They intervened in 226 sectors throughout most of the national territory. During the operations in which the various institutions that make up the “Cabinet of Action against Dengue” intervened, 85,000 units of abate (larvicide) were applied to prevent larvae production in tanks and other containers used to store water for domestic use.

Likewise, 14 thousand hygiene kits containing mainly chlorine, sponges to smear the tanks, educational material, more than 15 thousand posters, and brochures, among others, were delivered. In the house-to-house visits, 112 thousand 976 homes were covered, and the fumigation actions were 478. This first stage consisted of two intervention actions with fumigation teams composed of trucks and motor pumps and a second one consisting of a broad vector control operation, elimination of breeding sites, and decacharrization (the discarding any pot or container where water can accumulate to prevent the spread of mosquitos).

Interventions
The interventions were carried out in the sectors with the highest incidence in the National District, La Romana, San Pedro de Macorís, Barahona, Montecristi, San Cristóbal, Puerto Plata, Santiago, and Greater Santo Domingo. Some 27,375 men and women who form part of the different institutions that make up the COE, the entity responsible for the operational aspect, joined the work.

The call was successful and achieved an excellent response from the population involved in the dengue prevention tasks through neighborhood councils and other community entities and, together with the authorities, contributed to eliminating breeding sites. The aim is to prevent the disease through mosquito control and reduce transmission intensity during the current epidemic in the country.

abate (insecticide) for the prevention and control of the virus transmitted by the bite of the Aedes aegypti mosquito.

Rivera said that 334 thousand houses were fumigated in 478 sectors nationwide.

“We always visit where the cases appear, but on this occasion, we visited and fumigated areas where there were no reported cases,” he said about the advantage of mobilizing in unison throughout the provinces.

Lowering the mosquito population
On his side, the Vice-Minister of Collective Health, Eladio Pérez, assured that these massive fumigations “will help us significantly reduce the vector population. Therefore, we will have a much more abrupt decrease in the next weeks.”

The epidemiologist indicated that in Hermanas Mirabal, the border area, Samaná, and Higüey, “the minimum number of cases” of dengue fever are reported, contrary to Santo Domingo North, Santo Domingo East, National District, and Santiago, which have been the main centers.

Perez valued the confirmation of the Cabinet to intensify the plans against the reproduction of the mosquito.

“The fact that the president (Luis Abinader) is coming to support us is extremely opportune, since, at a time when the situation is practically stabilized, to come and give that last blow is going to enhance all the consequences that will come in chain by that intervention,” he said when interviewed on television.

He recalled that dengue serotype 3 is the most abundant and has not circulated in the country since 2019.

“This leads to a population being vulnerable and also leads to greater severity,” he added.

Emergencies continue to be complete; SNS says cases are decreasing
View of the Emergency Room of the Hugo Mendoza Hospital (DANIA ACEVEDO).

Despite the preventive actions, the emergencies of the pediatric hospitals were still full on Monday morning.

At the Robert Reid Cabral alone, 72 children with febrile syndrome under suspicion of dengue fever; 32 were newly admitted. This slightly increased compared to Friday’s cases, when 64 infants were admitted with possible dengue fever.

That hospital’s Intensive Care Unit (ICU) reported no inpatients on the weekend.

However, the official statistics of the National Health Service (SNS) register 82 admissions in Santo Domingo in the last 24 hours. The total number of hospitalized is 332 in the Metropolitan region, which includes Greater Santo Domingo and Monte Plata.

“These figures reflect a reduction in relation to the weekend, since between Saturday and Sunday those admitted were 90 and 336 remained hospitalized,” the SNS said in a press release.

In total, the Public Health Network at the national level admitted 157 people for dengue fever in the last 24 hours between Sunday and Monday, with a total of 637 hospitalized.

The SNS guaranteed the availability of beds, supplies, and medicines, as well as the necessary specialized personnel to respond to the demand for dengue care.

1,752 patients at the Hugo de Mendoza Hospital
Meanwhile, the director of the Hugo Mendoza Hospital, Dhamelisse Then, declared in a television interview that, during the present outbreak, 1,752 patients had been admitted to the center under suspicion of dengue, and two of them died.

The most affected are children with comorbidities, falcemics, and patients who have had dengue previously.

He pointed out that 5% of the patients may have affectations in the liver, heart, and other internal organs.

They then called parents, reminding them that children do not go to emergencies alone and to seek assistance with the first symptoms: fever, vomiting, abdominal pain, and pain behind the eyes.

Actions in Santo Domingo East
Regarding the actions being carried out in Santo Domingo East to combat dengue fever, Mayor Manuel Jimenez said he met last week with the Minister of Public Health, Daniel Rivera, and Vice President Raquel Peña to carry out specific preventive operations.

He informed me that Los Tres Brazos and El Almirante were identified as the areas of greatest vulnerability. Still, he added La Grúa and Villa Liberación as other places where a fumigation day began this Monday.

The most recent report indicates 12,991 suspected cases of dengue fever in the country and eleven deaths associated with the disease since the beginning of this year, 2023.

Two people died after several days of dengue fever while being treated at health centers in Santiago and La Vega, while a minor died while being admitted to the regional hospital of Barahona.

One of the deceased is a two-year-old boy declared dead at the Arturo Grullon Regional Pediatric Hospital in Santiago.

