Battling cholera in Haiti's frontier

Rural Haiti is posing one of the largest challenges in the fight against cholera.

Biggest challenge to tackling the disease lies in the countryside

A makeshift stretcher sits under a tree outside Hospital Albert Schweitzer, left there by a family who carried a sick young girl to the facility in Deschapelles, in Haiti's Artibonite department. ((Amber Hildebrandt/CBC))

A rusted metal twin-bed frame with strips of bamboo bowed to create a sheet-covered dome shield a girl inside from the beating sun. The makeshift stretcher is more elaborate than most, likely built for a long walk down a dusty road.

A corner of the thin, faded Little Mermaid sheet is turned up, revealing the girl's face and shoulders, heaving in deep breaths.

A young girl carried in a makeshift stretcher, a metal bed frame. ((Amber Hildebrandt/CBC))

The girl appears unconscious as her loved ones carry the bed on their shoulders, gripping two lengths of bamboo protruding from under the frame. 

The group walks the bed toward the first building they see at Hospital Albert Schweitzer in the town of Deschapelles, Haiti. A man points them to a building in the back. They trudge over and put the bed down. An American health care worker comes out and directs them to another building, the assessment centre. They pick her up again and walk slowly to their final stop before health-care workers take over.

"She probably has cholera," Paul Hendershot, the supporting director of hospital services, remarks after whisking the girl into the assessment centre.

Cholera patients descend on the hospital's doorstep every day in all manner of transport. "Doors. Doors are pretty standard. Or just a piece of wood, whatever they can find," says Carolyn Weinrobe, manager of monitoring and evaluation at Hospital Albert Schweitzer.

Families also bring patients on motorcycles and lug them on donkeys. Sometimes the patients even walk for hours.

Dying on the way

Nestled in the Artibonite department —  home to the cholera outbreak — the decades-old Hospital Albert Schweitzer takes in patients from the rural communities in the Artibonite Valley and surrounding mountainous areas in the central Haiti region.

The outbreak, first noticed on Oct. 19 in the Artibonite department, quickly spread to all 10 departments. The latest numbers from Dec. 9, show cholera has claimed 2,323 lives and infected nearly 105,000. The countrywide death rate is 2.2 per cent, but varies widely by department. Though that might not seem high, cholera is in fact a highly treatable disease — and should have a fatality rate of less than one per cent.

Many fear the death toll is much higher than reported. A sample study by the U.S. Centers for Disease Control and Prevention tracked the figures in one community. It found that out of 87 cholera-related deaths, 39 people, or 45 per cent, had died in the community, rather than in a health-care facility.

Of those who died, 41 per cent, or 16 people, said they had tried to seek health care. Eight of them died on the way to a health facility.

A long trek

What is cholera?

It is an intestinal infection caused by the bacterium Vibrio cholerae. You get it from consuming contaminated water or food.

About five per cent of infected people will become severely ill, with profuse watery diarrhea, vomiting and leg cramps. Most infected people don't get sick, but the bacterium is present in their feces for up to two weeks.

For more on cholera, read our feature on the 'diseases of disaster.'

It is hard-to-reach communities, like the ones Hospital Albert Schweitzer services, that are posing one of the greatest challenges in Haiti's fight against cholera.

From Barbe, a community in the mountainous area of Terre Nette south of Deschapelles, it takes six or seven hours to walk to Hospital Albert Schweitzer, says Weinrobe. No road leads all the way. A four-wheel drive might take several hours and reach halfway.

If a resident of Barbe comes down with cholera, it's a long trek to a medical facility. To help residents survive the long walk, Doctors Without Borders delivered oral rehydration solution by helicopter, says Weinrobe.

In the community, a health-care worker can now hook a person up intravenously to oral rehydration solution, before they begin walking down the mountain. Halfway to the hospital is a health-care facility, with several nurses on staff, where those infected can get oral rehydration solution to drink or in an IV bag.

Patients then show up at Hospital Albert Schweitzer, a wooden stick in hand, holding the IV bags aloft to keep the fluid dripping steadily into their veins, already starting the essential rehydration process.

The hospital and Doctors Without Borders are also teaming up to send mobile health clinics to the Bastien and Terre Nette regions "as far as we can go" by car and by foot, says Weinrobe, to try to help those with no access to nearby medical care. The Red Cross is using similar mobile health clinics to hand out supplies and educate remote populations about cholera prevention.

