Cholera in Haiti: Determinants (Blog 11)

Problem Definition: There have been 469.967 reported cases of cholera in Haiti between January 2010 and October 2011, resulting in 6,595 deaths.

This blog discusses the key determinants of the cholera epidemic in Haiti. All of the determinants that I’m discussing are inter-related and are difficult to separate. The determinants I will be looking at are biological, environmental and social/economic. A person’s social/economic status affects their environmental surroundings.

According to the WHO “cholera is an acute enteric infection caused by the ingestion of bacterium Vibrio cholera present in faecally contaminated water or food”. Environmental conditions allow the spread of cholera through biological determinants (faecally contaminated water or food).

Living Conditions: An estimated 634,000 people in Haiti lived in slums or displacement camps during 2010/2011. Needless to say, the slums and displacement camps were not great living conditions with cramped living spaces and had poor sanitation.  People in these camps were poor, lacked food and water. Their social/economic status affected their environmental surroundings.

           

Lowered Immunity: Overcrowded living conditions allow diseases to spread quickly and easily. All of the illnesses that the people’s immune systems were battling lead to generally lowered immune system effectiveness. Unfortunately people with lower immunity are not only more likely to be infected with cholera but they are also more likely to die from it.

Food Hygiene: UN officials estimated that 2 million people needed food supplies on a regular basis. Though food hygiene is very important, given the shortage of food, the main priority was getting food to the population. People are also more willing to eat food that may not be ‘safe’ if they are hungry. The combination of these two can result in food falling on the ground and still being consumed, not cooking food properly, etc. Food could have easily been contaminated with faecal matter further allowing the spread of cholera.

Water Sanitation: Some people – particularly those of low economic status –relied on rivers for water supply, as they were without plumbing. Not only did they do their laundry in rivers, they bathed, brushed their teeth and drank from the river. They were at risk to any contaminants dumped in the river upstream. Due to the destruction of infrastructure during the earthquake, sanitation became even poorer. Even the United Nations peacekeeping base in Meille had “significant potential for cross-contamination’ between toilets and showers”. Furthermore the UN base contaminated the Latem River. Yet the UN’s sanitation system would have been at a higher structural caliber than the general populations’. As you can imagine, if the UN base is contaminating the water than contamination from others would have been much worse. The poor water sanitation allowed the cholera to spread.

Sources:

WHO, (2012). Prevention and control of cholera outbreaks: WHO policy and recommendations. Retrieved from website: http://www.who.int/cholera/technical/prevention/control/en/index.html

2 weeks after haiti quake, food aid falls short. (2010, January 27). The Associated Press. Retrieved from http://www.msnbc.msn.com/id/35109377/ns/world_news-haiti/t/weeks-after-haiti-quake-food-aid-falls-short/

Haiti news. (2012, April 02). The New York Times. Retrieved from http://topics.nytimes.com/top/news/international/countriesandterritories/haiti/index.html

Cholera in Haiti: Surveillance, Magnitude & Indicators (Blog 10)

Problem Definition: There have been 469,967 reported cases of cholera in Haiti between January 2010 and October 2011, resulting in 6,595 deaths.

This blog will discuss the surveillance, magnitude, direct and indirect indicators of the cholera epidemic in Haiti as well as the reliability of the information.

The surveillance of the cholera outbreak is both passive and active. The passive surveillance occurs when patients seek medical attention and are diagnosed with cholera, which in turn is then reported. The active surveillance occurs in the form of cohort studies, although not always intentional. For example, agencies often check the quality of the sanitation and water supply after a natural disaster. People may get sick from the poor sanitation observed, which is then reported.

Within the first 12 months after the Haitian earthquake (January 2010- January 2011) there were an estimated 400,000 cases of which 80,000 were severe and 140,000 required hospitalization.  As of October 9 2011 there were 469,967 reported cases of cholera and 6,595 deaths. The mortality rate from cholera is 1.6%. To put all of these numbers into perspective, in 2010 the Haitian population was estimated to be 10,620,000; almost 5% of the Haitian population were sick from cholera.

Cholera is spread by the ingestion of faecal matter contaminated with Vibrio cholera. Many rivers, reservoirs and wells were likely contaminated with this bacteria which was a direct cause of the spread of cholera in 2010-2011. Improperly handled and unclean food was also a direct cause of the cholera outbreak. Again, even the slightest amount of faecal contamination spreads the disease.

The most notable indirect cause of the cholera outbreak is the earthquake that occurred in January 2010. The quake destroyed more than 250,000 homes and 30,000 businesses. It is difficult to find numbers pertaining to the damage to the general infrastructure but we can assume that it was equally as severe. The damage to these buildings and sewage systems indirectly affected the spread of cholera via the adverse impact to the overall sanitation.

