Disease Surveillance: Lesson From Haiti

One morning, I went with two colleagues to Haiti’s direction of epidemiology in order to collect information for a research project. As we enjoyed some local coffee with a familiar executive at his office, he instructed us about “the good old days of disease surveillance in Haiti”. This is how he referred to the era where people from remote communities themselves reported cases of malaria to concerned authorities. They would cross through villages to identify people who were suffering from fever in their homes, he said in a melancholic tone. The past years, my research works allowed me to learn, through such anecdotes, about the systems we have set up to observe the dynamics of diseases in Haiti. While he spoke, I observed with no great surprise that the walls of the office were garnished with many US CDC (Centers for Disease Control and prevention) logos. But I couldn’t help wondering in my deeper self, how can global efforts learn from Haiti’s history of epidemiologic surveillance.

While there are many definitions for epidemiologic surveillance, the authority for this matter in the US- which is the CDC– considers it as the continuous collection of health information and their dissemination to stakeholders in order to make public health decisions. This process lies at the heart of a common commitment that some countries and institutions made in 2014, through an initiative called the Global Health Security Agenda. They work to ensure a level of preparedness to face global health threats similar to the Ebola epidemic that happened in Western Africa from 2013 until 2016. Local surveillance and global security are thus intertwined.

In Haiti, although the US military used sanitary surveys to assess the country’s situation during the 1915 occupation, a site-based surveillance system has been created only in 1990, thanks to the support of various NGOs. In fact, these organizations have been operating in Haiti since the 1950s. But soon after a coup-d’état exploded in September of that same year, the deteriorating political situation has occasioned an abrupt halt in foreign aid, crippling the public health surveillance system. Later, foreign partners supported the Haitian Institute of Childhood in relaunching the surveillance of the following conditions : malnutrition, vaccine-preventable diseases, diarrhea, acute respiratory infections and cholera.

The Direction of Epidemiology, Laboratory and Research where I was discussing with my colleagues, is now in charge of epidemiologic surveillance. The CDC and a couple of NGOs are its partners and help bring modern diagnostic tools and technologies and contribute to the training of public health professionals. The cooperation with the CDC was crucial in the aftermath of the earthquake in 2010- because many infrastructures were destroyed- and the introduction of cholera, months later. Moreover, it allows for the surveillance of polio, malaria, tuberculosis, HIV infection, respiratory diseases among other diseases and the launch of a bio-safety laboratory recently. It is worth mentioning that some NGOs run independent surveillance systems or activities whose priorities are not necessarily aligned with Haiti’s vison. From the 1990s to this day, such foreign entities have played a major role in Haiti’s epidemiologic surveillance. It has resulted in a lack of sustainability and State ownership over that matter.

This history hence raises the question of Haitian sovereignty. How can foreign actors intervene so largely in this sector ever since epidemiologic surveillance started here? Who set the priorities? How does availability of international funds affect it? In fact, with progressing globalization, sovereignty can no longer be assessed through the lenses of the past centuries world, marked by violent conquers. Some common issues call for a shared responsibility and thus comes a shared sovereignty. But such interdependency does not have to favor the donors and leave the beneficiary of aid vulnerable. It needs to respect and promote local culture, language, history and institutions. As Dr. Nahid Bhadelia put it in a tweet, “the global health security agenda is as much an insurance for the resource rich world as it is for the global south… We need to address the question of inequity in trade and how we support development of stable national governance.”

And we can’t “technicalize”/medicalize all solutions. We need to address the question of inequity in trade and how we support development of stable national governance (though US has no moral high ground on that right now!)

— Dr. Nahid Bhadelia (@BhadeliaMD) February 28, 2018

This is the ultimate lesson Haiti’s experiences of disease surveillance can bring to the current global efforts even though the country is not a member of the security agenda. While it soon passed midday, I cheerfully thanked our host at the office for his hospitality and the coffee. What I learned beyond the malaria anecdote and through the days following that conversation, is that Haiti’s epidemiologic surveillance has always been an object of foreign influence, although such entities perform on a global scale. At times, it was left vulnerable. But with respect to Haiti’s identity, the limits can be overcome for a globally healthy future.

