Many illnesses and injuries go untreated in a country like Haiti, considered the poorest in the Western Hemisphere. The World Health Organization (WHO) estimates that only 50% of the Haitian population has access to primary health care services.1 In part, this is a distribution problem; 70% of health care providers work in the cities, while 70% of the population lives in the rural areas of the country.1 According to 1997 WHO figures, Haiti has only 1.2 doctors per thousand inhabitants and only one hospital bed per 1300 inhabitants.1 Pediatric deaths are tragically common. In the summer of 1996, however, a cluster of pediatric deaths due to acute renal failure attracted worldwide attention.
The first of the children with acute renal failure admitted to the General Hospital in Port-au-Prince died in November 1995. By May 1996, after more than 30 children admitted to the same hospital with similar symptoms had died, the situation was no longer a medical curiosity—it had become a medical crisis. Most of the children were younger than 5 years old, and their median age was only 29 months.2 Their story was later told in the US on the television program 60 Minutes, but the details of the successful investigation spearheaded by two US agencies, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), are being published here for the first time.
In 1997 and 1998, while the investigation was still recent history, the CDC and FDA participants recounted their experiences for the FDA History Office. The following account is based largely on the transcripts of these interviews.
An Epidemic of Renal Failure
On May 9, 1996, the CDC in Atlanta received its first information about the burgeoning epidemic. Neal Halsey, MD, a Johns Hopkins School of Public Health and Hygiene professor who had conducted research for decades in Haiti, was in the country to discuss his latest project, a study of HIV transmis sion between mothers and infants. Halsey, who had begun his career as an officer in the CDC s Epidemic Intelli¬gence Service (EIS), immediately sensed that a rapid, full-scale CDC investigation would be much more effective in pinpointing the cause of the epidemic than the ad hoc work then underway at the General Hospital.
Halsey called two former Johns Hopkins fellows at the С DCs National Center for Infectious Diseases (NCID) who had worked under his guidance in Haiti. Halsey also arranged for biopsy and autopsy kidney specimens to be shipped back to Johns Hopkins, where a pathologist concluded that the specimens showed evidence of damage from some kind of toxin.
Renal failure is an uncommon diagnosis in children or adults, and an epidemic of renal failure is particularly unusual. Most often, infectious agents are the cause. Hemorrhagic fever with renal syndrome, for example, was observed in more than 3000 United Nations troops involved in the Korean conflict, caused by one of several hantaviruses transmitted through inhaled rat excreta. In children, however, acute renal failure is more commonly associated with hemolytic uremic syndrome. Undercooked hamburgers from fast food establishments have been blamed for many recent US outbreaks of the the epidemic was not likely to be foodborne in origin, so the RDB took over the investigation. RDB officials suspected that the epidemic was not infectious, but continued their inquiry because their office was responsible for investigating “unexplained deaths,” both nationally and internationally.
At РАНО s invitation, the CDC elected to send Katherine L. O’Brien, MD MPH, then an EIS officer, to Haiti to conduct the epidemiologic investigations. EIS officers serve for two years and, among other assignments, are responsible for conducting outbreak investigations. By tradition, the EIS officers are designated by classes according to the year they entered the Service. O’Brien had completed her pediatric residency at Johns Hopkins and then spent a year in Haiti researching HIV transmission. There she had improved her French and learned some Creole before joining the EIS Class of 1995.
Even humanitarian efforts in a country such as Haiti are often vastly complicated by both national and local politics. In retrospective interviews, O’Brien and her colleagues expressed appreciation for and amazement at the Haitian government’s willingness to put aside issues of power and control to stop the epidemic. Nonetheless, national politics as well as public health politics in Haiti remained a matter of concern as the investigations unfolded.