On October 8, 2010 Nepalese troops deployed in Haiti to assist with the earthquake relief effort. However, Nepal had just previously experienced a cholera outbreak. It is unknown how many of these troops were infected with cholera but they would have furthered – and some have argued start – the spread of cholera within Haiti.

As discussed in my previous blog, statics from nations which have had a natural disaster and are poor countries can be rather misleading. Aside from simple data collection problems which exist even in developed countries not facing a natural disaster,  if the Haitian government wanted more money there would be an incentive to inflate the magnitude of the problem to gain public sympathy. However, as there were many agencies working in Haiti, many producing their own statistics, this influence was mitigated; there is a reliable sense of the magnitude of this cholera epidemic.

Sources:

(2011). Cholera persists in Haiti. America, 205(14), 08.

Key Haiti statistics. In (2012). The Lambi Fund of Haiti Retrieved from http://www.lambifund.org/news_HaitiStats.shtml

Renois, C. (2010, February 05). Haitians angry over slow aid. The Age. Retrieved from http://www.theage.com.au/world/haitians-angry-over-slow-aid-20100204-ng2g.html

Cholera: Description (Blog 9)

A public health topic that I find very interesting is cholera; a disease that causes diarrhea and can kill a person in a few hours if treatment is not received. Cholera spreads through unclean water and poor sanitation. According to the WHO, every year there are about 3-5 million cases of cholera and 100,000-120,000 resulting deaths. The WHO estimates that up 80% of the cases can be treated with oral rehydration salts. (http://www.who.int/mediacentre/factsheets/fs107/en/index.html)

The most severe outbreaks of cholera occur after natural disasters and areas of unrest. The Democratic Republic of Congo is in the middle of civil unrest which has lead to a a serious contamination of the water and very rudimentary (to be polite) sanitation system. In January 2011 there were “at least 22,000 cases and 584 deaths”. (http://www.passporthealthusa.com/localvaccines/travel-health-alerts.php) However, data in areas like the DR Congo is very difficult to find and if there is data, it is most likely untrustworthy. If a country depends on tourism, the government is likely to under-report the number of cases. On the other hand if the government wants more money, they are likely to inflate the number of cases. Due to these issues I will have to focus on an area that has hard data – a country that has experienced a natural disaster that received a lot of aid.

In January 2010, Haiti experienced a magnitude 7.0 earthquake. Like many other countries, the Haitian government seems to have tampered with some numbers. The Haitian government stated that about 316,000 people perished while USAID (US Agency for International Development) puts the death toll at 46,000-85,000. (http://www.bbc.co.uk/news/world-us-canada-13606720) In spite of this, statistics regarding Haiti are likely to be accurate than the DR Congo. As there were many governments and organizations were involved with the relief effort there should be a lot of reliable data on the situation.

One of the results of the earthquake was water contamination. Because of this water contamination, cholera was soon spread. I would like to study the outbreak of cholera in Haiti during 2010-2011 resulting from water contamination from the January 2010 earthquake.

As the numbers suggest, cholera is a very serious worldwide issue. Studying how an area that has dealt / is dealing with an outbreak of cholera (Haiti), may be applicable to other countries. In countries like the DR Congo, even a slight improvement in people’s lives brings an enormous social shift – people simply have more hope, which is crucial in the development process. As you might be able to tell, DR Congo holds a special place in my heart. According to aid workers and economists, DR Congo is an un-developing nation. (I was in Goma, DR Congo in the summer of 2010 on an aid trip and it must be one of the bleakest corners of the word.) The multi-decade civil unrest is slowly destroying everything that had been accomplished. Because of the dangers, many aid organizations have pulled out of DR Congo though a few are still there (including the UN). But DR Congo has essentially been left to its own devices. Even if the cholera prevention/intervention is unsuccessful, there may be a social impact. Hopefully, the Congolese will see the international effort and will no longer feel abandoned and alone.

Maternal and Human Rights (Blog 8)

“Human rights are basic rights and freedoms that all people are entitled to regardless of nationality, sex, national or ethnic origin, race, religion, language or other status.”  (http://www.amnestyusa.org/research/human-rights-basics) An example of a human right is that “all humans are born free.” (http://www.un.org/en/documents/udhr/) Human rights are important to public health and public health is important to human rights, because without both people will have neither. As such, the right is in protected in the Declaration and without that, it may not be honoured.

