promoting safety in a meaningful way, and diverts attention, as Kevin Pho points out, from where responsibility ultimately rests for ensuring safe medication practices: the senior management. Hospitals will fire nurses in the mistaken belief that removing a nurse who has committed a lethal error — an easy target, at that, if truth be told — will somehow reduce risk and liability and demonstrate commitment to patient safety. In fact, the precise opposite is true. By disciplining nurses who commit errors, and by not engaging in remediation with these nurses,  a climate is created where errors, if they occur, are likely to go unreported and unresolved — and substantially increasing risk.

It it enormously tragic a 8 month-old child died as a result of a medication error. And to be clear, none of this evades the ultimate responsibility of the RN to administer medications correctly. It’s important to note the state nursing board imposed substantial sanctions on this nurse, just prior to her suicide, including a requirement to be supervised while administering medications for four years.

Yet it’s also tragedy multiplied that the Seattle Children’s Hospital saw fit essentially first to scapegoat her, evading its own responsibility, and then to drive a 27-year veteran from the profession, leading to the point where she saw no other option but to kill herself. It’s interesting, in the context of the discussion around bullying this week in the nursosphere, that this news story should present itself. Were hospital administrators acting as bullies? When you think of how bullies behave and the sequellae of their behaviour on their victim — suicide being among them — you have to wonder.

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Robotic Triage

Long time readers know of my intense obsession dislike of equivocating nurses/nursing with robots, and here is a classic example. Somewhere, somehow, some engineer is just not getting what triage nurses do:

If a group of computer engineers gets their way, we will no longer hear stories of patients dying in the ER after excruciatingly long waits. A solution for overburdened triage staff and long emergency room wait times appears to be in sight.

If you’re willing to wait five years, robots could help speed the ER triage process, according to Mitch Wilkes, associate director of the Center for Intelligent Systems and associate professor of electrical and computer engineering at Vanderbilt University. He is the lead author of a paper presented yesterday at the Humanoids 2010 conference held in Nashville.

The paper describes an ER that would feature electronic kiosks (like those at the airport) at the registration desk and smart chairs. A mobile robot or two might monitor patients in the waiting room.

After I finished laughing a little too gleefully at the thought of patients screaming at a triage robot, it seemed to me there is some, um, misunderstanding about a nurse’s role at triage, which decidedly is not about taking the patient’s temperature and sending her out to the waiting room. And if patients are demanding more face time with a health care professional, installing robots seems, well, a little counter-intuitive.

Here’s a thought on how to relieve “overburdened triage staff”: instead of spending a gazillion dollars developing and setting up the technology, then a gazillion more for ongoing upgrades and maintenance (for you know these things will break down when someone looks at them cross-wise), why not just adequately staff emergency departments with real, live nurses?

Naw. Too simple.

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Haiti Cholera Update #19

The latest MSPP (Ministère de la Santé Publique et de la Population) report as of 29 November 2010 showed 80,860 cases of cholera accounting for 1,817 deaths since the outbreak began. There have been  36207 hospitalizations. The hospital mortality rate is 3.5%. Cholera promptly treated has a mortality rate of 1-2%. On the mortality rates, Jim Wilson at Haiti: Operational Biosurveillance offers the following comment:

Case fatality rates such as the most recent Health Cluster report of 2.3% is representative of gross national level aggregation of information available to officials, which represents a substantial bias towards CTC/CTUs staffed by experienced teams such as MSF. What is not reflected is the continually documented “first contact” pattern of daily clinical mortality seen by rural communities and urban environments such as Gonaives several weeks ago reported by officials do not reflect the true impact of cholera at the community level.  The daily mortality we have documented on multiple occasions may range from 10 to 100%. We often see sudden overwhelming of local capacity to the point of backloading corpses for burial, having run out of body bags.

