The cholera cases stream in at all hours of the day and night, turning sleepy rural medical clinics into emergency triage centres where the difference between life and death is measured in hours and millilitres of simple rehydration treatments.
The official death toll from Haiti's epidemic jumped to 917 on Sunday, but aid groups fear the actual death toll may be substantially higher as the illness ravages remote, rural areas and many of the dead go uncounted. Some 14,642 people have been hospitalized.
At the centre of the outbreak, in villages and small cities scattered around northern Haiti, clinics and hospitals are swamped. In Bod me Limbé, a tiny northern village, two Canadian doctors and student volunteers on long-planned, humanitarian missions were suddenly plunged into crisis response, bolstering local Haitian medical teams.
Janet Seale arrived at the rural clinic called Sante Pou Yo on Nov. 1 from her suburban practice in Ottawa, just in time to greet the first wave of patients from Haiti's first recorded cholera outbreak. At the tiny two-desk clinic, 43 patients have been treated, three have died.
"Right from Day 1, we've had a steady stream," Dr. Seale said in an interview.
"We've worked in flip-flops in rainstorms with water up mid-calf, putting in IVs in the dark. But this isn't a situation that requires great medical expertise. What is needed is organization, clean water, oral and IV rehydration."
In the larger Haitian town of St-Louis-du-Nord, further west along the northern coast, a handful of cases on Nov. 3 has accelerated to 50-80 cases a day. Maureen Moore, a Canadian missionary who is a pharmacist and lab technologist, says she is running low on Ringer's lactate and oral rehydration solutions, two simple treatments that can head off death if the illness is caught in time. Catching it in time is not easy. Severe dehydration can set in within hours of the first sign of severe illness, usually diarrhea.
Cholera patients have completely pushed aside the 120 patients that usually stream through Ms. Moore's clinic. "We just need prayer … and supplies," she said.
At both clinics, the initial rapid rise in the number of sick appeared to be leveling off, Ms. Moore and Dr. Seale both noted. Haitian officials also said the daily rate of deaths seemed to be leveling off at about 46 to 66 a day. At the same time, the disease appears to be spreading across the country to previously untouched communities.
The United Nations cautioned the outbreak has only begun. The agency has projected up to 200,000 Haitians could contract cholera, double the number of cases in a huge outbreak in Zimbabwe that ended last year after killing 4,287 people over 12 months.
The UN has put out an emergency call for $164-million (U.S.) in special aid. Canada previously pledged $1-million in cholera outbreak assistance and an official in Ottawa said Sunday the government has not ruled out giving more.
Haitian President René Préval addressed the country on Sunday giving tips on how to prevent the spread of the disease. Cholera is spread through the fecal contamination of food and water. Good hygiene and cooking methods and treated water can quickly limit the disease's spread. Most Haitians, particularly in rural areas, have no access to sanitation or clean water.
Marjorie Villefranche, a leader in Montreal's large Haitian community, said she is angry the UN and Haitian government weren't better prepared for an epidemic that seemed inevitable in the first rainy season after the Jan. 12 earthquake.
Ms. Villefranche said Haiti's leadership has been distracted campaigning for elections scheduled for Nov. 28.
"We knew this catastrophe was coming, they knew simple education would go a long way to limiting this kind of outbreak with simple care, boiling water. I'm very upset," Ms. Villefranche said.
"Why wasn't education being done before now? We had to wait for a catastrophe before anything was done."
Educating the population on cholera prevention is proving to be a big task, according to Emmanuelle Britton, a Toronto physician also working in Bod me Limbé. She has visited a number of villages along the flood-swollen, contaminated Limbé River offering advice and treating patients.
Villagers have lived for generations washing, cleaning and drinking from the river.
"It's not simply a matter of emphasizing sanitation, it's changing a way of life," Dr. Britton said.
Dr. Britton recounted a recent scene where she and clinic workers wanted to transport patients from a remote village to a hospital. Local villagers refused to help load the patients into pickup trucks at 4 a.m. for fear of being infected. Elsewhere in Haiti, rioters attacked one clinic, fearing it was helping the spread of disease.
"There was a big gap of knowledge there that it's not contagious by touch. It's an ongoing process."
Ms. Villefranche, the director of Montreal's La maison d'Haiti, said donor fatigue may be setting in. But with Haiti lurching from flood to earthquake to hurricane and now epidemic in the space of mere months, it's even hard for the Haitian diaspora to keep up. "The people of Canada and Haiti have done their part. It's time for the leadership to stand up," she said. "You can only ask so much."
With reports from wire services and John Ibbitson in Ottawa