A certain standard of living is necessary to be healthy and therefore is included in Article 25 of the UDHR. If a person has no money, they are unable to buy proper food and clean water and are subsequently more susceptible to diseases. According to Dr. John Butterfly, executive director of Dartmouth-Hitchcock Medical Center, “chronic malnutrition often leads to a compromised immune system and makes a person unable to fight off organisms ‘that a normally fed human would barely notice’.” (Wall Street Journal. “Starving in India: The Forgotten Problem”) This is not just a problem in other countries. The University of Wisconsin did a study of 3,000 counties in the USA. “The five least-healthy counties generally had more than twice the teenage birth rate of the five healthiest counties, and more than twice the share of poor children.” (The Economist. “Beyond the mandate: Improving America’s health will take more than universal insurance”) Clearly there is a link between a good standard of living and one’s health As the Wall Street Journal article points out, without a basic standard of living people die, thus it is a major human right.

States must guarantee “women of all racial and economic backgrounds timely and non-discriminatory access to appropriate maternal health services”. (Maternal mortality and human rights: Landmark decision by United Nations human rights body) A committee made some recommendations on how to provide “appropriate maternal health services”. There should be emergency obstetric care, professional training for healthcare providers, ensure that facilities are up to standards, and monitoring of maternal deaths.

Motherhood is specifically mentioned in the UDHR and addressed by the Committee of the Elimination of Discrimination Against Women simply because mothers are very vulnerable. Furthermore, because pregnancy is a cumbersome, long, and risky condition, women must be given further protection. Obviously, pregnant women have more physical limitations than they would have otherwise. Any risk that a pregnant woman faces also could harm the baby. Mothers are also specifically mentioned because women are generally the primary caregivers. Protecting the mother is protecting the children. For example, in countries where there are not a lot of infant food options, infants rely on breastfeeding. If the mother has died or is unable to care for her child, that child’s risk of mortality would be higher and their development would also be hindered which will impact their lifelong well-being.

Contagion (Blog 7)

This blog is discusses aspects of the movie “Contagion” directed by Steven Soderbergh.

Beth returns home from Hong Kong, while she is ill. She infects her son and they both die but her husband (Mitch) is immune. The virus spreads around the world rapidly but health officials do not immediately realise the severity. The CDC identifies the virus and develops a vaccine, while the world is crumbling around them. This movie show how important public health is. Doctors could only treat the virus in individuals after they had been infected, which is both too late and ineffective. Public health officials try to contain/treat the virus on a large scale, which is much more efficient than treating only individuals.

An outbreak occurs when the number of people with an illness is significantly higher than the norm. An outbreak investigation is following cases (looking at all those exposed), attempting to identify the cause, diagnose the problem and then implements treatment. Isolation is the separation of people who are ill from healthy people. Quarantine is the separation of people who have been exposed to an illness (to see if they develop symptoms) from those who have not been exposed. All of these were in the movie. There was a virus outbreak, the CDC conducted a nation-wide and worldwide investigation, Mitch was quarantined and they attempted to isolate those who were ill but the number of those who were was too great.

There are many ways that the CDC and other authorities could have been better prepared. Most importantly, authorities need to be better prepared for disasters. There did not seem that there was a plan in place to implement. In all fairness, no one could have expected how far reaching the virus would be – but they should have been some sort of general emergency plan. For example, there were not enough blankets for the ill in isolation; the dead were put into hastily constructed mass graves, which could damage the water supply. Also, public services stopped, creating risks of different diseases and health issues. Since everyone was panicked, crime skyrocketed – the authorities should have planned on using the military sooner. Finally, there was not enough food; the plan should have contemplated how to get food to people.

Another issue that could have been better prepared was the spread of information. For example, when Mitch and his daughter were traveling to another city they ended up being turned around on the outskirts, like many others. To address this, there should have been a way to mass communicate, like emergency channels. Also, there was a serious spread of misinformation. Of course there are always people that are going to take advantage of a situation for profit but this could have been better combatted. The CDC was tight-lipped about the virus for too long, so when they started releasing concrete information, people still believed that they were holding out on more information.

On the farm we had an outbreak of a pulmonary respiratory virus in our cattle herd. Within days we had over a dozen claves got sick and died quickly without any apparent explanation. It took a few autopsies to determine the best course of action. We couldn’t get the cattle to the corral to be treated (so we had to treat them in the pasture), but this was time consuming and in the meantime more calves got sick and died. There was a feeling of being helpless when so many got sick and died so quickly…

Effects of Climate Change (Blog 6)

This blog discusses the effects of climate change on the general public’s health and possible ways to deal with the issues that we face. The information is from “Climate Change: The Public Health Response”.

