Doctors Without Borders Doing Heavy Lifting with Cholera in Port-au-Prince

Doctors Without Borders-Drouillard Hospital in LaPlaine
This Cholera Treatment Center is located two miles north of Cite Soleil
April 29, 2012
(Photo by John Carroll)

Doctors Without Borders in Haiti is directing and staffing Cholera Treatment Centers (CTC) in the Port-au-Prince area. During this rainy season, the number of cholera cases increased and sick people need a place to go very quickly for IV hydration. From what I have seen here in Port, Doctors Without Borders is doing the heavy lifting regarding cholera.

I stopped by a CTC run by MSF-France today. (Doctors Without Borders translates to Medecins Sans Frontieres (MSF).  It is an area called Drouillard which is a section in LaPlaine. (Drouillard is spelled Douya in Haitian Kreyol. I know this could get confusing....) It is located just a few miles north of Cite Soleil.

This CTC is called MSF-Drouillard. They have 60 cots and had 52 of them are occupied. They received 19 new cholera patients just today.

Drouillard's roads are dirt and with huge potholes filled with water and almost impassable with a vehicle.  

It is very difficult for a real sick cholera patient from Soleil to get to Drouillard with the roads as bad as they are. As a rule, poor people with cholera have no private transportation, they have no access to an ambulance, and  tap-tap drivers are not wild about the idea of transporting sick cholera patients anywhere.

John A. Carroll, MD

www.haitianhearts.org

The Lady in the Wheelbarrow

Lucy in Front of St. Catherine's Hospital, Cite Soleil  (Photo by John Carroll)

As I left St. Catherine’s Hospital several days ago, there was a distraught sweaty man a few in front of me. He was standing next to an unconscious lady in a wheelbarrow. 

I was not startled because this is a common way of transporting sick people in Cite Soleil. 

I reached for her neck to see if she had a carotid pulse. It was weak...but it was there. 

I asked the man what was wrong. He told me that the lady had a sudden and constant onset of diarrhea and vomiting the day before. She had been "bien prop" (very well) the day before that. 

Her name is Lucy (made up name) and she is 26 years old. She is from Soleil 13. 

The man pushing the wheelbarrow wanted to enter the hospital but the guards were keeping the green doors closed. The guards said there was no doctor inside, but I knew there was since I had been working with the MSPP (Haitian Public Health) doctor in the emergency room inside. 

I insisted that there was a doctor inside so they slid the gate open and the man pushed the lady in. I guided him to the area outside the ER.

The Cholera Treatement Center (CTC) at St. Catherine’s is closed.  Doctors Without Borders (MSF) staffed the CTC and it saved the lives of thousands of people in 2011. But now there is no where close for the people in Soleil to go when they get cholera.... like Lucy in the wheelbarrow.

We parked her outside the ER and I rallied the ER doctor and nurse who responded immediately.  Lucy looked like death and barely made any motion with painful stimuli. 

We were able to start an 18 gauge angiocath in the back of her left hand and and 20 gauge angiocath in the right ankle saphenous vein as it hung it below the handle of the wheelbarrow. 

I handed the bags of Ringer's Lactate to people close by the wheelbarrow who held them high and squeezed the IV fluid into Lucy.

The ER doc calmly told the man who had pushed Lucy through the filthy crowded streets of Soleil that  St. Catherines’s does not have a place for cholera patients and she would need to go to MSF-Holland in a Delmas neighborhood in PAP. The doctor gently told the man that Lucy needed to leave. There was nothing more to do here. 

The man looked incredulously at the ER doctor. He could not push her the four miles to the CTC. 

I asked the man who drives the van for hospital employees if he would take Lucy and he said no.

So we hung another bag of fluid and pushed Lucy out through the hospital gate to the street in front of  the hospital. Jean-Claude, my driver, was waiting in his truck. We carefully lifted Lucy into the truck bed and slid her carefully towards the cab.  Two family members had arrived at that point and they supported Lucy and held the bags of Ringer's high over their heads. 

Makeshift Ambulance for Lucy (Photo by John Carroll)

In front of us on the right was a crowd of about a fifty young men. They were watching a soccer game on a tiny television. They totally ignored Lucy and her struggle for life because they have seen too much death in Soleil. 

Jean-Claude drove through the rainy streets of Port-au-Prince and about twenty minutes later we arrived at the MSF-Holland CTC. 

