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Cholera in Haiti: A Look From the Trenches

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To learn more about the current health situation in Haiti, I recently spoke with Dr. Andre Vulcain, co-director of the Justinien Hospital family medicine residency training program in Cap Haitien. Justinien Hospital is Haiti's second largest public hospital, and the residency is a collaborative program between the University of Miami Haiti Project and the Haitian Ministry of Health.

Dr. Vulcain divides his time between Haiti and Miami and has advised the Haitian Ministry of Health's HIV care program. He was in Haiti during the earthquake, and provided immediate care in the aftermath of the disaster.

Dr. Andre Vulcain

Q. 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?

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 was not enough trained human resources and not enough accommodations in terms of 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 one percent in the whole center.

Q. 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 health care 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.

Q. What were your primary objectives in treating cholera patients?

When you are dealing with cholera, you have to work with a two-pronged strategy. The two main things are first, that the patient needs to be treated to prevent fatality -- that's the medical care. (It) is not rocket science -- IV hydration for the patient who is severely dehydrated, or oral hydration salt for the patients who are moderately or lightly dehydrated.

The second aspect, which is very important, is to try to block the transmission of the cholera in the community, so you need to work on the education of the community and also, more challenging, see what you can do in the short term to mitigate the sanitation problem. Access to clean water is important.

We had mass communication education, and a lot of people were aware of what's going on, but you also need the kind of education that comes with a demonstration of what needs to be done. So what we did and what a lot of organizations are doing was to send community health workers who can teach people to make sure they understand how to apply preventive measures.

Q. 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.

Q. What are some of the misconceptions people in the U.S. may have about the cholera epidemic? Would you say things are better or worse than they are being depicted in the media?

From what I saw before I traveled to Haiti, the coverage was reasonably fair. I didn't see anything that was grossly distorted or any kind of misinformation. I have noticed since I came back that the election in Haiti has replaced cholera as news, so they don't talk a lot about the cholera epidemic. But it's still a serious situation and we will have to go two to three more months before seeing it subside totally. Eventually we will have to face the endemicity of this epidemic.

Q. 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.

Q. 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.

Q. Did you have any concerns about your personal health as you cared for cholera patients?

I had some concerns. Even in the center, the sanitation wasn't optimal. The patients were on plastic sheets on the floor and I had to kneel to start IV's and to examine patients. Basically, I abided by some specific rules. I tried to never touch my face or mouth with my hands. Every hour or so I went outside of the tent, where you can wash your hands with chlorine solution.

Every day before leaving the center I decontaminated the soles of my sneakers. When I arrived home, I had a bucket with chlorine water into which I dropped my scrubs overnight for disinfection. I took good showers with a lot of soap. I think that those measures are very effective. The key is your hands, because that's what brings something to eat into your mouth, so I made sure my hands were constantly being washed and I never touched my face.

Q. 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.

A similar version of this article originally appeared on the New America Media website.

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