Confidence and Cholera

Cholera is something new in Haiti. Preliminary results of testing at the Center for Disease Control in Atlanta suggest that the strain that has recently appeared here is South Asian.

With representatives from Nepal, Bangladesh, and Sri Lanka serving in the U.N.’s “stabilization” force, the most likely source of the epidemic is more or less clear. Signs point to a poorly planned, poorly managed septic tank at a Nepalese U.N. base near Mirebalais, not far from one of the smaller rivers that eventually joins the Artibonite, the most important river through the center of Haiti and the center of the epidemic. DNA testing is continuing.

But knowing the source of the epidemic is only so interesting, because it doesn’t contribute very much to the only thing that really matters right now: preventing people here from getting sick and dying, as they are doing in increasing numbers. The search for solutions has only grown more urgent as Tomas has brought heavy rains.

Our CLM members are, of course, especially vulnerable, especially when we are just beginning to work with them. Their extreme poverty guarantees that.

When we begin working with them, they have neither access to safe drinking water nor knowledge of its importance. Most are accustomed to drinking river water or water from springs that can be quite unsafe. And they’ll tell you when you ask them about it that they’ve been drinking the same water all their lives without it ever having caused them any problems. If, however, you ask them whether they have problems with upset stomachs or heartburn, they’ll tell you that they’ve had those problems all their lives, too. But they’ve never made a connection between such issues and the water they drink.

And drinking water isn’t the only problem. They are malnourished, and so their health is generally fragile. And almost all families when they join CLM lack even the most basic sanitary facilities. They have no outhouses, let alone anything like a reasonable bathroom. They use the fields around their homes for what Haitians euphemistically call “doing what’s necessary”.

Our older members, families that have been working with us a year or more, are in reasonably good shape to face the epidemic. They all have filters for drinking water. They’ve learned to use these filters together with chlorine to fight impurities. We’ve help them build hygienic latrines and taught them the importance of using them. They know about the importance of washing their hands. We will need to re-emphasize all these lessons with them as cholera spreads, but we’ve made a good start.

But we also have 400 newer members, 100 who joined in August and 300 who just joined. None of them have water filters yet, nor do they have outhouses. And though we’ve had the chance to talk to the first 100 about hygiene and drinking water, the more recent 300 have just begun to hear these messages. So, our highest priority is to get the news about safe drinking water out as quickly as possible.

Our first effort to do so ran into problems. It can show how hard it is to build the necessary degree of mutual trust with members we will be working with for the next 18 months.

The epidemic appeared right before our scheduled inauguration in Sodo. Though Sodo had not yet seen any cases of cholera — it has since then — we felt we should use the chance to speak with 300 families at once to make a first attempt at educating them about the crisis. In addition, we found some water purifying chemicals that we decided to distribute with instructions for their use. So we spent some time during the ceremony talking about hygiene and the importance of treating drinking water, and we distributed the purifiers we had.

But we don’t yet have these new members’ confidence. Most are happy to be in the program. Many have shown their excitement at receiving goats or other assets. They aren’t used to getting help. Such aide programs as might have passed through their neighborhoods in the past would fail to reach them, bringing scarce resources to people who need them a lot less than they do. Typical CLM members have been invisible. They have failed to matter enough to those around them to attract the attention they deserve. So they are surprised to discover that we really mean to work precisely with them.

Many are so surprised that they don’t quite believe it. It seems too good to be true, I suppose. They imagine that we’ll end up taking the goats back, or that we have some devious plan that will work against them in the end. These concerns are so real that in a few cases women refuse to be part of a program that costs them nothing and offers them multiple assets and other advantages as well, a program that offers them their best chance to escape from the miserable poverty they struggle with.

And even the families who join us — the vast majority of those whom we select do agree to join the program — do so with some trepidation. And their initial distrust can have consequences that are quite real.

Thursday morning, we learned that a new CLM member, one of the ones who had been part of October’s inauguration, had died of cholera. We wondered what happened. After all, she had had water treatment stuff.

This is what we learned: She hadn’t been using it. Most of the new CLM members in her village — a very poor area with a number of new members — had decided not to. A rumor had been going around that the chlorine we had passed out was a poison, that it was causing all the sickness and death. Apparently, someone decided to test the chlorine’s safety by feeding directly to chickens. The chickens died, of course. This made the water purifier, which could have been protecting them from cholera and other microbial dangers, come to seem like the danger to be avoided.

So now we’re rushing into the field with rehydration fluid and more education. We also hope to have more water treatment material to make available to members soon.

But as we make this additional help available, we’ll need to work hard to develop a deeper relationship of trust with our members. One sees that trust in those members who have had a little time to experience the way our case managers work with them and for them. It eventually becomes both far-reaching and implicit. But building up trust usually takes time, and we don’t have time. The presence of the cholera threat has made the first steps of our work more urgent than they’ve ever been.