This article was also featured on The Huffington Post.
Every weekday morning, the staff at Hopital Albert Schweitzer (HAS) convenes in the hospital's bibliyotek to discuss deaths and complex cases from the prior day. On October 18, 2010, a Monday, the doctors and nurses sat in the stuffy room under dim lights to discuss a patient with severe diarrhea and vomiting who had died the night before. "It was strange, but it was one person, so it might be something. We didn't know," said Dr. Silvia Ernst, the medical director, about the mysteriously rapid death.
When Dr. Ernst heard about this first perplexing case, it was her second month in Haiti. "By Wednesday many people were coming in with diarrhea" she said. At that point they knew "something was going on."
Only a few weeks later, this 130-bed hospital in Deschapelles was running a cholera treatment center that housed 250 to 300 people at a time.
Deschapelles is remote. So remote, in fact, that the medical staff of Hopital Albert Schweitzer began to see injuries from the January 2010 earthquake trucked to their doors before they even heard what had happened. As a result of its location and long-standing relationship with the community this hospital, which opened its doors in 1956, fell into a unique role as steward of community health.
Although the hospital has run its Integrated Community Services for decades, the outbreak of cholera instilled new urgency in improving basic sanitation and water treatment. Even in years before the earthquake, projects to build wells and latrines and to improve sanitation attempted to patch a fundamental gap in the country's infrastructure, but did little to stop the explosive spread of cholera. Now, HAS and similar organizations face a simply stated question: Almost two years after cholera erupted in Haiti, how do we stop people from getting sick?
Preventing cholera is now especially pressing because HAS recently closed their cholera treatment center. Others have also shut their doors: In Port-au-Prince, Doctors Without Borders consolidated five cholera treatment centers into two. The one in Verettes was empty the day we visited. As a result of faltering funding and resource clustering across the country, families in Deschapelles who have gone to HAS for generations may be sent elsewhere for cholera.
In order to stop cholera, a water-borne illness, you need to change the ways people interact with water. It is no easy task.
A Saturation Campaign
In 2002, when the British Centre for Ecology and Hydrology ranked 147 countries in water security, a metric for the accessibility of potable water, Haiti came in last place. "During this [rainy] season we also have a lot of children with other diarrheal diseases. Even before cholera, this was the season," Ernst said about other pathogens that thrive because of poor water quality and sanitation. Typhoid, norovirus, shigella, and other diseases are commonplace, but treatment centers in rural areas do not have the resources to do anything more than provide rehydration therapies for these diarrhea-causing pathogens. Lab diagnosis is both costly and unnecessary.
Cholera posed an unprecedented challenge to medical practitioners in Haiti. The crescendo of dying patients that reached 3,000 in the first few months of the epidemic brought an equally large response – a saturation of information on how to wash your hands, cook food, defecate in the right place, and treat your water. The government ran segments on the radio, sound trucks with stacks of amplifiers blared the message from the dusty streets, and thousands of community health workers permeated the rice paddies and mountain towns.
Haiti lacks infrastructure to distribute treated water and deal with sewage, so prevention falls largely onto the shoulders of individuals. This burden is especially difficult because 70 percent of people infected by cholera can cause others to get sick, but they do not show symptoms. The goal of the saturation campaign was to inundate communities with information and resources until basic sanitation and hygiene became second nature. Unfortunately, when people do not perceive themselves to be affected by a disease, it is incredibly difficult to achieve behavioral change.
Around Deschapelles, HAS distributed water sanitation tablets, soap, and oral rehydration solution so people could start to treat cholera before they left for the hospital. Since cholera is theoretically easy to prevent, the goal was simple: Prevent it.
In November 2011, one year after the outbreak started, a Study by the Center for Disease Control indicated high percentages of the population knew ways to protect themselves from cholera. Around Port-au-Prince, 86 percent of those surveyed recognized hand washing as a way to stop cholera. The news was positive and many Haitians hungrily internalized the information.
But in public health there is often an appalling gap between knowledge and action.
In the early summer of 2011, the rainy season flushed cholera out of the sewage systems and into the rivers. Once again, the death toll rose into the thousands. The United Nations Human Development Index from that year, a metric compiled through various quality of life indicators, ranked Haiti 158 out of 187 countries. In the same report, 54.9 percent of the country fell below the poverty line – in Haiti considered to be those living on less than $1.25 a day. Simply stated, there was a massive deficit of resources.
At HAS and other institutions that interact with some of the poorest populations in the country, the question remained the same: How do we stop people from getting sick? But now there was a new twist: Did Haitians lack the resources necessary to wash their hands, defecate in the right places, and drink treated water, or were they choosing not to do so? The answer, in many places, is both.
Information and Inaction
"Some people are very compliant," said Dr. Alain Bien-Aime, a community health physician at HAS. "Others, we can explain what to do, but they don't do it." Dr. Bien-Aime remembers seeing someone eating in the market: "He could explain to you how you get cholera, but he doesn't wash his hands." This disconnect between knowledge and action is not unique.
