Haitian Voices--December 2019

July 13, 2021

Haitian Voices--December 2019

Cholera Victim, Hopital Albert Schweitzer–July 9, 2011 (Photo by John Carroll)

Louise Ivers and colleagues published an article in 2018– ‘It was a ravage!’: Lived experiences of epidemic cholera in rural Haiti. In their research, they interviewed 55 Haitians living near the epicenter of the cholera outbreak. They wanted to hear the voices of people trying to survive the largest cholera epidemic in modern times.

My post below references this work along with my anecdotes from having worked in five Cholera Treatment Centers (CTC) in Haiti, including one in the Artibonite Valley where the research originated.

“In October 2010, a major epidemic of cholera began in the Central Plateau and Artibonite Valley of Haiti when Vibrio cholera was introduced into an extensive river system by United Nations peacekeepers. The outbreak rapidly spread to all 10 departments in the country within a month. In this population, with no prior exposure to the disease and insufficient safe water and sanitation infrastructure, the impact was devastating. In the first year of the outbreak alone, the Haitian Ministry of Health reported over half a million suspected cases and nearly 7000 deaths. Public health efforts have slowed the epidemic in the subsequent years, but by 2018, there was a total of 819,777 cholera cases and almost 10,000 deaths had been recorded.”

What did the Haitian people think was the cause for cholera? Ivers research revealed that …”lacking previous exposure to epidemic cholera, most (Haitians) remembered an attribution of the first cases and deaths to ‘malefisans’(maleficence): the deliberate use of witchcraft or ‘poud’, a disease-causing powder purportedly lethal following contact.”

“At the time, in October [2010], we were in the fields and a man named Jean…they came back with him very sick. ‘Se te dyare, vomisman’ [It was diarrhoea, vomiting]…But his family thought that something else was happening with him…like a ‘poud’ used on the streets…a ‘malfesan’ [maleficent person] attacking him.” (Female homemaker)

And early on in the epidemic, some Haitians thought of cholera as just another diarrheal disease that afflicts poor Haitians downstream from the Artibonite River. However, “As the outbreak rapidly expanded across localities, these initial views were largely abandoned and replaced with news reports or rumours tracing the source of the epidemic to a contamination of the Artibonite River.”

During my time in 2011 at the Hopital Albert Schweitzer Cholera Treatment Center in the Artibonite, we were seeing 300 new people a day with mild, moderate, and severe cholera. And we admitted only those patients who were so ill that they needed IV hydration.

It was not uncommon to be surrounded by five or six semi-conscious people who had just arrived at the CTC—all of them slumped in a chair or lying on a gurney. We started IVs immediately in these sick patients (and even did chest compressions as needed). We then manually squeezed in liters of fluid as quickly as the vein would accept it.

Most cholera victims, even the sickest of the sick, woke up and survived. One young lady received over 20 liters of fluid in her first 24 hours in the tent, eventually leaving the CTC on her own two feet.

And as the months passed in this epidemic, CTCs throughout Haiti actually improved and had lower mortality rates, as they saved thousands of lives. Cholera was new to Haiti and needed to be figured out.

However, the more time I spent in CTCs, it became obvious that the numbers of symptomatic Haitians infected with cholera was very underestimated. Many people were coming from so far away and were barely alive when they arrived. I wondered how many had died back in the village or on the way to the CTC and would never be counted in the final tally of cholera victims.

People interviewed in the study stressed how poor road conditions and limited access to health facilities, which were at times worsened by flooding, contributed to delayed care and preventable deaths. The arrival of cholera in October 2010, coinciding with the rainy season and rain in Haiti for the next few years, meant more cholera due to poor public infrastructure including sewage and water sanitation.

“It was a bit difficult at the time because of frequent rains. And the roads to get to the upper 5th section are not good at all. So, taking someone to [a health center] was very hard.” (Male community representative)

“We don’t currently have a health center in the lower 5th section…[And] when it [cholera] first arrived…if someone didn’t see a doctor within 4 hours, he could die. ‘Se sak fè te gen anpil moun ki te mouri’ [That’s why a lot of people died].” (Male community leader)

“In this environment, survival from cholera was considered dependent on one’s access to ‘means’ and ‘opportunities’ (eg, family resources, social assistance) that could mediate the exacerbating effects of structural deficiencies. For those lacking such means, death was the expected outcome.” I witnessed teams of stoic young men who had saved family members or neighbors carrying them for hours on their strong shoulders on wooden planks over the rough terrain to the CTC.

