The Haitian Cholera Outbreak: A Preventable Tragedy?
On October 21, a case of cholera was identified in Haiti for the first time in at least 50 years.1, 2 The disease spread rapidly through the Artibonite River basin, and by November 9, more than 580 people had died, and thousands more were gravely ill.3
Health Workers Downplay Cholera Threat
In the aftermath of Haiti’s earthquake, the leaders of the international health community did not acknowledge cholera as a serious threat. On March 2, the Center for Disease Control and Prevention (CDC) published a report entitled “Acute Watery Diarrhea and Cholera: Haiti Pre-decision Brief for Public Health Action.”4 While the report recognized that water-borne diseases could easily spread through Haiti’s poorly-maintained tent cities, it also stated that an outbreak of “cholera [was] extremely unlikely to occur,” largely because the vibrio cholerae bacteria had not been observed in Haiti in over half a century. The report downplayed concerns that the bacteria could be introduced by foreign relief workers or aid shipments and failed to consider that the bacteria might continue to exist undiagnosed in rural communities. In a February radio interview, Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, expressed agreement with the CDC report, saying, “There is no cholera in Haiti, so it would be extremely unlikely that there would be an outbreak of cholera in Haiti, even though you don’t want to completely rule it out, it’s not the first thing that you think of when you think of an outbreak of waterborne disease.”5
Health care administrators, trusting the consensus among experts that a cholera outbreak was unlikely, concentrated on more pressing health concerns. Trauma injuries received first priority after the earthquake, and health care specialists also devoted much of their time and resources to treating patients suffering from diabetes, heart disease, HIV, and tuberculosis. Health workers placed a high emphasis on immunization campaigns to prevent measles, rubella, diphtheria, tetanus, and pertussis.6 A cholera vaccine was available at a cost of only 50 cents a dose, but due to the perceived improbability of an outbreak, health care administrators did not seriously consider widespread distribution to be necessary.7 Hence, while health workers had the technical capability to prevent an outbreak, they did not have compelling reasons to implement such measures.
Unmet Obligations and Broken Promises?
While health workers did not perceive cholera as an active threat in post-earthquake Haiti, other water-borne diseases did draw significant attention from health agencies. In February, the Pan American Health Organization (PAHO) reported, “Sanitation is a massive challenge that must be urgently resolved; an increasing number of diarrhea cases are being reported. If shelter and sanitation are not adequately addressed before the rainy season arrives, the risk of epidemic outbreaks of water-borne and other diseases will increase.”8 These issues, however, were not sufficiently addressed. In early September, PAHO conducted a survey of health systems in northern Haiti, where the first case of cholera was diagnosed, in order to “identify programs, needs, and gaps in coverage.”9 A report later released by the institution emphasized that “water and sanitation, provision of clean drinking water, and insufficient health care services” remained serious health issues in the region.10
The persistence of these problems is due, in part, to the failure of foreign governments and international donor organizations to deliver aid efficiently. While a number of countries provided generous emergency relief immediately after the earthquake, many have been slow to fulfill promises of continued assistance for reconstruction and infrastructure development. Indeed, as of late September, only 15 percent of promised aid had reached Haiti.11 In many countries, legislative and bureaucratic processes have delayed further assistance. In the U.S., for example, Senator Tom Coburn has held up a five-year assistance authorization bill, and the State Department has delayed a USD 1.15 billion supplemental appropriations act that was signed by President Obama in late July.12
However, the relevancy of these shortcomings to the current crisis is debatable, and it is not clear whether a more urgent allocation of foreign assistance would have significantly hindered the spread of cholera. Aid funds certainly could have been used to supply clean water and proper sanitation facilities, but it is unclear whether governments would have allocated funds to improve conditions in temporary settlements. Furthermore, given that donor institutions had primarily focused on areas directly affected by the earthquake, it is doubtful whether the funds would have been distributed effectively to close gaps in coverage.
