This is a joint post with Richard Cash from Harvard School of Public Health.
Since October 2010, Haiti has struggled to control a deadly cholera outbreak—on top of ongoing recovery efforts from the devastating earthquake in January 2010. To date 7000 Haitians have died from cholera and more than half a million have been infected; PAHO recently called it the largest cholera outbreak in modern history. So last month, a group of lawyers in Haiti, on behalf of some 15,000 victims of cholera, sued the United Nations for $50,000 for each victim and double that for families of those who died.
While Time magazine asks, “Can Haitians sue the UN for the (cholera) epidemic?”, it may be useful to ask instead, “When can people sue others for spreading a disease in general?” The problem with infectious diseases, of course, is that they usually come from somebody or something other than you. The tendency to blame the immediate originator, often suspected and often incorrectly so, is a recurring theme. For example, in the 2009 H1N1 flu pandemic blame was laid on pigs (by calling it ‘swine flu’) and on Mexico (where it was first detected). Both attributions were incorrect but still led to the effect of temporarily cut pork prices, the unnecessary slaughter of pigs in Egypt and the reduction of tourism in Mexico. Similarly, polio has been reintroduced into Europe from India and conversely measles has been reintroduced from Europe into the Americas. The list of these examples in public health is truly endless—disease X spreads from country A to country B, so country A is blamed as responsible.
Yet the thought of suing the ‘sending’ government—Mexico for H1N1, India for polio, etc.—for the spread of these diseases seems absurd because it does not recognize the dynamics of infectious diseases. The spread of disease depends crucially on the conditions and context of the spread. In the case of cholera, the disease is preventable in a setting with protected and improved water and sanitation facilities and very treatable with functioning health-care facilities and providers who know how to treat cholera using IV and ORT (cholera mortality is as low as 0.1% at the ICDDR, B in Dhaka, Bangladesh). In Haiti, access to safe drinking water and water treatment is not widely available, good sanitation and hygiene are lacking, and proper treatment of diarrhea is not available to most. Just 17% of Haitians had access to proper sanitation. Who exactly in Haiti is responsible for water and sanitation – the government, the aid agencies, or the NGOs? In the case of the reintroduction of polio into Europe, the spread relied on the presence of ‘susceptible’ individuals, that is, people who were not properly immunized. As Pogo, the famous cartoon character put it, "We have seen the enemy and it is us."
Let us assume that the person who spread a disease from one place to another could be traced. Do we focus on that person or on the environment that contributed to its spread? Should we direct our attention to the person’s country (e.g. Nepal) or his/her organization? Focusing on these immediate objects of blame are of epidemiologic interest, but in fact deflect attention away from the country experiencing the disease, and in this case, unable to control the spread. In a country where aid agencies and NGOs play major roles relative to the government, this outbreak should draw attention not only to immediate causes but more importantly to the long-term failure by every involved party and to the urgency of improving Haiti’s water and sanitation as soon as possible. An event at PAHO today – with the presidents of Haiti and the Dominican Republic along with CDC, UNICEF, and PAHO – may mark the beginning to a “Cholera-Free Hispanola”.