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Business as Unusual

At our 4 a.m. census this morning, we saw 20 adults and 18 children with cholera - a constant level for the past 4 days. As I walked though the hospital between the adult cholera section to the children's cholera section, both of which are isolated from the regular hospital, it was immediately apparent that there has been no change in the demand for clinical services at HAS.

The pediatrics ward had 63 patients, including 10 in the neonatal special care unit, and the medical and surgical ward had 31 patients. There were 38 patients in the Evaluation, Diagnostic and Stabilization unit, which is designed for about 20 patients, so the hallways were crowded with litters and cots as patients were stabilized pending the morning rounds and scheduling for lab tests and X-rays. This total of 132 inpatients does not include the several women who were in the high-risk pregnancy unit.

By mid-morning, referred patients and others with return appointments were filling the benches under the large mapou tree, waiting for the ambulatory clinics for medicine, surgery and pediatrics to open in the large donated tent.

While every disease outbreak or epidemic is unique, there appears to be strong indications that cholera will be found in Haiti for years to come, and that in the near future, we may continue to see new cases of the disease at HAS. However, the level of the future demand is unknown. At this time, and for the near term, we will have to plan on managing an institution with a total inpatient load of about 170, of which almost 40 will require special care as cholera patients.

Cholera Patients Continue to Arrive at HAS

Today is a holiday – All Saints’ Day, as is tomorrow, the Day of the Dead. The hospital’s outpatient service is closed, but patients still arrive, either to the Cholera hospital, or to the regular hospital. Urgent cases are seen in the sal dijans (salle d’urgence, or emergency room), which is aptly named, because it is merely a room, off the primary care waiting area.  If the patient’s condition appears to be serious, the patient is transferred to the Evaluation, Diagnostic and Treatment room, a bay of about 25 beds under the direct observation of several physician extenders, nurses and physicians on call.

Patients with the symptoms of cholera proceed directly to the cholera reception area, where they are evaluated and either started on an IV drip, or offered oral rehydration solution, depending on the intensity of their symptoms. According to our visiting CDC team, as many as 80% of the persons affected by cholera do not show serious symptoms, and do not require substantial rehydration, or do not come to the hospital at all.

We watch two trend lines every day; one is the daily census, as this indicates our work load for cholera patients, and the other is the new admissions for each day. The daily census reflects a stabilization at about 30 patients a day for the past three days. The new daily admissions also reflects a stable pattern at about 15 patients a day for the past 4 days, and there appears to be a balance between admissions and discharges.  This pattern is apparently similar to that seen at the two other major cholera hospitals in this region, at St. Marc and Petite Riviere, although the total number of patients is higher at each of these facilities.

Many patients arrive with rather minor symptoms, receive oral rehydration and leave the same day (these do not show up on the admission or census figures). Several of the newly-arrived patients reflect a pattern which had caused us some concern, and they were the caregivers of a sick person, who were exposed to the patient’s effluents while caring for them.  While I was translating for a writer from Newsweek today, we talked with a woman who had arrived with serious symptoms yesterday. She said that she had cared for her 16-year old daughter who had died on Thursday, and she had prepared the daughter’s body for her funeral. Now she apparently also has cholera. This person-to-person transmission of the disease is of great concern to the Ministry of Health, the CDC, and the Pan American Health Organization, all of whom are tracking the trends in our area with great attention.  Their great fear is that the disease will spread in this way to the large camps of refugees in Port au Prince and nearby.

As if Haiti could not emerge quickly enough from one disaster to prepare for another, we are all watching the progress of Hurricane Tomas, as it drifts Westward just to the south of Haiti, with a forecast by the NOAA for it to turn sharply to the North on Thursday to connect with the southwest peninsula of Haiti, where the frequently-battered cities of Les Cayes and Jeremie are located.

As we monitor the daily census at 5am each day, we are observing several trends; the number of adult cases has declined dramatically from the numbers on Sunday, but have essentially remained stable in recent days. The number of pediatrics cases has also declined, but appears to be stable, with a total population in the HAS Cholera Hospital about 35-40. 

The CDC team has been visiting the courtyards of affected patients to evaluate the potential sources of the infection. Today they are visiting the health center in Petite Riviere, which received a large number of patients in the first days of the outbreak, but are now reporting a stabilization of the number of admissions. I was at the hospital in St. Marc yesterday, which had received the largest number of patients, but as of yesterday the numbers of cholera patients were reduced. In both the St. Marc facility and the Petitie Riviere heath center, primary support has been provided by Partners in Health. Now, each of the facilities has a staff from Medecins Sans Frontieres, which is caring for the cholera patients in an isolated area within the facility.

For all of us who are working with cholera patients, the demands for services remains high - HAS received a number of trauma patients last night from health care facilities in the region, and we also provide diagnostic services in the form of lab tests and X-rays for these facilities.

Today, our Community Health staff will meet with the Community Health workers, to provide current information about the spread of the disease, and also to thank them for their energetic pursuit of a public relations campaign for prevention of new cases. It is very probable that the decline in cases at HAS is related to these efforts.

Other visitors arrive daily at HAS - today we have a team from Massachusetts General Hospital's Diarrhea Treatment Center in Bangladesh, and additional members of the team will arrive tomorrow. They will serve as consultants to the Haitian Ministry of Health in planning for the management of the disease if it spreads beyond the Artibonite.  Our experiences here will be of relevance to their efforts, in the event of the further expansion of the incidence of cholera.

Cholera Containment and Prevention Message Getting Out

For the past several days, new cases of cholera came in, and an equal number of patients were discharged, and we are seeing a regular daily census of about 25 adults and 15 children. The public information program by the Ministry of Health, the local Rotary clubs, and by HAS field staff appear to have been effective, as patients come to the hospital early in the course of the disease.

