Clayton Bell, MD and Paul Pukurdpol, MPH of the Seguin Cloud Forest Medical Clinic Mountain Recon Team (CFMC-MRT) performed a recon of the western section of Grise River Valley from Jan 12-13th, 2011. Dr. James Wilson of HEAS produced the targeting assessment and geospatial information for route plotting. This report reflects the MRT’s observations while on mission. Supplemental photography may be found in Appendix A.
Mission Planning / Pre-Deployment
Dr. Wilson, based on HEAS operational biosurveillance information, performed multiple recon missions in the Fermate-Kenscoff-Furcy and Ganthier-Chacha-Belle Fontaine Town corridors running north to south from December 10th to 12th. While in Furcy on Dec 10th, inhabitants reported nearly two dozen cholera fatalities in remote areas of Belle Fontaine and specifically, in the village of Mahotiere Bourette. Dr. Wilson worked with Dr. Bell to schedule a recon of this site, which occurred on January 3rd, where the inhabitants confirmed reports of more than a dozen fatalities and a multitude of cases. Dr. Bell had taken water samples during their first survey of the Grand Riviere, which has tributaries that pass to the north and south of the village, respectively. Rapid test was positive for cholera, which prompted us to schedule this more in-depth recon due to concerns that thousands of people in the 20-mile long Grand Rivier-Grise River valley (highlighted below) were at serious risk. It was already known that hundreds of cases and multiple fatalities had been documented in the flood plain beyond into Port au Prince.
Integrated situational awareness produced hints of a much larger problem, as shown below, where the mountainous rural areas faced cholera without access to basic medical care. Based on experience with cholera in Africa, it was known the mortality rates might range between 20-50%. Most of sites referenced by others were 1) deep in the mountains, 2) accessible only by footpath, 3) of unknown access to a helo LZ, and 3) not precisely mapped by others. Therefore, verification of event information and emergency need also required validation of site name and coordinates. The latter step latter has proven to be a consistent operational time drain. It was noted that CTC/CTU/ORP presence in the Sud Est Mountain Region was extremely limited to non-existent (open triangles on the map).
Mission planning included route plotting and cross-check of US National Geospatial Intelligence Agency (NGA) 1:50,000 high resolution topographic line maps (TLM) and high resolution satellite imagery provided by GeoEye and Google. This provided the team with access to not only geographic features but mapping of habitation sites along the Grise and Redoute River Valleys. Of note, the team had limited pre-trip information about security status, which did come into play during Day 2 as noted below. The CFMC had difficulties with rumors about the origin of cholera and threats of violence against blan, such notions had been easily dispelled in the past through proactive community engagement. It was recognized the area surveyed represented some of the most remote and isolated communities in Hispaniola. The original route (highlighted in red) was projected to take a full 48 hrs and 19 miles of travel with substantial elevation loss and gain between Sequin and Kenscoff.
Day 1 / Jan 12th @ 1800
The trip began the evening of Wednesday, January 12th in Sequin at 1680m elevation with a 30-40 min hired motorcycle ride to Ca Jacques, followed by a hike on foot to Carrefour Badjo (spelling of the town is in question but marked with GPS coordinate on the below map) at 1612m elevation, which was 11 miles away on Route 101. Two additional team members who were trusted Haitian locals joined them in Carrefour Badjo. No security issues were encountered.
