The Haiti Epidemic Advisory System (HEAS)

HEAS Operational Infectious Disease Forecasting Has Been Reactivated

Through an incredibly generous donation from Direct Relief International, the HEAS' forecasting functions for Haiti have been reactivated.  Stay tuned...

The Passing of a Hero: "Big Dave" Bompart

Today the HEAS is silenced in respect for the passing of "Big Dave" Bompart.  Our prayers are with his family.

 

James M. Wilson V, MD
Haiti Epidemic Advisory System (HEAS)
Executive Director
Praecipio International
Washington-Houston-Port au Prince


Praecipio International is a charitable non-profit organization devoted to the promotion of operational biosurveillance worldwide.

The Current and Future Status of Cholera in Haiti

Within the HEAS, a  serious discussion has ensued regarding the current and future status of cholera in Haiti, which began with a question from an outside agency:

 

 

• [From a major NGO seeking to implement major prevention efforts in Haiti] We know these predictions can be somewhat uncertain, but we would be grateful to hear your opinion as a medical actor on the ground.  Your first-hand knowledge about the infection patterns and the current pace of health and water sanitation interventions makes you well poised to help us see a few years ahead into the cholera epidemic.

 

• [From me to HEAS partners internationally recognized as cholera experts]  Guys, I could use your input and advice regarding the [above question] and would like to form a consensus opinion, if possible.

 

• The usual cholera epidemic attack rate (AR) among immunological susceptible populations is 2%.  This estimated attack rate considers only severe and some moderate cholera cases requiring hospitalization. Most of the total cases (95%)  are mild or asymptomatic and may not be detected by the surveillance system

 

• [My reply] Is this AR what you guys observed in Peru in '91?  Reason why I'm asking is we are dealing with a totally naive environment (albeit we are in a time period subsequent to first introduction [i.e. first wave]).

 

• Yes, this is what it was observed in the 1919 Latin America epidemic as well as  previous descriptions of cholera epidemics in Asia and Africa. I think that once cholera is established in the environment , all population is affected sooner or later if the water and sanitation conditions are not adequate. That is the case of Southeast Asia, over there the only susceptible population is small children with no antibodies against cholera.

 

• [My reply] This is a very important observation- we are still seeing a high percentage of adults affected versus kids- at least in the case of Pestel if I'm not mistaken.  So, the situation may be endemic in Port au Prince but still epidemic in the rural areas?

 

• There may be a few pockets of susceptible populations. Nevertheless, after cholera strikes, we have to be very careful with the diagnosis. During the last waves of the 1991epidemic, I went to investigate diarrheal diseases outbreaks that were wrongly diagnosed as cholera. Many of these outbreaks were disenteric amebiasis, E coli, salmonella, cryptosporidium, etc. It is time to start to invest some resources in confirming the outbreak agents.

 

• [My response] Right, copy.  That seems to have been the problem with the Pestel situation [i.e. public health officials delaying 72 hrs to respond because the situation in Pestel was not laboratory-confirmed cholera]- a bias that it was not due to cholera until lab confirmation proves otherwise.  If we had not intervened, people would have needlessly died.

 

... Later,

• I just checked the number of cases accumulated in Haiti until January 2012:
  
  The Ministry of Health has reported 524,861 cumulative cholera cases, 282,989 hospitalizations and 7,018 deaths, as of 8th january 2012. The overall fatality rate is 1.3 percent nationwide. The general trend is towards a decrease in the number of new cases and fatality
  *Source: Last report of MSPP as of 8 january 2012
  
  If we have a total population of 10 million inhabitants it looks like the 282,989 hospitalized cases (~2.8%) shows that the population is exhausted and the cholera epidemic may have  entered into a endemic patter of transmission.  If  somebody comes to deliver the vaccine or establishes any control strategy it will look as a very effective intervention,  just by being temporally associated with the development of immunity among the population.

 

• [My response] What if these numbers are an underestimate given the 2/3 rural mountainous / unreached / poorly reported areas of Haiti?  Are we able to consider this?  Thank you for the discourse.

