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An Ounce of Prevention: Vaccination Campaign

03/15/2010

MEDICC's Conner Gorry on Cuban-trained doctors in Haiti

March 13

An Ounce of Prevetion: Vaccination Campaign in Port-au-Prince

"At the beginning we were vaccinating around 250 people a day, but it´s tapered off to 70 or so," Raysoly Yacob Flores, a Salvadoran nurse trained in Cuba tells me as we set out for the displaced persons camp where the Henry Reeve Contingent will vaccinate all comers. I´ll admit I´m slightly disappointed that I´m catching the tail end of the action. I´ve heard a lot about the massive vaccinations carried out by the Cubans and their ELAM-trained colleagues in the weeks immediately following the earthquake, when multiple teams fanned out through the sprawling encampments that hundreds of thousands of Haitians now call "home."

But my disappointment is premature: instead of tagging along with Raysoly or the other team to areas where vaccinations have already been initiated, I´m accompanying Cuban nurse (and head of the Port-au-Prince vaccination effort) Esmeris Atiñol to a camp where no one has yet been vaccinated. It should be interesting to watch the team inaugurate a new location. A recent report filed on the blog Haiti: Operational Biosurveillance by Dr. James Wilson describes health actions, including vaccinations, at a displaced persons camp in Petionville, "When word spread about sore arms and the occasional post-vaccination fever, very few showed up for the second day of vaccinations. The Red Cross left the area, leaving a best estimate of only 20 percent of the population vaccinated." Given the limited experience many Haitians have with health care in general and vaccinations specifically, I'm especially anxious to see the community's reaction to this basic preventative health measure.
Delmas 15 (as it's called by the Cubans) is formally known as La Place Dame Carrefour Aeroport in the post-quake language of Port-au-Prince. It's a postage stamp plaza at the city's major intersection of Rte de Delmas and Blvd T. Louverture where 1,060 people live in donated tents pitched on bare, blazing hot concrete.

Before we're even beyond the first line of dust-covered tents, nurse Esmeris is chatting up mothers in lyrical Creole, asking if they've been vaccinated. Though she hails from the remote Cuban municipality of Tercer Frente in Santiago de Cuba, Esmeris' fore bearers were Haitian and she has been working in Haiti as part of Cuba's Integral Health Program for the past year. She traverses the divide between Spanish and Creole easily and I can see the relief etched on the mothers´ faces as they converse in their native tongue. They follow this Cuban nurse to the vaccination post eagerly, small children in tow.

"Post" is an exaggeration. Each time the Henry Reeve Contingent initiates vaccinations in a new location, they have to find an accessible (and hopefully shady/rain-proof) location to set up. Luckily, La Place Dame is anchored by a pastel-colored gazebo that overlooks the fenced in camp. The columns are cracked and crumbling from the quake, the rebar laid bare like an open wound, but no matter: its visibility and staircases at either end provide natural patient flow, plus it's refreshingly sun-free. From nowhere, a pair of clean cut youths, badges of the camp's organizing committee dangling from their necks, appear carrying two chairs - each with three legs. Seems everything in Haiti these days is a balancing act. Once a table materializes (again I'm amazed at Haitian solidarity - that people so destitute and physically and emotionally battered still have the energy to share both among themselves and with us), the team is set to go to work.

The Henry Reeve Disaster Medicine Contingent currently offers three vaccines: a trivalent DPT (diphtheria, pertussis, and tetanus) for babies one-and-a-half to eight months old; a DPT/measles/mumps combination, paired with Retinol (Vitamin A) for children nine months to seven years old; and a diphtheria-tetanus duo for everyone eight and older. Once again, the supplies used by the Cuban team represent a kaleidoscope of international health cooperation with vaccines from India, Canada and the WHO Essential Medicines Program; disposable syringes from the United Arab Emirates; and nifty collapsible biohazard safety boxes from Finland.

Conducting an effective vaccination campaign in conditions like those in post-quake Haiti is extraordinarily complex. There are issues related to the vaccines themselves (primarily the maintenance of the cold chain and safe disposal of hazardous bio waste), but also to the particular health culture and context of the host country. And Haiti is as intricate and layered as they come. Fortunately, scores of Cuban health professionals - doctors, nurses, specialists and technicians - in Port-au-Prince have been serving in Haiti for a year or more as part of Cuba's Comprehensive Health Program. Veterans on these shores, they exhibit a rare affinity for this astonishingly foreign culture. Nurse Esmeris and several of her colleagues working on the capital's vaccination campaign were posted in Gonaïves before the earthquake. There, they vaccinated more than 40,000 people between October and Jan. 12, meeting the country's obligation made to the Pan American Health Organization as part of the national immunization program.

