The Diarrhea Iceberg?

     Diony is a community heath worker who works in our lab (see 10-30-13 blog post). Diony’s uncle died of diarrhea two days ago at the Hosanna clinic in Gressier. He was home for four days with diarrhea before going to the hospital. By then it was too late. We don’t know if it was cholera. They don’t test at the clinic. They just treat. His daughter also has diarrhea and is at the Doctors Without Borders clinic in Léogâne. She was caring for her father. Diony thinks his cousin will be all right. Diony told us he has another cousin who also has diarrhea. Meer and I decided we needed to go out to Diony’s neighborhood. It is not too far from Christianville so this afternoon we took out our mountain bikes and went up the road with Diony. We walked our bikes down a trail that runs between small houses, some just tents, some a little more solid, maybe a concrete block front and a tarp or a sheet metal roof. We met another one of Diony’s uncles. Diony gave him a sterile sample bottle and asked his uncle to fill it with water from their house. Diony gave his uncle four sachets of Pedialyte that I had brought with me from the U.S. and explained how to prepare it for his cousin who had diarrhea. We also collected water from two water sources near where Diony’s uncle lived. We took them back to the lab where Meer’s team will analyze them for fecal coliforms and test for the presence of Vibrio cholerae.

Diony points out a water source to test

     Meer and I are thinking that the cholera epidemic here is bigger than anyone realizes. We are looking at the tip of the diarrhea iceberg. Lots of cases are going unreported and people are probably dying from diarrhea out of sight of the public health eye. Haitians do not admit they have diarrhea. They find it is shameful, a stigma. So they stay home three, maybe four days with diarrhea and when they are too sick to do anything, they go to the hospital, maybe. And maybe they survive. Or maybe they die because it’s too late. They are too dehydrated from the persistent diarrhea that even intravenous fluid is not sufficient to save them. These are the hidden numbers of the cholera epidemic. We are not catching the number of Haitians with diarrhea who do not go to the cholera treatment centers or the local clinics. There is clearly a need for educational interventions in Haiti. First, to raise the level of awareness of diarrhea as a potentially life-threatening disease and to destigmatize the disease so that people are not ashamed to seek treatment. Second, people need to be taught how to prepare and use oral rehydration solution (ORS). It is simple and made with ingredients that are readily found in any home: salt, sugar and clean water. Use of the World Health Organization standard ORS has significantly reduced morbidity and mortality from diarrheal disease, particularly in developing countries. Simply put, use of ORS saves lives.

Kreyol patient ORS instructions