The association between the distance from the epicenter of the Haiti earthquake (2021) and medical diagnoses: A report from the field

Introduction

On the morning of Saturday, August 14^th, 2021, an earthquake struck Haiti. The epicenter of the earthquake was recorded 125 km west of Port-au-Prince, the capital of Haiti. The earthquake occurred in a depth of 10 km below the surface of the earth, at a magnitude of 7.2 on the Richter scale (PAHO, 2022). Following the earthquake, 2,246 people had died, more than 12,000 were wounded and about 650,000 people needed urgent humanitarian assistance (PAHO, 2022). The Haitian government appealed for emergency support, a call which was responded by the international community that included United Nations agencies as well as international non-governmental organisations (NGOs). The main support was obviously provided to the communities that were closer to the epicenter, as they were more affected and in line with previous studies (Balhara et al., 2018). The consequences were severe, especially following the previous and devastating 2010 earthquake in Haiti, which took the lives of approximately 220,000 people, with an injury rate of 40.2/1000 residents (Doocy et al., 2013). Beyond the urgent need to treat acute health problems (e.g., injuries, urgent surgeries), past experience with such missions have also pointed to the need to help with worsening of pre-earthquake chronic diseases (Millin et al., 2006; Worlton et al., 2022).

One of the NGOs that responded to the appeal was NATAN - Worldwide Disaster Relief, an Israeli voluntary NGO. Initially, NATAN sent an assessment delegation followed by a medical team (the authors of this study). The medical delegation included three physicians and a social worker. One of the physicians spoke French, the language which is understood by the local population. For further language barriers, the delegation relied on a translator. The medical team arrived a week after the earthquake and was working for six days. The team moved from village to village around the epicenter, operating a mobile clinic in collaboration with local physicians. The local clinics were often short of medications and equipment, and the arrival of the mobile clinic enabled the local physicians to invite to the relatively better equipped mobile clinic patients that could use their services. Based on past experience in previous humanitarian missions and in line with previous studies (Kligerman et al., 2017), the medical team prepared and provided medical response that met the needs following the earthquake. In several cases, patients were referred to hospitals for further treatment.

In this study we present and analyze data collected during this humanitarian mission. Furthermore, we examine if the distance from the epicenter (DfE) was related to the medical diagnoses. DfE was found to be a contributing factor to physical and mental morbidity following earthquakes. Cao et al. (2003) found large differences in the prevalence of mental health diagnoses as a function of the DfE following the Hunan 1998 earthquake, China. A shorter DfE could be associated with more severe physical injuries and higher stress, possibly resulting also in more psychiatric morbidity. We thus hypothesized that a smaller DfE will be related to worse health conditions.

Methods

Study design - This study followed the Strengthening the reporting of observational studies in epidemiology (STROBE) checklist. This was a cross-sectional study.

Results

As shown in Table 1, approximately half of the POCs were women (54.1%) and the other were men. One fifth were diagnosed with trauma (20.6%) and one third (28.4%) were diagnosed with internal medicine diseases, including infections. Half of the sample received symptomatic treatment (53.3%) such as pain relief or antiseptic treatment, and about one fifth received treatment for GI (gastrointestinal) symptoms (20.1%), such as anti-diarrhea medications. Finally, one third were prescribed and given antibiotics (23.1%). Nearly 45% were treated in a clinic that was 20 km from the epicenter, 37% were treated at a medium DfE and the rest (18%) were treated at clinics that from greater DfE. There were no missing data. For information on access to the raw data, please see Underlying data.

A strong U-shape association was found between age and DfE (F(2,180)=19.25, p<0.001), where POCs in the medium DfE were significantly younger (18.8 years) than the combined group of POCs in the closest and the most far DfE (39.76 years) (t(178) = 5.8, p<0.0001).

There was a significant association between the DfE and diagnoses (X² (8) = 29.62, p<0.001). Within the group closest to the epicenter, the most prevalent diagnosis was internal medicine diseases (40.3%). Within the medium DfE group, the most prevalent diagnosis was infections (41.9%) followed by internal diseases (27.4%).

Interestingly, approximately half of the trauma cases (50%), were more than 40 km from the epicenter, while the great majority of mental health cases were up to 40 km from the epicenter (81%). Similarly, an even greater majority of OgGyn cases were diagnosed up to 40 km from the epicenter (95.3%).

Women were significantly older (mean age = 34.7 years) than men (mean age=27.2 years; t(325)=2.7, p=0.007). No association between gender and DfE was found (X² (2) =0.7, p>0.5). No association was found between treatment and DfE (X² (6)=12.0, p=0.06). On the other hand, a significant association between gender and diagnosis was found (X² (4)=38.6, p<0.0001). These relations clearly stemmed from ObGyn including only women.

Discussion

The main and novel results in this study are the unequal distributions of diagnoses as a function of DfE. Surprisingly, unlike the expected observation of a physical trauma related to small DfE, ObGyn, mental disorders and internal medicine diagnoses were overrepresented in proximal DfE, compared to physical trauma. This is in line with past studies showing that several days after the index event, diagnoses of traumatic injuries related to the earthquake are declining (Chauhan & Chopra, 2017).

The poor medical system of Haiti before the earthquake and lack of medical services could be the reason behind the distribution of the health problems, and the effects of the earthquakes are exacerbated by these pre-conditions. Past studies show that improved infrastructure including internet and communication are factors in reducing risk (Anthony, 2011; Nagamatsu et al., 2011).

Nevertheless, the results observed in the present study could be explained in several ways. The most outstanding result is the relatively low prevalence of physical trauma, compared with higher rates of internal medicine problems and infectious diseases. First, unlike the major 2010 earthquake, the epicenter of 2021 earthquake was closer to rural areas characterized by wooden and small buildings. The type of buildings is a direct factor affecting the injuries, where poor structured buildings are more prone to collapse (Ellidokuz et al., 2005). Importantly, poverty as a sociological factor is leading to life in poor and underdeveloped conditions (Hu et al., 2011).

Another possible explanation might be that those who had physical trauma that resulted from the earthquake could not reach the clinic. Alternatively, because the clinic of NATAN arrived a week after the earthquake, those who had such trauma, may have already been treated (Chauhan & Chopra, 2017). Future humanitarian interventions operating more than a week after index events should be prepared to treat sub-acute diagnoses such as suture removal and percutaneous abscess drainage.

Furthermore, one could assume that the closer DfE may reflect a stronger stressor than farther DfE, and stress was found to be associated with physical trauma, internal medicine conditions such as myocardial infarction as well as with ObGyn problems and infectious diseases like the common cold (Meisel et al., 1991; Pedersen, 1998; Chi & Kloner, 2003; Khan et al., 2007; Traylor et al., 2020). A study done following the Hunan 1998 earthquake found a dose response relation between DfE and psychiatric problems, with a small DfE having 60.4%, medium DfE 48.2% and large DfE 44% psychiatric problems (Cao et al., 2003). Together these results suggest that stress related to DfE may be a risk factor for certain conditions treated following earthquakes. However, since stress was not assessed in the present study, such an explanation must be taken with caution. The high prevalence of infections may have also resulted from after-effects of the earthquake such as water systems breaking down, which could have increased the risk of infectious diseases (Chard et al., 2018; He et al., 2018).

The result which showed that POCs in the medium level were significantly younger than the combined group of POCs in the closest and the largest DfE, is difficult to explain. A reasonable explanation may be related to the timing in which the clinic operated in the medium level distance. The clinical service provided in the medium distance operated during the weekend, when the younger people are not at work or in other obligations.