He also has posted a map (above) showing areas of concern for HEAS (Haiti Epidemic Advisory system), which in of itself suggests actual numbers of cases are much higher than official estimates — and bound to get worse:

  • Red- where we continuously receive emergency requests for assistance due to “first contact” high mortality and have facilitated several mobile emergency responses.
  • Orange- where we occasionally receive notification of “first contact” high mortality but confirmation is difficult; we suspect there is far greater mortality in these mountains but it goes unreported because of very low NGO presence and difficulty of access.
  • Yellow- where we have confirmed cholera activity at multiple sites throughout the southern peninsula, however the majority of international response is focused on PaP, Artibonite, and recently the north… the south is left relatively untouched in terms of response.  As with the orange areas, we suspect far more activity that is what reported because of very low NGO presence.  We also note very large time lags in official reporting from this area.  The southern peninsula is the next battle front, where we expect the ‘war’ to go very badly given the low availability of response assets.

However PAHO (Pan-American Health Organization) thinks things are getting better:

The cholera epidemic gripping Haiti in the wake of national elections continues to spread throughout the country but is less lethal, the Pan American Health Organization said Wednesday.

“We went from nine percent of cases dying in the early days to 2.3 percent now,” said Donna Eberwine-Villagran, a spokeswoman for PAHO, a local branch of the World Health Organization.

“It’s improving,” she told AFP, adding however that the number of cases would continue to rise.

Given what is known about underreporting of cases, a mortality rate of 2.3% might be somewhat optimistic.

See, for example, James Wilson above, or HaitiLibre on conditions in the country’s south, particularly in Les Cayes:

The number of people infected in the Southern Department, although it is less than the number of cases recorded in Port au Prince (note that the government refuses to reveal the true assessment of PAP and Metropolitan area since November 24, 2010), continues to increase. Until now, throughout the department, 12 zone of infection, including 5 located in the city have been identified. Official figures show 160 cases treated, but they are largely underestimated.

Health authorities already sorely lacking resources, human and material to cope with a situation that continues to worsen. The only treatment center, a small structure built in emergency hospital in Les Cayes by Doctors Without Borders (MSF) Switzerland with the assistance of TDH, finds itself without the continued support of medical organizations. Located within the walls of the hospital, the CTU transitional, has a capacity of only 25 beds. women, men and children do not have separate spaces. Managed by inadequately trained personnel and overworked, lacking supervision, it recorded 10 to 15 daily admissions in recent days. It is completely saturated. Central Prison inmates are also referred.

There is no system of management of contaminated waste, the drums of vomiting and diarrhea are full, others are full of medical supplies clothes mixed with the sick and other household waste. TDH trying stopgap, while providing support WASH, but without appointed loading area, storage and processing of waste remains a major problem. No location was identified by the authorities despite repeated requests for a month.

Also:

  • If you click on nothing else, you must read this post from On the Goat Path. There is nothing pretty or romantic about the epidemic. It’s horrendous and gut-wrenching:

From our perspective, it wasn’t clear that cholera had hit the city, even though news reports were claiming otherwise.  You just don’t see it.  Living in our house in a relatively nice part of town, the presence of cholera was not obvious, which stresses that this is not a disease that people who have the proper resources get.  It’s a disease that affects the poor, but with the vast majority of people in this country living on less than $2 a day, almost everyone is vulnerable.  All we needed to do was travel downtown last Thursday and the toll of this cholera epidemic slapped us in the face.

Ben and I were driving around PAP Thursday looking for protests when we drove by a man who looked like he was dead on the side of the road.  We pulled over and looked down, “Yeah, he’s dead,” I said just as the man moved his head back and forth lethargically.  We were shocked, so we asked people who were standing close-by how long he had been laying there.  They explained that the man had cholera and that he had been there for a couple hours.  Soon after his mother came and began to wail, saying that he was her only child and asking “Why is this happening?” in Kreyol.

Special “cholera beds” have been created to help overtaxed nurses. These beds have a hole that allows the streaming diarrhea (like rice water) to drop into a plastic bucket. The hole is diamond shaped, and the beds are covered with a silvery foil. Diamonds and silver. The irony was piercing for a physician from wealthy Canada.

Secretary-General Ban Ki-moon today called for a speedy solution to the political crisis in Haiti after yesterday’s first round of elections, warning that worsening security would hamper efforts to fight the cholera epidemic in a country already devastated by January’s earthquake.

“The Secretary-General is concerned following the incidents that marked the first round of the presidential and legislative elections in Haiti on Sunday,” a statement issued by Mr. Ban’s spokesman said.

