GR2012-01 Global Health Opportunities For the Young Physician- My expe

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Global Health Opportunities For the Young Physician: My experiences in Haiti :

Global Health Opportunities For the Young Physician: My experiences in Haiti Ora Fried M.D. Pulmonary Critical Care Fellow California Pacific Medical Center / Alameda County Medical Center

Goals and Objectives:

Goals and Objectives

My History in Haiti:

My History in Haiti March 4th-15th 2010: (IMR) Disaster Response December 26th-Jan 3rd 2011: (IMR) Rebuilding, Cholera epidemic December 8th-Jan 3rd 2012: (Dr Megan Coffee, IMR) TB / HIV ward/clinic elective rotation

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The earthquake can be understood as an “acute on chronic” event. It was devastating because a history of adverse social conditions and extreme ecological fragility primed Port-au-Prince for massive loss of life and destruction when the ground began shaking Haiti After the Earthquake , Paul Farmer

History of Haiti:

History of Haiti Pre- colonialization : Arawak / Taino Indians 1492 : Columbus sets up first colony in New World 1697 : Spain  French the western 1/3 of the island Wealthiest colony in Caribbean (sugar, coffee) Slave importation, deforestation 1791-1804 : slave uprising and independence

History of Haiti:

History of Haiti 1915-1934 : US occupation (Wilson, Roosevelt) “to establish peace and order” 40% income paid to US as “debt repayment” 1957 : Dr Francois Duvalier (Papa Doc) Military controlled election, “president for life” Tortured/ exucution of all against him (30,000) Transferred 15 M USD to his own bank account 1971-1981 : Jean Claude Duvalier (Baby Doc) Protests, lack of food, eventually exiled (just returned) 1991 : Jean Bertrand Aristide elected in democratic vote Spoke for poor, persecuted by military Overthrown by army coup (drug cartel backed) and militant dictator appointed UN trade embargo to force coup members to step down

History of Haiti:

History of Haiti 1994-2004 : Aristade re-instated (Clinton support) Focused on poor (his army was violent to non-supporters) Bush freezes US aid Coup de etat 2004 Backed by US and France Aristade exiled to S. Africa Most Haitians did not agree, protests His party was banned from the 2006 elections 2004 : United Nations (MINUSTAH) To maintain civil order 2006 : Rene Preval Integration with Latin American countries, improving economy 2010 Earthquake

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158/187 countries in the Health Development Index (health, education, income) Lowest in western hemisphere

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WHO country health profile HTN, DM, cancer, heart disease, sickle cell -- Home / folk remedies, spiritual healers --3 doctors, 1 nurse per 10,000 people Global average 13, 28

Infectious Disease in Haiti Reported cases: 2003:

Infectious Disease in Haiti Reported cases: 2003 Typhoid >27,000 HIV / TB ** Malaria >20,000 Dengue 539 Rabies 28 Anthrax 239 Filariasis 141 Mumps Tetanus Helminth N.B.: Representativity of these data varies depending on the number of Cuban professionals in the Departments.

The Children of Haiti:

The Children of Haiti Almost half of Haiti’s population Pre quake 350,000 children lived in ‘orphanages’ Only 50,000 have no living parents 350 registered orphanages many other unregulated ones Balsari et al., NEJM; March 13, 2010

Jan 12, 4:53 pm: 2010:

Jan 12, 4:53 pm: 2010 7.0 magnitude earthquake 220,000 died > 300,000 injured 300,000 homes destroyed Rubble 19 mil. Cubic meters

Early Disaster Response in Haiti: the Israeli Field Hospital Experience:

Early Disaster Response in Haiti: the Israeli Field Hospital Experience Kreiss Y et al Ann Intern Med 2010;153-45-8

Hell in Haiti:

Hell in Haiti Raw field response: January 24, 2010 from Alison Thompson to ‘mum and dad’ re ‘Hell in Haiti’ Hi mum and dad, I wont be around when they announce my award …I am embedded with 15 doctors in the 82 nd US Airborne. Dante would describe it as hell here. There is no food and water and hundreds are dying daily. The aid is all bottlenecked and not reaching here. The other day I assisted with an amputation (holding them down) while they used a saw to cut a boys leg off with no pain killers.

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Camps are set up on every street corner. Sewage and body stench is everywhere. As I attend to a patient, 30 people crowd around and it is hard to breath. I fainted today as the sewage smell went straight down my throat, I couldn’t sit as sewage is running down the streets. There is much infection, the job is too big, there are no antibiotics... The 82 nd overlooks a 50,000 person refugee camp. Good news the refugees start singing songs at 4 am and line up for food the Army hands out at 8 am (that is if there is any food). The beautiful music draws me to them… There is no agenda but to save lives... Helicopters fly overhead constantly and it feels like Vietnam. Last night 50,000 people sung me to sleep and they sing every night for the world to save them. There is always hope, but she’s not here now

Tent Cities:

Tent Cities At its peak, 1.5 million people were living in camps

Where did the aid go?:

Where did the aid go? The problem with NGOs: Inefficient use of funds Culture of dependence Food, clothes, textiles from abroad kills local production Aid contracts going to foreign (not Haitian owned) companies 12,000 NGOs and still cholera epidemic Farmer P. 2012 Haiti After the Earthquake

Where did the aid go?:

