Cholera's Knockout Punch to Haiti--November 2010

 

Cholera’s knockout punch to Haiti

By Catherine Porter

Fri., Nov. 26, 2010

FERMATHE, HAITI—Rosemene Meristil carries a large pot brimming with water atop her head and gingerly navigates the rocky path to her home. She’s knocked on the gate of a neighbour’s mansion up the road to ask for dlo — water — from their cistern.

When I ask her to take me there, she shakes her head. “It’s not safe for you,” she says. A few days ago a group of white hikers a few kilometres up the mountain were attacked by a crowd claiming they’d come to poison their water with cholera.

The disease is spreading quickly through this country, the fear galloping ahead.

When the nearby Baptist mission hospital opened a small cholera clinic last weekend, a crowd of anxious parents protested in the parking lot. Just three patients have been admitted so far, but the hospital administrator expects more.

Everyone expects more.

Nobody knows where the disease came from. Nobody knows where it will hit next. Authorities know how to contain it — with chlorine and soap — but the message is outpaced by the disease, which can kill in hours, and many can’t afford those things anyway.

Most, like Meristil, are water-dispossessed. Their huts have no taps. They beg or buy their water from private tankers or kiosks that aren’t regulated by the government, or they take their chances and drink from pipes emerging from the ancient underground water system.

Meristil steps into the muddy yard beside the family’s temporary, two-room stone house and lowers the bucket for today’s bathing, cooking and cleaning. She follows the local church pastor’s instructions and adds three drops of bleach. Then, when her daughter Lovely returns from school, she calls her over to wash her hands in a bucket of sudsy clothes.

Her family has outlived the earthquake, and the hurricane. Meristil hopes they will survive Haiti’s newest deadly threat.

“We’re still praying to God to keep cholera away from us,” she says.

The fear was cholera would reach down from Haiti’s rural central plateau into the squalid tent cities — and it has. The country’s humanitarian chief says that if all preventative and responsive measures are “ratcheted up to a whole new level,” the country can hope to stem the deaths to 4,000.

“If there’s less effort, there will be 10,000 deaths,” says Nigel Fisher, the UN’s deputy special envoy in Haiti.

There’s a desperate need for more treatment centres. For more chlorine tablets and soap to be distributed. More doctors and nurses. More advertising to get victims to seek help earlier, and to sterilize the stigma around the disease.

But how to fund it? So far, only 10 per cent of Haiti’s $164 million cholera appeal has been delivered. And what of the millions raised in January and February by international aid groups, much of it unspent, Fisher asks.

This does not bode well.

Strangely, the earthquake has protected the capital from cholera to a degree. Many of the 1.5 million people living in refugee camps pinched into every available opening here have better access to clean water, toilets and health care than they did before. It’s the sprawling slums that are the main concern.

They have all the ingredients for an outbreak: crowded shacks, no toilets, few NGOs bringing in chlorinated water, fewer health centres.

Many of the first cases in this city emerged in the ragged outcropping of Wharf Jeremie, a port jetty overwhelmed by metal patchwork shacks. Thousands of people live here and none have a toilet, says Sister Marcella Catozza, an Italian Franciscan nurse who established a small health clinic in the area five years ago. They relieve themselves in the gutters and marshy outcrops, she says. When they have money, they buy untreated water in bags because it’s cheap.

“Cholera kills people here easily. They aren’t strong. They have worms. They’re malnourished. Three bouts of diarrhea,” she says, slapping her hands together, “and it’s over.”

Six people died here the first day cholera struck. Dead bodies greeted Catozza at the gates early one morning, so she decided to open the clinic at night. Two weeks ago, 156 bodies sprawled on the floor inside. Many of them died. But over the past few days, the situation has calmed. Locals, she says, are coming for treatment sooner.

The non-profit organizations she’s been begging to help for five years have finally arrived. Workers with the Brazilian organization Viva Rio started carting in plastic barrels of treated water. They’ve erected two banks of portable toilets and are paying locals to clean them with bleach each day. This month, they’ll build three biodigesters which will transform the human waste into methane gas to feed a planned communal kitchen.

 

It’s a brilliant, but expensive — the bill is $92,460 U.S. — solution for a country with no sewage system.

“People go in the street, all the shit goes everywhere, and now it’s a disaster,” says Mattia Vianello, assistant sanitation coordinator at Viva Rio. “We’re solving the problem at its root.”

He means this: cholera is caused by a bacterium that thrives in water contaminated with human excrement. No matter how it arrived here — through an infectious UN Nepali peace keeper, as many believe, or a sick aid worker, or changes in weather conditions, as some scientists posit — it came through infected fecal matter that got into the Artibonite River, which many on the central plateau use as their drinking water.

No one has determined how the disease seeped to the capital, although the city’s first cases were people returning to Port-au-Prince from the north. If they emptied their bowels near a local drinking source or washed feces-contaminated hands in a communal water supply, they would have spread the illness.

The country’s small elite have septic systems below their houses. But most people, like Lovely’s family, go to the washroom in makeshift privies they empty into the ravines.

