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Health in Haiti: Lessons to Learn for National Public Health Week 2010

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Co-authored with Pamela Savitz, Kate Pitts, Timothy Dempsey, Julia Liebner, and Anita Verma

A series of earthquakes have recently shaken the world, taking a traumatic toll on communities globally. More than half of the 130 cities worldwide with populations of over 1 million people are built on fault lines, making them susceptible to the calamitous impact of earthquakes, as witnessed in the recent events that occurred this Easter Sunday in southern California and Mexico as well as those that struck over the past several months . With 57 deaths following the March 8th earthquake in Turkey, 531 left dead after the February 27th quake in Chile, and an estimated 250,000 dead following the January 12th Haiti disaster, vulnerably located nations must be prepared with emergency response plans and strong public health infrastructures. Unfortunately, these natural disasters often occur in settings that are already shaken by financial instability and poor health systems. Haiti, a nation now devastated, had a weak public health system as well as a fragile economy when a 7.0 magnitude earthquake struck and shook Port-au-Prince on January 12, 2010. This traumatic event required extensive short-term emergency response efforts, but has also dramatically increased the need for health services and a strong public health infrastructure for the long term. With the United Nations Donor Conference pledging $15 billion last week, $9.9 billion of which is being allocated toward long-term reconstruction with the United States committing $1.15 billion over the next two years, it appears this urgent need will eventually be met.

The extent of Haiti's devastation can be seen not just through the rubble, but also in the economic and public health data detailing the damage from the quake. The earthquake has been more destructive than the Indonesian tsunami of 2004 and has caused five times more deaths per million inhabitants than the 1972 earthquake in Nicaragua. It has destroyed over 75 percent of Port-au-Prince, including 250,000 houses and most government buildings, injured at least 250,000 people, and displaced 1.5 million more who are now forced to live in make-shift tent camps. The Haitian government has assessed the death toll to be between 200,000 and 250,000 people with the potential to reach or surpass 300,000.Costs related to damage from the earthquake have been estimated at $13.9 billion, twice the amount of Haiti's annual GDP.

The earthquake has all but broken parts of this frail nation, exacerbating pre-existing conditions and creating new challenges as well. Even before the earthquake, Haiti had experienced social and health challenges in addition to facing severe economic problems. In 2006, Haiti spent just $96 per capita per year on health care (compared to the United States' annual per capita health spending rate of $8,160), and only 1 in 50 Haitians had steady employment. In a country so impoverished, where 80% of people were indigent before the quake struck, it is easy to see how the health of Haitians has also become quite poor. Infectious diseases are the leading cause of death for infants and children in this country, and HIV/AIDS is the number one killer of adolescents and adults. As people are forced to live in crowded makeshift camps with unsanitary conditions in the earthquake's aftermath, the threat of tetanus, typhoid, gastrointestinal infections and other water-borne communicable illnesses, such as malaria, looms dangerously close as the rainy season approaches this May. Furthermore, children, who comprise 40-50 percent of the Port-au-Prince population, are among those most at risk in disaster situations. Because their immune systems are less developed than adults, they face a range of threats, including malnutrition, acute respiratory infections, diarrhea, and susceptibility to illness resulting from a lack of availability of vaccines to protect against childhood diseases. Prior to the earthquake, only 58 percent of Haitian children under age 1 were immunized against diseases such as measles and tetanus.

The earthquake and subsequent aftershocks also had a devastating impact on Haiti's infrastructure for safe water sources. Thus, conditions will only worsen for the 250,000 left without shelter unless a public health system is developed. Sanitation is not the only concern for Haitians now residing in tent cities with limited resources. Once nightfall arrives, women face the constant fear of rape and attack. To make things worse, the earthquake destroyed many of the rape counseling centers including Haiti's Ministry for Women's Affairs, which was in the midst of implementing its five-year plan to reduce violence against women. Currently steps such as the distribution of solar flashlights and rape kits, along with providing better lighting and security patrols have been implemented to protect women in the camps.

While media coverage and relief efforts often focus on immediate support to provide food, water and medical aid, interventions are also needed to prevent the spread of another kind of wound caused by the wreckage -- the mental health effects of this traumatic event. The mental stress of the earthquake's victims must be emphasized and integrated into the reconstruction of Haiti's public health infrastructure. Hopefully, these needs will be addressed when allocations of the recently pledged $15 billion from the United Nations are prioritized and distributed. In disaster situations, three groups are particularly vulnerable and deserving of aid. The first are those who suffer from pre-existing mental illnesses such as schizophrenia, autism, mood and anxiety disorders. Their illnesses may be exacerbated when access to care and medication is lost. The second and largest group is comprised of those who may develop post-traumatic stress disorder from the devastating nature of the circumstances or whose illness is exacerbated following the event. Measures must be taken to provide these people with interventions and support. The third group consists of the immediate responders who face the horror of traumatic emergency situations and suffer from the emotional consequences of these experiences. Mental health interventions are under way with the assistance of the Pan American Health Organization (PAHO) and the World Health Organization (WHO) that are forming a working group to develop a long-term strategy for a more decentralized system of service delivery, as well as training new mental health professionals.