The parents of the minor identified their son as Dilan de Jesus Corona Reyes, who resided in the Nuevo La Herradura neighborhood southwest of the city of Santiago.

The father, Maicol Gabriel Corona, alleges that there was medical negligence on the part of the personnel of the medical center.

“We took him on Monday morning, there what they did was that they bathed him and gave him acetaminophen and then they sent him home,” said the child’s father.

Corona explained that the following day, his son got sick again; they applied the same methodology and sent him home again, and finally, on Saturday, his son died.

Maria Reyes, the little boy’s mother, said she does not want another child to suffer all that her son sustained just because he did not receive adequate care.

“If my son had been admitted since Monday when we first took him, we would not be watching over him today,” Reyes explained. Yesterday, a commission from the Ministry of Public Health went to the family’s residence and verified that the family has to store water because they do not receive service.

La Vega

The other person who died from the disease was 48-year-old José García Valdez, who lived in the municipality of Constanza and had received medical attention since Saturday in a private center in La Vega.

Garcia Valdez had been in a private health center for several days after being referred from a center in Constanza.

Jose was known throughout the region for his participation in various festivals and local events, where he stood out for his characteristic Mexican character, which delighted those present with his humor and sympathy. In addition to his presence on festive occasions, García Valdez was also an active figure in the local politics of Constanza, contributing significantly to the municipality’s development.

Child dies in Barahona

Another child died of dengue fever at the Jaime Mota Regional Hospital, bringing to three the number of deaths due to this disease in that center. At the same time, 45 patients were admitted, and another ten were waiting in the emergency area.

The victim is a boy of 4 years and nine months, who was admitted at 4:00 in the afternoon of Sunday, but at 10:00 at night, he expired, confirmed to Listin Diario sources of the unit, which gives attention to the cases of dengue fever.

The child, who lived with his parents in the community of Villa Central and studied in the Basic School Anaima Tejeda, had several days with fever, vomiting, and diarrhea, for which he had been taken to the hospital on at least three occasions, but his admission was not ordered. Teachers, students, classmates, administrative staff of the Escuela Básica Anaima Tejeda, as well as the medical and nursing staff of the Hospital Regional Docente Universitario Jaime Mota, showed their sorrow for this new death, which joins that of a 12-year-old girl who died of the exact cause in that health center.

Meeting

Yesterday, Mayor Victor Emilio Fernandez, the director of the Regional Health Services, and Wilkin Feliz, the UASD Barahona Campus general director, met with the municipality’s health promoters, who were asked to get involved in preventive actions.

The meeting was held to eliminate the breeding sites of the Aedes aegypti mosquito, which transmits the disease through its bite.

At a meeting convened by the Provincial Government last week with the mayor and the health sector, the medical director of the local hospital, Dr. María Elena Batista Rivas, complained about the two private health centers because they do not accept patients with dengue fever.

This situation causes the leading medical center here to be full of patients with the disease.

Dr. Batista Rivas said that, given this situation, she has increased the number of beds for the disease from 24 to 36, to which she will add 15 new beds starting this Monday, for a total of 51 beds exclusively for patients with this health condition.

The hospital’s medical director also informed that three new stretchers will be added to the ten existing ones in the emergency area for 13.

Sources of this hospital confirmed to Listín Diario that yesterday they had 45 patients admitted, both adults and pediatric, while in an emergency, more than ten people were waiting for a space to be admitted.

She explained that her husband began to feel ill on Friday the 20th of this month while he was singing in a local restaurant, presenting strong gastrointestinal pains, headaches, and fever, reasons for which he was admitted the following Saturday afternoon to the Titi Specialties Center of this city, being diagnosed with hemorrhagic dengue.

“From Titi, we took him at one o’clock in the morning yesterday to the La Concepción Clinic in La Vega. I took him by the hand to the Intensive Care Unit, but he died at three o’clock in the afternoon. At first, I thought he had the flu, and I prepared some tea for him, but he continued to be sick, so we admitted him to Titi,” she indicated.

She complained that, even though her husband had “good insurance,” the clinic in La Vega charged him RD$30,000 for less than one day he was hospitalized.

Valdez Araújo, 49, lived with his wife and three children in the Las Flores neighborhood. His coffin was buried this morning in the cemetery of El Cercado.

On the other hand, the director of the Dr. Pedro Antonio Céspedes Hospital here, Brianda Pujols Soriano, when consulted about the evolution of the dengue outbreak affecting this city and a large part of the national territory, said that there is a decrease in the number of cases arriving at the health center.

“So far this month, probable and confirmed cases of dengue have been reported day by day here at the Dr. Pedro Antonio Céspedes Municipal Hospital. At the beginning of October we saw incidences of confirmed cases of dengue, and we had rooms full, both of adults and children, but, thank God, this week we have seen that those cases have been dropping,” he said.

He indicated that up to this Monday, there were only five confirmed cases of the disease, which for months has had the Public Health authorities in check at the national level. He specified that 33 cases of dengue fever were admitted this month, and 55 probable cases.

Pujols Soriano urged the population to maintain the safety measures that have been recommended and not to resort to self-medication because some people administer to their relatives Acetylsalicylic Acid (Aspirin), which is contraindicated in cases of dengue.

According to the information available at the moment, with Mr. Valdez Araújo’s death, two people have lost their lives in this city due to dengue.

