Bautista Rojas Gomez

On 20 October, 2010, Bautista Rojas Gómez, Minister of Public Health and Welfare of the Dominican Republic, was notified about suspected cases of cholera in the central region of Haiti. The news arrived just as he was visiting the border region between Haiti and the Dominican Republic, and it was there that he made preliminary decisions, called on regional health directors, and provided information to local authorities on what is considered to be the most serious health threat that the country has faced in its history.

On returning to Santo Domingo, the Minister informed the President about the situation and the President called together leaders from the armed forces, immigration, water, and Ministry of Health. A plan was put in motion to mobilize resources and to maintain ongoing contact with the populations at highest risk. A strategy was developed to respond to and avoid a widespread epidemic that would have high mortality rates and dire consequences for the economy, particularly as it related to tourism.

From the province of Altagracia to Puerto Plata, important tourist hubs, a public information campaign targeted hotels, restaurants, and the thousands of workers in the tourism sector. “It was necessary to create awareness to keep the problem from spreading; everyone had to understand that water and sanitation are critical to preventing the advance of the disease,” Rojas Gómez said.

Later, an awareness and mobilization strategy was introduced in poor neighborhoods. In November, the first cholera cases were reported in the country, and by December, there were a considerable number of cases in the southern province of San Juan de la Maguana. However, rapid interventions halted the spread of cases.

Nearly a year later, the Dominican Republic has a low rate of cholera transmissions and deaths. Nonetheless, there are still challenges ahead. In this interview, the Minister of Health recounts the first days of preparedness, coordination, and response actions that were undertaken, and the challenges facing the country to eliminate cholera from its territory.

In the nine months of epidemic, what have been the biggest hurdles in the response?

The most serious challenges have to do with conditions in poor neighborhoods, including the quality and quantity of the water supply, education, living conditions, water management, and other conditions that affect basic sanitation where people live. Other factors that that we must address have to do with immigration, language barriers, and the cultural differences that exist between our Haitian neighbors and us; these factors have had an effect on the mortality rates. A large percentage of the deaths have occurred in the Haitian population who do not go to hospitals, and when they do, it is too late. We seek these populations out to provide medical care, to try to improve their condition, but it becomes difficult when we have to send them home with instructions for care and prevention.

In addition, we are facing a disease that was previously unknown to our health workers. At the beginning, case management was an obstacle. Another issue that we had to consider was the physical condition of the people. This is a disease of poverty, made worse because many people are undernourished. You see their physical condition; you see that life has not been kind to them; you see that they are victims of inequity.

In the context of the ongoing migration of Haitians to the Dominican Republic, what have the authorities done to prevent the outbreak from expanding?

We do not pursue illegal immigrants, nor do we care whether a person does or does not have documentation. Health is a human right and we must offer it to every human being on the planet. Our policy is to provide health services; it is our duty to treat Haitian nationals the same way that we would treat an American citizen with economic resources. We don’t provide only what we have a surplus of, but rather what we lack. We don’t have excess supplies of Ringer-lactate solution or oral rehydration salts, but we provide them without hesitation.

Cholera is already in the country and will remain for a long time. What short-, medium-, and long-term measures have been taken by the Ministry of Health to establish a structure to deal with the disease?

We convened a meeting with the National Commission on Cholera and I told them there was nothing to discuss. The recommendations from the experts are clear: all we have to do is apply them. We have response mechanisms for the short- and medium-term. For the long-term it is evident that to eradicate cholera from the Dominican Republic we must improve water and sanitation conditions.

At this meeting, I told the representatives from the Inter-American Development Bank and the World Bank (who asked what they could do to help in the health sector) that they should focus their resources in the water and sanitation sectors. More aqueducts, good water quality, proper management of wastewater, and basic sanitation are needed. However, this costs a lot of money. I am confident that if the money that the country needs to tackle the emergency is invested in water and sanitation, the cholera problem will be solved.

Minister Rojas coordinated response to the cholera outbreak.

Multisectoral coordination has been a key issue in the response from the start of the epidemic. Will it be maintained?

This coordination will continue and it will be led by the President; we have insisted on that. When we (the Ministry) call for a meeting, institutions send their representatives; when the President calls for a meeting, everybody wants to attend. At these meetings, points are made candidly and decisions are taken, making for effective coordination. The water sector participates in these meetings, and when necessary the Armed Forces also attend. Coordination has worked this way. As I mentioned before, this is not only a health issue, but an economic one as well.

Nine months have gone by since the epidemic started. How does the Ministry manage to face the fatigue and not let its guard down, considering all the organization that is required?

First of all, we have continued with meetings of the National Cholera Commission, which was first created in 1991. The Vice Minister of Collective Health is responsible for maintaining prevention and health promotion activities. You have to understand that if you are here you work from Monday to Sunday. And we have to do that without forgetting other health issues, including commitments made not only to our citizens, but at the international level We cannot put aside the Millennium Development Goals of reducing maternal and infant mortality, increasing immunization coverage, and working with dengue, rabies, and malnutrition. If we focus only on cholera, it is more than likely that another hot issue will arise.

What failures have you seen in coordinating response to the epidemic?

This is something that really worries me: Since November we have been talking about the Community Oral Rehydration Units (CORUs). At this point, these Units should be everywhere in the country; that is, for every 50 houses there should be one Unit where people can go in case they need oral rehydration, and everyone should know how to use ORS packets. Each house could easily have two or three packets of oral rehydration salts, and have the instructions on how to mix them.

Minister, what have been the most important lessons learned with this crisis?

The most important lesson has been to learn how to coordinate and to listen to the experts. To have big ears that listen, eyes wide open to see, and not to ignore what you have seen; to learn from experience and put that knowledge into practice.

For me, the most important issue has been the inter-institutional coordination and relying on participation from society to solve the problems. This is a basic issue; without it, we would have had a disaster in this country.