Ringer's Lactate for Lucy (Photo by John Carroll)

The IV in Lucy's right ankle had run dry but the other continued to function. The CTC opened their gates immediately when we honked and unloaded Lucy onto a dirty green stretcher.

I gave a quick history to the MSF doctor on call. Lucy was moving her arms now and her carotid pulse had slowed and was stronger. 

She was placed in a tent. Lucy needed an ICU for shock, but she got a tent instead.

Lucy at Cholera Treatment Center, MSF-Holland (Photo by John Carroll)

MSF-Holland told me that during the last two weeks they were evaluating 20 new cholera patients per day in their CTC in Delmas. 

There is a good chance that Lucien will survive now. She has a 26 year old heart that can accept the volume that she needs. 

-----

Conclusion:

Haiti is in the midst of the worst cholera epidemic in the world. This is not the way to save Lucy from cholera. 

If the man who had pushed Lucy in the wheelbarrow didn't have the strength or fortitude to get her to St. Catherine's Hospital,  or if they would have shown up just a little later, they would have found no physician or nursing staff to help her. And Lucy would have died in the wheelbarrow.

How many people in Soleil never get the chance Lucy got? We will never know. They die hidden in the maze of the slum.

When I have asked people in Soleil where is the closest CTC, no one has any idea. 

Can't a CTC or a CTU be set up now in Soleil with basic equipment like IV catheters and Ringer's Lactate and a nurse or two to stabilize the Lucy's of Soleil? 

Is this asking too much?

John A. Carroll, MD

www.haitianhearts.org

Joseph Accepted for Heart Surgery!

Joseph--April 26, 2012 (Photo by John Carroll)

On April 26, 2012 we received more good news.

Haitian Hearts patient Joseph was accepted by CHADASHA for heart surgery.

I examined Joseph for the first time in February, 2012 in the pediatric clinic in Soleil.

Joseph has constant respiratory tract infections and a loud heart murmur coming from a hole in his heart.

In clinic this week Joseph weighed 19 pounds and is now 23 months old. He and his mom live in a tent in Port-au-Prince.

I continued him on his furosemide and we started work on his passport.

John A. Carroll, MD
www.haitianhearts.org

A Sign in Haiti

Claudia in St. Catherine's Emergency Room, Cite Soleil--April 26, 2012 (Photo by John Carroll)

We lost our beautiful mother two years ago today. The last two years I have lived with a deep ache in my chest.

My mom meant everything to me.

As I prepared for pediatric clinic in Cite Soleil today, I asked my mom to send me a good strong sign that she is ok.

And for some reason before I left for clinic today, I threw one sterile Vidacare intraosseous needle (IO) into my beat-up doctor bag. Vidacare Corporation generously donated many intraosseous needles for me to use to treat cholera patients.  IO needles are put directly into the marrow space in the bone for people who are in shock and have collapsed veins. The marrow contains a great plexus of venous channels that will accept iv fluid very quickly.

On this trip I have never packed an IO needle because we are not seeing much cholera in Soleil, and the Haitian nurses I work with are excellent at starting IV’s in the usual fashion. But today I packed the needle... 

Pediatric clinic went well this morning considering this is the rainy season and mud and water are almost everywhere in Port-au-Prince and in Cite Soleil. Hundreds of babies showed up for for clinic with their mothers even though many of their shacks and tents are flooded inside.

After pediatric clinic was over, I walked across the street to St. Catherine’s Hospital and worked the ER this afternoon. 

It is a tiny ER with three stretchers and one MSPP (Haitian Public Health) doctor. This serves as the only ER for hundreds of thousands of people in the slum.

We had the usual slum sort of ER medical problems today. But when I poked my head out the ER door early this afternoon, I noticed a lady holding her tiny baby sitting on a bench a few feet from me.

The baby appeared parched and gaunt and her little eyes were sunk in her head. And she wasn’t moving.  

As I quickly gazed at the baby, her mother began crying. She said her three month old baby had diarrhea and she had come to Soleil from Croix-du-Boquets to try and save her baby.

I rushed her in the ER door and had the mom put her tiny baby on the first stretcher. The baby’s name is Claudia. And I "guestimated" her weight to be about ten pounds. 