“The Secretary-General looks forward to a solution to the political crisis in the country and calls on the Haitian people and all political actors to remain calm, since any deterioration in the security situation will have an immediate impact on the efforts to contain the ongoing cholera epidemic.”

  • Meanwhile, demonstrations in St-Marc against MINUSTAH (Mission des Nations Unies pour la stabilisation en Haïti) leave 6 dead and  injure 15. MINUSTAH has been implicated in introducing cholera into Haiti, which the United Nations has repeatedly denied.

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.

More resources:

#Haiti Daily (Twitter newspaper)

Haiti Information Project.

Haiti: Operational Biosurveillance (Twitter)

H5N1

HaitiLibre (English) (français) (Twitter — English and French)

Mediahacker: Independent multimedia reporting from Haiti (Twitter) (Flikr)

Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

Praecipio International (HEAS)

ReliefWeb Latest Updates on the Epidemic. Key Documents.

On the ground, good sources of information and of course needing donations:

Partners in Health (Twitter).

Médecins sans frontières

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Haiti Cholera Update #18

MSPP. Click to enlarge.

A short update: the elections in Haiti have nearly bumped cholera off the radar.

The latest MSPP (Ministère de la Santé Publique et de la Population) report as of 24 November 2010 showed 75,888 cases of cholera accounting for 1,721 deaths since the outbreak began. There have been 31,210 hospitalizations. The hospital mortality rate is 3.6%. Cholera promptly treated has a mortality rate of 1-2%. As mentioned in my last update, political interference may be tainting the figures: note the sharp drop in hospitalizations on the bar graph to the right just prior to yesterday’s elections.

  • Pictures from the blog The Life and Times of the Mangine Many illustrating the realities of water in Haiti. Comment from the blog:

    Everyone is sensitive about it. Rumors abound about how it can/cannot be transmitted. (And fyi–Rumors in Haiti might as well be fact with the way people heed them.) I’ve read article after article about how people are dying trying to get to treatment centers because public transport won’t pick them up. I read a quote from an article on CNN yesterday that said the two biggest needs right now in Haiti are doctors/nurses who know how to treat cholera and trucks to carry dead bodies.

    I had a good friend of mine (a fellow ex-pat) whose (Haitian) boyfriend’s father recently died suddenly in Port Au Prince with cholera-like symptoms. They did a bunch of labs. Turned out he did NOT have cholera. Still, the morgue initially wouldn’t take his body. They brought the labs proving it was not cholera from which he died. They finally agreed to take the body, but had to pay double the price because of the “risk” they were assuming.

    The cholera epidemic in Haiti continues to spread. Insufficient medical resources in the field are not able to control the disease. Faced with this alarming situation, the Dominican Republic, which decided to deploy significant military resources at its borders. “With cholera we can not play, or ignore the risks despite all measures of disease control, we are not fully shielded face of this threat” said a government official.

    While only 4 cases of cholera were confirmed and treated in recent days, Dominican Republic (no deaths), the authorities decided to close the border with Haiti where the disease has already made more than 2,000 dead.

    Major General Carlos Alberto Rivera Gates, the head of the Dominican army, said the reinforcement and the closure of the border for an indefinite period, met the dispositions adopted at a meeting held last Wednesday at National Palace, under the direction of the President of the Dominican Republic Leonel Fernández and attended, among others, Ministers: Public Health, Armed Forces and the directors of Cesfront, migration and other institutions.

    I will post the next update Wednesday (more likely) Thursday, or sooner if events warrant.  For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

    More resources:

    #Haiti Daily (Twitter newspaper)

    Haiti Information Project.

    Haiti: Operational Biosurveillance (Twitter)

    H5N1

    HaitiLibre (English) (français) (Twitter — English and French)

    Mediahacker: Independent multimedia reporting from Haiti (Twitter)

    Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

    PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

    Praecipio International (HEAS)

    On the ground, good sources of information and of course needing donations:

    Partners in Health (Twitter).

    Médecins sans frontières


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    Haiti Cholera Update #17

    MSPP graph. Click to embiggen.

    The latest MSPP (Ministère de la Santé Publique et de la Population) report as of 24 November 2010 showed 72,017 cases of cholera accounting for1,648 deaths since the outbreak began. There have been 31,210 hospitalizations. The hospital mortality rate is 3.6%. Cholera promptly treated has a mortality rate of 1-2%. There are reasons  to believe, as noted below, that these numbers are suspect.

