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Introduction
This research paper critically illustrates the perceptions and attitudes of Haitian cholera epidemic protection and management program and factors touching their motivation and exploration within the nongovernmental organizations engaged with the cholera preventive measures that addressed to educate people concerned with kid’s education and health workers. The research paper has been organized and contained the five major chapters mentioned below:
- Problem Statement: This chapter of the research paper has well thought-out with ongoing cholera epidemic crisis of Haiti, endow with the underlying problems of the cholera epidemic flowed the earthquake, theoretical principles of cholera management and prevention as an agenda for the present research; raises the research questions and affirms the limitations and scope of the research;
- Literature Review: This part of the research paper launches with a chronological indication of cholera management and prevention and its motivation; it would search for too more up-to-date literature integrating modern public health and guideline with the aim to theoretically arguing to the research questions that would be suitable for nongovernmental organization to mitigate risk of cholera;
- Research Methodology: This chapter of the research paper identifies the justification and the way out on how the research would be conducted, and provides clarification on the selected process for this study;
- Findings & Discussion: This cheaper of the research paper specifies the collected data, uses the information delivered from the cholera management and prevention practice of indifferent countries and generate idea for Haitian cholera crisis management through teacher involved with primary education and health workers;
- Conclusions: However, last chapter of the research paper advocates the sensible outcomes of the research that constructs the key recommendations; and promotes appropriate measures for implications of cholera prevention program.
Background of the problem
Back to the earthquake In January 2010, Haiti placed at 145th position in the United Nation’s HDI out of 169 countries that indicates the poorest condition of the economy, although the country was one of the richest counties in the history, but the brutal colonial exploitation of French turned the nation to be a poorest one. The economic data earlier 2010 demonstrates that almost seventy percent of the citizen lives under poverty level and around 86% citizens in the capital city survive slum conditions and have very poor access to public service like education, public health, and sanitation. The catastrophic earthquake of January 2010 with magnitude of 7.0 carried out a massive destruction in the country while at least 3.5 million citizens were seriously affected, 220,000 citizens lost their life, more or less 300,000 were seriously injured, and 1.50 million turned homeless, and the incident traced as a massive destruction of humanity (DEC, 2011, p.1). Following the earthquake, the country emerged with serious outbreak of cholera in October 2010 and further 5,899 people lost their life within July 2011 while 216,000 were infected and the rate of newly infected people were 84,391 per month in November 2010 and it stands at 13,419 per month at the end of 2011 (DEC, 2011, p.1). The increasing numbers of people are becoming sick with deadly disease in every month has turned a serious threat for the county to overcome destruction of earthquake and rebuilding the infrastructure of the county, while the government along with nongovernmental organizations and UN agencies stand beside the people of Haiti, while US. Responses to the earthquake were very swift (Millner, 2010, p.1).
The problem also turned into more serious while the struggling people of Haiti burst into demonstration against the UN that the peacekeepers of the organization working in the capital city Port-Au-Prince and accused them for the outbreak of cholera all over the country and started brutal attack on the UN peacekeepers. Mosk and Momtaz (2011, p.1) reported in the ABC News that with background to the half a million of the citizens infected with cholera in Haiti, one of the local activist group lodged the complaint that the UN peacekeepers deliberately mixed the bacteria of cholera into the stream of largest river of the country that generated massive outbreak of cholera. The IJDH publicly alleged the UN role in Haiti and raised the question the country where there are records of cholera for almost a century, how the cholera outbreak is going to ruin the nation devastated by the gigantic earthquake, obstinate poverty along with the continuous flow of political unrest has turned 5% citizens infected with cholera. They pointed their claim towards the peacekeepers from Nepal for the reckless actions to turn the country with crisis of regular contamination and death from cholera that is a deliberate outcome of United Nation’s multiple failures in Haiti.
Jack (2011, p.1) reported in the Financial Times that Haitian health officials have rejected an assistance containing almost ten of thousands of cholera vaccine from a Dutch company that offered the lot as a humanitarian aid to Haiti that generated further debate the management of the cholera epidemic in this region. This initiative stir up an intensifying debate with the dependability of the international institutions working in the less developed countries and bring the evidence of the involvement of the UN peacekeepers with cholera epidemic while an US based NGO working in Haiti supported that the rejection was justified. The Haitian representative at WHO headquarter added, although the country is under intensive stress to deal with multiple crises with limited resources after the earthquake, but the donor’s proposal for cholera vaccination incorporated ‘ring fencing’ in the originated area while the vaccines are not sustainable and it may trim down the possibility of low cost generic complexities. Thus, the antagonism with the international communities and UN agencies raised the Haitian cholera epidemic management and protection more difficult, which is essentially need to address by the local initiatives through people’s participation and the education program for children are more effective area to ensure citizen’s involvement.
Rationale for the research
There are huge number of medical scholars those kept their efforts to identifying the bacteria of cholera and identifying their preventive drugs, others tried to find out the solution of the question how cholera management and prevention in a certain country could influence the public health sector by mitigating the risk of such epidemic disease from last era. Most of the contemporary researchers have concentrated public awareness development and urged for sanitation improvement along with education expansion with public private partnership that could that manage and prevent cholera and can save the society from massive. Chingayipe (2008, p.5) conducted a field survey in the capital district of Malawi and pointed out that the cholera bacteria become more active in rainy season with higher fatality, which could be manageable through educating people and developing awareness, although the international development agencies are creating enough panic with this epidemic, but communities involvement is enough to administering the crisis. Through both qualitative and quantitative study, she explored that roles of communities and health workers have a vital contribution to develop the people’s awareness, insufficient and untimely information, lack of obligation of health workers along with cultural backwardness are the major factors that generate massive destruction with poor detection of the cholera (Chingayipe, 2008, p.5).
