Cholera in Pestel–January 14, 2012 Cholera Victim–Pestel, January 2012–Photo by John Carroll MD

This is my narrative of the last four days in rural Haiti.

I am going to try and not beat dead horses.

I am going to try and not be too cynical or too sarcastic or too snarky. And I will not point fingers at the UN, at the Haitian government, at international governments, at the gran mange in PAP, at the billions of NGO’s in Haiti, at the “where did all the pledged money go questions”, at church leaders or the voodoo priests, at the adacemicians, the “do gooder” blan doctors, or at Catholic nuns or the little church lady Protestant missionaries who spend 30 years of their lives here doing as much good as they possibly can do.

There is no time to criticize anyone right now.

Cholera is infecting and killing many Haitians as I post this from Pestel, Haiti this afternoon– January 14, 2012.

I feel very rushed to post this. My access to internet is almost absent. Electricity is never a guarantee.

My conclusions are probably not that complete, but I hope they are practical and they come from being on the ground here. And the good part of this post is that the conclusions and comments are located at the beginning. So if you don’t want to read further you don’t have too.

After the conclusion and comments is a blow-by-blow account of the last four days in very rural rural Haiti describing the chaotic situation and trying to describe the nuts and bolts of the cholera epidemic here. (I will post first names only of the team members here with me.)

And I don’t have any statistics that I am willing to give right now. I have lots of numbers and a good idea, but the numbers will be published by Miriam, our team leader, so we can give the most accurate information possible. It is not good to over estimate or under estimate cholera statistics.

My big thanks to Maria and Luke, Tommie and Diane, Ed and Mary, Jeffrey, Miriam, Judy, Shane, Mike and Kathy and Jim and Stephanie and Leslie and many others, and Madame Jacques for all of their support and help in every way. And thank you DIRT for showing up with all your supplies, hands, and hearts.

Conclusions and Comments:

There is still much cholera in rural Haiti. And people are dying in rural Haiti of cholera. And they shouldn’t have to.

The roads in Haiti and the communication in Haiti is bad. A poor person may have a phone but that does not mean he has money in the phone or the phone has a charge because electricity is hard to find much of the time. And Digicel works some places and Natcom works some places… but not all the time. Good communication is a must to beat cholera.

Cholera needs to be managed locally in rural Haiti. Local leaders need to take this responsibility themselves. The trickle down effect is not working except the stuff that trickles down will make you very ill. Community education needs to be done by local leaders. Aquatabs, Chlorox, etc needs to be passed out to every house by community people.

Nurses, community health workers, and CERT need to be done locally. These people all need to be paid fairly. And the nurses staffing Cholera Treatment Centers need good housing and somone to help prepare their food and do their laundary so they can take care of sick patients in the tents. The Haitian nurses need to have the patient’s survival at the top of their list rather than their own survival in this very difficult environment.

Cases of cholera or suspected cholera need to followed to the house in the village and then to the water source. Each water source needs to be tested. If cholera is found, water engineers need to intervene.

CTU and CTC need to be placed in strategic easy to find locations in the mountains so people don’t have to travel such long distances to receive care when their small intestines are attacked by cholera toxin and they are losing their body fluids and their lives.

The supply chain of cholera material has to be never ending and appropriate for the size of the tent and the patient census. No rationing of life saving IV Ringer’s Lactate or ORS should have to happen. If a patient needs 5 liters of LR in three hours, he/she should get it.

Our experts are telling us that there will be a fourth, fifth, and sixth wave of cholera in Haiti, starting in March/April of this year. And we better believe them.

From what I have seen during the last few days, rural Haiti will not do well with the new up coming outbreaks unless local changes are made immediately.

And each time there is a cholera death in Haiti, we should all take it personally. It is our responsibility to stop this epidemic because we are all part of the human race. It is not the poor Haitian’s fault when he gets cholera. I have heard the poor Haitians being blamed for getting cholera. We need to understand they have no clean water to wash their hands properly. I can tell you they don’t enjoy having cholera. And how many well to do Haitians or well to do NGO people do you know who have died from cholera in Haiti?


Tuesday, January 10, 2012

I arrived in PAP on Tues. January 10 at 4 PM. Stayed overnight in a guest house in Port.

Wednesday, January 11, 2012

I left PAP at 7:30 AM in a van I caught near Portail de Leogannes across from the soccer stadium in downtown PAP.

I arrived in Cayes four hours later and went directly to the new Natcom store and swapped out my Sprint BlackBerry SIM card for an Natcom SIM card. After trying with the new Natcom SIM card for hours, I could not get on the internet, but my BlackBerry does work like a dumb phone now so I can call and receive a call and a text when I am in Natcom country. But Natcom is not working here in Pestel. So I cannot use my BlackBerry with the natcom SIM card. Digicel is working. Natcom did work in the mountains just south of Pestel…but spottily.