On The Miscalculated Fear Of An Opioid Crisis In Haiti

Opioids are an essential class of drugs used in pain management. In recent years, complex mechanisms pertaining to their abusive use have prompted a deadly crisis which still unfolds in the United States. The US Centers for Disease Control and Prevention stated that 91 Americans lose their lives daily due to an overdose of opioid drugs. This public health crisis has inspired much apprehension even among Haitian diaspora in the United States. Although needed painkillers are notably lacking in developing countries, the fear of a similar path has led a high-profile personality to advise against their use in Haiti. Indeed, health professionals are alarmed about the addictive potential of opioid drugs used in the long run. But such fear-mongering statement could do more harm than good, especially for many suffering patients who desperately need opioid drugs. It also impairs trust in regulatory efforts to prevent drug misuse.

I often recall the days when René was hospitalized in Cap-Haitian’s hospital Justinien. What had him bedridden was a rare bacterial infection known as necrotizing fasciitis (or flesh-eating disease) which means that his right leg’s soft tissue was quickly dying. His daily wound care was particularly painful because a doctor or nurse had to unstrap his sticky bandage and clean all along under his skin, with no painkiller prior to or during the intervention. René used to scream his lungs out. In developed countries, patients are admitted to a specialized unit for such procedure and are given morphine (a common opiate) for pain relief. That wasn’t a chance available to René and many other patients who presented with acute conditions such as road injuries or bone dislocation. The lack of strong painkillers also affects chronically ill patients and those requiring palliative care. Patients dying from gastric cancer could suffer unbearable pain in their last days, relying only on first line painkillers. According to a study conducted in 2015, analgesics of all kind are available only in 63.8% of health centers in Port-au-Prince. When opioids are available, their use is strongly regulated.

Read my article on how we can fight drug resistance in Haiti

In Haiti, a collaborative initiative led by the Pan-American Health Organization is responsible to create a national list of essential drugs among which analgesic opioids are listed. They also procure from international market at low cost and distribute them through State-run institutions and programs and registered-NGOs, under regulation from the national department of drugs and pharmacology. In most institutions, prescription and acquisition of morphine requires filling a special record cart detailing the patient’s information, reasons to use the drug and the prescribing doctor’s signature. It helps to promote a rational use of such medicines. Despite these mechanisms, a parallel and less regulated market of pharmaceuticals has developed in Haiti which exposes people to unsafe products. However, there’s close to no empirical evidence that opioid drugs are sold over-the-counter on the street market or that over-prescription of such drugs is prevalent at large scale.

A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking.

It doesn’t mean that misuse and addiction to opioid drugs never occur in Haiti. This is why appropriate education is mandatory to mitigate such serious risks. Medical and pharmacological associations and societies in Haiti have the duty to address the use of medicines, train doctors and nurses and communicate in effective and innovative ways with the population. A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking. On the other hand, fear-mongering statements made by influencers have the potential to alter trust in regulatory efforts to promote a rational use of opioid drugs and put patients at greater risks. To maintain or regain that trust might be a new challenge for the national department of drugs and pharmacology of Haiti.

Lia’s Mental Battle After Her Pregnancy

I was once greeted at the home of a young woman named Lia who was bedridden since her recent delivery. The narrow, uneven staircase leading to her 3-piece apartment, on the second floor immediately struck me. Three plastic chairs and some dusty decorations adorned the living room. I was climbing the shaky staircase when her husband Manno appeared to welcome me. The couple was forced to marry 4 years prior, to escape public shaming when Lia unexpectedly became pregnant with their first daughter Zina. Zina was inside, busy undoing her braids. She was so unusually calm and silent that Manno asked her if everything was alright, with a strong smell of alcohol on his breath. Although she appeared serene, in reality, she was feeling like her world was crumbling ever since her mother, Lia, gave birth to her little sister, since then Lia’s behavior had started to change.

Manno led me into the bedroom where Lia was resting. A dirty-white mosquito net covered the bed. Children toys and elementary school books stood on cupboards and small tables. I quickly understood that the entire family was living in the same small space. Lia stared aloofly at the ceiling. The newborn girl was laying down to her left. While Manno was getting me a chair, I noticed how Lia dropped quick frightened glances towards the baby from time to time. As Manno entered the room again staring down, ashamed, Lia uttered insulting and incoherent words and even threatened to choke her own newborn baby. Manno instantly presented his deepest apologies to me, for his wife’s delirium. But I wasn’t surprised at all because I am familiar with such symptoms- confusion, paranoia, agitation, hallucinations and sleeplessness– evocative of a post-partum psychosis, which is a psychiatric illness affecting some women after delivery.