Nathan (2009, p.78) demonstrated that there is no single model has developed in the clinical research that could exclusively handle to encounter with the epidemic disease at the modern hospital management, there are enough opportunities to use generic approach by the social and medical institutions with appropriate strategy respond to the catastrophic of chorea outbreak management. However, Tuite et al. (2011, p.6) conducted a landmark research with the cholera epidemic surveillance data from Haiti and developed a mathematical model connecting the regional distance among the infected areas and their relation of cholera bacteria reproduction liking with population density of the region and their distance. MHPH (2011, p.1-50) presented a 360 degree analysis with the cholera outbreak and direction for the health workers of Haiti, but it has not indicated any implication plan or any collective measure to manage and administer cholera in this region. There is enough research with the cholera epidemic of Haiti, there is no research agenda yet has been raised on the importance of health education for kids in Haiti relating to Cholera, and thus this area has persisted with tremendous gap.
The rationale of this research is to analyze the cholera management and prevention experience by observing the real scenario of Haiti along with similar Latin American to evaluate to what extent cholera prevention would be effective for Haiti and would capable for implication through the involvement of primary teacher and health workers. In addition, the most recent cholera outbreak in Haiti has escalated the awareness of Health Ministry to control over the cholera management and prevention through community awareness; this research paper will assist the academia, regulators, and health workers with better understanding about the cholera epidemic including its preventive factors such as sanitation, pure drinking water, education, and community awareness development. Through this investigation, the nongovernmental organizations of Haiti will get a potential investment environment in the country and get a better level of donor’s confidence, which will provide the NGOs a practical advantage over their health workers and program managers concerned with cholera epidemic.
Research Question and Objectives
This research paper aimed to investigate how cholera management and prevention would incorporate the primary teachers and health workers could contribute the implication to encounter with the concurrent risk of cholera outbreak? The highly structured aim of the research paper has been designed to respond to the following research questions, the answer to this question would enable the legislators and regulating authorities of Haiti to organize the policy and towards a greater motivation for increased confidence on cholera epidemic control strategies. Three research objectives are listed below:
- To what extent, is the theoretical framework of cholera screening and prevention has developed to response to the cholera outbreaks?
- What are the effective measures for cholera outbreaks?
- How the non-formal health education could contribute to develop people’s awareness and understanding to encounter with the risk of cholera epidemic?
- How the cholera management strategy in Haiti could implement through primary teachers and health care worker?
All of these above issues will assess under certain considerations along with theoretical background and these tasks are significant since each of those issues are closely interrelated with scenario of the concurrent Haitian crisis with cholera outbreak and their serious efforts for cholera management and prevention.
Literature Review
The second chapter has deliberated with the appropriate theoretical arguments on cholera screening and prevention concepts supported by the most up-to-date authors and remarkable researchers recognized by the global institutions working with the risk of cholera outbreak and would organize with following sub-chapters as follows:
Historic Background of Cholera
WHO (2000) defined Cholera is a severe bacterial disease that infects to the digestive tract connecting the stomach to the anus and this syndrome causes by eating foods or drinking water polluted with ‘Vibrio Cholerae’ as well as ‘Serogroups O1’ or O139 and the indication of this fatal disease turn into watery diarrhea along with vomiting and severe dehydration. In such condition, if the patient kept without treatment, it can result to death rapidly within hours while the same bacteria spread out by drinking polluted water and food those can infect surrounding people of the patient (WHO, 2000; and Morger, et al., 1983). However, the Cholera spread out faster in the course of taking polluted food, infected drinking water supply, and person-to-person gets in touch with patients throughout oral routes while the unhygienic environment is another deadly reason of this disease in the less developing countries (WHO, 2000). In such countries, sanitation status and environmental pollution plays a significant role continue to exist and reproduce the Vibrio Cholerae’ bacterium out of the human body as well as can extend faster in the high density of population and water supply resources are not well protected and has possibility to come in contact with human feces (WHO, 2000)
The history of cholera evidenced that during 1817 the pandemic waves of the disease periodically spread out in different parts of South-East Asia; during sixties to nineties, the remarkable authors those visited in the Indian subcontinent had illustrated their bad experience with cholera (WHO, 2000; and Morger, et al., 1983). During 1961, Sulawesi one of the four leading Islands of Indonesia had identified with a particular smash up of the ‘Vibrio Cholerae’ bacteria named ‘El Tor’ and traced as a contributory agent of cholera, which is just biotype eltor and the presence of same bacterial infection identified by WHO in different countries including Europe, Latin America, and Africa in nineties. WHO (2000) reported that in 1990, Bangladesh ICDDRB innovated another new bacteria named ‘‘Vibrio Cholerae O139 Bengal” and later in 1991, four thousand people died in bacteria in sixteen countries out of 400000 infected patients and this fatal epidemic disease demonstrated the risk of further spread out in new areas rather than deteriorating. Further, clinical research demonstrated that the ‘El Tor’ is additional influence to produce unobvious infections that keep it up for a long time in the atmosphere and subsequently reproduce their biotype very swiftly coming in touch with food and water, and stir up with reducing resistance capacity than the conventional biotype as a result cholera turned as a chronic problem. All over the world, the indigenous cases of cholera has identified deadly consequence that remains the threat for several years in half of the countries while in other countries it has turned as an endemic crisis, thus implication of program to control cholera has raised significant awareness both in pubic and private sector including development agencies and health sector NGOs.
Cholera and its Epidemiology
Morger, et al. (1983, p.3) enlighten with the epidemiology of cholera in context of industrial countries of Europe and North America and identified that cholera is not often evidenced in the industrial countries, there are very rare cases for the local people, but evidenced by the travelers and the secondary infections in this region is extremely rare. WSDH (2011, p.1) pointed out cholera as a diarrhea infirmity that mostly evidenced in the less developed countries and this syndrome is robustly related with utilization of polluted water, lack of cleanliness, vulnerable sanitation along with congested living conditions where etiologic agents Vibrio cholerae, O1, O139 and O141 multiply themselves very quickly and cause diarrhea that turn into cholera. Cholera has recognized as a sensitive bacterial enteric syndrome that illustrate its rigorous shape by rapid inception and starts repeatedly painless watery stools along with vomiting, if the patient left untreated, the repeated dehydration would turn circulatory collapse and no way to protect life, although it is manageable at the early stage. The mild infection by El Tor biotype could commence serious injury and may cause death within few if the patient is not treated appropriately while different study demonstrated at the case of higher fatality the rate survival is only 50% at clinical care and it varies depending on the types of cholera bacteria by which the patient has infected. The Species of Vibrio Cholerae has demonstrated in Appendix -1, Figure- 1.
