Learning to Dance Together: Lessons from Haiti’s Experience with Cholera

By Henry (Chip) Carey

Recently, there have been suggestions wafting through America’s political scene in favor of privatizing the government’s emergency response capability for natural and human-caused disasters and infectious diseases. One might want to look at Haiti for a case study in the effects of bypassing the government health sector for private organizations.

In 2010 alone, Haiti suffered an earthquake in January, a cholera outbreak in October, Hurricane Tomás in November, and violent protests after the country’s election. But since aid to combat these problems has been separated from the state, the Haitian government has not been given the chance to rise to the occasion and stand up to these hardships.

Haiti has had a rocky relationship with community health workers and hygienists ever since the reign of U.S.-backed doctor Francois Duvalier, who rose to power in Haiti through his work to control infectious tropical diseases. When his dynastic dictatorship ended in 1986 with the ouster of his son Jean-Claude, the community health program in Haiti was shut down because the transitional government thought it had been infiltrated by the Tonton Macoutes, Duvalier’s officially disbanded paramilitary militia. Haiti then implemented a U.S.-funded system of parallel NGO health clinics that ultimately replaced the state-run health care system.

Unfortunately, when non-governmental organizations undermine state building and accountability, there can be serious consequences. In Haiti, the result of decoupling the state from health care has been across the board decreases in water and sanitation quality, two things that have been steadily improving in the rest of Latin America in the past two decades. The contamination led directly to Haiti’s cholera outbreak two years ago.

After the January earthquake, the Haitian Ministry of Public Health and Population (MSPP) decided to organize its own epidemiological surveillance with assistance from the U.S. Centers for Disease Control and Prevention (CDC). This new disease tracking system allowed for the detection of various diseases, including the cholera epidemic. Additional aid came from the Pan American Health Organization (PAHO), which established a warehouse of supplies, distributed by Doctors without Borders. There were also three French NGOs, along with Catholic Relief Services, which provided the trucks that distributed the fluids, water purification packets, and latrines that were necessary to control the epidemic.

But even with all of this help, Haiti is currently home to probably the world's largest cholera epidemic. In the last two years, over 7,500 Haitians have died from the disease. While the cholera bacteria thrives best in estuaries, where rivers meet the bays and oceans, the fear is that it may have also become embedded in the country’s groundwater.

Three weeks ago, the UN Security Council voted unanimously to renew its controversial mission in Haiti through October 15, 2013, despite Haitian President Michel Martelly’s stated desire to replace the mission with a rejunevated Haitian army. A January 2012 survey by Mark Schuler found that 43 percent of Port-au-Prince households wanted the UN Stabilization Mission in Haiti (MINUSTAH) to leave within one year.  Despite its successes in guaranteeing political stability and supplementing the disaster response efforts of PAHO and Doctors without Borders, MINUSTAH has become increasingly resented by many Haitians, especially after it became known in 2011 that cholera may have been introduced by a MINUSTAH peacekeeping unit.

The cholera epidemic in Haiti began in the country’s most fertile and flat region, the Artibonite Valley through which the Artibonite River and its tributary, the River Meye, flow. The most likely source of the introduction of cholera was feces from someone infected with a ‘hybrid’ strain of cholera recently found in Nepal, which subsequently contaminated Haitian drinking water.  An al-Jazeera television report appeared to show sewage runoff from the Mirabelais MINUSTAH camp in the Artibonite Valley, where Nepalese troops are stationed, flowing into a river upstream from where the cholera epidemic began.

On the recommendation of UN Secretary-General Ban Ki-moon, the new Security Council Resolution reduces MINUSTAH’s previous force levels by 15 percent. But the UN continues to stonewall investigation of the claim that cholera bacteria was introduced by the Nepalese peacekeeping unit. A May 2011 UN study found that it could not be proven how cholera came into the country, and a University of Maryland study concluded that cholera in Haiti was a natural part of the ecosystem. In June of 2011, however, the CDC concluded that poor sanitation practices at the Mirabelais camp was the very likely cause of the outbreak.

Haitian Prime Minister Laurent Lamothe met with UN Secretary-General Ban a fortnight ago, but says that he did not discuss the Nepalese peacekeepers and instead focused on the future of the MINUSTAH mission. And the fifty class-action suits filed against the UN for its role in the cholera outbreak probably won’t succeed, given the UN’s official immunity from criminal claims in its 2004 host country agreement for the UN Mission. The important thing now is what can be done to stop the disease from spreading.