Claudia’s hands and feet were cold and she was breathing quickly. I could not feel her femoral pulse. She was clamped down. Babies like this die sometimes within minutes after arriving at a health center. 

She needed a line right away. But she had "no veins", as we like to say.

The Haitian doctor slapped a way-too-large oxygen mask on Claudia’s face and turned on the oxygen to six liters. We used an adult pulse oximeter and taped it to three tiny fingers on her right hand. Claudia's heart rate was about 200. 

It occurred to me that I had my IO needle in my bag a few feet away. I opened the bag and opened the sterile needle.

I thought of my mom watching and urging me on. She urged everyone on her entire life. 

I quickly prepped Claudia’s little shin bone on the right and felt for the flat spot below the knee cap. This was going to have to be it.

I pushed the thick needle through her skin and skewered the cortex and drove the needle into the center of the bone. Claudia moved a little and made a weak little pathetic cry. I aspirated blood from the inside of the bone and we attached the IV solution. 

But the iv didn't drip well. It just didn’t seem right.

So I removed the IO needle and felt for the landmarks on her tiny shin again. I stuck her again. The needle seemed like it entered the bone and I had good blood return on aspiration again. 

We hooked up the IV again and it happily dripped microdrops of fluid back into Claudia's bloodstream.

I gave her about 150 cc’s of fluid through the IO needle and a pediatric nurse came down in an hour and after a few sticks was able to obtain a 24 gauge IV angiocath in Claudia’s left forearm. And it worked too.

Claudia quickly warmed up and began to breathe hard and fast. She had a reflex sort of breathing as she was breathing off her volatile acid to compensate for her non volatile lactic acid that had built up.

I held Claudia’s right shin to secure the IO needle. I kept thinking of my mom.

Claudia opened her eyes and stared, but she did not track. Her pulse came down to 160, then to 150, then to 140 and her breathing slowed to a normal rate. Her little body liked the IV fluid.

As time went by, she began to kick her legs some and developed a stronger cry on stimulation.

We gave her a strong antibiotic in her iv to cover her for sepsis.

We drew labs. Claudia's hemoglobin was 7.9 and her white blood cell count was 21,000. And her glucose was 173.

So what now? Time to admit? What would my mom do?

I went and got a Haitian pediatrician friend of mine who works during the afternoons in the pediatric ward at St. Catherine's.  She came to the ER and “eyeballed” Claudia. The pediatrician said to send her away because the hospital closes after 4 PM and Claudia would be on her own on the pediatric ward.

Right after this discussion,  my mom gave us another miracle. My driver Jean-Claude miraculously showed up in front of the hospital with his beat up truck.  I ran to Jean-Claude and told him that we needed to take a very sick baby to a children's hospital several miles away called Petit Freres et Soeurs. He agreed right away.

So I ran back to the ER, took the baby’s oxygen off, disconnected the pulse oximeter, and carefully carried her across St. Catherine’s courtyard with people holding the IV bags up in the air. 

I carried Claudia carefully attempting not to fall in the street in the commotion. Jean-Claude was parked too close to a canal of green stagnant water and so I motioned for him to pull up so I could get in the front passenger door with the baby.

I pushed my way into the front seat protecting Claudia's head and her IV sites which were keeping her alive.  The IV tubing went out the window and up to the IV bags that we hung from scaffolding hanging off the bed of the truck.

Claudia’s mother shoved in besides me. 

Jean-Claude took off. And when he would hit about 20 mph the truck would start to wobble. 

As we wound through the streets of PAP, things did not go well. The streets were packed with huge water filled potholes, car breakdowns, and chaos. Jean-Claude is a skilled driver and actually drove into oncoming traffic many times blaring his horn for drivers to give us room.

And whenever we slowed or stopped in traffic, which was often, people would stick their heads in the cab and gaze at Claudia. 

However, when we reached the airport area we were almost out of gas. So Jean-Claude pulled over in a gas station and screamed how much he wanted to the attendant. We got a little gas and threw the money out the window.

We left the gas station and Jean-Claude was shifting hard. And each time his hand came back off the stickshift, his right hand hit my left hand which was cradling Claudia's beautiful little curly head.

During the trip Claudia looked at me quite a bit like babies do.  She was tracking very well. And at one point I thought she gave a little baby smile. 

I couldn’t quit thinking of my mom making this happen and guiding all of this from Heaven. I knew Claudia would make it.