    At less than 48 hours of the elections, the last official assessment of the Ministry of Public Health and Population (MSPP) for the Wednesday 24 and published on Friday 26 indicates that for the area of Port-au-Prince region Metropolitan (Port-au-Prince, Carrefour, Cité Soleil, Delmas, Kenscoff, Petion-Ville, Port-au-Prince, Croix des Bouquets and Tabarre) there was 0 death and 0 hospitalization between November 23 and 24… Already yesterday, we had questioned the validity of the mortality figures published by the Ministry , which indicated an increase in deaths abnormally low +0.4%, whereas in the previous 48 hours (November 21 and 22) the death rate average was +23.68% per day.

    Knowing that health personnel in the ground, informs us that the area of Port-au-Prince represents nearly 50% of cholera cases, the only explanation to this brutal and instantaneous stop of the epidemic, must find its answer in political reasons and not in treatment efficacy (unfortunately).

    This article obliged me to go back and look at earlier reports. From November 17 to 23, the cumulative number of hospitalizations in Port-au-Prince increased from 1,457 to 3,097. The cumulative number of deaths rose from 64 to 146.

    But something’s wrong with the cumulative totals:
    11/19: 1,618 hospitalizations; 77 deaths
    11/20: 2,140 (h); 95 (d)
    11/21: 2,066 (h); 85 (d)
    11/22: 2,866 (h); 140 (d)
    11/23: 3,097 (h); 146 (d)
    11/24: 3,097 (h); 146 (d)

    We see a sharp jump in hospitalizations and deaths on November 20, then a drop in hospitalizations and deaths the next day. That makes no sense.

    Then hospitalizations and deaths both jump on the 22nd, rise a bit more on the 23rd, and then stop on the 24th. Apart from these updated numbers, the Ministry has offered no interpretation or analysis.

    • Jon Kim Andrus, Deputy Director Pan American Health Organization (PAHO), presser, 23 November 2010. (Transcript ~ YouTube) The situation, he says, is bad, and there are no resources, either human or material:

    We believe certain critical issues need to be addressed if our efforts to treat patients and save lives are to be successful. Safe water and sanitation are lacking. In the short term, efforts must focus on distributing chlorine tablets as well as oral rehydration salts to everyone. In the long term, we must create the systems and infrastructure to ensure equitable access to these basic services.

    Official reports confirm 8 of 10 departments with cases of cholera. We know that in the other 2 departments, clusters of cases are now being investigated. So, for all intents and purposes, as we fully expected before, cholera is virtually everywhere in the country. Given the extremely poor sanitary conditions that existed well before the earthquake, the recent hurricane, and now the epidemic, we expect the number of cases to continue to grow. We have not yet reached a peak and we don’t know when that peak will occur.

    [snip]

    For many of us here, this brings up memories of the cholera epidemic that began in Peru in 1991 and spread to more than 16 countries in the Americas within two years.

    Considering the intensity of travel and trade in the Americas, we know it’s difficult to prevent importations of isolated cases of cholera in other countries, but there are important steps that can be taken to prevent cholera from spreading and causing epidemics.

    [snip]

    We are working with other UN agencies and many NGOS to respond to the outbreak, but a lot more is needed, especially in providing safe water and adequate sanitation to Haitians particularly in Port-au-Prince and the provinces. About 58% of the population before this crisis lacked access to potable water. About 76% of Haitians earn less than $2 a day. We now know that about 1.6 million Haitians are living in precarious conditions, particularly those in the 1,300 displacement camps.

    We must work together to manage the impact of this outbreak, particularly to minimize loss of life. This requires an integrated approach bringing together those who provide clean water, improve sanitary conditions, and those who provide treatment to the ill. We need more of everything: more training for staff in Haiti, more doctors, more nurses, more treatment centers, more medications, more toilets, more clean water.

