A growing body of evidence suggests that in Africa a Zika epidemic could be undetected and overlooked. Cameron Nutt and Patrick Adams report. In April of 2016, reports were streaming in of Zika cases across the Americas: Panama, Martinique, Chile, and Peru. Just as officials had predicted, the epidemic was spreading fast. Each report reinforced the conventional wisdom that Zika was primarily a threat to the western hemisphere and that, so far, mainland Africa had been spared its pernicious effects. Then came a report from Guinea-Bissau. According to the country's Ministry of Health, from April to June, 2016, six infants in the small west African nation had been born with microcephaly after possible exposure to Zika. Clusters of suspected infection in adults were also reported across the country. Similar reports from South America had prompted swift responses from international health agencies, but it would be 3 months before blood samples from the infants in Guinea-Bissau were sent to an international laboratory and more delays followed. Not until September, 2016, did the public learn that the adult cases were confirmed to have been caused by a local African strain of the virus, not one imported from Latin America. In November, diagnostic testing indicated three of the newborn babies had been exposed to either Zika or chikungunya, though further studies were ordered to differentiate between antibodies to the two viruses. “In Guinea-Bissau, the surveillance system has detected a number of microcephaly cases which appear to be above the national baseline”, said WHO spokeswoman Monika Gehner. “With the support of foreign reference laboratories, Guinea-Bissau is diligently investigating cases of congenital malformations to determine whether the suspected microcephaly cases are caused by Zika virus infection in utero.” A year after the first report from Guinea-Bissau, those investigations have yet to produce results. The delay itself is telling: a measure of the degree to which key assumptions have shaped the global response to this Public Health Emergency of International Concern. One such assumption is that the absence of evidence of congenital Zika syndrome in Africa constitutes evidence of its absence. There is also the widespread but unproven assertion that genetic differences between strains were primarily responsible for the ability of the virus to damage the CNS. Media outlets widely printed this as fact, yet a growing body of evidence has challenged these claims. To date, at least 30 laboratory-based studies have suggested that African strains of Zika are capable of causing the same, or worse, damage to cells in the CNS, and reproductive and immune systems as the so called Asian lineage strains circulating in the Americas. Many of these discoveries have occurred incidentally. Research teams were unable to obtain Zika samples from Brazil in 2015 and had to work with the original strain collected in Uganda in 1947. It was based in part on studies of this 70-year-old isolate, known as MR766, that international health authorities first concluded that Zika infection during early pregnancy is causally linked to microcephaly. “Using MR766 was not our choice”, said Hongjun Song, a neuroscientist at Johns Hopkins University, MD, USA, who, together with Guo-Li Ming, published the first paper to show the ability of the virus to infect and kill human neural progenitor cells. “It was simply the only strain available to us at the time of our study”, Song said. Few scientists chose to highlight this fact or to discuss its implications for populations in Africa; some papers only identified the strain used in technical appendices. But as Song's and Ming's findings are replicated in laboratories around the world, they have become increasingly difficult to ignore. One recent study by virologists at the French National Institute of Health and Medical Research showed that a strain of Zika from the Central African Republic is more than twice as deadly to human neural stem cells as the variant circulating in Latin America. “Unexpectedly, we found stronger virulence for the African strain”, said Sara Salinas, the study's senior author. “We reproducibly detected higher rates of infection, viral reproduction, cell death, and antiviral responses with the African strain.” Later comparative studies in mice reported similar trends. “Many key questions remain about understanding the differences between African and Asian Zika strains”, said Darci Smith, a virologist at the US Army Medical Research Institute of Infectious Diseases, MD, USA, who led one of these studies, “but in general we believe strains of both lineages are equally concerning from a public health perspective”. Scientists now know that Zika is asymptomatic in up to 80% of those infected, and that only a small fraction of infections during pregnancy result in microcephaly. A wide spectrum of more insidious neurological sequelae is just starting to be defined. But before May, 2015, health officials had little reason to be concerned; what weak health systems could not detect, epidemiologists and scientists could not see, much less study. “It's one of those things where sometimes we don’t realise there's a problem, so we don’t know to look for it”, said Ann Powers, acting chief of the arboviral diseases branch at the US Centers for Disease Control and Prevention (CDC). “Until we know there's a problem, there usually isn’t funding for it.” Zika has probably been circulating in nature in a sylvatic cycle for many decades, spilling undetected into human populations across Africa with unknown regularity, according to Powers. Indeed, studies have claimed to show widespread human exposure to Zika in at least 25 countries across the continent, and scientists recently reported definitive evidence that Zika has been continuously circulating across west Africa for decades. On analysing 387 frozen blood samples taken from febrile patients in Senegal and Nigeria between 1992 and 2016, 6·2% were positive for IgM antibodies to Zika virus. “We were a bit surprised by how much we found”, said Phyllis Kanki, a virologist form Harvard University, MA, USA, and the study's senior author. Four patients in the study also showed infection with an African Zika virus strain by real-time PCR. “It certainly is possible that there is a level of ongoing Zika virus infection in sub-Saharan Africa that is associated with microcephaly in fetuses of women infected during pregnancy”, said Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases. However, he said, the region could be “well past the outbreak stage and now has a low level of endemic infection that may result in some cases of microcephaly”. In February, 2017, two studies suggested another potential explanation for the lack of observed birth defects associated with Zika in Africa. A research group at the University of Missouri, USA, reported that human trophoblasts making up the early placenta are killed much more rapidly by a Ugandan Zika isolate than by a Cambodian one. “This virus is so destructive of placental cells that pregnancy loss may be occurring very early on”, said coauthor and obstetrician Danny Schust. “If so, women may not even realise they were pregnant.” A team of immunologists and obstetricians at Johns Hopkins have extended these findings to mice. Alongside Zika isolates from across Latin America and southeast Asia, they infected immunocompetent pregnant mice with a strain collected in Nigeria in 1968 and found “no significant differences in relative viral load, transmission rate, or fetal outcome”. Each strain tested was able to cross the placenta, and to result in either spontaneous abortion or neuroinflammation and cortical thinning of neonatal mouse brains. “This all could have been going on for 100 years for all we know, and we just didn’t notice it”, said Michael Wells, a Harvard neurobiologist, who with his colleague Max Sallick showed that the Ugandan strain can infect primitive brain structures with effects that are nearly indistinguishable from those caused by the Asian lineage strain. There is a critical need for sensitive and specific diagnostics to do proper surveillance. The discovery that Zika was causing birth defects in the Americas might have prompted investigations on the continent where the virus originated. But this wasn’t the case. In September, 2016, the US Congress allocated $1·1 billion for a domestic response to Zika, partly by re-appropriating $109 million previously set aside to enhance surveillance of infectious disease in west Africa after the region's Ebola epidemic. The $2 million specifically dedicated by the African Development Bank to Zika surveillance across all of Africa pale in comparison. In light of the circumstantial evidence collected by bench scientists, said Fauci, one thing is clear: “There is a critical need for sensitive and specific diagnostics to do proper surveillance and epidemiologic fact-finding regarding Zika in sub-Saharan Africa”. According to Powers, early efforts are underway. Less clear, however, is whether this nascent work can survive the acts of a US leadership unconvinced of the need for any surveillance. President Trump's administration has ended US contributions to the UN Population Fund, which supports reproductive health care for women across Africa, and proposed eliminating the US Agency for International Development's Global Health Security programmes, which help African ministries of health detect outbreaks of pathogens like Zika and prevent them from becoming pandemics. Writing from Uganda in 1952, Zika co-discoverer George Dick observed that the “absence of the recognition of a disease in humans caused by Zika virus does not necessarily mean that the disease is either rare or unimportant”. It was a prescient insight.

Cryptococcal meningitis, a co-infection of HIV, is a leading killer of patients with AIDS worldwide. Yet it receives little global attention. Patrick Adams reports from Uganda's capital, Kampala.