It is notable the MRT had previously conducted a recon of this route on December 23rd:
Today we hiked from the Cloud Forest Medical Clinic in Seguin over the mountains to the North and stopped in the mtn village of Carrefour Badjo. Badjo is situated about 1/2 way between Kenscoff and Seguin on the main trade route 101. A local community leader, Pastor Raymond, called a community health meeting and over 80 local villagers attended. We gave a 2 hr lecture on cholera which included an intensive Q & A session and handed out Aquatabs to all participants. We were able to ascertain knowledge that there have been 19 reported cholera deaths between Ti Boucan (village a 1 hr hike to the South from Badjo) and the Kenscoff area. The most alarming statistic was that 17 of these deaths have all been from the remote mtn village of Mawotye Bouret (Marotie Bourette, not sure of exact spelling). This village is apparently very isolated and a 2 hr hike to the East of Badjo. They have no medical personnel and have had much trouble getting their sick to a CTC. Villagers told me that many of their cholera patients had been sent to Fermate to receive healthcare (most likely to the Baptist Mission but I have not confirmed that with anyone who works there). The villagers in Badjo were very frightened about cholera and extremely eager to learn preventative measures. Today we also had 4 people delivering cholera prevention education and selling aquatabs at the Seguin Market which is attended by about 1,000 people every Thurs. Yesterday we had 2 teams deliver cholera prevention education to the market in Mabriole. Tomorrow we have 2 teams delivering education and aquatabs to the village of Fean Jean Noel and the large weekly market in Marigot/Peredo area. –Dr. Clayton Bell, writing to the HEAS
Day 2 / Jan 13th @ 0800-1st Stop: Mahotiere Bourette [18°23'14.70"N, 72°15'53.87"W]
The MRT’s first stop was at Mahotiere Bourette at 804 meters elevation and 2.5 hours’ downhill hike from Carrefour Badjo. The team surveyed this village previously on January 3rd, where the inhabitants confirmed reports from Dec 10th captured by Dr. Wilson’s team in Furcy of more than a dozen fatalities. In total, 90-100 cases were reported with 18 fatalities (estimated 20% mortality). Many died on the way to Kenscoff, which is 5 hours’ hike and 645m of elevation difference. The nearest CTC is located at the Baptist Mission on Route 101, another 2.5 km north of Kenscoff, on the way to Fermate. There had been no additional cases since the team’s last recon, when they provided preventive education, ORS, and Aquatabs. They were presented with a mildly ill little boy who had initially become ill on December 27th but was doing well now. Mahotiere Bourette had not seen a single fatality since they received ORS and education by the MRT.
During the team’s prior recon of this village, they were told no blan had ever visited the village. The inhabitants were friendly and thankful for assistance.
2nd Stop: Grande Riviere [18°23'5.78"N, 72°14'11.10"W]
Approximately two hours’ hike and 2.2 miles east of Mahotiere Bourette the MRT found the village of Grande Riviere at 672 meters elevation. Upon initial approach, the team found women washing clothes in the river. Male workers from nearby fields later joined, as did additional women from the nearby village. Education was provided to approximately 30-40 people. Aquatabs were also distributed. They were friendly; it was the team’s impression they were the first blan to visit this village. The villagers reported that cholera first appeared locally on Dec 8th. They estimated that 80 people died in the general area, 25 of which were in Grande Riviere itself. In the prior week, 8 deaths were reported in the general area, 2 or 3 of which were in Grande Riviere. They thought hundreds had been sick since Dec 8th, and activity continued to be high, as dozens in the last week were sick in the area. It was the team’s impression that mortality of upwards 20-40% were not unreasonable.
The MRT witnessed a funeral procession involving a victim that had died of causes unrelated to cholera. The team asked the villagers, "You don't wash the cholera fatalities in the river too, do you?" The answer was, "Of course we do… Where else do we get the water?" The team confirmed that food preparation, clothe washing, drinking, urinating, defecation, and corpse washing all occurred in the Grande Riviere waters, which flowed east and north to form the Grise River. It appeared the initial HEAS assessment of these rivers being contaminated was validated. Additional water samples were collected by Haitian staff and have since been sent the University of Maryland, results pending.
3rd Stop: Belle Fontaine IV/V [18°24'7.20"N, 72°12'49.86"W]
Another two hours’ hike northeast along the river valley brought the team to Belle Fontaine IV/V at 651 meters of elevation, where Belle Fontaine V was north of this point, and Belle Fontaine IV was south of this point. As in Grande Riviere, the MRT found women washing clothes in the river. The team sat down to eat lunch and provide preventive education for the women, who were friendly and receptive. As with the prior village, the MRT had the impression they were the first blan to visit the site.
The women told them the first cases were reported locally on Nov 28th, with hundreds of cases and ~50 fatalities to-date. Five 5 fatalities from 2 houses were reported yesterday, highlighting tremendous impact to families in the village. The MRT confirmed drinking, food preparation, clothe washing, urination, defecation, and corpse washing all occurred in the river. The community reported having no access to chlorination supplies for point-of-use water treatment. Aquatabs were provided to heads of households The team had a similar impression as mortality reported in Grande Riviere, where 20-40% fatalities would not be an unreasonable estimate.
