More than two years after the disease broke out in October of 2010, cholera still festers in Haiti. The disease has killed nearly 8000 people and infected 6% of the Haitian population. There has been much blame and ill-will placed on the United Nations (UN) for its instigating role in this epidemic, and indeed the UN likely played a necessary (but not sufficient) role in the cholera outbreak in Haiti, which then spread to other parts of the Caribbean (see Recipe Box at bottom). But more concerning is their slow and small response to the epidemic in Haiti.
Blame aside, there are undoubtedly lessons to be learn by looking back at how this epidemic came to pass in Haiti. More importantly, looking ahead there are key steps that should be taken to eliminate cholera in Haiti. Here I unpack some of the the preventive steps that could have been taken to avoid sparking such an epidemic, and I outline the actions that might be taken by the UN and other donors moving forward.
Hindsight’s 20-20: What Could the UN Have Done?
I’ll start by looking back. Several questions on the causes and conditions of the epidemic still persist – and some naturally lead to prescriptive recommendations in hindsight for emergency responders.
First, how do we know that it was likely the Nepali MINUSTAH force that brought the bacteria to the country? The Haitian Ministry of Public Health and Population (MSPP)’s National Public Health Laboratory (LNSP) tested the strain from the outbreak and confirmed that it matched that found in South Asia. Recent molecular tests from the US and elsewhere confirmed that the strain matched that in Nepal, and cholera broke out via the Artibonite River not far from where the MINUSTAH camp was stationed. (As an aside, the LNSP is currently the only public health lab in the Caribbean that can do such genetic testing and was one of the few MSPP buildings to withstand the earthquake – indicating the importance of long-run investments in public health surveillance. LNSP was built by the Taiwanese and furnished by the Americans in 2002.)
Second, if it was known that cholera is endemic in Nepal, why weren’t the Nepali soldiers tested for cholera? Ten days before deployment, only Nepali peacekeepers presenting with diarrhea were tested for cholera. Some peacekeepers, however, may have been asymptomatic carriers (that is, they carried the bug without showing any symptoms), while others may have been infected in the 10 days before deployment. While the UN likely followed standard protocol for disease testing, these measures, even if adhered to, were insufficient. Moving forward, it has been recommended by the Independent Expert Group that emergency responders travelling from cholera-endemic areas “should either receive a prophylactic dose of appropriate antibiotics before departure or be screened with a sensitive method to confirm absence of asymptomatic carriage of Vibrio cholerae, or both.” This recommendation might be applied not only to UN peacekeeping forces, but to all emergency responders of any disaster. In hindsight this seems only obvious; this will need to become the standard for relief to any country which has not seen cholera in a long time.
And finally, how the heck did sewage from the MINUSTAH camp get leaked into the river? This is still not clear. One potential reason is that the sanitation system was not designed correctly and another reason may be that the sewage system was not maintained properly – i.e. that the septic tanks were not emptied on time, leading to the pipes overflowing and leaking into the river. In both cases, it may be that the protocol for designing sanitation facilities is insufficient. There is some movement to revise the protocol for designing fecal waste systems of UN facilities to make it better withstand leakages and poor maintenance. This is an important step that needs much more attention.
In hindsight, it seems clear what the UN might have done to “do not harm” which should be a core value. The UN should reflect openly on how it has learned from these lessons—including appropriate disease screening and prophylactic testing of emergency responders, and more robust design and maintenance of its sanitation facilities of its camps.
Looking Forward, How Will Cholera Be Eliminated from Hispaniola?
The UN Should Step It Up
Given the UN’s likely role in sparking the epidemic in Haiti, which then led to the disease spreading to other countries, the UN has an ethical responsibility in eliminating cholera from Haiti. Their recent announcement in December 2012 by Secretary-General Ban Ki-Moon in support of the call for $2 billion initiative for a cholera-free Hispaniola is welcome. But this support of comes, a year late, and many dollars short. The initiative was launched in January 2012 by the governments of Haiti and the Dominican Republic with support from CDC, PAHO, and UNICEF. The UN’s belated and paltry pledge of $23.5 million amounts to a mere 1% of what has been called for to improve the water and sanitation infrastructure in the Hispaniola. Surely, the UN’s role in sparking the epidemic amounts to more than 1% of the harm done in Haiti; its 1% investment will not be sufficient to stem the epidemic.