In a dramatic technical innovation, yesterday morning all of us with Haiti cell phones (and who doesn’t have one these days), received a text message which said “to get more information about cholera, send a free SMS to “maladi" (illness). Shortly thereafter, we all received a voice message from the director of our local UCS, Dr. Willy Staco, with brief instructions on how to avoid cholera, and the need to come to a health center immediately if symptoms occur.  We had been in discussions in the summer with local telephone carriers about the whole concept of MHealth (Mobile Health), but now we have a clear example of how effective such an approach can be.

Later today, a team from the US Centers for Disease Control will arrive at HAS to spend a week or more researching the sources of the disease, visiting the homes and courtyards of patients, and taking samples from water sources, wells, rivers and canals. The Mellon house has been converted to a research center, with map tables, a wi fi internet line, and a sample storage facility.

HAS field staff have visited many of the households from which our cases have come in the past several days, and have found concentrations of cases in courtyards where the water table is quite high (it is possible to dip water out of the well with a cup), and the wells are very near to latrines and canals.  The wells are treated with chlorine powder, but it is apparent that continued exposure to the pathogen will continue in the absence of a dependable potable water source.

Our nursing staff, which has been working long hours the past ten days, has been supported by a group of nurses from Jacmel and Les Cayes (far from the current cases), and today a group of five nurses from Project Hope have arrived to provide more support for what is essentially a nursing disease.  Most of the Hope nurses had been in Haiti previously during the earthquake.

The hospital (more appropriately “the hospitals” because of the separate facilities for the cholera patients) are quiet and orderly, the patterns of care have become systematized, and the work flow is becoming second nature.  After a flurry of visits from various news agencies, their attention span appears to have waned, and we are able to return to our work undisturbed.

The forecast for the progress of the disease is at the moment unclear; we hope that the pattern of admissions will decline, but are afraid that it will remain steady, or even increase in the days ahead.
We send to you all our thanks for your concern and support…

New Patients Continue to Arrive

HAS continues to receive new patients with cholera- at the same time, we are able to discharge approximately the same number, so our census of cholera patients remains fairly stable for the moment.  Hand in hand with treatment, our focus has been on containment and prevention at the community level.  We are fortunate to have well trained community health workers and volunteers - numbering over 1,500 - to bring a the crucial prevention message to people throughout the Artibonite Valley.   HAS field staff are sharing educational materials with residents of their service areas, carrying the same messages which have been developed by the Ministry of Health. The local Verettes Rotary club, many of whose members are HAS staffers, has energized a community education and awareness campaign, including local radio stations, schools, and churches to pass messages about personal hygiene and water purification.

Over the weekend, the demand for services from our normal patients declined, and this provided us with the opportunity to review our current approach to managing the cholera patients. Initially, we had admitted cholera patients to the Observation Unit, and after stabilizing the patients for one or two days, transferred them to a transition and discharge unit in the courtyard. Children with cholera were cared for in the former physical therapy class rooms, next to the pediatrics unit, but many children were outside in the halls. 

HAS designed a plan whereby all of the patients with cholera were assembled in the courtyard, and access to that space was restricted to clinical staff caring for these patients.  The pediatric patients were transferred to a single large room in the annex, with closed access. Now, as Monday starts and we begin to receive the normal flow of outpatients and continue to care for the hospital's 130 inpatients, we are actually operating two hospitals - one for patients with cholera, and one for the remaining patients.  The halls of the hospital have been cleared of the beds which had been filled with cholera patients, and the flow of medical personnel and patients has returned to normal. A large tent which was donated by the International Medical Corps has been set up outside the hospital as a triage and treatment center for non-cholera patients, in order to reduce the number of patients in the hospital.

Because of restriction in travel to and from Port-au-Prince makes it difficult for the amputees to get to HAS, the Hanger team of prostheticians and physical therapists has joined the hospital staff to provide patient support services, to allow the nurses to focus exclusively on clinical care. The technicians repaired a number of beds in order to make them available for the patients, prepared and distributed oral rehydration solutions, and providing logistics support.

The spirit of thoughtfulness, consideration, and respect which was so clear in the days following the January earthquake is in full view now, where patients and their caregivers have to find spaces to live and to accommodate to the demands of the disease. Despite the large number of people in the cholera areas, they are very quiet. Whenever possible, we teach as we provide care - we explain the ways in which the disease can spread, and provide information which they can share with others when they get home. We have been asked by the many media organizations about the panic about the outbreak, and they are surprised when we tell them that there is no panic; people are curious about how they got sick, and about how their neighbors can prevent, but they absorb that information, and begin to plan for what they will do when they get home.

The CDC team which is conducting epidemiological surveillance was at HAS yesterday, establishing a framework for mapping the geographic course of the disease. They will return next week and use HAS as a base for their analyses in this region. The origins of this outbreak are a mystery, but are not a primary question at this time. What is of most concern will be the modes of transmission. In our area, the initial cases were from men who were working in the rice fields in the lower Artibonite River, who traveled to HAS to receive care for the disease. More recently, cases have involved young children.  These families, who live closer to the hospital and also near to the river and its canals, report that they had been drinking from wells in their courtyard or at their neighbors.

The coming week will be very instructive in terms of the broad direction of this disease, both in our area as well as in Port au Prince (where new cases have been reported) and in other parts of the country.

Week One of Cholera Epidemic

This is the one-week anniversary for the cholera epidemic at HAS; it was last week on Saturday that we first saw the few cases of severe diarrhea, and without recognizing it for the relatively obscure disease that it was, treated the patients successfully. Several more patients arrived on Sunday and by Monday we began to recognize that there was a serious trend which connected them all. At the same, we were hearing from our partner facilities in St. Marc, Petite Riviere, and Verettes that they were seeing similar cases. When I visited St Nicolas hospital in St. Marc on Wednesday, it was overrun with patients, and they had to ask the numerous family members to stay outside so the nurses could get to the patients.

