American Indians and Haitians--Power of Community Medicine--July 2020

 

Mother and baby in Cite Soleil (Photo by John Carroll)

The July 2 New England Journal of Medicine has an e article titled “Contact Tracing for Native Americans in Rural Arizona”. The authors describe the way their response plan works regarding Covid-19 for the 18,000 Native Americans they serve in eastern Arizona.

The article states:

“After watching Covid-19 push the capacities of larger, better-equipped hospital systems, we knew that a surge of cases could easily overwhelm our small facility. Helicopter transport to a tertiary care center takes hours, and such facilities could quickly reach capacity from local admissions alone. We developed an aggressive, integrated early-response plan that relied heavily on contact tracing to limit the spread of Covid-19.”

The authors also report that so far they have had good results with their tracing teams:

“More than 1600 cases of Covid-19 have been diagnosed on the reservation served by our hospital, with only one of these patients being intubated in our emergency department. Of some 400 patients who needed hospitalization, nearly half have been transported to facilities that provide higher-level care. Our community’s case-fatality rate so far is 1.1%, less than half the rate reported for the rest of Arizona.”

As I read this article, it is obvious that this “Arizona approach” could be widely adopted in Haiti to serve 11 million Haitians.

In the paragraphs below I have put in italicized type the authors’ statements and then my thoughts on how and why this could and should be done in Haiti.

Crowded home environments are a part of life in our community. It’s not uncommon for eight or more people to live in a two-bedroom house, so self-isolation is nearly impossible. Several families in our community set up camping tents in their yards to quarantine infected household members, but the sharing of bathrooms and eating utensils contributed to secondary household attack rates above 80%. Nearly every household here includes a grandparent, and many include a great-grandparent. It’s rare to encounter a patient with Covid-19 who doesn’t live with at least one high-risk person.

Crowded home environments are the norm in Haiti, also. And self-isolation is almost impossible.

Identifying high-risk patients who would benefit from early intervention became our top priority. Our tracing team went from asking, “Where have you been?” to asking, “Who are your grandparents?” We perform rapid testing of newly identified contacts, and a team of clinicians visits people who have tested positive as often as every day. Public health nurses call high-risk people who have been exposed to Covid-19 but tested negative to verify that they are remaining asymptomatic throughout the incubation period.

Why doesn’t Haiti have tracking teams also? The Haitian government would have to fund MSPP for this. Thousands of people would have to be trained to identify contacts in the slum and if people are sick with Covid-19, the team would need to notify clinicians. These clinicians would need to assess and examine sick folks to determine who could remain at home and who needed to be treated at a clinic or hospital with oxygen. High-risk people would need to be checked each day.

This type of intensive outreach effort is important for two reasons. First, several people in our community have had cases of “happy hypoxemia,” with little awareness that they had a serious respiratory disease. Waiting for patients to seek care only when symptoms become intolerable reduces the utility of most interventions. By detecting hypoxemia sooner, we can start patients on oxygen and, in some cases, keep them at home.

Hypoxemia refers to low oxygen in the bloodstream. And oxygen is easily measured with pulse oximeters that are non-invasive, cheap, and battery operated. This outreach effort could easily be done in Haiti, also. To wait until people are very low on oxygen and “circling the drain” in Haiti does not work…not only for Covid-19 but for any critical illness. Most Haitian hospitals do not have critical care, intensivists, or the technology necessary.  Prevention in Haiti, as anywhere, is cheap and much more effective than waiting too long.

Any success is due in large part to strong partnerships with tribal leaders who have acted decisively to curb the spread of infection, supporting social-distancing measures despite obvious challenges. In addition, our hospital and clinicians have built a level of trust with the community that we do not take for granted.

In Haiti, the community workers could be from these very neighborhoods where they would work, and could educate the people on the reality of the virus and thus help attenuate the dangerous stigma associated with the virus.

There is absolutely no reason this community approach with tracking teams could not be successfully implemented in Haiti. Most people sick with Covid-19 do not need sophisticated technology such as ventilators. But many people do need to be screened to see if they are candidates for oxygen and other therapy which can be life-saving.

 

John A. Carroll, MD

www.haitianhearts.org