 

• I agree. Indeed, there must be an underestimation of the number of cases. The 2% attack rate is based on similar or even less sensitive surveillance systems. If the number of cholera cases is greater, again , this means that most of the Haitian population is immune. The sadness  of this history is that we did not concentrated all our efforts in saving the lives. To achieve this level of natural immunity with more than 7,000 deaths is a failure. At this point water interventions will be strongly associated with no cholera cases, latrines will be strongly associated with no cholera cases, voodoo bone powders will be strongly associated with no cholera cases. The colloquium of this disaster is the return of UN "experts" to say that their presence has been the key factor in stopping the epidemic.

 

 

 

Operational Highlights of the HEAS

Our team was interviewed by a major international press organization this afternoon, and they asked about key achievements of the HEAS.  The following was provided as a list of highlights:

1.  HEAS performance / forecasting functions the first 150 days post quake

2.  Our first public statement regarding reports of severe diarrheal disease in Artibonite (ie cholera)

3.  Our first public report of linking the UN Nepalese base in Mirebalais to the cholera disaster (this was actually an update, posted a couple of hours after the initial report).  This was the first public report describing probable attribution for the cholera disaster in Haiti.

4.  Referral to the Paul Keim (a member of the NSABB, the same panel reviewing the controversial studies on avian influenza) study proving the link to Nepal

5.  First case of acute flaccid paralysis identified.  It remains our belief Vaccine-Derived PolioVirus (VDPV) Type 1 continues to transmit in Haiti.  What is required to disprove this belief is a comprehensive field investigation by a neutral third party.

6.  11th case of acute flaccid paralysis identified

7.  Field ops: description of HEAS warning-response ops in rural mountainous areas of Haiti, note the report on Borgne as an excellent example

8.  Intercept Team field ops reports from Belle Fontaine (Dec 10-12th and Jan 12-13th)

The reporter asked us what we thought about cholera transmission now in Haiti.  Our response was cholera continues to transmit in the rural, mountainous 2/3 of Haiti's landmass difficult to appreciate by the major NGOs and officials based in the 1/3 of Haiti that is urbanized.  There is little question the highest fatality rates and destructive social outcomes are observed in these rural areas.  Case fatality rates still reported by officials represent underreporting and bias towards areas of Haiti with the best access to health care. 

We also emphasized the HEAS did all of this for less than $20,000 US. 

 

 

Confirmation of the Origin of the Haiti Cholera Disaster: UN Nepalese Troops

Hendriksen et al today published their findings on whether the ongoing cholera disaster in Haiti was sourced from Nepal (i.e. Nepalese UN troops).  AAAS' Science magazine just published a brief contextual discussion of how scientific concern had been brewing for some time.

Here we highlight, it was the HEAS members who first publicly alerted the world to the possibility of Nepalese UN troop involvement in the origins of the cholera disaster on October 26, 2010.

 

The HEAS was conceived and facilitated by the same operational team that provided warning of the 2009 H1N1 influenza pandemic to CDC and WHO, a discussion of which may be found here (see 4:25 and 10:24).

PAHO Official Statement Regarding Acute Flaccid Paralysis (AFP) in Haiti- HEAS Response

We thank the editors of ProMED for assisting in bringing visibility to reports of AFP in Haiti.  Below we provide a public response to PAHO's official announcement in ProMED of their investigation in Haiti.

In reporting the event, we were aware of the low case fatality rate associated with wild type polio, however we offer the following counterpoints to consider:

1. the denominator associated with any infectious disease in Haiti is elusive due to poor public health (including diagnostic laboratory capacity) and medical infrastructure- and despite international attention to cholera- therefore reporting bias remains on the side of severe illness and fatalities;

2.  the 2000-2001 outbreak of VDPV Type 1 was associated with 2 fatalities and involved cases in Port de Paix;

3.  and we offer the current polio outbreak ongoing in the Republic of Congo, reported in the 24 December 2010 (vol 330) copy of Science titled "Polio Outbreak Breaks the Rules", where we find the article's observation a relevant commentary on surveillance bias:

