Cholera Camps

Cholera Camps

 

One month of cholera response in Haiti – and I am sitting on the north Dominican coast, only thirty minutes’ drive away, watching the sun set over a quiet sea, reflecting on another world, a war I have left on another planet.

Part of this personal war zone is the culture of an emergency response, the 16-20 hour 7 day working weeks that I have lived for the past month, the pressure to ‘save lives’, to deliver to the local health ministry and the local population what we have promised, the race against the disease, the ‘raison d’être’ for a humanitarian organisation in a disaster-stricken area.   Practically, as a logistician, there is constant pressure from the medical team – if they do not have medical supplies and other background logistics with which to care for a patient, there can be another death – they don’t want it on their hands, and I don’t want it on mine – it becomes a distorted reality, distant from the usual timeless cycle of life and death in North Eastern Haiti.

Each patient who arrives at a treatment centre needs beds, buckets, shelter, latrines, rehydration salts, medicines and basic medical equipment.  Behind that, a treatment centre has a system – different zones to prevent the disease being further transmitted (by touching the vomit and liquid faeces which gets everywhere in the cholera centre) – this means putting up large tents or shelters, building fences, creating gates and baths for washing feet, taps for washing hands, employing, training and supervising staff to clean and disinfect the latrines and constantly provide chlorinated water.  Behind the camps, there is more – a freshly rented depot with 30 tons of buckets, brooms, gloves, medicines, medical equipment, tents, building material, and the need to replenish the depot and ensure that the stuff in it is delivered on time to all the sites.   And behind this, a fleet of cars, lorries and drivers to ensure all the staff and materials are in place on time.  Then there is a necessity to establish a base to sleep and operate out of, and to ensure that all the staff, especially the medical team, have a place to sleep tonight.   Finally, an emergency response requires the rapid recruiting and training large amounts of staff at very short notice to diagnose, prescribe, nurse, buy, build, clean, drive, guard, storekeep, and manage.  All this in area where we had no local staff, no knowledge of where things can be bought, bartered or rented, and where there was a lot of fear and inexperience of cholera, and coupled with a financial pressure to keep costs down.

As well as fear, some have a curiosity as to what is to be found in a cholera treatment centre – once I found some obese American tourists, unnecessarily kitted up in surgical clothing, face masks, shorts and sandals, traipsing round our cholera centre snapping away. They were evangelicals from the deep south – a lot hang out on the north coast of Haiti. And I have seen some very good missions – but these were the worst type – clueless, unaware of the world beyond the US borders, unconscious that people are still humans when they have cholera.  Once, I arrived on site to find an American film-maker on site, with no medical personnel, no prior communication with the local health authority, no car, and no knowledge of the area and with his camera right up the nose of a small choleric child.  I politely escorted him off site, feeling ashamed, as we are responsible for the treatment centre, with the families of the patients hanging around in hordes at the gates watching what happens in the camp.

In the North-East we thankfully had a week or ten days before the patients started to arrive at the camps (although, since no-one knows about cholera here, there were people dying in the communities before coming to the camps).   Now, while the epidemic is on the downward curve in the first Southern and Western provinces, it is exploding in the North-East. From an initial number of 200, there have now been over a 1000 confirmed cases, 500 of which have passed through our centres, and about 70 deaths, about 10 of which have been in the centres, most in the early days).  Over the last few weeks our humble two 20 bed treatment centres have increased to about 80 beds each, which are all permanently occupied and overflowing, and we have two more large centres opening soon.  Every day is a rapid production line of putting up new tents, building beds, latrines and showers, addressing water supply problems, installing electricity (it is hard to put an IV line in a vein without good light).  It is the evening when the most new cases arrive – the camps are a seething mass of people – patients and family caretakers, nurses, cleaning staff.  We have run out of space at both sites (both in the empty spaces of hospital compounds), and need to get to work on the new sites quickly. The organisation responsible for community level oral rehydration points, a way of easing the caseload on the treatment centre (which should only be for the most severe cases), is behind with their work, as we inevitably are with ours – in the northern province, next door, a larger organisation have 50 expatriates working on 1000 beds, started a few months ago, we have 5 working on 300 beds, having arrived 1 month ago.   Even with these odds, there seems to be some success – within the treatment centres, while the case load doubles weekly, the mortality rate is halving – I am starting to see a notable improvement in the organisation and success of the centres, and the confidence and knowledge of the staff.