We entered Tabarre which is the section of Port-au-Prince where Petit Frere et Soeurs Hospital is located. But we had to go down a dirt road with deep water. I was mentally preparing a plan to get out and carry Claudia the rest of the way through the water because I could see the hospital about one quarter mile away. 

But Jean-Claude is unflappable and handled this impossible last road and water barrier with his normal acumen. As we wheeled up to the hospital gate, the guard saw the baby in my arms and told us to go “fast” to the ER.

I carried Claudia into the ER and her mom followed. 

The ER was filled with 20 babies in all sorts of distress. And there was one very hard working Haitian doctor in charge.

I gave Claudia another bolus of fluid in the ER because I think we fell behind on her hydration during the horrible trip through the streets.

The Haitian doctor seemed competent and polite considering the circumstances. She was writing orders and Claudia’s mom was calmly holding her when we left. And Claudia was asleep and peaceful.

Mom, you sent me a definite sign today. I am a weak person and needed a sign from you. I know you are fine. I miss you so much I hurt. Thanks for giving all of us a great life. Help us live our lives like you lived yours. And thanks for intervening for Claudia today. 

Say "hi" to dad and to everyone up there...

See you Mom.

Love,

John 

www.haitianhearts.org

Chaos in Haiti

Outside Pediatric Clinic, Cite Soleil--April 24 (Photo by John Carroll)

I have never seen Haiti so bad.

Read this.

As President Convalesces in Florida, Confusion and Chaos Grow in Haiti 

By Kim Ives and Isabelle Papillon, published in Haiti Liberte, April 25, 2012 

Nearly a year after President Joseph Michel Martelly's inauguration, Haiti appears to be descending into anarchy. Rebellion among policemen and former soldiers is growing, and several high profile killings have contributed to the atmosphere of crisis permeating the country.

Meanwhile, rumors and doubts about President Martelly's health continue to swirl as he reportedly recuperates out of the country from a post-surgery pulmonary embolism which caused him to fly hastily to Miami on April 16. He had been in Florida from April 4 to 12 to undergo shoulder surgery.

On April 17, a few dozen former soldiers, many of them armed, barged into a session of Haiti's deputies to demand that they ratify Martelly's Prime Minister nominee, acting Foreign Minister Laurent Lamothe. Intimidated, the deputies adjourned, although they had been meeting to review Lamothe's ratification.

Acting Prime Minister Garry Conille, who resigned under pressure from Martelly on Feb. 24, called the paramilitaries' action an "assault on the public order" and called an emergency meeting of all the acting ministers for April 18. Not one of them showed up, presumably in solidarity with Martelly. Senator Kély Bastien described the ministers' boycott of the meeting "rebellious," but it was not the first time they had refused to be summoned by Conille.

On April 19, Conille convened a meeting of the Supreme Council of National Police (CSPN), including Justice Minister Michel Pierre Brunache and Haitian National Police (PNH) chief Mario Andrésol. The meeting, which failed to produce any plan of action, was also attended by representatives of the international community. "If the presence of armed men does not bother the Executive, it is because it feels comfortable" with them, said Senator Kély C. Bastien.

Senator Andrice Riché was more direct. "No paramilitary force could exist in the [national] territory without the complicity, tolerance and the blessing of those in power," he said. "Democracy is in danger."

The Chamber of Deputies announced a work stoppage to protest the paramilitaries' assault. The lower house's first secretary, Jude Charles Faustin, said that the deputies would not resume their posts until they got a satisfactory explanation from Martelly's executive.

On April 23, Lamothe submitted 59 personal documents to the deputies, which a special commission of the lower house will review for ratification.

Police in rebellion over murder of a colleague Meanwhile, a policeman's murder, also on April 17, has sparked demonstrations and a walkout by PNH officers. In broad daylight in the capital's Martissant 27 neighborhood, gunmen fatally shot and then stole the vehicle of Walky Calixte, 27, an Agent II assigned to the Directorate of Traffic and the Traffic Police (DCPR).

Walky's killing came hours after he arrested the driver and close associate of Port-au-Prince legislative deputy Rodriguez Séjour for illegal possession of a firearm. The driver was later released after the intervention of senior state officials, including Justice Minister Brunache and District Attorney Jean Renel Sénatus.