"Polio usually strikes children under age 5, paralyzing one in 200 of those infected and killing at most 5%, occasionally up to 10% in developing countries. The new outbreak tearing through this West African country has so far killed an estimated 42% of its victims, who, in another unusual twist, are mostly males between the ages of 15 and 25. Since it began in early October, the outbreak has paralyzed more than 476 people and killed at least 179, according to World Health Organization (WHO) estimates from early December, making this one of the largest and deadliest polio outbreaks in recent history. And one of the most mystifying, too, says polio expert Neal Nathanson of the University of Pennsylvania: 'There are too many things that don’t fit or are unexpected.'" [see attached]

We also would like to provide several points of clarification to the PAHO report:

1.  First notification by HEAS to PAHO and CDC was time-stamped and dated 9 January 2011 at 1958 EST, with acknowledgement by PAHO received on 10 January 2011 at 0735 EST

2.  Samples have been reportedly difficult to obtain because the bodies were unavailable due to burial

3.  An additional 6 cases (9 total) beyond the apparent cluster in Port de Paix have been identified, described as "ascending paralysis", a total of 4 had died

4.  We propose an inability under these circumstances to obtain positive samples may not represent a negative finding but rather, an inconclusive finding

5.  Regarding the discussion of ODS, we are aware, anecdotally, of debate among clinicians in the beginning of the cholera epidemic regarding the use of normal saline-based IV fluid resuscitation versus lactate ringers- improper electrolyte management is certainly a worthy consideration

Field experience in Haiti has shown us prior assumptions of epidemiological baseline and infectious disease behavior have been challenged dramatically, as revealed most recently by the debate of whether the cholera disaster was due to an endemic or exotic introduction.  Further, we have found reported vaccination coverage to be extremely difficult to validate, owing to lack of a patient identification system, vaccination records, and the challenge of reaching remote mountainous areas containing populations that have not been censused or even provided a geographic coordinate.  We have found the northwest in particular to be an area of Haiti associated with reporting delays and associated difficulties with situational awareness due to limited infrastructure.

We applaud PAHO's proposed conservative intervention, "As a prudent measure, polio vaccine has been added to an upcoming vaccination campaign against diphtheria and measles in the Nord-Ouest Department", but remain perplexed why the 2000-2001 outbreak of Vaccine-Derived PolioVirus Type 1 was not acknowledged in the historical review of poliovirus activity in Hispaniola.  Peer-reviewed, published findings at the time provided evidence of not only transmission of a reverted, recombined poliovirus that was lethal but was associated with biological properties indistinguishable from wild type.  Subsequent studies by Vinje et al revealed presence of VDPV Type I in stream and sewage waters. 

We invite commentary regarding the potential of VDPV Type 1 persistence in Haiti's environment, especially given the difficulties in ensuring vaccination coverage.  We also invite commentary regarding the continued use of OPV versus IPV in that country.



James M. Wilson V, MD
Haiti Epidemic Advisory System (HEAS)
Executive Director
Praecipio International
Washington-Houston-Port au Prince
jim.wilson@praecipiointernational.org
+1.571.225.3671

Praecipio International is a charitable non-profit organization devoted to the promotion of operational biosurveillance worldwide.





On Jan 27, 2011, at 8:41 AM, ProMED-mail wrote:

ACUTE FLACCID PARALYSIS - HAITI (03): OSMOTIC DEMYELINATION SYNDROME,
PAHO
********************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1] PAHO/WHO news release
[2] Comment

******
[1] PAHO/WHO news release
Date: Wed 26 Jan 2011
Source: Pan American Health Organization (PAHO) press release
[edited]
<http://new.paho.org/hq/index.php?option=com_content&task=view&id=4646&Itemid=1926>


PAHO/WHO investigating paralysis cases in Port-de-Paix, Haiti
-------------------------------------------------------------
Officials from the Pan American Health Organization/World Health
Organization (PAHO/WHO), along with colleagues from Haiti's Ministry
of Health and the US Centers for Disease Control and Prevention (CDC),
are looking into 4 cases of paralysis in recovering cholera patients
in Port-de-Paix, Haiti and, pending laboratory results, are likely to
rule out polio as a cause.

