by Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

I have put my faith in my education and dedicated myself to continuing the effort of supporting people's health with the knowledge imparted to me over the past two years. Doubts certainly cross my mind as I question if what I am doing is effective, right or even necessary, whereas other times my faith is supported by the curative effects of medicine. There are nuances to the body which we cannot control, but we must rely on continued research to improve best practice techniques. Despite occasional skepticism and my desire to permit my body to heal without medicine, I will take cold and flu medication just to reassure myself that I support the practice that I preach. The advancement of science has helped us prolong life and alleviate illness, but occasionally signals are left unnoticed or the wrong test is ordered, despite the good intentions and full payment of diligence. Sometimes medicine can't control everything it encounters and last week entailed two very difficult patient cases who were both attended to properly, but something was missed.

The first day of last week brought a newborn child into the world who was the child and grandchild of two very close friends of the clinic. Being a boy in Guatemala, he was the prize of the family and of course incurred a higher cost from the birthing midwife. Tuesday the warmly wrapped baby was seen by a medical provider because he was crying a lot which worried the family, but everyone at the clinic received reassurances from the mother she had been told his crying was merely part of his adjustment to a whole new world. We received word that he had no fever, his lungs sounded good, heart sounds were regular, and there were no abnormalities upon exam. But modern medicine missed something with this newly born human being and with Thursday morning came the devastating news that he had passed during the night. Thursday morning was brutal for the clinic as we were slammed with patients, a new group of medical students started their first day at Primeros Pasos and there was a penetrating cloud of sadness pushing into the conscience of every team member at the clinic as we dwelled on the well-being of our close friends.

Almost everyone involved with Primeros Pasos attended the burial, which was held 10 hours after the baby's passing. The sadness of this death was not directly penetrating to my emotional core, but watching people I care about suffer so acutely pulled tears from my less than stoic eyes. The casket was tiny, emotions were high and the grandmother of the baby was as strong and beautiful as I've ever seen her. She was not visibly weeping, but her soul was drenched in tears as the trauma of losing her 2 day old grandson wore heavily upon her posture. We slowly followed the casket from the front gates to the back hill of the giant cemetery and the whole time Lauren, myself and another medical provider all watched the sadness, absorbed the pain and questioned what had the modern techniques of medicine missed on this precious child that could have prolonged his life. We wished we had more information or could review charts and have a long discussion trying to discover the cause of this death, but we were not working, we were mourning.

The other patient that pushed our emotions into a puddled mess was a 5 year old boy. He came from a town over an hour away and his mother spoke for him because the boy only spoke Kiche. I went in to see this patient alone, but I retreated within minutes for the assistance and expertise of the medical director. He was cute, just as most of the children we see at Primeros Pasos, and he was still shy at his young age, but quick to smile and laugh. As I was speaking to the mother, I realized his expressions were becoming more worried and he started to tear up. I asked him if he was scared and he nodded and I reassured him that there would be no shots or painful procedures and he brightened up. After his mother told me he had swelling near his neck, I began my exam while she finished telling me his story. There was a hard and barely mobile mass at the base of his neck on the right side and he flinched when I touched it. Upon examining his axillary region, I noticed a 3 inch scar, which his mother remembered to notify me was from when surgeons removed a mass 3 months ago. My heart dropped and I asked her what the doctors said about the mass after pathology and she didn't have any idea. She said they hadn't told her what the growth was and after the surgery they just sent him home without further treatment. No chemotherapy, no radiation and no extra patient education except a discharge three months ago and now I may have lied to this child about there not being any painful procedures, I just wouldn't be part of the process.

I palpated along his small chest between his armpit and the mass on his neck and found other small masses, then excused myself with my head low and desperately needing the doctor's second opinion. The medical director entered, examined the child and then we stepped out to discuss treatment options. It was either an ultrasound and biopsy or a direct referral to the hospital. Since he wasn't eating well because it was painful to swallow, we elected for the hospital. It was likely that this child had some form of cancer that was initially in his axillary lymph nodes and it spread before the surgeons could remove all of the cancer cells. Now the growth was in his cervical lymphatic chain and would be a much more complicated treatment, especially since he was having trouble swallowing. In August he had zero follow up care or pathology results to confirm any form of diagnosis, but he was back in the medical system 3 months later with swelling of other lymph nodes in his lymphatic chain. The medical director and I sent the mother and child to the hospital and hung our heads for a 10 minute discussion that basically entailed multiple derivations of, "What can we do?"