Haiti's Ministry of Health has published a 10-year plan to halt cholera transmission, but aid groups say help is needed now to treat a surging caseload. Patrick Adams reports. Nearly 2·5 years after it began, Haiti's cholera epidemic is getting worse, not better, and efforts to treat the sick are desperately short of funds, say aid groups on the ground. Since the first reported cases in October, 2010, cholera has killed 8000 people and sickened some 649 000 more, wreaking havoc in a country bereft of effective water and sanitation systems and among a population with no natural immunity to the disease. Now, with the rainy season fast approaching, some fear a surge in new cases could overwhelm Haiti's ill-equipped cholera treatment centres, many of which have struggled to retain staff and replenish supplies in the face of donor fatigue and errors of perception about the state of the epidemic. “For those of us who are providing care to patients with cholera, the emergency phase is still ongoing”, says Louise C Ivers, a senior policy and health adviser at Partners in Health (PIH), the largest non-governmental health-care provider in Haiti. “It's not as dramatic as it was in 2010, but we've seen in our clinics double the number of cases early this year compared to last.” Ivers says that uptick observed in PIH clinics may be explained in part by the fact that many smaller non-governmental organisations (NGOs) have since pulled out, leaving more patients to those providers that remain. But it's probably also a reflection of the overall increase in cholera cases nationally. According to the UN Office for the Coordination of Humanitarian Affairs, 11 220 cholera cases were registered in Haiti in December, 2012—an increase of more than 3000 over the same period the previous year. “What's clear is that it hasn't burned itself out”, she says. “Cholera in Haiti won't just go away.” Nor will it stop killing people in parts of the country where treatment programmes have been crippled by a lack of funding. As Médecins Sans Frontières reported in March, the mortality rate in some treatment centres has reached an alarming 4%, the result of sharp declines in the quality of care brought on by worn-out equipment, staff shortages, poor waste-management, and a dearth of essential supplies, including everything from cots to the chlorine used to disinfect shoes. “Cholera is not difficult to treat if it's done promptly”, says Joan Arnan, MSF head of mission in Haiti. “But sometimes there are only two nurses to manage 50 patients. That's not nearly enough to ensure quality care.” Meanwhile, the reality remains that around half of the population lacks access to clean water and only one in five people have improved sanitation. Indeed, such is the structural poverty that allowed cholera to spread and become endemic, adding yet another obstacle to the country's recovery from the devastating earthquake in January, 2010. Last year, PIH and Haitian NGO GHESKIO vaccinated 100 000 people against the disease in an effort to demonstrate that vaccination could serve as a stopgap until the construction of new water and sanitation systems. And the campaign was an unqualified success; 91% of those who received the first dose received their second dose 2 weeks later. In August, the Pan American Health Organization (PAHO) issued a recommendation to make the vaccine, an oral formulation called Shanchol, universally available across Hispaniola (Haiti and the Dominican Republic). And in February, the Ministry of Health announced an initiative targeting the country's most vulnerable populations—including the some 230 000 babies born since the outbreak began. PIH is helping the Ministry as it scales up that initiative—part of a US$2·2 billion plan to eliminate cholera by 2022, primarily through investments in water and sanitation. But the question now is who will step forward to fund it? In December, the UN said it would contribute $23·5 million, or about 1% of the total cost. Ivers and others say that isn't nearly enough, especially given that the UN was largely responsible for the outbreak in the first place. One thing, however, is certain: rain is on the way, and with it will come more cases of cholera, not to mention malnutrition; as the UN reported last week, flooding from last year's heavy storms damaged crops in the country's south, leaving more than 1·5 million without enough to eat. “If we really mean what we say, we should be coming together as partners to support the government's efforts to interrupt transmission”, says Jon K Andrus, deputy director of PAHO, which, along with the US Centers for Disease Control and Prevention and UNICEF, spearheaded the creation last June of the 18-member Regional Coalition on Water and Sanitation to Eliminate Cholera Transmission in the Island of Hispaniola. “The bottom line is that there's a lot of commitment and growing momentum to contribute to the capacity and infrastructure that Haiti needs.”

Wielding water cannons, tear gas, and batons, Turkish police have cracked down violently on peaceful dissent—and the world is watching. Patrick Adams reports from Istanbul.5 weeks ago, Turkish riot police attacked a group of peaceful demonstrators in Istanbul's Taksim Square as they protested against the government's plans to replace a park with a shopping mall housed in a replica Ottoman-era army barrack—one of a number of controversial urban renewal projects pushed through in recent years without public consultation.When word of the attack spread on social media, thousands came out in support of the Gezi Park protesters, and within days the small-scale sit-in had ballooned into mass, nationwide antigovernment protests. In a clumsy attempt to put these protests down, police fired water cannons into crowds and filled the streets with tear gas, frightening away tourists and sending Turkish stocks tumbling.In the 5 weeks since the attack, say human rights groups, five people have died and more than 7500 have been injured, several of them critically. And still the crackdown continues—a heavy-handed response characterised by widespread police brutality, arbitrary detentions, efforts to intimidate and discredit journalists, and threats of criminal investigations of “provocateurs” alleged to have insulted state officials or incited riots through posts on social media sites such as Facebook and Twitter.As a result, the ruling Justice and Development Party, known by its Turkish acronym AKP, has come under increasing criticism for its harsh handling of events. On June 13, the European Parliament adopted a resolution expressing concern over “the disproportionate and excessive use of force by Turkish police to break up peaceful and legitimate protests” and urging Turkish authorities to respect the rights of all citizens to freedom of expression and assembly. Days later, the UN High Commissioner for Human Rights, Navi Pillay, added her voice to the chorus, reminding the Turkish Government that it must ensure that the policing of demonstrations complies at all times with international human rights obligations.“Reports that tear gas canisters and pepper spray were fired at people from close range, or into closed spaces, and the alleged misuse of rubber bullets, need to be promptly, effectively, credibly, and transparently investigated”, Pillay told reporters. Also worrying, she said, is the substantial number of people who have been arbitrarily detained for acts other than recognised crimes, as well as reports of their ill treatment in detention.Yet in the face of criticism from all sides, including within his own party, Turkish Prime Minister Recep Tayyip Erdogan has remained defiant. Lashing out at critics—Erdogan said he does not recognise the European Parliament and exchanged barbs with the White House—he defended riot police tactics such as the use of tear gas and water cannons as necessary to combat what he calls a “plot against Turkey” by “enemies from abroad”. Indeed, perhaps most troubling about the Prime Minister's response, say observers, is his tendency to paint the protesters as terrorists bent on burning and destroying all in sight.There is, after all, an ugly precedent for this tactic in Turkey, where national security has been used to justify a growing crackdown on dissent, including a campaign against the news media that has made the country of 74 million the world's leading jailer of journalists, ahead even of China and Iran.Days before the bombing this February of the American Embassy in the Turkish capital, Ankara, authorities there arrested close to 100 people thought to have ties to the Revolutionary People's Liberation Front, the outlawed organisation to which the bomber belonged. Among those arrested were journalists, lawyers, and even musicians.As Human Rights Watch (HRW) said in a report condemning those arrests, “Turkey's overbroad antiterrorism laws have been used against an ever-widening circle of people charged for nonviolent political activities and the legitimate exercise of freedom of expression, association and assembly”.The same might have been said about the ongoing protests, during which hundreds of people have been detained, held incommunicado, and denied due process. The Committee to Protect Journalists says it has documented dozens of attacks on journalists, mainly by police, over the course of the unrest, including detentions, assaults, obstruction, threats, and the unlawful confiscation and destruction of protective gear.A protester is carried away after being tear-gassed by Turkish police, June 12View Large Image Copyright © 2013 Patrick AdamsLast week, the Mayor of Ankara, Melih Gökçek, singled out one journalist in particular—the London-based BBC presenter Selin Girit—for special abuse, labelling her a “traitor” and a “spy” and inciting his Twitter followers to do the same in a stream of rabble-rousing Tweets. When the BBC objected to what it called government intimidation, Prime Minister Erdogan himself stepped into the fray, accusing Girit of being “part of a conspiracy against her own country”.Although most of those detained by police have been released, 18 members of a legal leftist organisation (ESP) remain in pre-trial detention on charges of membership of an illegal organisation, as do two members of a football team fan group, who are under investigation for being members of an organised criminal gang and for possession of explosives, according to HRW. “The majority of the Gezi Park protesters did not engage in violence, let alone anything that could be described as acts of terrorism or organised criminal activity”, says HRW senior researcher Emma Sinclair-Webb. “Nor did they use guns and explosives during their protest. But imprisoning people linked to the protests under the Anti-Terror Law and for weapons possession looks like an effort to discredit the legitimate aims of the protesters.”