Upon his release and accompanied by Deputy Rodriguez, the driver is said to have uttered death threats against Walky Calixte. Three hours later, the policeman was dead.

The next day, April 18, Deputy Séjour went to Radio Caraïbes to deny reports he was the "intellectual author" of Walky's murder. Policemen descended on the station, firing their guns off outside and demanding his immediate arrest. The deputy barely escaped from the radio in a chaotic scene.

Since then, the police have been on strike in solidarity with their slain colleague, creating massive traffic jams throughout the capital. In Carrefour, on the Rues des Rails, area residents held protests on April 19 and 20 to protest Walky Calixte's killing. The residents said that Calixte was an "exemplary man" who was part of the PNH's 18th promotion and graduated with a psychology degree from the State University's Faculty of Humanities.

More protests involving burning tire barricades were held in the capital on April 23, paralyzing traffic and commerce. The policemen's strike call has been 90% respected. Almost nowhere in Port-au-Prince does one see a policeman on the street.

Demonstrators say their movement is not just for Walky but for all police officers enduring mistreatment from Haitian authorities who think they are above the law. Walky's father, Ezekiel Calixte, said his son played a major role in supporting the family. "The best assistance that we expect from the authorities is that they provide justice for our son," he said.

Judicial authorities and the police say they are vigorously investigating Calixte's murder. District Attorney Sénatus said he has already issued arrest warrants for suspects. One of Walky's suspected killers known as "Johnny," wounded in the thigh and groin by the slain policeman, died from his wounds at the Cuban-run Peace Hospital on Delmas 31, Sénatus said.

The killing has also created tension in the Chamber of Deputies. The lower house's president said that Deputy Séjour, who still has parliamentary immunity from prosecution, is now in a safe place until the investigation sheds more light on the matter.

Police chief Andrésol has sought to calm the PNH ranks and get them back to work. "The police are not allowed to strike or to take part in protests," Andrésol publicly declared on April 23. "All sorts of people are now trying to manipulate the police, including drug traffickers and those who cannot enter the institution."

On the evening of April 18, another murder shook the country. At the Haitian/Dominican border town of Fond Parisien, Calixte Valentin, one of President Martelly's close political advisors, allegedly shot dead a merchant, Octanol Dérissaint. Killed with three rounds, Dérissaint, 32, was the father of two children, including a three-month-old infant.

On April 20, the district attorney for the jurisdiction of Croix-des-Bouquets, Mario Beauvoir, arrested Valentin, who was then transported to a jail in Port-au-Prince.

As the situation worsens, politicians are weighing in. "We are in a country which is like an aircraft without a pilot, a ship without a rudder," said Mirlande Manigat, Martelly's challenger in the March 20, 2011 election, noting that during Martelly's absence this month there is no real prime minister, only the resigned Conille, to step in and assume the reins of power. "So the state has no leader right now in Haiti."

Deputy Accluche Louis-Jeune of the OPL for the Dame-Marie constituency opined that the "political situation in Haiti has never been so confused. We are facing a real political imbroglio compounded by a set of affairs which are sensitive, to say the least. Parliament is unable to assume its role as the final bulwark, and the Executive is in agony." He appealed for an emergency convention for "a political dialogue with all forces in the country" to avoid the country's "total collapse."

Haiti's progressive forces, grouped in anti-imperialist organizations, fronts, unions, and parties, are preparing for severe political turbulence in the weeks ahead, as different factions of Haiti's ruling groups vie for power. Although weakened by the 2004-2006 coup d'état and disenfranchised by the illegal 2010/2011 elections, Haiti's popular sector has been regaining its strength and organizational footing.

"The people must get ready to rise up," said Sen. Moïse Jean-Charles, who has led the charge in Parliament against the Martelly regime's corruption and flouting of the Constitution. "We have to gird ourselves to save this country from the disaster that Martelly has brought upon us."

No Sewer System for Three Million People--What's New?

Read this article from the Huffington Post.

Water in the Time of Cholera

See this excellent NPR article on Haiti's struggle for clean water.

MSNBC Video on Cholera

I sure don't agree with every word uttered in this video, but it is worth watching. (JC)

Saving Lives in the Time of Cholera...by Tina Rosenberg

See this great article on cholera.