Friends and family think that jealous neighbors took advantage of Lia’s pregnancy to cast a spell on her. Her father has even proposed that she travel to the North of Haiti to find him, to try to ward off this miserable fate. In the northern town where Lia’s father lived, he was very respected thanks to his land, livestock and his expertise in traditional medicine, despite his proclaimed Christian beliefs. Manno informed me that even the doctor they contacted in Port-au-Prince had recommended they go visit a hougan, a Vodou priest that sometimes serves as healer. It is difficult to be clear about the impact of traditional or religious practices on mental illnesses (especially if these diseases are observed from the perspective of Western medicine, as in my case), but I am, nonetheless, aware that they are often the only resource for people suffering from such diseases in Haiti, especially in remote areas. And, Lia or her entourage’s interpretation of her disease, whether it may sound irrational to you or not, is already a step towards treatment. How she understands her disease is important to her healing. If she thinks it is a supernatural misfortune, her caregiver should not disregard her conception.

However, in my mind there was no supernatural misfortune. Unwanted pregnancy, a history of chronic major depressive disorder or depression during pregnancy remain factors that make many women vulnerable to mental illness after childbirth. In fact, although these factors are numerous  (biological, psychological and social), in Lia’s case, the living conditions were the most likely cause. Many stressors in her life as a Haitian woman, as a wife, as a mother, as an employee, were always present prior to her pregnancy, but were perhaps seen as isolated situations that have all now bubbled to the surface. Many Haitians are fragmented in this way, as sections of their history are separated but yet unknowingly linked, and can be a source for many ailments.

Read about unwanted pregnancy and abortion in Haiti here

To provide some context: poverty affects more than 80% of the Haitian population and social exclusion and alienation often go hand in hand. Despite counting for 56% of the population, women are too often denied the most basic rights. When it comes to mental health, such a context is hardly favorable. Opportunities for prosperity are available to the few who have had access to the right education, those who can take advantage of a broken system and the very few born within a supportive environment. On the other hand, elements that could promote resilience and health, such as family support, are rare or poorly integrated.

But, in Haiti, the relationship with mental illnesses is difficult even among the more privileged. No matter the systems of thought, traditional or modern, most of the times, patients are simply dismissed as “mad” or possessed by an evil spirit, regardless of the mental illness the individual suffers from. Local obstetricians (in case of pregnancy-related mental illnesses) and mental health professionals, psychiatrists and psychologists, struggle to address the most pressing health issues concerning women. Numerous medical NGOs also support maternal health in Haiti. But while they often heal the body, mostly focusing on communicable diseases, the mind is highly overlooked. So women usually don’t freely express their real preoccupations and needs, reinforcing the barriers to proper care.

The last time I asked after Lia, she had joined her father’s lakou in the North and was taking pills prescribed by a psychiatrist while simultaneously going through mystical treatment. I was happy to hear that she was doing better. That was good news for her baby. But as I said goodbye to Manno and he replied, the scent of his breath reminded me of someone I had forgotten to ask about. “How’s Zina doing, by the way?” I asked as memories of her sad face resurfaced. – “She’s doing good replied Manno, she’s at school right now, I took her this morning. With Lia gone, I’m the one taking care of her” he added. I nodded with the largest smile I could muster and told him our traditional.  “ankouraje.” But I left with a heavy heart, full of fear and prayer for Zina.

Climate Change, Migration and Healthcare in Gonaives

In 2006, I spent my first night in Gonaives during a trip from Port-au-Prince. Hurricane Anna and Ike were two years away from burying the city under water one more time. All I knew about Gonaives at the time was its historical significance as the site of the very first declaration of Haiti’s Independence. But after participating in a recent study on cholera in Gonaives, I have gotten a clearer image of not only the city, but of the impact of climate change on urban development, and its consequences on healthcare accessibility. I believe traditional medicine can help reduce this problem.

