Those Emergency Blues

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.)

ReliefWeb Latest Updates on the Epidemic. Key Documents.

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

Cholera, Haiti, Les Cayes, Pan-American Health Organization, Port-au-Prince

1 Comment

Haiti Cholera Update #18

Posted by torontoemerg in Battered Nation Syndrome, Cholera in Haiti, Humanitarian Crisis or Crisis in Humanitarianism? on Monday 29 November 2010

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.

Updated news of the election can be found at HaitiLibre.

Pictures of the election from Ansel Herz.

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.

HaitiLibre is also reporting the border with the Dominican Republic is now closed:

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:

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.)

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

Cholera, Dominican Republic, Haiti, Pan-American Health Organization, Port-au-Prince

Haiti Cholera Update #17

Posted by torontoemerg in Battered Nation Syndrome, Cholera in Haiti, Humanitarian Crisis or Crisis in Humanitarianism? on Saturday 27 November 2010

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.

According to HaitiLibre, the release of data related to the epidemic is politically motivated:

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).

Commenting on the above, Crawford Killian thinks he might have misread the tables. (I don’t think he has.)

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]

HaitiLibre on the elections:

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.

PAHO thinks the elections will not have the effect of potentializing the outbreak:

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.

James Wilson has written a truly damning post on bureaucratic obfuscation and obstruction related to the epidemic on his blog Haiti: Operational Biosurveillance. in the context of Nigel Fisher’s remarks at the U.N.:

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.

Photographs.

“Haiti needs a surge of foreign nurses and doctors to stem deaths from a raging cholera epidemic that an international aid operation is struggling to control, the United Nations’ top humanitarian official said.”

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:

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.)

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

Cholera, Cité Soleil, Haiti, Pan-American Health Organization

4 Comments

Haiti Cholera Update #16

Posted by torontoemerg in Battered Nation Syndrome, Cholera in Haiti on Wednesday 24 November 2010

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:

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.)

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

Cholera, Haiti, Nigel Fisher, Pan-American Health Organization, United Nations

(But read the whole article.)

Haiti Cholera Update #14

Posted by torontoemerg in Battered Nation Syndrome, Cholera in Haiti on Friday 19 November 2010

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.

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:

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.)

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

Artibonite River, Cap-Haïtien, Haiti, James Wilson, Pan-American Health Organization, Port-au-Prince

[UPDATE: minor word changes for clarity]

3 Comments

Haiti Cholera Update #9

Posted by torontoemerg in Cholera in Haiti, Humanitarian Crisis or Crisis in Humanitarianism? on Saturday 06 November 2010

As of writing there have been no further reports of cases or deaths from cholera from MSPP (Ministère de la Santé Publique et de la Population). The MSPP’s last release three days ago noted 6,742 hospitalized cases of cholera and 442 deaths since the outbreak began. This represents a crude mortality rate of 6.6%. Cholera promptly treated has a crude mortality rate of 1-2%. Cholera is now found in five départements: Artibonite, where the outbreak began, and Centre, Nord, Nord-Ouest, and Ouest. It is important to note that even this information was stale at the time of its release, and represented data three days old, from 31 October 2010, meaning effectively, there has been no official release of information for nearly a week. James Wilson at Haiti: Operational Biosurveillance (HOB) believes this number represents significant underreporting:

Current official stats are 6,742 cases and 442 fatalities. This is definite under-reporting. If we assume the case counts are 1/4 the true community load, then we now have nearly 27k cases shedding pathogen into the environment. We believe the true statistic to be closer to 50k based on the degree of under-reporting.

Tropical Storm Thomas has passed Haiti, though rainfall associated with the storm continues; 2.5-5 cm of additional rain is expected to fall over the country. HaitiLibre reports significant flooding, and authorities have evacuated hospitals in Leogane, Les Cayes and Saint Louis Hospital in Delmas (Port-au-Prince). HaitiLibre is providing updates on the flooding on their website. According to PAHO (Pan American Health Organziation) the storm produced:

rain accumulations of 5 to 10 inches over much of Haiti and the Dominican Republic, with possible isolated maximum amounts of 15 inches. This brings additional challenges to the current health situation, with reduced availability of drinking water, difficult hygienic conditions, and limited access to health services and to waste management.