At that point, the ASEC from Grand Fond approached the group, who was welcoming and appreciative of the MRT’s visit. He indicated no one- NGO or MSPP- had come to help. The MRT had almost finished providing education and were preparing to leave when three men approached, agitated and fearful each with a machete, club, and bottle in-hand and knives tucked into their clothing. The team immediately felt the situation had deteriorated to a life-threatening situation. The women intervened to calm them down. The CASEC arrived unarmed but carrying handcuffs. He was angry, saying they needed identification and approval of the Seguin CASEC and CASECs from all intervening areas to travel in the valley. The two Haitians with the MRT thought Dr. Bell and Mr. Pukurdpol would have been killed if they had traveled without Haitian escort. The motivation for fear and the aggressive reaction of the village men was due to 1) lack of prior experience seeing blan in the area, and 2) pervasive rumor throughout the region that blan were traveling throughout the country deliberately poisoning rivers and water sources with cholera to kill Haitians.
The CASEC was eventually calmed down, but he indicated they could not continue down the river. Otherwise village inhabitants further downstream who were considered more isolated and fearful of outsiders would kill them. The CASEC remarked that three non-Haitians crossed the border from the Dominican Republic and were killed by locals in the mountains, which was an explicit warning to the team. The team expressed concern about the prospect of no further aid coming to the valley if villagers maintain a threatening posture. Both the ASEC and CASEC expressed interest in receiving medical aid, medicine, and supplies but remained insistent the team depart immediately. The ASEC then escorted them up out of the river to the northwest.
4th Stop: Despiseau [18°25'29.88"N, 72°14'18.18"W]
On their way west towards Kenscoff, the MRT passed through Despiseau at 1,086 meters of elevation. They did not hear of cholera and noted a local pharmacy and NGO activity in the area.
1. The Grande Riviere and Grise River Valleys and associated communities are contaminated and exhibit high cholera activity. Reported cases exceeded 1000 along the 10-mile route with estimated mortality ranging between 20 to 40%.
2. Serious security risks are present for non-Haitian personnel venturing into areas east of Despiseau / Grande Riviere.
3. Assessments conducted from December 10th onward by the HEAS and ground recon teams accurately highlighted this as a region of concern requiring immediate intervention.
4. Aside from the delivery of ORS to Mahotiere Bourette, interventions for the peoples of this region have been non-existent, resulting in preventable high mortality, community disruption, and likely contribution to negative community receptiveness to subsequent intervention.
5. Involvement of the mountainous areas west of the Route 101 corridor is assumed.
1. IMMEDIATE ACTIVATION OF CTUs WITH ABILITY TO UPGRADE TO CTCs AT THE REGISTERED UNHAS HELO LZs OF GRAND PLATON [18°23'6.00"N, 72°13'40.00"W], COTEAUX [18°24'25.00"N, 72°12'26.00"W], OR GWERAN ELECT. [18°24'27.00"N, 72°10'21.00"W]:
2. IMMEDIATE ACTIVATION OF COMMUNITY EDUCATION / OUTREACH WITH ACCESS TO ORS. HAITIAN-LED RECON TEAMS RECOMMENDED, DRAWING FROM TRAINED HAITIANS PERSONNEL LOCAL TO THE ROUTE 101 CORRIDOR. RECON BY NON-HAITIAN PERSONNEL IS STRONGLY DISCOURAGED UNLESS ACCOMPANIED BY HAITIANS AND WITH SIGNED LETTERS OF APPROVAL FROM ALL CASECS IN THE AREA. SECURITY DETAIL IS A RECOMMENDED CONSIDERATION IF CASEC APPROVAL CANNOT BE OBTAINED.
3. IMMEDIATE LOCALIZATION AND EXPLOITATION OF REGIONAL MARKETS SUCH AS THE ONE IN SEGUIN THAT WOULD ENABLE PROACTIVE WEEKLY COMMUNITY EDUCATION AND ACCESS POINTS TO ORS.
4. AGGRESSIVE CONTINUED RECON IS RECOMMENDED FOR
a. AREAS WEST OF ROUTE 101;
b. BELLE FONTAINE REGIONS I, II, AND III;
c. AREAS WEST OF ROUTE 102; d. AREAS EAST OF SEQUIN TOWARD ROUTE 102 AND SOUTH TO THE BETTER ASSESSED AREAS OF THE COAST;
e. AND AREAS WEST OF MACARY.
The team members would like to thank the Cloud Forest Medical Clinic, MSF-Spain, the Haiti Epidemic Advisory System community, and especially Haiti’s first operational biosurveillance analysts, Mr. Lionel St. Pierre, Patrice Talleyrand, and Maxime Louis.
Appendix A- Photographic Record of the Recon in Grande Riviere Valley, Sud Est Mountains (credit: Paul Pukurdpol, MPH)