Day 1. Intercept Team plotted a course through the Fermante-Furcy mountain corridor to conduct a rapid recon of the area for cholera activity. The team stopped at various locations along the roadway beginning in Kenscoff asking locals if they were aware of cholera in the area. Locals in Kenscoff indicated no presence of cholera. All were sensitized to the presence of cholera in Haiti and were well educated about cholera prevention. Multiple separate sources in Furcy indicated the presence of cholera in a location called “Belle Fontaine” with 8 fatalities in addition to another site called “Morotere Brouette” with 10 fatalities. No cholera had been identified in Furcy, and the community indicated they were well aware of cholera prevention.
Upon the return to Petionville, the team stopped at the Baptist Mission Hospital located at the mid-point between Fermante and Kenscoff on the west side of the road. The hospital was well staffed, and had seen 10 cholera patients, 2 of which were discharged, and no fatalities. These cases came from Petionville, Thomassin, Laboule, and Bonga. They had not heard of cases in Belle Fontaine. In the case of Bonga, we noted penetration of cholera into the front range of the mountains south of Port au Prince. This was an important implication for rural, more remote mountain communities south of the front ranges.
That night, we engaged in a vigorous debate as to the composition of the team and the right balance of personnel with specific skill sets and materiel. The major point of debate was, “if we discover a village full of illness and mortality, what do we do?” This continues to be a challenging discussion because one must balance the following factors that center around logistics:
- Number of vehicles going in and weight capacity
- Number of personnel
- Amount of materiel, particularly Ringers Lactate (RL), which are very heavy in bulk
- Equipment to support possible overnight deployment
The central issue is whether a 24-hour ad hoc medical response capability will be required for the worse-case scenario of a discovered isolated community experiencing high mortality due to no medical support. The moral and ethical decision was to provide immediate medical relief, however the reality of logistics, particularly in the mountainous regions, made this prospect difficult.
For this particular operation, we elected to form a convoy of four vehicles fully prepped to provide 24 hours of emergency medical relief in the event of the worse-case scenario.
Day 2. Based on information from the previous day, the Intercept Team proceeded to Belle Fontaine:
In the above figure, the blue line highlights the driving route, which once our convoy of 4WD vehicles left Route 102 was a non-paved road through the flood plain and a very difficult off-roading route all the way to the community of Belle Fountaine. This took approximately 2.5 hrs between Route 102 and Belle Fountaine. The mountainous portion of the route cost us two vehicles: one was a Toyota Land Cruiser that could not continue up the front range, and the other a Jeep that blew the clutch at the town of Belle Fountaine. We were forced to abandon the Jeep in Belle Fountaine, where we are still attempting to identify an appropriate extraction mechanism. We therefore lost 2 of 4 vehicles.
On our way along the route checking directions with locals, we encountered the village of Tisource (below figure). They did indicated they had cholera, however we did not observe cases. Locals indicated they were transferring patients to clinics and CTCs, hence the lack of obvious illness in the village. We obtained the cell number of the local administrator (“Casec”), who later contacted us during the drive up the mountain to say their community had seen 300+ cases. We decided to continue on to Belle Fountaine and backtrack to Tisource given concerns about Belle Fountaine potentially with active cholera transmission and without any local medical support. Tisource was believed to have some degree of medical support access, to be clarified upon our return.
Upon arrival to the top of the front range ridgeline, we discovered what we later found to be the community of Cha-Cha (pronounced “Sha-Sha”):
Cha-Cha is a loose aggregation of settlements located along the ridgeline. They reported multiple fatalities, thought to be less than five. We were unable to visually confirm their report via observation of gravesites or visibly apparent illness. We continued on into Belle Fountaine valley. Upon arrival to the town of Belle Fountaine, we found a pleasant agricultural community who indicated they had no cholera. One local mentioned two fatalities in a community southwest, one hour’s hike. We believed it might be the community of Bayard, however we were forced to leave due to loss of daylight.
Upon arrival in Belle Fountaine, the Jeep blew its clutch, and we were forced to leave about 300 liters of Rings Lactate and other medical supplies in the Jeep and make the return out of the valley. We paid the community a small amount of money to keep an eye on the Jeep.
During the entire route, we experienced no security issues. We were in Voodoo country, and the people were cautious but curious.
Day 3. We headed straight to Tisource [N 18 deg 30.398', W 72 deg 07.255'] to investigate Casec Kenol Porcia’s claims of a large outbreak. Casec Porcia administers the Ganthier/1ere Galette Chambon Commune. He reported 3-4 cases daily in Tisource that were referred immediately to Turbe Hospital approximately three miles away. Tisource is in Coupette (pop 5000), where they had 300+ cases with 13 deaths. He indicated there was an ongoing flow of cases with no signs of slowing down. The Casec identified the following communities that were affected:
- Dame Marie
- Troupo (immediately across river from Tisource)
- Bois Blanc
Tisource is located at the point most upriver of a series of irrigation canals, where the river immediately east of Tisource that drains the Belle Fountaine region is diverted to the canal system. All of the communities downriver / canal of Tisource have reported cases.