MHPH (2011) pointed out that the clinical investigation already identified different species of bacteria ‘Vibrio cholerae’ that occurs serious harms of cholera which are critically demonstrated in the above figure. Some of them occur mild syndrome, but do not take place any epidemic cholera; especially strains of “O antigen 1” can produce cholera toxin and both turn into epidemic cholera; while most recent investigation in Bangladesh has innovated identified that the strains of ‘O antigen 139’ could cause massive epidemics of cholera in Asian region. Here, it is remarkable that ‘Vibrio Cholerae’ has evidenced with at least seventy varieties of ‘serogroups’, which are clarified as ‘O antigen’ that forms ‘O1 antiserum’ with great peculiarity and rapidity while the other cholera bacteria are collectively identified as ‘Non-O1 Vibrio Cholerae’’, simultaneously the strains of ‘Serogroup-O1 or O139’ are defined as biotype without forming cholera toxin. The biotypes has categorized into two classes such as ‘Classical Biotype’ and ‘El Tor’ those were identified during 1961 while the serotypes are also categorized into two classes for instance ‘Inaba’ and ‘Ogawa’ those are not caused fatal cholera epidemic. Although most of the O1 bacteria infections are toxinogenic bacterium, there are some non-toxinogenic bacteria while out of seventy varieties eight combinations of biotype, serotype, and toxin status demonstrate the threats of cholera epidemics. At this connection, it is notable that the concurrent Haitian cholera epidemics are rooted with toxinogenic ‘Vibrio Cholerae O1’, ‘Serotype Ogawa’; along with ‘Biotype El Tor’ those are the major source of the synchronized crisis for public health of the country.
Modes of Cholera Circulation
The communicability of cholera bacteria is a major concern to identifying the strategy for management, prevention and treatment of this fatal disease, thus the community leaders, health workers and primarily school teachers who are concerned to volunteer for cholera epidemic must know how the disease transmit. However, Tuite et al. (2011, p.5) presented a cholera transmission model for Haiti and demonstrated that the Cholera in the majority of cases generally attain by ingesting foodstuff otherwise drinking water infected with human feces and vomits of the patient screw up cholera and suffered for few days. The captivatingly of cholera through direct person-to-person spreading is generally a rare case and evidenced that it is essential to have elevated inoculums media to transmit the disease in view of the fact that ‘Vibrio Cholerae O1’ as well obviously happen in watery atmosphere it could attain next to ingesting polluted food or water and even shellfish originated from sea. However, the Model of Cholera Transmission in Haiti has illustrated in Appendix – 2, Figure- 2 to get more information in this regard (Tuite et al., 2011, p.5).
Tuite et al. (2011, p.5) presented the compartmental model of cholera transmission that illustrate the inhabitants as vulnerable for contamination and carry out the disease to others while it has integrated water compartment into the model and this part could be impure with contaminated substances along with infectious people and can turn risk of cholera epidemic within a wirer area. The above figure illustrates the depiction of the model and approaching the simulation of cholera in Haiti where it could transmit by both ways like the one individual get in touch with infected patient and water and food which contaminated by the transmission ‘Vibrio Cholerae’. The reason of water pollution with ‘Vibrio Cholerae’ is more often than not the feces of cholera patients and this bacterium has an ecological basin, predominantly in the climate with warm coastal salty waters, while the individual-to-individual contamination could occur by direct contacts like shaking hands and touching the patient to care. MHPH (2011, p.6) specified the particular media of cholera transmission vehicle such as waters from municipal supply, shallow well, river and even bottled water while seafood like raw mussels, oyster, and fishes included a variety of processed and frozen foods and so on which may identified by laboratory investigation connecting with epidemiologic and environmental conditions. WSDH (2011, p.2) pointed out to be caring about the incubation period of cholera bacteria that it typically lasts from a few hours to seventy two hours diarrheal fluids are highly infective and needed caution up to five days, the patients after recovery most likely pointed to be communicable until his stools remain positive, which may prolongs for several months.
Treatment of Cholera
Here the paper would present the treatment process of cholera in to two different sub-heads as follows:
Primary Treatment of Cholera
Page (2007, p.1) pointed out that the bacteria ‘Vibrio Cholerae’ introduce the diarrheal disease in the human body first starts with dehydration and turn into injurious cholera, such gram-negative bacteria bring into being of heat-stable toxin into the bacterial cell that prevents the G protein into the pattern of promoting cyclic adenosine mono-phosphate. The CAMP operates the cellular level to generate a variety of metabolic processes that mediate the reserve of sodium and chloride and drives cells to release water and massive diarrhea come into evidence to cholera symptoms. At the early stage, the primarily process to treating cholera suggest to restore the fluids that already lost by repeated diarrhea, for cholera taking oral rehydration solution (ORS) is a potential re-hydration therapy to treat dehydration along with electrolyte sleekness while the disease also treated with antibiotics at moderately severely stage.
CDC (2010, p.1) identified the symptoms of moderate and primary stage of cholera that could be treated at home would involve with weakness and bad temper, cadaverous eyes with drying mouth, increasing thrust, decreasing urine, but increased frequency of stools and discharge of diarrheal fluids. MHPH (2011, p.11) pointed out that earlier than detection of rehydration therapy with ORS, the world evidenced at least fifty percent of the patients with representative stern of cholera had lost their life; but the innovation of ORS in the concurrent era has reduced the death from this disease and now the mortality stands at 1% even less. Countries with cholera epidemics have now managed the causality of the disease and about 90% of infected individuals are treated with ORS, patients who at the starting of discharging diarrheal fluids for three to four times would require start therapy with ORS. In the case of diarrhea, even there is absence of the symptoms of dehydration ORS therapy is essential, the formula of ORS recommended by WHO has presented in the Appendix-1, Table -1 (DOH, 2010, p.4).
Patients who have diarrhea and no signs of dehydration be supposed to taking ORS in every loose of stool to sustain the hydration at the normal level and the process must continue in anticipation of diarrhea ends, WHO has provided an indicative dosages of ORS that has presented in Table- 2, Appendix- 1.
