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

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

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

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

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

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

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

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

From the American Enterprise Institute, Washington, DC.

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

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

Reforming Health Care Reform in the 112th Congress

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

Related article, p. 33

The earthquake that struck Haiti on January 12, 2010,

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

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

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

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

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

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

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

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

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

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

Waterborne pathogens and fe-

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

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

Responding to Cholera in Post-Earthquake Haiti

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

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

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

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

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

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

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

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

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

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

Responding to Cholera in Post-Earthquake Haiti

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