The other victim was Mr. Pablo Álvarez, 69 years old, who died on September 25 at the local hospital. He lived in the El 9 sector of Constanza.

In Episode 7 of “Eradicating Smallpox,” Shohrab, a man who was displaced by the 1970 Bhola cyclone, shares his story. After fleeing the storm, he and his family settled in a makeshift community in Dhaka known as the Bhola basti. Smallpox was circulating there, but the deadly virus was not top of mind for Shohrab. “I wasn’t thinking about that. I was more focused on issues like where would I work, what would I eat,” he said in Bengali. 

When people’s basic needs — like food and housing — aren’t met, it’s harder to reach public health goals, said Bangladeshi smallpox eradication worker Shahidul Haq Khan. 

He encountered that obstacle frequently as he traveled from community to community in southern Bangladesh. 

He said people asked him: “There’s no rice in people’s stomachs, so what is a vaccine going to do?” 

To conclude this episode, host Céline Gounder speaks with Sam Tsemberis, president and CEO of Pathways Housing First Institute. 

He said when public health meets people’s basic needs first, it gives them the best shot at health. 

The Host:

Céline Gounder
Senior Fellow & Editor-at-Large for Public Health, KFF Health News

@celinegounder

Read Céline's stories

Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board. 

In Conversation With Céline Gounder:

Sam Tsemberis
Founder, president, and CEO of Pathways Housing First Institute

@SamTsemberis

Voices From the Episode:

Shohrab
Resident of the Bhola basti in Dhaka

Iftekhar Iqbal
Associate professor of history at the Universiti Brunei Darussalam

Shahidul Haq Khan
Former World Health Organization smallpox eradication program worker in Bangladesh

Click to open the transcript

Transcript: What Good Is a Vaccine When There Is No Rice?

Podcast Transcript 

Epidemic: “Eradicating Smallpox” 

Season 2, Episode 7: What Good Is a Vaccine When There Is No Rice? 

Air date: Oct 24, 2023 

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast. 

[Ambient sounds from a ferry play softly.] 

Céline Gounder: I’m on a boat in southern Bangladesh, headed toward Bhola, the country’s largest island. 

We’re traveling by ferry on calm waters. But my head spins — and my stomach roils just a bit — as I imagine how these same waters nearly destroyed Bhola Island. 

[Tense instrumental music begins playing.] 

It was 1970. 

In November, under an almost-full moon and unusually high tides. 

The island was hit by one of the most destructive tropical storms in modern history: the Bhola cyclone. 

[Shohrab speaking in Bengali fades under English translation.] 

Shohrab: There were floods. Back then there weren’t any embankments to stop the water from rising. 

Céline Gounder: Counterclockwise winds, torrential rains, and treacherous waves swept entire villages into the sea. People held onto whatever they could to keep their heads above water. 

[Shohrab speaking in Bengali fades under English translation.] 

Shohrab: I remember at that time the water level rose so high that people ended up on top of trees. The water had so much force. Many people died. 

Céline Gounder: The Bhola cyclone killed some 300,000 people. And for those who survived, there wasn’t much left to return to. Hundreds of thousands of people lost their homes, their farms, and their access to food. 

The man whose voice you’ve been hearing was one of the survivors. 

[Shohrab speaking in Bengali fades under English translation.] 

Shohrab: My name is Shohrab. I am 70 years old. 

Céline Gounder: Shohrab was a teenager when the cyclone hit. And in the days and weeks after the storm, he and his family joined a mass migration of people who fled southern Bangladesh. 

They traveled about a hundred miles north from Bhola Island to the streets of Dhaka, the busy capital of Bangladesh. 

There, they settled in a makeshift community, a kind of unsanctioned encampment dubbed the Bhola basti. 

In Bengali that word,“basti,” means settlement — or “slum,” in some translations. 

The residents forged a community, but soon, the poor people there — and what they built — would be seen as a threat to the effort to keep smallpox in check. 

Not just in South Asia — but around the world. 

I’m Dr. Céline Gounder. This is “Epidemic.” 

[“Epidemic” theme music plays.] 

[Ambient sounds from the Bhola basti, including voices of people speaking Bengali, play softly.] 

Céline Gounder: More than 50 years after the cyclone, Shohrab lives in the same area in Dhaka. 

I interviewed him at a tea stall near his home. It’s the kind of place where men gather to gossip and share stories over hot drinks. 

Inside there’s a colorful display of snacks and sweets hanging from the ceiling. Just outside we sat on well-worn wooden benches. 

And as we sip our tea, he tells me about life in the encampment in the 1970s … 

[Sparse music plays softly.] 

[Shohrab speaking in Bengali fades under English translation.] 

Shohrab: I used to rent a place there. Five or six of us used to live in one room. Sometimes it was eight people in a room. 

Céline Gounder: To cover his portion of the rent he worked as a day laborer, doing odd jobs here and there. Over time the basti became home. 

But Shohrab’s new home was likely seen as an eyesore by outsiders — and by the Bangladeshi government. 

Such settlements often lack running water, or electricity, or access to proper sanitation. Those conditions spotlight suffering — and for local leaders that spotlight can be uncomfortable. 

But, public health experts had a different concern: that the settlement of Bhola migrants in Dhaka would become a deadly stronghold for smallopox. Cramped and unsanitary living conditions put the residents at high risk. 