Experts including toxicologists are investigating possible
contamination at a hospital or at home from medication, food or
another source as the cause of death in these cases. PAHO and CDC
officials are conducting field studies and will report their findings
as soon as laboratory results are available.

Polio was one of the 1st possibilities looked into because of the
public health implications. However, the clinical characteristics and
epidemiology of these cases make poliomyelitis a remote possibility;
in simple terms, polio does not produce a high mortality rate.
Although considered highly unlikely, polio has not been completely
ruled out, pending laboratory results of samples.

PAHO/WHO has suggested that health officials remain vigilant for
further cases and has supported local health authorities in the
investigation with technical staff including epidemiologists, a
clinician and an immunization nurse to continue the investigations. A
nurse who works with PAHO/WHO's immunization program returned from
visiting the affected communities Monday [24 Jan 2011] with samples
from some of the families. A PAHO/WHO clinician and a PAHO/WHO
immunization advisor are participating in the investigation.

PAHO/WHO field epidemiologists and local health authorities from the
Department of Nord-Ouest first reported a cluster of acute
neurological syndromes in that department [10 Jan 2011]. As of [24 Jan
2011], 4 cases with acute neurological syndrome, including 3 deaths,
were reported, with dates of onset from November to December 2010 in
the La Pointe area, Commune Port-de-Paix, and the neighboring commune
of Saint Louis du Nord. All of the cases were seen at the same cholera
treatment center and returned 2-4 days later with neurological
symptoms, at which point they were hospitalized.

Working with the Director of the Department of Nord-Ouest and local
officials, interviews with medical staff and relatives showed that the
patients were admitted to the hospital between early November and the
end of December [2010]. These patients, hospitalized for severe
cholera, presented an ascending bilateral flaccid paralysis of acute
onset 24 to 72 hours after the end of the cholera treatment. No
additional cases were detected after the initial field investigation
in the Nord-Ouest Department. Samples of blood, feces, and CSF were
taken from one patient, and laboratory results are still pending.
PAHO/WHO field epidemiologists and local health authorities notified
the central Alerts and Response Unit of these cases [10 Jan 2011].

Of the suspected cases, only 4 had symptoms and signs compatible with
paralysis. 3 have died, and one is hospitalized in Port-au-Prince. He
is recovering slowly. As a prudent measure, polio vaccine has been
added to an upcoming vaccination campaign against diphtheria and
measles in the Nord-Ouest Department.

Polio was eradicated from the Americas in 1994, 3 years after the
last case was reported in Junin, Peru. A global polio eradication
initiative was launched in 1988 and has reduced the incidence of polio
worldwide by more than 99 percent. When it was launched in 1988, more
than 350 000 children were paralyzed in more than 125 endemic
countries. In 2009, 1595 children were paralyzed in 24 countries.
Today, only 4 countries remain endemic: Afghanistan, India, Nigeria,
and Pakistan and in those countries with endemic poliovirus
transmission, cases of poliomyelitis had declined by 85 percent in
2010 compared to the same period in 2009.

--
Communicated by:
Daniel B Epstein (WDC)
Information Officer
Pan American Health Organization/World Health Organization
<epsteind@paho.org>

******
[2]
Date: Wed 26 Jan 2011
From: Niklas Danielsson <Niklas.Danielsson@ecdc.europa.eu> [edited]


Re: ProMED-mail Acute flaccid paralysis - Haiti (02): ?post cholera,
RFI 20110125.0307]
----------------------------------------------------------------------
Having read the description by Dr James Wilson on ProMED-mail [22 Jan
2011] of a group of cholera patients in Haiti who developed acute
flaccid paralysis during the recovery phase after receiving treatment
for severe dehydration/hypovolemic shock, I would propose a possible
differential diagnosis. The symptoms he describes fit a rare but well
described condition called osmotic demyelination syndrome (ODS). The
syndrome has high mortality and is associated with intravenous
correction of hyponatremia. Cholera itself, as well as oral and IV
rehydration treatment for cholera, can result in hyponatremia. A
typical feature of ODS is the biphasic presentation. Patients
initially respond well to the treatment for dehydration and
hyponatremia but later deteriorate rapidly. The patients described by
Dr Wilson first recovered, but then deteriorated within 72 hours.
Classical symptoms include symmetrical quadriplegia, dysarthria,
dysphagia, confusion, and pseudobulbar palsy. Hyponatremia seems to be
the common denominator for ODS which is also linked to chronic
alcoholism, liver disease, malnutrition, psychogenic polydipsia, and
post-surgery.

