TB Notes Newsletter

No. 4, 2010

Temporary TB Advisors to Haiti Responding to the Earthquake

Haiti has the highest incidence of TB in the Western Hemisphere, with a rate of 306/100,000 persons, compared to the rate in the United States of 3.8/100,000 (1, 2). On January 12, 2010, an earthquake in Haiti left an estimated 300,000 people dead and 1.5 million homeless.

I volunteered to go to Haiti to help in whatever capacity was needed. I was honored to be the first CDC employee to go to Haiti to specifically work on TB as an advisor to the Global AIDS Program (GAP)/Haiti and the National TB Control Program. I went twice, for almost a month each time (April 13–May 8, and July 1–31, 2010).

The following staff also volunteered and worked in Haiti for 1-month TB assignments: Dr. Stefan Goldberg, DTBE (May 2–29); Dr. Cheryl Scott, DTBE (May 28–June 24); Dr. Kassim Sidibe, Center for Global Health, TB/HIV (July 12–August 6); and Dr. Miguel Ocana, Division of Global Migration and Quarantine (Sept 24–Oct 29, 2010).

We worked with partners from GAP/Haiti and multiple nongovernmental organizations (NGOs) to provide assistance to TB control (see list of partners). Much of our job was to act as advocates to ensure that TB was on the agenda of public health priorities in Haiti.

Our “Terms of Reference” activities were to

• Determine Haiti’s current TB control needs and structure of tracking TB patients;
• Provide technical assistance to International Child Care (ICC), which is the NGO responsible for maintaining the national TB database;
• Assist in strengthen linkages between the national TB program, GAP, and key NGOs;
• Determine relevance of other NGOs providing clinical care for TB patients;
• Assess ability to perform diagnostic testing;
• Enhance linkages between surveillance and clinical data; and
• Participate in TB control meetings to support ICC, the TB program, and GAP.

Other activities included

• Delivering TB educational materials to medical providers and community members in hospitals, clinics, and camps for internally displaced persons (IDPs); materials included WHO guidelines, MDR TB treatment guidelines, TB treatment cards, a comic book about TB, and a book about cultural literacy in Haiti (available in French, Haitian Creole, and English);
• Visiting NGOs in IDP camps to provide a 1-page sample infection control plan questionnaire to encourage reporting of suspected or former TB cases; and
• Initiating TB partners meetings; the first was attended by 22 partners from 13 organizations in May, many who had met for the first time; TB partner meetings are currently continuing.

Typical day in “Tent City”
We stayed in tents on the U.S. Embassy compound with two or three other CDC employees in each tent (about 20 tents total; usually the CDC team was around 10 people, and 20 or so people from other agencies stayed in Tent City). Everyone was out of the tents no later than 7:00 am because the temperature was already over 90°F outside, and even hotter inside the tent.

Photo by Lauren Lambert: Sleeping accommodations, Tent City, U.S. Embassy compound, Port-au-Prince

A typical day was as follows:

1. Untangle from the mosquito net when the first alarm in the tent chirps.
2. Grab your toothbrush and walk over to the shower by the Embassy (I learned early about the “secret” shower in the air conditioned gym, with hot water – ahhh).
3. Return to the tent momentarily to gather back pack and all provisions for the day: laptop, local cell phone, international blackberry (thanks, Director’s Emergency Operations Center [DEOC]), camera, sunscreen, DEET, and doxycycline (or whichever medication you’re taking to prevent malaria! And don’t forget anything else you might need for the day; did I mention it was hot in the tent?).
4. Eat breakfast with the CDC team at the snack shop inside the U.S. Embassy (usually a foot-long roll with egg and cheese; the other half is often lunch).
5. Then walk to the nearby Embassy building, where you open several extremely heavy doors, and show your CDC identification card (which you are required to wear at all times) to the nice U.S. Marines.

The rest of the day was either spent in the offices at the Embassy (arranging meetings, writing reports, updating contact lists), or traveling to the field to meet with partners at NGOs, hospitals, clinics, or IDP camps.

Internally displaced persons (IDP) camps
On one occasion, Dr. Steven Blount, Director of the Center for Global Health, and I were able to visit several IDP camps with a group from Partners in Health (non-profit health care organization, founded in 1987), including Dr. Paul Farmer’s assistant, Emily Bahnsen. At the camps we saw difficult living conditions, but hard-working people with smiles.