Appropriate dosages of ORS could very effectively reduce the chance of the patient to gain clinical status and proper home care with timely monitoring is vital approach especially while the patient lives in a remote area and far from medical facilities, but for severe attack, it would not be wise to keep the patient at home without care. The highest care is needed for not to leaving patient’s stools with diarrheal fluids in touch with drinking water sources or in the open place, it could generate serious outbreak all over the region. During the home care, enough dosages of ORS are essential give and measure the frequency of discharging diarrheal fluids for at least two days while the ORS must be prepared with fresh drinking water and the solution may not keep in open place for a long time. It is better to use boiled water to prepare ORS, if the frequency of discharging diarrheal fluids decrease within two days than there is no need to think about clinical care, but in case of increased frequency, it is essential to transfer the patient at hospital or nearest health care center.
Clinical Treatment of Cholera
CDC (2010, p.1) in case of severe cholera it is essential for the patient to provide clinical care, while patient infected with cholera bacteria and demonstrate mild diarrhea symptoms has no need for clinical care, it has evidenced that about seven percent of the patients infected with ‘Vibrio Cholerae O1’ have the necessity to go for clinical care.
Before the laboratory investigation, there are several symptoms those may confirm the status of severe cholera, after huge vomiting and discharge of diarrheal fluids if the patient becomes unconscious, feels extremely dried mouth and tongue, missing pulse, reduced urine along with low blood pressure, then the patient is under attack of rigorous cholera and must send for clinical care.
At this instance, it is notable that although the patient would send for clinical care, by any means, it would not be wise to stop rehydration therapy with ORS; however, the health care worker must keep in mind that swift high-volume rehydration would save the patient’s life while the medicines are given along with ORS therapy must continue.
At the clinical care antibiotic would be given to the patient orally and it will diminish the frequency of diarrhea, especially antibiotics are recommended for the patients who prolong to discharge huge volumes of stools with diarrheal fluids at the time of rehydration therapy and all those who are hospitalized with severe cholera infection.
It would not be wise to give antibiotics depending on wrong assumption, better to go for laboratory investigation whether the patient carries ‘Vibrio Cholerae O1’ or not. If the patient is a child, it is better to give zinc orally and it would not be allowed to give any other drug except antibiotics and zinc for any other symptom like vomiting.
Table – 3: Cholera Treating with Antibiotics
In case of children with cholera infection, beside the suggested antibiotics above it is more effective to give zinc supplementation at the rate of 10-20 mg zinc per day and it will help the children to quick recovery from the cholera epidemics.
Diets for Cholera Patients
Different world-renowned research institutions suggest to feeding normal diet for the cholera patients next to vomiting stopped, generally it is better to provide normal food within a few hours starting rehydration therapy, breast feeding babies are allowed to get feeding in regular basis. In this connection, it is mentionable that rather than WHO recommended ORS, it is more effective to continue rehydration therapy by ‘Rice Saline’ or Rice-ORS developed by ICDDRB of Bangladesh and later recognized by WHO and UNICEF. However, rice-ORS is extremely effective both for combating with dehydration and recovery of patient’s energy level, at the same time for its availability of the ingredients from the households and easy preparation made it more popular to as a diet for cholera patients. ICDDRB (2012, p.1) mentioned that the miracle solution was first innovated by the Bangladeshi scientists during 1960 and were tested in the refuge camp of diarrhea patient in the border of India, the result was extremely successful and now it has been using as life saving solution for cholera epidemic worldwide, the preparation of Rice-ORS has given as follows-
For bulk preparation of Rice-ORS, it will require half kg of fine power of parboiled rice would be mixed with 11 litters of pure drinking water and let the solution to boil for five minutes, it is necessary to continue moving the solution with a spoon for not condensed at the lower part of saucepan. The boiling of the solution would continue until its volume become 10 litters, remove it from the burner and have to add 35gm table salt (sodium chloride), 15gm potassium chloride, 29 gm Trisodium Citrate Dehydrate (commercially known as Sodium Citrate) or 25gm sodium bicarbonate and mimed them very well, let the solution to be cool up to tolerable heat. The hot Rice-ORS is more effective than the cool, after one preparation it would not be used more than 8 to 12 hours, for home preparation for a single patient, it is better to prepare one litter each time and after dieting with it, then need to prepare another litter.
Preventive Measure of Cholera Outbreaks
This chapter of the research paper would enlighten on the preventive measures of the cholera epidemics and to do so first it is necessary to identify the media by which the bacteria of cholera spread out, this part of the paper would identify the process of bacteria spreading along with their preventive measures that are discussed as follows:
Emergence for Safe Water Supply
WHO (1998, p.9) pointed out that water is the most significant media for cholera epidemic, people become affected by using infected water that carries bacteria, thus to prevent cholera outbreaks at a certain region, it is necessary to ensure safe water supply for that region. The pubic health authorities and the local governments of every region are supposed to consider that access to pure drinking water is the basic requirement for the prevention and management of cholera epidemics as, thus it necessary to keep highest efforts to provide pure drinking water to the people and for food preparation. In the municipal and metropolitan areas, public health authorities would keep active monitoring to maintain the safe supply water; by any chance, the pipelines may not amalgamate with sewerage water, while the drinking water reservoir also required regular monitoring. There are many ways by which the water supply of an area could be infected, and people are supposed for not to depend on the supply water, they must conduct filtration and boil their supply water at 100 degree centigrade for four minutes to avoid the risk of cholera.
As in the rural areas of less developed countries has no facilities to supply water, people of those are needed to use tube well, although there are enough evidence that in remote villagers drink water from open natural resource like pond and rivers. So, people have to learn about the risk of using open source water and taught how to putrefy water domestically, there are mainly two affordable process of making drinking water safe and they can easily do it at home firstly by boiling water and secondly by chlorination. The chlorination process is also safe and affordable while it needs a stock solution of chlorine 1 % concentration made with 15 gm of Calcium hypochlorite volume 70% or 33 gm of bleaching powder volume 30% and it could be preserved for water purification for one month and it would be effective to make ‘Vibrio cholerae O1’ inactive. The stock solution of chlorine 1 % concentration also could make with 250 ml of Sodium hypochlorite volume 5% or even with110 ml Sodium hypochlorite volume 10%, and can purify drinking water as well to combat with cholera bacteria and would be able to ensure safe drinking water.