--
Niklas Danielsson
Senior expert communicable diseases
Scientific communication section
Country Cooperation and Communication Unit (CCU), ECDC
<Niklas.Danielsson@ecdc.europa.eu>



[[The news release from PAHO above mentions 4 identified cases with
an acute neurologic syndrome within 24 to 72 hours following treatment
for cholera in the Nord-Ouest Department of Haiti. In the prior
ProMED-mail report on this event there was mention of a possible 7
cases (see Acute flaccid paralysis - Haiti (02): ?post cholera, RFI
20110125.0307) under investigation. In the early stages of
identification of an outbreak, it is not uncommon to hear differing
case counts from different sources often reflecting different
reporting sources of information and often different case definitions.
At this point in time, pending results of the thorough investigations
underway, one cannot rule in or out a possible infectious etiology or
toxic exposure.

The mention of the osmotic demyelination syndrome [ODS] by Dr
Danielsson (see [2] above) is very interesting. A literature search
revealed the 1st discussion of a post hyponatremia treatment
associated demyelination by Kleinschmidt-DeMasters BK, Norenberg MD in
Science in 1981 (ref 1). The 1st published article referring to this
syndrome specifically referred to as osmotic demyelination syndrome
was by Sterns, Riggs, and Schochet in the NEJM in 1986 (ref 4).
Reviewing the references available, most of the publications refer to
single occurrences or small groups of patients identified, supporting
Dr Danielsson's mention that this is a rare syndrome and is associated
with a rapid increase in sodium following a severe hyponatremia. The
clinical description of the presentation of ODS (well summarized by Dr
Danielsson) is compatible with the presentation of the cases in Haiti
reported by Dr Wilson in the 2 prior ProMED-mail reports. It is
curious that it has not been described in the literature in
association with cholera outbreaks elsewhere in the world.

We await further information on the results of the pending laboratory
studies and further epidemiologic investigations.

ProMED-mail would also like to thank Viki Hansen-Landis and
ProMED-mail Rapporteur Mary Marshall for submitting the same PAHO/WHO
news release.

For the interactive HealthMap/ProMED map of Haiti, see
<http://healthmap.org/r/00Yn>.

References
----------
1. Kleinschmidt-DeMasters BK, Norenberg MD: Rapid correction of
hyponatremia causes demyelination: relation to central pontine
myelinolysis. Science. 1981 Mar 6; 211(4486): 1068-70 [abstract
available at <http://www.ncbi.nlm.nih.gov/pubmed/7466381>].
2. Laureno R: Central pontine myelinolysis following rapid correction
of hyponatremia. Ann Neurol. 1983 Mar; 13(3): 232-42 [abstract
available at <http://www.ncbi.nlm.nih.gov/pubmed/6847135>].
3. Norenberg MD, Leslie KO, Robertson AS: Association between rise in
serum sodium and central pontine myelinolysis. Ann Neurol. 1982 Feb;
11(2): 128-35 [abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/7073246>].
4. Sterns RH, Riggs JE, Schochet SS Jr: Osmotic demyelination
syndrome following correction of hyponatremia. N Engl J Med. 1986 Jun
12; 314(24): 1535-42 [abstract available at
<http://www.nejm.org/doi/full/10.1056/NEJM198606123142402>].
5. King JD, Rosner MH: Osmotic demyelination syndrome. Am J Med Sci.
2010 Jun; 339(6): 561-7 [abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/20453633>]. - Mod.MPP]]

[see also:
Acute flaccid paralysis - Haiti (02): ?post cholera, RFI
20110125.0307
Acute flaccid paralysis - Haiti: RFI 20110121.0256
.................................................mpp/mj/jw
*##########################################################*

