Haiti, Coronavirus, and Enlightenment--March 2020

 

Hospital in Southern Haiti–Photo by John Carroll

“One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.”

Dr. William Osler

I am not an epidemiologist nor an expert in public health. My job is to evaluate single patients and determine if they are sick or healthy. I am not used to thinking of the collective health of millions (or billions) of people.

However, thanks to the Haitian cholera epidemic early last decade, I was forced to think in terms of a big population of people who were made ill by the cholera bacteria after it was released by UN forces into a river in central Haiti.

So I am going to ask some questions below which will PROVE that I am no expert in public health regarding the coronavirus pandemic and how it pertains to Haiti.  And  I am sure my questions and comments can easily be answered by the experts.

Two days ago, the Haitian government announced the first confirmed coronavirus cases in two people in Haiti. This, of course, is not a good thing and Haitians are afraid as they should be. The coronavirus is easily transmissible and has a case fatality rate that is supposedly 10X that of the flu.

Haiti’s President Jovenel Moise has declared a state of emergency and he told a news conference that all of Haiti’s ports, airports, and borders would be closed to people from midnight on Thursday, though they would remain open for goods traffic. And Moise has invoked a curfew.

But I want to know if any of this will work.

Why have flights to Haiti been stopped as of yesterday? Is it to stop the traveler to Haiti who is considered high risk for having and spreading the virus? I guess this makes sense, but if Haiti’s coronavirus outbreak takes off now like it has done in multiple countries in the world, does it make sense to restrict flights? In other words, is walling Haiti off really very helpful in controlling the virus?

Haiti does not have a functional health care system on a good day let alone a system that can effectively fight this virus. State-run hospitals are frequently on strike, and they often lack basic services. Critical care beds in Haiti are limited and there are an estimated 100 ventilators available for 11 million Haitians.

So should we turn our attention from hospitals and ventilators to preventing the disease in the first place? That seems reasonable but is the prevention of coronavirus transmission possible on an industrial scale in Haiti?

During the last few weeks, we have all learned about the concept of “flattening the curve” regarding coronavirus infections. But I want to know if the usual public health interventions will work in Haiti during this pandemic. In other words, should Haiti be subject to containment policies or to social distancing to flatten the curve like we are attempting to do in the United States?

Why do we want to flatten the curve with coronavirus infections? My understanding is that flattening the curve will not stop the virus; it’s likely the same number of people will ultimately still get sick. But it could mean the difference between a manageable surge of patients and one that overwhelms scarce resources, resulting in unnecessary deaths.

And this sounds good. But are all these efforts worthwhile in Haiti?  Is it worthwhile to flatten the curve in Haiti in order to protect Haiti’s scare resources which hardly exist in the first place?

Consider the very important Community Health Worker (CHW) in Haiti during the days of coronavirus. He or she needs to be paid and protected with the critically important Personal Protective Equipment (PPE) to walk around the slum in 95-degree heat.

And this specially trained CHW will do public health surveillance to see if people could have Covid-19.  And if they meet criteria, then what?

There is no treatment in Haiti that will be accessible by the masses. But there is quarantine to stop transmission. But how do we isolate people in the Haitian slum where the population density is so high and people need to have human contact in order to survive?

So let’s say the CHW identifies a family of 10 in the slum who all have mild  signs and symptoms of Covid-19. Does the CHW advise them to stay quarantined in their one-room shack for 14 days? I don’t think this will work because the breadwinners in the house need to score some bread because they all need to eat.  And this family’s neighbors next door don’t have the time or abilities to help out because they have equally severe challenges surviving the slum also.

And would identifying people in the slum as possibly having coronavirus put them in danger of being attacked?

Without social distancing, the virus will spread quickly in Haiti and live under the big mean curve we have all come to abhor. But under these circumstances, is this the better more humane curve for Haiti? Wouldn’t it be better for Haitians to get sick at once, develop herd immunity, and be done with this horrible virus?

