Anand is a senior at Stanford, studying biology and writing an honors thesis in International Securities Studies. He is originally from Houston, Texas, and aspires to become an infectious disease doctor working in the developing world. He has extensive international health experience, most recently working with community health workers in the rural Guatemalan highlands to implement a survey regarding conceptions of prenatal care. He also partook in a service-learning trip studying social determinants of health in Oaxaca Mexico, and spent a summer devising and teaching an interactive health curriculum in India through Project Dosti.

Patient Report: We have now seen approximately 150 cholera patients, and currently have 18 in the ward. We reached a peak of patients early this week, with up to 40 or 45 patients in the ward at one time (note that the graph shows date of admission through Thursday, and does not include patients currently in the ward; click on the image for better resolution). The atmosphere at the clinic is significantly calmer than earlier this week, but it is highly likely that we will see a rise in patient numbers again. The biggest problem continues to be that people in remote areas are not drinking ORS before and during their journey to the clinic. For example, one pastor reported that 14 people died over the last few days in his community, several of them on the way to the hospital. We are working with local pastors and other groups to spread the homemade ORS recipe and educational messages far and wide. Theoretically, there is already a government-run health center in the hardest-hit area (Bokbanik), but the information we are hearing about deaths suggests that it is not functioning. World Vision may have a tent coming that could be used to open a treatment center there, but the problem would be staffing such a center.

Supplies: We received 4000 packets of ORS and 1500 liters of Ringer's Lactate IV fluid on Friday, thanks to the help of Fr. O'Hare and Tom Brock, two wonderful contacts we have right across the Dominican border. Thank you to everyone who has donated to the clinic, we appreciate your support and are dedicated to maintaining an adequate stock of supplies at all times. We have designated a room in the clinic as the 'Cholera Depot' and it now contains all of the supplies needed for treatment, employee protection and cleaning. We have also been receiving materials from other local organizations, such as the Red Cross and World Vision; in turn, World Vision has been distributing our soap and hygiene packs during their education sessions.

Cholera has now taken a firm grasp on Thomassique and our clinic. We have seen over a hundred cholera patients, and have had twelve deaths.

It is hard to express the conditions here, which is possibly why we have not been updating the blog (combined with the fact that we are beyond busy handling this crisis). The scene in the cholera ward is unsettling: Cots fill the room, strewn with bodies showing varying levels of alertness. Cholera is not a pretty disease, and the massive quantities of diarrhea and vomit mixed with Clorox give the room a highly distinct and foul scent. On several occasions the ward has been at or above capacity, with two or three children sharing a single bed, and hardly any space for nurses and doctors to move between the approximately thirty-five patients. The sight of coffins and the sound of grieving families have become all too common.

The good news is that cholera is not a particularly complicated disease to treat. As long as the patient is kept hydrated using Oral Rehydration Solution (ORS) and/or IV fluids, they can typically recover. One of the bad pieces of news though (which contributes to the high death rate) is that many of our patients are coming from great distances and are not beginning rehydration at home. For example, the towns along the Artibonite River, such as Bokbanik and Nan Kwa, are a four-hour walk away; patients that manage to get to the clinic without dying on the way are so weak by the time they arrive that recovery is very difficult. Therefore, along with the importance of preventive precautions (treating water, washing hands, cooking food), a main educational message we are promoting is to prepare and begin drinking ORS at home, using a simple recipe of sugar and salt that we distribute on slips of paper.

Producing an effective cholera response is also influenced by the cultural beliefs and practices that provide the backdrop for this epidemic. Voodoo, though not particularly visible on a daily basis, is an important part of many people's belief systems. We do not purport to serve as experts on Voodoo, but we can relay to you some interesting things that community members have told us over the last week: They explained how some Voodoo priests have been spreading the idea that cholera is the result of a 'powder' (powders are a central component of Voodooism) and claiming that they can cure the condition. Therefore, people seek care from Voodoo priests for cholera, rather than accessing the actual care they need (rehydration). Many rumors have been circulating about a public incident in the market last week: In one version we have heard, two men hired by a Voodoo priest 'infected' a woman with cholera using a powder, and the woman was subsequently 'cured' by the Voodoo priest as a publicity stunt. However, several observers caught on to the plot, and the two men were attacked. This is not a simple situation of Western medicine vs. Voodoo; how can the two become more compatible to improve health outcomes?

Another conception we have encountered is the frustrating belief that death from cholera (and other diseases) is simply inevitable. Though it is true that some people cannot be saved, the vast majority of people should be able to survive cholera if they receive proper treatment. We have even seen this attitude among some staff members at the clinic, who seem resigned to the idea that many of their patients will die. Perhaps this conception is the result of experience; premature death is a much more familiar aspect of life in Thomassique than in the United States. But should not all people, Haitians and Americans alike, be able to expect life rather than death in largely-treatable cases like cholera? How can people gain the power and voice to expect and demand quality living conditions and medical care?

In times like these, it is also important to recognize the positive developments. One bright point is the newly formed Thomassique Cholera Committee, which brings together Thomassique's leaders in health, education, religion (including Voodoo), sanitation, water, police and government (though the local government is extremely evasive and goes to great lengths to avoid any involvement in cholera efforts) to address the challenges facing the community. This committee had its second meeting yesterday and will meet again tomorrow. Though we took the initial steps to form the committee, we are encouraged to see that the community itself is now taking more ownership over this committee and working to find solutions to problems such as mass-purification of water and the burial of corpses. One of our hopes for the committee is that collaboration with other organizations can support and expand our community education activities. Education is an absolutely critical component of handling this epidemic and reducing deaths. In the clinic, we provide detailed, one-on-one cholera education for the highly-susceptible families of patients, and our doctors continue to reach large audience through churches and the radio, but the demands of patient care necessitate that we prioritize the essential medical function of the clinic. Therefore, collaboration with other organizations is vital to mount a sufficiently aggressive education campaign in areas such as the previously mentioned towns along the Artibonite.

As we sign off, we want to highlight another bright aspect of the previous week, which was having Dr. Charlie Dyer at the clinic. It was wonderful to have him here, and we want to thank him sincerely for providing his excellent medical skills and advice. We look forward to the arrival of another team of American medical professionals on Monday.