I would advise anyone coming to this part of Haiti to buy an unlocked latest generation iPhone from Apple and put a Haitian provider SIM card in it. It will work much of the time with a local provider. Wish I had had the time to do that prior to this trip.

Communication is very important in rural Haiti during this cholera epidemic. In the 80′s and 90′s all we had was Teleco here to make a call. But cell phones, ideally smart phones, if they work are so important right now during this epidemic. By the way the Haitian dumb phones (Nokia) works well here in Pestel with Digicel.

On Wednesday night, I stayed in Cayes at Cite Lumiere and made plans to leave for Pestel the next day.

Thursday, January 12, 2012—

I left Cayes for Pestel after seeing a 30 year old tetrology of Fallot patient of mine who I have been following in Haiti for 12 years. Mona needs heart surgery…pulse ox is 87 and I have her echo video if anyone is interested operating her.

The trip towards Pestel was beautiful but dangerous. We went on the new road to Camp-Perin and then on up the mountains to Duchity. I saw quite a few Caterpillar graders and tractors, but did not see any one using them.

Their was hardly any traffic. The road is one lane much of the time, and the side of the mountain goes straight down. We had to put the Land Rover in reverse at times as a big truck or bus came towards us. The big guy is always going to win in these situations. We literally had inches on the right side where the mountain went down.

We passed over Riviere Glace (Ice River) and the water looked pretty good to me.

After Duchity we seemed to be coursing down some through the mountains and slowly inched our way north to Pestel.

I got a call from Judy at this point and she asked me to call a team called DIRT. I called the number and spoke with John, leader of the DIRT team. John had spoken with my wife Maria in Illinois and Maria explained to John how to get hold of me. John said they had supplies for cholera treatment units and that they were in PAP and that they would come right away with the supplies. They had eight on their team. I told him that I would call him back when I knew more.

I called our team leader Miriam and she said they were in JoliGilbert high in the mountains above Pestel. Believe it or not, I was right in front of the local pastors house when I called her and she and her team of seven were standing off to the side of the road near the house. What good luck! It was the first time we had met. Introductions took about two minutes. It was great to be wherever I was.

Squatted down in front of me was man of about sixty with one day history of vomiting and diarrhea..he had his wife with him. He was very weak. And there was a father cradling his two year old little boy with the same history as the old man. also appearing weak with vomiting and diarrhea.

So we loaded both of them up in our vehicles and headed for Desvereaux about 15 minutes down the road.

There was a tent set up and all we had was 12 liters of normal saline in quarter liter bags. This was not ideal but it we had to go with it. We had 22 gauge needles and IV tubing so we put two 22s in the old man and one in the baby and started IV rehydration on both. The old man could go through the entire 12 liters himself in the next 24 hours…we were doing the best we could and both patients could still drink and we did have ORS packets.

While we were starting the IV’s we hired a Haitian nurse on site and dickered with her about her salary. We offered her three and one half times the salary of MSPP nurses I had worked with in the past and she asked for more anyway. This Haitian nurse had recently worked in Beaumont, about 1.5 hours south of Desveraux, and treated hundreds of cholera patients. She needed a job and we needed her.

After these two patients were stabilized we unpacked our supplies in the adjacent depot.

A large hole had been dug in the back of the cholera tent area to dump all garbage and human waste from the cholera tent. The hole looked to be about 10 feet long and 5 feet wide and about 10 feet deep. The soil appeared to be largely red clay.

An older lady got my attention and said that she lives just down the hill from where the hole is dug and she asked me when it rains is it going to be safe for her husband and her to live in her house which is made of the red clay and rocks. (No cement because it is too expensive.) She was bringing up good point so the hole will be covered and another hole dug further away…we need help here from experts.

We headed to Perla, another “locality” in the Pestel area at this point. We slowly coursed through downtown Desvereaux with the market women on the sides of the street scurrying to move their tables.

The road to Perla was the worst road I have ever been on in Haiti. It was more like a wide path with leaves of trees and bushes poking in the windows as we went by. Many rocks and holes were in the path and we could only go a couple of miles per hour.

We passed a little house with many kids and an older lady waving at us from the front yard. Rumor had it that there were four cholera deaths recently from that house alone. So I jumped out of our vehicle and talked to the lady who appeared to be in charge. She told me that in the last couple of months she had lost two of her children, a two and one half year old and a five year old, as well as her brother and her mother to vomiting and diarrhea. I assume this was cholera.

About 30 minutes later we arrived in a community of Perla. Clean water and fortified rice was passed out and we met with some local leaders who had numbers of cholera cases and deaths, and the names of springs that fed the area of Perla and the mountain village in the distance called Pavion. And Pavion has six smaller villages with about seven springs. (This could get confusing if we are not careful.)

After Perla, we headed back down the horrible path and back to JoliGilbert…about an hour trip. We rested for a few minutes, ate supper outside under a tarp while holding our flashlights on our plates of food. We then loaded back in the car and headed for another mountain village called Tozia.