The management of corpses has been a challenging issue – two weeks ago, with no local alternatives for patients arriving at our half-finished camp, I turned up on one site to find a mountain of rubbish all over the site because, amongst other reasons, 2 bodies were occupying the incinerator building for lack of a better option. There was also a body lying on the ground behind one of the tents.  Apart from moving bodies outside the tents and hosing them down with chlorinated water, no-one wanted to touch them, and, unfamiliar with local customs it would be unwise for us to handle the bodies – it therefore falls to the town councils, who are slow to act, both with community deaths and deaths in our centres.  Two days ago, a patient was carried in on a motorbike in a very bad way, and lain down in the reception area where I was working.  Within a few seconds, before she could be seen, she started to fit, and a large crowd, silenced by the experience, watched her die from outside the fence.  The body lay there for an hour, simply hosed down with chlorine – we informed the authorities and work carried on around – staff had to be more concerned with the living patients.  We resolved the immediate problem by constructing a wood and tarpaulin morgue in a corner of the treatment centre.

In an emergency, a new country, a new environment, under pressure, there are inevitable mistakes, rash judgements, conflict, despite the best efforts to avoid them – after the earthquake, for example, medical teams were criticised for performing too many amputations.  In such chaos, emergency teams are also accountable for responsible for basic financial accountability to donors – Under pressure from head office, I had to battle between spending two days sorting the finance paperwork, knowing that it would slow crucial construction work at the camps.  Constantly in the back of my mind, adding to the multitude of stresses and the drowning of many of the usual social rules under the onslaught of the cholera waves, was a long global history of badly managed disaster responses, with Haiti at the centre of many of them.

In fact, with the centres largely up and running, most of my days actually consist of only one or two hours at the treatment centres – there is breakfast at the hotel, early mornings in the depot, late mornings in the Dominican Republic to procure material before the siesta, meetings, supervision of staff and sub-contractors, the odd joke, evenings in the camps, late evenings on the paperwork – and a society outside trying to live normally outside our odd bubble of cholera warfare (and, indeed, in the case of jobs and local business, profit from it).

Negotiation is the bread and butter of this Haitian emergency response – I had to procure everything, from tarpaulins to spades to a blind eye at the border crossing – Usually a clever bit of barter, involved a couple of cheeky tricks, white lies, an intellectual battle arguing of each arguing why the other is overcharging, then with a joke, a handshake, with hopefully a dollop of mutual respect, and a cheeky internal chuckle for the thrill of the game.  The constant search for supplies gave me a whistle-stop tour of the northern Haitian elite, from dirty-handed politicians to drug dealers, brothel owners and opportunists.  I kept bumping into the appropriately named Haitian-American, Handy, at the residence of an inappropriately named politican named ‘Estime’.  Most confident of men about town, and never seen without his gold-laced baseball cap, I first met him with a vague interest in renting his house, when he was rifling through a massive box and optimistically stuffing every pocket of his trousers with handfuls of condoms – I regularly saw him at the hotel, apparently abashedly and sensitively trying to chat up a different girl every night.

Back in the Dominican Republic, and many people seem to walk around with an unfamiliar happy-go-lucky smile, which I first encountered in a barrel-bellied and toothy-grinned Dominican trucker in front of the Brazilian soap operas in our Haitian bank.  I am staying in a clean hotel, one of many new buildings constructed with minimal permissions, with air-conditioning and good coffee, at half the price I pay in a Haiti devoid of mid-range economies, but where I arrived on the back of a motorbike so stripped-down it could have been a bicycle, and ridden helmetless and one-handed by a boy who was probably no more than 12.

Two weeks further down the road, and the situation changed immeasurably.  Cholera is, for the moment in the North-East, on the retreat.  Our overwhelmed centres are now half occupied, our tired staff beginning to take a breather, and Haitian radio is full of optimistic messages for the new year – it will certainly be interesting: the ever-present threat of a resurgent cholera epidemic, the next stage of election results and inevitable riots in early January, and the 12th January anniversary of last years’ earthquake.