    We have asked for $164 million for this emergency, and so far have received about 10 percent of this amount. It is clear the country will need more funding. Our response, along with all the partners, has not been as rapid as we would like. The reason is that, even before the crisis, the country lacked the building blocks of health, which are water, sanitation, safe food, and adequate health services. Our aim is to help Haiti overcome these obstacles and build self-sufficiency in these vital areas. [Emphasis mine]

    The head of the UN mission in Haiti (Minustah), Edmond Mulet, gave us last Saturday, one of his statements that he has the secret, to make us share his idyllic reading of the situation has 1 week of the elections. He says that presidential and parliamentary elections next Sunday will take place in a “Haitian climate calm, tranquil, serene, and without violence” (!!), adding “in the circumstances of Haiti”.

    Should we understand if his words, that there are “Haitian circumstances” where the climate of violence may be considered “as serene or acceptable” according to its criteria? Of course, Mulet, skilful desinformator with the service of UN, was quick to qualify his remarks by stating “If we compare the current electoral process, the election campaign last year, or the 2006 presidential or even presidential before”. Compare with worse, does not justify the current situation of violence. Know Mulet one death is one death too many, and no level of violence in our country is unacceptable, violence does not trivialize.

    The kind of movement and congregating you see with people going to vote is not the kind of movement that creates an increased risk of cholera transmission,” Andrus said. “Close contact does not put people at greater risk of cholera the way it would, for example, for flu.

    As with any crisis or disaster of any etiology, blame is a common feature.  The same is true in infectious disease disasters, particularly when there is a strong suspicion of accidental (and potentially culpable) virgin soil introduction of an exotic agent.  Nigel Fisher’s recent comments on behalf of the United Nations are typical of a bureaucracy facing intense scrutiny that has not engaged in effective management of risk communication and public accountability.  The scrutiny is warranted.

    If you want some understanding on how a disease which is easily treated is rapidy becoming a disaster, it’s a must-read.

    About 1,000 trained nurses and at least 100 more doctors were urgently needed to control the epidemic, which has struck the impoverished Caribbean nation months after a destructive earthquake.

    The outbreak has killed more than 1,400 Haitians in five weeks and the death toll is climbing by dozens each day.

    “We clearly need to do more,” Valerie Amos, the U.N.’s Undersecretary-General for Humanitarian Affairs, told Reuters in Port-au-Prince during a visit seeking to increase the scale and urgency of the cholera response.

    “But it’s not just money, it’s crucially people, in terms of getting more doctors, nurses, more people who can help with the awareness-raising and getting information out there,” she said in an interview late on Tuesday at the U.N. logistics base in Port-au-Prince.

    The real death toll may be closer to 2,000, U.N. officials say. Hundreds of thousands of Haitians are likely to catch the disease, they say, and the epidemic could last a year, complicating an arduous recovery from the Jan. 12 earthquake.

    I will post the next update Monday, or sooner if events warrant. (I apologize for the delay of a day with this one.) For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

    More resources:

    #Haiti Daily (Twitter newspaper)

    Haiti Information Project.

    Haiti: Operational Biosurveillance (Twitter)

    H5N1

    HaitiLibre (English) (français) (Twitter — English and French)

    Mediahacker: Independent multimedia reporting from Haiti (Twitter) (Flikr)

    Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

    PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

    Praecipio International (HEAS)

    On the ground, good sources of information and of course needing donations:

    Partners in Health (Twitter).

    Médecins sans frontières

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    Haiti Cholera Update #16

    From MSPP Rapport du Cas. Click to enlarge.

    The latest MSPP (Ministère de la Santé Publique et de la Population) report as of 20 November 201 0 showed 60,240 cases of cholera and 1,415 deaths since the outbreak began. There have been 25,248 hospitalizations. The hospital mortality rate is 3.8%. Cholera promptly treated has a mortality rate of 1-2%.

    The United Nations’ Nigel Fisher on the epidemic:

    But U.N. humanitarian coordinator in Haiti Nigel Fisher said the real death toll might be “closer to two thousand than one” because of lack of data from remote areas, and the number of cases 60,000-70,000 instead of the official figure of around 50,000.

    Addressing a U.N. news conference by video link from Haiti, Fisher said experts from the World Health Organization were now revising their estimate that the diarrheal disease, spread by poor sanitation, would cause 200,000 cases within six months.

    “They are now revising that to 200,000 in closer to a three-month period. So this epidemic is moving faster,” he said, adding that it was now present in all 10 of Haiti’s provinces. “It’s going to spread.”

