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International Society for Infectious Diseases
Date: Fri 5 Feb 2010
Source: The New York Times [edited]
At a fly-infested clinic hastily erected alongside the rubble of the
only tuberculosis sanatorium in this country, Pierre-Louis Monfort is
a lonely man in a crowded room. Haiti has the highest tuberculosis
rate in the Americas, and health experts say it is about to
drastically increase. But amid the ramshackle remains of the hospital
where the country's most infected patients used to live, Mr Monfort
runs the clinic alone, facing a vastness of unmet need that is as
clear as the desperation on the faces around the room.
"I'm drowning," said Mr Monfort, 52, flanked by a line of people
waiting for pills as he emptied a bedpan full of blood. All of the
hospital's 50 other nurses and 20 doctors died in the earthquake or
have refused to return to work out of fear for the building's safety
or preoccupation with their own problems, he said. Mr Monfort joked
that the earthquake had earned him a promotion from a staff nurse at
the sanatorium to its new executive director.
In normal times, Haiti sees about 30 000 new cases of tuberculosis
each year. Among infectious diseases, it is the country's 2nd most
common killer, after AIDS, according to the World Health Organization.
The situation has gone from bad to worse because the earthquake set
off a dangerous diaspora. Most of the sanatorium's several hundred
surviving patients fled and are now living in the densely packed tent
cities where experts say they are probably spreading the disease. Most
of these patients have also stopped taking their daily regimen of
pills, thereby heightening the chance that there will be an outbreak
of a strain resistant to treatment,experts say.
At the city's General Hospital, Dr Megan Coffee said, "This right here
is what is going to be devastating in 6 months," and she pointed to
several tuberculosis patients thought to have a resistant strain of
the disease who were quarantined in a fenced-off blue tent. "Someone
needs to go and help Monfort, or we are all going to be in big trouble."
A further complication is that definitively diagnosing tuberculosis
takes weeks. So doctors are instead left to rely on conspicuous
symptoms like night sweats, severe coughing and weight loss. "But look
around," Dr Coffee said. "Everyone is thin, everyone is coughing from
the dust and everyone is sweating from the heat."
Dr Richar D'Meza, the coordinator for tuberculosis for the Haitian
Ministry of Health, said his office and the World Health Organization
had begun stockpiling tuberculosis medicines. "We are very concerned
about a resistant strain, but we are also getting ready," he said,
adding that he is assembling medical teams to begin entering tent
camps to survey for the disease. "This will begin soon," he said. "We
will get help to these people soon."
For Mr Monfort, it is not soon enough. He scavenges the rubble daily
for medicines and needles. He sterilizes needles using bleach and then
reuses the bleach to clean the floors. In his cramped clinic, 8 of the
sickest and most contagious patients lay on brown- and red-stained
beds. He said he had lost count of how many more were sleeping in
other pockets alongside the hospital. Hundreds come daily to pick up
medicine. Outside the clinic, the air is thick with the sickening
smell of rotting bodies. Occasionally a breeze carried a waft of char
from small cooking fires nearby, offering a respite from the stench
and the flies.
Mr Monfort began to explain that his biggest problem was a lack of
food. Suddenly a huge crash shook the clinic. A patient screamed.
Everyone stood still, eyes darting. A man outside yelled that another
section of the hospital had collapsed. People looking for materials to
build huts had pulled wood pilings from a section of the hospital
roof, which then fell as the scavengers leapt to safety, the man said.
Mr Monfort looked to the ground silently as if the weight of his
lonely responsibility had just come crashing down. "These people are
dying and in pain here," he said. "And no one seems to care."
The dire scene at Mr Monfort's clinic speaks to a larger concern: as
hospitals and medical staff are overrun by people with acute
conditions, patients who were previously getting treatment for cancer,
HIV, and other chronic or infectious diseases have been pushed aside
and no longer have access to care.
At the Champ de Mars, [a man] sat on a curb, one shoe missing, his
blue polo shirt torn, his head cupped in his hands. "I have TB, and I
am also supposed to get dialysis every other day," he said, explaining
that he was a doctor's assistant before the earthquake and meticulous
about his treatments. "I have not had dialysis in 3 weeks, and I feel
my blood is rotting from inside." Waving his hand over a sea of tents
and tarpaulins, he added, "It is like this country."
Back at the clinic, Mr Monfort struggled to fix an IV that had missed
the vein and was painfully pumping fluids under a patient's skin.
Another ghost of a man hobbled to the doorway on crutches, moaning for
help. "Please wait, please wait," Mr Monfort said in a tense whisper.
The biggest source of stress, Mr Monfort said, is that his 3 children
and wife are living on the street because the earthquake destroyed
their home. His wife begs him daily to stay with them. Instead, unpaid
and without a mask or gloves to wear, he walks to the sanatorium each
day at 6 am and stays until 8 p.m. when most of the patients drift to
sleep. "Why don't you just leave us to die?" asked [a patient]. Mr.