“What's especially disappointing is that the Prime Minister has made inflammatory statements threatening to mobilise the supporters of the ruling party against the demonstrators”, says Amnesty International's researcher in Turkey, Andrew Gardner, who was himself hit by a police water cannon in Taksim Square. The excessive use of force by Turkish police isn't uncommon at demonstrations, he says. “But even by these standards, what we've seen in the last few days is absolutely disgraceful and should be put to an end immediately.”From the start of the protests, says Gardner, Amnesty International has kept its office near Taksim Square open around the clock, giving it over to teams of doctors and medical workers who have used the space to care for injured protesters out of harm's way. Similar makeshift clinics have been set up in houses, hotels, restaurants, and mosques, and doctors from around the country have volunteered their expertise and time.Now those doctors are finding themselves the target of an investigation by the Turkish Ministry of Health, which recently launched a probe into the Turkish Medical Association (TBB), requesting that the association immediately turn over the names of all volunteer medical workers and their patients. “We tried to help the wounded and we didn't distinguish between protesters and police because that is our humanitarian duty as doctors”, says Mehmet Tok, a general practitioner and spokesperson for the Istanbul Chamber of Medicine, the governing body of the TBB. “The Ministry of Health should have made these services available, but they didn't. So we had to. We are providing these services, and now they want to punish us for it. They are making a mistake.” A spokesperson for the Ministry did not respond to requests from The Lancet for comment.In a written reply to Chief Inspector İzzet Taşçı in the Ministry of Health, representatives of the TBB declared that they would not share the names of any colleagues or patients—not even that of the police officer they treated on a recent afternoon. “He had been hit in the head by something that fell from the AKM building”, said Tok, referring to the flag-draped Ataturk Cultural Center at the top of Taksim Square. “There was no ambulance for him, and at first the police said, ‘We don't want your help’. But then they saw that it was serious—he had been knocked unconscious and was in a lot of pain—and they changed their mind.”For a moment in mid-June, it seemed as though the Prime Minister might do the same. He invited the protest organisers to his home for talks, and agreed to allow a legal challenge to the government's construction plans to run its course. But before the protesters could convince their rank-and-file to vacate the park, the Prime Minister dispatched riot police to forcibly evacuate them. In doing so, the police fired tear gas into a hotel lobby where hundreds of people had taken refuge, and on the grounds of a hospital, and assaulted protesters in hospitals and make-shift clinics. Those attacks showed “a dangerous disregard for the wellbeing—and indeed the lives—of protesters and bystanders”, says HRW's Sinclair-Webb. “The repeated violence against people who are dissatisfied with government policies has deeply polarised Turkey. The government urgently needs to change police tactics and issue a clear signal for restraint.” Wielding water cannons, tear gas, and batons, Turkish police have cracked down violently on peaceful dissent—and the world is watching. Patrick Adams reports from Istanbul. 5 weeks ago, Turkish riot police attacked a group of peaceful demonstrators in Istanbul's Taksim Square as they protested against the government's plans to replace a park with a shopping mall housed in a replica Ottoman-era army barrack—one of a number of controversial urban renewal projects pushed through in recent years without public consultation. When word of the attack spread on social media, thousands came out in support of the Gezi Park protesters, and within days the small-scale sit-in had ballooned into mass, nationwide antigovernment protests. In a clumsy attempt to put these protests down, police fired water cannons into crowds and filled the streets with tear gas, frightening away tourists and sending Turkish stocks tumbling. In the 5 weeks since the attack, say human rights groups, five people have died and more than 7500 have been injured, several of them critically. And still the crackdown continues—a heavy-handed response characterised by widespread police brutality, arbitrary detentions, efforts to intimidate and discredit journalists, and threats of criminal investigations of “provocateurs” alleged to have insulted state officials or incited riots through posts on social media sites such as Facebook and Twitter. As a result, the ruling Justice and Development Party, known by its Turkish acronym AKP, has come under increasing criticism for its harsh handling of events. On June 13, the European Parliament adopted a resolution expressing concern over “the disproportionate and excessive use of force by Turkish police to break up peaceful and legitimate protests” and urging Turkish authorities to respect the rights of all citizens to freedom of expression and assembly. Days later, the UN High Commissioner for Human Rights, Navi Pillay, added her voice to the chorus, reminding the Turkish Government that it must ensure that the policing of demonstrations complies at all times with international human rights obligations. “Reports that tear gas canisters and pepper spray were fired at people from close range, or into closed spaces, and the alleged misuse of rubber bullets, need to be promptly, effectively, credibly, and transparently investigated”, Pillay told reporters. Also worrying, she said, is the substantial number of people who have been arbitrarily detained for acts other than recognised crimes, as well as reports of their ill treatment in detention. Yet in the face of criticism from all sides, including within his own party, Turkish Prime Minister Recep Tayyip Erdogan has remained defiant. Lashing out at critics—Erdogan said he does not recognise the European Parliament and exchanged barbs with the White House—he defended riot police tactics such as the use of tear gas and water cannons as necessary to combat what he calls a “plot against Turkey” by “enemies from abroad”. Indeed, perhaps most troubling about the Prime Minister's response, say observers, is his tendency to paint the protesters as terrorists bent on burning and destroying all in sight. There is, after all, an ugly precedent for this tactic in Turkey, where national security has been used to justify a growing crackdown on dissent, including a campaign against the news media that has made the country of 74 million the world's leading jailer of journalists, ahead even of China and Iran. Days before the bombing this February of the American Embassy in the Turkish capital, Ankara, authorities there arrested close to 100 people thought to have ties to the Revolutionary People's Liberation Front, the outlawed organisation to which the bomber belonged. Among those arrested were journalists, lawyers, and even musicians. As Human Rights Watch (HRW) said in a report condemning those arrests, “Turkey's overbroad antiterrorism laws have been used against an ever-widening circle of people charged for nonviolent political activities and the legitimate exercise of freedom of expression, association and assembly”. The same might have been said about the ongoing protests, during which hundreds of people have been detained, held incommunicado, and denied due process. The Committee to Protect Journalists says it has documented dozens of attacks on journalists, mainly by police, over the course of the unrest, including detentions, assaults, obstruction, threats, and the unlawful confiscation and destruction of protective gear. Last week, the Mayor of Ankara, Melih Gökçek, singled out one journalist in particular—the London-based BBC presenter Selin Girit—for special abuse, labelling her a “traitor” and a “spy” and inciting his Twitter followers to do the same in a stream of rabble-rousing Tweets. When the BBC objected to what it called government intimidation, Prime Minister Erdogan himself stepped into the fray, accusing Girit of being “part of a conspiracy against her own country”. Although most of those detained by police have been released, 18 members of a legal leftist organisation (ESP) remain in pre-trial detention on charges of membership of an illegal organisation, as do two members of a football team fan group, who are under investigation for being members of an organised criminal gang and for possession of explosives, according to HRW. “The majority of the Gezi Park protesters did not engage in violence, let alone anything that could be described as acts of terrorism or organised criminal activity”, says HRW senior researcher Emma Sinclair-Webb. “Nor did they use guns and explosives during their protest. But imprisoning people linked to the protests under the Anti-Terror Law and for weapons possession looks like an effort to discredit the legitimate aims of the protesters.” “What's especially disappointing is that the Prime Minister has made inflammatory statements threatening to mobilise the supporters of the ruling party against the demonstrators”, says Amnesty International's researcher in Turkey, Andrew Gardner, who was himself hit by a police water cannon in Taksim Square. The excessive use of force by Turkish police isn't uncommon at demonstrations, he says. “But even by these standards, what we've seen in the last few days is absolutely disgraceful and should be put to an end immediately.” From the start of the protests, says Gardner, Amnesty International has kept its office near Taksim Square open around the clock, giving it over to teams of doctors and medical workers who have used the space to care for injured protesters out of harm's way. Similar makeshift clinics have been set up in houses, hotels, restaurants, and mosques, and doctors from around the country have volunteered their expertise and time. Now those doctors are finding themselves the target of an investigation by the Turkish Ministry of Health, which recently launched a probe into the Turkish Medical Association (TBB), requesting that the association immediately turn over the names of all volunteer medical workers and their patients. “We tried to help the wounded and we didn't distinguish between protesters and police because that is our humanitarian duty as doctors”, says Mehmet Tok, a general practitioner and spokesperson for the Istanbul Chamber of Medicine, the governing body of the TBB. “The Ministry of Health should have made these services available, but they didn't. So we had to. We are providing these services, and now they want to punish us for it. They are making a mistake.” A spokesperson for the Ministry did not respond to requests from The Lancet for comment. In a written reply to Chief Inspector İzzet Taşçı in the Ministry of Health, representatives of the TBB declared that they would not share the names of any colleagues or patients—not even that of the police officer they treated on a recent afternoon. “He had been hit in the head by something that fell from the AKM building”, said Tok, referring to the flag-draped Ataturk Cultural Center at the top of Taksim Square. “There was no ambulance for him, and at first the police said, ‘We don't want your help’. But then they saw that it was serious—he had been knocked unconscious and was in a lot of pain—and they changed their mind.” For a moment in mid-June, it seemed as though the Prime Minister might do the same. He invited the protest organisers to his home for talks, and agreed to allow a legal challenge to the government's construction plans to run its course. But before the protesters could convince their rank-and-file to vacate the park, the Prime Minister dispatched riot police to forcibly evacuate them. In doing so, the police fired tear gas into a hotel lobby where hundreds of people had taken refuge, and on the grounds of a hospital, and assaulted protesters in hospitals and make-shift clinics. Those attacks showed “a dangerous disregard for the wellbeing—and indeed the lives—of protesters and bystanders”, says HRW's Sinclair-Webb. “The repeated violence against people who are dissatisfied with government policies has deeply polarised Turkey. The government urgently needs to change police tactics and issue a clear signal for restraint.”