Given all this back story, I shouldn't be surprised when the trickle of people to be vaccinated turns into a stream and eventually a torrent of the Place de Dame community. A teacher lines up her grade-school class for the free vaccines (school still hasn't started, but this camp is well organized, with young people especially assuming whatever responsibilities required, like this teacher caring for her out-of-school students), and there are grannies and well-dressed men too - even the camp tough guys are rolling up their sleeves, anticipating the jab with a squint and a smile.

But it's the work of Elvire Constant that really ratchets up the work flow.

Once she happens on the scene, people start arriving in droves, from other camps and the street even, belying Raysoly's 70 or so prediction. A strong, wiry woman with the intricate braids favored by many Haitian women, Elvire is president of the organizing committee of a nearby camp where the Cuban teams previously worked. "Thanks to her, we vaccinated that entire camp," Esmeris tells me. I can see why there has been such great acceptance. Elvire arrives, picks up a bullhorn, presses ‘talk' and begins singing in a lovely, lilting Creole about the ‘free vaccinations, available here all morning, given by Cuban doctors.' She threads her way between tents and out to the street calling vendors, office workers, and passers-by to get vaccinated, like some muezzin of better health.

Each person receives a yellow vaccination card with the seal of the Haitian Ministry of Public Health indicating their name, age and vaccine administered (and schedule of additional shots in the case of DPT). Everything is in Creole and explained by the Cubans with the help of Haitian volunteers who lend a hand wherever the medical teams are found. Today, Jackson Pierre Louis and Gladimir Alexime, members of the Place de Dame camp organizing committee, appear unsolicited to help fill out the yellow cards and explain the procedure. Given the language barrier and the novelty of the concept of vaccination (several people from Place de Dame line up for a second vaccination for demonstration), I ask Esmeris how the program is administered. "We keep detailed records of where we've been and how many people of each age group we've vaccinated. In two months' time, we'll re-visit each area to administer second doses for those requiring them. After that the Haitian health system provides the booster shots." I raise an eyebrow at this last part, given that the public health system is in such disarray. She tells me that's the ideal. Still, there is hope. The Haitian government and the Bolivarian Alliance for the People of the Americas (ALBA) presented a plan for reconstructing the Haitian health system to the World Health Organization last week. In today's Haiti, it's imperative that such ideals get translated into realities.

In the meantime, the work of the Cuban teams takes on increasing urgency as the rainy season approaches, says Dr. Jorge Pérez, director of the hospital at Cuba's Pedro Kourí Institute for Tropical Medicine, Cuba's reference center for infectious diseases. In Haiti to conduct an epidemiological assessment, Dr. Pérez said that vaccination, health promotion and prevention are the most important tasks right now. "It's important to be vigilant. The epidemiological picture is going to get much more complicated when the rains come."

With this in mind, the Cuban health professionals, accompanied by graduates of the Latin American Medical School, and innumerable Haitian volunteers, continue their massive vaccination efforts in post-quake Haiti. And Raysoly's estimate? That day in Place de Dame, the Cuban team vaccinated more than 400 people. And the folks keep on coming. Esmeris just visited my tent to report that they broke a record in another camp where the teams are working. "We vaccinated more than 500 people in Delmas 83 today. We worked from 9 to 2 and had to ask people to come back tomorrow."

March 4

A Day at the Leogâne Field Hospital

Haitian children in Leogâne, waiting for the music to begin. Photo courtesy of MEDICC

Leogâne, Haiti-Leaving Port-au-Prince is an exercise in self-defense: the assault of sights, sounds, smells, and emotions requires closing your eyes, covering your nose, and shielding your heart from Haiti´s brutal realities.

Haitian drivers - jumping dividers on their motorcycles into oncoming traffic or taking blind curves at high speed in colorful, emblematic taptaps - are additional hazards. On the map, Leogâne is only 20 miles west of Port-au-Prince, but pedestrian congestion and car traffic combine with the earthquake-buckled road to make it an hour-long trip. The city of 16,000 isn't far from the epicenter and according to some estimates, 90% of the homes here were damaged in the quake. The widespread destruction caused by the disaster, compounded by the pre-quake health picture has manifested in a wide array of health problems, making it a logical location for a Henry Reeve Emergency Medical Contingent field hospital.

Staffed by Cuban doctors and graduates of Havana's Latin American Medical School (ELAM) from eight countries, plus five Haitian ELAM students who serve as translators and health promoters, the hospital in Leogâne offers free pediatric, OB-GYN, internal medicine and other services in individual tents divided by specialty; the most serious cases are referred to the hospital in nearby Saint Croix, while others are admitted to the limited-capacity tent wards on site.