    “The medical specialists all say that this cholera epidemic will continue through months and maybe a year at least, that we will see literally hundreds of thousands of cases,” Fisher said.

    It was “almost impossible to stop the spread of these cases because it is so contagious, and those who carry the cholera bacterium often take days to show it, and in that (time) they may move anywhere,” he added.

    Fisher said U.N. and other aid workers needed to “significantly ratchet up” their response, including going through faith groups to distribute chlorine tablets to purify water, and increasing the number of treatment centers.

    Furthermore:

    Deaths from the cholera epidemic in Haiti could rise above 10,000 if help doesn’t quicken, but bureaucracy is slowing aid down, says a Canadian who heads the United Nations humanitarian efforts in the Caribbean country.

    “All the conditions for a massive cholera epidemic are present in Haiti,” Nigel Fisher told CBC News. “It is exploding.”

    The United Nations puts the reported cholera death toll at 1,344, but says experts believe the tally could be as high as 2,000. Though official numbers state about 50,000 Haitians have been stricken by the disease, Fisher believes the true number could be closer to 70,000.

    “If we don’t move — we, the whole community and national counterparts — don’t accelerate the process, we could see deaths going above 10,000 or so.”

    Via H1N1, one obstacle stalling relief efforts:

    He cited a previous price of $2,000 to clear a container at customs recently jumping up to $5,000 or more.

    It’s a complicated situation, he said. Buildings where customs officers used to work were levelled by the earthquake, and the workers are often not being paid by the government, which is broke, he said. “The only way of getting money for them is by ripping people off,” Chauvin said. “It’s complete corruption down there. I don’t know what the answer is. If you think of something, let me know.”

    An article in the Guardian is sharply critical of the UN’s presence in Haiti:

    Rather than examine its role in the epidemic, however, the UN mission has opted for disavowal and obfuscation. UN officials have refused to test Nepalese soldiers for the disease or to conduct a public investigation into the origins of the outbreak. Rather than address the concerns of an outraged population, the agency has preferred to characterise the fresh wave of protests as a “politically motivated” attempt to destabilise the country in the runup to presidential elections on 28 November. Protesters have been met with tear gas and bullets; so far at least three have been killed.

    So far, in fact, so normal. The truth is that the whole UN mission in Haiti is based on a violent, bald-faced lie. It says it is in Haiti to support democracy and the rule of law, but its only real achievement has been to help transfer power from a sovereign people to an unaccountable army. (But read the whole thing.)

    In its most recent Cholera Haiti Health Cluster Bulletin 4 (Nov 23 2010), the Pan-American Health Organization (PAHO) reports on structural and organizational difficulties:

    The situation in Haiti is urgent and will only become worse over the coming weeks. One month after the initial cases of cholera, 24 Non-Governmental Organizations (NGOs) are now providing cholera response health services in Cholera Treatment Centers (CTCs) and Cholera Treatment Units (CTUs). Throughout Haiti, 36 CTCs are operational with a total bed capacity of roughly 2,830. These centers atheir current capacity will not be sufficient to meet the population’s needs as the outbreak grows.

    A serious concern has become ever increasing pressure on CTCs to treat patients. Renewed emphasis must be placed on implementing the first two components of the National Cholera Response Plan, which aims to protect families at the community level and strengthen primary health centers already operating across the nation .CTUs,which are smaller than CTCs and are attached or near an existing health center, have not scaled-up their capacity quick enough. Increasing the number of CTUs throughout the country is essential for triaging patients and relieving the burden of care on CTCs. The operational role of the CTU also prevents primary health centers from becoming overwhelmed with cholera patients, which results in neglect of those with non-cholera conditions.

    [snip]

    Taking into account stockpiles at the PAHO/WHO warehouse PROMESS, as well as other agency warehouses, there appears to be sufficient supplies for treatment today. However, in many health facilities throughout the country, medical professionals are only using IV fluids when patients present with cholera symptom. In most cases, simple rehydration salts are enough for treatment and the over use of IV fluids is depleting supplies more rapidly than is necessary. Extensive and regular training activities need to be undertaken to address this issue.