“All the spring water is contaminated with not merely biological agents, but also chemical agents,” says Evens Emmanuel, a professor of water and waste water treatment at Haiti’s Quisqueya University and the director of the city’s only water quality lab. The groundwater is no safer, he says, as limestone cracks allow surface water to drip below.

The government presented a sanitation master plan in 1998, Emmanuel says. But it was never implemented. Local incompetence or corruption alone were not to blame: a $54 million loan from the Inter-American Development Bank, earmarked for planning a waste water system and improved potable water access in 15 town and cities around the country, was blocked by the United States as part of its informal embargo against the left-leaning Jean-Bertrand Aristide government, a 2008 report concluded.

By 2008, close to 70 per cent of the country’s population couldn’t access clean water, the report by Partners In Health and two American legal groups states. The number of people in the country with septic tanks decreased by 162 per cent between 1990 and 2006.

So, like the earthquake before it, the disease comes as a second punch. Natural disaster — wham — and then epidemic — knockout.

“HIV kills people who are immune-depressed,” says Dr. Anany Gretchko Prosper, looking over at a young mother who after vomiting profusely into a bucket has now claimed a bed inside the small cholera clinic his organization, Partners In Health, has set up on the edge of the city’s second-biggest refugee camp. “Our country’s sanitation and hygiene system is immune-depressed, so we have cholera.”

“Some people are too weak to stand up and go to the toilet,” MSF’s Aurélie Baumel tells me as we rinse our hands under one spigot of chlorinated water after another. “It’s sudden and it’s very fast. They don’t have time.”

The tragedy of death from cholera is that it is so easy to treat. No chemotherapy or blood transfusions, just some sugar and salt and clean water. Even severe cases require only IV fluid with potassium mixed in and one round of antibiotics.

“We have 50,000 cases a year in Bangladesh and nobody dies,” says Dr. David Sack, an international health professor at Johns Hopkins University who ran the International Centre for Diarrhoeal Research in Dhaka until 2007. “Seventy-five per cent of the people arrive at the doors with no pulse or blood pressure. We have them going home within one to two days.”

The problem for many in the far-flung regions of the country is reaching a clinic on time. But in the city, where many have been set up, it’s fear and stigma that hold people back. Many hide their disease at home until it’s too late, and they die of complications caused by severe dehydration — a heart attack or renal failure.

A two-year-old boy sat alone on a cot in the Tabarre camp, his parents having fled two days earlier in fear. Mechanics demanded surgical gloves and face masks to change the oil of the Partners In Health ambulance. The mortuaries and cemeteries have refused to take bodies. The fear is loaded with memories of the first appearance of AIDs.

They cut through the traffic like a convoy of the dreaded Tonton Macoute militia — eyes following them fearfully, mouths whispering “ale kolera.”

They charge up a hill in the poor neighbourhood of Carrefour-Feuilles, and scream to a stop before a small lottery ticket stand, where a crowd has assembled. The body of a 57-year-old street vendor is stretched along the sidewalk in a fresh set of clothes, his eyes glassy, his feet bare.

Members of the team leap from their vans, trucks and one tap-tap (shared taxi) lined with a silver tarp, then pull on their poor man’s hazmat suits — rubber boots, rain jackets, surgical masks and chemistry lab goggles. As the man’s daughter, Nadine Joseph, pleads with them, they spray the area with heavily chlorinated water and then shower her father’s body. One rolls his head to one side to stuff chlorine-soaked cotton balls into one ear and then the other, before moving to his eyes, nose and finally his open mouth. Mercifully, they do not remove his clothes, although many bodies they find are naked, and they stuff the anuses too.

They bind his legs with blue flagging tape, cross his arms and then lift him awkwardly into one body bag and then another.

I imagine if this was my father, doused and stuffed for all to see on the street. It is too much to bear.

“It’s not cholera. It’s not cholera,” his daughter wails. “He had a heart attack this morning on the way to the hospital.”

Her mother has ordered a coffin.

“Why are they treating my dad this way?” she says, tears welling in her eyes. “My dad died. I want him to have a funeral.”

Of course you do. But cholera affords no dignity. The city is in a panic, and no one is taking any chances.

“Why was the body left on the side of the road?” asks Hanz Legagneur, sanitation director for the province, when I call him later. “It’s very difficult.”

His team was attacked a few days ago by a crowd that thought they’d come to drop bodies off. They’ve learned efficiency. They load Mr. Joseph into the back of the tap-tap, and scream off to the next stop on their morbid procession, as his daughter scrambles behind them to flag down a motorcycle taxi. She wants to follow his body, but traffic is too chaotic, and she loses them before the next stop.

By the end of the day, the crew will have collected more than a dozen bodies — one of them a half-naked man found among the rats and garbage in a ravine and yanked up onto the road by his feet by firemen.

They trundle them onto the national road north out of town to Cabaret, the only local jurisdiction that to date has accepted cholera’s victims. There, Mr. Joseph and the others are dumped in a pit — no ceremony, no farewell wave.

Just down the road is Titanyen, the traditional burial site for the Duvalier regime’s tortured opponents. It was there that many of the 300,000 people killed in the earthquake were carted last January.

It’s become a tradition in this country.