Well Protected Sanitation
WHO (1992, p.20) and WTO (1993) pointed out that most of the rural communities have lack of knowledge with modern scientific reason of cholera spreading out, which is deeply concerned with the people’s awareness of cleanness, purity, and pollution for which they do not bother to discharge their stools at the open areas. Discharge their stools at any unprotected place could easily spread out cholera and other air communicative disease by polluting the environment and food supplies, rivers and other water resources and generate epidemics. Well-protected sanitation can obviously diminish the threats of cholera and other bacteria transmission that can seriously hamper the stability of public health and can destroy the civilization, thus well-protected sanitation is a major initiative to keep the water resources safe from cholera infection.
WHO (1997, p.31) added that the modem sewerage system is a costly solution for the remote villagers of the less developed countries and sometime it is a concern of local governments which are not enough strong, so the local communities would require to introduce basic sanitation services with their own efforts to ensure hygienic and healthy solution. There are different types of sanitary solution, depending on the const effectiveness and availability of the raw materials WHO urged for at least Pit Latrine, which is easy to on-site solution. The construction costs of the Pit latrines is very low and rural householders could build it with their own efforts without any external support and can effectively contribute the society by protecting the routes spread cholera bacteria and other diseases while this form of sanitation have the life cycle of 25-30 years. This form of sanitation required several concrete rings of 1 miter diameter, boring the soil at 1.5 miter depth, the pit would set up and covered with a slab with fixed latrine, it should be covered with tin sheets with appropriate ventilation. Such sanitation is the minimum requirement for prevention and control of cholera and other parasitic infections, people in the remote areas who have the financial capabilities could construct further improved and latrines.
Awareness for Food Safety
Food pollution is another most significant vehicle of ‘Vibrio cholerae O1’ organisms, thus it is essential for the public health authorities and NGOs working in the field of public health area must drive to build up awareness among the people for not to eat any raw or rotten foods. It is also necessary to establish a special authority for quality control of processed foods, nations without such measures would face difficult crisis with cholera epidemics. At the same time, some people directly consume seafood, they have to know that seafood has the propensity to be infected with cholera bacteria, so they need to wash them very well and cook them with appropriate temperature for a standard time before eating. People would wash their hands with soap or ash before eating food and feeding their babies, it is also suggested for not to take cool food, rather it is better to take some extent of hot food while the restaurants and street food- store are essential to take under regular monitoring as they are one of contributor of cholera outbreaks.
Health Education for Cholera Outbreaks
Njoh (2010, p.34) pointed out that the health education is the most influential weapon to fight against the cholera epidemics that can reduce the severity of cholera in the endemic regions of the world by restructuring the human behavior and life by developing hygienic sense of hummer, safe sanitation, rehydration, appropriate medication that would bring paramount reconfiguration of individual behavior. Health education would also develop the personal responsibility of the communities in regard to combat with the severity of cholera by understanding the barriers of healthy sanitation, and safe water supply including the scarcity of resources. Njoh (2010, p.34) explored sixteen major factors that incorporate with health education for cholera and other epidemics while the first eight factors are associated with the health education activists and the next eight factors are designed for youths and females of every household who manage and administer the individual families, the following figure has demonstrated in Appendix -1, Figure- 3.
Educating People & Training for Health Workers
It is most essential to design some leaflets describing the risk and awareness of cholera while the guide for health workers would demonstrate the detailed instruction and illustration to construct cost effective latrines, water purification systems for small areas or independent families, rehydration process with ORS and common drugs used for chloral patients. The health workers also taught how to treat the patients at home and when they have to carry the patients to the nearest health centers, moreover their training package would contain general guiding manual, including slides show, video tape that would teach the health workers how the doctors treat and manage cholera patients at urban hospitals. After a two or three days theoretical training program, the health care workers would send to the health care centers or hospital for one day practical training that would ultimately motivate them to work with cholera patient.
Availability of Essential Supplies
It is most significant job for the public health authorities to build buffer stocks of essential supplies requited to combat with cholera with the aim to prevent massive death of lives and the essentials involved with ORS, Rice Ors, Antibiotics, and intravenous fluids, such stocks would be made at the public health facilities at district level. The district level health facilities would be well connected with the distribution centers of remote area for quick supply of essentials; otherwise, it is essential to keep small stock of essential supplies of cholera at the health centers of remote areas, at the same time, it is more important to increase public health facilities all through the country.
Surveillance and Epidemic Reporting
It is crucial to maintain a compulsory registration process at the remote health centers and urban hospitals for diarrhea cholera patients every day, where it has clear entry register for the surveillance and number of death from this disease including their race age and gender entry. However, such recording would provide a better opportunity for further national policy determination to fight against severity of cholera; health workers in the remote areas also maintain a diary to register cholera victims at their working area. Moreover, the IHR – 1969 made it mandatory for the all nations to reporting the cases of cholera and other epidemics to the WHO at any instance including the laboratory reports in the national territories that would enable WHO to take further initiates and protective measures to suggest (WHO 1993, p.11).
The national health authorities would coordinate cholera prevention and management program at regional, national, and international level and serve the patients with appropriate treatment while data collection and information exchanged through countrywide coordinating team, vigilance control teams and by modernization of laboratories for cholera epidemics. At the same time, such initiatives would also keep ready organize temporary health service at the infected areas and carry out campaign to broadcast information aimed to reduce public panic with cholera epidemics while there is emergence to establish epidemiological study center at national level.
Research Methodology
Introduction
The objective of this chapter is to expound how the chosen research approach will apply to organize the paper; however, the subsequent heads, such as, research design, secondary data, and secondary data analysis process along with scope of the research, questionnaire design will discuss the approach more elaborately.
Research Design and Research Approach
Many researchers like Cohen, Manion & Morrison (2007), Malhotra (2009) and Saunders, Thornhill & Lewis (2006) provided a number of methods to formulate the paper with primary and secondary data; however, the author of the present research will use mainly descriptive research approach to discuss the problem and identify solution and quantitative research approach to quantify data.