Efforts to tackle what WHO describes as “the largest case of mass poisoning of a population in history” are being hampered by a dearth of funding for research. Patrick Adams reports. “Water, water everywhere—nor any drop to drink.” The plight of Coleridge's ancient mariner is that of present-day populations in some 70 countries on six different continents. From China to Chile, unsafe levels of naturally occurring arsenic—a potent human toxicant and carcinogen—have been detected in the drinking water. And nowhere is the problem more pronounced than in Bangladesh. Beginning in the 1970s, hand-pumped tube wells were installed throughout the country in an effort to provide rural communities with clean water for the prevention of cholera and other water-borne diseases. It wasn't until the early 1990s, however, that geological surveys revealed substantial contamination of the aquifers from which these wells drew their water. In the decades since, as many as 77 million people in Bangladesh alone are believed to have been chronically exposed to raised concentrations of the toxic metalloid. That exposure has been associated with a wide variety of adverse health effects, including reduced cognitive function, peripheral neuropathy, respiratory complications, diabetes and cardiovascular disease, and cancers of the skin, lung, kidney and bladder, among other problems. “Now it's just a matter of adding new items to the list”, says Habibul Ahsan, director of the Center for Cancer Epidemiology and Prevention at the University of Chicago and principal investigator on the Health Effects of Arsenic Longitudinal Study (HEALS). A prospective cohort study of 30 000 men and women in Bangladesh, HEALS has yielded important new findings about the health risks of arsenic exposure. “Like tobacco, arsenic has multi-systemic effects”, says Ahsan, a native of Bangladesh, who reported in a 2010 article in The Lancet that just under a quarter of all chronic disease related deaths in the HEALS cohort could be attributed to arsenic-contaminated well water. Given that well water is the only pathogen-free water to which most Bangladeshis have access, he says, “it's not as though they can easily switch to something else”. Hence the importance of determining exactly how much arsenic people can safely consume—and using that information to tailor sustainable mitigation strategies. “What's the minimum dose and how long does someone have to be exposed?” he says. “We still don't know the answer to that.” Indeed, in spite of the magnitude of the crisis—WHO has called it “the largest case of mass poisoning of a population in history”—experts say measures to mitigate the health effects of arsenic contamination have fallen far short of what is needed, leaving millions of Bangladeshis vulnerable. “This is a neglected public health problem”, says Mahfuzar Rahman, an environmental epidemiologist with the International Centre for Diarrhoeal Disease Research, Bangladesh. In one of the few studies of childhood mortality associated with arsenic-contaminated well water, Rahman and colleagues reported earlier this year that arsenic exposure was associated with “substantial increased risk of deaths at young age”. “We have plenty of evidence of arsenic's effects on human health.” Yet still, he says, “about a quarter of the population is drinking contaminated water”, reflecting the failure of mitigation strategies implemented by a patchwork of poorly coordinated stakeholders. Having largely ignored the problem for years, the Bangladeshi Government, with support from the World Bank and the Swedish International Development Cooperation Agency, adopted in 2004 a national arsenic mitigation strategy. A US$30 million undertaking, the project took a two-pronged approach to mitigation, including screening and identification of the country's 12 million tube wells and the introduction of alternative arsenic-safe water options like rainwater harvesting, dug wells, pond sand filters and arsenic-removal technologies. “At that time, a lot of money was available for mitigation”, adds Rahman. But with so little success after the project's first year, donors began to lose interest and progress stalled. Now, he says, no one wants to support the kind of operational research needed to find out what works. “This is a major environmental challenge. We need a sustainable strategy that is low cost and easily accessible, and to find that we need to evaluate the different options. But we don't do anything because we don't have the money.” Even in low doses, arsenic is an insidious killer. Odourless and tasteless, it produces no acute symptoms, and disease onset often occurs decades after the contaminated water is consumed. “It's a forgotten issue”, says Ahsan. “Policy makers in Bangladesh have the impression that skin lesions are the only health-related outcome of arsenic exposure. But we clearly documented a large proportion of deaths that can be attributed to arsenic contamination, and these findings don't resonate with policy makers in Bangladesh because they aren't visible to them.” When Allan Smith, director of the arsenic research programme at the University of California, Berkeley, first visited Bangladesh, he was struck by what he saw. “I thought that it should have been declared a public health emergency”, recalls Smith. “And that was in 1997, long before we knew what we do now.” In studies of early-life arsenic exposure in Chile, Smith and colleagues found increases in mortality among young adults from several different causes, including lung cancer and bronchiectasis, bladder cancer, liver cancer, and chronic renal disease. They also reported marked increases in respiratory symptoms among children in Bangladesh who were exposed to arsenic in the womb, underscoring the urgent need to reduce exposure among pregnant women and young children. “You drink crystal-clear water and you end up doing damage to your lungs, and then 20 or 30 or 40 years later you die of lung cancer”, he says. “It's remarkable. Looking back now, I think of all of those mothers and young children who had what turns out to be the highest risk we know of for anything in early life environmental exposure.” Mitigating that exposure is no easy task, Smith adds, and it's made all the more difficult in Bangladesh by a lack of monitoring and evaluation of the various interventions implemented in different contexts. “That leaves you at the mercy of data that may not be valid”, he says. And bad data can lead to false assumptions—such as, for example, that people will always drink arsenic-safe water where it's available. “If a person—and it's always a woman—has to walk half a kilometre or more in the heat everyday to get that water, you can't assume she's actually doing it. These people are struggling to live. It can be very hard for them to always do what they're told they should do by the experts in Dhaka.” Smith has long called for regular testing of urine, the only reliable metric of current exposure, as a way of evaluating programme impact. Also an obstacle to success is the general lack of awareness of arsenic among the people of Bangladesh. In a recent survey of 6700 households, 70% of respondents said they believed that boiling water could cleanse it of arsenic and that by eating or sleeping with someone who has arsenicosis a person could become infected. Those and other misconceptions can undermine even the best solutions, say experts, and their prevalence suggests a need for new approaches to communicating the dangers of contaminated drinking water. That said, well water may not be the only route of exposure. Scientists fear that food crops irrigated by contaminated groundwater, including rice, the region's staple food, could also put people at increased risk of death and disease. “We need comprehensive research, and we need a sustainable mitigation option”, says Rahman. “But to get funding for this now is extremely difficult.” When it comes to mitigation, “there's no simple answer”, says Smith. “But there's an unfortunate idea that you can install in a community an inexpensive arsenic-removal technology and that when you go back a year later it will actually be working—that you've solved the problem.” More often than not, he adds, that isn't the case. “The situation requires much more focus and careful attention than it's been given.” Smith stresses that Bangladesh is not alone in neglecting the problem. “The most inadequate response is in the USA, where millions of people are drinking water from wells that aren't required to be tested.” But the scale of the problem pales in comparison to that of Bangladesh, which experts believe could soon see a dramatic rise in cancers as a result of arsenic exposure. “There is not the political will to tackle this”, says Ahsan. “Bangladesh is a poor country with many other problems. But if the government were committed to solving this, they could engage the NGO [non-governmental organisation] community and get it done. And they haven't done that.” For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ For The Lancet News podcast see http://www.thelancet.com/lancet-news-audio/ The Bangladesh paradox: exceptional health achievement despite economic povertyBangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Full-Text PDF Harnessing pluralism for better health in BangladeshHow do we explain the paradox that Bangladesh has made remarkable progress in health and human development, yet its achievements have taken place within a health system that is frequently characterised as weak, in terms of inadequate physical and human infrastructure and logistics, and low performing? We argue that the development of a highly pluralistic health system environment, defined by the participation of a multiplicity of different stakeholders and agents and by ad hoc, diffused forms of management has contributed to these outcomes by creating conditions for rapid change. Full-Text PDF Bangladesh: innovating for healthWriting earlier this year, as part of a series of country case studies on good health at low cost, Dina Balabanova and her colleagues concluded that “Bangladesh has made enormous health advances and now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south Asia, despite spending less on health care than several neighbouring countries”.1 Why is this so? Full-Text PDF

While Haiti gears up for the rollout of a much-needed vaccine against cholera, some experts fear continued neglect of the country's water and sanitation systems. Patrick Adams reports. 15 months into the world's worst cholera epidemic, nearly 7000 people have died in Haiti. A total of 515 699 people, roughly 5% of the Caribbean nation's population, have been sickened by the disease, more than half of them severely enough to require hospitalisation, according to the most recent data compiled by Haiti's Health Cluster. And while international aid groups and the Haitian Government have managed to reduce the mortality rate to less than 1%—the product of active case finding, chlorine tablet distribution, and an aggressive treatment regimen, among other measures—transmission continues, threatening further loss of life in one of the most water insecure countries on the planet. Now, with the new year comes a new chapter in that fight. In anticipation of another rainy season and a surge in cholera cases, health officials are preparing for the rollout of a vaccine they believe can help staunch the spread of disease, particularly in rural areas where access to clean water is most scarce. “We need to bring every resource available to stop this epidemic”, says Paul Farmer, UN Deputy Special Envoy for Haiti and cofounder of Partners in Health, which is spearheading a pilot vaccination campaign set to begin later this month on the banks of the Artibonite River close to where the outbreak began. That campaign, and another led by the Haitian non-governmental organisation Gheskio in Port-au-Prince, will seek to assess the feasibility and effectiveness of vaccinating Haitians with Shanchol, an oral formulation recently approved by WHO. “There's no argument that this wouldn't save many thousands of lives and prevent many, many times more new cases”, says Farmer. According to studies, Shanchol, which is manufactured by the French pharmaceutical company Sanofi Pasteur, is nearly 70% effective and protective for up to 36 months. At US$1·85 per dose, it is also fairly inexpensive. But as Scott Dowell, director of the division of global disease detection and