HaitiLibre continues to report violence on the Border with Dominican Republic, associated with the outbreak-induced closure of the transnational markets on the Dominican side of the border.

Medical supplies obtained by PAHO seem to suggest the health organization is digging in for the long haul:

Immediate distribution [of medical supplies] covered over 3,500 liters of IV fluids, more than 64,000 sachets of oral rehydration salts, and 180,000 antibiotic tablets. Additional distribution to hospitals and health facilities in Haiti can cover at least 600,000 ORS doses, 50,000 liters of Ringer’s Lactate, and more than 3,500,000 antibiotic tablets. In addition, 10 complete WHO Diarrheal Disease Kits, each able to treat 400 to 500 people, have been purchased and are arriving Nov. 4

Crawford Kilian writes on the cognitive gap between the hype of humanitarian relief and the reality on the ground, sentiments I tend to agree with:

The NGOs, UN agencies, and individuals who are blogging this disaster on the ground are remarkable people, doing wonderful things. Many of them are putting themselves in harm’s way. Haiti would be far worse off without them.

But a lot of them are using Haiti as a sales pitch for donations or political support. They describe the frightful conditions the Haitians are dealing with, and then they describe their own heroic efforts to improve those conditions. Much as I admire them, I’m beginning to gag a little when I read their self-congratulating posts.

(But read the whole post.)

Also via Crawford’s blog, H1N1, American earthquake relief to Haiti is still held up in the U. S. Congress:

The US Congress put up another obstacle today to delivering the $1.15 billion (£600 million) in reconstruction money that it promised to Haiti in March but has so far failed to deliver.

The State Department will have to prove to Congress’s satisfaction that the money will not be stolen or misused, which may be a difficult target before the cash even reaches the country.

Without the reconstruction money, temporary shelters have gone unbuilt, rubble has not been removed and 1.3 million people remain homeless because they are unable to afford safe places to live.

More resources:

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

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

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

Cholera, Crawford Kilian, Dominican Republic, Haiti, Pan-American Health Organization, Port-au-Prince

Haiti Cholera Update #8

Posted by torontoemerg in Cholera in Haiti, Uncategorized on Thursday 04 November 2010

Via the Pan American Health Organization (PAHO), as of 3 November 2010, MSPP reports, there were in Haiti 6,742 hospitalized cases of cholera and 442 deaths since the outbreak began. This represents a crude mortality rate of 6.6%. Cholera promptly treated has a crude mortality rate of 1-2%. Cholera is now found in five départments: Artibonite, where the outbreak began, and Centre, Nord, Nord-Ouest, and Ouest.

Tropical Storm Tomas has begun to affect Haiti’s southwest peninsula. However the latest forecasts have some good news: the storm has veered further west than expected, and it appears the heaviest rains and the greatest risk of flooding will be limited to the southwest peninsula. Further, the storm will not stall just to the north of Hispaniola as previously feared. Rainful amounts of 10-20 cm are expected over the southwest peninsula, but much less, 2.5-10 cm will fall over the earthquake zone, enough to cause serious but not catastrophic flooding.

HaitiLibre reported more violence at the border with Dominican Republic, caused by the closing of the transnational markets during the epidemic.

PAHO has created a useful interactive map to track the outbreak.

An article on the politics of finding the source of the epidemic: “‘The idea that we’d never know [the source] is not very likely. There’s got to be a way to know the truth without pointing fingers.'”

More resources:

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

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

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

Cholera, Haiti, Hispaniola, Pan-American Health Organization, Port-au-Prince

Haiti Cholera Update # 7

Posted by torontoemerg in Cholera in Haiti on Wednesday 03 November 2010

As of writing, MSPP (Ministère de la Santé Publique et de la Population) has not released updated information on cases/deaths. The latest figures were to be released at 1000 this morning, but I have been unable to find any information regarding them. The last report was on 30 October 2010 when 337 deaths and 4,764 were noted. According to HaitiLibre: “[T]he government has not issued (at the time this article was written) any new assessment since Saturday on the evolution of the cholera epidemic in the country because of public holidays [!], this is, despite the maximum health warning level (the holidays seem to take precedence over the government’s crisis and information to the population).”

