January 30, 2011

Haiti 2010 © Aurelie Lachant/MSF

The MSF CTC in Cap Haitien

In the immediate aftermath of last January’s earthquake, when hundreds of thousands of people were stepping through rubble and taking shelter in ad hoc displacement camps with grievously substandard hygiene facilities and little or no services, the potential of an outbreak of disease was a major concern. Months went by without it coming to pass, though, which seemed like a rare victory for the battered population.

In September, however, word came from the Artibonite region in central Haiti, north of the capital, that patients were presenting with cholera-like symptoms. Cholera had not been seen in Haiti in many decades, but the signs—rapid and severe dehydration caused by excessive vomiting and diarrhea—were all too apparent.

Knowing that the post-earthquake conditions in the country were ideal for cholera to work its way through significant portions of the population, a four-person MSF team quickly responded, traveling to the town of St. Marc on October 21, the day after initial reports were received, to confirm the diagnosis as best they could. They didn’t have access to lab testing, but the symptoms and progression fit, and they could see that many patients needed assistance right away. MSF immediately opened a cholera treatment center (CTC) in the town of St. Marc. “The most important thing is to isolate the cholera patients there from the rest of the patients, in order to best treat those people who are infected and to prevent further spread of the disease,” Federica Nogarotto, MSF’s emergency coordinator in St. Marc, said at the time.

Haiti 2010 © Benoit Finck / MSF

A public information campaign in the Artibonite region.

As it got to work, the organization had to keep one eye on the treatment of the sick in Artibonite and the other on the immediate area and other parts of the country, scanning the terrain for any new cases. Preparations were made in the capital: 10 beds were set aside for cholera treatment at St. Louis Hospital and 25 beds at MSF’s facility in Tabarre. Extra supplies were sent into the country as well, along with a nineperson emergency team that could respond as needed. As it happened, more cases presented in St. Marc, as well as nearby Petite Riviere, and then in Gonnaives, forcing teams to rapidly scale up their capacity in the region. Next to experience the outbreak were the northern cities of Cap Haitien, Port de Paix, and Gros Morne, beginning on October 29. Three members of the emergency team went to the north, and at one point, sending the entire emergency team up there was considered. They stayed put in the capital, however, in what would later prove to have been a prudent move.

At this point, it was clear that the cholera outbreak was going to require a large-scale response across several sectors. And then, on October 31, large numbers of patients began coming to the CTC at Tabarre in Port-au-Prince with the symptoms of cholera.

The transmission dynamics were nearly impossible to predict because there were no models for cholera in Haiti, noted Dr. Greg Elder, MSF’s Deputy Operations Director. Aside from saying that it was likely to spread widely in a country where most people lacked access to clean drinking water or sanitation, where the population was unfamiliar with the necessary prevention measures, and where national health staff had no past experience with the disease, there was little to go on. Further complicating the issue was the fact that it was extremely difficult to determine whether or not the numbers being reported by the health ministry were comprehensive. MSF could really only count the people showing up at its own facilities and work from there.

There was no question that the caseload was growing. In the capital, the number of people seeking treatment at MSF-run and supported medical structures jumped from 350 for the week ending November 7 to 2,250 the week ending November 14. And in the north, MSF teams logged 280 cases during the week ending November 7, but that number jumped to 1,200 for the week ending November 14. And they continued to grow after that.

What’s more, people were becoming increasingly frightened and angry. Treatment for cholera is straightforward, but when an unknown and fatal disease suddenly presents itself, even the heartiest of populations can be rattled. The UN was the main target of opprobrium, but MSF’s work was affected as well. On October 26, a molotov cocktail was thrown at an MSF structure in Petite Riviere, forcing a temporary suspension of activities there. “The ultimate consequence is that we are now unable to respond to the cholera outbreak in the Artibonite region in the most effective manner and under the best possible conditions,” said Francisco Otero, head of MSF’s emergency response in St. Marc. Later, Cap Haitien was rocked by two days of riots during which two people were killed. Efforts to transport patients and dead bodies in ambulances were complicated when some vehicles were pelted with rocks, though MSF vehicles and facilities were left alone, and the organization was able to carry out its work. The prevailing unease spread elsewhere, however, and attempts to open CTCs in certain Port-au-Prince neighborhoods were delayed by resistant local communities. (Violence hit the capital again after the results of the first round of the presidential election were announced in early December, but MSF teams were once more allowed to cross barricades that had been placed in the streets and continue their work unimpeded.)