emergency response at the US Centers for Disease Control and Prevention notes, a cholera vaccine comes with its own set of challenges, including the need for continuous refrigeration and a follow-up dose 2 weeks after the first. “We're hopeful that the vaccine can be an additional adjunct to the response to cholera”, he says. “But we have a lot to learn about how to use it.” There is also the concern that a vaccine could divert the focus from large overdue investments in Haiti's water and sanitation systems. Indeed, cholera, a preventable, easily treatable disease, is the latest and most visible symptom of longstanding neglect, say experts. “It's been decades of failure on the part of donors”, says Jon Andrus, deputy director of the Pan-American Health Organisation. As a result, he says, Haiti remains an outlier in the western hemisphere; just 63% of the population enjoys access to clean water and fewer than 20% of Haitians have improved sanitation. For that, he says, “we all share the guilt”. In 1991, cholera spread to the Americas for the first time in nearly a century. Over the following decade, 19 countries had epidemic outbreaks. And in country after country, it was the strengthening of water and sanitation infrastructure—not a vaccine—that led to the elimination of cholera as an epidemic threat. “No one is saying [a vaccine] cannot or should not be a part of the package”, says Andrus. “It certainly should be if the evidence supports it. But prevention and control strategies are not sufficient. If donors don't honour their pledges, we're going to continue to see several hundred cases a day.” As of late December, 2011, health officials in Haiti were reporting a daily average of 300 cases, a sharp decline from the 500 per day in November. “It's going to require a major investment, a major overhaul.” Exactly how much is major? “We're trying to get resolution on that—a billion at least.” What's clear, he says, is that the time to push for it is now. “For the first time ever, the countries of the Americas have all embraced Haiti as a brother. You have the Brazil response, the Chile response, the Dominican Republic response, Puerto Rico, Jamaica, Cuba, Colombia; Haiti is now part of the family, and we have to take advantage of that.” This online publication has been corrected. The corrected version first appeared at thelancet.com on March 23, 2012 This online publication has been corrected. The corrected version first appeared at thelancet.com on March 23, 2012 Department of ErrorAdams P. Haiti prepares for cholera vaccination but concerns remain. Lancet 2012; 379: 16—In this World Report (Jan 7), the fourth sentence of the penultimate paragraph should have read: “As of late December, 2011, health officials in Haiti were reporting a daily average of 300 cases, a sharp decline from the 500 per day in November.” This correction has been made to the online version as of March 23. Full-Text PDF

After decades of turmoil, thousands of Palestinian and Iraqi refugees in Lebanon are beginning to get access to the long-term mental health care they need. Patrick Adams reports from Beirut. In Bourj el-Barajneh, anxiety is endemic. Ever since its creation in 1948, the embattled refugee camp located in a Beirut suburb of the same name, has been caught up in the crossfire of violent conflict, its bullet-riddled buildings a bleak testament to the suffering of the largely Palestinian population. And though the fighting has stopped—at least for now—much of the trauma remains untreated. Such is the state of mental health care across the Arab world, where the burden of illness, both chronic and acute, has long exceeded countries' capacity to address it, hobbled as they have been by political instability and decades of war—to say nothing of the stigma surrounding a condition few understand and fewer still care to acknowledge. Indeed, not until 2006, when researchers at Beirut's Institute for Development, Research, Advocacy and Applied Care published an evaluation of the burden of ailments in Lebanon, had any Arab country ever assessed the prevalence of mental illness on a national scale. Part of WHO's World Mental Health Survey Initiative, Lebanon's first large-scale psychiatric epidemiological study showed that a staggering 49% of the population had experienced war-related trauma of some kind; another 17% met the criteria for having a mental disorder. And as though to mock those efforts, fighting erupted anew—between Israel and Hezbollah—just weeks after the paper was published. It was during that month-long war that Médecins Sans Frontières (MSF) was first alerted to the problem. As Israeli forces rained mortars on Hezbollah strongholds in the south, MSF worked with psychologists at Beirut's St George Hospital University Medical Centre to provide counselling in the bomb shelters. “We had never done that before”, says Elie Karam, head of the department of psychiatry and clinical psychology at St George. “We had the 24-h help line and we've always remained open during conflicts”, he says. “But we had never sent people to the shelters. That was new.” Karam was lead author on both the national survey and a later assessment of the lifetime prevalence of mental disorders in Lebanon, another first for an Arab country. The latter, published in 2008, found that the lifetime prevalence of any mood disorder in Lebanon was more than 1·5 times that of Iraq, and that fewer than half of those with a lifetime mood disorder had obtained treatment. Months after going into bomb shelters, MSF took a new tack, establishing a permanent presence in a place practically synonymous with its own heroic acts of emergency care. It was in Beirut, after all, that the agency first proved itself on the battlefield, as doctors and nurses undertook life-saving surgeries in the midst of a brutal civil war. By 1984, the non-governmental organisation had treated about 5000 of the conflict's wounded, cementing its reputation as an impartial actor and a force for good. To many of the present-day inhabitants of Bourj el-Barajneh, however, MSF has recently become code for a more quotidian concern—and one far less likely to make international headlines. “We've been providing free mental health services to the adult population since 2009”, says Fabio Forgione, MSF head of mission. “This is our first long-term health project, and it has to be long-term; mental health requires commitment and continuity.” According to Forgione, Bourj el-Barajneh offered an ideal entry point for the new intervention. With a population of roughly 18 000, the camp is small and stable relative to others in the country. And whereas many other camps are closed, residents of Bourj el-Barajneh may come and go as they please. Then there is its history of hardship. In 1982, Israeli and Christian Phalangist forces laid siege to the camp for months on end, battering its already crumbling infrastructure. In 1984, the Syrian-backed Amal militia did the same, imposing a 3-year blockade aimed at driving out the forces of the rival Palestinian Liberation Organization. And in 2006, as Israeli war planes pounded Hezbollah headquarters just miles away, residents readied for an onslaught, building makeshift shelters out of blankets and mattresses. Raising awareness, says Forgione, was objective number one. Although residents of Bourj el-Barajneh could now access quality care at no cost, misconceptions persisted. “Many people thought a mental disorder just means that you're crazy”, says Stephanie Giandonato, MSF field coordinator. “They didn't know that there are different types of disorders and different levels of severity—or that you could treat something like depression.” Religion plays a part, too. “Whenever someone complains of a mental illness, the first choice is to take them to a sheik”, says Rola Charkieh, an MSF health promoter and herself a Palestinian refugee, whose home was destroyed during the 1982 Israeli invasion of Lebanon. “They say, ‘He is not a good Muslim. Maybe that is why he complains’. But many times, these ‘sheiks’ are not really ‘sheiks’. They are just saying this to make money.” To date, MSF has set up three clinics in Bourj el-Barajneh, two of them within the camp itself. And although at first they struggled to overcome the stigma surrounding mental illness, daily information sessions aimed at sensitising people to patients' needs have had a palpable effect. “MSF means ‘mental health’”, says Charkieh. “Everyone in the camp knows that. But now many people attend the sessions. They even allow us to enter their homes.” That is reflected in the rising number of referrals, she says. Last year, 780 residents of Bourj el-Barajneh received treatment for mental disorders—more than double the number for 2009—prompting MSF to scale up activities in collaboration with local partners, including the UN Relief and Works Agency and the Palestinian Red Crescent Society. “With what we've learned in Bourj el-Barajneh, we think it can work in bigger camps”, says Forgione. Next on the list: Ain el-Hilweh, Lebanon's largest camp. Meanwhile, the non-profit International Medical Corps (IMC) is addressing the mental health needs of the region's Iraqi refugees, mainly through capacity building initiatives aimed at minimising the use of psychotropic drugs. In Lebanon, Syria, and Jordan, IMC teams are training general practitioners and midlevel staff to recognise mental disorders and treat non-severe cases. “The aim is to incorporate mental health services into the country's primary health-care system”, says Colin Lee, IMC country director, who first arrived in Lebanon in 2007 to oversee the agency's post-war relief efforts, including the rehabilitation of damaged clinics and psychosocial assistance for both Iraqi refugees and vulnerable Lebanese. According to Lee, attendees of the 12-session course, which is certified by the health ministry, earn continuing medical education credits on completion of the training. They are also given an IMC standard manual based on the book Where There Is No Psychiatrist by Vikram Patel. Although the latter is available in Arabic, says Lee, much was lost in the translation. “So we've made it Lebanon-specific by including a number of case studies from clinics around the country. And it's been endorsed by the Lebanon Order of Psychiatrists as well as experts at the American University of Beirut [AUB].” Over the past 2 years, IMC has trained 79 practitioners and 35 midlevel staff on everything from common mental disorders like anxiety and depression to gender-based violence, cognitive behavioural therapy, and the patient-doctor relationship. The agency also provides on-the-job supervision to ensure that lessons learned in the classroom are translated into practice. “The end goal is to have the Inter-Agency Standing Committee guidelines on mental health institutionalised”, says Lee. “That's our goal in every country that we work in. But given the political climate here, we have to be realistic about what we can achieve.” Indeed, it is not for lack of human resources that Lebanon lags behind its peers in terms of mental health. Its ratio of 274 physicians per 100 000 people is the region's highest by far. And its experts, at AUB among others, are internationally renowned. Rather, as one of only two Arab states without a mental health policy—a symptom, say experts, of the constant political upheaval that can thwart even the most anodyne of legislative acts—Lebanon has yet to place mental health at the forefront of a national agenda, leaving it instead to private practitioners whose services no refugee can hope to afford. And of course, it is refugees like those in Bourj el-Barajneh who are in the greatest need of that care. “Look at what they have lived through”, says Medyeb Abu al-Einein, director of the Pro-Syrian Popular Committee in the Bourj el-Barajneh camp, on a rainy afternoon in January, just days after the collapse of the Lebanese Government and a march on Beirut by black-clad supporters of Hezbollah. “Conflicts, bombings, poverty, and unemployment.” And fear, he added. “That's the most important thing. People here are worried. Every night, I sleep with my gun. Perhaps I don't need to. But I worry.” Abu al-Einein is not alone. Tense negotiations over the composition of a new government have renewed fears of armed conflict in the streets, as Lebanon's various factions vie for power. And should the worst come to pass, MSF might well find itself, once again, doing the role for which it was founded.

