by Lauren Eppinger
Vanderbilt School of Nursing
Xela, Guatemala

I have been back in the United States for a week and a half now. Coming home from Guatemala during the holiday season is a strange transition. I couldn't help but look at all of the (admittedly exciting) products and services being offered, and think "oh, that money for that completely useless thing could pay for 'x' children's medicine, or food." I have been trying to adjust to life in the US, and accept the differences between life here and the poverty in places like Xela, trying to enjoy the luxury but maintain the perspective. In the midst of all of this enjoyment, I am reminding myself periodically that too much acceptance of this sort of disparity leads to complacency, which only further harms people.

The last couple of weeks in Xela were exciting. I worked hard on wrapping up the malnutrition project, and Cody and I got the suero (oral rehydration solution or ORS) going at the clinic. We got materials together and taught clinic staff how to mix up the bags of powder for families to make in their homes. All children with diarrhea, vomiting, or risk of dehydration can now be given enough suero to prevent dehydration, or treat mild to moderate dehydration. The families add one bag of ORS mix into one liter of water, and it is good for 24 hours. We can now make suero for 1/10 of the cost of the previous supply, which means that $1 allows us to make 20 liters of suero, which treats 5-10 children for a day. The project was well-received at the clinic, and may be shared with other clinics after we get things running smoothly at Primeros Pasos.

Now that I am at home, and see how much $1 and some hard work can buy, I have been trying to be careful about my spending. I have encouraged my friends and family to consider giving money to organizations such as Primeros Pasos (or Hope Through Healing Hands) to help support projects like this suero project or malnutrition treatment, and clean water initiatives. I'm not trying to advertise for any specific organizations, but I think that this sort of giving is extremely important. Here is a link to donations for Primeros Pasos, if you are interested.

I would like to thank Hope Through Healing Hands for the opportunity to do such rewarding work in Guatemala. I hope that the work that was done was as helpful for the community as it was inspiring for me!

Note: Senator Frist  sits on the board of the Clinton Bush Haiti Fund.

Helping Haiti not just survive but thrive

By Gary Edson

The stakes are high as Haitians struggle to resolve disputes over the accuracy of preliminary vote tallies from the November 28 national election. Haiti's next president and its parliament must be able to lead the nation from catastrophe to prosperity.  But it is equally important that the international community helps Haiti's new leadership establish an environment in which the nation can thrive.

Amid this latest crisis and the persisting pains for millions of earthquake victims, the approaching one-year anniversary of the January 12 disaster is a reminder of all that must still be done.  The world must redouble the efforts of the past year to tend to the many remaining urgent needs. At the same time, we must not lose sight of a need just as critical: creating the building blocks for long-term, vigorous economic expansion and job growth — the only real path to a stronger and better Haiti.

Indeed, the goal of the donor community should be to put itself out of the Haiti aid business. To do that, we need to be laser-focused on helping Haitians create and build their own livelihoods.  There are no straight lines from pain to promise in this equation, but Haiti has one important thing on its side: despite the devastation, the Haitian people are ready to write a positive new chapter in their country's troubled history.  We must help them do so by promoting job growth and economic opportunity— and then by getting out of the way.

As Paul Farmer, Partners In Health's founder and United Nations Deputy Special Envoy to Haiti said in a recent Foreign Policy column: "Haiti has 9.8 million people, and at least half were unemployed even before the earthquake. If we focused our efforts on the singular task of getting them jobs -- even if we did nothing else -- Haiti's reconstruction could be a success."

This is the focus that former Presidents Bill Clinton and George W. Bush have given the Clinton Bush Haiti Fund.  Since we began independent operations in May 2010, we have dedicated ourselves to making targeted, thoughtful grants and investments in four areas that are at the foundation of viable economic growth:


  • Restarting, expanding and creating new small businesses, in which women play a large role;
  • Supporting a transition from an underground economy to a formal one;
  • Bolstering job creation, particularly jobs providing direct social benefits; and
  • Empowering people, especially women and youth, with life skills and job training to embrace economic opportunity.


For example, in July the Clinton Bush Haiti Fund announced a $245,000 grant to INDEPCO, Haiti's largest network of garment micro-entrepreneurs, which provided an injection of capital that will enable 1,000 workers to complete 40,000 school uniforms.

In late November, the Fund, announced a $5.68 million partnership with MasterCard Foundation, YouthBuild International, and the Haitian NGO IDEJEN to support construction job training for at-risk young people. We've also just announced a grant to Architecture for Humanity in support of the Haitian Rebuilding Center in Port-au-Prince, which will provide design support and technical expertise to Haitian construction firms.