Gonaives is Haiti’s third most populated city, sheltering 356,324 people as of 2015. According to ESA Consultance’s recent study (which I contributed to), Gonaives is at an important crossroad for commerce from the northern region of the country towards Port-au-Prince, the capital. The concentration of public services in the city attracts people from all over Haiti. Despite its demographic and geographic importance, Gonaives is infamously vulnerable and weak in the face of natural disasters.

In the 1970s, many countryside citizens began moving to urban centers to work in the then booming manufacturing industry. Although population movement continues to happen, employment is not its only guiding force. According to the International Organization for Migration, rural-urban movements in Haiti are often due to environmental events. My experience in Gonaives taught me how climate change contributes to inflate the city’s population.

People who live in vulnerable areas in dry seasons move up to the hills, in neighborhoods in the periphery of Gonaives, to be safe from floods during the rainy seasons. The impact of hurricanes Hanna and Ike in 2008 influenced Gonaives’ population increase and even forced the emergence of new neighborhoods. The city’s population almost doubled from 2003 to 2015. As a matter of fact, between 1954 and 2012, no less than 19 major hurricanes have affected Haiti. Due to persistent vulnerabilities and fiercer hurricane seasons (maybe due to warmer temperatures), such disasters will continue to haunt us. With category 5 hurricane Irma currently approaching Haiti, vulnerable populations are still ill-prepared. How does this affect population health?

As cities expand, services such as clean water, sanitation, and healthcare become less accessible, since the existing structures fail to match the growing demand. In a 2000 national survey in Haiti, they determined that a large number of people consult traditional healers when they are sick before they turn to a physician, because of the former’s proximity to the people.  Trends in drugs sale in cities like Port-au-Prince show that most drugs are available over the counter and sold in the streets. Self-medication is also an essential option for Haitians when it comes to treating an ailment. Leveraging self-medication to bridge the gap in healthcare accessibility is not the answer. However, traditional medicine might be worth considering, as it is already playing an important role in the care system in general, particularly in the work being done to eliminate cholera.

Let me explain through an anecdote. Most traditional healers, like one middle-aged woman whose presentation on a panel I recently listened to, draw a line between what she called “natural cholera” and one they consider “mystical.”  According to her, “mystical cholera” is mild diarrhea that lasts a few days unlike “natural cholera” which kills within hours if left untreated. When people come to a Lakou or Vodou temple for treatment for “mystical cholera,” the mambo said, they are treated with starch, molasses, and a little nutmeg. If this does not improve the person’s condition, they refer him/her to the closest hospital or health center. In my professional opinion, mystical cholera does not actually exist, but the natural remedies used to treat it are perfectly suitable for healing many kinds of diarrhea. Fortunately, most healers know how to recognize symptoms of actual cholera, provide first aid and oral rehydration and redirect people to cholera treatment centers.

The lesson here is that as a part of the healthcare system in Haiti, traditional healers can leverage their know-how regarding natural treatment and their proximity to a large part of the population to improve access to care. But the department of pharmacopeia and traditional medicine of the Ministry of Health needs to do more extensive work, by surveying and training the traditional healers and promoting their expertise locally. But, being a tradition rather than a formal profession, traditional medicine could pose some challenges as the practices are not backed by a uniform and evidence-based science.

Given the continuing increase in global temperature, it would be delusional to imagine Haitian cities less vulnerable to natural disasters as they continue to expand. Haiti signed the Paris agreement, which propels initiatives to empower peasants and fight the effects of climate change. Therefore, despair is unnecessary. As stated on a lotto stand during one of my visits, we need to prepare for tomorrow Panse ak demen. Climate change will continue to disrupt our society and the accessibility of health care. This liability can be turned into an opportunity to build upon the knowledge and position of traditional healers to close the gap. Traditional medicine and community members can be among the most important steps towards progress.

Published on Woy magazine before Hurrinace Irma hit Haiti on September 7, 2017

A tale of two Haiti(s)

My brother Keddy and I grew up in Karenaj, a then hassle-free neighborhood in the world-renowned city of Cap-Haitien. Although our family had relatives in Saint-Michel de l’Attalaye, an Artibonite county south of Cap-Haitien, we lived far removed from rural Haiti, except for a few sporadic trips to “andeyò” which is the term Haitians use to refer to rural areas. It’s a Kreyòl word derived from the french “en dehors” translated as outside. So my twin and I, we were raised unfamiliar with most traditional food and to a greater extent, the language and culture of Haiti’s rural regions with their complexity and richness.