"We had to adjust our strategy to reach more people," says Dr. Wilbert Barral from Potosí, Bolivia, an alumnus who heads up the ELAM component of the Leogâne team. "Many Haitians haven't seen a doctor before or aren't sure how our services work. They think we may charge them, for instance, so we began going into the communities to provide consultations and tell people about the field hospital, explain the services, and that they're free." With this new strategy, the previous daily average of 500 patient visits has increased to 800. Dr Barral told me that pregnant women and children are the priority since they are the ones at highest risk in post-disaster situations. Patients with chronic disease are also a priority. "We're seeing a lot of hyperthyroidism, but not one case of leptospirosis, which is surprising since it's endemic in Haiti," explained ELAM alum Dr. María Esther from Nicaragua.

The doctors at Leogâne emphasize that the emergency health phase has passed-the challenge now is to provide public health services that emphasize disease prevention and health promotion, including vaccination campaigns. Unfortunately, the emergency phase has also passed for the owners of the land where the Henry Reeve field hospital is located. The team has been given 14 days to vacate the grounds to make way for an internationally funded orphanage which has agreed to pay rent. The team of 60 (53 doctors, 5 Haitian ELAM students, 2 support staff) will be distributed throughout the system of 39 health centers, including hospitals, which will be established or rehabilitated in the next phase of the team's commitment to rebuilding the Haitian health system.

But today, the current Leogâne hospital was full of song and dance, thanks to the voices, drums, and infectious energy of Agrupación Vocal Desandann, a musical group of Cubans of Haitian descent. Hailing from Cuba's Camagüey province, the group is part of the Henry Reeve's mental health project, and came to Leogâne to sing traditional Creole songs, accompanied by dancing and lots of audience participation. The group first visited Haiti in 1996 and has been back over half a dozen times since to perform and deepen their ties with their ancestral roots. Many members speak Creole, including director Amelia Díaz and composer Marcel Andrés whose 50th birthday is today. Slowly but surely, as the melodic strains came floating over the camp, community members began gathering. Before long, children were clapping, teens were dancing, and a terribly shy grandmother broke into a gap-toothed ear-to-ear grin. March 4 is the 16-year anniversary of Agrupación Vocal Desandann and what a way to celebrate - in Haiti, bringing smiles and laughter to Haitians.

Feb. 28

Cuban-Trained Doctors Complete Haiti Mission

A team of U.S. doctors trained at Cuba's Latin American Medical School (ELAM) returned home today after serving a month alongside colleagues from Haiti, Cuba, Honduras and elsewhere in the Cuban field hospital at Croix des Bouquets east of Port-au-Prince. The seven women - five New Yorkers and two Californians - belonged to the Henry Reeve Emergency Medical Contingent, a specially trained disaster response team established by Cuba.

"It was awesome doing what we always dreamed of doing and putting what we were taught to the test. I really don't want to go," said Dr. Melissa Mitchell. The young physicians typically worked eight hours day seeing patients with a variety of pathologies including typhoid, malaria, diarrheal illnesses and respiratory infections in the field hospital that sees an average of 500 patients daily. "People start lining up at 4:30 in the morning and are incredibly gracious," said Dr. Mitchell.

One medical student from ELAM, Joanna Mae Souers, is staying in Croix des Bouquets to continue disease prevention efforts with Haitian and other students working in teams headed by ELAM graduates and Cuban doctors.

The Henry Reeve Contingent currently staffs five field hospitals and more than three dozen health installations throughout Haiti including health centers, community hospitals, rehabilitation centers and reference hospitals. The aim is to assist Haiti long-term in building a public health infrastructure to meet the needs of the country's population.

The contingent's Cuban volunteers began arriving in Haiti on Feb. 13, adding to some 370 Cuban doctors already staffing health care facilities across Haiti. Since then, they have been reinforced by ELAM graduates from 23 countries; this is the first time international doctors have joined Cubans in the contingent that has served in Guatemala, Indonesia, Pakistan, China and elsewhere.

MEDICC's Work in Haiti

MEDICC (Medical Education Cooperation with Cuba) is supporting long-term recovery efforts in Haiti by sending material aid to the Cuban-trained Haitian doctors on the front lines in Haiti's public hospitals and clinics. Now 400-strong, they were already on the ground when disaster struck, serving in 120 communities throughout the country, including the hard-hit capital of Port-au-Prince. Working with PAHO and Global Links, essential medicines, medical supplies and equipment are being sent to Haiti's young doctors as they rebuild the country's health-care infrastructure. Read more about MEDICC's work in Haiti at www.medicc.org.

Conner Gorry, senior editor of MEDICC Review, has been on assignment in Haiti since Feb. 27.