I ask Shohrab if he remembers seeing or hearing about people with smallpox when he first arrived. 

[Shohrab speaking in Bengali fades under English translation.] 

Shohrab: I wasn’t thinking about that. I was more focused on issues like where would I work, what would I eat, etc. 

Céline Gounder: As he tried to rebuild his life, other things — like food and shelter — were more urgent. 

[Music fades to silence.] 

Widening beyond that one migrant encampment in Dhaka, researchers say the picture was similar in cities and villages all across the country. 

Bangladesh was hit with a series of crises. Environmental historian Iftekhar Iqbal says each brought human suffering — and that each was a blow to the smallpox eradication effort. 

Iftekhar Iqbal: Seventies was really a time when, the coming of the smallpox couldn’t come at a, at a more unfortunate time. 

Céline Gounder: In 1970 the Bhola cyclone hit. In 1971, just four months later, the country fought a bloody liberation war. Then, in 1974, heavy rain and flooding triggered a famine. And in 1975 there was a military coup. 

Iftekhar Iqbal: The 1970s was the deadliest decade in the history of Bangladesh. 

Céline Gounder: This period is when the country became Bangladesh — winning its independence from Pakistan in the liberation war. But residents of the young nation faced cascading upheaval and turmoil. And too much death. 

[Instrumental music plays softly.] 

On the global stage stopping smallpox was important, but many in Bangladesh were just trying to make it to the next day. 

Daniel Tarantola: No. 1 priority is food and food and food. And the second priority is food and food and food. 

This was an area where survival was always in question. 

Céline Gounder: That’s Daniel Tarantola. 

He’s from France and arrived in the region with the mission of helping to eradicate smallpox, but he says the people in front of him needed help with many other things. 

Besides hunger, some of the villages he visited were dealing with two epidemics: smallpox and cholera. 

Daniel Tarantola: And we were not equipped to do anything but smallpox containment and smallpox eradication. By design or by necessity, we didn’t have the means to do anything much more than that. 

Céline Gounder: Over the course of this season we’ve talked about big, complicated issues — like stigma and bias, distrust, or First World arrogance — that threatened to derail the smallpox eradication campaign. We’ve documented the public health workers who found a way around those roadblocks. 

But sometimes the need is so big, so entrenched, that your inability to meet it can be demoralizing. I sometimes felt that during my own fieldwork: battling HIV and tuberculosis in Brazil and southern Africa, and during an Ebola outbreak in Guinea, West Africa. 

Daniel Tarantola says in South Asia the best he could do was focus on the task at hand. 

Daniel Tarantola: Meaning that you had to set up a program to eradicate smallpox or at least eliminate it from Bangladesh and at the same time not get … if I can use the word distracted, um, by other issues that prevailed in Bangladesh. 

[Music fades out.] 

Céline Gounder: Those were tough emotional realities for health workers and the people they wanted to care for. 

But … 

Daniel Tarantola: The level of resilience of this population is absolutely incredible given the number of challenges that they have had to survive. 

Céline Gounder: One of the main ways people survived the upheaval in Bangladesh was by picking up and moving away from the things trying to kill them. 

Remember how Shohrab fled to Dhaka after the cyclone? 

Well, mass migration is a survival strategy — but one that can worsen disease. 

When the cyclone refugees from Bhola landed in that under-resourced basti in Dhaka, all smallpox needed was an opportunity to spread. 

[Solemn music begins playing.] 

That opportunity came in 1975 when the Bangladeshi government decided to bulldoze the Bhola basti. 

Daniel Tarantola says it was a bad idea. 

Daniel Tarantola: We knew there was smallpox transmission in this particular area and therefore they should wait until the outbreak subsides before dismantling the shanties. 

Céline Gounder: Government officials did not wait for the outbreak to subside. They bulldozed the basti anyway. 

Daniel Tarantola: That resulted in a wide spread of smallpox. 

Céline Gounder: Here’s environmental historian Iftekhar Iqbal again. 

Iftekhar Iqbal: This eviction is considered one of the policy errors that led to the second wave of postwar smallpox. 

Céline Gounder: In the wake of that eviction in 1975, thousands of people scattered. Some surely returned back home to Bhola. 

[Music fades out.] 

Céline Gounder: Public health’s failure — the government’s failure — to meet the basic need for safety, for food and housing, delayed the goal to stop the virus. 

Shahidul Haq Khan, the Bangladeshi public health worker and granddad we met in Episode 4, says he learned that lesson over and over as he urged people to accept the smallpox vaccination. 

Their frustration with him — and by extension public health — was clear. 

[Shahidul speaking in Bengali fades under English translation.] 

Shahidul Haq Khan: There was no rice in people’s stomachs, so what is a vaccine going to do? “You couldn’t bring rice? Why did you bring all this stuff?” That was the type of situation we had to deal with. 

[Atmospheric music begins playing.] 

Céline Gounder: What good is a vaccine when there is no rice? 

Next up, I speak with Sam Tsemberis, founder of Pathways Housing First Institute. It’s an organization that advocates for meeting people’s basic needs first, so they’ll have the best shot at health. 

But in the beginning, he found out convincing institutions was easier said than done: 

Sam Tsemberis: I try to explain this rationale that I’m telling you, like people need housing first and then services. The hospital is like, “No, no, we’re in the hospital business. We’re not in the housing business.” 

