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Haitian Cholera Outbreak Highlights Need for Infrastructure, Not Blame

The views expressed are those of the author and are not necessarily those of Scientific American.


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A cholera epidemic has infected more than 700,000 people and killed over 8,000 in Haiti over the last few years, a country of just over 10 million people. Why did the epidemic strike Haiti, when the disease has been absent from that region for a century? And why has the outbreak been so difficult to control?

Arindam Banerjee/iStock

In January 2010, a powerful earthquake struck Haiti.  Earthquake damage may have made the country more vulnerable to a communicable disease outbreak, but no cholera was reported until ten months later. An outbreak then spread rapidly from the Arbonite region across the Haitian part of the Caribbean island that it shares with the Dominican Republic.

Cholera spreads via contaminated drinking water or direct contact with the Vibrio cholera bacteria in human fecal material from infected individuals. Typically, about 20 percent of infected people become severely dehydrated. Treatment with oral rehydration fluids, popular from the 1970s forward, has reduced death rates in most outbreaks to about 1 percent.  But conditions in post-earthquake Haiti made it even more difficult than usual to reach isolated communities and treat patients, which raised the death rate far higher.

There had been no cholera in Haiti at least 100 years. But considering the existing infrastructure in the poorest country in the Americas, this should have provided little comfort to Haitian health authorities. Writing in Nature 2010 and 2011, Declan Butler offered succinct answers to the public health question, why Haiti? (Scientific American is part of Nature Publishing Group):

  • “Cholera is a disease of poverty, and spreads rapidly in communities lacking clean water supplies and sanitation.”
  • “Until clean water and sanitation are readily available in Haiti, cholera outbreaks will continue.”

Haiti presented the perfect environment for a cholera epidemic. It awaited only the introduction of the pathogen. Haiti, like many low-income countries, could never afford and had never built a sanitary infrastructure to protect its citizens.

Courtesy of Michael Ritter, DSI

Over the last two centuries, science has taught us a great deal about cholera, but control of the disease in richer parts of the world has never depended on a sophisticated understanding of the organism, or on antibiotics and vaccines. Public health progress was achieved by controlling filth – by sanitary engineering. Communities with clean drinking water and properly treated human wastes are largely protected from rapidly spreading cholera.

Ironically, around 1900, public health practice suffered something of a setback from the understanding of communicable diseases generated by the new science of bacteriology. As it became possible to identify pathogenic microorganisms and their carriers, the focus of public health shifted from filth, infrastructure and sanitation, to blaming, chasing and isolating the carriers. It shifted from prevention toward treatment.

Fast-forward a century: It is not surprising that once cholera was detected in Haiti, many observers asked, “How did cholera get to Haiti?” As I wrote in an editorial for the Journal of Public Health Policy (published by Palgrave Macmillian, which is a sister company of Scientific American):

In the old days, health authorities might have found the physical source, like London’s Broad Street pump, but today even more could be learned about the source and who carried the pathogen to Haiti. Genetic typing made it possible to recognize that the strain afflicting Haiti came from Asia, most likely brought to the island by Nepalese soldiers working with the United Nations emergency response to the earthquake.

Very interesting, a triumph for laboratory methods that typed the pathogen! But once the disease was spreading, how cholera got to Haiti has offered little help in ending the outbreak or preventing future ones. The source didn’t much matter. Haiti’s abysmal sanitation infrastructure meant that Vibrio cholera, introduced from almost any source, could have caused an epidemic.

Yet many are now seeking compensation from the United Nations for illnesses and deaths. They blame the international earthquake relief operations for the epidemic. And perhaps the U.N. was negligent in the way it managed the human fecal waste of its people responding to the earthquake disaster.

For experts in public health this debate could be a dangerous distraction. The central question is: how are we going to protect people in low-income countries from the deadly risks they face due to inadequate sanitary infrastructure?

To their credit, the Haitian Ministry of Health and the National Directorate for Water Supply and Sanitation, understood how to control and prevent cholera. They kept their focus on sanitation and drinking water infrastructure even as they tried to control the ongoing epidemic. In 2011, the U.N.’s Independent Panel of Experts on the Cholera Outbreak in Haiti reported:

To prevent the spread of cholera, the United Nations and the Government of Haiti should prioritize investment in piped, treated drinking water supplies and improved sanitation throughout Haiti. Until such time as water supply and sanitation infrastructure is established:

(a) Programs to treat water at the household or community level with chlorine or other effective systems, hand washing with soap, and safe disposal of fecal waste should be developed and/or expanded; and,

(b) Safe drinking water supplies should continue to be delivered and fecal waste should be collected and safely disposed of in areas of high population density, such as the spontaneous settlement camps.

As noted in my editorial for the Journal of Public Health Policy:

In 1991, Dr. Robert Knouss, who was serving as the Deputy Director General of the Pan American Health Organization, appeared before a committee of the U.S. Congress to testify about the cholera epidemic in Peru that threatened to spread across Latin America. ‘What would it cost to eliminate cholera in the Americas?’ he was asked. He had not prepared for just that question, but his answer was quick, if not precise: ‘$25 billion–enough to build modern drinking water and sewage systems for every major city in the region that lacks one today’. (The number would be far larger in today’s dollars.)

Populations around the world who live without potable water and proper management of human fecal waste remain dangerously vulnerable. We shouldn’t be distracted by how cholera got to Haiti. Instead, we should urge the United Nations and donor programs that contribute money to build infrastructure to learn the lesson of prevention. Think as the late Dr. Knouss did. Invest now in water and sanitation before you are ‘surprised’ by an epidemic of cholera or other waterborne diseases, from any source.