By Wednesday evening HAS had also begin to see an influx of new patients, and these numbers continued to grow through yesterday (Friday). We reorganized the patient care units so that the 25-bed observation unit was set aside for acute-level patients (by that time the disease had been confirmed by the CDC as cholera), and we set up a transitional unit of about 25 beds for patients who were evaluated for discharge. By the middle of the day today a pattern had emerged in which it was possible to discharge about 15 patients, who were then replaced by patients from the observation unit, who were in turn replaced by new, acutely ill patients. Currently, most patients seem to recover well within 2-3 days, and are discharged with an additional supply of oral rehydration powder.

The halls around the observation unit are an overflow area, from which we try to
bring patients into the unit as soon as possible.

The transitional unit is located on the former horse courtyard, where, when we first opened the hospital, patients tied their horses when they came to the outpatient clinics.

On Friday, when we had a large number of patients who were scheduled for return appointments, it was with some difficulty that we were able to separate the cholera patients from the normal patient group. By Monday, we will have acquired a tent which will be placed outside, where the outpatients will wait unitl they can see a physician in small offices in a formerly unused office building.

More than 30 children have to HAS with acute cholera; we opened up two rooms which had been used by the rehabilitation technician training program, which is now in vacation. The patients were interested to see the skeleton being carried out of the storage closet as we cleaned the rooms.

During the day today, several international relief agencies arrived with very useful resupplies of gloves, oral rehydration packets, antibiotics and buckets. We accompanied them to the Ministry of Health facility in nearby Verettes,, which is receiving a large number of cases, and which had used up their meager supplies. They were restocked, with a promise of another shipment tomorrow.

We are awaiting the arrival of the CDC epidemiological team which will continue the research to identify the source of the pathogen.Most of the early patients had reported drinking from the Artibonite river, and they clustered in an area where the rice fields now require a large number of day laborers. More recently, however, the cases are from a wider region, especially the children, and the incidence pattern no longer has a clear focus. The major concern, of course, is the potential spread of the disease more broadly in our area, but of even greater impact, into the urban areas, where so many people live in tent cities with poor hygiene and limited water supplies.

Ian G. Rawson

Cholera has been Confirmed in the Artibonite

Last evening, the CDC confirmed that the cases of diarrheal illness that HAS and other hospitals in the Artibonite region have been receiving have been identified as Cholera. HAS has instituted the World Health Organization Cholera treatment protocol, and redesigned the hospital's patient flow to keep the cholera patients in a separate area.

All HAS staff have been provided with training on cholera and its effects and its treatment. HAS remains in close contact with the Center for Disease Control (CDC), whose efforts are now focused on localizing the source of the disease. A CDC team was at the hospital last night to study maps of the region and to review our patient data, especially the localities where the patients have been living during the previous week.

Most patients appear to have contracted the disease from one or several sites at some distance from the hospital. We have received very few patients from the immediate area.

Under the able direction of our newly-arrived Medical Director, Dr. Silvia Ernst (who was formerly at the Schweitzer hospital in Lambarene), HAS has been able to manage the patient flow without undue stress. All of the staff have served long hours with great professionalism.

To a great extent, cholera is a nursing disease, requiring the establishment and maintenance of IV lines, education to the patients' families to remain hydrated, and the administration of antibiotics as appropriate. Most patients so far have been able to recuperate and return home within several days.

Disease Outbreak in Haiti's Artibonite Region

During the day yesterday, reports came in to us at HAS that there was a suspected outbreak of severe diarrhea and vomiting, with most of the cases in the Artibonite region. By the late afternoon, HAS began to accept an influx of such cases, all with similar symptoms, and we reviewed charts from Monday and Sunday to identify possible earlier cases. A total of 30 patients had been received by the middle of the night on Wednesday, mostly adults and primarily male. The patients came from localities near the Artibonite River, and many reported that they had drunk water from the river. The regional director of our Unite Communautaire de Sante, Dr. Willy Staco, came to HAS and reported that there were many cases in Petite Riviere. HAS staff who had been to the hospital in St. Marc reported that there was a large crowd outside the hospital, with an estimated 60 patients there.

As more patients came in during the afternoon and evening, the HAS mass casualty protocol was implemented, and patients started to line the halls and crowd the inpatient bays. Patients in the hospital’s Evaluation, Stabilization and Treatment unit were either discharged or admitted to the ward, and this unit became the intensive management site for the diarrheal patients.

The causative organism has not been identified and initial suspicions have focused on typhoid. Dr. Bien Aime, the epidemiologist in Integrated Community Services, began to take oral histories and identify where the patients were living when the fell ill.

All through the night, we maintained contact with HAS board member Scott Dowell, of the CDC, who updated us on reports from the CDC field staff in Haiti. Scott sent us very useful references for patient care.

This morning, we collected relevant specimens between 2am and 4am and sent them to the National Lab for evaluation by midday. In the meantime, we are pushing hydration and maintaining hygiene. No new cases came to HAS after midnight, and we are waiting to see what the morning brings.

HAS Observes World Mental Health Day

Sunday, October 10th was World Mental Health Day, which HAS observed the following Monday with a presentation by a psychologist who discussed the long-term effects of traumatic events such as natural disasters. As he talked, I, and I am sure others in the room, were carried back to the days after the January earthquake.


Several weeks after the earthquake, we visited several churches and schools which had welcomed people from Port au Prince, and provided them with temporary shelter before they could be placed with generous families. The pastor asked me to look in on a young woman who had moved her cot to a corner and lay on it in a fetal position with her face to the wall. Unresponsive to any overtures, she huddled in her bright Chinese blanket.

I asked if she was like this all of the time, and the pastor said that no, she had terrible nightmares whenever she tried to sleep, and appeared to be reliving her experience in the falling houses. He asked for help for her, saying that he was worried about her and the other refugees in the church.