Haiti 2010 © Ron Haviv/VII

A mother and her child at the Bicentenaire CTC

Nevertheless, MSF set up 20 CTCs in the country not long after the middle of November and 40 by early December. Oral rehydration points were set up in all the affected areas as well. Some 3,300 beds were set aside for cholera treatment, and as of mid-December, MSF had provided care for more than 62,000 people.

Finding the people to provide that care—and to carry out information campaigns about the disease—was no easy task. Cholera treatment is relatively simple for the patients, involving rehydration and antibiotics. Often, patients can go home after two or three days. But responding to an outbreak is extremely labor intensive. One staff member is needed for every five patients. Patients must be tended to day and night. Huge amounts of fluids must be brought into facilities and administered on a regular basis, and a great deal of waste must be disposed of. And if patients die, the bodies must be removed and a host of other procedures followed, all of which require medical and paramedical staff to carry out the work.

MSF hired and trained hundreds of new national staff members, but the organization nonetheless struggled to keep up with the growing caseload. Increasingly, it seemed as if other actors were not doing as much as they could, that there were too many meetings occurring without enough action. An MSF press release on November 19 stated that “despite the huge presence of international organizations in Haiti, the cholera response has to date been inadequate in meeting the needs of the population.”

Whatever the reasons, it was affecting both treatment and prevention efforts and delaying urgent sanitation and hygiene activities, provision of clean water, and other crucial measures (According to one calculation, more than 9,000 beds would be needed if the worst-case scenario came to pass, something beyond MSF’s ability or resources to provide). Soon after the press release was issued, a high-level MSF delegation that included Dr. Unni Karunakara, president of MSF’s International Council, traveled to Haiti to lobby the Haitian government, UN agencies, and others to increase their activities related to cholera.

MSF, meanwhile, continued to scale up activities, focusing on case management and making more beds available—while also making sure that noncholera activities continued as normally as can be. As of early December, the cases in the north seemed to be stabilizing, with around 80 new cases emerging per day. In some opinions, that meant another six to eight weeks or so before projects in the north can be closed. Others think it will still be several months. And that could be affected by what happens in Artibonite, if the cholera spreads into the west and south (as it seems likely to do), and by what occurs in Portau- Prince, where dynamics could be different from neighborhood to neighborhood (the slums, for instance, have thus far been harder hit than the displacement camps because the camps have received more and better services from aid groups). There seems to be a consensus that the cholera response in the capital will have to last several more months at the very least.

In a smaller outbreak, MSF would be as focused on trying to break transmission as it is on treatment, carrying out community awareness and education efforts, distributing water, and so forth.

In this situation, though, it has been necessary to decide how the organization can be most effective given the resources it has. MSF is doing prevention work, and it continues to engage in a wide range of information campaigns, but, in the main, it has focused on serving the most severe cases, on saving lives, while hoping other actors will fill in the gaps elsewhere. “If that doesn’t happen,” said MSF Operations Manager Duncan MacLean, “the cases will perpetuate themselves.”

Early supply issues appear to have been solved. Staffing is in much better shape than it was. Some of the education efforts are proving effective as well. But challenges remain. More than 2,000 people had died as of early December. Tens of thousands had been affected, and on November 24, the Pan American Health Organization, which was taking a prominent (if not necessarily a leading) role in coordinating the response, raised their estimate of how many people they thought would ultimately be affected from 200,000 to 400,000. Given what Haiti has already endured this year, one hopes the worst has passed. But in 2010, such optimism was repeatedly proven premature.

By the end of 2010, MSF estimates it will spend all of the $138 million donated by private supporters for the earthquake relief effort and the cholera outbreak response in Haiti. As of October 31, MSF had spent $104 million of these funds. MSF estimates it will spend a total of $124 million in 2010. The remaining funds raised for Haiti will be used to mobilize MSF’s cholera response. MSF estimates it will spend approximately $14.2 million on cholera emergency programs in 2010. Another $9.9 million is projected to be required for cholera treatment in 2011.

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