Where did the aid go? The problem with the government Lack of infrastructure Police, courts, banks “We have the tools for prevention and diagnosis and care; what we lack is an equity plan linked to a delivery system” Farmer P, Ivers L: Cholera in Haiti: The Equity Agenda and the Future of Tropical Medicine/ Am J Trop Med Hyg, 86 (1) 2012: 7-8

The emergence of pathogens:

The emergence of pathogens Population growth, shifts, urban migration Poverty, lack of sanitation Advances in new technology/industry Economic development and changes in land use patterns Behavioral problems Travel/commerce Microbial adaptation/change Breakdown of public health infrastructure Institute of Medicine

The Cholera epidemic:

The Cholera epidemic 28 y/o mentally ill man from Mirebalais Small town, 35 km from PaP Would bath and drink from Latem River Died within 24 hours of symptoms 2 people who prepared body for wake developed severe diarrhea First hospitalization 4 days later 600, 000 cases (10M pop) 6400 deaths Organism shed in stool days --> weeks Dose dependant disease

The Cholera Epidemic:

The Cholera Epidemic Globalization “Increasing interconnectedness between societies such that the events in one part of the world increasingly have effects on people and societies far away” Nepali strain (faulty sanitatian in UN base camp) New paved road from Merbalais to PaP 90,000 people moved to Center Dept from PaP Many moved back and forth looking for food, work, relief mostly located in PaP Small rural town with poor infrastructure, poor sanitation practices, new road and increased movement Ivers, LC, Walton, DA: The First Case of Cholera in Haiti: Lessons for Global Health Am J Trop Med Hyg 86 (1) 2012: 36-8

Cholera: Preventable and potentially treatable:

Cholera: Preventable and potentially treatable Prevention: Of Illness: Clean water (boiling, SODIS), personal hygiene and food handling practice (eg cooking food, street roadside selling), vaccine? Of transmission: Isolation precautions, including in households (keep fecal matter in toilets, clean bedding, funerals) MUCH EASIER SAID THAN DONE Management (aggressive rehydration): strain is sensitive to doxycycline, and azithromycin

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….expectations are lowered for diseases that disproportionately afflict poor people. Investment in long term public sector water and sanitation systems have stalled or failed to keep up with demand. Safe, effective and affordable oral vaccines exist, and yet remain unavailable in Haiti, as do, too often, timely diagnosis and care. When some suggested integrating vaccination into the response, public health officials were quick to note that vaccination was not cost effective (as if “cost” were fixed in stone, and “effectiveness” well understood). Some dismissed the idea as a “trial” as if the vaccine had not been tested…others wrote off the feasibility of vaccination during the chaos of a post earthquake epidemic…. Paul Farmer

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WHO targets (Haiti 2007) 70% detection ( 49%) Dx: smear microscopy 85% DOTS treatment success ( 70%) Barriers 30% HIV coinfection Stigmata, cultural barriers 1998: Programme National de Lutte Contre la Tuberculose Little political and financial support 2008: USAID 1.3 m to PNLT TB rates in Haiti

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Trend of TB incidence, prevalence and mortality

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HIV / AIDS Estimates in Haiti

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INH resistance: 11.6% MDR Prevalence in Haiti: May be higher

Foreign Aid for TB / HIV:

Foreign Aid for TB / HIV Partners in Heath USAID WHO PEPFAR

Relief Efforts: Partners in Health:

Relief Efforts: Partners in Health Founded by Paul Farmer in 1987 The largest health care provider in rural Haiti Staffed by 4000 people mostly Haitians Has brought HIV and TB under control in the province called the central plateau Kidder T. NEJM March 4, 2010

Relief Efforts: USAID and TB:

Relief Efforts: USAID and TB

US Presidents Emergency Program for AIDS Relief (PEPFAR):

US Presidents Emergency Program for AIDS Relief (PEPFAR) Landmark US achievement in global health Initially focused on 15 countries mostly in Africa. Reauthorized in 2008 for 39 billion and now supports HIV all over the world Over the first 5 years supported antiretroviral treatment for 2 million people, prevent 7 million infections, provide care for orphans and vulnerable children for 10 million individuals Supplies ARV’s to Haiti

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Relief Efforts: USAID and HIV

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WHO TB finance profile Total National TB Program (NTP) budget, available funding and expenditure 1. WHO funds directly to govt programs have not changed 2. Grant funding has  -Govt funds are now a primary source of TB budget 3. Majority of WHO funding is now directed at DOT therapy

HUEH TB Center:

Earthquake response Quarentine ward (tent) “I didn’t want to start TB meds without a plan for 6 months” Meds, food, oxygen, phones, transportation, home phone calls Patient adherence network 1500 patients so far 500 outpatients / month All entered into registry for country Only place for critically ill TB patients to be hospitalized Many without TB or comorbidities HUEH TB Center

HUEH TB center:

HUEH TB center 20 nurses Medications PEPFAR: HIV meds WHO: TB meds Donations: others 501 c 3 status $ 75,000 dollars in 2011 100-1000 dollars per day Oxygen

What you can do:

What you can do GO Before committing to a relief effort you should have an understanding of what it will entail security, living conditions, weather Emotional challenges are important to consider Time to spend, many organizations require a long commitment Donate USAID PEPFAR UNICEF WHO


Conclusion Public health in Haiti needs to be built from the ground up Improving education, sanitation and providing access to clean water and food are key to eradicating infectious disease and improving mortality in Haiti Haiti needs our help. Support wisely Anyone can make a difference

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Thank You

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