The pastor’s wife then introduced me to several other people who were suffering from flashbacks and nightmares, and then told me that her husband was also waking up every night, reliving the experiences of the people who were in the church and who had shared their stories with him. She asked if the hospital could help them. I explained that in most cases the reactions of the people at the church were understandable, and common following traumatic events. I told her that I would see what we could do for her guests.

Before the earthquake, HAS had been fortunate to find a young Haitian psychologist to work with the AIDS program. Her contract was coming to a close with the transition of the AIDS patients to Partners in Health, and she had stayed on the staff to support that transition. During the earthquake, she had come into the hospital for long hours every day. Initially she supported the acute needs of patients and their families, and then offered counseling to the physicians and nurses (and occasionally administrators) who had been caring for the crush of patients.

I found the psychologist in her office, which was the hallways of the crowded hospital, calmly listening to a patient whose terrible memories were now accompanied by the fear of the unknown in an operation on her leg later that day.

She agreed to come to visit the people in the church, and another group which had been housed temporarily in an empty rice warehouse (all of these groups were placed with families within weeks of their arrival in the region, and most remain today). She was able to provide immediate support to several patients, and to the families who were with them.

On the way back to the hospital, we talked about what she had been able to achieve in the past weeks, and her heroism and professionalism poured through her simple reports of types of cases she had seen. We discussed what we could do in the coming days, recognizing that everyone on the staff had been stretched beyond their limits of endurance. She sat in her seat, looking out the window, obviously reflecting deeply, and suggested that we could talk about it the next day.

When I saw her, she shared with me that she had been on the phone with several of her classmates from the psychology program who had suffered personal losses in the city. She asked if it would be possible for her to host them in her small house on campus. Of course, I assured her, and asked if there would be a chance that they might wish to work here. One step at a time, she said with a sly smile.

Today, HAS has three psychologists, which represents approximately one-quarter of the professional psychologists in Haiti. They offer individual, as well as group counseling, and their schedule is fully booked all day and into the early evening. Their residence has been converted into an office, and signs guiding people there are dotted throughout the campus and hospital.

With the good fortune which seems to been gifted to HAS in recent months, Rolf Maibach contracted with AMURT, an international emergency aid organization, to support this program, and we have come to recognize that, as is the case with physical therapy and prosthetics, that this will be a permanent element of our service package.

At the Monday conference, the psychologist presented statistics of our service volumes, with an estimate of the current need for counseling services throughout the country, as well as the small resources available to meet these needs. As with many other clinical services in Haiti, there is a tragic mismatch between the demand and the resources, and in this case, HAS is fortunate to be able to serve many of those who come to us in need.

High School Student's Visit to HAS

My name is Robin Brody and I am a high school student in Colorado who had the incredible opportunity to spend nine days at HAS. The experience was one I will never forget.

My appreciation for everything we have access to here in the United States grew exponentially since my visit to Haiti. It amazes how abundant our resources are, and it troubles me greatly. We waste too much of everything here; but the one thing that now troubles me most of all is our waste of food. While at HAS I worked with the children and families in the Annex (the malnutrition unit) whose major challenge has been to get enough food to eat.

While at HAS, I worked with the kids and families in the Nutrition Annex. I visited and painted with them many afternoons during my stay. I noticed how closed off and sad all the patients and their families were. After only a few minutes of interaction, they opened up and started laughing and smiling.

I became very curious as to how these children became malnourished in the first place. The hospital’s community-based workers, Animatrices, had collected data to find which areas have the highest risk households for having a malnourished child. I helped to enter the data from these surveys into a register, and once the data was compiled and the areas with the most risk factors identified, we headed up to the mountains (where there were the most household with high risk factors) to see where the children who came to the Annex came from.

We went to house after house with four or five risk factors. The established risk factors are simple; If a family has a metal roof rather than thatched they are at less of a risk. If they have a latrine they are at less a risk then those without. If the family uses a method of family planning then they are at less of a risk of having a malnourished child. If they cook on some sort of elevated “stove” they are at less of a risk then if they cook on three stones on the ground. If a family has a pump near their house they are much better off then if they have to walk miles to a stream and if they have a filtration device for the water their children are less likely to be mal-nourished.

At the houses with high risk factors, we found malnourished kids by measuring their arm circumference (less then 12cm indicates a malnourished child. 12cm shows the child needs to be watched carefully and over 12cm means they are OK).

Robin Brody

On the positive side not every high-risk home had a malnourished child. In the houses with malnourished children we gave the families pre-packaged bags of dried rice, bean, vegetables and vitamins in hopes that the children could gain a little weight each week, and the other children could be kept from becoming malnourished.

It was fascinating and devastating to see the relationship between the high-risk factor houses and the children who had dipped to low and ended up in the Annex at HAS. The experience made me incredibly grateful and eager to do something more to help!

ALFA Program

One of the great tragedies in Haiti today is the large number of adults who are analfabete; illiterate, and not able to participate in the normal exchanges which are the foundation of contemporary society. For example, the majority of HAS’ animatrices, who are the front lines of the hospital’s connection with the residents of the HAS region, cannot read or write. For that reason, when we conducted a Risk Factor Analysis for infant malnutrition, we used a graphic check sheet so that all of the animatrices could participate.

The HAS alphabetization project has been operating for two years with the generous support of the Hummingbird Foundation, and has graduated more than 200 participants in a 2-year program of 3 afternoons per week.

Last Thursday, the 2010 graduating class invited Dawn Johnson and me to join them for their graduation ceremony in a shady church yard in Marin. More than 123 people from 8 mountain communities arrived for the ceremony, dressed in their finest, and quite proud of their achievement. Each of the community groups contributed something to the ceremony; a short theatre piece, a song, a dance, or speeches of welcome or gratitude, all of which involved reading.