Inadequate coordination between NGOs has also been detrimental to Haiti’s reconstruction effort. After the earthquake, various individual NGOs assumed responsibility for many of the tent cities occupied by those displaced by the earthquake, but there were no uniform standards or procedures in place to govern the distribution of resources among the camps. The capabilities of the NGOs in question varied widely, and as a result, some camps were adequately maintained, while others experienced catastrophic shortages of food and potable water. According to a joint study by the Institute for Justice and Democracy in Haiti, the University of San Francisco School of Law, and Lamp for Haiti, 44 percent of families in Haiti’s tent cities drink primarily untreated water, and only 9 percent received drinking water relief over a 30 day period. In most cases, clean water is only available to Haitians who can pay for it, and illnesses due to unsanitary water are common. The study also found that only 69 percent of Haitians in tent cities have access to basic toilet facilities, and toilets are often unclean, unsafe, and overcrowded.13
While poor coordination among NGOs has exacerbated conditions in Haiti, it is unclear to what extent this shortcoming contributed to the cholera epidemic. Prior to the earthquake, much of the population lacked access to clean water and adequate waste management systems, and water-borne diseases were common.14 Thus, conditions were ripe for the spread of cholera even before the catastrophe. In the aftermath of the earthquake, over 160,000 Haitians were forced to resettle temporarily in the Artibonite region, where most of the cholera cases have been diagnosed.15 The increase in regional population has strained resources and compounded challenges in the removal of waste. While post-earthquake resettlement patterns certainly aggravated conditions that would facilitate the spread of cholera, it is difficult to determine to what extent the population shift has actually accelerated the spread of the disease. Cholera has just begun to infiltrate the tent cities,16 so conditions in the camps have not played a significant role in the outbreak thus far. However, cholera is now prevalent in Port-au-Prince,17 and it seems to be only a matter of time before the disease also becomes prevalent in the camps surrounding the capital. When the epidemic does make its way into the camps, the lack of a coordinated effort to provide clean water and proper sanitation will surely have devastating consequences.
Containment
Prior to the outbreak, the CDC had, in fact, developed a contingency plan to detect and respond to a cholera epidemic. The effort included the establishment of health monitoring sites to rapidly detect an outbreak of the disease. Proper methods of sample collection and analysis to confirm cases of cholera were also addressed in the plan, which provided several options for public health action should an outbreak occur. After the outbreak, the international community responded quickly to contain the disease. Soon after the first case was diagnosed, the CDC sent health experts to Haiti to conduct laboratory diagnoses. Cuba immediately dispatched several hundred doctors and nurses to administer antibiotics and assist those in need of treatment,18 and NGOs such as Médecins Sans Frontières set up cholera treatment centers and provided workers to staff local hospitals.19 Many of the public health options presented in the CDC report have been implemented, and containment objectives have been clearly defined.
The Haitian government, often criticized as corrupt and incompetent, has also done its part in responding to the outbreak. The Haitian Ministry of Health was first to detect the disease, and it has since played an active role in the containment effort. In addition, the government took decisive steps to help Haitians prepare for Hurricane Tomas and minimize the spread of cholera due to flooding from the storm.20
Conclusion
While the damage from the epidemic could certainly have been lessened by more anticipatory actions, it is unlikely that it could have been prevented completely. Health workers, operating under the assumption that a cholera outbreak was unlikely, understandably focused on more pressing concerns. While they may have had the capacity to significantly reduce the risk of an outbreak through vaccinations, health workers acted logically given the information they had. Although the failures of national, international, and nongovernmental organizations did not cause the outbreak, they may be partially responsible for the rapid spread of the disease. Whether or not poor coordination or delays in assistance actually facilitated the spread of the epidemic, as more Haitians are affected, increased (and long overdue) scrutiny of these shortcomings is inevitable. Reasonable preparations to contain a possible cholera epidemic were made in the months following the earthquake, and although it is premature to evaluate the international response, the effort to contain the disease seems to be well-coordinated.
According to PAHO deputy director Jon Andrus, cholera is not likely to be eradicated in Haiti for several years,21 and health workers have begun to prepare for a prolonged campaign against the disease. Speculation that Nepalese peacekeepers may have introduced the bacteria has led to protests and widespread anti-UN sentiment, which will likely inhibit the UN’s ability to operate effectively in the country. There are also fears that the flooding brought by Hurricane Tomas could expedite the spread of the disease, which is expected to eventually move across Haiti’s porous border with the Dominican Republic.22 Clearly, the international community must be fully committed to controlling the spread of the epidemic. While it is important to hold institutions accountable for any fault that may exist, excessive criticism at this juncture may be an overreaction. There is simply not enough available information to demonstrate the culpability of any one organization. Furthermore, attempts to assign blame for the crisis distract from and may even impede efforts to contain the disease. Given Haiti’s already unbearable suffering, it is imperative that the international community, the Haitian government, and its people are unified in their response to the cholera outbreak, which, if allowed to become a point of division, has the potential to make a dreadful situation even worse.
References for this article are available here