Anthony Robbins, MD, MPA About the Author: Anthony Robbins, MD, MPA is Professor of Public Health and Community Medicine at Tufts University School of Medicine and co-editor of Journal of Public Health Policy.

The views expressed are those of the author and are not necessarily those of Scientific American.






Comments 6 Comments

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  1. 1. jgrosay 11:20 am 03/27/2014

    I’m sorry, but there’s somebody to blame for the Haiti Cholera tragedy: the ones who made the decission of sending there troops from a region with a high prevalence of Cholera, high rank officers should consider this kind of elements in making a decission on who and from where to send men to an emergency, for simple decissions as ‘Go ahead’, just a Sargeant or the soldiers themselves suffice; paying high rank salaries to people that make such silly decissions is absurd.

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  2. 2. JonathanMKatz 5:34 pm 03/27/2014

    Dr. Robbins brings a valuable perspective, but there are some factual errors here whose correction could bring him to rethink his conclusion. For one thing, scientists overwhelmingly disagree that the 2010 earthquake had anything to do with the cholera outbreak, which began and spread primarily in parts of the country not damaged by that disaster. It’s also incorrect to say that the UN peacekeepers in question were engaged in “international earthquake relief operations”; the peacekeeping mission dated from 2004, and, again, their base (which also predated the quake) was not in the quake zone. It’s further a mistake to assume, as Dr. Robbins does, that the sorry state of Haitian infrastructure leading to the epidemic was a purely domestic affair: donors including the United States had deliberately withheld promised money for Haiti’s water and sanitation in the years before the epidemic, and in fact show little inclination to pay it out now. Much of the evidence he cites here, particularly the UN Independent Panel report, would never have been written without heavy pressure in the face of UN stonewalling to determine the source of the epidemic. And while reasonable people can disagree about the efficacy of the current lawsuits against the UN, one of their stated purposes is to force exactly the kind of investments Dr. Robbins recommends.

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  3. 3. AdamRHouston 3:36 am 04/4/2014

    It is certainly true that investment in sanitary infrastructure is key for the prevention of cholera. However, the idea that “we should urge the United Nations and donor programs that contribute money to build infrastructure to learn the lesson of prevention” is one that sounds good in theory but has proven remarkably insufficient in practice. It has always been much easier to find parties who will loudly proclaim that prevention is the best use of resources than parties willing to make a meaningful contribution to those resources. In the case of Haiti, when the carrot of doing the right thing has failed, using the stick of accountability to achieve the same outcome is hardly a “distraction”, particularly when the ongoing legal case is the main reason the cholera epidemic still attracts any outside attention at all.
    The pricetag placed on the eradication of cholera on Hispaniola is $2.2 billion. In December 2012, Ban Ki-Moon latched onto this pre-existing plan with a press release trumpeting UN support for the initiative. This vocal show of support was accompanied a financial contribution of roughly 1% of that cost (by comparison, the MINUSTAH peacekeeping force costs over $500 milllion a year, in a country with one of the lowest homicide rates in the Caribbean). Unfortunately, moral responsibility has not been sufficient to get the UN to practice what it preaches in terms of human rights and the rule of law; hopefully establishing legal responsibility will get them to actually take the steps – building infrastructure and not only ending the cholera epidemic they started but helping to address a wide range of other public health concerns in the process – that we can all agree are necessary to protect the health, and lives, of the people of Haiti.
    Similarly, when discussing prevention, it is important to remember that it came as no surprise to the UN that “Haiti presented the perfect environment for a cholera epidemic [...i]t awaited only the introduction of the pathogen”. Another well-established method of prevention is to take appropriate precautions to mitigate known risks, particularly in hazardous circumstances. If you know the forest you are entering is dry and flammable, be careful where and how you discard your matches; if you know the country you are entering has no functional sanitary infrastructure, be careful where and how you discard your feces. The fact that the UN has shown little interest in implementing the recommendations made by its own Independent Panel of Experts, who were tasked with studying the origins of the cholera epidemic, suggests that the organization is not giving prevention its due. It also suggests that the next time something similar – and similarly preventable – happens, it won’t be a surprise either.

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  4. 4. aminatakone 8:42 am 07/2/2014

    We all know that the Minustah troops were involved in the spread of cholera, but it is important to keep in mind that only good sanitary infrastructures and sensitazion campaigns will end the spread of the disease. In this respect, since 2010, a think tank (Global Alliance Against Cholera) has been created. The GAAC is composed of senior representatives from public, private and international organisations, they pool their skills and energy for an efficient and sustainable fight against cholera in the African continent as well as the Caribbean.
    A collective action is most likely the key to overcome the transmission of cholera and to reduce the death pool. However, the financial support granted by the United Nations is not sufficient, thus it is essential to gather more money from international donors and public authorities in order to support the program for the elimination of cholera.

    Link to this
  5. 5. aminatakone 8:43 am 07/2/2014

    is composed of senior representatives of public, private and international organisations

    See more at: http://en.choleraalliance.org/

    Link to this
  6. 6. aminatakone 8:45 am 07/2/2014

    We all know that the Minustah troops were involved in the spread of cholera, but it is important to keep in mind that only good sanitary infrastructures and sensitazion campaigns will end the spread of the disease. In this respect, since 2010, a think tank (Global Alliance Against Cholera) has been created. The GAAC is composed of senior representatives from public, private and international organisations, they pool their skills and energy for an efficient and sustainable fight against cholera in the African continent as well as the Caribbean.
    A collective action is most likely the key to overcome the transmission of cholera and to reduce the death pool. However, the financial support granted by the United Nations is not sufficient, thus it is essential to gather more money from international donors and public authorities in order to support the program for the elimination of cholera.

    See more at: http://en.choleraalliance.org/

    Link to this

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