Cholera, Global Health, Public Health, Public health concern

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.

 

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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

 

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Public health concern

Is Port-au-Prince’s Environment Making Us Sick?

The original version of this article is published on Woy Magazine.

A few years ago, I picked the front seat of a tap-tap heading to Pétion-ville. As usual with these common public transportation vehicles, the old car hardly moved up the hill to my destination. A couple of minutes later, a truck with the sign “O-Lavi”, selling clean water across the city, drove past.  A thick line of dark smoke coming from its muffler spread in the air and through the tap-tap which had no windows. The passengers started coughing, including the driver who had to park the car for a while because the dark smoke prevented him from seeing the road ahead.

Since then, I’ve experienced such events more and more frequently, making me wonder if Port-au-Prince’s environment is becoming a source of diseases. In fact, 12.6 million deaths linked to the environment occur annually in the world.  Many of the causes are partly due to environmental hazards identified by the World Health Organization: air pollution, community noise and poor sanitation. In Port-au-Prince, exposure to such hazards is almost unescapable. So I decided to look into how environmental factors are potentially affecting the residents of Port-au-Prince.

Air pollution

Toxic gas emissions often pollute places where most people live, since they also attend their occupations there. These emissions usually come from vehicles engines or burnt domestic wastes. For example, when vendors setup their businesses along the streets, trucks or motorcycles regularly pass or stop nearby. When the engine is started, merchants and passersby often inhale expelled gaseous components. People who travel via public transportation also inhale these while  stuck in traffic, because tap-taps and other vehicles used for Haitian public transportation are usually semi-open.

According to a study published in 2016, children from lower socio-economic households have a higher risk of specific respiratory health problems due to traffic volume and air pollution exposure. Further research found that air pollution contributes to the development of asthma throughout childhood and adolescence. Even when no specific link between air pollution and respiratory infections has been established in Haiti as of this writing, the latter is one of the most common causes of death among children. Despite these heavy potential consequences, air pollution is never a lone factor.

Community noise

Often associated with heavy traffic, community noise increases with the fast urbanization of Port-au-Prince. Business development attracts more people to the city every year and results in more and more noisy traffic jams.  In many neighborhoods, street vendors using megaphones to attract clients, churches with loud sound system, or a motorcade with roaring sirens are common occurences. In fact, the typical street scene in Port-au-Prince produces a cacophony. But the absence of a proper legislation shows the little importance attached to community noise.

In such environment, the level of stress among most people can quickly rise; especially among the poorest who tend to live in cluttered neighbourhoods. A study conducted in Ghana in 2015 revealed that occupational noise might increase the level of a stress hormone and the heart rate consequently. In my opinion, similar results can be found in Port-au-Prince. Overtime, this lifestyle might lead to a heavy burden of cardio-vascular diseases.

Poor environmental sanitation

Besides air pollution and community noise, poor sanitation is another environmental factor impeding the health of the population in Port-au-Prince. The remoteness of certain neighborhoods usually leaves little access to the city’s trash collectors. The high price of private services is often a barrier for many. So, people frequently fill the nearest gully and even the main roads with domestic wastes. When they don’t burn it, the trash remains in the communities for days. So as one goes through the streets, it is not uncommon to notice plastic bottles, used tires, or a dead animal among the wastes. Sometimes, even human feces stain the sidewalks, possibly a consequence of 6.3% of households in the metropolitan area having no toilets. The rain might easily carry away the wastes, polluting clean water sources.

The lack of a proper waste management system has made Port-au-Prince more vulnerable to the rapid spread of the cholera epidemic since 2010. It also opens doors to other diarrheal diseases- less known- affecting most children and malaria which is endemic in Haiti. Furthermore, a Zika epidemic to which poor sanitation is a vehicle is currently unfolding in Haiti, affecting thousands of people so far. Most of the people affected live in Port-au-Prince.

If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

On my way back from Pétion-ville that day, the bus I rode in trudged on despite the apparent malfunctions of the engine. Along the road, people went about their daily activities with no worry about any threat. Usually, the three factors described in this article here combine to provoke the worst. But life goes on in Port-au-Prince inside the smog filled air and ambient noise, merchants lay their foods on the bare ground, among garbage and dust. This is the daily life of most of the population amidst a lack of medical services. Actually, considering the potential impacts of air pollution, community noise and poor sanitation, the environment of Port-au-Prince suggests that the population’s health is unlikely to improve in the next few years. In hopes to reverse this trend, the public health and prevention advocates must join hands with environmental activists to fight these threats. If we are willing to leave a healthier Haiti to the future generations, it starts with the courage to assess where we are and come together to change it for the better.

Paradigm shift

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