It was a week of what ifs and how comes as we watched children struggle. We pondered what type of care the child with the likely cancer would have received in the United States. What if he had the resources for prolonged treatment and follow up chemotherapy? Or how come children are suffering? How come nothing was picked up on the exam of the newborn? Because sometimes medicine misses, but oftentimes it misses something that we cannot yet see. Thankfully medicine usually remedies most ailments and with more research, better resources and continued diligence, we will continue to prolong life and alleviate illness, but for now we share condolences and look to the future from Xela Guatemala.

This week, CIFA released the long awaited strategic framework report entitled:

"Many Faiths, Common Action: Increasing the Impact of the Faith Sector on Health and Development."

This report was presented on November 23rd the at a meeting with high level United States Government representatives at the White House. Following a welcome from Reverend Joshua DuBois, and remarks by representatives from the Departments of State, Health and Human Services, USAID, and the White House Office of Faith Based and Neighborhood Partnerships. Bishop Dinis Sengulane of Mozambique, Ruth Messinger of American Jewish World Service, Abed Ayoub of Islamic Relief and Bill O'Keefe of Catholic Relief Services speaking on behalf of GIFHD Task Force presented specific asks of the USG, including requests for a high level Working Group for ongoing consultation with the faith sector in policy planning, support for the creation of multireligious collaborating mechanisms at the country level, and support for tools and research supporting congregation mobilization for health and development at the local level in developing countries.

The group was addressed by Dr. Nils Daulaire, USDHSS; Ms. Gayle Smith, NSC; and Dr. Rajiv Shah, USAID. It was clear they were taking the Strategic Framework for Action Report very seriously. Ms. Smith commended the value of the faith sector approach as a strategy for increased public sector engagement with the faith community, and Dr. Shah called for a roundtable to advise on the implementation of the recommendations at USAID. 

Senator Frist currently sits on the board of directors of CIFA, and Jenny Eaton Dyer, Ph.D. sits on the steering committee and task force for the Global Initiative for Faith, Health and Development.

by Senator Bill Frist, M.D.

I write to you today a little more optimistic than my last post on the developing disaster in Haiti. I will be keeping on top of the situation there and encourage you to stop by to read updates on my personal website, BillFrist.com. This weekend, I urgently emailed around the medical community, searching for desperately needed supplies for Haiti's ongoing cholera outbreak. From starting with nothing Saturday morning, we now will have a massive bulk shipment of Ringers Lactate and IV sets arrive this week in Haiti, be distributed that afternoon to 8 facilities by evening. Impressive response on short notice.

I also just got word from USAID that they now are also sending more Ringers Lactate. Yesterday morning I was told there were 200,000 in Haiti in storage and 400,000 in pipeline. When I said my people alone on the ground were using 75,000 per month there was a long pause. Now people seem to be getting the picture.

The Clinton Bush Haiti Fund, where I sit on the board, has recently announced an emergency $100,000 grant to the African Methodist Episcopal Church Service and Development Agency (AME-SADA). This wonderful organization is the only organization providing health care to the 350,000 residents of Archaie and Cabaret in the Artibonite region of Haiti. These funds will be used exclusively to fight the cholera outbreak, and USAID's Office of Foreign Disaster Assistance is matching our grant with in-kind, instead of monetary, support.

However this is only the start. As I said last week, estimates vary, but it is almost certain that 200,000 to 800,000 Haitians will be infected with cholera. The death toll has risen over the weekend to 1,250 and the outbreak finally appears to have fully hit the capital, Port-au-Prince, with a reported 15% to 20% increase in cases every day. The successes above are crucial in beginning the wave of support that Haiti and the NGOs on the ground critically need, but they are only the start of the solution. For now, think about donating to one of the charities below (or to one that I haven't listed!) and always remember to spread the word.

Samaritan's Purse

Doctors without Borders

Save the Children

by Senator Bill Frist, M.D.

As the cholera outbreak continues to ravage through Haiti, killing hundreds and inciting terror and riots throughout the country, I'm afraid I may have more bad news. It has come to my attention today that the cholera outbreak is being vastly underreported and underestimated. My sources on the ground in Haiti have estimated that the current epidemic is up to 400% worse than the official numbers reflect. Considering that the official numbers already state a toll of 1,110 dead and another 18,000 sick, the scope of this savage outbreak is shocking.