When our grand-mother passed away, I could feel that the few stories of Saint-Michel along with anecdotes of our elderly’s rural trips had also vanished. But now, as adults and doctors, we’ve managed to visit the entire country apart from Grand-Anse, either during professional endeavors or on personal adventures. As far as we could tell, decades later, differences still persist between how us, city-raised gentlemen, perceive and express reality and how rural populations do. Not only the rhetoric differs but the very elements of culture struggle to collide. During our trips, those gaps even impaired our ability to communicate with the locals. In terms of local tourism, this situation wouldn’t be much of an issue. But consider the heavy toll of such discrepancy when it comes to patients explaining their symptoms or when it comes to us doctors communicating health risks and treatment options.

In the 1970s, as Haiti’s agriculture sector plummeted, people massively moved from rural regions to adjacent towns in search of a better life. Throughout the decades, the dynamics of rural exodus have only made this transit skyrocket. More than half of Haiti’s population now live in cities. Needless to say that the emigrants carry what they have accumulated as a cultural background with them. The vacuum left by such demographic movement and social context leaves the rural areas very vulnerable. Which in turn often leads to city dwellers, with their own culture, to commute to rural areas for work-related projects, many of them provided by NGOs. This is how we found ourselves on a day-to-day journey trying to comprehend each other.

In rural populations, overcoming issues such as academic illiteracy or comprehending the beliefs in magico-spiritual forces is often a pre requisite for creating rapport and therefore to have impact on a patient’s health outcome. But some other concerns are subtler. I recall having examined an old woman named Annia in Saint-Antoine, a neighborhood next to Poupelard avenue, in Lalue, Port-au-prince. The old woman was from the South and had settled in Saint-Antoine less than 2 years prior to her consultation. Visibly uncomfortable, she described her pain to me in those words: as if a stack of millet was being pounded upon with a big pestle. She made it clear: – “The big ones Doc, not the small ones”. Coffee is very much engrained in every Haitian’s life and I’m very familiar with scenes of people pounding coffee roasts in big pestles, it happens in rural zones as in certain towns, but I sure had no idea as to what it feels like. And can’t obviously make the difference between the big and smaller ones, except for their size. While I was expecting her to describe her symptoms using my words, she relied on images of her daily life. As she spoke, even though we speak the same language, I could feel the gap between us widen and as if we were losing each other.

Keddy has also experienced such “language barrier” when he asked a patient from a locality near Montrouis, when she’d last had her period and she casually replied: – “On the last moon”. While he was anticipating an exact date, ignoring when the last moon was or even what that actually means.

It’s not a mere matter of language (French versus Kreyòl) as the concern is raised ad nauseum but instead a collusion between two different cultures, impairing understanding and proper health communication between two people speaking the same language.

These cultural barriers to communication stress the difficulties to assess and address health risks in patients and communities alike. I remember visiting Maniche with a team of Port-au-prince-based health agents. Most of them were hailed from this very Southern locality, and although our job was to raise concern about the safety of a water source, because they used to drink it and were actually baptized in these waters in their youth, it became harder for them to question its quality. The same goes for patients suffering from high blood pressure who dismiss any change in the way they prepare food because they’ve been taught a particular way by a parent since they were kids. Habit is more powerful than science and without the psychological tools of social and behavioral change communication the work of healthcare providers might as well be for naught.

I went back to Karenaj recently. As I sat in furniture that feel older than the city itself, I was thinking that until we reduce the gap between urban and rural realities we will not be able to understand each other, recognize what puts us at risk and heal our common evils. As I thought of my conversation with Annia and the way many pride themselves as educated, I asked myself if we were hardly doing any good. What good is a doctor’s vast knowledge if he can’t even understand his patient, let alone help her improve her behavior? There is not a single way to resolve these differences. But if we at least stop considering distance as difference, maybe we can start learning and improving together.

Questioning Ban Ki Moon’s plan to address cholera in Haiti

Lately, a spotlight has been placed on the United Nations in Haiti. Outgoing Secretary-General, Ban Ki-Moon has delivered pivotal statements at the General Assembly and via the Miami Herald concerning the UN’s response to the cholera epidemic in Haiti. Right now is as good a time as any to remember the critical work that has already been done to eliminate the disease, long before Ban Ki-Moon’s big statement.  Right now is as good a time as any to remember the fact that Haiti’s future lies only in our own hands.