Thousands of Haitians displaced by January's earthquake are living in temporary camps and are vulnerable to the worst the wet season has in store. Patrick Adams reports from Port-au-Prince. More than 2 months after the Haiti earthquake, relief efforts continue apace as a sense of normality creeps back onto broken streets, many of them now cleared of rubble, if not rubbish. Yet even as aid agencies settle in for the long haul and Haitians set about rebuilding what was lost, heavy rains over the next 3 months threaten to compound the crisis, putting the country's estimated 1·2 million displaced at increased risk of vector-borne and enteric diseases, including malaria, dengue fever, and acute watery diarrhoea. “The rainy season poses a big risk for the camps, and we're particularly concerned about outbreaks of diarrhoea due to faecal contamination of the water supply”, said Stefan Wiktor, a medical epidemiologist with the US Centers for Disease Control and Prevention (CDC) and the agency's team leader in Haiti. “The camps are extremely crowded, and the sanitary facilities are inadequate”, he added, citing the potential for “explosive epidemics of, for example, shigella dysentery”. Between Jan 25 and Feb 22, Haiti's Ministry of Public Health and Population reported seven deaths from diarrhoea, all of them children younger than 5 years, and a steady increase in diarrhoea among children 5 years and older over the same period. Diarrhoeal diseases account for an estimated 12% of infectious diseases in the affected area, although bloody diarrhoea represents a small proportion of those cases. Haiti's woeful sanitation predates the earthquake, which has exacerbated the problem by forcing people into even closer proximity with little-to-no access to latrines, a shortage of which remains one of the relief effort's most glaring gaps. “There is still a long way to go to ensure appropriate solid waste, drainage, and excreta disposal both inside and outside the spontaneous settlements”, said Souleymane Sow, a waste management expert with UNICEF, the lead agency for the Water Sanitation and Hygiene (WASH) cluster. “Many efforts are underway”, he said, “but I must acknowledge that the needs are overwhelming”. Although Sphere Standards recommend one latrine for every 20 people in a disaster zone, Sow says that this is not possible in the current context. Rather, with some 3670 latrines on the ground—roughly one for every 200 people—WASH cluster partners and the Haitian Government are aiming for roughly 13 000 latrines (or one for every 100 people) by the end of March, and an additional 21 000 (or one for every 50 people) by the end of June. WASH partners have also distributed close to 90 000 hygiene kits to more than half a million people across the country. Further complicating camp management is the constant movement of populations. According to Haiti's Civilian National Protection Agency, 604 215 people fled the capital for the rural provinces in the days after the quake. However, that number does not reflect the many thousands of residents who have since returned in search of work, swelling the already overcrowded camps, more than 80% of which lack any form of management or security and are largely cut off from health-care institutions. Most alarming is the finding by USAID and WHO that fewer than 40% of 24 000 HIV-positive Haitians taking antiretroviral drugs before the quake are now able to access treatment. Public health experts caution that interrupted HIV and tuberculosis treatment could lead to the emergence of drug-resistant strains, and put displaced people, particularly children, at far greater risk of acquiring communicable diseases like measles and diphtheria. As a 2007 Johns Hopkins study showed, even those HIV-positive children who have been vaccinated for measles could be susceptible because of their waning immunity. “We're very concerned about the rainy season—particularly floods and landslides”, said Felix Diesner from the International Organization for Migration (IOM). “But also contamination of the water supply; latrines can overflow, people continue to defecate in the open, and vector-borne diseases could be a big problem by the end of the rainy season.” In an effort to avert disaster and alleviate congestion in some of the largest camps, the IOM and its camp coordination and camp management partners are setting up six transitional settlements for about 100 000 registered displaced people on 270 hectares of land outside the capital Port-au-Prince. In keeping with Sphere Standards, all six new settlements will provide 30 m2 per person and handicap-accessible latrines and hand-washing stations (panel). Camp coordination and camp management partners estimate that a total of 200 000 people are living in 23 high-risk settlements.PanelRehabilitation amid the rubbleIn early March, as the 2-month anniversary of the Haiti earthquake drew near, fears that a second crisis was coming with the rains—floods, landslides, and outbreaks of infectious disease—dominated the discussion. And well they should have. But for some of Haiti's 3000 or so amputees, early March meant something else as well: a new artificial limb.“It's usually about 6 weeks after surgery that a patient is ready for the prosthesis”, said Becky Jordan, an occupational therapist with Handicap International (HI), the lead agency for the injuries and disability subcluster, charged with coordinating all rehabilitation activities in the affected area. According to Jordan, so far about 211 amputees have had their limbs assessed for the new devices. “The stump needs to have a shape that can fit the prosthesis”, she said. Once the prosthesis is on, though, the road to rehabilitation has only begun.Indeed, as donors, aid agencies, and the Haitian Government sketch the broad outlines of a long-term recovery—an international donors' conference on Haiti will take place on March 31 at UN Headquarters in New York—the country's amputees offer a glimpse of the health-care hurdles ahead. “Mobility aids are just the tip of the iceberg of a system that rehabilitates and reintegrates people into society”, said Wendy Batson, executive director of HI's US office. “People tend to think of a prosthetic as a simple one-off thing, but it's just not.”After care is intensive, she says, and, from a systems standpoint, demanding and very costly as well. “You have training needs, material needs, psychological needs, vocational needs—all of the small pieces that don't get talked about much.” In a country like Haiti, where the economic burden of an amputation can be immense, those pieces are often as important as the prosthesis itself.Amputees are also evidence of mistakes made in the past. “If skin wounds aren't dealt with within 2 or 3 days, they get infected”, said Sahan Rannan-Eliya, a plastic surgeon volunteering with the UK-based charity MERLIN (Medical Emergency Relief International). “I suspect that's one reason we have such a high amputation rate. The bone could be screwed together, but the skin couldn't be stitched. It couldn't envelope the bone. And since bone can't fight infection as well as skin, the fracture wouldn't heal.”At MERLIN's 40-bed facility in Port-au-Prince—a collection of tents on a tennis court with two operating rooms, a radiogram ward, and a temperamental autoclave nicknamed Bertha—orthopaedic and plastic surgeons see patients in teams of two, rebuilding soft tissue and setting fractures. “If we could have gotten plastic surgeons in earlier, we could have saved many more limbs”, said Rannan-Eliya, a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons, which is partnering with MERLIN. “Even if people have bad limbs, having two is extremely important here. But we'll never know how many could have been saved.”Looking ahead, Batson is optimistic on at least one front. “The disabled are now such a large subset of the population that I think there's a broader understanding and awareness of their needs.” Spurred by the UN Convention on the Disabled, she says, “institutions worldwide are realising that it is possible to make structures accessible to disabled people from day 1. And more and more, I'm hearing the word disabled come into conversations.”But the big question, Batson says, is whether the wherewithal will be there in the months and years to come. “This is a complex emergency with a long and very hard recovery in an economy that wasn't feeling real plush to begin with. We'll see.” In early March, as the 2-month anniversary of the Haiti earthquake drew near, fears that a second crisis was coming with the rains—floods, landslides, and outbreaks of infectious disease—dominated the discussion. And well they should have. But for some of Haiti's 3000 or so amputees, early March meant something else as well: a new artificial limb. “It's usually about 6 weeks after surgery that a patient is ready for the prosthesis”, said Becky Jordan, an occupational therapist with Handicap International (HI), the lead agency for the injuries and disability subcluster, charged with coordinating all rehabilitation activities in the affected area. According to Jordan, so far about 211 amputees have had their limbs assessed for the new devices. “The stump needs to have a shape that can fit the prosthesis”, she said. Once the prosthesis is on, though, the road to rehabilitation has only begun. Indeed, as donors, aid agencies, and the Haitian Government sketch the broad