To date, the Fund has raised $52 million, of which nearly $20 million has been committed to organizations that support our mission of economic growth and empowerment. We seek to empower and catalyze — letting Haitians lead the way and promoting projects with ripple-effect potential.

We also have addressed selected humanitarian needs, playing a "gap-filling" role.  For instance, the Clinton Bush Haiti Fund responded to the recent cholera outbreak by redirecting a portion of a recently announced $1 million grant to GHESKIO, a 28-year-old Haitian healthcare organization, to its cholera treatment centers in Port-au-Prince.

Cholera is a disease of poverty and, like so many of the challenges Haitians face, the symptom of a much larger problem. It threatens lives, but also the island's ability to prosper. That's why we are remaining focused on the difficult but critical work of growing economic opportunity. In the coming weeks we will announce additional grants and investments, including financing for Haitian artisan exports and support for emergency medical training.

In the months since January 12, and for so many years before, the story of Haiti has been one of aid. The Clinton Bush Haiti Fund supports initiatives that will write very different stories — of Haitian mangoes sweetening Coca Cola beverages; of Haitian artisans producing crafts for Macy's; and of Haitian youth emerging from the shadows to obtain skills and jobs. These will be stories of the new Haiti: Haitians producing and exporting to thrive, rather than depending on aid to survive; stories not just of help, but of hope.

Gary Edson is CEO of the Clinton Bush Haiti Fund and former senior advisor on security and economic affairs to President George W. Bush. He co-led the development of the President's Emergency Plan for AIDS Relief (PEPFAR), and also led the effort that established the Millennium Challenge Corporation to combat global poverty.



by Lauren Eppinger

Vanderbilt School of Nursing

Xela, Guatemala

eppinger 6

As I am nearing the end of my time in Guatemala, I have been wrapping up all of the projects I have been working on here. Cody Bowers has been writing about the Oral Rehydration Solution (ORS) project, so I will let him update about that in a different blog. The project that has been taking most of my time here is the creation and implementation of protocol for the screening and treatment of malnutrition.

After participating in care of children at the clinic, and talking with the clinic staff it was apparent that the solution to the inadequate treatment of these children would need to be multi-disciplinary, to address the problem from multiple angles. The clinic's previous protocol was to do exams, give vitamins, and educate the patients. These are all important things to do for the treatment of malnutrition, but the guidelines were so vague that they were rarely being implemented fully. After looking over the current research and discussing ideas with the directors at the clinic I developed a detailed treatment plan, and set out to identify available resources.

In speaking with patients, it became clear that there was a huge deficit in nutritional knowledge. Most people didn't know the difference between protein and carbohydrates. In order to fulfill the clinic's need for an educational plan, I designed one that could be made into a handout and used as a guideline for discussions in the clinic. I made up a food pyramid that was specific to the needs I saw at the clinic, and I included information about each food group, the functions of the nutrients, effects if deficient, examples of the foods in the group, and daily requirements. The other side of the food pyramid handout has information on malnutrition and hygiene, as well as a table to keep track of the child's weight. The clinic now has a sheet for each malnourished child's chart, and a master spreadsheet to keep track of the patients with malnutrition. The educational materials are now stored in each exam room, and a color laminated copy of the pyramid is on the wall in each room.

Another part of the project involved researching ways to get vitamins to these children. Due to supply issues, the clinic was only getting occasional bottles of B vitamins, but no multi-vitamins, and no iron for anemic children. I checked all of the local pharmacies and found an inexpensive multi-vitamin that we are looking into purchasing for the clinic. At the very least, we can write a prescription for the vitamin, and families can purchase it for $1.60 a bottle. Even if we have to wait on more donations or funding, it was important just to know what the local supply was. Previously, no one at the clinic knew what multi-vitamin was affordable, or even how to dose it. This information is very product-specific, and the foreign volunteers really struggled with it. The same thing was done to research an appetite stimulant.

Last Friday the whole clinic came together for a meeting. One of the most important parts of initiating a change like this is having the support of the people who will be doing the work. I was lucky to have support from the entire clinic. They realized the huge need for a specific treatment program, but didn't have the time or resources to create one on their own. Once everything was complete, we held a training session, where the medical students, volunteers, and medical director (head doctor) all took part in learning about how to institute this treatment protocol.

A major part of the training session was reminding people how to help motivate families to return for follow-up, and to have parents take a part in this process. It's easy for people to think there's an element of neglect involved when the parents do not bring their children in for follow-up, but I think it is much more complex. We have to win the trust of the families, and show them that the child's health is a collaborative process. We don't want to take all of the control, nor do we want to be left out when we are needed. There seems to be a stigma here about malnutrition, and many mothers are anxious to see the child's weight, and know if he is at a healthy weight. Any interventions we have to resolve malnutrition seem to be very well received.