Furthermore, it seems that nearly all the organizations on the ground were caught by surprise by this sudden outbreak and are grossly undersupplied. Simply put, eradicating the cholera outbreak requires resources beyond Haiti's capacity. Ringers Lactate fluid (required for intravenous rehydration) remains incredibly scarce within the country. The UN also refuses to provide any cholera treatment supplies to any NGO, instead dedicating all its supplies to the Haitian government. Medications from the Haitian Ministry of Health are also currently not forthcoming. Certain organizations are simply waiting for the disease to strike the capital, Port-au-Prince, before acting. A group I frequently work with, Samaritan's Purse, is receiving reports of high mortality in remote areas with no assistance reaching them. The U.S. government claims that materials are in place to respond to this developing disaster, but this does not seem to be the case and I worry that false confidence may cost lives.

The spread of cholera now seems past controlling, and using Pan American Health Organization calculations (in the MOST optimistic, with an attack rate of 2% scenario) around 200,000 people will require IV fluid. As around 75% of all cases require hospitalization, each patient uses 8 liters per day for three days, the conservative estimate for IV fluid needed stands at 3.6 million units. Unfortunately, some experts believe that the attack rate will rise above 2% due to lingering sanitation and hygiene conditions caused by the devastating earthquake combined with a Haitian population with no exposure to cholera and immature resistance.

With much of the country living in squalid post-earthquake conditions, we should expect an attack rate of up to 5-8%, according to the Refugee Health Manual. At this rate, we can expect as many as 500,000 to 800,000 cases of cholera. Due to the intense overcrowding, these cases might not be spread out over six months, but rip through the population in six weeks. Roads in Haiti, already devastated by the earthquake and again recently by Hurricane Tomas, continue to keep sick people from seeking and receiving proper aid, meaning that more advanced treatments are needed to halt the disease.

Save the Children, which has been in Haiti for over 30 years and currently operates in 17 large urban camps, is desperately struggling to fight back the disease. They are scrambling to set up new treatment centers around the country as current ones, such as their facility in Port-au-Prince now operates 24 hours a day and still cannot do enough. On the preventive side, Save the Children has distributed 10,000 hygiene kits, 19,000 bars of soap, and chlorinated water to schools and camps. These actions are important and have saved thousands of lives, but in a country of 10 million people, they are simply not enough to hold back the tide.

Similarly my friends at Samaritan's Purse, who remain a major national player in Haiti, report that even with their huge public awareness WASH program, 400 treatment beds, and over 300 staff dedicated solely to cholera, they were completely unprepared for this outbreak. I find it hard to believe that many organizations were prepared for this and I simply cannot imagine that any hidden capacity exists.

This issue needs immediate global attention. Many organizations on the ground do not have the resources to quickly buy, deliver, and administer necessary cholera medications, like Ringers Lactate. Even if they can afford these costs, it is only the beginning of the current logistical nightmare. The airport in Cap-Haitien has been shut down and there are roadblocks between Cap-Haitien and Port-au-Prince, effectively isolating the entire North of the country. If supplies do make it to Haiti, customs holds these shipments 3 to 10 days and the backlog of supplies, not just at Port-au-Prince but around the country is staggering and costing lives every day. NGO's are unable to receive and distribute supplies and are resorting to covert and illegal means in some cases to secure these life-saving medicines. Civil unrest around the country, caused by the belief that the UN Peacekeepers are connected to the outbreak, are further hampering the delivery of supplies that eventually do get through the ports.

These hindrances to saving lives must be eliminated. Haiti needs IV fluids sent in massive quantities. Life-saving supplies must be allowed to enter immediately into the country, not sit on pallets for 3 to 10 days out of bureaucratic formality. Organizations on the ground have sophisticated software that allows all the various partners to work together to comprehensively treat the population; we simply do not have enough supplies. The immense backlog of supplies at the ports has strained the entire response grid to the point of collapse and the internal rioting makes it difficult and dangerous to move supplies inside Haiti. The world must help, and must help now.

In addition, the United States needs to seriously and objectively consider a military airlift of supplies into Haiti. While this may appear a drastic measure to some, we cannot sit idle while our neighbor to the south suffers through this nightmare. Our military provided crucial support to those suffering after the Indian Ocean tsunami, Hurricane Katrina, and the earthquake that ravaged Haiti in January, and can do so again in this dire time of need.

Cholera is a disease we can defeat if we work together. Up to 80% of cases can be successfully treated with relatively simple medicines, such as rehydration salts. So join me in telling your friends, writing your congressman, volunteering, or writing a check to one of the many worthy organizations on the ground. We need to spread the alarm, and quickly. This epidemic is larger than previously thought or reported, we are drastically underequipped to deal with it, and it's moving fast.