Secondary Data
Secondary data is the processed data, which is easy to access with minimal or no costs, for example, numerous books, e-books, renowned journal, government publications and many report of relevant organizations available in the library and online databases (Malhotra, 2009, p.37; Yin, 2003; Saunders, Thornhill & Lewis, 2006; Sekaran, 2006; and Zikmund, 2006). However, secondary data is not always suitable to concentrate on the particular issue, but this research paper would concentrate on such data because the researcher of previous studies have organized by gathering either primary or secondary data to get precise results; therefore, it will consider it to analyze the factors importance of health education to prevent cholera outbreak in Haiti. At the same time, the researcher used many available secondary resources like journal articles, news release and reports of World Health Organization, Washington State Department of Health (WSDH), CBC News, WTO Department of Health, Center for Disease Control and Prevention, Disasters Emergency Committee, and so on.
Secondary Data Collection Methods
Cohen, Manion & Morrison (2007), Marshall & Rossman (1999), Miles & Huberman (1994) and Malhotra (2009) provided the sources of secondary data to formulate the paper, such as:
- General Sources: Guide, directories, indexes, and statistical data;
- Government Sources: it includes Census Data & Other Government publications;
- Computerized Database: These sorts of sources contain online, offline and internet sources
However, the Figure-4 in Appendix- 1 shows the data collection methods more elaborately to understand the secondary data collection method
The researcher of this research paper would remarkably focus on the internet databases since it is one of most cost effective and familiar way of collect processed data; however, available reports of WTO, UNICEF, and ICDDRB had properly analyzed the cholera outbreak in Haiti along with the possible solution and treatment to save the children from cholera outbreak.
Secondary Data Analysis Process
As the researcher will thoroughly study the existing research paper, it can assume that the previous researchers has removed all errors before providing results; however, after studying the prior study it will be analyzed in this present paper considering demand of the topic of this research paper.
Scope of the Research
Although the Haiti has evidenced cholera epidemic in October 2010 following the earthquake of January 2010 at first instance, the disease has almost a century back history to generate disaster for human race. The Haitian people has been facing the catastrophes of cholera for the last two years, but the people of South Asia and Africa has experienced to combat with cholera, as a result the literature of this epidemic has enriched to a higher extend. Thus, the availability of rich research resources with cholera is the major scope for the present research. There are also some landmark researches with the cholera epidemic in Haiti; especially WHO, MHPH, UNICEF and academia have provided few milestone report and guidance those have considered a valuable scope for the author of this research. On the other hand, the previous research works demonstrate that citizens of Haiti are very loyal, easygoing, and cooperative, which is also a scope for the author to interview them with the aim to reach at the goals of this research.
Limitation of the Research
The main problem to organize the paper was specific word limit since the topic “the importance of health education for kids in Haiti relating to Cholera” is the vast area of research and it should discuss too many relevant factors in this regards. Moreover, the time limit was not sufficient to complete the research work on this complex area because it needs to discuss many issues to address the topic, such as, about the literature on cholera disease, the way cholera spread, preventive measures to save the Haitian from cholera, and the treatment of cholera, the position of Haiti. In addition, there were too many secondary data sources regarding cholera outbreak in Haiti, but there were no fruitful outcomes of the previous research on this segment to integrate, as prior studies had not concentrated more on the position of educating the children in Haiti as a primary way to stave off the Cholera epidemic.
Discussion
Community Education as Alternative Solutions
Smith (2007, p.2) and CBC News (2012) explored that informal community education is an alternative to the formal education without any border barrier of age limit and institutional framework, which is a raising demand for the social motivation, political changes and higher extend of community interest. During the last century, the community education has flourished progressively more all over the world and the ranges of such educational practices kept very positive impact in the social progress in comparison to the formal schools, colleges, and universities and get the attention of social worker for greater motivation of the society. In context of health education for cholera epidemics, the formal medical education is a time-consuming matter while community based informal education could educate all greater communities with the process of cholera management and prevention within a few sessions of community based discussion. As the natural calamities have kept serious economic disaster on the country, the community education is a cost effective solution for the nation to combat with cholera.
Understanding the Community & Haitian Culture
WHO (2010, p.5) argued that the couture of modern Haiti has developed through a long historical background, in 1492, Christopher Columbus arrived in this region, and Spain established its colonial rule for sugar cane cultivation. France and Spain simultaneously continue to settle here, and in 1697, it came under French administration, turned into richest one that served two-thirds of the resources of foreign trade for French. Haiti is the first Black Republic in the world that proclaimed independence in 1804, and the county flourished with its hope, pride, and economic growth during the nineteenth century, but the imperialist governments and investors exploited the nation and ruined it economy and turned into one of the poorest county.
Haiti is the poorest country in the Americas and it has many external and internal economic problems such as severe trade deficit though this country is a member of World Trade Organization, which gives the chance to take the benefit of free market economy to export its product all over the world particularly in the US market (Indexmundi, 2012, p.1). At the same time, the initiatives of the Governments to change the financial and social position of the people of this country is not bring fruitful results due to lack of investment, and higher inflation than similar low-income countries, increase unemployment rate, natural crisis like earthquake, high corruption in every sector, poverty, and poor access to education, etc. (Indexmundi, 2012). In addition, natural disasters, racial discord, political instability, severe deforestation, lack of infrastructure, monetary policy, and soil erosion problems are the prime reasons of economic crisis of this country; therefore, more than 80% of the population living under the poverty line and Only one in 50 Haitians has a steady wage-earning job (Library of Congress, 2006, p.12 & Indexmundi, 2012). Most significantly, two-thirds of all Haitians rely on the agricultural sector and economy based on other industries along with HOPE Act 2006 increased apparel exports and investment by giving opportunity of duty-free access to the US; however, in spite of such initiatives, over 54% of the population living in abject poverty line (Library of Congress, 2006, p.12 & Indexmundi, 2012).