In my last few days at the clinic I will be able to help make sure that the new malnutrition treatment program gets going smoothly. It has been exciting already to see families walking away with their educational information. Education is one of the best tools for health promotion, and I look forward to seeing it put to use in a variety of ways here.

When Medicine Misses

Dec 15 2010

by Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

bowers 6

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.

December 2, 2010

by Lauren Eppinger
Vanderbilt School of Nursing
Xela, Guatemala

eppinger los vahos

One of the interesting things about being in Xela is the high volume of foreigners living and working here. Xela is rather well known for its Spanish language schools, which draw people from around the world. In addition to the linguistic draw, Guatemala is filled with NGOs, and there seems to be an especially high concentration in this area.

The clinic where Cody and I are working has something of a partnership with a local group of hiking guides called Quetzaltrekkers. This group of outdoor-friendly hikers throws fundraising parties and divides the proceeds between the Primeros Pasos clinic and a school for children who otherwise would have no access to education. In return, medical volunteers from the clinic give classes on wilderness medicine.

A few weeks ago when Cody an I were asked to teach this class, we were a little bit caught off guard, because neither of us had had any specific educational training on the topic. But after a few hours of research, we were able to focus in on some important topics (fractures and sprains, concussions, and allergic reactions). The class went so well that we were invited back for a second one, and given specific topics to cover.

The opportunity to work with a different population (hiking guides who will be in charge of the safety and wellbeing of groups of people venturing out into the nearby wilderness) has been exciting. Our latest class was on medications to use while hiking, and some information about common illnesses. It has been interesting to work with this group because we can easily see how important it is for them to have this information. We are working on a lot of emergency management, and safety.

by Jenny Eaton Dyer, Ph.D.

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.

November 23, 2010

by Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

bowers pump

Primeros Pasos is a clinic that charges $0.62 cents for a pediatric consultation and $3.75 for an adult to see a provider. Any medicine in the pharmacy is free with the cost of admission and some remedial laboratory work is included in the nominal fee as well. The clinic is constantly receiving miscellaneous grants and substantial financial support from Inter-American Health Alliance (IAHA) to pay the salaries of the few employees that run the place and then volunteers take care of the rest. Lauren and I noticed two issues at the clinic that we felt we could address to cut costs and improve patient care. She moved directly into improving malnutrition treatment protocol and wrote an entire study that is waiting approval. We also have found that the clinic is frequently without oral rehydration salts (ORS) used as treatment for people, but especially children, with diarrhea. Lauren and I were frustrated by the absence of ORS packets in the pharmacy, which led us to create a project to expand care at Primeros Pasos. Finding the perfect recipe for ORS and buying 100 pound bags of salt and sugar is our immediate goal.

Severe diarrhea causes extensive loses of fluid and electrolytes and a child's body does not have the reserves to compensate for missing essentials. Before ORS (known as suero in Spanish) was instituted, intravenous fluids were used to correct diarrheal dehydration and millions of children were dying because they didn't have access to technical medical care. Now we can remedy the situation with salt, sugar and clean water. quotes that ORS therapy saves 1 million lives a year, costs about 10 cents per liter of solution and can prevent about 90% of diarrheal deaths in children. The initial recipe for ORS included 8 teaspoons of simple sugar, 1/2 teaspoon of table salt and one liter of pure water. Through many research studies and trial and error efforts, the recipe has been refined and enhanced to optimize diarrheal treatment for the vulnerable, yet resilient bodies of children. There are websites suggesting that vitamin C and zinc can be used to diminish the length and severity of diarrhea by up to 25%. Other sources have been adding artificial flavorings and additives to make ORS more palatable, but in our search for the best recipe we have chosen to abide by the most trusted and overarching source of pediatric medical care. The World Health Organization and UNICEF have combined to create a 123 page manual about oral rehydration therapy and this is now our guiding light. The WHO and UNICEF offer a simple recipe of 2.6 grams of salt, 1.5 grams of potassium chloride, 2.9 grams of trisodium citrate dihydrate and 13.5 grams of glucose. Four ingredients with life saving potential, all of which are usually available at any nearby grocery store.