Tropical Depression Tomas weakened significantly overnight, and is not now forecast to regain hurricane strength before making landfall on the southwest peninsula Friday morning. However, Jeff Masters writes the gravest danger is not from the winds, but the heavy rainfall, which may well be an event spread over several days:

It doesn’t take much rain to cause a flooding disaster in Haiti–ordinary seasonal heavy rains have killed 23 people in southern Haiti over the past month, including twelve people in Port-au-Prince this past weekend. According to the Associated Press, most of last weekend’s deaths occurred when surging rivers burst through houses built in ravines. With the soils already saturated from last weekend’s rains, the stage is set in Haiti for a significant flooding disaster capable of causing heavy loss of life.

[snip]

Crucially, the storm has waited too long to begin this process, and it now appears unlikely that Tomas will have time to grow beyond Category 1 hurricane strength before landfall in Haiti on Friday. NHC is giving Tomas a 5% chance of reaching Category 3+ strength, which is a reasonable forecast. With the atmosphere expected to be very moist, it is likely that Tomas will dump very heavy rains of 4 – 8 inches over much of Haiti, even if Tomas strikes as a tropical storm. Rains of this magnitude are capable of causing heavy loss of life due to extreme floods running down Haiti’s deforested mountain slopes.

In the context of the cholera epidemic, it is probably not necessary to add the much increased risk of exacerbation of contaminated water supplies. From the Pan-American Health Organization’s briefing yesterday:

We cannot overlook the vulnerable populations who do not live in these resettlement camps and may not have access to safe drinking water. The response must be comprehensive.

An emerging top priority now for all of us is preparing for Tropical Storm Tomas. We have received reports that the storm has already had a serious impact on St. Lucia, with mudslides and severe damage to the island’s water systems.

If the storm hits Haiti, it’s obvious that is will make a difficult situation even worse. Cholera is mainly being spread through contaminated water, and more water supply disruptions pose additional increased risks for cholera and other waterborne diarrheal diseases.

The bad sanitary conditions in many areas, combined with what the hurricane poses as huge amounts of rain and possibly flooding, are very likely to accelerate the spread of infection, making the overall caseload increase earlier and faster.

MINUSTAH (La Mission des Nations Unies pour la Stabilisation en Haïti — United Nations Mission for the Stabilization in Haiti) issued a statement revealing test results absolving peacekeeping troop of any role in the transmission of cholera:

La Mission des Nations Unies pour la Stabilisation en Haïti (MINUSTAH) se félicite de la contribution scientifique du Laboratoire National de Santé Publique (LNSP), en Haïti, et des Centres de Prévention et de Contrôle des maladies (CDC), à Atlanta, qui apportent des éléments de compréhension de l’épidémie de choléra en Haïti.

Selon leurs conclusions, la souche de choléra responsable de l’épidémie est identique à une souche trouvée en Asie du Sud. Toutefois, en raison de la rapidité des mouvements des souches de choléra à travers le monde – transmises par des aliments, des eaux contaminées ou par des personnes infectées – des spécialistes de la santé ont souligné la difficulté, voire l’impossibilité de déterminer, avec précision, la manière dont le choléra est arrivé en Haïti.

La MINUSTAH continuera à prendre les mesures préventives nécessaires dans le but de protéger le peuple haïtien et son propre personnel. Des tests des échantillons d’eaux prélevés à l’intérieur de la base militaire à Mirebalais et à l’extérieur, aux abords de la rivière, ont été conduits le vendredi 22 octobre et le mardi 26 octobre, et les résultats se sont tous révélés négatifs. Des tests supplémentaires ont été effectués le mercredi 27 octobre, à la demande du Commandant de la Force, à l’intérieur du camp et entre le camp et la rivière. Ces tests ont été analysés par un laboratoire indépendant et se sont aussi révélés négatifs.

(The UN Mission for Stabilization in Haiti (MINUSTAH) welcomed the scientific contribution of the National Laboratory of Public Health (LNSP), Haiti, and the Centers for Disease Control (CDC) in Atlanta, all of which provided basic understanding of the cholera epidemic in Haiti.

According to their findings, the strain of the cholera responsible for the epidemic is the same as the strain found in South Asia. However, because of the rapidity of movement of cholera strains around the world — transmitted by food, contaminated water or by infected persons — health specialists have pointed out the difficulty or impossibility of determining precisely the means by which cholera came to Haiti.