Céline Gounder: That’s after the break. 

[Music fades to silence.] 

Céline Gounder: One of my mentors was Dr. Paul Farmer, the legendary doctor and anthropologist whose work in Haiti was documented by Tracy Kidder in the book “Mountains Beyond Mountains.” Paul always pushed us to look beyond the symptoms to root causes. It’s a lesson we keep having to learn in public health again and again. 

Sam Tsemberis is one of the first to apply it to homelessness. He’s the CEO of a nonprofit called the Pathways Housing First Institute. The organization promotes a model of addressing homelessness that begins with putting people into housing. 

That idea seems pretty obvious. But back when Sam first started working on homelessness — in New York City in the 1980s — the prevailing model was more like a staircase. People had to work their way up to show they were ready for, or even worthy of, housing. 

Sam Tsemberis: If you showed up applying for housing, you had to acknowledge you had a mental illness, you had to demonstrate that you were taking medication, and that you understood why you were taking medication. And you also had to have — if you had any history of alcohol or substance use, you also had to demonstrate a period of sobriety. 

It was a very tough regimen to get into housing. 

Céline Gounder: Sam said he quickly realized that wasn’t working, even though it was the only approach at the time. 

Sam Tsemberis: I was working very hard to help people navigate that. I was doing street outreach. So, “Come come to the shelter, come to the hospital, come to a treatment program, a drop-in center,” hoping that they would engage and successfully make it up the stairs and get housing eventually. 

And what began to emerge was that even if people were willing to take the first step — let’s say go to detox or go to the hospital — far too many people ended up returning to the street, which was, which was a signal that, you know, something was wrong with this system. It’s like, why are people falling back? 

And the stories on the street were compelling. You know, people would say, “No, I don’t need to go to detox. What I need is a safe place to stay.” 

Or, “Yeah, I’ve been diagnosed with schizophrenia, but … you know, and I still hear voices, but I don’t pay attention to them. Right now, I’m just cold, I’m tired, I’m hungry, I need a place to be safe. I need to go inside. That’s what I need first.” 

And the repeated pleas for safety, security, a place to call home, from people that had tried and failed and tried and failed that staircase system is what compelled me to, you know, try something different, because what we were doing wasn’t working. And that’s when we started this housing-first approach. 

Céline Gounder: Can you explain: What is that, and what’s its impact? 

Sam Tsemberis: Housing-first is the answer to a question that we ask people. “OK, what is it that you want?” And people would inevitably say, “I want a place to live, isn’t it obvious?” 

So our job as providers, then, was to figure out a way to have a program that we can get money for rent, and money for case management services, and give people who had previously no opportunity to get into housing on their own terms, and also offer the kind of clinical or social or emotional support that’s needed after people get housed. 

Céline Gounder: So how did you pilot or how did you jump-start this effort? What did that look like? 

Sam Tsemberis: So we ended up having to start our own nonprofit agency, apply for a grant, and we, with fingers crossed, we started to take people that were actively using and in some cases actively symptomatic and put them into apartments of their own and visit them a lot, not knowing how it would turn out. 

What we found, much to our shock and surprise, very pleasant surprise, is that 85% of the people we housed, even in that first year, remained housed. And we thought, well, you know, we’re onto something here. 

Céline Gounder: So instead of insisting that people be treated for addiction and mental health issues before they got into housing, you gave them housing first. And that was really sort of the measure of success. 

Sam Tsemberis: Yes. 

Céline Gounder: How successful was the program in treating addiction and mental health? 

Sam Tsemberis: The addiction and mental health treatment outcomes were modestly better for the housing-first group that didn’t require to be in treatment. But you know, their treatment was no worse and a little better than the group that required treatment and sobriety. 

And there, a measure called the overall quality of life, you know, like, how happy are you with living in the community, with your contacts with relatives, and so on. The group that went into housing first had a significantly higher quality of life than the treatment-first group. 

Céline Gounder: So I know there are people out there who will say, Well, you didn’t solve their addiction issue or their mental health issue; how is that a success? How would you respond to that criticism? 

Sam Tsemberis: This was never advertised as a program that cures addiction or cures mental illness. Recovery, in some ways, is not abstinence. Recovery, at least in the mental health business, is having a life in spite of your diagnosis. 

The main thing is you’re no longer homeless. You know, you don’t have to be on the street until you’ve cured your illness. Because if that was the case, people would likely die on the street before they cured their illness because we don’t have cures for some of these illnesses. 

Céline Gounder: So, Sam, Dr. Paul Farmer was a mentor of mine, actually, over the course of my training. And in Tracy Kidder’s biography of Paul, there’s a quote of one of Paul’s colleagues, Haitian colleagues, who says that, “Giving people medicine for tuberculosis and not giving them food is like washing your hands and drying them in the dirt.” 

Sam Tsemberis: That is so on target for what all of these issues are about. I think of homelessness, actually, as a poorly named term for all of the systemic failures that people have faced in order to end up homeless. 

We need to get, you know, take care of the emergency, put everyone in housing, but that’s sort of the beginning of the job. Then the real work starts to address the root causes that contribute and continue to increase the problem as opposed to just dealing with the symptom all the time. 