Before 2010, cholera, which mostly affected Asia and Europe centuries ago, did not exist in Haiti. It was imported from Nepal in October 2010 because of the continuous dumping of feces into a river by UN peacekeepers based in Meyes, near Mirebalais, in central Haiti. Weak hygiene and sanitation conditions since the beginning of the last decade, partly due to political instability, facilitated the rapid spread of the disease to the rest of the country. This shows the UN’s direct responsibility in the emergence of the disease in Haiti, a claim which epidemiologists have backed, and which the UN has fiercely denied and hidden over the last few years.

In 2016 the United Nations has suddenly changed their posture in regards to their role in the spread of cholera in Haiti and their response to the epidemic. The first hint at this change of heart came in a report by Philip Alston, a UN adviser criticizing the organization for its disastrous response. “The UN’s explicit and unqualified denial of anything other than a moral responsibility is a disgrace,” he stated. In early December this year, 6 years and thousands of deaths later, Ban Ki-Moon apologized to the Haitian people for the role his organization played in bringing cholera to Haiti.

In his Miami Herald Op-Ed, Ban Ki-Moon revealed the outline for what he called a “new approach to right a wrong” in Haiti. This approach revolves around intense response to outbreaks, reparations to the victims’ families, and long term development strategies to provide safe water to the population. As a physician familiar with the Haitian government’s already laid out plan to eliminate cholera by 2022 and the ongoing instrumental work of human rights advocates to hold the UN accountable, I struggled to find what was new about this proposal. Is the UN simply publicly parroting the existing national plan to eliminate cholera, or are they finally heeding the victims’ unceasing call for justice?

At the beginning of 2013, while the United Nations was still denying responsibility for the outbreak, the Haitian government with support from various international partners, initiated a 10-year cholera elimination plan, with a short-term component ending in 2016. At the time, many criticized this plan as being too broad. Among other things, it aimed to guarantee access to drinking water for 80% of the population. That was quite impossible in the planned timespan, given the lack of resources.

In fact, in 2014, Haiti came close to eliminating cholera. Were it not for repeated cases of vandalism on water systems in several regions among other factors, the strategies put in place would have been successful. The Ministry of Public Health and Population (MSPP) and the National Direction for Drinking Water and Sanitation (DINEPA) have learned from these experiences, and launched the mid-term part of the plan in August 2016 (before the UN’s change of stance ) with support from partners including UNICEF. This part focuses on axes similar to what Ban Ki-Moon introduced as the UN’s new approach: water and sanitation, healthcare services and management, epidemiological surveillance, health promotion, hygiene and nutrition.

While he did acknowledge the ongoing efforts against the cholera epidemic, the public health orientation Ban Ki-Moon outlined in his op-ed is not different from what has been laid as the basis for every actor in the national plan. His proposal uses the language and solutions proposed by advocates that the UN spent the last 6 years denying. Looking back, the path we have traveled in this fight is paved with lessons for Haiti as well as for the world. The General Assembly has agreed to support the new plan to eliminate cholera in Haiti, but I will not forget where the crucial work began and continues. As I continue my travels through various Haitian communities as a Haitian public health researcher or for personal activities, the notion that Haiti’s future lies only in our hands will remain a dear mantra.

Many thanks to Nathalie Cerin for the fantastic editing of this article.

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A Path to Fighting Cholera in Haiti After Hurricane Matthew

The rain was pouring as the car rolled towards Hinche. Kal and I were leading a team of doctors and researchers on a week-long investigation of factors related to the cholera epidemic in Haiti’s Center department a few weeks ago. As we went along the road, we could only look as far as five meters ahead due to heavy rainfall. I vaguely recalled hearing of a Hurricane Matthew forming in the Atlantic Ocean a few days before. The rain beating down on the area known as the “Bas Plateau” (Southern region of the Center) gave me a glimpse of the massive environmental and health consequences such a hurricane would bring to Haiti. My anxiety increased knowing that this specific department was the first, and one of the most severely, affected by the cholera epidemic ever since it was introduced in Haiti in 2010 due to improper waste management by UN peacekeepers.