MINUSTAH will continue to take preventive measures necessary in the end to protect the Haitian people and its own personnel. Tests of water samples taken from inside of the military base at Mirabalais and exterior to it on the banks of the river were conducted on Friday 22 October and Tuesday 26 October, and results were shown to be all negative. Supplementary tests were done on Wednesday on the order of the Commandant of the Force, in the interior of the camp and outside the camp and river. These tests were analysed by an independent laboratory and again were found negative. [My translation.])

Finally, a few excerpts from an interview with Laurie A. Garrett, Senior Fellow for Global Health, Council on Foreign Relations:

But it’s inexcusable that we cannot control cholera today. We fully understand the disease. It is generally treatable with a combination of appropriate antibiotics. But most important is heavy-duty hydration with consistently safe water. The main thing with cholera is that you dehydrate. And death is associated with massive dehydration. If the water is the source of the cholera and you rehydrate with that water, you’re simply redosing yourself with the microbe, and you subsequently die. If you have safe water, you can slow down the pace of dehydration. Then you can slam with the appropriate antibiotics.

***** ***** ***** ***** *****

[Question.]There’s aid money flowing into Haiti, and people have known about the deplorable sanitation and water systems in Haiti for a long time.

Actually, money isn’t flowing in. Senator Tom Coburn (R-OK) has held up more than $1 billion dollars for Haiti because he is unhappy with the State Department appointment for an individual who will play a key role in relief operations. So while dollars have been committed, they’ve not flowed at a rate that would allow us to feel comfortable that there is sufficient funding. Bulldozers and heavy lifting equipment to deal with the debris and to destroy shattered buildings only started moving really in the last couple of weeks on a major scale.

It’s shocking how far down the road we are without doing what you would do in any American city in a similar situation–mow down anything that would have been declared unsuitable for habitation and then start rebuilding. But most of Port-au-Prince is still debris, and it’s hard to build plumbing systems, sewer systems, water treatment systems when the debris is sitting in the way. However, I have to say that it’s my understanding that most of the water being distributed in the form of drinking water in Port-au-Prince is actually coming from specifically pumped water stations. That may actually protect Port-au-Prince from a serious outbreak.

More resources:

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

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

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

Centers for Disease Control and Prevention, Cholera, Haiti, Pan-American Health Organization, Port-au-Prince, United Nations Stabilization Mission in Haiti

Haiti Cholera Update #6

Posted by torontoemerg in Cholera in Haiti, Health Care, Uncategorized on Tuesday 02 November 2010

PAHO released its ninth situational update yesterday evening (PDF). MSPP (Ministère de la Santé Publique et de la Population) still has not updated its case figures from 30 October 2010.

Tropical Storm Tomas continues to strengthen, and is expected to cross Hispaniola beginning Friday and into Saturday morning. As of this morning, indications are it will not be a glancing blow.

James Wilson at Haiti: Operational Biosurveillance writes that there is probable massive under-reporting of cases because cholera infection is subclinical in the majority of cases; the extent of the outbreak may be more dire than thought, despite reassurances the epidemic is under control:

As of Friday, October 29th, PAHO has reported more than 4,700 cases and more than 330 fatalities (apparent case fatality rate approximately 7%). PAHO was unable to report updated statistics because MSPP had not released them on Monday, Nov 1st. Statisticsquoted by the media over the weekend indicate fatalities approaching 340. If approximately 25% of cholera cases are clinically apparent, then a highly conservative estimate places the true case count at nearly 19,000. We estimate the case counts to be closer to 40,000 based on the level of under-reporting and rural transmission occurring in areas not being serviced by responders. Cholera epidemics often follow a waxing and waning pattern of transmission and therefore can be unpredictable.

Further:

Further evidence of cholera transmission in Cite Soleil has not been reported, which is a key sentinel site for the greater Port au Prince area. Vigilance and sensitization for cholera in Cite Soleil has been elevated to the maximum extent possible.

We are aware of 12 confirmed cases of cholera reported within PAP but not publicly reported by officials.

(But read the whole thing.)

According to Gabriel Timothée, Director General of MSPP, the epidemic is neither “suppressed nor controlled.” Speaking at a briefing, he said, (PDF – français)

Selon M. Gabriel Timothée, aucun système de santé de la planète ne peut prétendre juguler une épidémie ou contrôler son évolution en un temps si court (10 jours). « Nous ne sommes pas encore arrivés au pic de l’épidémie a souligné Dr Timothée, précisant toutefois que des efforts sont entrain d’être déployés afin d’éviter sa propagation à travers lepays». Ainsi invite-t-il la population à rester vigilante et à respecter les dernières consignes des autorités sanitaires.