Rehydration posts

One of the ways Doctors Without Borders hopes to win the cholera battle in isolated locations is by setting up oral rehydration posts. Run by a trained local, the post is outfitted with chlorine to clean the local water and oral rehydration solution to add to it.

Carolyn Weinrobe, manager of monitoring and evaluation at Hospital Albert Schweitzer. says mobile teams visit remote areas to try to help people who are hours away from help. ((Amber Hildebrandt/CBC))

"This is very simple [but] it could be one of the keys to manage the outbreak outside the cities in the remote areas," says Matthieu Bichet, emergency co-ordinator for Doctors Without Borders in Port-au-Prince.

It gives communities almost immediate access to the rehydration that is key to surviving cholera. Proximity to rehydration fluids is so important, in fact, that the Centers for Disease Control and Prevention recommends that all people at risk of getting cholera should be no more than an hour away from a place where they can get oral rehydration solution.

In about 80 per cent of cholera cases, patients recover simply by drinking oral rehydration solution, a mix of sugar and salt in water. But cholera at its most severe causes such a loss of bodily fluids from diarrhea and vomiting that it causes shock and leaves the victim unable to drink or keep down fluid. In those cases, intravenous rehydration is the only option.

Upon the onset of symptoms from the bacterium, Vibrio cholerae, it can take as little as two hours for the person to die.

Bichet says getting access to rural communities in order to rehydrate those infected with cholera before they reach a critical state is one of the largest challenges facing medical workers. In cities, sheer concentration of the population — especially with 1.3 million Haitians still living in tent cities since the Jan. 12 earthquake — poses problems of its own, but ones he feels the agency currently has a grip on.

"There are enough beds for everyone," says Bichet, even in outbreak hotspots where recent flare-ups, like in the north coastal city of Cap Haitien, have overwhelmed medical teams.

"Of course, it can spread more quickly in the city, which has a big concentration of population," said Bichet. "But in the countryside, it goes quite fast. People are moving from [one] village to another. And in families, it's also spreading."

Educating the population about cholera can be just as important as treatment. Bichet says Doctors Without Borders must first gain the confidence of the residents before setting up cholera treatment centres. Some Haitians still fear and don't understand cholera.

"The word cholera, for them it means you're going to die. And nobody can be around you," says Malik Nouie, an aid worker at a cholera treatment centre in the Port-au-Prince suburb of Petionville.

One way Hospital Albert Schweitzer seeks to educate the remote communities is by training dozens of volunteer animatrices, or health outreach workers. Armed with oral rehydration solution and knowledge, the volunteers then visit households to talk with families one-on-one.

Conditions 'lousy' for most

To truly eradicate the disease, however, Haitians need a large scale makeover of their current conditions to give them access to such basics as latrines and clean water. Even before the Jan. 12 earthquake, conditions were "lousy for most Haitians," Nigel Fisher, the Canadian heading the United Nations' humanitarian efforts in the Caribbean country, has said, noting most of them are impoverished, living in substandard dwellings, with no access to running water or latrines. 
Rehydration is key to recovering from cholera. ((Amber Hildebrandt/CBC))

Weinrobe has seen the effects first-hand. In a neighbourhood in Coupon, a community near Deschapelles she visited, there was not a single latrine — and each household had at least one case of cholera. Even in more populated communities in the area, Weinrobe says, "They're still going to the bathroom behind a tree and it's spreading from there."

But as Haiti continues to struggle with the cholera outbreak, expected to rise exponentially to 200,000 cases within three months, there might be a silver lining, albeit a tiny one, in the midst of it all.

In a country where medical workers worked tirelessly this past year to help the victims of the earthquake, hurricanes and election-related violence, watching a cholera patient recover — as many do — can be quite rewarding, even a "morale booster," says Weinrobe.

"It's like if you have a dying plant and you watered it and you watched the leaves spring back up," says Weinrobe. "It's like the life is coming back into them."

Eyes once sunken look bright and a person lying limp on a bed can suddenly sit up.

"In an hour or two, somebody you thought was going to die is up and drinking," says Weinrobe. "You can hardly believe that giving somebody fluid could make this difference." And it makes it all that more important that those who can be saved are.