Two climate change issues that severely affect people in my area are: winter weather anomalies and droughts, floods, and increased mean temperature. Winter anomalies are essentially the same as droughts and floods. As you can imagine, in Canada we get a lot of snow and cold weather. Most of our precipitation comes in the form of snow. If we do not get the enough snow it is a drought. The soil is not going to be very fertile because there is no water for the crops to suck up. If the crops don’t have enough water there is a lot of loose soil blowing around (think the “Dirty ‘30s”). Blowing soil harms the respiratory system and affects eyes (too much soil in the eyes).  On the other hand, if we get too much snow, when spring comes it takes a lot longer to melt. If seeding is done late, the growing season will be too short. People will be forced to harvest the crops before they are ready. This means that the crops will be moist when harvested. This wreaks havoc on the public’s respiratory systems. Imagine being in a musty environment for a long period of time. A significant consequence is higher levels of ochratoxin A (OTA). Higher levels of OTA have been shown to cause kidney failure, particularly in infants. This is not very well known but is a very serious issue - levels higher than 5 parts per billion or 2 kernels in an 18-wheeler truckload are toxic for infants (Prairie Oat Growers Association). Also, in this moist environment bacteria thrives and all of the resulting health consequences.

I was surprised to see that climate change affects people’s mental health. People in areas with continuous climate issues would have a burden. I was not aware that people who are not displaced worry about climate change so much that they have mental health issues.

Mitigation (primary prevention) in the context of climate change is to reduce green-house gas emissions in order to slow or even reverse climate change.  Adaptation (secondary and tertiary prevention) prepares for the effects on public health resulting from climate change.

If many people from the same area are getting sick, public health officials would look at how the patients are connected. The people turn out to be using the same well for their water. As a result of the increased mean temperature, bacteria is able to thrive in the well. By tracking the trends, the source of the problem was located, so the issue could be rectified.

A government agricultural experimental farm is located just outside our town. Their research primarily focuses on how to make crops survive and thrive with climate change. If the crops are better prepared for climate change, many of the health issues decline significantly. As previously stated, the most obvious health issues our area a result from bad crops. As we are located in the middle of the country and have very few trees, we do not need to be concerned about many of the issues discussed in this paper.

Public Health Achievements - Except for Farm Kids? (Blog 5)

This blog covers some of the aspects of “The 10 Greatest Public Health Achievements - United States 2000-2010” according to the CDC.

           

As the title of the article suggests, it summarizes the ten significant changes in public health. There are impressive decreases in pneumococcal conjugated, hepatitis A and B, as well as varicella due to vaccines. State and local public have improved in controlling infectious diseases while laboratories identify and control spreading of diseases. The government have increased the taxes in order to control tobacco. There is standard screening for babies to identify six disorders. Motor Vehicle Safety has improved by safer vehicles, improved roadways and safer road use. Cardiovascular Disease prevention is done by controlling the causes and earlier screening, similar to what is done for cancer. Due to regulations injuries in the nursing profession, farms (in children) and fishing industry have decreased. Regulations have also prevented childhood lead poisoning. Finally, the public health system has improved its response to cases of bioterrorism and dealing with pandemics. All of these are important improvements.

           

Occupational safety is an issue in my hometown. As an agricultural area, all of the kids work on the family farm. Kids work within their capabilities (as decided by their parents); which are underestimated by policy makers. For example, all farm kids drive while underage. The learner-permit age is 15. When their parents deem them responsible, the kids are allowed to drive on their own (~age 13). But according to the government these kids do not have the skills to drive. (Ironically, the dangerous drivers are kids who didn’t grow up driving.) Parents know their child’s capabilities (like their ability to drive) better than people who have never met the kids. The current premier, a farmer, was taken to task by urban opposition politicians for letting his pre-teen kids drive… the urbanites badly lost that PR battle. Yes, children have accidents when working on a farm but so do adults. A neighbouring farmer almost lost his hand, while cleaning out a hay bailer. No one denies that there is a risk to farming but realistically putting new guidelines is not going to change farmers’ behaviour – look at all the underage drivers.

           

Another issue discussed that is important is the increase of taxes on tobacco. Getting cigarettes in high school was really easy to do (or so I’m told). Kids had to pay a ‘risk charge’ (for the risk the adult seller faced) on top of the cost of the actual cigarettes. When the government increased the taxes on cigarettes, prices soared – making smoking too expensive for most teenagers in my school. This prevented quite a few potential addictions.

           

One of the more pressing issues we face is obesity. This problem affects the rest of the healthcare system and thus is important to everyone. According to Health Canada the risks of obesity include: hypertension, high blood pressure, heart disease, type 2 diabetes, etc. Many people are obese because junk food is cheaper than healthy food – ensuring that people have access to healthy food would be a step. Another is changing the public’s mindset. In regards to child obesity, parents control their children and without their effort their children are more likely to become obese. However, there is no specific way to solve this problem.