outlines of a long-term recovery—an international donors' conference on Haiti will take place on March 31 at UN Headquarters in New York—the country's amputees offer a glimpse of the health-care hurdles ahead. “Mobility aids are just the tip of the iceberg of a system that rehabilitates and reintegrates people into society”, said Wendy Batson, executive director of HI's US office. “People tend to think of a prosthetic as a simple one-off thing, but it's just not.” After care is intensive, she says, and, from a systems standpoint, demanding and very costly as well. “You have training needs, material needs, psychological needs, vocational needs—all of the small pieces that don't get talked about much.” In a country like Haiti, where the economic burden of an amputation can be immense, those pieces are often as important as the prosthesis itself. Amputees are also evidence of mistakes made in the past. “If skin wounds aren't dealt with within 2 or 3 days, they get infected”, said Sahan Rannan-Eliya, a plastic surgeon volunteering with the UK-based charity MERLIN (Medical Emergency Relief International). “I suspect that's one reason we have such a high amputation rate. The bone could be screwed together, but the skin couldn't be stitched. It couldn't envelope the bone. And since bone can't fight infection as well as skin, the fracture wouldn't heal.” At MERLIN's 40-bed facility in Port-au-Prince—a collection of tents on a tennis court with two operating rooms, a radiogram ward, and a temperamental autoclave nicknamed Bertha—orthopaedic and plastic surgeons see patients in teams of two, rebuilding soft tissue and setting fractures. “If we could have gotten plastic surgeons in earlier, we could have saved many more limbs”, said Rannan-Eliya, a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons, which is partnering with MERLIN. “Even if people have bad limbs, having two is extremely important here. But we'll never know how many could have been saved.” Looking ahead, Batson is optimistic on at least one front. “The disabled are now such a large subset of the population that I think there's a broader understanding and awareness of their needs.” Spurred by the UN Convention on the Disabled, she says, “institutions worldwide are realising that it is possible to make structures accessible to disabled people from day 1. And more and more, I'm hearing the word disabled come into conversations.” But the big question, Batson says, is whether the wherewithal will be there in the months and years to come. “This is a complex emergency with a long and very hard recovery in an economy that wasn't feeling real plush to begin with. We'll see.” Although disease transmission remains stable across the affected area, with no known outbreaks to date, public health officials have grown increasingly concerned about a possible malaria epidemic in the making. “Cases are already rising”, said Alexandre Existe, chief parasitologist in Haiti's ministry of health, during a discussion about when to begin distribution of bednets at a vector control cluster meeting in early March. “June may be the right time in a normal situation”, he said. “But this is not a normal situation.” Sarah Hoibak, Haiti representative of the MENTOR Initiative, a group devoted to facilitating the delivery of effective malaria control interventions in humanitarian crises, agrees and has been urging other agencies to take action. “Health facility data in Petit Goave, Leogane, and Carrefour appear to indicate focal epidemics”, she said. “And it's only March. We can be sure that as the rain waters recede, the mosquito population will increase dramatically.” What is needed, she said, is an integrated vector control strategy comprised of larviciding, intermittent-residual spraying, and insecticide-treated plastic sheeting—none of which are approved under Haiti's National Malaria Control Programme. Echoing those concerns, the CDC warned in its March 5, Morbidity and Mortality Weekly Report, that “displaced persons living outdoors or in temporary shelters in Haiti are at substantial risk for malaria”—due, in part, to the fact that the principal mosquito vector, Anopheles albimanus, frequently bites outdoors. The government and non-governmental partners are currently discussing the best strategy and timing for the distribution of nets, and CDC entomologists have recently arrived in country to assist those efforts by characterising breeding sites and assessing levels of insecticide resistance (A Albimanus is susceptible to pyrethroids, although high resistance to dichlorodiphenyltrichloroethane has been documented). Vector control cluster partners estimate that 1·4 million long-lasting insecticide-treated bednets (LLINs) are needed to cover the entire affected population, including in camps with internally displaced people in areas of high transmission. The recent procurement of 400 000 bednets by UNICEF has brought the total in the pipeline to about 800 000, yet fewer than 70 000 have been distributed as part of non-food item kits by agencies like the Pan American Health Organisation (PAHO), the International Federation of the Red Cross, and Population Services International (PSI). Unlike other non-food items however, bednets cannot simply be handed out to families in need. “We know from experience that in order to ensure proper use, we had to take the time to distribute and educate door-to-door”, said Alison Malmqvist, PSI country director, referring to PSI's pilot distribution to a camp of 5000 people in Petionville. “Our team worked with residents to confirm the number of recipients and reinforce messages about consistent use, which is critical to a successful distribution.” That campaign will inform future efforts, she said, including the 3·4 million LLINs slated for distribution through the yet-to-be signed Global Fund Round 8 grant to Haiti for malaria. Michel Van Herp, Médecins Sans Frontières (MSF) epidemiologist, acknowledged that malaria control efforts are needed but said that dengue fever is more likely to be a problem in the immediate future. “It's a question of the vector”, he said. “Aedes aegypti is born with the virus inside, whereas Anopheles must first contract the parasite.” Van Herp said that MSF plans to do a survey of febrile illnesses to get a better picture of the malaria burden vis-á-vis dengue and other high-fever diseases. MENTOR and the CDC are already doing fever surveillance in 36 facilities using data from rapid diagnostic tests (RDTs) deployed throughout the affected area, and the two are planning a differential diagnosis study of cases of “presumed malaria”, said Hoibak. Throughout February, presumed malaria was the number two cause of morbidity in the affected area, behind respiratory illness. Haiti reports roughly 30 000 cases to PAHO yearly, but PAHO officials say the actual number of cases might be as many as 200 000. RDTs, which can be used in community settings, are proving useful because of damages to the country's laboratories and microscopy services. “The current situation has created the need for greater diagnostic capacity”, said Jacques Boncy, director of Haiti's National Public Health Laboratory (LNSP). “But we need to confirm diagnoses made using RDTs, and we have to evaluate the quality of RDTs being used in the field.” Scientists at LNSP are investigating the sensitivity of P falciparum to chloroquine, the first-line treatment for uncomplicated malaria in Haiti and the Dominican Republic, with support from the CDC and MENTOR. “Malaria in Haiti is still sensitive to chloroquine”, said Wiktor. “But resistance could develop, and that would have serious implications, since infected persons would not be adequately treated.” Yet what might do the most to protect Haiti's displaced population from the rains is a new surveillance system tailored to the situation on the ground. For the past 2 months, epidemiological monitoring and surveillance has relied on 51 sentinel sites supported by the US President's Emergency Fund for AIDS Relief to report suspected cases of disease. Reports were to be made daily using a form previously developed for surveillance in the aftermath of hurricanes. That data was then analysed by the CDC and submitted to the ministry of health for final review. But flaws in the system soon became apparent. “A number of the sites were not reporting daily”, said Roodley Archer, a CDC Epidemic Intelligence Service officer. “And we started noticing problems with data quality.” One source of those problems was a complex surveillance form that lacked case definitions for the listed diseases. Days-long dips in reporting were explained by the fact that many sites had closed on weekends. And because most sites were health facilities, little data was coming from the camps, where outbreaks were most likely to occur. With technical support from PAHO and the CDC, the ministry of health set about establishing an emergency reporting and response system with more sentinel sites and reporting based on confirmed cases. CDC Epidemic Intelligence Service officers simplified the surveillance form and distributed it to aid workers in 21 priority sites. The aid workers were trained in the use of RDTs and the collection of serum samples and stool specimens for analysis at the national laboratory. The result, say CDC officials, is a nimble system capable of identifying outbreaks and assessing risk in the most disease-prone populations.