Throughout the turmoil of the last two years in Haiti, there was unbelievable cooperation between the CDC and their Haitian governmental counterparts. Over 400 CDC staff have been deployed to Haiti, and instead of relying on outside NGOs, they chose to trust in the Haitians, both in the government and the NGO sector. The CDC has extensive experience in bringing health relief to Haiti after a decade working to end the country’s AIDS epidemic. During the cholera outbreak, most Americans and other foreigners employed by the CDC worked 16-18 hour days, often sleeping on cots on the grounds of the relatively new U.S. Embassy.

Dr. James Wilson developed the Haiti Epidemic Advisory System," which first raised questions about the possibility that the Nepalese peacekeeping unit of MINUSTAH had imported cholera to Haiti. Dr. Wilson wonders if the MSPP surveillance has systematically underreported cholera and other diseases in the two-thirds of the Haitian population living in remote, often mountaneous areas from which no samples are ever taken for testing. Dr. Wilson has noted, "Cholera continues to transmit in the rural, mountainous 2/3 of Haiti's landmass difficult to appreciate by the major NGOs and officials based in the 1/3 of Haiti that is urbanized.  There is little question the highest fatality rates and destructive social outcomes are observed in these rural areas.  Case fatality rates still reported by officials represent underreporting and bias towards areas of Haiti with the best access to health care."

However, considering Haiti’s lack of experience with combating cholera, one can argue that the CDC actually enhanced the epidemiological data that was collected on a daily basis, even now that the epidemic has slowed. Deaths in hospitals declined from 4 percent to under 1 percent, while over 97 percent of those identified with cholera by health workers did not die. Furthermore, Haiti has identified more cholera cases than in all of Africa, in part thanks to its superior reporting. There are countries, such as Bangladesh, that do not track cholera, despite being at the center of cholera epidemics.

The surveillance system for tracking the cholera epidemic was coordinated with existing and new community treatment centers, training health care workers across the country. And today, Haiti has by far the most detailed discrete data of any cholera epidemic in history, allowing for prediction of where and when outbreaks will occur next. This data has greatly enhanced Haiti’s decision-making regarding the distribution of cholera vaccines to those populations that are at the highest risk. Normally, this is not possible in countries like Haiti, because cholera vaccines have to be refrigerated, making adequate response that much more difficult.

Regardless of how it began, Haiti’s poor sanitation and water quality made it possible for cholera to spread extensively. The efforts of the CDC in Haiti are admirable, but remain mostly curative rather than preventive. What would really help the country prevent future outbreaks are clean water pipes and latrines that could be accessed in each community, so Haitians don’t have to continue drinking water from contaminated rivers. Haiti lags so far behind the urban sewage systems developed in early 20th century America that even the basics would be revolutionary. Until recently, Port-au-Prince was the only city in the world without a water treatment plant. When one was recently built with international help, critics pointed out that most people were in the city were not connected to the new water system, leaving open defecation practices and leaking sewers unchanged.

In rural areas, protected wells for villages would be the best option compared with piping water in over long distances. The World Bank estimates that the cost of covering the 4 million Haitians who still lack improved water and the 8 million without improved sanitation would be $1 billion. Overall, the country’s infrastructure still needs considerable maintenance, considering that most of its people do not have access to treated water, and only 17 percent have access to improved sanitation.

This year in January, PAHO, the CDC, and the Lancet called for donors and private sector partners to emphasize and accelerate water treatment in Haiti, but it has yet to be treated as a priority in the U.S. What is needed are comprehensive, low-tech sanitation systems and clean, common water sources throughout the country, overseen by the Haitian government. In the past three decades, the U.S. has not given Haiti's leaders the chance to show us that they can rise to the occasion. It is high time we change course and help the Haitians help themselves.



Henry (Chip) Carey is an Associate Professor of Political Science at Georgia State University in Atlanta. He is the author of  Privatizing the Democratic Peace: Policy Dilemmas of NGO Peacebuilding and Reaping What You Sow: A Comparative Examination of Torture Reform in the United States, Israel, France and Argentina.

Photo courtesy of mediahacker.

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