Haiti’s Cholera Epidemic: One Nurse’s Account

[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.

Haiti Cholera Update #14

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.

[snip]

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.

(But read the whole article.)

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.

Via H1N1,  two new source of information: a Twitter newspaper and Haiti Information Project.

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.

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

[UPDATE: minor word changes for clarity]

Haiti Cholera Update #13

The last report of the MSPP (Ministère de la Santé Publique et de la Population) on 12 November 2010 reports 14,642 cases of cholera and 917 deaths. The hospital mortality rate is 3.8%. Cholera promptly treated has a mortality rate of 1-2%. It is probably worthwhile to bear in mind that in the view of James Wilson at Haiti: Operational Biosurveillance, the number of cases is likely enormously under-reported. He currently estimates approximately 100,000 people have been infected. If 75% of these cases are subclinical, and we accept a (conservative) 3.8% mortality rate, the estimated number of deaths would be 950 — a figure strikingly close to official reports. The United Nations is estimating 200,000 persons will be infected during the epidemic. According to Nigel Fisher, Deputy Special Representative and Resident and Humanitarian Coordinator, MINUSTAH,

The Cholera continues to, the number of cases continue to expand quite rapidly as foreseen. We do have cases now in every ‘Department’ as well as in Port Au Prince. The numbers of cases that we’ve had so far have been Ministry of  Health cases of hospitalized patients, we’re now trying to ramp up the collection of data from communities so that we can get a more realistic figure. We expect to have, once that data comes in, a significant increase in recorded cases so people should not be surprised at that.

The U.N. has launched a US$164 million appeal to combat the epidemic in Haiti.

The World Health Organization meanwhile has declared that finding a definitivre source of the epidemic is not a priority:

A WHO spokeswoman says controlling the outbreak and helping those infected is more important.

Fadela Chaib told reporters in Geneva on Tuesday that “at some time we will do further investigation but it’s not a priority right now.”

One protester was killed late Mondays as anti-U.N. riots spread to several Haitian cities in what WHO described as politically motivated unrest.

The U.N.’s spokeswoman in Geneva, Corinne Momal-Vanian, described the suspicion that Nepalese troops were to blame for the outbreak as “misinformation.”

Rioting has been reported in were reported in Cap-Haïtien, and The Guardian is reporting UN soldiers shot and killed one protester. Mediahacker is reporting two deaths, and other civil disturbances in Hinche and Gonaives. In Hinche, says Mediahacker, “protesters tried to leave the coffin of a man who died of cholera in front of the city’s UN peacekeeping base.” The violence has been variously attributed to the presence of MINUSTAH (United Nations Stabilization Mission in Haiti), who are widely suspected by the Haitian people and politicians of bringing cholera in to the country, the upcoming national elections on the 28th, or the establishment of cholera treatment centres in the community, which has been a point of contention in other places. One account:

The earthquake, the hurricane, and now the cholera. The manifestasyon which began this morning around 6:30 a.m. is strictly about Cholera and the UN, and people are serious about wanting them out. I asked a man on the street if he thinks this will go on into tomorrow: “Wi, demen sidyevle,” yes, God-willing, he says, “we won’t stop until Minustah quits the country. They brought cholera here and many many people died.” One woman told me that there are riots like this in Port-de-Paix and Hinche, but this is so far unconfirmed.

Spanish Minustah soldiers are coming from Ft. Liberte, but groups of protesters went out to Limonade to set up road blocks earlier today. Rt 1 leading into Cap from the south and out to the east are blocked. The picked-apart skeletons of trucks make quick barricades across the roads, sometimes within 100 yards of another. Groups have also set burning tires up to block paths. You have to identify yourself as NOT Minustah or else people will throw rocks. One man told me “Ameriken se Ameriken, Minustah se Minustah.”

We heard helicopters around 2:00 p.m., but haven’t seen them since. The airport is closed and the US Embassy has sent out a new warning on their site. Earlier this afternoon, protesters burned the police stations at Pont Neuf and Barriere Bouteille before heading to the one at l’Arsenal in downtown Cap. As of 3:00 p.m., one person has died and 26 others are hospitalized from the altercations. The man who died was shot by a Minustah soldier.

Médecins sans frontières on the present course of the outbreak:

The situation in the north of Haiti remains extremely serious. MSF teams working in the region are overwhelmed by the needs of the many new patients arriving at facilities in Cap Haitien, Port de Paix, Gonaives, and Gros Morne every day. Fears persist in the communities, including in Port-au-Prince, over the presence of cholera treatment centers (CTCs), in spite of their importance to immediate lifesaving measures against the epidemic.

[snip]

In the lower Artibonite region, where the outbreak started, MSF teams in Petite Rivière and St. Marc are still very busy. While there are some indications of the epidemic possibly stabilising, the CTCs in both places are at capacity. The caseload in Dessaline, however, is still increasing; 177 people were admitted on Friday and a 280-bed capacity facility is being built. In general, as in the north, it is still difficult to reach remote areas to offer treatment where it is needed. MSF has resorted, in some cases, to dropping materials from helicopters to support some local health centres.

In Port-au-Prince, the picture remains chaotic and troubling. The Cite Soleil neighbourhood, a sprawling slum, is essentially the frontline of the outbreak in the capital. Efforts are underway to increase admissions to 250 per day at the MSF-supported, Ministry of Health, Choscal Hospital. People presenting with severe symptoms are transferred to CTCs in MSF facilities in the nearby Sarthe and Tabarre neighborhoods. Teams are also looking for another place to construct a cholera treatment unit (CTU) in the neighbourhood.

I missed this quote in the last update, but it’s worth going back to. From James Wilson, somewhat facetiously:

Direct quote from senior US government official:

…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.

Cholera has spread to inside Haiti’s prison system:

After the death, last month, of 5 prisoners to the Civil prison of Hinche (of the cholera), it is the turn of the National Penitentiary to be affected by the cholera epidemic. In recent days, four prisoners died, reported a spokesperson for the Haitian National Police (PNH), indicating that more than ten others presented all the symptoms of the cholera.

The National Penitentiary, principal prison of the capital, houses 1.469 inmates (figure of October 2010) with sub human living conditions, compared to that, the life is good in the IDP camps. Danielle Boisvert, who heads the correctional unit of MINUSTAH since June 1st, 2010 was declared in September “On average, each prisoner has access to less than 1 m2 and in certain prisons such as the National Penitentiary, they have less than 0.5 m2. In less than one half-m2 a person cannot sleep wide nor even squatted” ideal conditions for the spread of cholera.

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

More resources:

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