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Public Health in Haiti — Challenges and Progress Scott F The NEW ENGLAND JOURNAL of MEDICINE Perspective Public Health in Haiti — Challenges and Progress Scott F. Dowell, M.D., M.P.H., Jordan W. Tappero, M.D., M.P.H., and Thomas R. Frieden, M.D., M.P.H. t has been a year since the earthquake of January The earthquake destroyed the 12, 2010, devastated the poorest country in the building housing the Haitian Min- I istry of Public Health and Popu- Western Hemisphere. Piles of rubble remaining lation (MSPP) (see photo). Meet- throughout the Haitian capital and a devastating ing initially in a cramped set of rooms above a generator retailer, cholera epidemic provide stark re- tality before the earthquake was a small group of surviving Haitian minders of the challenges that already high at 171 per 1000, public health leaders has worked arise in the absence of the infra- women died in childbirth at an to build public health systems structure and institutions that unacceptably high rate, and Haiti that are better than before. most of us take for granted. was a hot spot for diseases such Their efforts have been buoyed by Strong public health systems are as malaria, filariasis, and rabies generous support from around the essential for maintaining and im- that were controlled long ago in world. The Pan American Health proving health and well-being. most other countries in the Amer- Organization has provided lead- Fortunately, progress has been icas. Underpinning these chal- made in public health during the lenges was the fact that public past year, which should encour- health work was underfunded age those who hoped that tack- and understaffed. Routine cover- ling the challenges of an unprece- age for measles–rubella vaccina- dented disaster could lead to tion was only 58%, national sur- long-term improvements in the veillance systems were unable to health of the Haitian people. provide the most rudimentary The earthquake laid waste to data for decision making, and what was arguably already the the national laboratory processed Collapsed headquarters of the Haitian hemisphere’s weakest public an average of only four bacteriol- Ministry of Public Health and Population, health system. Childhood mor- ogy specimens per month. Port-au-Prince, Haiti. 10.1056/nejmp1100118 nejm.org 1 The New England Journal of Medicine Downloaded from nejm.org on January 10, 2011. For personal use only. No other uses without permission. From the NEJM Archive. Copyright (c) 2010 Massachusetts Medical Society. All rights reserved. PERSPECTIVE public health in haiti — challenges and progress ership for hundreds of interna- the number of patients receiving response teams from Port-au- tional donors and institutions. As therapy at sites supported by the Prince were on site investigating part of a U.S.-government-wide President’s Emergency Plan for the earliest reports of severe effort to assist with the public AIDS Relief was back to 94% of watery diarrhea from Saint-Marc health reconstruction effort, the pre-earthquake levels. By April 1, and Mirebalais on the day the Centers for Disease Control and 67% of patients on pre-earthquake reports came in. Technicians at Prevention has deployed more tuberculosis registries in the Port- the national laboratory identi- than 300 technical experts to au-Prince area were again receiv- fied the pathogen through rapid Haiti over the past year, and the ing medication (as many as 30% testing of stool specimens with- U.S. Agency for International De- may have died in the earthquake in hours and confirmed the re- velopment has provided addition- or moved away). sults by microbiologic culture al experts and tens of millions Nevertheless, long-standing within 2 days. They also charac- of dollars. public health problems remain. terized the antimicrobial suscep- The foundations of a function- Efforts to improve roads to re- tibility of the organism, allowing ing public health system are be- duce traffic injuries, provide life- the MSPP to issue treatment rec- ginning to coalesce. A national saving community and obstetri- ommendations to clinicians, and surveillance system and a camp- cal services, and repair, upgrade, they have confirmed the epidem- based system serving the inter- ic’s spread to new departments nally displaced population are re- and monitored for changes in porting disease-specific data that antimicrobial susceptibility. have been used to assess reports A nationwide surveillance sys- of diphtheria and typhoid out- tem specific for cholera has breaks and to monitor for in- tracked the epidemic with nearly creases in disease incidence war- daily reporting, allowing resourc- ranting field investigations.1 The es to be directed where they are national laboratory, one of the most needed. The response has few public health structures in been adjusted as new information the capital to survive the earth- Cholera Treatment Center, Artibonite has come in from case–control Department, Haiti. quake, was equipped with rapid studies, mortality surveys, and diagnostic tests for pathogens or build safe water and sanita- rapid assessments of the com- with