During my first trip, a CDC colleague in Haiti told me that a physician at an IDP camp at the former golf course said many TB cases were being referred from their camp, which is run by an NGO, the Jenkins/Penn Haiti Relief Organization (JP/HRO). Dr. Stefan Goldberg and I arranged a trip to JP/HRO to discuss TB with the medical director, Dr. Justine Crowley, and to deliver TB educational materials, as she requested. While we were speaking with her, Sean Penn, manager of the camp, passed by. Then, the next guy walking past took his sunglasses off and said, “Lauren Lambert?” I was surprised to see a friend from Atlanta, Stephen Duvall, who was volunteering at the camp. My friend introduced us to Penn; Dr. Goldberg and I suggested that Haiti’s national TB program and CDC could assist in conducting a TB training session for the camp volunteers. Penn replied, “That would be great.”

Later that week, I happened to be sitting in the right place at the right time to answer the phone and passed it to someone who could help. Workers at JP/HRO were searching for an antitoxin for a 15-year-old boy who had diphtheria. I gave the phone to someone who passed it to a physician from the Pan American Health Organization (PAHO), Dr. Kam Mung, who happened to have access to the key to the warehouse of medicine.

On May 8, we learned that Penn had mentioned CDC and PAHO favorably during a television interview on CNN with Anderson Cooper and Sanjay Gupta on May 7. A clearly frustrated Penn gave a passionate talk about difficulties finding the diphtheria antitoxin. Sadly, the boy died shortly after the medication was located. A heartbreaking tragedy developed into an opportunity, and vaccinations were provided for the boy’s classmates and family members.

Lessons learned
The following are examples of lessons that can be learned during travel; lessons that, to me, were reinforced in Haiti:

• The more I travel, the less I know.
• People are the same all over the world.
• The definition of “success” may require rethinking; progress is not as quick as one might like.
• It’s a small world (and shrinking).
• The secret is sharing; after the earthquake, displaced families often moved together with their entire community. Neighbors supported each other like family, sharing shelter, food, water, and news.

A note about meals-ready-to-eat (MREs)
I ate several MREs (provided by DEOC) in Haiti, especially in April/May when we had few options. A typical MRE contains an entree, energy bar, crackers, tea or coffee mix, salt and pepper, napkin, two Chicklet gum pieces, spoon or fork, and a chemical heater. Also, some have a tiny Tabasco sauce, and if you’re really lucky, you’ll get Skittles! MREs contain about 2000 calories each, have a 5-year shelf life, require only 2 ounces of water to activate the heater, and are ready in about 5 minutes. MREs once included cigarettes, but they were discontinued in 1972.

Acknowledgments
We are grateful to our Haitian colleagues for the opportunity to work together, and we thank DEOC and the many DTBE employees who assisted our efforts during these assignments.

Thank you to Dr. Andy Vernon for introducing me by e-mail to his friend Dr. Jean (Bill) Pape, director of the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), the world’s first HIV/AIDS organization (founded in 1982). Dr. Pape was kind enough to meet with me, and provided a telling overview of TB activities in Haiti. Specifically, Dr. Pape said more TB training for health care workers is needed, similar to training that was provided to workers about antiretroviral therapy (ART) for persons with HIV/AIDS.

Thank you to Allison Maiuri and others in DTBE’s Communications, Education, and Behavioral Studies Branch for arranging multiple orders of TB educational materials.

Thanks to Michael Iademarco who, before my first trip to Ethiopia for 3 months in 2002, told me, “Don’t be afraid of DEET!”

And thank you to Anthony Degina, Chief Executive Officer of the University of Miami Hospital for donating hundreds of surgical masks to trained physicians to use with symptomatic persons in IDP camps. When asked about contributing masks, he kindly replied, “How many do you need?”

Key TB partners:

• The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO)
• International Child Care (ICC)
• National TB Control Program/Haiti
• Nation Public Health Laboratory/Haiti
• Pan American Health Organization/World Health Organization (PAHO/WHO)
• Partners in Health (PIH)
• U.S. Agency for International Development (USAID)

I met so many compassionate and caring Haitians. Many people thanked me for being there; each time I responded the same way, that it was my pleasure and honor.

References

1. WHO, 2007
2. DTBE Surveillance Report, 2009

—Reported by Lauren Lambert, MPH
Div of TB Elimination