The emergency medical response in Haiti was one of the few success stories of the relief effort, but the influx of foreign doctors has had several unintended consequences. Patrick Adams reports. Before the 7·1-magnitude earthquake that devastated Haiti last January, 39-year-old Delson Merisier, physician and father of three, was one of only two obgyns permanently residing in the city of Leogane, population 30 000. Inundated with patients and always on call, Merisier seldom had a full night's sleep. “I needed help”, he says. “I was too busy.” Though his small outpatient clinic was badly damaged in the quake, Merisier, and the baby he had delivered only moments before it struck, survived unharmed. His house, however, did not. Nor did his private practice, which had generated much of the thousands in savings he had poured into the two-storey home. In the weeks that followed, foreign doctors flooded into Leogane from as far away as Japan, and for the first time in its troubled history the city had a surplus of skilled care. 7 months later, the emergency phase long since over, the foreign doctors are still there, helping to rehabilitate Haiti's thousands of new amputees and providing the basic care that many in the impoverished country have forever gone without. Indeed, although many have criticised the general recovery effort as plodding and ineffectual, few dispute the success of the emergency medical response spearheaded by Haiti's Ministry of Health, with support from groups like Médecins Sans Frontières (MSF), Partners in Health (PIH), the Red Cross, International Medical Corps, WHO, and the Centers for Disease Control and Prevention (CDC). “It was phenomenal”, says Tom Streit, founder and director of the University of Notre Dame Haiti Program, which provided relief teams from the USA with low-cost guest housing at its compound in Leogane. “Health care here has never been better. People are being treated for things they've had their whole lives, because for the first time they have access to care.” Yet the influx of foreign doctors had one unintended consequence: it caused many local private clinics to lose business, displacing Haitian medical professionals, who soon found themselves competing for patients in a marketplace dominated by volunteers. “It's a very serious problem”, says Streit. “We have to find some kind of compromise.” Delson Merisier is fortunate in one respect: Since 2003, he has served as head obgyn for Family Health Ministries (FHM), a small, faith-based non-profit organisation devoted to maternal and child health with a focus on the treatment and prevention of cervical cancer. When Leogane's only public hospital closed in January, 2008, FHM took up much of the slack, building an outpatient clinic where indigent women could deliver their babies for free. Founded in 1993 by David Walmer, a professor of medicine at Duke University, FHM employs three Haitian physicians, including Merisier. “The pay is modest”, says Walmer. “No more than 25% of their total income.” But by devoting half their time to a private practice, the doctors can afford to help. “They work with us because they're altruistic”, he says. “And they value the relationships.” After the quake, those relationships served Merisier well: the Walmers (David's wife, Kathy, is FHM's executive director) increased his salary in an effort to offset his private practice losses. But making ends meet is still a struggle. “I was seeing about 20 patients a week last year”, he says. “Now I have, at the most, two patients a week. I cannot make my life with that.” If aid agencies' enduring presence has forced medical professionals like Merisier out of a paying job, it has also been a lifeline for many others. Nearly 1000 Haitian doctors and nurses are employed in health facilities run by MSF, which scaled up its activities soon after the quake. And US$3·8 million in funding from the American Red Cross (ARC) has allowed Port-au-Prince's General Hospital, the city's largest public hospital, to keep its doors open—at least for now. “We've been worried about this very same issue”, said Winnie Romeril, a spokesperson for the ARC. “That's why we've teamed up with Partners in Health to pay the salaries for General Hospital's 1800 Haitian staff members.” The staff will be back paid from the date of the earthquake through September, she said. But come October, other donors will have to pick up the tab. Before the earthquake, PIH, the largest health-care provider in rural Haiti, already employed close to 5000 locals (about 90% of its total staff) in 12 hospitals across the central plateau. But when the Ministry of Health asked it to take over emergency care in several of the capital's largest refugee camps, PIH had to hire more hands. “The staff we hired in Port-au-Prince—about 240 community health workers—were entirely Haitian”, said Donna Barry, PIH's director of advocacy and policy. “No US volunteers”. In fact, PIH has stopped sending short-term volunteer teams to Haiti altogether, she said, becoming the second major aid organisation to do so after International Medical Corps transitioned out of General Hospital in early July. “Our position has always been that we want to strengthen public health care for the poorest of the poor”, said Barry. “So we've made a point of expanding only in the public sector.” Indeed, PIH recently broke ground on a new facility in the city of Mirebalais, 35 miles north of Port-au-Prince. At 320 beds and 180 000 square feet, the state-of-the-art teaching hospital will be the largest outside of the capital when it opens in late 2011. “We're building it”, said Barry. “But eventually the government will be the owner.” In Leogane, FHM aims to do the same; the small NGO has applied to USAID for an out-of-cycle grant to speed the construction of an $8·3 million Leogane Family Health and Research Center. Once built, say the Walmers, the new teaching and research hospital will become part of the public infrastructure. Still, for all of the investment in Haiti's public health capacity, the question of how long free foreign doctors should stay, and what may happen when they leave, remains at the heart of a heated debate. “It's extremely complicated”, says Stefano Zannini, head of mission for MSF. “We often discuss this, and several questions arise.” Among them, he says: “how many Haitians were able to afford private care before the earthquake? How many can afford it now? Would a patient who can afford to go to a private clinic, with air-conditioning and immediate consultation, go instead to an MSF clinic in a hot, crowded tent in a dangerous part of town?” Although all MSF services are free for any patient—and will remain free for as long as MSF is in the country, says Zannini—a free health care system is not the group's objective. “Rather, it's universal access to care”, he says. “The medical needs of the majority of the Port-au-Prince population are still important. Considering the extremely difficult situation, we think a free system is the most reasonable solution.” Others disagree. “We know that the government does want international organisations to start charging fees for medical services”, said Julie Sell, spokesperson for the ARC. And several Red Cross hospitals will begin doing so in the months ahead, she said. “The plan is to gradually phase out free service and charge patients a larger percentage of the total fees over time.” In the end, though, the fate of Haiti's private medicine—and perhaps its health-care system as a whole—might have less to do with free foreign doctors than it does with low-interest loans. “Access to financial capital: that's the really critical thing”, said Harry Beauvais, an obgyn in Port-au-Prince whose private practice was brought to its knees after the earthquake. “The last 6 months were very difficult”, he said. “The worst in terms of revenue since I started my practice in Haiti 22 years ago.” Despite slashing his fees, Beauvais's patient numbers dropped by 70% compared with the same 6 months in 2009. Surgeries, he said, were down even more. Beauvais says he is doubtful that the government will decide to reimburse him and other providers for their work, a move that some argue would salvage the private sector by removing competition between foreign doctors and local private doctors. But nor does he blame the government for providing the free care Haitians so desperately need. Rather, he says, “the private sector has to devise a new strategy”. And in Beauvias' view, the best strategy is to provide highly specialised quality care. “People will pay for quality. But providing it costs a lot of money. For example, I would like to buy a new ultrasound machine, a Korean-made machine that I saw in India last year. But it's too expensive in Haiti. The interest rates are too high. That's the way it is with so many things. We have lots of ideas. We would like to do this and that. But we're not sure about tomorrow.”

As emergency operations wind down in Haiti, relief agencies are preparing for long-term recovery and rehabilitation work in the earthquake-hit regions. Patrick Adams reports from Jacmel, Haiti. As news crews begin to head for the exits, and Haiti coverage recedes from the front page, the situation on the ground remains extremely dire. 3 weeks after the 7·0-magnitude earthquake that devastated Port-au-Prince and surrounding areas, the official death toll is 212 000 and as many as 700 000 people might have sustained traumatic injuries, according to the Haitian Government. So far, tens of thousands of those survivors have been treated in mobile clinics, field hospitals, and inflatable buildings by aid groups like Partners in Health, the International Committee of the Red Cross/Red Crescent, and Médecins Sans Frontières (MSF). The latter alone has treated roughly 7000 patients and done nearly 1000 surgical operations in some 17 sites throughout the affected area. “The first phase of emergency surgery is more or less over”, said Renzo Fricke, the MSF emergency coordinator in Port-au-Prince. “Now we're transitioning to the second phase of post-operative care and rehabilitation, and that brings its own set of challenges.” Fricke compared Haiti's health situation to an amputation: “The operation itself can be done in a couple of hours, but it requires long-term management.” It is an apt analogy; the disaster's defining injury, amputations could leave some 200 000 Haitians without at least one of their limbs, many surgeons say. While aid and personnel continue to pour into the country, it is unclear how the present level of care will be sustained. “Lots of field hospitals are working with the Comfort”, said Fricke, referring to the US Navy hospital anchored a mile off of Port-au-Prince, where, as of Jan 28, nearly 500 critical cases had been transferred by helicopter. “But the ship won't be there forever. We have to be committed to the long term—to strengthening Haiti's health-care system.” Of the dozens of hospitals and clinics in Port-au-Prince before the earthquake, only eight remain standing. The rest, including all three MSF facilities and the AIDS clinic Gheskio, which oversees more than half of Haiti's AIDS patients, lie in rubble. The main hospital in Leogane, the epicentre of the earthquake, collapsed as well, whereas overwhelmed hospitals in Jacmel, 40 km to the south, are running out of drugs. “We're out of chloroquine and we don't have anything left for gastrointestinal infections”, said Lisa Johnson, an American pharmacist volunteering at Hospital Emmanuel on the outskirts of Jacmel. “Because of the poor water and sanitation, GI [gastrointestinal] infections make up about 60% of our cases.” “Our first priority is to restore access to care”, said Dana van Alphen, director of a 12-member WHO team charged with coordinating the many disparate relief efforts underway. In collaboration with the ministry of health, WHO has begun drafting a long-term strategic plan that incorporates the work of some 160 organisations on the ground. “Coordination is a major challenge”, van Alphen said. “We have to work together to strengthen hospitals in rural areas.” Asked how long the team would be in Haiti, she could not say: “I don't know. I don't think anybody knows.” In addition to secondary infections, communicable diseases threaten to ravage displaced communities. The government estimates that more than 1 million Haitians have been made homeless by the earthquake. Although there have been no documented outbreaks to date, medical teams in Leogane have reported a growing case load of diarrhoea and tetanus. In Jacmel, several suspected cases of measles prompted the recent vaccination of children in the city's largest refugee site. And, on Feb 2, UNICEF, in collaboration with the ministry of health and WHO, launched a vaccination campaign against diphtheria, tetanus, and measles aimed at covering the entire quake-affected area. Still, despite the high-level strategising and the throngs of medical workers arriving every day, Haiti's devastation has rendered even the most basic tasks substanital obstacles to progress. At a recent UN health cluster meeting in Jacmel, the director of the Haitian Red Cross, Madame Germaine, explained that she could not store the measles vaccine overnight; the Red Cross building was too damaged to enter. “Does anyone else have a refrigerator?” she asked. No one raised a hand.