And in Haiti’s reaction to this, I see the same opportunistic enjoy-life-while-you-can attitude to New year – I was under immense pressure to pay 300 staff salaries before the evening of the 31st, so that the obligatory rent-a-disco flatbed trucks could roll.  I was looking forward to a beer and a dance with the logistics team, only to be told by a concerned driver that drunk Haitians on New Year’s Eve would be too dangerous for foreigners – I’d like to take my well–intentioned advisor on a Saturday night in any English town.  Although motorbiking there may be a bad idea – yesterday I saw 3 motorbike accidents.  One involved a motorbike carrying 3 people, which inexplicably veered off an empty road, spilling its passengers and somersaulting one of them down the road.  We were travelling the opposite direction in the car, emblazoned with our medical name, and an expat nurse in the back seat.  The driver began to slow down, we all hesitated, shocked at what had happened, and not quick enough to react, already late and under a great deal of pressure to deliver the promised salaries to four cholera centres over a large area, silently continued.  I felt sick – I couldn’t explain why we hadn’t stopped – just one of life’s unsatisfactory eventualities that was momentarily decided for us, one of the rules that break down when society decides to live by the altered code of emergency or war.

On a more recent car ride, I was accompanied by: Gustave, my ‘homme des affaires’ driver who greases all the right people’s hands to get my goods through the stonewall of Haitian customs; Anthony, the charming Kenyan nurse with a mischievous sense of humour; Michel, the logistics-hater from Burundi, and Pierre ‘heeey maaan’ the translator, who has worked for years in nursing homes in the States and tried very hard on his chilled out New Yorker image.  After plugging in our music systems, we spent a happy hour singing along to the same songs – amazingly all wired into us from our wildly different childhoods and memories on different continents – a truly profound moment, were it not for Bryan Adams.

Emergency Impressions

Emergency Impressions from the Disaster Country

 

After nearly two weeks in Haiti, I find myself in an uncomfortable – that of being in a country that historically, academically, and culturally, I know very little about.  Since my arrival, it has been a whirlwind of emergency logistics and healthcare politics – trying to establish a cholera camps, a base and a team in an area where there is little experience or existing local networks – a rapid immersion into Haitian disaster mitigation that has left little time for background research or touristic observation.  I am forced to learn on the job – listening to my drivers, chatting with sub-contractors, scrabbling for information about the inner workings of the health authorities.

I am not sure I had expectations of Haiti, but either way, it has not met them.  The most stark contradiction came today – on election day, when the people are out on the streets in numbers, and 11 of the main candidates have opted to bypass the elections and incite the people to riot, we are in a security lockdown, in a hotel in Fort Liberté, and I passed perhaps the first calm 20 on a small Caribbean beach, the wind blowing and the sun shining, a few precious moments of solitude in an intensely social job.  There is much to be understood – Wyclef Jean, for example, the famous presidential candidate, born in Haiti but raised as a non-Créole speaker in America like many of Haiti’s rich elite, is immensely popular, and inciting the people to riot.  Like his opponents,   Wyclef’s supporters spend a lot of money on the elections – in Fort Liberté they hire cars, hand out t-shirts in enormous quantities, and pay for weeks of street parties.  Aeroplanes fly over with electoral banners, above a bizarre 6 foot high electoral bicycle on a remote road across the Northern delta.  The young men of Haiti, often unemployed, hire themselves out to the political parties – for good money, they will drive round town shouting slogans and inciting people to vote, often covering their faces to shout for a different party the following day.  I saw these events being organised in our hotel, by the largest man I have ever seen, twice my width and weight, with his gold chains a stern look, and a pair of dainty cycling gloves.  Carrying a large hamburger, and in deep conversation with him, was an immaculately dressed nun with the most reverent of smiles.

