Yesterday we went to the courtyards of some of the people who had been discharged from the hospital in the past several weeks. We wanted to get a sense of how each person might have been exposed to cholera, and to design interventions which might reduce the spread of the disease. We went to the locality of Coupon, a low-lying area between the main road and the Artibonite River. The area is primarily rice fields, with the bright green mature shoots standing thigh-high above the flooded fields. Despite the seeming wealth, most of the land is owned by several large business men who had loaned money to the farmers who had defaulted on the loans. Now the farmers work on their former land as day laborers, and live in poor conditions.
Most of the households we visited had wells in their courtyards, but they did not have disinfectant tablets to control the cholera. Only half of the courtyards had access to latrines and the rest used the fields behind their houses. In several cases, household wells were located near irrigation canals or near the river, with possible pollution to water sources. Several households had HAS biosand water filters.
Almost all residents could repeat the community education messages, and were well aware of the need to purify water and to wash their hands. However, their poverty was a barrier to having adequate resources such as water purifying tablets, soap and oral rehydration tablets in case someone in the household had symptoms of cholera.
Near the river, a group of young men were shoveling sand into the back of a dump truck. The sand had been brought from the river by young men who dive to the bottom with a bucket and dump it in a pile which they sell to construction teams. It’s hard and dangerous work; most do not know how to swim, and they have to struggle against the current as they scrape the sand from the river bottom. So it is probable that most of them drink some of the water during their dives. Watching them as they shovel the sand into the truck, they were the personification of young risk-taking adolescents. They heckled the animatrice as she tried to talk to the residents about hand washing and water treating, our two core messages. They asked if we would be paying them to not work in the river, or how did they think they were going to make a living.
As we were talking with them, our Tulane epidemiologist, Carrie Weinrobe noticed that women were going over to a hand pump to get water for the afternoon meal. She also noticed that the pump was almost on the bank of the river, and that the place where that pump was drawing water would probably be polluted by the river water, which was almost at flood level. We went back to the households we had visited earlier and asked if they were treating the well water, and they all said yes, when they have the disinfectant solution or powders.
These visits were very productive. We learned that the preventive messages which have been carried by the HAS field workers were getting to their audiences. But we also learned that the message to Trete Dlo, treat your water, is only as effective as the distribution of disinfectant. From our discussions with these families, it was clear what their preference was if the hospital were to offer direct assistance in their communities. Latrines. They matter-of-factly pointed out where they went to the bathroom, pointing vaguely beyond the back fence of candelabra cactus. But it was clear that they took no pride in that, and later many of them mentioned to one or another of us how much they would appreciate having a safe and private place. The HAS Water and Sanitation team has contracted with Bos Masons in the past to make latrine slabs and seats on site, and this is obviously the time to re-connect with them and send them out to the highest-risk communities. We have already contracted with one of the masons to build biosand filters, which are very effective against coliform bacteria, and have some effect on v. cholera, but there is still a benefit in treating the filtered water with disinfectant.
We are getting some respite from the influx of new patients, but the trend lines remain highly erratic and there is little comfort in one or two days’ statistics — we have been there before, and have to prepare for further surges.
Overall, cholera is a new disease which now represents a 60% increase in our patient volume, all being carried by our current staff. Gifts to HAS now will help us manage the severe impact of cholera, which will be with us for the long term.