One of the skits involved a small group walking to their Alfa class, and greeting a farmer in a field, inviting him to join them. “Too busy” he grunted. As the students walked back and forth each day, they told the farmer what they had learned. “I can measure my field and calculate my corn harvest” one said. Another said that she can read the label on a can of fertilizer. Another said that he will make a list of everything he will buy in the Verettes market. Eventually, the farmer’s restraint dissolved, and he followed the students off stage with his hoe on his shoulder, stimulating a standing ovation.

Agathe Geneus, our animated project coordinator, asked several participants what they could do now, that they could not do before the class. “I can read my child’s vaccination card” one said. “I can read my prescription, and now I don’t miss my medications” said another. One woman reported that now she can read with her children when they come home from school. An older farmer stated formally “Alfabetizaston se lavantage nou!”; being able to read and write gives us an advantage.

One group arrived in white shirts with a handwritten message on the back “ABA TI +”. All through the ceremony, I stewed over what this word meant. As the final act, they came to the microphone and sang a song about how they finally have learned to write their own names on documents, and don’t have to be embarrassed by having to make an X mark. Thus the motto on their shirt; “No more small cross”, sung with great pride.

Periodically during the ceremony, Dawn Johnson, who supports the literacy project, and I were invited to join the groups who were performing dances. Dawn is graceful, and I am less so. At a quiet moment, a young woman went to the microphone and, reading from a paper, announced that she wanted to ask me a question. She asked “How did you learn to dance, M. Jean?” The audience was teetering on the edge of open laughter, so, in as much of a deadpan I could muster, I said “I learned to dance from a book”, which gave everyone permission to give full vent to their laughter.

It’s possible that our culture has lost the gift of ritual in ceremonies; we have much to learn from Haitians, for whom ceremonies hold a vital function, to celebrate, to honor transitions, or to mark the beginning or end of important life stages. For the participants in this ceremony, their two years of effort were capped by a memorable, happy and important event. The flowery certificates which they took home with them will, long into the future, trigger memories of a morning in which they were honored for their commitment to self-development, and recognized for achievements. And I will long remember it also.

HAS Welcomes New Medical Director, Dr. Silvia Ernst

Hôpital Albert Schweitzer Haiti (HAS) wishes to thank and bid a fond farewell to Rolf Maibach, MD. Dr. Maibach has served at HAS as medical director for 2 ½ years, pediatrician for 1 ½ years and as a board member of HAS for 10 1/2 years, as well as 14 years of short term volunteering. He is returning to his home in Switzerland but will remain on the HAS board. Dr. Maibach wrote the following touching letter to express his deep attachment to HAS and to introduce the new Medical Director, Dr. Silvia Ernst:


Dear Friends and Colleagues:
Today is my last day as Medical Director at Hôpital Albert Schweitzer Haiti (HAS). Dr. Silvia Ernst will arrive in Haiti this morning, welcomed by Ian at the airport, briefed about the news at HAS and will immediately take over as Medical Director. Silvia and I had the opportunity of brainstorming for 10 days in Switzerland and for an additional day in Ilanz and from those meetings, it is clear that Silvia is very well prepared for her important and difficult task at HAS. Silvia brings with her a wide range of professional and personal experience from her excellent work in Switzerland, India, Belgium and Africa. HAS is very fortunate to have Silvia as its new “Directrice Medicale”. Along with Silvia, HAS is privileged to have two outstanding Haitian physicians who have served as Acting Medical Directors, Dr. Harryo Sannon, Chief of Internal Medicine, and Dr. Maurice P. Toussaint, Chief of Pediatrics. Another important member of the team is Ms. Eda Sam who will succeed my wife Raphaela as Haitian Chief of Laboratory.

Raphaela and I are not leaving Haiti or HAS at all. In fact, we will be in Haiti several times a year assisting with the supervision of the Swiss Pediatric Transition Project and the Social Service and Laboratory Projects. I will also remain as a Member of the HAS Board.

Now it is time for me to express my thanks. The farewell party that the employees of HAS arranged for me was wonderful and touching and I thank you for putting it together for me and for the years of your service with me. I wish to thank the patients of HAS as well. I would also like to extend my thanks to the Board of Directors and the Senior Management, especially Ian and Nevin and Jimmie and Dawn; and of course, the team at the Pittsburgh office. Thanks to all of you for your help during the last few years. As you all know, my heart will always be with HAS as I share with you a deep concern for its future and the health and well being of the people of the Artibonite Valley.

Raphaela and I are thankful for the privilege of being a part of the wonderful HAS team.

Sincerely,
Rolf Maibach

Hôpital Albert Schweitzer Haiti wishes to welcome Dr. Silvia Ernst as HAS Medical Director!


A little bit about Silvia Ernst, MD:

Silvia Ernst, MD, Internal Medicine (FMH), General Medicine(FMH)Diploma in Tropical Medicine and International Health.

Silvia was born in Switzerland and is fluent in German, French and English. She studied at the University of Zurich, the University of Lausanne, the University of Basel and the Tropical Institute of Antwerp, Belgium. Her specialty is Internal Medicine and General Medicine with a post graduate certificate in Tropical Medicine and International Health. During her training, Silvia has worked in gynecology/obstetrics, surgery, anesthesiology, emergency medicine, intensive care, pediatrics, radiology and infectiology.

Silvia is a member of the Swiss Medical Association, the Swiss Association of Residents and Consultants and the Swiss Association of Internal Medicine.

Silvia’s work in the developing world, and in particular her recent work at the Albert Schweitzer Hospital in Lambarene, Gabon immediately identified her as the top candidate for medical director of Hôpital Albert Schweitzer Haiti. She has served on the board of directors of the hospital in Lambarene, and is well acquainted with the Schweitzer philosophy that is central to HAS.

She also has been very involved with humanitarian activities at the Leprosy Hospital in Kothara, India. Hôpital Albert Schweitzer Haiti is very pleased to welcome Dr. Silvia Ernst to our team.

Silvia Ernst, M.D.

