Date: Fri 5 Feb 2010

Source: The New York Times [edited]

<http://www.nytimes.com/2010/02/06/world/americas/06tuberculosis.html?hp>

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]
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[Photo of a hospital in Haiti today
<http://www.donation4charity.org/blog/wp-content/uploads/haiti-earthquake.jpg> - ProMed Mod.JW]

[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 <http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/lac/haiti_profile.html>:

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 available at <http://www.who.int/diseasecontrol_emergencies/publications/haiti_earthquake_20100118.pdf>.

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 <http://healthmap.org/r/00Yo>. - ProMed Mod.ML]