“[W]e have…nothing to survive on. If you’re already struggling and this disease is ravaging you and you can’t find anyone to provide some assistance, what’s going to happen to you? Aren’t you going to die? But if there was someone to provide assistance, death wouldn’t come near you. You wouldn’t die prematurely.” (Female homemaker)

“Several participants used this indirect language of ‘struggle’ or ‘lack of means’ to allude to poverty, or employed words such as ‘someone’ or ‘they’ to refer to those in authority or with the perceived power to address its impact.” For almost 40 years now, sick Haitian patients have looked at me with sad eyes and said “I do not have the means” when referring to their ability to take care of sick family members.

People felt abandoned during this huge cholera epidemic. A few participants in the study simply observed that communities were abandoned both before and during the epidemic, making no references to unspecified culpable entities.

“If the disease had started in the Artibonite, in the 5th section…no one would have come near us, as we were already abandoned as it was.” (Male farmer)

‘Zòn lakay mwen manke jwenn sèvis’ [My home area doesn’t receive enough services]…The river water flows down to the locality and people still use it. (Female homemaker)

What would my cholera patients have said if they had the strength to tell me in the CTCs? I don’t think the majority would have blamed anyone except their own conditions. I don’t think they would have blamed the “authorities” for the horrible state they were in.

Cholera was (and is) a “political disease” in Haiti. (Maybe it is everywhere.) People against the UN occupation of Haiti were happy to state that cholera was brought to Haiti by the UN soldiers who dumped their waste in the Artibonite River.

At another CTC where I worked, cholera was not written on the chart of people with obvious clinical signs of cholera and who responded to IV fluids. And health authorities in different parts of Haiti were underestimating the numbers of cholera victims in their departments. At times I worked in remote areas and my experiences did not match official figures.

“Where aid was provided, many claimed that it was insufficient, inequitably distributed, based on friendship or political ties, and coming at first mainly from individuals who were campaigning for political office.”

“They gave one bar of soap for handwashing, but you have as many as 4 to 5 children in the house.” (Female participant)

In one CTC where I worked, I called authorities on the phone and begged them for more IV fluid. Rationing this life-saving fluid was not “best medical practice” in the tents where people in shock needed every drop they could get.

“If you were not in step with [the candidates], you couldn’t receive it…‘Yo fè politik avè l’ [They played politics with it]…They protected us so we’d still be alive to go vote for them.” (Male taxi driver)

Conclusion—

The Ivers article elegantly describes the experience of Haitians as they recounted their lived experiences with a deadly disease. The voices of Haitians who suffered the cholera epidemic’s consequences had not been elevated before this research.

What are the take-home lessons?

Prevention campaigns emphasizing individual-level actions caused some community members to feel shame and self-blame, believing that cholera resulted from personal ‘dirtiness’ or ‘neglect’.
In cholera epidemics, public health education must be matched by appropriate resources to address structural barriers and reduce gaps between water, sanitation and hygiene knowledge and practice.
Public health campaigns should balance individual-level recommendations with calls for institutional investments and policies that support disease prevention to address shame and self-blame among populations that are often already stigmatized by poverty.

We need to listen to people everywhere. “Downstream people” who suffer the most from “upstream policies” have much to offer in finding public health solutions.

John A. Carroll, MD

www.haitianhearts.org

4 thoughts on “Haitian Voices”

J. Reed
says:
December 2, 2019 at 10:59 pm Edit
Amazing “on-the-ground” insight that you won’t find in the major news outlets or the history books: The people that can’t be counted; the rationing of treatment; the pain and shame felt by the sick….incredible insight into the real story of the cholera epidemic in Haiti. Thank you for sharing this information and caring for the sick.
Reply

John Carroll, MD
says:
December 3, 2019 at 12:25 pm Edit
Thank you, J. Reed.
During medical school I saw slides of brown-skinned emaciated people on cholera cots with the bucket well placed underneath. Not for a second did I ever think I would care for a cholera patient.
Cholera has a lot to teach. Even without any labs, a patient with a severe ileus and secondary respiratory distress in a cholera tent in Haiti was hypokalemia until proven otherwise (and we never “proved it otherwise”.) And there were cholera disease-mimics which could hide in a hot tent and raise their ugly heads.
Having said this, the real learning experience for me with Haitian cholera was witnessing how the lack of infrastructure propagated this epidemic and how a disease of the poor can be politicized as one sees fit.
Reply

David Volk
says:
December 3, 2019 at 12:49 pm Edit
How incredible, and incredibly sad.
Thank God that so many were helped by simple rehydration, and thank you for you helping.
Reply