Download Science-2010-Roberts-1730-1

Another Note of Serious Concern From a Senior HEAS Member

This was a response to the prior post, reflective of a perception within the nearly 800 member HEAS network that the cholera response effort was badly mismanaged.  Many suggest a Congressional Investigation is in order:

As you know, I share the view that governments, particularly the U.S., have under-estimated the magnitude of the problem, and as a consequence seek to put this into a long-term context, saying that eventually it will end.  USAID and CDC, among other political entities, put their heads in the sand and wait for the storm to blow over.  I really hope [the HEAS] network exposes the relative passivity and inaction of the U.S. Government.  This can be easily done by meeting with the Congressional Black Caucus in tandem with the Haitian-American leadership and calling this failure for what it is.  As a retired U.S. Government official, I have been dismayed by the lack of U.S. Government leadership in Haiti - first by not providing much-needed resources for meaningful recovery to date and now by not committing sufficient assistance to shut down the cholera.  Were I still in a senior government decision-making position, this inaction would not have happened.  I would have done whatever it took, even if it meant shaming colleagues, to stop the cholera in Haiti.  Now, watching developments from the sidelines, I feel helpless and frustrated, wondering how many more Haitians need to die before Washington, D.C. gets off dead center.  I commend the invaluable efforts by the many in-country medical personnel on [the HEAS] network who are saving lives every day.

A Note of Serious Concern From a Senior HEAS Member

From: "Jim Wilson, MD" <iceaxe5@gmail.com>
Sent: Nov 28, 2010 8:09 PM
To: Haiti Epidemic Advisory System <haiti-epidemic-advisory-system@googlegroups.com>
Subject: A Note of Serious Concern From a Senior HEAS Member

Dear HEAS,

I share the below commentary from Dr. [REDACTED], an esteemed colleague here in the HEAS community with years of experience working for the World Health Organization and having lived in Haiti for many years as well.  His thoughts are a treasure to many of us, and he was initially reluctant to share the below commentary with the group.  I told him I believed many of us in the HEAS have these same thoughts. While we have made substantive efforts to remove political commentary from the HEAS in order to emphasize operational communication, it is nevertheless important to recognize a perception things may not be going so well...

One month after the cholera outbreak started, it's my feeling, as an epidemiologist, that there is something terribly lacking in the actions of the health community, both national and international.

In large-scale catastrophies, the pressure, at the same time human, humanitarian, political and mediatic, on the deciders to show determination and visible action is overwhelming. And in the absence of quick results, they know they will be blamed anyway.

In the case of the cholera epidemic in Haiti, the overwhelming pressure is to do everything possible to treat the sick and prevent deaths. Unfortunately, the context is daunting: impossible logistics, with scattered, isolated habitats all over the country; poor roads and few transport facilities, an uninformed populace; an insufficiency of health resources, both human and material. As a result, the best curative efforts, costing millions, are only a rearguard action, while the endemic spreads.

This is frustrating, as cholera is an easily preventable disease, provided the correct information and the cheap means of prevention are supplied to the individuals. This would be feasible in Haiti through a well-conceived mass information campaign, based on focused, simple messages, with a wide distribution of inexpensive water purification tablets. It should not deter the current curative efforts, the main ingredient being leadership, more than money.

Unfortunately, this is not even started. The public is largely left to itself, trusting desperately ineffectual preventive cure-alls... Barring a mass information campaign, expect the epidemic to go on, with its trail of suffering and deaths, and to establish itself endemically.

Personally, I could not agree more with Dr. Dresse's sentiments and welcome the community's thoughts.

Cheers,

Jim

James M. Wilson V, MD
Haiti Epidemic Advisory System (HEAS)
Executive Director
Praecipio International
Washington-Houston-Port au Prince


Praecipio International is a charitable non-profit organization devoted to the promotion of operational biosurveillance worldwide.

 

The United Nations Validates HEAS Projections

The HEAS has been stating, for weeks now, the level of under-reported cases in the community grossly exceeded official statistics published by MSPP, CDC, USAID, OCHA, and PAHO.  The United Nations now publicly acknowledges these projections. 