The Casec had believed Turbe Hospital was in Ganchier, so the Intercept Team proceeded there only to find no such facility. We were referred to the Fond Parisien CTC located in La Source:
This has been successfully managed by International Faith Missions, who reported more than 1,100 cases so far with a patient flow of 50-80 patients daily and 12 fatalities. They identified a focus of cholera activity across the lake in Po Plum, where Haitians working there return home to Balan and Toman. International Faith Missions aggressively intervened with community health workers in Toman and have not seen cases from the Fond Verrettes mountain corridor.
We returned to the Ganchier flood plain to find Turbe Hospital [N 18 deg 32.161' W 72 deg 10.000']. We met Dr. Jercois, a Haitian physician who speaks excellent English. Turbe Hospital is an excellent example of a Haitian-led triage clinic that could be upgraded to a CTC. This is what he related:
- Total inpatient capacity for cholera= 10 patients, however they do overflow into outside tent if patients can sit up and take fluids
- They do have IV therapy capacity, with 7 patients in-house on IV now
- Epi trend increasing, per the impression of Dr. Jercois; we took photos of his epi notes for conversion to Excel spreadsheet
- Total patients since the beginning of the outbreak on Nov 14th= >400 with 5 in-house fatalities; he was aware there were many other cases and fatalities in the community unknown to Turbe Hospital
- Multiple fatalities out in the community, with additional fatalities on the front range of the mountains immediately south from the community of Cha Cha (otherwise known as Belle Fountaine I) located on the front range ridgeline- immediate threat and implications for spread into Belle Fountaine II and III in the extremely rugged areas south of Cha Cha- once this happens, we may expect very difficult to control high mortality given there is no medical clinic south of the floodplains communities.
- Fatal outcomes also facilitated by motorcycles and tap-taps charging increasingly high rates for patient transport, with an increasing number of them refusing to transport cholera patients. Turbe Hospital receives patients in 360 degrees @ estimated 7 mile radius
- Turbe Hospital capacity not meeting community demand, as they refer the more seriously ill patients on a daily basis to the MERLIN clinic in Basboen
- They currently receive supplies from Plan 80 (Cuban NGO) and MERLIN; they are chronically under-supplied
- Travel distances for the patients are directly contributing to serious clinical outcomes
The Intercept Team immediately elected to drive over the mountain to retrieve the 300 liters of RL, angiocaths, gloves, and bleach, which was accomplished without incident in the descending night. On the way to Belle Fontaine, we discovered an elderly patient and his wife being transported on the back of a motorcycle leaving the community immediately west of Tisource- the gentleman was being propped up by his wife. He clearly required IV therapy. We arrived at Turbe Hospital for the supply drop at approximately 2000.
The below figure represents our updated understanding of the situation in the Ganchier flood plain:
Day 4. The Intercept Team contacted MSF-Holland on 12.13.10 and strongly recommended personnel / materiel support to Turbe Hospital with expectation to assist in expanding capacity as patient volume increases due to community awareness of capacity increase. Decompression of regional patient flows is needed, as well as an expectation Turbe may become a staging site for mountain expeditionary deployments if the situation south destabilizes.
As expected, the community of Seguin reported its first clinically confirmed cases of cholera. Seguin is a major trade nexus for the Sud Est mountains. We therefore are seeing both north and south “pincher” penetration of cholera into the Sud Est mountains.
Conclusions. We have arrived at several conclusions thus far based on lessons learned during this experience:
- When multiple independent villages and locals are reporting cholera in the area, the index of suspicion should be high
- Verification of sites, cases, fatalities, etc is a time-consuming and complicated process but must be done carefully to empower deployment of others capable of creating CTC/CTUs or supporting facilities treating cholera
- Direct observation of cholera cases and fatalities in a community may be difficult to observe. The communities are stoically burying those that die and rapidly transporting those that are ill out of the community. We found little evidence of high anxiety, an indicator of tremendous social resilience our team has noted previously. It was to our collective chagrin we drove oblivious through a major cholera zone on our way to Belle Fontaine on Day 2.
- There is a clear operational need for specialized advance medical recon teams that are able to rapidly scan a region for cholera activity, produce situational awareness, and are linked to immediate medical response reach-back by car or helo able to stabilize the situation for 24-48 hours until MSF or other such NGO is able to arrive and establish a CTC/CTU. These recon teams should be lightly configured, with minimal supplies and personnel but with rapid reach-back capability for immediate medical response should it be required.
- Evidence so far suggests the central mountain communities of the Sud Est mountains are not experiencing sustained transmission or contamination of their water sources yet, however rapid intervention is recommended to establish contact networks and train community health educators able to spread the message throughout the communities. Trade nexus sites such as Seguin and clinics located at the base of the mountains such as Turbe Hospital may serve as excellent bases of operations for difficult to access areas.
- Rapid helo and ground support may easily be compromised by rain and fog in the mountains. Deployment teams should be prepared for overnight stays depending on conditions.