Seasonal Malnutrition in Rural Haiti

The SCI team visits the home of a household with high risk factors for malnutrition

The Nutrition Rehabilitation Unit at the hospital has the most severely malnourished children in the region; most of them have been sent to the hospital from the mountain dispensaries in Tienne and Bastien. The surveys by HAS of households of risk factors for malnutrition indicated that the area served by the Tienne dispensary included the highest proportion of high-risk households. This was corroborated by the most recent monthly weigh-ins which showed an inordinately high rate of Low and Very Low Weight for age children.

A community health worker shows off the
normal weight record of a child in a high-risk household

            In order to better understand the actual conditions of households in this region, a team of four members of the SCI team went to Tienne and accompanied animatrices in home visits to selected houses.  In many of these houses, we found children who had been admitted to the hospital's Nutrition Rehabilitation Unit, which validated the survey findings. However, in the locality where my son Edward and I were visiting, we also encountered a number of homes which had high risk factor ratings, but the children's weight charts showed normal growth. This raises the question as to why households with extremely limited resources do not have malnourished children. Part of the answer to this question lies in the concept of Positive Deviance, in which the expected negative conditions are not found. An understanding of the strategies which are deployed to avoid the hazards and health consequences of poverty can help to shape an effective intervention strategy, to help other families to discover approaches to preventing malnutrition and illness.
            Our discussions with the mothers of PD children brought out some of the steps taken by mothers to ensure that their children were well provided for.
            When we complimented one mother on her child's obvious good health, and noted that surely life was difficult in the mountains, she explained "nou pa chita"; we don't sit down. Very animatedly, she told how during that week, she had bought limes from neighbors, loaded them in straw bags on her donkey, and took them down to the Verettes market to sell. She took the money which she earned from the limes, and bought toothpaste and imported foods from the Dominican Republic (which are not available in the mountains) and sold them to her neighbors. With her small profits, she bought rice, which only grows in the irrigated lowlands, for several nutritious meals for her family.
            Her energy and creativity, as well as her concern for her family, combine in the design of her work week to add income to the household and to protect her children.   

The strategic plan for HAS’ nutrition services include the establishment of nutrition rehabilitation services at the two mountain dispensaries, which will reduce the need for the children and mothers to spend several weeks far from home, and will provide a base for community-based education in nutrition. One of the key resources for this effort will be the mothers who have developed strategies to protect their children. These shining examples of Positive Deviance  will be folded into the educational programs as local experts, to share their success stories with their neighbors.

Ian Rawson

A conversation with Carsten Stauf

The patients at the HAS Hanger prosthetics lab have appreciated the gift of new mobility which comes with the prosthetics device. Recently, they have been able to benefit from a new device, the Haiti Knee, which was designed by the Medi corporation in Germany to address the specific needs of Haitian patients. Recently, Rebecca Rawson had the chance to talk in Deschapelles with the engineer who designed the Haiti Knee.

Carsten Stauf shows the Haiti Knee
to HAS Managing Director Ian Rawson

Carsten Stauf is the chief project engineer and inventor of the “Haiti Knee.”  He and his colleagues at Medi, a German company headquartered in Bayreuth, Bavaria, have been providing prostheses to the Hanger Corporation for decades.  When Hanger opened the prosthetics lab at HAS, Medi sent them the first prosthetics systems for Haiti. These have been life-altering for over 500 Haitians.

Carsten developed the “Haiti Knee” to respond to the unique challenges in Haiti, such as the uneven terrain and the gait of the people.  The “Haiti Knee” is lighter and more durable with a titanium head that features greaseless Teflon to make it easy to articulate, and therefore to walk.  The head attaches to 2 carbon rods that can be adjusted to the individual’s height.  It is a neat and efficient system.  Medi has given HAS 300 of these units as well as 300 pairs of shoes, made in Austria, which will cover the hospital’s needs until next summer. 

Long term plans between these collaborators include 2-week rotations at the Hanger lab of Medi-related personnel, such as certified prosthetic orthoticians and physical therapists, to alternate with the Hanger personnel.  Medi is also making a 15-minute documentary by a German film crew that will premiere in Orlando, Florida at the upcoming World Congress meeting of Orthotics and Prostheticians.  It will then be sent all over Europe during the holidays with the aim of creating a registry of doctors, CPOs and physical therapists who would come to volunteer at HAS.

As each patient puts on a new leg at the Hanger Clinic, they may not understand that this prosthesis is the result of an international collaboration which reaches from Germany to the United States to Haiti, but they are overjoyed to have this new mobility, and to be able to look forward to a future which includes the possibility of employment, going to market, and being with family.

Prevention of Water-borne Diseases in Flood Zones

Following the floods in the Deschapelles and neighboring areas earlier this month, volunteer animatrices visited all of the households to which they are assigned to assess the risk factors for disease. A graphic chart was designed to allow the mostly illiterate animatrices to report damage to latrines, well-heads, water storage, or household materials which might contribute to gastrointestinal and other diseases.

More than 1,000 households were surveyed in the three major flood zones, and the results were synthesized in order to identify regions and households where the damage was the most extensive and severe.

I, along with the director of the HAS Wells and Water team, and the senior community relations manager, visited over 50 high-priority households to validate the findings of the survey, and to establish our priorities for reconstruction. We selected three localities with a total of 8 separate households, and over 65 residents in total. In each of these 8 households, we will build a latrine to replace the ones which had been damaged beyond repair. At the same time, we will decontaminate wells and evaluate the need for repair of the well heads.

Work begins Monday on this strategy, with the purchase of cement and hiring a bos mason who will oversee the construction of the latrines at three central sites. Each latrine costs approximately $300, the funds for which have been received from generous and concerned donors.

As the work proceeds on these latrines, we will go to several other nearby localities which have been identified by the surveys to have been seriously damaged. There, our priorities will be latrine construction and well decontamination, plus possible construction of flood-proof wellheads.

