Prayer and Preparation: How One Haiti Hospital is Confronting COVID-19

May 18, 2020

BY JACQUELINE CHARLES

Miami Herald

It was the biggest single-day increase since an ill-prepared Haiti first confirmed that the novel coronavirus had arrived at its shores. After days of single digits and spikes still in the teens, the number of confirmed infections in just one day had peaked to 39. Reading the latest update from the ministry of health on Thursday, Marc Jumlisse, a nurse at the University Hospital of Mirebalais, the first medical facility to open its doors to infected patients, had only one reaction. “I said ‘Let’s pray.’ ”

Jumlisse, who worked 12 years as a licensed practical nurse and registered nurse in the United States before moving back to Haiti in 2010, and the medical staff at Mirebalais have been dreading a tide in the deadly infections that they know is coming, and that the Pan American Health Organization warns could overwhelm an already weak health system. In just one week, the number of confirmed infections of COVID-19, the disease caused by the flu-like virus, had more than doubled in Haiti. They increased from 123 laboratory-confirmed cases on March 8 to 310 as of Friday. By Saturday, the number had jumped by an additional 48 cases and by Sunday, the number of confirmed infections stood at 456. Of that total, 20 people have died — four of them at Mirebalais.

While the spike in positive cases has yet to translate into a deluge of sick people at Mirebalais’s wrought iron gates, things are starting to get critical. Several directors of private hospitals earlier this week reported an increase in patients showing a range of severe symptoms that are the markings of the virus: respiratory problems, coughing, an acute fever. The government’s water agency reported the death of a driver from the coronavirus, and confirmed that several employees had been tested and were in self-isolation.

The director of the country’s prison system, while pushing back rumors that the virus had hit his overcrowded prison population, acknowledged that there was a rapidly spreading fever inside the National Penitentiary. On Thursday, residents in the coastal town of Arcahaie, 30 miles north of the capital, protested after hearing that 75 inmates at the prison in the middle of town had been moved to make room for eventual COVID-19 prisoners. And on Friday, the medical director of Port-au-Prince’s St. Luke Hospital, a private nonprofit that only recently began receiving COVID-19 patients, acknowledged that 11 patients suspected of having the disease had died since Sunday, within three to four hours of arriving at the facility. Dr. Marc Edison Augustin also said with infected patients desperately in need of life-saving oxygen, the hospital was running low on stock.

Marc Jumlisse, a nurse at the University Hospital of Mirebalais, the first medical facility in Haiti to open its doors to infected COVID-19 patients. Courtesy of Partners in Health The staff at Mirebalais, which is two hours from Port-au-Prince through the mountains of central Haiti, say they are also seeing an increase in the numbeof suspected COVID-19 patients who are critical, and know it’s just a matter of days before they, too, face tougher decisions.“‘What’s going through our heads is, ‘Get it ready,’ Jumlisse said. “How many beds do we have, how many can we get prepared? How many staff... how many people can we train now?”

With patients continuing to come for regular medical care, resources are being stretched thin. With a background in emergency response and public health, Jumlisse, wonders if she’s taking her best nurses away from other critical patients in the intensive care unit to put them in the COVID-19 treatment center, where an initial fear from healthcare workers to be assigned there has now turned into a raise of hands.

Loune Viaud, the executive director of Zanmi Lasante, the Haitian non-governmental organization that operates the hospital along with its U.S. partner, Boston-based Partners In Health, also worries. Hundreds continue to show up daily, traveling six hours or more on public buses and on the back of motorcycles to sleep in the hospital’s parking lot in order to secure a place in line at first light to see a doctor. “Every night when I go to sleep, I am thinking I am going to wake up and hear that the cases have spiked and they are going to send us more patients,” said Viaud, who is also running COVID-19 sites in St. Marc, Hinche and Belladère and has a team doing rapid testing at the Belladère crossing at the Haiti-Dominican Republic border.

According to Dominican immigration officials, 25,000 Haitians have returned to Haiti since the start of the pandemic, deepening fears of rapid community transmission given the high number of infections in the Dominican Republic, where the health ministry reported 12,314 cases on Sunday and 428 coronavirus-related deaths. Haitians are crossing despite the official closure of the border. Last week alone, 1,321 Haitians crossed the official Belladère border in Haiti’s central plateau, according to the International Organization for Migration. There are at least 59 other crossings, all unofficial and unmonitored, in the same region. ”I keep thinking, ‘What I am going to do when the cases start to increase, and for how long can we hold on?’ ” Viaud said.

A non-profit solar-powered teaching hospital, the University Hospital of Mirebalais is one of five officially designated COVID-19 hospitals in Haiti, where medical experts estimate they will need at least 9,000 hospital beds to combat the infection when it peaks. Combined, the hospitals have less than 300 beds devoted to individuals infected with COVID-19. Envisioned before Haiti’s devastating 2010 earthquake, the hospital’s $21 million construction was fast-tracked after the quake left more than 300,000 dead and the main government hospital was destroyed. Today, it is not just the country’s biggest operating hospital with its 300 beds but perhaps the best equipped to confront the global pandemic, even with just 17 beds dedicated to COVID-19 patients.