It’s not clear that attempting to strong-arm the UN into taking responsibility through a lawsuit will do any good. If the lawsuit fails, on the contrary, the UN might feel absolved of any responsibility. But legal responsibility is different from ethical responsibility; there are many things which are legal but are still unethical. If only to save face from what is an embarrassingly small donation, the Secretary-General should step up its support to eliminate cholera in Haiti. Doing so would have the added benefit of possibly assuaging anger against the UN, while raising the institution’s credibility in Haiti.
Early Performance in the Health Sector is Encouraging
In a previous post, I wrote that cholera in Haiti was the responsibility not of any one party i.e. the UN, but rather all parties involved in the country (see Recipe Box at bottom). But if the UN fails to step up despite its likely role in the epidemic, will other donors be willing to put up the $2 billion? Or are donors generally fed up and disillusioned from the lack of results from aid to the country, as my colleagues Vij Ramachandran and Julie Walz have persuasively described – see here and here?
Donors may be doubtful and hesitant that further investments in Haiti will lead to impact. But not all aid to Haiti has failed and there is reason for optimism. The health sector (not counting water and sanitation sector) has seen some positive, though limited, successes, in spite of the challenges of the cholera outbreak. For example:
- A new paper released last week in the New England Journal of Medicine shows that the number of cholera cases is down, and the cumulative case fatality rate has been declining, although it has plateaued. But further declines in incidence will require substantial changes in the infrastructure and regular access of water and sanitation in the country – with the not-yet-materialized $2 billion.
- Haiti’s National Sentinel Site Surveillance (NSSS) System was kick-started 2 weeks after the earthquake with support from PAHO, and CDC, and it has been crucial for monitoring disease outbreaks and disease burden. What was amazing was that this system was built shortly after the earthquake and still continues today. Moreover, it built on the existing PEPFAR surveillance system, a great example where PEPFAR investments in data collection translated to building a country’s health system.
- Follow-up of existing HIV/AIDS anti-retroviral treatment (ART) patients remained very high, though there was a temporary decline in new ART patient enrollment following the earthquake.
The list of encouraging successes in Haiti's health sector goes on: Immunization coverage among children has been sustained and high; the country is on track to eliminate lymphatic filariasis; a new demographic and health survey found that malnutrition is down. See this new Lancet comment for more examples. Things are not all gloom and doom in Haiti.
Recommendations for the Cholera-Free Hispaniola Initiative
Moving forward, what can the still fledgling initiative for a cholera-free Hispaniola do to better convince donors of a ‘good buy’? What lessons can be learned from the health sector?
First, supporters of the Initiative need to impress upon donors the fatal consequences of cholera. Use pictures (something like this) of children dying of cholera. Think back to Paul Farmer’s extensive use of one of his HIV patients before and after ART. After all, “one death is a tragedy; a million deaths is a statistic.”
Second, the Initiative needs to deploy performance-based financing. Make the results of aid central to this initiative to eliminate cholera from the Hispaniola. Many of the global health donors – PEPFAR, Global Fund, GAVI – have had a strong emphasis on results and measuring the number of people receiving an intervention or adhering to a treatment regimen. In the case of eliminating cholera in the long run, a key indicator is the number of people with sustainable access to improved water source and, separately, the number with access to improved sanitation. For each additional person receiving the intervention, the recipient of the aid – be it the government, NGO, or some private entity – would be paid accordingly. If the results are independently measured, then one might call this approach Cash on Delivery.