However, the overall economic position highly influenced on the all sectors of Haitian’s life particularly education sector, for instance, education standards in Haiti are extremely low along with Haiti’s literacy rate of about 53%; therefore, in 1997 the government approved a 10-year education plan and increased budget by 22% in 2000 for education sector (Library of Congress, 2006, p.12). In this circumstance, the government of this country arranged a literacy campaign, and distributed 700,000 literacy manuals in 2002 to develop this situation and encouraged the people to take available public services to reduce costs of education though most Haitian schools (around 90%) are private (Library of Congress, 2006). As a result, the people of Haiti are not health conscious because of lack of knowledge in this regard (Library of Congress, 2006; & UNICEF, 2011). At the same time, Library of Congress (2006, p.11) pointed out that health related problems have pushed Haiti to the underneath of the World Bank’s rankings (as this country has only 25 physicians and 11 nurses for 100,000 people) and UNICEF (2011) further reported that the people of this country has no experience to handle a public health crisis.
Moreover, they have suffered numerous problems related with health (sanitation problems, poor nutrition, lack of pure drinking water, and limited health services) those can be removed by increasing awareness of the children and their families though most of them live below the poverty line (Library of Congress, 2006; & UNICEF, 2011). Therefore, development of awareness of the people by introducing health education in the existing educational system can one of the most effective solutions to reduce the threat of Cholera epidemic and other diseases.
How to communicate within the Haitian culture
To communicate with the Haitian culture, it is most significant to understand their family construction, their lifestyle and religion believes while the families of Haitian society are very complicated in nature and absence of gender equalities. Most of the rural families of Haiti consist of huge relatives including friends and neighbors those are organized with interdependency on each other, for their common interest, they share their works and childcare within the family by living at same square and such family unites are called “Lakou”. Urban families are organized with an amalgamation of Haitian and Anglo-American style and there no strong lakou and evidenced less interdependency, although headed by fathers, but the fathers are in most case escapist and the mothers have to take family responsibilities.
Due to insensitivity of fathers, mothers have to take responsibility for economic, spiritual, and emotional life of the family members for which the number of mother headed families is continuously increasing, even the mothers do not bother to getting support from the lakou system. Gender inequalities have strongly accorded in the Haitian society females are extremely posed with physical violence and sexual abuse, while single mothers possibly have the alternative to exchanging sex for cash to maintain their families. There is no single homogeneous religion in the Haitian society, Catholicism, Vodou and Protestant are the three believes simultaneously belonged among the citizens, and to some extent, they are influencing the political life, social values moral issues as well as health factors, thus to communicate with the Haitian society, all these factors have to take into account (WHO 2010, p.10)
Educating the teachers and healthcare providers
WHO (2005, p.5) argued that before providing effective teaching for the health care providers, it is essential to outline a course by a legend educator from the concerned academia that would facilitate the healthcare providers with a variety of learning outcomes that would ultimate helps them work more efficiently with the target communities. In context of educating primary school teacher and health care workers for cholera epidemic in Haiti necessitate to introduce a flexible package of training materials that come together with understanding the cholera bacteria, their process of infection, dangers, remedies, protection and treatment incorporating with individual scope of study and practice of learning from the educator. To conduct such training for the teachers and healthcare providers, the training materials includes a healthcare Providers reference manual along with learner’s guide that covers all of the significant steps to combat with cholera epidemics, indication of planning for working at the remote areas, and goodwill to serving the infected people to survive. However, the contributors of the program have to keep in mind that the primary teacher and health worker may not get enough inspirations to involve themselves jut for volunteering, so it is indispensable to arrange cash incentives for them.
The crucial rudiments of the course designed for this training has three areas to address, firstly, educating drinking water purification process, secondly, learning how to set up pit latrine with practical knowledge and finally, teach them how to conduct rehydration process and use of antibiotics, a number of figures have given in the appendix for better understanding of the learners. Rajasingham et al. (2010, p.1) strongly argued that the community health worker’s train materials would must incorporate WHO technical guidance, message from ICDDR, Bangladesh and CDC direction would be more effective materials to get quick response against cholera in Haiti.
Conclusion & Recommendations
Following are the vital recommendations and conclusion of this study:
Recommendations for Implication
From above discussion and findings of the paper, it is clear that Haiti is in crisis both from the aspects of political economy and public health, vale that the country paid for its independent from the colonial rule of French has seriously hampered it’s economic growth, social progress and political stability that ultimately turned its position at poorest one. The country has not enough resources to combat with the catastrophes of earthquake and cholera epidemic simultaneously, the dynamics of relief effort for reconstruction and humanitarian aid in Haiti has emergence to reconsider its foreign policy whether it may not align into the trap of foreign aid that turn its independence fruitless. The foreign policy of the country necessarily will set the stage for the long-term recovery and reconstruction while international cooperation to combat with epidemic has special appeal for quick recovery and less suffering for the people. Obviously, the rejection of vaccination assistance by the Haitian authority has demonstrated it courage to the international communities ostensibly, its emergence to keep into consideration on two key concerns- firstly the limited facilities of the Haitian government to combat with cholera epidemics and requirement of huge investment for earthquake reconstruction, while the policy response carried disbelief among donors. Thus, it is essential for the political institutions of Haiti to unite in a platform in the question of national interest and mitigate internal conflict with influence of the international agencies and external forces. A class of civil society and NGOs who working with the funding of donor agencies are most likely eager to making business in the name of social work and they are eager to uphold donors interest rather than emphasizing on national interest and the meaningful welfare of the Haitian society and people. Thus, it is appropriate time to bring the civil society, political parties, and NGOs under one banner to encounter simultaneously with the reconstruction work of concurrent earthquake and protection of cholera epidemic in the country that would ensure safe and social life for the Haitian people.
The ‘Three Angels Haiti’ is a nongovernmental organization that aimed to engage its efforts to combat with cholera epidemics in Haiti by mobilizing people through an extensive educational program that addresses the children and their families regarding the process and guidance to combat with cholera including its management and treatment process of this deadly disease. The organization would like to conduct its educational program at three phases where the orphanages of Port-au-Prince, second and third phases are the schools and medical clinics those are organized and conducted by the organization at its operational areas of Haiti; still the organization believes that education is the most powerful weapon to fight against poverty and chloral epidemics. Following are the recommendation for ‘Three Angels Haiti’ to combat with cholera outbreaks through educational program that would implement gradually.
