The Interview, Issue 115 - April 2011

News and Press Release
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Dr. Dana Van Alphen, the regional advisor for the PAHO/WHO emergency response team, arrived in Haiti two days after the devastating earthquake of 12 January 2010. As the coordinator for the health cluster, it was her responsibility to work with some 400 health agencies that came to provide humanitarian aid after the quake. The cluster facilitated planning strategies and established a clear leadership system. The first days were difficult due to the number of actors with different levels of experience in disaster relief, language barriers, logistics problems, and other factors. Coordination efforts were further challenged by the cholera outbreak in October 2010. To date, cholera has caused the death of over 4,000 people. Humanitarian assistance and response efforts have been hampered by severe weather conditions, the cholera epidemic, and social upheaval. As the relief work continues, PAHO/WHO is determined to ensure the population’s access to health care and the creation of a decentralized health system to provide medical services.

Haiti is facing one of the most severe outbreaks of cholera in the last century. What are the implications for the health cluster given that the epidemic occurred when the country has not yet recovered from the earthquake?

From the coordination point of view, the epidemic was less complicated than response to the earthquake. When the first cases were reported there were only 20 partners in the health cluster. Many of these actors have experience with cholera outbreaks in other regions of the world. Technically, there was more clarity about what had to be done.

Coordination was not the biggest problem; the problem was the way it was portrayed by some agencies and the information war that resulted. Suddenly, everyone was an expert. On the other hand, the population showed greater antagonism during the epidemic than during the earthquake. They “accepted” the earthquake as a natural disaster, but blamed foreigners and even the voodoo church for the cholera epidemic.

What response did the health cluster provide to meet the population’s needs?

Cholera treatment centers were set up with capacities ranging between 100 and 400 beds and cholera treatment units were established close to existing health centers so that the centers can continue to function without becoming overwhelmed. Oral rehydration points were also established to treat patients whose lives are not in danger. PAHO/WHO worked with NGOs since it was they who, along with Cuban medical brigades, cared for the patients, ran the rehydration centers, and went to the field. I would say that more than 30% of the patients were seen by Cuban medical brigades and 50% by Doctors without Borders.

The cluster expanded its presence to all Haitian departments and worked in areas such as management of dead bodies. It helped develop a national strategy for the distribution of essential medicines and supplies to the 10 departments. In conjunction with the Ministry of Health, PAHO/WHO developed a disease surveillance program that paid special attention to the 1.5 million people living in shelters and developed a cholera alert and response system to identify cholera “hot spots.” An outbreak response team was sent to investigate cases and take action. In the first two months of the outbreak, nearly 200 alerts were reported.

What lessons have been learned as a result of the cholera crisis?

We realize that we must decentralize the assistance: we cannot stay in the capital, but we must go to the countryside. In the beginning of the epidemic all the patients came from urban areas. Mortality in rural zones was higher, which revealed a problem of access. There are areas where people have never had access to health services.

We have also learned the importance of having a system for epidemiologic alert and response to treat the outbreaks. Cholera is not only about health; it is about water, hygiene, and management of waste.

What are the challenges for the health sector from now on?

Once the reports of cases decrease, many of the NGOs will leave and the money from agencies managing earthquake funds will be exhausted. Then we will have to think about mid- and long-term projects and resource mobilization. The projects have to be planned for the mid- and long-term because Haiti’s problem is a development problem, a poverty problem. Instead of distributing Aquatabs [water purification tablets] it is better to build a water tank and chlorinate that water. We have to do things that offer solutions, but not necessarily with major infrastructure projects. Solving the water problem is a great challenge.

The health sector will work on improving access to primary care. In fact, the Ministry of Health’s strategy for rebuilding is to ensure the provision and continuity of medical services in all the affected structures. The sector will work to support the most vulnerable populations. It is important to maintain and strengthen the governance of the Ministry of Health so that essential health care functions can be carried out. Building partnerships with other governments and NGOs will help to improve the capacity of the health sector.

Rebuilding hospitals and building new health facilities is an essential activity for the health sector. It is important to ensure that all health facilities incorporate mitigation measures in order to make them more resistant to disaster.

Is the international community aware of this situation?

Yes, but I am afraid that the donors will get tired… there are so many problems. But instead of offering funds every time there is a disaster, it would be better to think about mid-term solutions. It would be better to think more about how to help the government take leadership so that things are managed better.

What role will PAHO play?

PAHO must support the Ministry of Health to improve the epidemiologic surveillance system and to improve health services. We have to help the Ministry to ensure that the hospitals that will be built are safe. The construction of 10 new hospitals is already under way.

What is the situation regarding cholera in Haiti right now?

We are still responding. There are still cholera alerts in isolated areas. The large NGOs are closing their cholera centers, but since they are training medical personnel locally, the transition is less abrupt. They are leaving from 3 to 5 beds for cholera patients in each public or private institution.