[“Epidemic” theme music begins playing.] 

Céline Gounder: Next time, on the series finale of “Epidemic: Eradicating Smallpox” … 

Rahima Banu. 

Redwan Ahmed: Rahima Banu. 

Daniel Tarantola: Rahima Banu. 

Iftekhar Iqbal: Rahima Banu. 

Larry Brilliant: The last case …  

Steve Jones: The last case …  

Alan Schnur: The last case of variola major smallpox. I think this time we’ve got it. 

Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions. 

Additional support provided by the Sloan Foundation. 

This episode was produced by Taylor Cook, Zach Dyer, Bram Sable-Smith, and me. 

Saidu Tejan-Thomas Jr. was scriptwriter for the episode. 

Redwan Ahmed was our translator and local reporting partner in Bangladesh. 

Our managing editor is Taunya English. 

Oona Tempest is our graphics and photo editor. 

The show was engineered by Justin Gerrish. 

We had extra editing help from Simone Popperl. 

Voice acting by Susheel C. and Pinaki Kar. 

Music in this episode is from the Blue Dot Sessions and Soundstripe. 

We’re powered and distributed by Simplecast. 

If you enjoyed the show, please tell a friend. And leave us a review on Apple Podcasts. It helps more people find the show. 

Follow KFF Health News on X (formerly known as Twitter), Instagram, and TikTok. 

And find me on X @celinegounder. On our socials, there’s more about the ideas we’re exploring on our podcasts. 

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news. 

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.” 

[“Epidemic” theme fades out.] 

Credits

Taunya English
Managing Editor

@TaunyaEnglish

Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects.

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This is established in a report presented by the Ministry of Public Health, where it collects data from epidemiological weeks 38 to 41.

It states that 63% of patients came late to seek medical attention after three to five days of symptom onset and that 24% requested care promptly.

These 16 most in-demand centers hospitalized more than 3,000 patients with dengue symptoms in the last month, not counting the number of cases treated in their emergency areas, which continue to receive a high demand for medical attention from patients with fever and other signs that lead to suspicion of the disease.

Among the health facilities that have admitted the most patients with dengue in the last month are the Hugo Mendoza Pediatric, with 632 hospitalized, of which 612 had warning signs, three of them severe; the Robert Reid Cabral with 368 patients and of these 363 present warning signs and the UCE Medical Center that has hospitalized 185 patients with warning signs.

There is also the Jaime Mota Hospital, with 175 patients hospitalized with warning signs; the Marcelino Vélez Santana, with 160 patients with these conditions; the Arturo Grullón, which reported in the last month about 111 patients with warning signs; and the Unión Médica Clinic with 101 patients in alarm conditions.

Other centers with the highest number of admissions are the Altagracia Clinic, the San Lorenzo de Los Mina Maternal and Child Hospital, the Ramón de Lara Air Force, the Santiago Metropolitan Hospital, the General de la Plaza de la Salud, Padre Fantino, the Boca Chica Municipal Hospital, Juan Pablo Pina and Vinicio Calventi. Pediatric hospitals are overwhelmed with dengue patients, says Infectious Diseases Society

WARNING SIGNS FOR DENGUE FEVER
Among the warning signs for dengue are fever, abdominal pain, vomiting, drowsiness, lack of appetite, and tiredness, which, according to specialists, the patient is beginning to deteriorate and requires immediate medical attention to avoid severity and death.

Meanwhile, following the order of the President of the Republic, extensive days of social mobilization against the mosquito that transmits dengue were carried out throughout the weekend, which involved government institutions and civil society in an attempt to curb the incidence of the epidemic that has caused the death of 11 children and some 13 thousand affected so far this year.

A 48 horas de su nacimiento en un hospital del área de Seattle en 2021, Layla Babayev fue sometida a una cirugía por una obstrucción intestinal. Dos semanas después, tuvo otra cirugía de emergencia. Luego desarrolló meningitis.

Layla pasó más de un mes en terapia intensiva neonatal en tres hospitales mientras los médicos buscaban la causa de su enfermedad.

Sus padres la inscribieron en un ensayo clínico para buscar una condición genética. A diferencia de las pruebas genéticas centradas en algunas variantes causantes de enfermedades, que pueden tardar meses en producir resultados, el estudio en el Hospital de Niños de Seattle secuenciaría todo el genoma de Layla, buscando una amplia gama de anomalías, con la posibilidad de ofrecer respuestas en menos de una semana.

La prueba reveló que Layla tenía un trastorno genético raro que causaba defectos gastrointestinales y comprometía su sistema inmunológico. Su padre, Dmitry Babayev contó que, por este hallazgo, sus médicos la aislaron, comenzaron administrarle infusiones semanales de antibióticos, y se pusieron en contacto con otros hospitales que habían tratado la misma condición.

Hoy en día, Babayev atribuye a la prueba, conocida como secuenciación rápida de todo el genoma, la vida de su hija. “Es por eso que creemos que Layla todavía está con nosotros hoy”, dijo.

Sin embargo, la experiencia de Layla con su trastorno es rara. Pocos bebés hospitalizados con una enfermedad sin diagnosticar se someten a la secuenciación rápida de todo el genoma, una herramienta de diagnóstico que permite a los científicos identificar rápidamente trastornos genéticos y guiar las decisiones de tratamiento de los médicos al analizar todo el ADN del paciente.