There are now additional considerations:

1. Population mixing during the elections pose a great risk of enhanced transmission.  Political obfuscation of these facts does not change this potential.
2. The "rule of thumb" used by PAHO to estimate clinically-apparent versus subclinical, shedding cases in the community is 1:3.  This is worrisome, because officials are now acknowledging more than 56k cases in the community, most of whom were not hospitalized.  This implies case counts may be closer to 200k.
3. Again, anything known and reported by officials is still under-reporting.  The HEAS is currently overwhelmed with the volume of reporting by mountainous regions who have no phone or even awareness of the nearest CTC.  And for each of these sites, we see reports of "first contact" mortality, meaning dozens are dead by the time emergency aid is requested.
4. As mentioned above, while official acknowledge potentially 2,000 fatalities, this still is a gross under-estimate.  Approximately 2/3 of Haiti is "off the grid" and therefore the plight of hundreds of thousands in rural areas is not being represented.
5. We are less supportive of a hypothesis that this strain of cholera is somehow more aggressive than anything seen elsewhere in the world than we are of the observation this is a "virgin soil" epidemic disaster.  Analogous to the introduction of West Nile virus to North America, Chikungunya virus to Asia, and influenza virus shift events, the associated transmission are typically "explosive".  When appropriate early warning and forecast systems are not implemented, utilized properly and coupled to rapid medical response, the outcomes are typically very bad.
6. Surveillance and response operations continue to be improperly managed.  At this point in the disaster, the opportunity of mitigation is now lost as the epidemic is likely to continue relatively uninhibited.  Response is inadequate to meet the need, and in most sites it is a recovery operation (IF any form of response / recovery is able to be achieved for the given site).

 

 

Commentary: The Perspective and Reality of HEAS Operations

[REDACTED],

The reality is, as we watch our colleagues on the ground fight countless battles as the entire response grid loses the war, nothing further can be done without funding provided in a non-biased, transparent, and accountable way. 

One of the key sociological observations of the entrenched hierarchical command and control bureaucracy, which includes our government, the Haitian government, UN, and the favored core of large NGOs, is continued siloing of information and further acquisition of funding and resources to "feed the beast", therefore perpetuating the enormous problem we now face.  It is actually an indicator of a failed social system, as many others have noted.  For those who study the collapse of societies, it is a classic indicator, where the impact and scope of the challenge-event becomes magnified.

This is a "war" best fought asymmetrically, with light, fast, and agile ground teams of those capable of starting IVs and "oh by the way" hand out educational material.  The war for adequate water and sanitation was never a realistic prospect and remains a particularly unrealistic prospect now.  This is due to the hundreds of years of ingrained cultural behavior that required counteraction.

We are most certainly at the point where the terrible triage of what communities will be supported versus not is being made… notice the deliberate use of the verb "is".  The story of Gonaives is being played out silently in the mountains, where many of the communities have no phone.  Meanwhile back in the original epicenter of St Marc, we have report in the Haiti MPHISE that clinics have run completely out of personnel and supplies, leaving many to die unassisted.  There is now no more time to train Haitians to train others for many parts of northern and central Haiti.  … Perhaps this may be done in the relatively nascent South. 

The effort has shifted from one of response to one of recovery in many locations, and I find myself again asking the question of "what good has our country done here?" as I ponder the implied meaning of these events for disaster response in our own country.  The story of Katrina is certainly being played out for the third time in Haiti.  The second was the earthquake.  Some in the HEAS, in a fit of despair and helplessness, believe this event to represent nothing more than a natural evolutionary process of population reduction. 

I and about 25 members of our team walked away from a multi-million dollar effort funded by our government, compelled to do so by the bureaucratic behavior you see now.  This action was preceded by our walking away from entrenched and stymied efforts to integrate national biosurveillance within a similar bureaucratic framework.  On my way out the door, one government official referred to me as a "traitor".  One thing is sure, I am certainly gaining an education as a Christian and American that the definition of "traitor" is certainly a political one, as is "The Right Thing To Do". 

The analogy of "Normandy" is a good one, and one that should be answered immediately and non-ambiguously by deployment of our military.  Trust that regardless of the political resistance we have witnessed, we will continue fighting until (if) the military arrives.