(According to Gabriel Timothée, no health system on the planet can claim to suppress an epidemic or control its progress in such a short time. (10 days). “We have not yet reached the peak of the epidemic,” Dr. Timothée underlined, however adding “efforts are being made to prevent its spread across the country.” Consequently, he asks the public to remain vigilant, and to follow the latest instructions from health authorities. [My translation.])

CBC News reported yesterday the cholera strain found in the Haitian epidemic matches those found in south Asia. The CDU press release is here. This will undoubtedly continue to complicate the role of MINUSTAH.

Media reports on the epidemic here.

More resources:

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

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

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

Cholera, Haiti, Pan-American Health Organization, Port-au-Prince

Media reports on the epidemic here.

Haiti Cholera Update #5

Posted by torontoemerg in Cholera in Haiti, Health Care on Monday 01 November 2010

Updated information on cholera deaths and cases from the Pan-American Health Organization (PAHO) or any of the other usual sources has been lacking this morning. Evidently MSPP (Ministère de la Santé Publique et de la Population) has not issued any reports in the last day or so. As of 30 October 2010, via PAHO, MSPP reports 337 deaths and 4,764 cases since the epidemic began. This represents a crude mortality rate of 7.1%. Cholera promptly treated has a mortality rate of 1-2%. I will update this today if more recent figures become available.

Tropical Storm Tomas is expected to regain hurricane strength before potentially striking Haiti’s southern coast early Friday morning. There is, the U. S. National Hurricane Center notes, “considerable uncertainty” about the hurricane’s strength at landfall. Meanwhile DPC (Direction de la Protection Civile — Civil Protection Office) has begun mobilizing resources. The immediate needs are staggering:

The DPC and the humanitarian community are using the planning figure of 100,000 families (500,000 people) to be affected by the hurricane in the west and southern departments. The humanitarian community has assessed its current stock of available material and the following gaps have been identified:

Tarpaulins: 150,000
Field tents: 200
Blankets: 100,000
Jerry cans: 150,000
Bars of soap: 90,000
Water purification tablets: at least 90,000
Hygiene kits: 90,000
Buckets: 90,000
Emergency kits to supply 10,000 people for 3 months: 4
Oral rehydration salt sachets: 200,000
Chainsaws to cut trees
Water bladders: number to be determined

HaitiLibre is reporting voluntary evacuations have begun. The website notes dryly, “An evacuation may be complicated by the presence of the cholera epidemic in the Artibonite and plateau Central.” Also, disturbingly: “‘We have launched an appeal for voluntary evacuation, particularly in the camps,’ said Alta Jean-Baptiste, the director of the Haiti’s Civil Protection Office. ‘We have plans to evacuate the camps but we won’t be able to evacuate everybody.'”

Regarding the mortality rate, HaitiLibre notices a gap:

The average rate of deaths on the number of people infected (recognized cases) (1) between October 24 (assessment # 1) and October 30 (assessment # 8) is of 7.42 %, a rate abnormally high if one refers to the figures released by WHO. In 2008, about 56 countries (190.130 cases reported) 5.143 deaths reported (2.7% morality rate). WHO estimates on its website that the real between assessment of cholera in the world, amounting to 3 to 5 million cases and between 100,000 and 120,000 deaths per year (a mortality rate between 2.4 and 3.33%).

(But read the whole thing.)

Via H1n1, a physician’s account in Cité Soleil:

I have not checked one child who had a history consistent with cholera.

There are no confirmed cases of pediatric cholera in Saint Catherine’s Hospital in Soleil either. We admit our sickest kids to this hospital which lies across a field from the pediatric clinic.

However, the kids seems sicker than usual. Lots of malnutrition, diarrhea, fever, colds.

And we have about 5 documented cases of malaria each week at the clinic in the back of Soleil.

Port-au-Prince and its slums do not need a cholera epidemic. I can’t hardly think of a worse nightmare. Haiti is beyond fragile at this point and the people are suffering more than I have ever seen.

More resources:

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

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

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

Cholera, Haiti, Pan-American Health Organization, Port-au-Prince

[UPDATE: minor puncutation correction]