Esto se debe en gran parte a que muchos seguros de salud, públicos y privados, no cubren el costo que oscila entre $4,000 y $8,000.

Pero una alianza de empresas de pruebas genéticas, farmacéuticas, hospitales infantiles y médicos ha presionado a los estados para aumentar la cobertura bajo Medicaid, y estos esfuerzos han comenzado a dar resultados.

Desde 2021, programas de Medicaid en ocho estados han agregado la secuenciación rápida de todo el genoma a su cobertura o la cubrirán pronto, según GeneDX, un proveedor de la prueba. Esto incluye a Florida, donde la legislatura controlada por los republicanos ha resistido la expansión de Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA).

Georgia, Massachusetts, Nueva York y Carolina del Norte también están considerando cubrirla, según el Rady Children’s Institute for Genomic Medicine, otro importante proveedor de la prueba.

Que Medicaid cubra la prueba puede expandir significativamente el acceso para los bebés; el programa de salud federal gerenciado por los estados que asegura a las familias de bajos ingresos y que cubre a más del 40% de los niños en su primer año de vida.

“Esta es una prueba extraordinaria y poderosa que puede cambiar el curso de las enfermedades de estos niños y nuestra propia comprensión”, dijo Jill Maron, jefa de pediatría en el Women & Infants Hospital en Providence, Rhode Island, quien ha investigado sobre este test.

“Lo único que está interfiriendo con un uso más generalizado es el pago del seguro”, agregó.

Los defensores de la secuenciación de todo el genoma, que ha estado comercialmente disponible por alrededor de seis años, dicen que puede ayudar a los bebés enfermos con enfermedades potencialmente raras a evitar una odisea de pruebas y hospitalizaciones de meses o años sin un diagnóstico claro, y aumentar la supervivencia.

También señalan estudios que muestran que las pruebas rápidas de todo el genoma pueden reducir los costos generales de salud al disminuir las hospitalizaciones, pruebas y atención innecesarias.

Pero la prueba puede tener sus limitaciones. Aunque es mejor para identificar trastornos raros que las pruebas genéticas antiguas, la secuenciación de todo el genoma detecta una mutación solo alrededor de la mitad de las veces, ya sea porque la prueba no detecta algo o porque el paciente no tiene un trastorno genético en absoluto.

Además, plantea preguntas éticas porque también puede revelar que los bebés, y sus padres, tienen genes que los colocan en mayor riesgo de condiciones que se desarrollan en la adultez, como el cáncer de mama y ovario.

Aun así, algunos médicos dicen que la secuenciación ofrece la mejor oportunidad para hacer un diagnóstico cuando las pruebas de rutina no ofrecen respuestas. Pankaj Agrawal, jefe de neonatología en la Escuela de Medicina Miller de la Universidad de Miami, dijo que solo alrededor del 10% de los bebés que podrían beneficiarse de la secuenciación de todo el genoma la están recibiendo.

“Es súper frustrante tener bebés enfermos y no tener una explicación de qué está causando sus síntomas”, dijo.

Ahora, algunos seguros privados cubren la prueba con ciertas limitaciones, incluidos UnitedHealthcare y Cigna, pero otros no. Incluso en los estados que han adoptado la prueba, la cobertura varía. Florida agregará el beneficio a Medicaid más adelante este año para pacientes de hasta 20 años que estén en terapias intensivas.

Adam Anderson, representante estatal de Florida, un republicano cuyo hijo de 4 años murió en 2019 después de ser diagnosticado con la enfermedad de Tay-Sachs, un trastorno genético raro, lideró la campaña para que Medicaid cubriera la secuenciación. El nuevo beneficio de Medicaid estatal lleva el nombre de su hijo, Andrew.

Anderson dijo que persuadir a sus colegas republicanos fue un desafío, dado que generalmente se oponen a cualquier aumento en el gasto de Medicaid.

“Tan pronto como escucharon el término ‘mandato de Medicaid’, se cerraron”, dijo. “Como estado, somos fiscalmente conservadores, y nuestro programa de Medicaid ya es enorme, y queremos ver Medicaid más pequeño”.

Anderson dijo que a los médicos les llevó más de un año diagnosticar a su hijo, un momento emocionalmente difícil para la familia mientras Andrew soportaba numerosas pruebas y viajes para ver a distintos especialistas en varios estados.

“Sé lo que es no obtener esas respuestas mientras los médicos intentan descubrir qué está mal, y sin pruebas genéticas, es casi imposible”, dijo.

Un análisis de la Cámara de Representantes de Florida estimó que si el 5% de los bebés en las terapias intensivas neonatales del estado se sometieran a la prueba cada año, costaría al programa de Medicaid alrededor de $3.3 millones anuales.

Los líderes legislativos de Florida se persuadieron en parte por un estudio de 2020 llamado Proyecto Baby Manatee, en el cual el Hospital de Niños Nicklaus en Miami secuenció los genomas de 50 pacientes. Como resultado, 20 pacientes, aproximadamente el 40%, recibieron un diagnóstico, lo que llevó a cambios en el cuidado de 19 de ellos.

El ahorro estimado superó los $3.7 millones, con un retorno de inversión de casi $2.9 millones, después del costo de las pruebas, según el informe final.