The two ingredients that are rather abnormal for a grocery store are the trisodium citrate and potassium chloride, but thankfully there is research suggesting that baking soda can be substituted for the trisodium compound. Trisodium serves as a buffer for the acidosis of severe diarrhea and thus baking soda can serve the same purpose. Potassium being the second issue was not a worry because in the United States we prescribe large quantities of potassium chloride to patients on diuretic therapy and potassium chloride can also be bought as a salt substitute in most stores. Furthermore, I can walk into any pharmacy in Xela and buy almost any medicine I desire, except of course potassium chloride. I felt very few qualms about finding a source of potassium, but I should have realized that the recipe wouldn't be so easy to complete. Potassium chloride seems to be non-existent in Guatemala after a long and thorough search throughout the medical and scientific community.

We started this project with the idea of having four ingredients locally available and we would then have an suero recipe working at the clinic within a week, but the obstacles to our creative alternatives are becoming all too common. These barriers we have found are very frustrating because it is yet another reflection of the restricted resources in comparison to what is at our medically oriented finger tips at home. We have visited a half dozen pharmacies, called local laboratories, considered having volunteers bring prescription potassium from the states, but all proved to be without potassium chloride or expensive, unsustainable and hapless. Lacking a reliable source of potassium chloride has forced us to be inventive in our search for this electrolyte and our team has been delving through research studies as we attempt to compensate for the missing ingredient. Due to the importance of potassium, we want to include as much of it as possible even if we cannot add the 1.5 grams stated in the WHO/UNICEF recipe.

There is a unadulterated, unprocessed sugar in Guatemala called panela or piloncillo and it is apparently loaded with potassium and could be perfectly useful, if we only knew how much potassium there is in every gram. Panela is a locally grown, produced and useful ingredient for the ORS suero recipe, which would keep cost down, make the recipe useful for other clinics in the area and be a culturally sound contribution to the medical efforts in Xela. And knowing that the original life-saving recipe lacked any form of potassium, we are confident that the increased amount found in panela will be very beneficial as long as we keep the osmolarity balanced. Along with the potassium in panela, we can also include potassium iodized salt as another minimal, but useful source of the vital electrolyte.

We still need to standardize and exact the recipe, but thankfully we have a Phd trained chemist back in Nashville to calculate the exact osmolarity (number of solutes per liter of water) to ensure that the amount of additives we are using will be perfectly therapeutic and beneficial for patients with diarrhea. The osmolarity must be kept below 245 per liter of pure water to avoid dehydrating the body further and the chemist will be able to give us the weighted measurements for a safe recipe including sugar, salt, panela and baking soda. We shall continue to seek the answers to our long list of questions and we hope that this research experiment will soon produce necessary results to cut costs and increase the availability of oral rehydration therapy at the Primeros Pasos clinic in Palajunoj Valley, Guatemala. 

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, 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


November 19, 2010

by Greg Schnepper, M.D.
Vanderbilt International Anesthesia
Kijabe, Kenya

shnepper kijabe

While it feels as if I just arrived, I can't believe I will be heading back home tomorrow. What a phenomenal experience this has been. This month has not only had a high impact on my education, but has been a unique, once in a lifetime experience. I say once in a lifetime, but I certainly hope this is not the case. I would love and certainly hope that I will be back to visit Kijabe in the future.

Much of our time here has been spent working with the student nurse anesthetists. My co-resident and I have helped conduct their practical exams, have provided intraoperative teaching, and have given them lectures while rotating through the icu. Their education is vitally important, as when they become nurse anesthetists many of them will be in parts of Africa where they are the sole anesthesia provider.

We have also spent a fair amount of time teaching regional anesthesia. One nurse anesthetist has shown an inordinate enthusiasm for nerve blocks, and it has been a joy teaching her. I have provided a picture of the two of us performing a nerve block using ultrasound, something that will surly help patients with postoperative pain relief.

Our experience has also included time rotating through the intensive care unit. While taking call in the ICU, I helped take care of a very sick 8 year old boy. The boy had severe respiratory failure and sepsis, requiring an emergent exploratory laparotomy operation. I helped provide anesthesia during the surgery. Sadly, the boy passed away. His death was devastating, and it is often difficult or impossible to find any silver lining in events like this. But I did take away hope by the passion shown by all those involved in taking care of the child. Our team of anesthetists, nurses, pediatric surgeons, and critical care intensivists did all we could to save this child, but sadly he was just too sick. The deep desire of the people here to help those in need is unparalleled. The passion shown for others is inspiring. Unfortunately, despite being one of the top tier hospitals in all of East Africa, the resources at Kijabe are often limited and lacking. But hopefully with such a strong base of people wanting to make a difference, this will continue to improve. My experience at Kijabe has been touching and incredible. I have been inspired, and I only hope those I've been in contact with have been too. I can't wait to come back.

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.

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