Cholera in Haiti: Acute-on-Chronic
Long before the devastating earthquake on January 12, 2010, Haiti struggled beneath the burdens of intractable poverty and ill health. The poorest country in the Western Hemisphere, Haiti also faces some of the highest rates of maternal and infant mortality—widely used indicators of the robustness of a health system—in the world ([S1] in Text S1; [2], [3]). The October 2010 cholera outbreak is the most recent of a long series of affronts to the health of Haiti's population; it is yet another acute symptom of the chronic weakness of Haiti's health, water, and sanitation systems.
Water and sanitation conditions highlight these systemic weaknesses. In 2002, Haiti ranked last out of 147 countries for water security [4], [5]. Before the earthquake struck, only half of the population in the capital, Port-au-Prince, had access to latrines or other forms of modern sanitation, and roughly one-third had no access to tap water [6]. Across the country, access to sanitation and clean water is even more limited: only 17% of Haitians had access to adequate sanitation in 2008, and 12% received treated water [7]. Not surprisingly, diarrheal diseases have long been a significant cause of death and disability, especially among children under 5 years of age [6].
The cholera outbreak began less than a year after a 7.0-magnitude earthquake took the lives of more than 300,000 people and left nearly 1.5 million homeless [6]. Almost 1 million Haitians still live in spontaneous settlements known as internally displaced persons (IDP) camps [8]. While post-earthquake conditions in Haiti were ripe for outbreaks of acute diarrheal illness, cholera was deemed “very unlikely to occur” by the United States Centers for Disease Control and Prevention (CDC) and other public health authorities [9]. Cholera had never before been reported in Haiti [S2] [10], [11]; health providers were unprepared for an influx of patients presenting with acute watery diarrhea.
The cholera epidemic has been most severe in rural areas and large urban slums. Rural communities were charged with hosting hundreds of thousands of displaced people after the earthquake, placing greater demands on their already-scarce resources, including water. Surface water drawn directly from the source or piped from rivers and streams constitutes the principal supply of drinking water in rural Haiti. The lack of adequate piping, filtration, and water treatment systems (including chlorination) made these rural regions vulnerable to the rapid spread of waterborne disease. While most IDP camps have been supplied with potable water, large urban slums have had to rely on existing water sources—some of them containing Vibrio cholerae—and have therefore been vulnerable to rapid disease spread. Most slums also have poor sanitation infrastructure. Since the first cases were reported in Saint-Marc and Mirebalais, cholera has spread to every department in Haiti, and to other countries, too [S3] [12]–[14].
Public suspicion (ultimately validated by genomic sequence analyses [15]) of the strain's link to South Asia, home to a group of United Nations peacekeepers stationed in central Haiti, triggered blame and violence that interfered with response efforts. As we have learned from the global AIDS pandemic and other infectious disease epidemics, cycles of accusation can continue for years, diverting attention and resources from the delivery of care and prevention services [16]. Systemic problems that brought cholera to epidemic levels in Haiti will (unless addressed) continue to facilitate its spread. As a disease of poverty, cholera preys upon the bottom of the social gradient; international trade, migration, and travel—from South Asia or elsewhere—open direct channels for pathogens that follow social fault lines.
Abstract Chances are that on any given day, the daily newspaper of every major U.S. city will present a snapshot of America’s growing problem of violence. Articles will cover a range of violent acts: murder, suicide, assault, child abuse, and rape. Although these daily stories catch people’s attention, readers all too often view the violence as a fact of life, something that is unpredictable and unpreventable. Our society and even health and public health professionals too infrequently realize that violence is a problem that can be studied, understood, and prevented (1).
Abstract A study was made of the microstructural changes that occur in ultraviolet irradiation under vacuum of thin films of 1,2‐poly( cis ‐1,4‐hexadiene) (CHD), 1,2‐poly( trans ‐1,4‐hexadiene) (THD), 1,2‐poly( trans ‐1,3‐pentadiene) (TPD), equibinary (1,2,‐1,4) polybutadiene (EB), and equibinary (3,4‐1,4) polyisoprene (EI). These polymers—all containing pendant double bonds—undergo important photoinduced loss of unsaturation, presumably through cyclization of the double bonds, by analogy to the previously reported photocyclization of 1,2‐polybutadiene (VB) and 3,4‐polyisoprene (VI)films. For the equibinary polymers, which contain internal as well as external (or pendant) double bonds, the loss of unsaturation is considered to involve photocyclization of 1,2‐1,4 and 1,2‐1,2 dyads in EB and of 3,4‐1,4 and 3,4‐3,4 dyads in EI. Accompanying thecyclization process in CHD, THD, and TPD is a direct photochemical cis‐trans isomerization of CHCHdouble bonds analogous to that originally noted for 1,4‐polybutadiene. The photorearrangements in the above polymers with pendant double bonds were compared to the corresponding thermally induced rearrangements reported previoulsy;for VB and VI, in particular, the thermal, photo‐and radiation‐induced cycli‐zations were found to be very similar, possibly having a common nonradical, nonionic mechanism involving excited double bonds.
This paper provides an overview of this special issue of Injury Control and Safety Promotion, which is devoted to road traffic injuries and health equity. The issue includes nine country reports that provide baseline data on the burden of road traffic injuries. The reports also analyze current road safety activities, key stakeholders and major constraints to road safety. The country reports all emphasize that a critical first step toward improving road safety conditions is accurate data collection. A number of other common challenges are reported, including the lack of properly organized public transportation systems; highways that cross populated areas and markets; inadequate provisions for pedestrians; and ineffective national road safety councils. The reports were part of an international conference to review the current impact of road traffic injuries in low- and middle-income Asian, African and Latin American countries, assess interventions to reduce the burden of these injuries, and begin to develop multi-country intervention plans for reducing this toll through programs, policies, research and action. As a result of the discussions at the conference, a call to action was developed as a shared statement of purpose and commitment to work together to reduce road traffic injuries.
Intimate partner violence (IPV) is a critically important public health problem. Physicians and other health care providers have a unique opportunity to help IPV victims, not only in treatment but in prevention of this devastating problem. Health-care providers should receive thorough and on-going training and administrative support for identifying, appropriately treating, and referring IPV victims to IPV advocates and other community-based resources with whom the provider has developed a close working relationship. In the clinical setting, health-care providers may intervene early as the victim’s first and only point of contact concerning the violence in their lives. In the larger community, health-care providers can become spokespersons and educators to help change social norms and can get involved in coordinated community responses to ensure cohesive actions by all societal sectors to prevent IPV in their communities.
