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.