Another major concern in rebuilding Haiti lies with the estimated 100,000 amputees and the thousands of people with serious wound infections that could lead to amputation in the future. Since an estimated 2% of the population now has an amputated limb, the demand for prosthetics outweighs the incoming supply, and rehabilitation services are limited, innovative solutions must be developed to tackle this new public health problem for the nation. Already in place to aid amputee victims are physical therapy efforts established by Handicap International, University of Miami, and Healing Hands in over half of the existing 91 hospital facilities to aid the victims. Experts have suggested establishing a large-scale prosthetic industry and rehabilitation center in Haiti.

Priorities for rebuilding a stronger Haiti start with building the foundation for a modern, sustainable public health infrastructure. The Centers for Disease Control and Prevention (CDC) has described areas of long-term focus that address the need for water and sanitation, health care, food, verifying the status of health care facilities, assisting in supporting health care services, and providing health education to the people of this distressed nation. Social and economic needs, such as building schools, churches, and health facilities, must also be addressed so that aid provides both immediate relief and also establishes the foundation for rebuilding a nation that had only a marginally functioning public health system to begin with.

Since the quake's strike in January 2010, aid and relief efforts have found their way to Haiti with the help of several countries. An estimated $2 billion had already been pledged internationally in February before last week's United Nations Donor Conference, which promised an additional $15 billion to provide relief efforts to Haiti. With the help of volunteers from NGO's including the Red Cross, UNICEF, Save the Children, and other partners, over 400,000 adults and children have been vaccinated against diseases such as measles, diphtheria, pertussis, and tetanus. While cases of acute respiratory infections, acute diarrheal disease, and tetanus have been reported, as of February, the numbers do not reach epidemic standards. The World Health Organization has reported that there are currently no increasing trends in disease outbreaks, and that widespread vaccination campaigns were successful in preventing them. To combat the prospect of a malaria outbreak during the upcoming rainy season, thousands of anti-malarial bed nets have been distributed in addition to programs financed by The Global Fund to Fight AIDS, Tuberculosis and Malaria that have supplied emergency anti-malaria drugs. Long-term goals are also being considered. Last week, Haiti's Prime Minister and 300 Haitian and international experts at the United Nations Donor Conference presented a post-disaster needs assessment that requested not only food and supplies, but also called for a reconstruction of the country's social, economic, and health systems over the next five, ten, and fifteen years.

To truly improve the health of Haitians, the social and economic drivers of disease must be addressed. This means providing educational and occupational opportunities for all, as well as establishing a sustainable, modern public health system. The public health lessons learned from this and previous disasters such as the tsunami of 2004 should be remembered and collected to inform future emergency response efforts in other nations. The creation of a web-based global resource bank that includes best practices and protocols in disaster response for all agencies of government, in collaboration with NGO's, outlining their roles and responsibilities, is needed in order to more effectively respond to events that might occur in the months and years ahead.

As Louis Pasteur said, "Chance favors the prepared mind." Today as we mark the beginning of National Public Health Week 2010, let us learn from the Haitian experience to help rebuild this country as well as put in place emergency preparedness and response plans to diminish the impact of natural disasters that may occur in the future around the world.

By Susan J. Blumenthal, M.D., Pamela Savitz, Kate Pitts, Timothy Dempsey, Julia Liebner, and Anita Verma

Rear Admiral Susan Blumenthal, M.D. (ret.) is the Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, and Chair of the Global Health Program at the Meridian International Center.

Pamela Savitz, a senior Biochemistry major and Federal Semester Fellow at the University of Maryland, College Park, is a Health Policy Intern at the Center for the Study of the Presidency and Congress in Washington, D.C., and will attend medical school next year.

Kate Pitts, a Master of Public Health candidate at George Washington University, is a Health Policy Fellow at the Center for the Study of the Presidency and Congress.

Timothy Dempsey, a Master of Public Health candidate at the Dartmouth Institute and a recent graduate of the University of Pittsburgh, is a Health Policy Fellow at the Center for the Study of the Presidency and Congress. He will be attending Robert Wood Johnson Medical School next year.

Julia Liebner, a recent graduate of Stanford University, was a Health Policy Fellow at the Center for the Study of the Presidency and Congress.

Anita Verma, a recent graduate of Stanford University, is the Special Assistant to Dr. Blumenthal and a Research Associate at the Center for the Study of the Presidency and Congress.