We currently have several “onion layers” of operations in-place now to facilitate the movement of alerts to response. These layers follow the steps we have to go through before getting emergency aid to a site in need:
Initial report. This is the first report of a site either reporting cases of cholera for the first time, sudden surge, or “first contact” mortality. The degree of alarm to us is related to this sequence. That said, we prefer to engage as quickly as possible to avoid “first contact” mortality, however this is often difficult to a number of factors such as degree of site isolation (i.e. a community’s access to communications), pre-contact awareness there is a cholera disaster in-country (we have had communities who had no awareness of the epidemic!), and social thresholds of tolerance for adverse clinical outcomes. The general rule of thumb is people typically alert for mortality, not non-mortal cases. We encourage reporting of at least “first surge” or the window of opportunity to avert unnecessary fatalities may be lost.
Verification of event features. We generally see the majority of reports validate, however the actual case counts may vary tremendously between the HEAS reporter, the officials, and any on-site NGO(s). We want to make it clear that accuracy in case counts is not important to us. What IS important is verification of impact such as the ability of local medical responders (if there are any) to manage the demand of patients. This is important to because we are looking for specific, prioritized items of need involving materiel or personnel (see below). Collapse of a clinic or high daily clinic mortality is associated with a distinct psychosocial impact on the involved community that does play a role in civil stability dynamics. In short, we seek verification of impact first, accuracy of case counts last.
There are several key caveats to keep in mind. There MUST be a false positive rate when reporting or we are not doing our job. While we as warning analysts are very tolerant of false positive reporting, those that manage deployment of response are NOT. This highlights the crucial importance of verification as an operational bridge.
Now, we do monitor sources of reporting and will “dial back” reports from a source to the HEAS if we observe a high rate of unverifiable reporting. We see this rarely, but it does happen. There is also a triage of reporting, where sources unknown to us typically require more attention to verification than trusted sources. That said, we have observed many instances where highly trusted, credible sources have either misinterpreted their information or were simply wrong. It happens to the best of us, as we are all human.
When verifying information, we are seeking to pin down several aspects of event information. The name of the site is often problematic for us, as there are often different names for the same site in Kreyol versus French or English. GPS coordinates or Google map links are also very problematic, especially for the rural areas, because these sites are often not even well known to NGOs who work in the region unless they have worked there directly. We have found this can be problematic to lock down even for indigenous Haitians. The effect of multi-source reporting often distorts information as elements are passed from person to person. In general, the more steps you are away from direct ground observation, the more probable distortion has occurred above and beyond the basic limits of human observation. And of course, two people standing at the same site observing the same thing will often come away with two different interpretations based on life experiences, for instance. If multiple NGOs are managing a given community’s needs, we often see conflicting reporting depending on the relationship between those NGOs.
Bottom line, verification can be a difficult and time-consuming process.
The firehose of information now streaming through the HEAS community is at once an incredible accomplishment for the community but also a challenge from an information management perspective. To address this, we have broken off a much smaller group of HEAS partners that manage event reports, verification, triage of those reports to the HEAS Community Watchboard as potential sites for response consideration, and ground logistics and response. Events on the HEAS Community Watchboard are triaged according to a simple scale of need:
Level 1= Request For Emergency Assistance triggered; requires IMMEDIATE attention via deployment of emergency supplies or personnel (time delta= hours-48 hrs)
Level 2= Request For Emergency Assistance triggered; requires URGENT attention via deployment of emergency supplies or personnel (time delta= multiple days)
Level 3= No Request For Emergency Assistance triggered yet, but Request For Verification triggered
Level 4= Awareness of active cholera treatment noted but no action required at this time
Validation of emergency need is often entwined with the verification process. Here we ask for a strict prioritization of need, which sometimes indicates how much trouble a site is in. For instance, a site requesting supplies but no personnel appears less urgent to us than a site requesting body bags over other supplies and “as many people as we can spare”. There is an implied anxiety level in the requesters that we also monitor.
Some use a case count cut-off of 50 cases or above to prompt mobile response. We have struggled with this guideline because we are looking at the psychosocial dynamic from the viewpoint of expected local capacity: i.e. the local medical clinic. One community, as mentioned above, may have a high psychosocial tolerance for morbidity but become tremendously anxious upon observation of 5 fatalities. Another community may be very resistant to high fatalities and wait to report until the last possible moment. This is of course due to a whole range of factors. Bottom line, it is a difficult and terrible triage to decide which site, all things considered, should be prioritized for response.
We have observed now several instances where the HEAS core team did not need to directly push for response, but the HEAS community self-triggered response on its own, offline from the main group communications. This is a tremendous positive development and indicates the "living entity" that is the HEAS. Response coordination, however, has been a serious challenge for us in that we have seen a general trend of no response report from organizations planning to mobilize to a site. The problem arises when multiple organizations arrive with duplicative assets due to lack of communication. This becomes a tremendous problem because when organizations perceive possible duplication of effort, hesitation results. Hesitation may cost lives. This is the purpose of the HEAS Google group and Community Watchboard: to assist in coordination. So, the HEAS is experiencing "growing pains" that we are addressing as they arise.
Grid level response has been tricky at times due to grid overload. That said, we HAVE seen an increased awareness on the ground that 2/3 of Haiti is likely under-supported due to extreme terrain and lack of access or communications. Thus, there has been a concerted effort on our part to emphasize the consideration of helo and rapid mobile medical team support. This has been tremendously challenging, as many of the mountain sites do not have a suitable landing zone for helo support, resulting in a many-hour hike across terrain that makes hauling mass quantities of IV fluids impossible. As we have seen so many times throughout the world, the more isolated a community is, the more likely one sees adverse outcomes in the context of an infectious disease crisis or disaster.
We conclude with an important observation: that the HEAS has now evolved into a self-regulating, distributive, complex, adaptive, net-centric warning and response community. This is a major, positive development as we continue to struggle to support the people of Haiti.
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