Monfort looked offended by the notion. But he did not answer and the
question seemed to stick with him.
The ancient Greek playwright Aeschylus once wrote that there was a
type of suffering so intense that, even in our sleep, it bores into
the heart until eventually, "in our own despair, against our will," it
taps into a terrible wisdom. After several minutes in silence, Mr
Monfort spoke of that wisdom. He referred to it as a "strange hope"
that had sprung from the suffering of his patients and the loss and
abandonment of his fellow staff members. "These people here are dying,
but they keep me alive," he said. "I know they are hurting more than
me and not complaining. So," he said, handing another walk-in patient
a packet of pills, "I must continue."
[Byline: Ian Urbina]
ProMED-mail Rapporteur Mary Marshall
[Photo of a hospital in Haiti today
[Following the devastation caused by the earthquake on 12 Jan 2010
that centered about 10 miles (15 kilometers) southwest of Haiti's
capital, Port-au-Prince, the interruption of treatment for chronic
diseases (such as, TB, HIV, diabetes, end-stage renal disease,
hypertension) and loss of patient follow-up were likely to cause
significant problems. However, even before the earthquake,
tuberculosis and HIV infection were major public health problems in
Haiti. The following is extracted from USAID report on tuberculosis in
Haiti available at
Haiti has the highest per capita tuberculosis (TB) burden in the Latin
America and Caribbean region. After HIV/AIDS, TB is the country's
greatest infectious cause of mortality in both youth and adults (6814
deaths in 2007). Haiti is among the 8 priority countries identified by
the Pan American Health Organization (PAHO) for TB control in the
region. According to the World Health Organization's (WHO's) 2009
Global Tuberculosis Control Report, Haiti had and estimated 29 333 new
TB cases in 2007 [incidence of 306 cases per 100 000 population].
...The DOTS [that is, directly observed therapy, the internationally
recommended strategy for TB case management] treatment success rate
was 82 percent in 2006, a slight increase from 78 percent in 2003.
DOTS coverage fell to 70 percent in 2007 compared with 91 percent in
2006, though it was still above the 2005 level of 55 percent. However,
in some highly dense metropolitan settings, such as areas in
Port-au-Prince, coverage can be as low as 13 percent. ...
Since 1998, the Ministry of Health (MOH) has supported the DOTS
strategy in order to strengthen the national TB program, the Programme
National de Lutte contre la Tuberculose (PNLT -- National Prtogram of
the Fight Against TB), and approved national guidelines and norms for
TB control in 2002. However, the program lacked political and
financial support from the government, and there is a lack of skilled
technical human resources at the central level of the PNLT. A major
problem in combating TB is that co-infection with HIV can run as high
as 30 percent in some urban areas. Strong stigma and cultural barriers
attached to TB also interfere with case detection and adherence to
treatment. Multidrug-resistant (MDR) TB has increased from 1.4 percent
in 2004 to 1.8 percent in 2007 [among new cases]. ...
WHO has issued a public health risk assessment to facilitate the
response of those aiding the earthquake-affected population in Haiti
Haiti and the Dominican Republic occupy the Caribbean island of
Hispaniola in the Greater Antillean archipelago. A
HealthMap/ProMED-mail interactive map of Hispaniola can be found at
Meningococcemia, fatal - Dominican Republic ex Haiti 20100206.0401
Tuberculosis, XXDR - USA: FL ex Peru 20091230.4387
Tuberculosis, MDR - China 20090114.0151
Tuberculosis, XDR - Austria ex Romania 20080803.2373
Tuberculosis, MDR, XDR - Peru 20080412.1337
Tuberculosis, XDR - Namibia 20080403.1231
Tuberculosis, XDR - UK (Scotland) ex Somalia 20080322.1094
Tuberculosis, MDR, XDR - Worldwide: WHO 20080228.0813
Tuberculosis, MDR - South Africa 20080208.0521
Tuberculosis, MDR - Papua New Guinea 20080206.0478
Tuberculosis, XDR - Botswana, South Africa 20080118.0222
Tuberculosis, XDR, MDR: genome sequences 20071122.3780
Tuberculosis - Uganda (02): MDR, susp. RFI 20071004.3284
Tuberculosis, XDR - South Africa (11): fugitives 20071002.3251
Tuberculosis, XDR - worldwide (02) 20070623.2034
Tuberculosis, XDR, airplane exposure - multicountry (USA, France,
Canada, Czech Rep.) 20070529.1738
Tuberculosis, XDR, 2003-2006 - Europe (Germany, Italy) 20070403.1132
Tuberculosis, XDR, 1993-2006 - USA 20070322.1005
Tuberculosis, XDR, 1991-2003 - Spain 20070302.0738
Tuberculosis, XDR - worldwide 20070205.0456
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