In some communities, we have identified the need for biosand water filters; water is accessible through shallow wells, but the water is consistently polluted, so a household water filter will remove coliform bacteria to render the water potable.

The flooding and its aftermath have shown us how vulnerable the local families can be to environmental impacts; as we visit households, we are invited into neighboring courtyards which did not suffer flood damage, but still need latrines, wellheads and water filters. As a result, this work will extend beyond the present urgent state into the near future.

With the encouragement and support of an NGO which is active in the north of Haiti, we will construct several multi-user composting latrines, to be located in several clusters of large compounds of extended families (20 or more residents).

Ian Rawson
Managing Director

Responding to the Deschapelles Floods

Immediately after the floods, volunteers spread out to the most affected households in our region to assist in cleaning and trash removal. By the end of the week, our volunteer community-based workers conducted household visits in these stricken areas to assess other damage from the flooding. They reported on destroyed latrines, contaminated wells, and the loss of animals and property. It was evident that immediate action should be taken to reduce the possible incidence of typhoid, oral-fecal contamination and other water-borne diseases.

The planning team from HAS Integrated Community Services determined that the most important intervention at this time would be to ensure that each household in the most affected areas would have access to a decontaminated well, water filter and a functioning latrine. Each of these involves the construction of the filter, a toilet base and seat, or collar for the well to keep out ground water.

Today, the emergency response team will go to areas where there are clusters of houses with these needs and identify locations where we can set up a small production plant for these items. Because of the weight and the lack of road access, our experience shows that it is easier to set up the fabrication as close as possible to the location where they will be installed.

So far, we have identified 4 priority fabrication sites and we expect that number to increase to 10 sites. Each site will receive 10 latrines at a cost of $3,575 and 10 well covers costing $1,500. We have been assured by World Vision that they will offer food for work support for the people who provide labor at the fabricating sites.

We are fortunate that donors have already made contributions that cover almost all the funds needed for 2 sites. These and other emergency requests that we make are due to extraordinary circumstances and are not covered by our budget. A gift designated for emergency relief will allow us to address this crisis and future ones in a timely and effective manner.

The community is appreciative of the rapid response which HAS has been able to mount in response to this urgent situation, and we are hopeful with your help that the entire program can be funded and implemented by the middle of August.

Ian Rawson, Managing Director

Measuring the Flood Impact in Deschapelles

In the days after the Sunday flood of the Ca Charles watershed, volunteers and part-time workers with the UN project went to all of the affected homes and assisted in clearing away mud, rocks, trees, and trash, helping the residents to gain some sense of order, and to cope with their losses.

Many of us joined the volunteers, and we were shocked by the extent of the damage to the homes and the crops. In a team meeting of the staff of Integrated Community Services (all of HAS’ activities outside the hospital), it was suggested that we would conduct a survey of homes which were in the flood cone, to determine the extent of the damage, and to identify priority families for assistance in rebuilding. We had hoped to immunize 3,000-4,000 people in the area of worst flooding against typhoid. Sadly the vaccines were not available in our area, so instead our health workers provided education about typhoid prevention.

We activated the animatrices, community volunteers who work with HAS as contacts with the community, reporting on births and deaths, finding cases of illness and referring them to the dispensary or hospital, and providing health education. Most of the women (and a few men) had previously participated in the survey of risk factors for malnutrition, so we used the same concept of a graphic survey, so that the mostly-illiterate women could mark the objects which they saw.

Today, most of the surveys have come into the office, and we are compiling them to cluster by sub-zones within the immediate hospital area. Over the weekend, we will compile the results and identify the highest-priority households to be visited and support with whatever resources we can find. We appreciate the responses which have come in after the first blogs in this series, and we have already seen that the needs are greater than we had imagined.

Ian and the Integrated Community Services team.

In the Aftermath of the Flood

On Monday morning following the rains and the flood, the HAS managers of the UN Cash-for-Work project allocated more than 100 workers, who had been cleaning local canals or fixing roads, to the flooded areas. Using wheelbarrows, shovels, and other tools from the project, they joined the people in the mud filled courtyards to clear out the piles of trees and branches, and to clear the mud from the house floors.

Some of the women collected the clothes from the houses and washed them, putting them out to dry on fence lines and bushes. By the end of the day, most of the large debris had been cleared, and the houses had been emptied of the furniture to be assessed for future use. Many households had mattresses, but few had bed frames, and thus were soaked with muddy water. When they are dry, most of them will be burned.

The physical, visible, effects of the flood have started to disappear, but the sense of loss and having been invaded by a powerful force will remain for a long time. The HAS team of psychologists, who have been supporting the needs of the earthquake victims who live in this region, will go to the flood areas tomorrow to conduct group therapy sessions, and to try to help them to deal with the sense of insecurity which comes from such a powerful event and it losses.

While the force of the flood was greatest as it passed by the narrow channel behind the market, it gained strength from a web of small watersheds, each of which contributed a rapid flow of water, mud and debris into the main channel. This morning, one of our security guards, who had volunteered to help other families the day before, shared with me that he cannot get into or out of his house, because one of the upstream feeder channels, which is usually a small stream, had flooded and swerved, washing away the gentle slope to his front door. Now there is a steep ravine in front of his gate. Later today he will cut a new gate in the back fence, and negotiate with his neighbor the rights to pass through his courtyard to get to his house."

As always in Haiti, volunteers came from all over the community, to assist the people in the flooded zones, and to show solidarity with them, in the face of a tragedy which might have affected any of them.

Weather forecasters have been predicting for months that a punishing hurricane season is on the horizon. We are watchful and hoping for the best for all of the people of Haiti.

Ian Rawson
Managing Director

Torrential Downpours Flood Artibonite Valley

Five years ago on this date, a short but powerful rain created a flood which rushed down the Les Forges ravine and washed out the Deschapelles market and most of the houses below the bridge which leads to L'Escale, a residential village belonging to HAS.