And what of the cholera, and the earthquake, Haiti’s unfortunate claims to international fame?  Cholera is nasty – people are dying faster than we can set up the camps, rapidly escalating from the early figures of 200 deaths in a population of 300,000 for the North-East.  But that which is never seen on television is that life continues as normal – the markets run, half the population continues to runs across the border to the Dominican Republic as usual every day, and my driver will still have several near crashes each day craning his neck at the young belles on the pavement.  Cholera is all over the radio, schools, communities – and there is a real fear, and a lack of knowledge – Haiti has not had cholera for 60 years – but, in situations that the West is wont to describe as desperate and unthinkable – Haitians seem to share with many in Africa a far greater capacity for accepting that they will die of whatever they die of whenever they die.

And why have the world’s eyes turned to Haitian cholera, as they did in Zimbabwe last year? Because cholera is a magical disease – incredibly easy to cure, and not too hard to prevent – the results can be impressive and instant.  Without treatment, mortality rates are high, but with simple rehydration salts (orally for most, IV in the most severe cases), survival moves above to 90%. T transmission is oral-faecal, so prevention is simple, through clean water supply, hand washing, heating food, and good latrine systems.  Setting up a cholera camp is similarly straightforward in principle, albeit logistically heave – basically fences, tents, beds, latrines, showers and lots of handwashing stations, and  human resources (nurses, cleaners, hygienists, guards), all washed down with plenty of chlorine.  However, the 100/200 bed camps are a last resort – the heart of cholera prevention, and reaction, is a wider question of community sensitization, education and development – clean water supplies, hygienic systems of defecation, clean feeding practices.  In the absence of such resources, some aid agencies have been returning to the same places in Congo and setting up cholera camps every year for 20 years.

And where cholera is unknown, you can set up a perfect cholera camp, and patients (and even staff) will not come because they don’t know what happens inside – they see the body bags coming out and they are scared.  Even the local authorities are scared – our cholera camps are both in existing hospitals, with directors who are worried about future development on the land, and water sources nearby that could be contaminated by cholera latrines.  They are also worried about the balance of resources devoted to cholera, when the health system has insufficient resources to cope with existing demand.

And the earthquake, which shot Haiti to top spot on the global pity rankings only one year ago?  In the north, it had little immediate impact.  But in the south, it was a humanitarian disaster that did truly merit any coverage it received – the stories from the few days following the 12th January are quite astounding – huge proportions of fatalities – even at the other side of Port-au-Prince from the epicentre, many of our staff had lost sons, daughters, wives husbands.  From UN officials to slum dwellers, the earthquake struck the rich just as much as the poor – and more devastating, it hit many of Haiti’s already weak institutions of government – in the health sector, for example, the principle nurse training college was destroyed, taking with it most of the graduating class of nurses.

And we are blessed with the presence of two incredible drivers.  Davide has been astutely described by our experienced French doctor, as ‘primitive’ – not in intelligence, but most certainly in humour.  He always has a conspiratorial smile, and will spend the whole journey talking at you, either about the cow’s milk his father used to make, but usually a running commentary of the beautiful ‘Chantales’ on the roadside. He enjoys playing boyish tricks – grabbing your feet as you run up the stairs above him, driving away when you try to open the car door – quite refreshing to see in someone who is highly regarded in his profession.   His double act, Pascale, an equally brilliant team member was summed up with the observation that ‘if he was American, he would be gay’.  His French is almost incomprehensible, even to national staff, which I think could only be put down to its camp lilt, and he will spend long journeys pouring out his heart on his emotions, on how much he misses his wife, which I suspect may be an overegging of the pudding.

A WHO doctor I met, an emergency junkie who spent her life running round the world dealing with crises, regarded the world as a disaster and everyone in it incompetent, and tending to cause more damage than good in her fleeting visits, considered Haiti worse than Congo.  There is clearly an immense social divide here, malfunctioning institutions of government, and severe poverty, but it is hard to compare to Congo – even in remote North-Eastern Haiti,  there are a couple tarmac roads, banks and people with bank accounts, markets, hotels, internet, and a semblance of local authority systems and health centres.  And across the border in the Dominican Republic – a logistics holy grail, albeit inaccessible to most Haitians: PC world, supermarkets, ATMs, hardware stores, motorways – two worlds on the same island.