Discussion Disaster Management To participate in the Discussion Board: Each student must write a response to the prompt (minimum 250 words not counting

Discussion Disaster Management To participate in the Discussion Board:

Each student must write a response to the prompt (minimum 250 words not counting

Click here to Order a Custom answer to this Question from our writers. It’s fast and plagiarism-free.

To participate in the Discussion Board:  

Each student must write a response to the prompt  (minimum 250 words not counting reference list)

Select ONE of the following:

1) Analyze the vulnerability situation in Haiti before the earthquake using Week 2 Coppola’s vulnerability types: physical, environmental, social and economic vulnerabilities. Link these pre existing vulnerabilities with the consequences of the earthquake. Note: Review Coppola reading on vulnerability (week 2): no need to define each type of vulnerability, it is common knowledge now so focus on this weeks case, Coppola does not count for the 2 minimum sources.

2) Discuss the cholera outbreak after the earthquake. What was the UN’s role in the cholera outbreak and what are the lasting effects of this outbreak to this day. 

Requirements: Prompt responses should answer the question and elaborate in a meaningful way using 2 of the weekly class readings (250 words of original content). Do not quote the readings, paraphrase and cite them using APA style in text citations. You can only use ONE multimedia source for your minimum 2 sources each week. The readings must be from the current week. The more sources you use, the more convincing your argument. Include a reference list in APA style at the end of your post, does not count towards minimum word content.

n engl j med 364;1 nejm.org january 6, 2011

P E R S P E C T I V E

3

nancially strapped and concerned
about the cost of reform and its
ability to meet their population’s
needs.

Maine, Florida, Iowa, and other
states have already indicated that
they will seek waivers for some
insurance rules that could desta-
bilize local insurance markets.
A recent proposal by Senators Ron
Wyden (D-OR) and Scott Brown
(R-MA) would grant states addi-
tional f lexibility but falls short
of giving them full authority to
develop their own reform ap-
proaches. Since reform cannot be
implemented without them, states
could choose to take a more in-
dependent role even if Washing-
ton is slow to give it to them.

Will the President’s health care
reform look burdensome and un-
workable 2 years from now? Re-
form is no longer a 2000-page
bill sitting on the desk of a sen-
ator or representative. The exec-
utive branch has been issuing
guidance and regulations that
are beginning to fill holes in the

legislation and will change the
way the law works in practice.
Much to the chagrin of the leg-
islation’s most ardent support-
ers, Secretary of Health and Hu-
man Services Kathleen Sebelius
has been granting waivers when
the rules don’t work for every-
one, albeit on a selective basis
designed to avoid the worst po-
litical heat.3 Although such de-
cisions will soften the impact of
reform, they neither alter the
shift toward greater government
control nor slow the growth of
health care spending.

Despite the talk of repeal,
Congress will not pass any major
health legislation over the next
2 years, and the health sector and
private employers will be hard at
work preparing for 2014, when
many ACA provisions take ef-
fect. That does not make health
care reform a fait accompli. Ab-
sent a miracle, the country will
still face crushing budget defi-
cits when the next president takes
office. A Republican president,

backed by a Republican Congress,
would be wise to delay enroll-
ment in the health insurance ex-
changes, using the time and mon-
ey to develop a more targeted plan
that closes off open-ended sub-
sidies for health insurance and
gets the economic incentives right.
A Democratic president would
do the same thing out of neces-
sity — but it would take longer.

Disclosure forms provided by the author
are available with the full text of this arti-
cle at NEJM.org.

From the American Enterprise Institute,
Washington, DC.

This article (10.1056/NEJMp1012299) was
published on December 8, 2010, at NEJM.org.

1. Streeter S. Continuing resolutions: FY2008
action and brief overview of recent practices.
Washington, DC: Congressional Research
Service, 2008. (CRS report RL30343.) (http://
www.rules.house.gov/archives/RL30343.pdf.)
2. Idem. The congressional appropriations
process: an introduction. Washington, DC:
Congressional Research Service, 2007. (CRS
report 97-684.) (http://www.senate.gov/
reference/resources/pdf/97-684.pdf.)
3. Adamy J. Federal agency flexible on Mc-
Donald’s plan. Wall Street Journal. October 1,
2010.
Copyright © 2010 Massachusetts Medical Society.

Reforming Health Care Reform in the 112th Congress

Responding to Cholera in Post-Earthquake Haiti
David A. Walton, M.D., M.P.H., and Louise C. Ivers, M.D., M.P.H.

Related article, p. 33

The earthquake that struck Haiti on January 12, 2010,
decimated the already fragile
country, leaving an estimated
250,000 people dead, 300,000
injured, and more than 1.3 mil-
lion homeless. As camps for in-
ternally displaced people sprang
up throughout the ruined capital
of Port-au-Prince, medical and
humanitarian experts warned of
the likelihood of epidemic disease
outbreaks. Some organizations
responding to the disaster mea-
sured their success by the ab-
sence of such outbreaks, though

living conditions for the dis-
placed have remained dangerous
and inhumane. In August 2010,
the U.S. Centers for Disease Con-
trol and Prevention (CDC) an-
nounced that a National Surveil-
lance System that was set up after
the earthquake had confirmed
the conspicuous absence of high-
ly transmissible disease in Haiti.