Article pasted below:

Cholera Patient--Artibonite (Photo by John Carroll)

APRIL 7, 2012, 3:30 PM

Saving Lives in a Time of Cholera

By TINA ROSENBERG

Damon Winter/The New York Times

A health worker was disinfected after bringing cholera victims to a grave near Port-au-Prince, Haiti, in November 2010.

Cholera is on the rise around the world. Last year, according to Unicef, West and Central Africa had “one of the worst ever” cholera outbreaks. An outbreak in Haiti sickened 1 in 20 Haitians and killed more than 7,000 people. The World Health Organization estimates that there are between three million and five million cases of cholera each year, and between 100,000 and 120,000 deaths. New and more virulent strains are emerging in Asia and Africa, and the W.H.O. says that global warming creates even more hospitable conditions for the disease.

In most parts of the world, the last few months have brought a respite. But April is the start of the rainy season, which is also the cholera season.

Cholera should not be a terror. It is easy to treat if you know how. Countries that live permanently with endemic cholera, like  Bangladesh, see fewer than one death per 100 cases. But in recent epidemics in Zimbabwe, Somalia and Haiti, death rates in some areas have been reported at 10, 20 or even 50 percent. In countries unfamiliar with the disease, people don’t know the steps to take or have the tools they need.

With cholera, speed matters. It can kill very quickly — in a few hours if victims are already malnourished. And since the incubation period for the cholera bacteria can be as short as two hours, it spreads fast.

Until now, early action has been nearly impossible. Governments, fearing stigma and a loss of tourism, often cover up cholera, and international organizations sometimes go along with the fiction. Even when governments  do call cholera by its name and start inviting international help and expertise, the W.H.O. and Unicef are bureaucracies — and such invitations can come weeks after a widespread epidemic is under way.

A new partnership between two organizations that battle cholera will make it possible to get supplies and knowledge to cholera-stricken areas much faster. Early next month, AmeriCares, a United States-based  aid group that specializes in airlifting medical supplies into disaster zones, will finish assembling a group of pallets containing everything necessary to treat 15,000 cases of cholera.

AmeriCares says it can get those pallets from the assembly site in the Netherlands to anywhere in the world within 48 hours. The know-how will be brought — also at top speed — by doctors and nurses from the International Center for Diarrheal Disease Research, Bangladesh, the world’s leading cholera experts. Instead of waiting for an invitation from a government or international organization, the center will bring the medical help in right away, alongside AmeriCares. “Until now, we’ve waited for an invitation from the World Health Organization or Unicef or the local medical authorities to come in,” said Mark Pietroni, the center’s medical director. “That’s sometimes six weeks late.”

This is increasingly the future of disaster management: prepositioning to get what’s needed to where it’s needed earlier. Instead of buying and shipping food stocks after a crisis begins, for example, the United States Agency for International Development and the World Food Program are increasingly buying food during harvests, when it is cheaper, and storing it near potential crisis zones, much of it in W.F.P.’s huge warehouse in Mombasa, Kenya.

Bangladesh is famous for its nongovernmental organizations — the Grameen Bank and the anti-poverty giant BRAC are the most widely known. But the Center for Diarrheal Disease  has achieved just as much. The center invented oral rehydration solution, a packet of salt and sugar that mothers can mix with clean water and give to a child with diarrhea. That packet saves the lives of some three million  children a year.

Despite its name, the center works on a lot of problems  — nutrition, H.I.V. and reproductive health, to cite a few. At its headquarters in the Dhaka, the Bangladeshi capital, it has trained more than 27,000 people from 78 countries. At its main field site in the subdistrict of Matlab, about 30 miles from Dhaka, the center has been collecting demographic data for more than 40 years. Interviews with a population that is now about 250,000 have provided researchers with key information: for example, the fact that 63 percent of child deaths are because of diseases preventable with vaccination. The results of the center’s health research in the area guide programs that have significantly reduced child mortality around the globe.

But in Bangladesh, the center is known as the Cholera Hospital. During the cholera season the center treats 1,000 people a day. “Cholera is a Bengali disease, coming from the Ganges delta,” Mr. Pietroni said. “The treatment is also a Bengali treatment.”

The center also invented the cholera cot — a cot made  of a plastic tarp with a hole in the middle and a bucket that goes beneath. Without such cots, doctors and nurses in cholera wards find themselves wading through pools of infectious stool. And center’s staff have traveled to epidemics around the world, training local health officials, doctors and nurses.