Publication of Cholera Booklet
For implication of cholera prevision, management, and treatment program, firstly, it is essential to prepare a most easygoing and shot descriptive guideline that would be organized with colorful image and sketches, which demonstrate how to maintain hygienic lifestyle, wash their hand and face before taking meal, and how to purify drinking water. Most significantly, such a publication would incorporate the procedure of ORS and Rice-ORS preparation and most common drugs to treating a patient with cholera at home and emphasis on the appropriate rehydration process that is the most vital factor for a patient for not to be hospitalize and overcome the risk of death from cholera.
Teachers and Health Workers Training
It is essential to conduct orientation program for the primary schools of Port-Au-Prince where the children taught about the management and prevention of cholera epidemics to select the teachers interested to volunteer for cholera prevention. However, it ought to keep a provision for cash incentives for the teachers who would be interested to take part in this program, as most of the teacher may suffer from confusion that volunteering with cholera epidemic may cause infection to them, thus the orientation program would mitigate misunderstanding with cholera by outlining the educating program. NGOs can make it compulsory for the teachers and health workers to take part in the cholera-educating program at their schools and health centers. Selecting the right teacher and health workers, training program starts with from the historical evidence of cholera, process of its bacteria spread out, and the appropriate prevention measures with treatment. In the training program the teachers and health workers also learn how to educating people and how to communities with the target group and how they would more easygoing with the aim to be acceptable to the people as well as to the children at school.
Global Warming and Environmental Awareness
Beside the management and prevention measures of cholera pandemic, the awareness development drive also address that global warming and climate change has a further influence to leading the grounds of morbidity and mortality through epidemics, while Haiti has no history of cholera in the past centuries, for least few years it has been provoked by sudden appearance of cholera epidemics. Until the earthquake, cholera was in fact rare in Haiti, following the earthquake, the country has evidenced more vulnerable than the South Asian countries due to lack of preparation and immunity, even the vulnerability of public health due to global warming and climate change has influenced people to cope with adaptive capacities, but there is no concentration on this regard. Although there is anecdote that the UN peacekeepers have willingly supplied the cholera bacteria in Haiti and the reason of cholera epidemic spreading out is a political agenda, but awareness development program must enlighten on the global warming and climate change.
Taught to Children
Different studies demonstrated that in most cases of cholera epidemics the infected patients are children and women, as they are most vulnerable by the wave of cholera, the ultimate objectives of educating children campaign has to ensure that in every family, there should be at least one member, who knows the symptoms of cholera and how to treat and manage. If the government and policy makers appropriately design book for children on cholera management and pretension, which would introduce from school level and the teachers concentrate on its regular study, then the students would be well familiar with the pros and cons of cholera epidemic management. At the same time, parents would get a further opportunity to learn all about cholera and would be capable to attentive to the defensive measures to be infected with this waterborne disease along with its treatment and management.
Parents Orientation and Motivation
The educational institutes of kids where the cholera awareness program would be conducted, the school should frequent arrange parents meeting and orientation program where parents would take part at an open discussion following the orientation with cholera education. Primarily the orientation and motivation program would be guided for the parents to make them efficient to save their children from the infection of cholera, but the ultimate goal of this program to identify the local community leaders through whom the cholera prevention and management program would expand in new areas for further campaign with cholera awareness program. The parents would share their views and experiences in their personal encounters with cholera, if any evidence comes into a platform to continue their cholera awareness program at their local communities where the schools would provide cooperation and technical assistance including cholera publications for the communities.
Social Marketing Campaign
The recommended approach of this paper would urge to initiate a well-designed social marketing campaign with exceptional features rather than traditional hygiene and sanitation program, but a 360-degree approach to combat with cholera epidemic. As the people lived in the programmed area is the major focus of this social marketing campaign, the campaign actively incorporates various diverse groups in society to whom it organizes a shared agenda for action to combat with cholera epidemic. The social marketing campaign starts with data collection with the aim to identify the exact needs of the target communities and then coordinate appropriate interventions of health specialist to design and develop strategic approach that would be capable to draw the attention of the target people and communities.
The approaches of this social marketing campaign would work as well in a basis of participatory coordination community-by-community basis, as the campaign would conduct same approaches of propagation with same materials, it would most useful and cost-effective on a large scale combating with cholera epidemic where the people’s participation would be in a small-scale and gradually get exploration. Due to participatory manner of the campaign, it will start from the areas of Port-Au-Prince where the program conducting NGO has its own schools and health centers and then expanded across regions of urban and rural areas of Haiti that the authorities would consider as best fit.
The basic approach of the social marketing campaign uses most prevailing measures of cholera prevention that matches the available resources with social needs of Haiti and applies service provision, integrates the development of treatment and rehydration process with people’s acceptance of products by motivating their behavior with a new approach of hygienic lifestyle. The development of knowledge of hygiene and necessity of safe sanitation is at the baseline of the drive against combating with cholera and the promotional approach of this campaign would coordinate it as a firm agenda to address to the people by ensuring their participation and partnership with their communities along with evaluation of the progress time-to-time.
The implement the process that stated in this recommendation, the organizers would time-to-time exchange their views with the civil society and media with the aim to assess the own strength and weakness to achieve the goals of conquer the threats of cholera epidemics in Haiti and to get more refined and collective findings that would strength the fight against cholera. At the same time, this implication process would also keep a live communication with the Ministry of Health of Haiti and donor agencies to keep them informed with progress of the program and to get in touch with the latest information of cholera epidemics.
Conclusion
The simultaneous attack of earthquake and cholera outbreaks had seriously distressed the nation, while the political unrest has added a new dimension in the concurrent multifarious crisis of Haiti. Introduction of cholera bacteria in Haiti by the UN peacekeepers and Haitian government’s rejection of vaccine assistance have generated more complication between the local action groups and donor agencies that has seriously hampered the quick encounters with this waterborne disease, as a whole the people’s sufferings prolonged for long duration. At the conclusion, this study would urge that rather than any political alignment for fighting against cholera, it is essential to uphold the Haitian people at the center of all concerns and to ensure a safe life from cholera epidemic without any debate. Right now the emergence and the prime necessity is to educating kids and their parents for cholera management and how they combat with this fatal disease with their own resources and capabilities without any external influence while the vaccination has an appeal for the people living in crowded places with limited access to clean drinking water and safe sanitation.
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