    The official line: the Haitian ambassador to the U.S. speaks at a news conference:

    QUESTION: Hi, (inaudible). You might have said that one of the protestors (inaudible), that there have been some forces deliberately trying to destabilize the country, taking advantage of the situation. (Inaudible) and can you stand on (inaudible) and A, whether – who these forces might be and what are their names? And then I (inaudible).

    AMBASSADOR MERTEN: Right. Quite perfectly frankly, I don’t think we have a really completely clear picture of who those people were who were fomenting unrest up in the North. There are – there is no shortage of people with suggestions as to who may be behind it, there – and that those suggestions go across the political spectrum and the social spectrum here in Haiti.

    I think the important thing to remember is that things have calmed down and the United Nations has been able to respond and is doing its job, again, with coordination of the Haitian police, with the Haitian police. I think as we move forward towards Election Day, we’re – I believe that they will be able to fulfill their mandate as outlined.

    [snip]

    QUESTION: Oh, okay. I’m wondering what the U.S. has done to deal with the public health challenge of containing the cholera epidemic while still getting people out to the polls.

    AMBASSADOR MERTEN: Well, the U.S. has done a great deal in partnership with many NGOs here on the ground, the Haitian Government, UN organizations, and other donors to combat this cholera outbreak. We have been transporting and importing rehydration solution, making sure it gets out to people. Our colleagues from CDC, which there are quite a few here right now, have been training Haitian and other trainers so that people can go out to the countryside and talk to people and help people learn how to get the treatment they need and get the care they need, because cholera is, in effect, a very treatable malady if you catch it in time and give it the proper treatment. We’ve been very active in that regard, as have many of our donor partners.

    [snip]

    QUESTION: One other thing, actually, for this election is going to have any impact on what happened or what is happening there, and if anything U.S. can do more or the international community?

    AMBASSADOR MERTEN: We meet and discuss on this subject every day and meet with our colleagues to try and determine what more we can usefully do to help the Haitian people confront this issue. This is not a static process. This is not something where we’ve decided we are going to do X and X is all we’re going to do. We continue to evaluate and see what we can bring to bear to be most helpful.

    But again, I’m not really sure that discussing this in terms of the election is really all that germane. I see them as two separate issues. We have a cholera problem here, which is something that the Haitians and we are all grappling with, which is a major public health challenge here. And we have the elections which should take place, need to take place, and we are here to support that effort.

    Via H1N1, Ansel Herz’s Flikr Photostream. Very worthwhile.

    More pictures from the ground.

    PAHO’s updated interactive map  on the cholera outbreak on Hispaniola.

    Enormously unhelpful.

    I will post the next update Friday, or sooner if events warrant. For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

    More resources:

    #Haiti Daily (Twitter newspaper)

    Haiti Information Project.

    Haiti: Operational Biosurveillance (Twitter)

    H5N1

    HaitiLibre (English) (français) (Twitter — English and French)

    Mediahacker: Independent multimedia reporting from Haiti (Twitter) (Flikr)

    Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

    PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

    Praecipio International (HEAS)

    On the ground, good sources of information and of course needing donations:

    Partners in Health (Twitter).

    Médecins sans frontières


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    Haiti Cholera Update #15

    As of writing, there are no updated figures from MSPP (Ministère de la Santé Publique et de la Population). The latest figures released on 16/11/10 showed 49,418 cases of cholera and 1186 deaths since the outbreak began. The hospital mortality rate is 3.9% Cholera promptly treated has a mortality rate of 1-2%.

    James Wilson reports on conditons in the epicenter:

    The rural camps, hardest hit by cholera are in the worst situation because there is NO relief aid presence and no UN presence.  During this last trip it would take almost 5 hours to drive from St. Marc back to Port au Prince to try and secure supplies.  We are purchasing ORS, water, and pedialyte (now absent from stores because we are buying so much of it).  [REDACTED] gave me 10 cases of pedialyte and some other supplies, which is all they could afford because they feared an outbreak in Port au Prince.  Finally, after running out of medications, fluids, etc. and being turned away from most all sources for medical supplies, including the UN, there was no way to help those suffering from cholera.  It was simply too difficult to watch another baby die of dehydration and I came home to recover from the worst week I’d experienced in Haiti since the earthquake.