Maybe it is not quite this simple. I am open to enlightenment.

 

John A. Carroll, MD

www.haitianhearts.org

8 thoughts on “Haiti, Coronavirus, and Enlightenment”

1. David Volk

2. says:

3. March 21, 2020 at 10:20 pm
   Good questions.
   Reply

4. Kyle Ramsey

5. says:

6. March 22, 2020 at 12:01 pm
   You’re concerns are valid. Most everything that works in the US will not work in Haiti. As just one example, social distancing would be nearly impossible. The average Haitian cannot stock up on supplies and hunker-down. The often over-crowded conditions, the absolute need to be out and about for most Haitians in order to survive, the under-nourishment and malnourished population, the lack of things we take for granted related to personal protection (routine access to clean water and soap for hand hygiene for example) will all make this a poor outcome for Haiti. This is just as you predicted a few weeks ago.
   Reply

1. John Carroll, MD

2. says:

3. March 22, 2020 at 2:24 pm
   Thanks for reading and for your comments, Kyle.
   Reply

7. Monique Germain, RN, MS, CNE

8. says:

9. March 22, 2020 at 6:37 pm
   This is a very important discussion. What we should encourage the people of Haiti to do is to routinely practice basic public health principles. If we focus on infection control every single day (regardless of the presence of Covid-19 or not), we will be able to prevent certain diseases that occur on an everyday basis. I remember the days we use to worry about TB occurrence in Haiti. People did not understand the importance of avoiding coughing in the presence of each other. Let alone the cultural practices that sometimes conflict with what good health practices are but also the environment not lending itself to self-discipline.
   Although health care workers are challenged to facilitate the implementation of good health principles, we should provide them all the support they need to work and educate. This is a humongous task we are charging the health care workers to do. Thinking population will keep us focused.
   Thank you for initiating this discussion.
   Reply

1. John Carroll, MD

2. says:

3. March 22, 2020 at 9:36 pm
   Thank you, Monique.
   Reply

10. John Carroll, MD

11. says:

12. March 22, 2020 at 9:53 pm
    “In contrast to hand-washing and other personal measures, social distancing measures are not about individuals, they are about societies working in unison. These measures also take a long time to see the results. It is hard (even for me) to conceptualize how ‘one quick little get together’ can undermine the entire framework of a public health intervention, but it does. I promise you it does. I promise. I promise. I promise. You can’t cheat it. People are already itching to cheat on the social distancing precautions just a “little”- a playdate, a haircut, or picking up a needless item at the store, etc. From a transmission dynamics standpoint, this very quickly recreates a highly connected social network that undermines all of the work the community has done so far.”
    Jonathan Smith–Epidemiologist/Infectious Disease
    Reply

13. Anonymous

14. says:

15. March 27, 2020 at 7:15 pm
    Sir, I am a woman living in Kentucky who went to Port-au -Prince to bring a gift to a children’s home and be of service. This was in May of 2011. Even in the short time I was there the devastation impacted me. Although I’ve had no ongoing contact with anyone from Haiti, from time to time I think of them and pray for them. Today is one of those times.
    I am healthy and those around me are. Our governor has been praised , which he deserves, for aggressively mandating social distancing and isolation. Yet I , myself, can’t help but wonder how this all works and where this all leads. When do we know that it is “safe to come out”?
    I still have a critical doctor appointment which I will keep. I have to go to the store or send someone. I know that this is not about Haiti that I am speaking, but I myself am wondering , is this all over with when the population has all slowly gotten it? And if we just stay apart aren’t we just postponing the inevitable? I don’t understand at all. Does someone gave an answer for me?
    Reply

1. John Carroll, MD

2. says:

March 29, 2020 at 12:41 pm
This article explains the big picture regarding pandemics. Social distancing is a means of slowing the transmission of disease so the health capacity of a country is not overwhelmed. Thanks for your comments.
https://thehill.com/opinion/healthcare/490028-anticipating-the-next-waves-of-covi