a propensity to cause out- tion systems are just beginning modity supply chain. With train- breaks, and its technicians were to be scaled up. For example, in ing and increasing experience of retrained to conduct confirmatory 2008, only 63% of Haitians had clinicians and improvements in laboratory tests for surveillance access to adequate water sources the supply chain, mortality in for reportable diseases. Clinicians, and 17% to improved sanitation health care facilities in Artibo- recognizing the laboratory’s ca- facilities,2 so fecal contamination nite, the first department affect- pacity, have submitted specimens of drinking water was common, ed (see photo), had fallen to the — an average of 181 bacteriology and diarrheal disease was a lead- international standard of 1% by tests per month, to confirm diag- ing cause of childhood deaths. December 2010. New information noses of typhoid, diphtheria, me- When cholera struck in mid- about the use of antimicrobial ningococcal meningitis, and lepto- October, it moved easily from agents and vaccine availability spirosis. sewage to drinking water sources has prompted a recommenda- The control of chronic infec- and spread within 2 months to all tion that antibiotics be given to tious diseases such as AIDS and departments (provinces) of the patients with moderate-to-severe tuberculosis requires meticulous country, sickening more than cholera, including all hospitalized follow-up of patients to prevent 170,000 people and killing more patients,4 and a strategic discus- treatment lapses that can pro- than 3600 by December 31, 2010.3 sion is under way to explore the mote antimicrobial resistance. Almost unprecedented in its fe- utilization and evaluation of a After the earthquake, there were rocity, the epidemic has tested limited global supply of cholera intense efforts to locate patients the recovering public health sys- vaccine. who had been receiving antiretro- tem — which has, for the most Most important for the cholera viral therapy, and by May 2010 part, performed admirably. Field response and for the future of 2 10.1056/nejmp1100118 nejm.org The New England Journal of Medicine Downloaded from nejm.org on January 10, 2011. For personal use only. No other uses without permission. From the NEJM Archive. Copyright (c) 2010 Massachusetts Medical Society. All rights reserved. PERSPECTIVE public health in haiti — challenges and progress public health in Haiti, the MSPP break, much remains to be done. Disclosure forms provided by the au- thors are available with the full text of this has exerted consistent leadership. Cholera will ultimately be con- article at NEJM.org. For example, the ministry ini- trolled when municipal and rural tially declined free donations of water systems separate drinking Dr. Frieden is the director of the Centers for rapid diagnostic tests for malaria, water from sewage. Other coun- Disease Control and Prevention, Atlanta, out of concern regarding sus- tries in the Americas accom- where Dr. Dowell is the director of the Divi- sion of Global Disease Detection and Emer- tainability in Haiti and potential plished this task after the 1991 gency Response and Dr. Tappero is the di- diversion of resources from stan- cholera epidemic. Although there rector of the Health Systems Reconstruction dard smear microscopy. After re- are nonbudgetary challenges, de- Office. viewing the Haitian National Pub- velopment of a safe water and This article (10.1056/NEJMp1100118) was lic Health Laboratory’s controlled sewage system in Haiti is well published on January 10, 2011, at NEJM.org. comparisons between commer- within the range of resources cially available rapid tests and provided by post-earthquake com- 1. Rapid establishment of an internally dis- microscopy, the MSPP leadership mitments of international assis- placed persons disease surveillance system changed its policy, enabling wide- tance. Plans have already been after an earthquake — Haiti, 2010. MMWR Morb Mortal Wkly Rep 2010;59:939-45. spread availability of rapid tests developed, and donors found, for 2. WHO/UNICEF Joint Monitoring Pro- in peripheral sites and continued campaigns to eliminate filariasis, gramme (JMP) for Water Supply and Sanita- use of microscopy in reference control canine rabies, and lay tion. Progress on sanitation and drinking 5 water: 2010 update. (http://www.wssinfo hospitals. Firm leadership that the groundwork for malaria con- .org/fileadmin/user_upload/resources/ requires and implements data- trol in coming years. Political 1278061137-JMP_report_2010_en.pdf.) driven decision making is unusual stability will be essential, and a 3. Données preliminaires. Port-au-Prince: Republic of Haiti, 2011. (http://mspp.gouv even for some countries with re- central challenge will be to train .ht/site/downloads/Rapport%20journalier% sources far exceeding Haiti’s. and employ an adequate public 20MSPP%20du%2001%20janvier%202011 Much credit is due to the health workforce to carry on the .pdf.) 4. Update on cholera — Haiti, Dominican MSPP for its effective use of re- work of the small cadre of pub- Republic, and Florida, 2010.
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