Unlike other health care facilities, which depend on an oxygen dispensing site in a gang-controlled area of Port-au-Prince, Mirebalais’ ventilation system produces its own oxygen and uses cylinders as back ups if needed. One COVID-19 patient could use a minimum of two to three cylinders of oxygen a day. The COVID-19 treatment unit at the University Hospital of Mirebalais in central Haiti before it received the country’s first two cases in mid-March. Courtesy of Zanmi Lasante Between the time the hospital received the health ministry’s Feb. 7 request asking if it could help care for COVID-19 patients, and when it received the call on March 19 saying Haiti had two confirmed cases and they were en route, staff had just six weeks to transform the hospital’s grounds.

Going into overdrive, they immediately started making preparations, doing so while managing threats from the neighboring community that they will burn the hospital if it were to open it doors to COVID patients. “We’ve tried to manage it,” said Viaud, who was forced to beef up police presence around the premises and called on local leaders for help. “That isn’t to say that the threat has gone away. But we’ve been trying to be more open and educate people as well.” With its own entrance, the COVID-19 response compound is located to the left of the main hospital, a 200,000 square-foot facility. Off limits to non-authorized personnel, the specialized compound includes a converted rehabilitation unit that is used for staff who test positive. The one-time Mother’s Waiting Home, where new and future moms were once housed while being monitored, was transformed for family members and others who have been exposed to the deadly virus and are in need of monitoring.

The actual COVID-19 treatment center was originally designed for patients with cholera and acute diarrhea, a leading cause of death for children under 5 in Haiti. It includes an intensive care unit for those who are critically ill. To gain access, staff must first suit up in hazmat personal protective wear covering every inch of their bodies. Dr. Benoucheka Pierre, who heads the unit, said there are five doctors, each with a different specialty, assigned to the COVID-19 patients. There are also seven nurses, four nursing assistants and housekeeping staff. There is a triage team that includes another set of doctors and nurses assigned to doing screenings of suspected cases. Within the unit, patients are further segregated. Those with underlying health issues like tuberculosis, for instance, are kept apart in another area that is separated by a glass partition. As soon as patients arrive, she said, they are immediately evaluated. Tests and X-rays are performed, and oxygen is given. Medication is also provided, she said, “to treat the COVID and whatever illnesses that accompany it.” All of it is free of charge.

Before beginning their shift, health workers first pass through the cafeteria where they eat, use the bathroom and prepare for a 12-hour shift that could go without a break in order to preserve the two personal protective equipment each is assigned per shift. On average, the unit is going through about 100 units of PPEs per week, and that’s only because the night shift staff works the entire 12 hours without ever exiting the unit. “We’re trying to conserve it because we don’t know what’s coming at us,” said Viaud. Before St. Luke’s Hospital opened in Port-au-Prince and took some of the pressure off, Mirebalais was it, receiving referrals from the ministry of health. One day last month, when cases were still moderate and small, staff counted 16 patients in 17 of the available beds. There was one suspected case in isolation, and five more were on their way.

The treatment protocol so far, Pierre said, has focused more on oxygen therapy rather than ventilator use. Pierre and the other doctors caring for COVID-19 patients benefit not just from their own experience of working at a teaching hospital, but that of a slew of physicians and global health experts outside of Haiti. These include Harvard’s Brigham and Women’s Hospital, the second largest teaching hospital of Harvard Medical School in Boston, and it’s Department of Global Health and Social Medicine. They also rely on expertise at Massachusetts General Hospital and of course Paul Farmer, the world renown medical anthropologist and infectious disease expert who is also the founder of Partners In Health.

Farmer and Viaud have been on the front lines of every major epidemic that has hit Haiti in the last three decades: HIV/AIDS, tuberculosis, cholera, Chikungunya and Zika. “Cholera, Zika — these were fast-moving regional epidemics when they hit Haiti. AIDS was a slow-moving global pandemic,” Farmer said. “COVID-19 is a fast moving global epidemic hitting everywhere at once.” Farmer is on the phone almost daily, the staff say, checking in on patients and discussing treatment protocol. “It’s the same drill,” he said about the approach to COVID-19 compared to other epidemics. “Try like hell to work with Haitian authorities, be confident that the folks like [Hospital CEO Dr. Maxi Raymondville]..... and the 6,400 other... folks are the best there is on the ground, some with 30 years experience fighting epidemics... Work on care protocols because that’s what the Haitian people expect of us. “Never accept second best as a policy goal,” he added.

It’s not an easy fight. Though it has taken on the role of a public hospital in Haiti, where the construction of the country’s rebuilt 534-bed General Hospital continues to be mired in construction overruns and delays, Mirebalais doesn’t receive any ministry of health funding. It relies on private funds and foundation support, which in recent years have declined along with other foreign donor money for Haiti. The U.S. Agency for International Development recently announced it was providing $16.1 million for Haiti to help it respond to COVID-19. None of that money is going to Zanmi Lasante. For now, the Haitian nonprofit is carefully managing its stock of available personal protective equipment, but that won’t be the case for too long, Farmer and others say. In Haiti, Viaud is looking to see if she can hire more nurses and quietly wonders as the disease rapidly spreads if she will find herself in the same dilemma as some hospitals in the U.S: forced to decide whether to devote the entire structure to COVID-19 patients.

Jacqueline Charles has reported on Haiti and the English-speaking Caribbean for the Miami Herald for over a decade. A Pulitzer Prize finalist for her coverage of the 2010 Haiti earthquake, she was awarded a 2018 Maria Moors Cabot Prize — the most prestigious award for coverage of the Americas.

Photo Credit: Miami Herald