Related More From Fixes

Read previous contributions to this series.

Their most important message is the importance of early and massive hydration — if a patient is too weak to drink, then IV solution is necessary. “The biggest mistake is that patients do not get enough hydration fast enough,” Mr. Pietroni said. “You have to give huge amounts of IV fluid in the first three hours — seven or eight liters. In Dhaka at the end of April you see people with IVs in each arm and leg. But as soon as the patient can drink, you switch them to oral rehydration.”

Flooding patients produces Lazarus-like effects. People who come in barely showing a pulse are sitting up and drinking just a few hours later. This September, in the midst of an outbreak in Somalia, two doctors and a nurse from the center gave a five-day cholera course in Mogadishu. “They did have an outbreak, but conditions in Somalia are really ripe for a really large, Haiti-scale outbreak, and it hasn’t happened so far,” said Gregory Anderson, a program officer for the Conrad Hilton Foundation, which gave a grant to AmeriCares and the center to provide training and supplies in Somalia and Kenya.

AmeriCares and the center realized they needed each other during their work in Haiti. “AmeriCares had the capacity to send things, but sometimes lacked the expertise,” said Alejandro Cravioto, the executive director of the center. “And when groups like us arrive, sometimes we have enough to work with, and sometimes we don’t. This was an obvious fit.”

In many cholera outbreaks, AmeriCares is already there: 70 percent of the disasters they respond to are water-related, like floods and tsunamis, and cholera usually follows two or three weeks later. Now, as soon as cholera is suspected, AmeriCares will ask a local partner to invite the Center for Diarrheal Disease. The center’s job is to confirm that the disease is cholera, work with a hospital to set up a treatment clinic — often a tent on the grounds — and, most important, train local medical personnel. AmeriCares handles the logistics: “We’d work with the ministry of health to get duty-free clearances,” said Ella Gudwin, vice president for emergency response. “We’d look at the generator, the supply chain, the availability of materials, where the water is coming from.”

AmeriCares and the Center for Diarrheal Disease  are employing an idea — a preventive, proactive approach to disaster — that is starting to get attention. The project was highlighted as particularly promising at the Clinton Global Initiative meeting in 2011. “This has definitely not been philanthropy’s role in the past,” said Mr. Anderson of the Hilton Foundation. “It’s been a very reactive sector. But we’re very focused on it. The return on investment is much better.”

Join Fixes on Facebook and follow updates on twitter.com/nytimesfixes.

Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book is “Join the Club: How Peer Pressure Can Transform the World.”

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Haiti Mission Project in Cite Soleil

Photo by John Carroll

The Haiti Mission Project started the SafeWater for Haiti project in response to a need communicated through contacts in the field in Haiti. 


We knew the need was great in Haiti, especially in the rainy season, but we couldn't put our hands on a tangible way to help.  After hearing a call for help, we realized we could get our hands on Aquatabs to be distributed through clinics in Haiti already serving an at risk population.
  
We agreed to send down 2000 dollars in seed money from our funds, and start a fundraising campaign.  We have already made sure that 60,000 Aquatabs are in place for use through the Rosalie Rendu Pediatric Clinic in Cite Soleil, and now have other clincs expressing interest as well. 


Since starting the fundraising appeal we have raised an addition 2500 dollars, with the initial total fundraising goal of 6000 dollars.  Next week we will send more funds to purchase more tabs for distribution.  


More information can be found at www.haitimissionproject.org/water, or by following us on Facebook. 




Editor's Note: 


The Rosalie Rendu Pediatric Clinic in Cite Soleil is run by the Daughters of Charity. The Daughters are Sisters of St. Vincent de Paul which is the largest group of missionary Sisters in the world. The Clinic has a general pediatric clinic, a vaccination clinic, a pre natal clinic, a newborn (umbilical cord) clinic, and a malnutrition clinic.

The clinic has a pharmacy with a good selection of medication to treat the medical problems encountered in the slum. 


Approximately 400 patients are treated at the clinic each day.


The clinic is open Monday through Friday. 


Please give whatever you can to Haiti Mission Project to purify more water in Soleil. Providing clean water helps prevent not only cholera but dozens of other water borne diseases.


Thank you.


John A. Carroll, MD

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See this article on the jump in cholera cases happening now in Haiti.