Thursday, October 28, 2010

A Cuban Look at Cholera

Cholera Catastrophe Spreads in Haiti

by Kim Ives

"They are doing exactly the wrong thing," said Dr. Manolo Castro. "When you
bring cholera victims into a hospital, especially one with poor conditions,
you stand a good chance of infecting all the patients in that hospital."

Dr. Castro, 74, is a Cuban doctor working at Haiti's finest pediatric
hospital, St. Damien, in Tabarre. When it comes to cholera, where a virulent
bacterium provokes severe vomiting and diarrhea which can kill in a few
hours, he knows what he is talking about. He has tangled with the deadly
disease before.

In 1990, a cholera epidemic struck the Zambian town where Dr. Castro was a
teacher at a hospital as part of a Cuban medical mission. Soon there were
some 6,000 cholera victims. The hospital's Zambian director packed up his
family and fled. The Cuban Embassy and Zambian government asked Dr. Castro
to step in to help the panicked population. Dr. Castro went to the Public
Health Ministry's office in town and with them identified a local stadium
where they could quarantine hundreds of cholera patients. Within a few
weeks, Dr. Castro's team of six Cuban and six Zambian doctors had brought
the outbreak under control.

"It is essential to isolate cholera victims from other patients, especially
where there is poor sanitation," said Dr. Castro, who helped squelch another
cholera outbreak when stationed in the Cape Verde islands in 1994. "The
government should also stop all traffic and travel between the affected area
and those not affected. Otherwise, the disease is going to spread."

The day after Dr. Castro spoke those prophetic words, it was announced that
Haiti's cholera epidemic had propagated from the Central Plateau and
Artibonite departments (where it emerged) to Port-au-Prince, the capital
through which thousands of people from all corners of the country circulate
every day.

But far from taking aggressive and proactive measures like stopping traffic,
Haitian Public Health authorities have been trying to minimize the crisis,
claiming, as the Health Ministry's general director Gabriel Thimoté did Oct.
25, that the disease's progress has been "stabilized."

At press time on Oct. 26, the only official government figures are that
3,769 people have become sick with the disease in the Artibonite and Central
departments, with 273 fatalities in the Artibonite. Since other areas are
not being tallied, the actual figures are much higher.

For instance, Dr. Ernst Robert Jasmin, the Health Ministry's Northern
Department director, says that there are 17 probable cases in Pilate,
Plaisance and Limbé, with three fatalities. Other authorities report seven
cases in the southern town of Petit Goave and several other cases and deaths
in the town of Arcahaie.

But there is also growing dissension between authorities. Nigel Fisher, the
Canadian assistant head of the UN Stabilization Mission in Haiti (MINUSTAH),
on Oct. 25 put the death count at 284 and said that there were five
confirmed cases of cholera in the capital (as did the Pan American Health
Organization or PAHO). The Haitian government disputes this, saying only one
of the five cases tested positive.

"It is an extremely serious situation and on the basis of the experience we
have had with other epidemics in the world, it would be irresponsible not to
plan for a much larger epidemic," Fisher said. Ironically, he dismissed the
idea of cutting off traffic out of affected areas as impractical.

Dominican health authorities have not been so sanguine. They closed the 130
mile-long border with Haiti on Oct. 25 to everybody except students and
Dominican visa-holders, who have to wash their hands and be checked by
health workers at border crossings. On Oct. 25, MINUSTAH troops fired
teargas to disperse a crowd of Haitians trying to cross over from
Ouanaminthe into the northwestern Dominican town of Dajabon, reports
"Dominican Today."

Meanwhile, Haiti's cholera "will not go away for several years," said Dr.
Jon Andrus, PAHO's deputy director, at a Washington press conference on Oct.
25. "We know that the bacterium is going to spread very rapidly and... we
will see a rapid upswing on the epidemic curve of the number of cases
reported in these early weeks and months."

"The official numbers almost surely under-represent the true number of cases
largely because, in general, approximately 75% of the cases have no
symptoms, they are asymptomatic, yet they can carry the bacterium and
transmit it to others," Andrus said. "And these same asymptomatic cases may
carry the bacterium for up to two weeks and shed that bacterium back into
the environment."

The epidemic is really expected to explode when it reaches the 1.5 million
people living in some 1500 tent cities sprinkled from the capital to
Léogane. Just like the sprawling slums of Cité Soleil and Carrefour, the
tent camps lack sanitation and are regularly flooded by torrential rain
storms. Water used for cooking and washing often contains sewage, cholera's
principal vector.

Doctors and medicine have been pouring in from Haiti's neighbors. Cuban
Ambassador to Haiti Ricardo Garcia Napoles has traveled to Mirebalais, St.
Marc and other towns to help organize the response of Cuba's hundreds of
in-country doctors to the crisis. The South American alliance UNASUR is
dispatching a planeload of medicine and equipment to fight the epidemic on
Oct. 27, with medical teams to follow soon. Brazil said it was making an
additional grant of $2 million for medicine.

Despite the incoming aid, Dr. Castro is very concerned that Haiti lacks
enough doctors to respond to this nightmare scenario. "There is a cholera
stool sample kit, which gives immediate reliable results, but many Haitian
doctors are not trained in how to use it," he said. For the past 13 years,
Dr. Castro has worked at different hospitals in Haiti and taught at the
Aristide Foundation's medical school until it was militarily closed and
occupied by U.S. soldiers immediately following the 2004 coup d'état against
and kidnapping of President Jean-Bertrand Aristide. When closed, the school
was producing about 125 Haitian doctors per year, twice the number of the
state university.

"If you multiply 125 doctors per year, and it could have been more, by the
last six years, you will see that the 2004 coup d'état has deprived Haiti of
close to 800 doctors," noted Hilaire Toussaint, who runs the Aristide
Foundation. He is now looking for funding to reopen the medical school next

The last cholera epidemic in the hemisphere was in Peru in 1991, which had
about 500 cases over the course of two years, with a fatality rate of less
than 1%.

In 2008, "56 countries reported 190,130 cases [of cholera], 5,143 of them
fatal," Dr. William Pape, Haiti's leading doctor in the fight against the
HIV virus, told Le Nouvelliste. "But many cases were not recorded due to the
limitations of the surveillance systems and the fear of sanctions limiting
travel and commercial exchange. It is estimated that the disease's true
figure is about 3-5 million cases with 100,000-120,000 deaths per year."

"It is going to be a long battle," Dr. Pape said. "I fear for the slums of

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