On Sunday, in the late afternoon, a similar rain created a flood of the same magnitude. Trees are piled up around the houses below the canal, cars and motorcycles are covered with mud, and the interiors of many houses are flooded to a height of about 3-4 feet.

By Sunday evening, it was still raining, and the floods had receded, but it was impossible to walk very far without slipping in the mud and tripping over trees and branches. Thus far, there are no reports of physical injuries or losses, but we can see a substantial impact on the residences, courtyards and fields of food crops. Also, we have not heard from the upland communities, which will have endured the same rains.

Our extended family here at HAS has suffered losses. Manite, employed at HAS since the very early days, found her house was flooded to the height of her waist, washing away many of her treasured herbal plants. Another long-time HAS employee, Tyranie, also lives in that lacour, a small cluster of homes, and her house was flooded as well. The children from that lacour were brought over here to my house, and we had a bit of a camp party there with hot chocolate and blankets.... Fortunately, guests left yesterday, so we have space for the temporary visitors.

In Haiti, we live very close to nature, and its vagaries impose themselves without warning or selection. But the poor suffer more, because they are less well protected, and the margins on which their lives are led are so narrow. The miracle is the resilience of Haitian people, and their ability to carry on in the face of disaster, and to be able to visualize a better situation even in the face of disaster.

Our role is clear; to be considerate and concerned, to share resources as they may be available, but to share with them the experience of loss and also of recovery, hand in hand and shoulder to shoulder.

This incident may not be carried on your national or regional TV shows; the media who were here last week to mark the 6-month anniversary of the earthquake left before this new challenge emerged. Our son Edward came back from Port au Prince yesterday evening along the coastal road, and he reports that the devastation is remarkable all along the road, with flooded rivers and mudslides down from the steep mountains, and people wandering out to and into the road in a state of shock. Today will bring a broader perspective, one of loss and disaster, but ultimately of perseverance and hope.

Ian Rawson

Managing Director

HAS 6 Months After the Quake

Six months ago, a powerful earthquake shook Haiti’s capital city and other crowded residential areas to the south west. Only estimates are available of the number killed or injured, who have endured life in tarp cities, or who have migrated to rural areas.

HAS, unscathed by the tremblors, accepted over one thousand patients, most of whom were admitted to the hospital and received advanced care, most frequently orthopedic interventions. With time, most of the patients were discharged, some to an uncertain future, and HAS began to return to a semblance of its former status as a regional referral center.

However, the earthquake has changed everything in Haiti. The country’s healthcare infrastructure has been severely disrupted, and leaving a significant shortage in surgical and specialty services in the main city. Almost a million refugees are estimated to have left the capital to stay with relatives or acquaintances in rural areas, and approximately half of them came to the Department of the Artibonite, where HAS is located. Many of the refugees in the Artibonite have located in the major towns, but we estimate that our population in the HAS district has increased by 15%, with many of these residents needing primary health care and immunizations.\

The earthquake has also changed everything at HAS. The hospital, normally a 80-bed facility, now has more than half again as many inpatients. Most of the added inpatients are scheduled for surgery, and many of these are orthopedics cases who have been injured in motorbike accidents. The pediatrics ward has also expanded, with children with gastrointestinal and respiratory diseases, often complicated with malnutrition. As the patient population expands, so do the diagnostic services in the laboratory and radiology.

The prosthetics services, provided by the Hanger Corporation and Foundation, is racing to keep pace with the demand for new limbs for amputees. Over 400 patients have received prostheses, and more are on the waiting list. Today, there were more than 40 patients at the clinic; some are living at l’Escale, a temporary residential space just off the campus, and the others were brought up from Port au Prince by bus.

HAS, which prior to the earthquake, was a regional referral hospital for the 300,000 residents of three communes, now serves as a vital resource for the population of the destroyed capital as well, with patients coming from that area for surgery and diagnostic services. The national plan for prosthestics calls for the establishment of 8 laboratories, with four in the capital and four in the periphery. Not all of these services have yet come on line, and HAS appears to be one of the major provider for the entire country of Haiti. HAS now has a new, expanded role in the total scope of health services in Haiti.

The malnutrition ward always expands during the rainy season, while crops are growing and there is little food in the house. Almost half of the patients in the ward today are from two mountain communities, and we are making plans to develop nutrition rehabilitation units at these two dispensaries, to be more convenient for the mothers. In the long run, it is our hope to be able to substantially eliminate malnutrition in the mountain region through preventive intervention, especially among the most vulnerable children, those who are going through weaning to a transitional diet, and those who live in resource-poor mountain communities during the rainy season.

Just as more international aid agencies arrive in Haiti to set up long-term recovery projects, there appears to be a sense of malaise and frustration among many young Haitian professionals about the slow pace of change and the lack of a coherent recovery model. HAS, along with other healthcare organizations, has noted the departure of physicians to Canada and Europe, probably on a permanent basis. Several of our all-Haitian permanent staff positions are vacant, and will have to be filled by short-term clinical volunteers.

HAS was very fortunate to have been generously supported in the weeks following the earthquake, and the funds which were sent to assist HAS in that crisis have been expended in addressing the need for resupplying the hospital, accommodating volunteers, Now, the increased demand for our services, and the resource-intensive nature of the surgical and other services, have placed pressures on the planned expense budget for 2010. While cost reductions have been instituted, the redefined mission of HAS represents a challenge for the organization.

We appreciate the concern and support for HAS and for Haiti which our supporters have expressed in so many ways, and we look forward to our new challenges with confidence, and with appreciation.



As we sit together today in Haiti, making plans for the near term and longer term at HAS, we appreciate the concern and support for HAS and for Haiti which have been expressed in so many ways, by so many people. Some have known HAS for a half century, but countless others are new friends. We look forward to our new challenges with confidence, and with appreciation.



Ian Rawson, Managing Director & John Walton, Board Chair