Third, rather than merely call for commitments, the Initiative might call for the creation of a bilateral or multilateral or public-private fund for water and sanitation improvements, e.g. the Fund To Eliminate Cholera in the Hispaniola (FECH). FECH could be temporarily housed within the Global Fund, any willing bilateral donor (admittedly, these first two are unlikely), or even constituted within the United Nations (more reasonable given their likely role in the epidemic). The FECH could pool bilateral and multilateral funding as a public-private partnership akin to the Global Fund, by bringing partners together through a Global Fund-like “Country Coordinating Mechanism” (CCM) to fund the National Directorate for Drinking Water and Sanitation (not unlike the National Malaria Control Program or National AIDS Control Program) or other competitors. Central to FECH would be its use of performance-based financing as described above, and the CCM-like mechanism could help to ensure accountability to the different long-run development actors in Haiti, including local NGOs, government as well as international donors.
Finally, while Haiti waits for $2 billion to materialize, Haiti should run small-scale pilots for water, sanitation, and hygiene and demonstrate progress with what little funding is available. Piloting is crucial for learning and has many benefits, as I've argued here and here. This in turn can convince donors of what is possible.
I for one am hopeful about Haiti.
Simple Four-Step Recipe for a Deadly Cholera Outbreak
It is worthwhile to breakdown the recipe for a deadly cholera outbreak in four simple steps. If any step is skipped, will an outbreak occur? The answer is no; the recipe is incomplete. For example, consider what would happen if only Step #1 occurred: when cholera was brought into its neighbors Cuba and Dominican Republic, the disease caused far fewer deaths (3 and 408 deaths, respectively, compared to 7912 in Haiti), precisely because the remaining steps were not present. Note that Steps #1-#3 lead to an epidemic which is not necessarily deadly; step #4 is the possibly the deadliest step of them all.
- First, the pathogen must be introduced to the country. In this case, the deadly bacteria Vibrio cholerae, which causes eruptive and dehydrating diarrhea, was likely brought into the country for the first time after a hundred years by a UN peacekeeping force from Nepal, where the disease is prevalent.
- Second, the pathogen must proliferate in a conductive water environment. Here the UN peacekeeping force in Haiti (“MINUSTAH”) was stationed in a camp in Mirebalais near the Artibonite River. The camp's pipes likely leaked into the river, which has an excellent temperature and salinity for the rapid proliferation of cholera.
- Third, people must be exposed to the pathogen. In this case, the Haitian population relies on the Artibonite River for a wide range of daily activities including washing, bathing, drinking and recreation, as well as for irrigation. Thus the population was readily and intensely exposed to the pathogen.
- Fourth, people infected with the pathogen must lack correct treatment to the disease, which if not done hygienically, can lead to the spread of the disease to other patients and health workers who encounter those infected. Not having experienced the disease in a hundred years, Haitian medical facilities were not prepared to treat the disease, which led to an initially high case fatality rate. Fortunately, with good treatment, fatalities eventually declined within the first three months to internationally accepted goal of 1.0%.
Footnote: Those reading this current blog post and another post a year ago on the same topic may presume that I have changed my positions on assigning blame for the cholera epidemic. I don’t think I have. I still don’t think there is much of a legal case against the UN (though I’m no lawyer) and I think calling the UN to fork up money to victims is unrealistic. If one were to believe that the legal case against the UN (at the tune of $50,000 per cholera victim and double that for each cholera death) were reasonable, then the same argument could also be made against Haiti for spreading it to other parts of the Caribbean, including its neighbors the Dominican Republic and Cuba. This is the kind of blame game that is unproductive. Nevertheless, there may still be an ethical case for the UN’s involvement to address cholera in Haiti as a whole. Just because there is no legal case does not absolve the UN from the considerable “harm” ultimately done, even if all the rules and protocol were followed and even though the harm done in Haiti was much worse because of conditions outside of the UN’s control.
The author thanks Matthew Brown, Steve Kuo, Daniele Lantagne, Richard Cash, Jenny Ottenhoff, and Rachel Silverman for excellent comments. Matthew Brown gave helpful background on disease surveillance in Haiti and recommendations for the future. All errors are the author's.