Tozia was about 45 minutes away on another horrid road. We arrived in the little village of Tozia that had one working street light and all else was dark. We went to the building that was the local health center and found three patients inside being treated for cholera. The inside of the building was terribly depressing in the dark. A middle aged man was quite weak on one cot and so we put in an IV using flashlights and his wife held a small kerosene lamp. I kept pushing her hand away so the flame didn’t burn me as I inserted the IV. The man’s daughter lay in the corner on another cot and she seemed kind of sluggish but had a good radial pulse and was drinking without vomiting and so I did not put an IV in her. (An IV had been removed earlier in the day after her vomiting had slowed.)

The nurse at this CTC in Tozia explained to me she had been there for 13 months and had seen the place overflowing with cholera patients. The other nurse who worked there recently fell and has a large intrarticular hematoma of her knee and is unable to work now. So Tozia has one very overworked nurse. She also explained to me that they receive patients from all over the Pestel area. And that people carry their family members for hours on their shoulders on a wooden door or stretcher of some sort to get to Tozia.

We left Tozia and crept slowly down the road again back to JoliGilbert and crashed for the night. The air was cool and damp but lying supine felt pretty good.

Miriam had contacted the DIRT team and told them that we needed any supplies they could bring us. needed. They left PAP at 5 PM and were headed our direction…about an 8-10 trip in the dark.

George, one of Miriam’s team, volunteered to lie on his cot all night long on the side of the dirt road outside of our sleeping quarters at the Pastor’s house. At 4 AM when he heard vehicles approaching, George got up and flagged down the three DIRT vehicles with their very tired paramedics, nurses, and an anthropologist piled out. He got them some of our left over food from supper and they went to sleep for a few hours.


Friday–January 13, 2012:

I got up about 6 AM and took some photos of our camp as the sun was coming up. The red clay mud was slippery but I promised myself to be careful. However, I wasn’t careful enough and slipped going down a slippery embankment. As I was going down on my back, all I could think about was protecting my camera in my left hand. I lifted my left hand high but fell hard and my camera came jamming down beside me in the wet clay. I was really,really mad. The bottom of the SLR camera was caked with red clay which started to harden almost immediately. So for the next 45 minutes I was gently scraping off the clay from my camera bottom, hinges, and screen. The lens was not damaged.

I had red mud all over me and my scrubs. So I washed off with a bucket shower and got red clay in my bucket of water which I was slopping all over me. Not so good..but the camera was ok.

We had breakfast and the DIRT team got up, introduced themselves, and Miriam called for a meeting of both of our teams so everyone would be on the same page.

DIRT had brought over 2000 liters of Lactated Ringers, IV tubing and set ups, antibiotics, plus many more supplies. We had no LR before they arrived. Fabulous.

So we all headed back down the road to Desvereaux to visit our patients in the cholera tent. Two new patients had been added to this tent to make a total of four now. All their IV’s were either out or infiltrated.

The tent was a disaster. One new middle aged man’s IV was disconnected, and he told me he was “pa bon net” (not good at all). He had got sick the night before with vomiting and diarrhea and could barely move he had lost so much fluid. So I put two 18 gauge angio caths in him and we hung the new RL and blasted him with fluid. A new four year old also got a 22 gauge and I put the rate at slower than usual because he was drinking and alert and he looked like he had some kwashiorkor and I didn’t want to be to cavalier with his fluids because I thought he could third space alot.

The Haitian nurse we hired for this tent the day before was gone and before she left she had turned over responsibility of the tent to an auxillary nurse. She may have been there, but during the havoc to resuitate the patients I did not notice if this nurse was on site.

After another cruel trip to Perla we all headed down the mountain to Pestel.

Pestel is the largest village in the area with about 4,000 people. It is located on the ocean. It took about 75 minutes to slowly course down the mountain roads so we didn’t go over the edge.

The general hospital in Pestel has a CTC. The hospital is in total disrepair and filthy. There were only a couple of inpatients. I saw no employees at all in the hospital. This is the only hospital in the Pestel area (including the mountain villages where whe had just come from) for 80,000 people.

The Pestel hospital has four nurses assigned to the CTC but none were present because none have been paid by the Haitian government in four months. The CTC in Pestel at the hosptial had four patients…a young father and his two sons ages six years and three years…both were naked and covered with flies on the cholera tents. Another 5 year old child and an old man were the remaining patients. And all of these patients had come from Desvereaux during the last three days. The old man had come by motorcycle.

Dr. Phillipe is the head doctor in the this part of the peninsula. His responsibilty includes everything east of Jeremie to Pestel. This is a huge swathe of land with tens of thousands of people. We met with Dr. Phillipe and he outlined the population section by section as well as the number of cases of cholera and deaths from cholera during the last few months. (Miriam has the info and will publish it when she can.)

When Dr. Phillipe was asked what he needed the most, he replied “money to pay my Cholera Treatment Center nurses”.

John A. Carroll, MD


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