However, on October 20, more
than 55 miles from the nearest
displaced-persons camp, 60 cases
of acute, watery diarrhea were
recorded at L’Hôpital de Saint
Nicolas, a public hospital in the

coastal city of Saint Marc, where
Partners in Health has worked
since 2008. Stool samples were
sent to the national laboratory in
Port-au-Prince for testing. The
hospital alerted Ministry of Health
representatives in the region and
in the capital, as well as World
Health Organization representa-
tives managing the Health Clus-
ter, a coordinating group formed
after the earthquake. In the next
48 hours, L’Hôpital de Saint Nico-
las received more than 1500 ad-
ditional patients with acute di-
arrhea.

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P E R S P E C T I V E

n engl j med 364;1 nejm.org january 6, 20114

By October 21, preliminary re-
sults from the national laborato-
ry confirmed our clinical impres-
sions: though cholera had not
been seen in Haiti in at least a
century and may never have been
recorded in laboratory-confirmed
cases, it had somewhat unexpect-
edly emerged in a densely popu-
lated zone with little sanitary in-
frastructure and limited access to
potable water. As the contours of
the epidemic began to take shape,
following the winding course of
a large river in the Artibonite re-
gion, hospitals in central Haiti
started recording rapidly increas-
ing numbers of cases of acute
diarrhea. Between October 20 and
November 9, Partners in Health
recorded 7159 cases of severe
cholera. Among these patients,
161 died in seven of its hospitals
in the Central and Artibonite re-
gions.

In Port-au-Prince, sporadic
cases were reported in the early
phase of the outbreak; most were
deemed “imported cases.” On No-
vember 8, 48 hours after Hurri-
cane Tomas caused flooding and
worsening of living conditions in
Parc Jean-Marie Vincent, one of
the largest settlement camps,
Partners in Health reported seven
clinical cases of cholera within
the camp. On the same day, Doc-
tors without Borders reported see-
ing as many as 200 patients with
cholera in nearby slums. By No-
vember 9, the Ministry of Health
had reported 11,125 hospitalized
patients and 724 confirmed deaths
from cholera.

Although we responded as
quickly as we could, we were ham-
pered by the rapidity with which
the epidemic spread, overwhelm-
ing our hospitals with hundreds
of patients and stretching already
thin resources, staff, and mate-
rials. Because there was minimal

practical institutional knowledge
about cholera in Haiti, we worked
with other nongovernmental or-
ganizations to design treatment
protocols and institute infection-
control measures in affected hos-
pitals. Our network of community
health workers began distributing
oral rehydration salts, water-puri-
fication systems, and water filters
and instructing people about hy-
giene, hand washing, and decon-
tamination of cadavers. Body bags
were distributed to community
leaders, and rehydration posts
were set up throughout the coun-
tryside. A network of cholera
treatment centers and stabiliza-
tion centers was established in
coordination with the Ministry
of Health.

The cholera outbreak took most
people by surprise. Unexpectedly,
it was centered in rural Haiti and
not in the displaced-person camps
that are situated mainly in the
greater Port-au-Prince area. But
history would suggest that an
epidemic outbreak of waterborne
disease was just waiting to strike
rural Haiti. It is well known that
Haiti has the worst water secu-
rity in the hemisphere. In 2002,
it ranked 147th out of 147 coun-
tries surveyed in the Water Pov-
erty Index.1 After the earthquake,
more than 182,000 people moved
from the capital to seek refuge
with friends or family in the
Artibonite and Central regions,
increasing stress on small, over-
crowded homes and communi-
ties that lacked access to latrines
and clean water. In addition, in
many areas of Haiti, the costs
associated with procuring water
from private companies and the
lack of adequate distribution sys-
tems have rendered potable wa-
ter even less accessible for those
most at risk.

Waterborne pathogens and fe-

cal–oral transmission are favored
by the lack of sanitation in Haiti.
Typhoid, intestinal parasitosis, and
bacterial dysentery are common.
Only 27% of the country bene-
fits from basic sewerage, and
70% of Haitian households have
either rudimentary toilets or
none at all.2 But the sudden ap-
pearance of cholera, a pathogen
with no known nonhuman host,
raises the question of how it
was introduced to an island that
has long been spared this dis-
ease. Speculations on this ques-
tion have caused social and po-
litical friction within Haiti in
recent weeks. Early in the epi-
demic, the CDC identified the
cholera strain Vibrio cholerae O1,
serotype Ogawa, biotype El Tor.
Chin and colleagues (pages 33–
42) report on DNA sequencing
of two isolates from the recent
outbreak, which showed that the
cholera strain responsible for the
Haitian epidemic originated in
South Asia and was most likely
introduced to Haiti by human
activity. The implications of the
appearance of this strain are
worrisome: as compared with
many cholera strains, it is asso-
ciated with increased virulence,
enhanced ability to survive in the
environment and in a human
host, and increased antibiotic
resistance. These factors have
substantial epidemiologic ramifi-
cations for the entire region and
implications for optimal public
health approaches to arresting
the epidemic’s spread.