“Hemos demostrado que podemos justificar esto como una buena inversión”, dijo Parul Jayakar, directora de la División de Genética Clínica y Metabolismo del hospital, quien trabajó en el estudio.

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What's
all the fuss about hair relaxers? Recently, public attention was drawn to hair relaxers, because the Food and Drug Administration (FDA) in the United States proposed a ban on those products that contain formaldehyde.

In Jamaica, we commonly use hair relaxers to straighten hair, by chemically changing the bonds that cause the hair to curl. Hair products of concern might contain ingredients that are synonyms for formaldehyde or methylene glycol, such as formalin, methanal, methanediol, or formaldehyde monohydrate. Hair salon products might also contain chemicals that release formaldehyde when the product is heated, such as during flat ironing or blow-drying.

Some examples of chemicals that release formaldehyde include timonacic acid, dimethoxymethane, or decamethyl-cyclopentasiloxane. All of these are big, confusing chemical names that are usually found on the back of the package in the ingredients list. Even with all this information, it can still be difficult to tell which hair products contain or can release formaldehyde. Even products that do not list formaldehyde or methylene glycol on the label, or that claim to be "formaldehyde free" or "no formaldehyde," can still expose workers and clients to formaldehyde.

In addition to formaldehyde, chemical relaxers contain many other substances that are irritants to the skin, eyes and lungs and may cause other health problems with prolonged exposure.

Haircare products are a multi-billion dollar business in Jamaica. An article in the Jamaica Observer in February 2022, highlighted that total imports in 2019 and 2020 were above $676 million, and hair waving or straightening products remained the best-sellers in the haircare market. They reported that according to the Statistical Institute of Jamaica (Statin), the largest market was for hair straighteners and lacquers, with just over $314 million imported from the United States alone in each year.

So why is a gynaecologist concerned with something that goes on the head? In December of 2022, researchers published the results of a study, called the Sister Study. They wanted to see if there was an association between hair-straightening products and uterine (womb) cancer. Previous studies had already noticed an increased risk of breast and ovarian cancer with use of these products and they wanted more information.

They asked women to report their use of hair dyes; straighteners, relaxers, or pressing products; and permanent or body waves in the prior 12 months. They found that using hair straighteners frequently (more than 4 times in 12 months) versus none at all, was associated with higher rates of uterine cancer. The rates of cancer more than doubled, from 1.46 per cent up to 4.45 per cent for those who used it frequently. They concluded that these findings indicate that hair relaxers need to be researched in greater depth, because some of the chemicals in these products may have the potential to cause cancer. It's also possible that some of the chemicals in hair straighteners are endocrine disruptors, and may interfere with hormone production in some way.

In Jamaica, cancer of the lining of the womb (endometrial cancer) is the second commonest gynaecologic cancer (following cervical cancer), with the highest incidence occurring in the 60 to 65 years age group. In my local clinic, endometrial cancer is the second most common diagnosis for new patients joining the clinic for the first time, and patients with endometrial cancer make up the greatest percentage of follow-up patients. The number of patients presenting with womb cancer has also been climbing slowly over the years worldwide and in Jamaica, and is thought to be due to increased rates of obesity, sedentary lifestyles and prolonged life spans. Of concern also, is the fact that survival rates have not been improving over the past 30 years, unlike other cancers, despite improvements in diagnostic and treatment capabilities.

Several risk factors for endometrial cancer have been identified, with most being linked to excessive oestrogen stimulation, or genetic mutations causing a predisposition to atypical endometrial changes.

The risk factors include: Obesity, older age, not ever being pregnant (especially if due to infertility related to certain hormonal imbalances), starting periods very early and going into menopause late, using high doses of tamoxifen, diabetes, and a strong family history. Now we have potentially identified another risk factor, especially in black women.

From the FDA's website, I found the following useful questions you can ask your salon or haircare provider:

1. Does the product contain formaldehyde?

2. Is there an ingredient list available for this product that I could read?

3. Would it be possible for me to review the Safety Data Sheet for this product?

4. Have you been trained to apply this product, and do you know the necessary safeguards to minimise exposure to formaldehyde?

5. May I see your training certificate from the manufacturer and the directions for product use?

6. Does the salon have proper ventilation?

7. Do you periodically test the air for adherence to the Occupational Safety and Health Administration's limits for formaldehyde?

8. Do you have an alternative hair smoothing product that does not release formaldehyde when heated?"

As an oncologist who deals with women's cancers daily, it is my duty not just to treat cancer, but to help provide information on and strategies for prevention of gynaecologic cancers.

It's important to note that in science, association doesn't mean causation, so this study does not explain the relationship noted. But it does tell us that we need to pause and do more research to figure out the exact links and possible causative agents with respect to hair relaxers.

Anything that we can do to identify risk factors and decrease the number of women diagnosed with uterine cancer is helpful. Hopefully women will take this information, look at their lifestyle and risk factors and consider individually whether or not they really need to use these products.

I encourage schools, employers and society as a whole to accept women's hair in its natural state, without pressuring them to conform to standards that require them to use harmful chemicals to achieve the goal.

Dr Anna-Kay Taylor Christmas is a consultant obstetrician and gynaecologist, gynaecologic oncologist and laparoscopic surgeon. She is located at Suite #15, Winchester Business Centre. Contact: 876-908-3263, 876-906-2265