    I cannot begin to explain how much worse the situation is in Haiti and how there is very little coordination of any relief aid or the NGO’s.  The following is the mission statement of the UN for its mission in Haiti.  It is not being carried out now during this cholera outbreak and has not been carried out since the earthquake, which is more than a failure to the Haitian people.

    “The mission of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) is to mobilize and coordinate effective and principled humanitarian action in partnership with national and international actors.”

    I have shared all my findings with the CDC in order to give them as much data as I can gather for their investigators.  I have also given our findings to the MOH and OCHA -mainly for informational purposes because I’ve given up the hope of obtaining necessary supplies.  I wish the news was better and sadly the deaths will continue because there is little to no support available for those providers in rural areas.  There is very little available in the way of supplies even in the larger cities now facing patients with cholera.  I am contacting organizations here at home to try and get the ORS, which comes in small packets, donated so I can take it back on my next trip.

    The Columbia Journalism Review on Haiti as disaster porn:

    CNN’s twenty-four-hour coverage of the aftermath of Haiti’s earthquake, which took an estimated 300,000 lives, doubled the network’s viewership. This coverage undoubtedly played a role in the America public’s response to the tragedy—one out of two Americans donated money to aid organizations. But little reporting has been done since then that asks how exactly that money is being spent, holds aid organizations accountable to their promises, or investigates the American government’s development and economic policies in the country. These policies, argues sociologist Alex Dupuy, have kept Haiti frozen in a destructive cycle of aid-dependence and exploitation for decades, stripping Haiti of its self-determination. “For the level of tragedy, no one’s really being very honest,” said Michael Fairbanks, a development expert, of the American and international community’s rhetoric about Haiti since the earthquake. “[Haitians] are constantly put into the position of adolescence and being infantilized so they can prey on the charity from the rest of the hemisphere.”

    The longer American news outlets ignore these critical and complex issues, the easier it will become to view their occasional jaunts to Haiti with cynicism: it’s an convenient place to get B-roll of tragedy and disaster. Their coverage increases viewership, but without a moral component of responsibility towards Haitians themselves over the long-term, such coverage is basically exploitative. And over time, superficial reporting on Haiti’s problems—which plays a role in soliciting charitable donations from Americans-will arguably make the media culpable in the very system of aid-dependence and misguided development policies that help keep Haiti poor.

    MSF criticizes the current response to the  epidemic:

    Despite the huge presence of international organizations in Haiti, the cholera response has to date been inadequate in meeting the needs of the population.  According to national authorities, the epidemic has already caused more than 1,100 deaths and made sick at least 20,000 people nationwide.

    “MSF is calling on all groups and agencies present in Haiti to step up the size and speed of their efforts to ensure an effective response to the needs of people at risk of cholera infection,” says Stefano Zannini, MSF head of mission in Haiti. “More actors are needed to treat the sick and implement preventative actions, especially as cases increase dramatically across the country. There is no time left for meetings and debate – the time for action is now.”

    Crawford Killian at H1N1 has a couple of sharp posts, first on his own learning curve on Haiti and what he’s concluded, and second, an eye-opening read on the results of various charities’ fundraising after the earthquake — ones readers may well have donated to — compared to the actual money disbursed.

    The Canadian government, incidentally, has released an additional $4 million to fight cholera in Haiti. Much of this money is directed primarily for long-term projects for the provision of clean water and on education campaigns. Many aid agencies have suggested the need for funding has moved from mitigation and education to more basic needs, such as for supplies like intravenous solutions and antibiotics.

    Pictures of the cholera protests.

    HaitiLibre on the anti-Haitian protests in the Dominican Republic, ten cases of cholera have been reported.

    I will post the next update Tuesday or (more likely) Wednesday, or sooner if events warrant. For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

    More resources:

    #Haiti Daily (Twitter newspaper)

    Haiti Information Project.

    Haiti: Operational Biosurveillance (Twitter)

    H5N1

    HaitiLibre (English) (français) (Twitter — English and French)

    Mediahacker: Independent multimedia reporting from Haiti (Twitter)

    Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

    PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

    Praecipio International (HEAS)

    On the ground, good sources of information and of course needing donations:

    Partners in Health (Twitter).

    Médecins sans frontières

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