ARTICLE - A DOCTOR'S WORD: CHOLERA

A DOCTOR'S WORD: CHOLERA AND HAITI'S CONTINUING HEALTH NIGHTMARE
(New America Media)

New America Media, Question & Answer, Erin Marcus, M.D.

EDITOR”S NOTE: The Obama administration announced earlier this week that it is lifting its ban on deportations to Haiti. Immigration and Customs Enforcement says it expects to resume deporting Haitian immigrants next month—the one-year anniversary of the earthquake that killed more than 300,000 people. Human rights groups have criticized the move amidst a cholera outbreak, election-related violence and the ongoing devastation from the earthquake.

To hear more about the situation on the ground, NAM contributor Dr. Erin Marcus spoke with Dr. Andre Vulcain, co-director of the Justinien Hospital family medicine residency training program in Cap Haitien, a collaborative program between the University of Miami Haiti project and the Haitian Ministry of Health. He divides his time between Haiti and Miami and has advised the Haitian Ministry of Health’s HIV care program.

NAM: You recently returned from a three-week trip to Haiti, where you were treating cholera patients. What was the situation you faced during this most recent trip?

Vulcain: When they announced there was a formal epidemic, we started putting together an embryonic cholera treatment center in Cap Haitien even before [the epidemic] got there. We expected 25 to 50 patients a day, but there was a quick escalation of the epidemic. It was a very difficult situation. The center was designed for 200 to 250 patients and they were taking care of 600 patients.

The big problem was there were not enough trained human resources and not enough beds. I was in charge of a room with 80 patients with three to four nurses. Most of the patients we had were severely dehydrated, and 100 percent needed IV hydration. One week earlier, there was political agitation in the city, and for five or six days, people were staying home or people died in the streets. It was a very difficult situation, but I think our results were good because the mortality rate was maintained below 1 percent.

You were in Haiti during the earthquake, and treated thousands of patients in the immediate aftermath of the disaster. Do you see things worsening from a public health perspective?

Before the earthquake, the public health system was falling apart. Since the earthquake, things are more challenging. We had to divert energy to the earthquake effort itself. The fact that we have to concentrate on the cholera epidemic displaces attention from other healthcare programs, which are already weak. Now, on top of that, you have this election that went bad.

During the past 25 years, Haiti has made progress only in one major indicator of health care status—the infant mortality rate, which has been reduced by 50 percent for the past 20 to 25 years. All the other indicators, [such as] maternal mortality, malnutrition of children, are steadily going up. The maternal mortality now has reached an astronomical level. It’s over 600 maternal deaths for 100,000 live births—[and this was] prior to the earthquake.

What were some of the barriers you faced in caring for cholera patients?

The sheer number of patients was difficult to manage, even though the basic logistics were there. We definitely needed more human resources. But everybody was doing his best.

[More generally[, there is a lack of knowledge about cholera and skills among the health care workforce. This is the first time that we have had cholera in Haiti. We have started a medical education program that will train most of the providers. We think that cholera is here to stay in Haiti for a long time, given the conditions, so it’s important for the whole workforce to be familiar with the cholera epidemic.

What are some of the misconceptions people in Haiti have about cholera?

Some people thought you could contract cholera through the air, and on the street some people were wearing medical masks. But I think the education that’s being done has minimized that.

Some people thought that it could have been something intentional related to some political situation, or something else. The communities that are affected don’t spend a lot of time speculating about those things —they are more interested in how to protect themselves.

Cholera is, in large part, caused by inadequate infrastructure and unclean water. Do you see the epidemic abating anytime soon? Will it be possible for the government to end this epidemic soon, given the need for significant improvements in infrastructure?

Political instability has always had a negative effect on public health programs in Haiti. The ability of the state to provide for the needs of the people has been weakened. You need time to build a sanitation infrastructure. It’s not going to happen tomorrow, it’s more a long-term thing.

What changes have you seen in Haitian society since the disaster?

I think people’s fatalistic attitude has increased. The other thing that is worrisome is that you have so many people living in a tent-city culture. Even in the slums, there was some organization, there was some sense of community, you knew the people close to you. Under a tent, it’s a new environment, new people, way less privacy, you are constantly exposed.

It’s very concerning in terms of how it’s going to affect the values of this society, how people relate with other people, how people express their solidarity, how people are going to value self-reliance, because in those tents, people are totally assisted with food, water, medical care. A child who spends five years under the tent— what kind of mentality does he have, what does he think of life, what is his vision of normalcy when he grows up, what kind of contribution will he be able to make when his reference frame has been to live under a tent for so many years? It’s a big human issue.

Dr. Erin Marcus is associate professor of clinical medicine at the University of Miami Miller School of Medicine.