For example, after Haiti became one of the first high-risk groups for HIV/AIDS in the early 1980s, a widespread condom use campaign started. In 2010, a survey performed by Dr. Paul Farmer and others indicated that 93 percent of Haitians recognized condoms as a barrier to HIV/AIDS, but less than half the men had used them in their last act of high-risk sex. ("High-risk" is defined by number of partners, sex work, and other factors).
Nor are Haitians the only ones susceptible. After all, how many Americans don't "eat healthy" despite massive education campaigns about obesity and its risk for type II diabetes and heart conditions? When measured by how many of us are obese, the answer is 35.7 percent according to CDC data – more than a third of our country. So is the gap because of access (it's easier and cheaper to get unhealthy food) or choice (fast food is delicious and cathartic)? For Dr. Bien-Aime and other community health workers, the need to transform information into action is much more urgent. Cholera, unlike obesity, can be contracted in a moment and kill you within hours.
In Coupon, a small town downriver from HAS, latrines are often built by nearby organizations without walls. The idea, on paper, is that families can build temporary walls with palm fronds and stronger walls with mortar. Meanwhile, because the organization saved money on walls, they can build more latrines for more families. HAS hopes that having families build part of the structure will promote the use of latrines and dissuade a culture of reliance.
In practice, however, palm trees are hard to find. Local builders recognize a niche market and charge more for latrine walls. Many latrines sit unused, without walls and in plain sight (no one wants to use a latrine in plain sight) with a large rock covering the yawning toilet mouth. Therefore, even though most everyone knows that using a latrine will protect the water table of this alluvial plane (a vital task because it is shallow and easy to contaminate), there are unused latrines with no walls spattering the dirt yards of families in rural Haiti.
For many, there is a logistical and financial reason for the disuse. This summer in Coupon, people passing by stopped on their tired-looking horses and old motorbikes to talk about why latrines need walls. Dawn Johnson, the Technical Coordinator of Integrated Community Services at HAS, sometimes rides into towns on horseback, but today she arrived in a Jeep.
For every logical suggestion Johnson made to build walls (you can buy enough bags to make walls with the money for one round-trip ride to the capital), the 10 or 12 people gathered around her posited an equally logical counterpoint (termites will quickly eat the bags). In most cases, it is a financial impossibility to build walls; in some cases, it is a matter of postponing it until an easier time.
Johnson, in many ways, is a translator. She understands both the language of aid programs as well as the culture of Coupon, so she must connect the two worlds. Her job is to take a latrine or piece of information about sanitation and make it fit reasonably into the life of this bare bones agrarian community. "This is my life," joked Johnson while bantering with people in town about what obstacles they need to overcome to put walls on the latrine – after 15 years at HAS, it is indeed much of her life.
There is a scale in people's mind that dictates what is important, so information about sanitation and the prevalence of cholera must outweigh the daily concerns of farmers in Haiti in order for walls to be the most pressing thing on their mind.
How exactly you tip the scales is an extremely complicated matter. In the fields and rice paddies when people need to use the bathroom, they just go. By the river, when people are thirsty in this heat that makes your breath draw like gel, they just have a drink. It is the muscle memory of their lifetime.
"We don't have any place to get water, we don't have any money to get water," said Donnie Dusanville, a dapper man who farmed around Coupon for 28 years. When asked about what people do when they cannot afford a truck ride to go purchase water, he said, "If they are in this area, you can figure they are drinking river water."
Some people are unable to drink treated water because they can't afford to purchase it everyday. Others don't wash their hands because it is easier not to.
"Why should we?" is absolutely not a question of naivety or sloth. It is a question of whether paying for the latrine wall is more important than paying for food, a child's education, or other necessities.
Working against Johnson and tipping the scales against new healthy behaviors, the El Niño rainy season was light and early this year so cholera cases didn't spike as they did in 2011. Right now, thousands are not dying, and there seems to be little incentive to build walls – the daily routine in Coupon proceeds undisturbed.
Charting a Course
In public health, the disciplines of social and behavioral sciences attempt to vivisect the relationship between programs and their acceptance in communities. The goal is to accurately chart every factor that will influence behavioral change – from family pressures to stigma to fear of a disease. It may be all of the above. Ideally, a well-conceived chart will lead to latrine walls.
Complex public health models have fancy names in programmatic vernacular, a language that Johnson speaks fluently: the Transtheoretical model and the Health Belief model are some of the more arcane titles. The paradox is that in practice these multi-faceted and dynamic models are supposed to play out in accessible and near thoughtless behavioral change exactly because they are perfectly tailored to the community and individual. It should be as simple to apply the models as it is to say: "Cholera is theoretically easy to prevent – so prevent it."
The Haitian Ministry of Health and Population and the Division of Water Supply and Sanitation are working to create infrastructure that will protect people from disease, but it will be a long time before the pipes reach Deschapelles. Until then, the burden of healthy behaviors remains on the shoulders of individual Haitians, both those with the financial and logistical capacity to carry the weight – and those without.
In a race against the next rainy season, community health workers try to marry programmatic services with the motivation to use them. One without the other is about as useful as a latrine without walls.
But, as Dr. Bien-Aime said, "to change minds, it takes a long time."
This article was also featured on The Huffington Post.