As the infection makes its way
to the capital city, there is de-
bate about the likely attack rate
inside displaced-person camps,
as compared with the rate in sur-
rounding communities. The latter
often have worse access to water
and sanitation than the former.
But 521 of 1356 displaced-person

Responding to Cholera in Post-Earthquake Haiti

The New England Journal of Medicine
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n engl j med 364;1 nejm.org january 6, 2011

P E R S P E C T I V E

5

camps listed by the United Na-
tions camp-management cluster
reportedly have no water or sani-
tation agency, and most are far
from reaching the established
guidelines for sanitation in hu-
manitarian emergencies.3 The liv-
ing conditions of most of Haiti’s
poor, whether they’re living in
camps or communities, are equal-
ly miserable in terms of the risk
of diarrheal disease.

The reported numbers of cases
and deaths, though shocking, rep-
resent only a fraction of the epi-
demic’s true toll. We have seen
scores of patients die at the gates
of the hospital or within minutes
after admission. Through our net-
work of community health work-
ers, we have learned of hundreds
of patients who died at home or
en route to the hospital. In the
first 48 hours, the case fatality
rate at our facilities was as high
as 10%. Though it dropped to less
than 2% in the ensuing days as
the health system was rein-
forced locally and patients be-
gan to present earlier in the

course of disease, mortality will
most likely climb as the disease
spreads and Haiti’s fragile health
system falters.

This most recent crisis in Haiti
has reinforced certain lessons
regarding the provision of ser-
vices to the poor. Complemen-
tary prevention and care should
be the primary focus of the re-
lief effort. Vaccination must be
considered as an adjunct for con-
trolling the epidemic, and anti-
biotics should be used in the
treatment of all hospitalized pa-
tients. These endeavors should
proceed in concert with much-
needed improvements to sanita-
tion and accessibility of potable
water. More generally, reliable
partnerships are essential, espe-
cially if local partners are depend-
able and have practical experi-
ence and complementary assets.
Long-term reinforcement of the
public-sector health system is a
wise investment, permitting pro-
vision of a basic minimum set of
services that can be built upon in
times of crisis. And community

health workers who can be rap-
idly mobilized as educators, dis-
tributors of supplies, and first
responders are a reliable back-
bone of health care. In Haiti,
such workers can bring the time-
sensitive lifesaving therapy of
oral rehydration right to the pa-
tient’s door.

Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.

From the Department of Global Health and
Social Medicine, Harvard Medical School;
the Division of Global Health Equity,
Brigham and Women’s Hospital; and Part-
ners in Health — all in Boston.

This article (10.1056/NEJMp1012997) was
published on December 9, 2010, at NEJM
.org.

1. Sullivan CA, Meigh JR, Giacomello AM.
The Water Poverty Index: development and
application at the community scale. Nat Re-
sour Forum 2003;27:189-99.
2. Ministère de la Santé Publique et de la
Population, Haiti. Enquête mortalité, mor-
bidité et utilisation des services (EMMUS-
IV): Haiti, 2005-2006. (http://new.paho.org/
hai/index.php?option=com_docman&task=
doc_download&gid=25&Itemid=.)
3. 101112 WASH Cluster situation report.
November 12, 2010. (http://haiti.humanitarian
response.info/Default.aspx?tabid=83.)
Copyright © 2010 Massachusetts Medical Society.

Responding to Cholera in Post-Earthquake Haiti

Antibiotics for Both Moderate and Severe Cholera
Eric J. Nelson, M.D., Ph.D., Danielle S. Nelson, M.D., M.P.H., Mohammed A. Salam, M.B., B.S., and David A. Sack, M.D.

Related article, p. 33

The 2010 Haitian cholera out-break has pressed local and
international experts into rapid
action against a disease that is
new to many health care provid-
ers in Haiti. The World Health
Organization (WHO) has time-
tested management protocols for
emerging cholera outbreaks. These
protocols have been used by the
Haitian government to fight an
epidemic that is merely one of
several recent tragedies in Haiti.
The use of these protocols has

allowed for a high standard of
care in this complex and evolv-
ing medical landscape. But where-
as the current WHO cholera-
treatment protocol (www.who.int/
mediacentre/factsheets/fs107/en/
index.html) recommends anti-
biotics for only severe cases, the
approach of the International
Centre for Diarrhoeal Disease Re-
search, Bangladesh (ICDDR,B),
recommends antibiotics for both
severe and moderate cases.

Several antibiotics are effec-

tive in the treatment of cholera,
including doxycycline, ciprof lox-
acin, and azithromycin, assuming
that the cholera strain is sensi-
tive. Currently, the epidemic strain
in Haiti is susceptible to tetracy-
cline (a proxy for doxycycline) and
azithromycin but is resistant to
nalidixic acid, sulfisoxazole, and
trimethoprim–sulfamethoxazole.
The WHO advocates giving anti-
biotics to patients with cholera
only when their illness is judged
to be “severe.” This recommen-

The New England Journal of Medicine
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.

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