Hurricane Matthew mostly devastated Haiti’s Deep South, affecting nearly 80% of homes in Jeremie, a coastal town in Grand Anse. Crops, livestock and drinking water systems also perished. As foreseen by health authorities and the population, outbreaks of cholera, which is endemic in Haiti seem to have quickly risen in several localities of the South peninsula. In light of my experience on the field in the Center, I propose a few strategic insights pertaining to cholera elimination in the aftermath of this disaster.

Decision making and public health interventions are more likely to be successful when they include members of the community served.

That is to say, the people from there who hold an attachment to that particular region, who maintain hope in the face of adversity and challenges as in post-Matthew Haiti. In my opinion, the water and sanitation technicians of the municipalities known as TEPACCs embody this idea. They are residents of the respective communities they serve. Oftentimes university students or local professionals, they are responsible for listing water sources and oversee the management of sanitation structures in the most remote areas of the country. The TEPACCs are widely responsible for the safety of the water consumed by most of the population and ensuring that waste is properly disposed.

These workers are familiar with all the localities and their physical and structural characteristics. During our time in Mirebalais, the TEPACCs Grandin and Cameau,  guided us to the remote areas, and informed us on the unspoken truths of these places where cholera has remained for 6 years. The cholera efforts and results all around the country would be far more effective if they were provided the necessary equipment they often lack such as, motorcycles so they can access remote areas easier, computers and cellphones to facilitate communication. In the aftermath of Hurricane Matthew because so many water sanitation structures have been destroyed, offering more resources to the TEPACCs is crucial.

The epidemic situation in the Center also reveals the vulnerability of specific regions where cholera persists in Haiti. Floods may have worsened the contamination of water sources in the South, as shown by more than four hundred suspected cholera cases, unconfirmed as of this writing. However, the focus should not be taken off previously identified zones of cholera persistence such as specific towns or regions in the North, Center, Artibonite and West even when they were not the strongly affected by Hurricane Matthew. Studies show that these zones of persistence play an important role in re-emergence of cholera during the rainy season because the transmission lingers even during the dry season. The increased cases during the rainy season such as the situation in Randel (South) right now- where an outbreak erupted even before the hurricane- is nothing but a mere consequence of cholera enduring in Haiti for 6 years. So, in addition to the added risk that Hurricane Matthew brought, these preexisting persistence zones remain the pressure points on which our attention should remain if we hope to eliminate Cholera on the island.

The reconstruction of water systems and protection of sources should indeed take into account these towns whose vulnerability have not decreased after Matthew. In Mirebalais, I visited a Cholera Treatment Centre (CTC) where there were more than a hundred cases in the last three days at the time of my visit. An officer of an international organization working with outbreak response teams on the field reminded me that the epidemic had been raging long before the hurricane. It is imperative that we do not forget that.

 

La Theme River. Photo credit: Karolina Griffiths

In such a context, I do not share the opinions of some of my colleagues who dismiss the importance of vaccination, thinking it would be a waste of time, money and energy. As a matter of fact, the World Health Organization pledged one million vaccine doses to Haiti that 500,000 people could benefit from. Vaccinations may not the cure to the epidemic, but they can help save precious time and resources while we focus on strengthening our response capacity to outbreaks, improving access to safe water and sanitation, and educating at-risk populations especially in a post-disaster context. Education is crucial for behavior change, because many still believe that “cholera is spread through the air.” One man told us these words right before he nonchalantly dove in the Artibonite River that visibly contains dirt and sewage from the marketplace, the slaughterhouse and the prison.

The effects of Hurricane Matthew will be long term. The challenges of eliminating cholera by 2022 are uncountable. Based on my experience in research on the determinants of the cholera epidemic in the Center department alone, I foresee the benefits of strengthening the TEPACCs in their role, keeping epidemiologic surveillance in known areas of cholera persistence in Haiti and seizing this opportunity to vaccinate at-risk populations to prevent new cholera infections. This will be a heavy task, but this is a time where we, as a people, cannot afford to sink into fatalism or complacency. Hurricane Matthew is surely a step back, but it is also an opportunity to push Haiti forward towards progress and sustainability.

Read the original version on Woy Magazine