Months after a severe earthquake devastated Haiti in 2010, UN peacekeeping troops exacerbated Haitians’ suffering by introducing cholera to the country, via waste that leaked from a UN housing base into the Artibonite river. The disease sickened 800,000 people and killed more than 9,000 – although a study at four sites in northern Haiti found the actual death toll could be substantially higher than the official count. In August 2016, UN Secretary General Ban Ki-Moon acknowledged the UN’s role in Haiti’s cholera epidemic, accepting moral but not legal responsibility.

The UN was working to secure funding for water and sanitation improvements and direct assistance to Haitian communities affected by cholera when Hurricane Matthew struck in early October. The country’s southwestern region bore the worst of the storm damage, which included destruction of water-distribution systems and flooding. Those conditions allowed cholera to spread rapidly – and with difficult travel conditions and 40 of the country’s 74 cholera and acute diarrhea treatment facilities damaged, many cholera patients have struggled to get the oral or intravenous rehydration they need.

UNICEF and its partners are providing safe water and distributing cholera prevention kits with water purification tablets, soap, and oral rehydration salts. With help from the Pan-American Health Organization/World Health Organization, the Haitian Ministry of Health plans to vaccinate 820,000 people in the affected areas, with a campaign beginning November 8^th.

While vaccination can blunt the impact of the disease, the main long-term solution is assuring clean water and appropriate sanitation. In an interview with The Verge’s Alessandra Potenza, UN cholera response leader David Nabarro explained what an imposing task this is:

We are not going to be able to provide the resources required for sanitation of the whole of Haiti to get it up to the standards that it’s appropriate, because only 25 percent of people in Haiti have got proper lavatories and actually only 50 percent have got access to drinking water. But on the other hand, what we do plan to do is to work with a number of partners who already quite active on water and sanitation. These include the Inter-American Development Bank, the World Bank. Other partners include a number of governments like the United States and Spain and also there’s some private sector groups who would like to be involved in water and sanitation.

It needs to be quite a long-term approach because, as you’re implying, plumbing is not straightforward and we’re anticipating that it might take until 2030 to get everybody in Haiti having a properly functioning lavatory and of course water supplies that you need if your lavatory is going to work.

The UN aims to raise $400 million to fight cholera in Haiti, though it’s currently far short of that amount. Some suggest it’s too little, too late. Somini Sengupta and Jonathan M. Katz report in The New York Times:

[Independent UN human rights adviser Philip] Alston has already criticized the package, saying that one-time payments do not let victims have their day in court.

“It will be a travesty of justice if, having moved so far in such a short time, the United Nations finds itself at the last moment unable to accept the principle of accountability, the avoidance of which has motivated the long years of total denial, and if it is similarly unable to embrace the principle of respect for the rights of victims to compensation as opposed to charitable payments,” he wrote to [UN Deputy Secretary General Jan] Eliasson on Oct. 5.

… “Cholera is now endemic to Haiti,” said Louise Ivers, the senior health policy adviser at Partners in Health, a medical aid group that has worked in Haiti for years. “If there had been massive influx of resources in the first year, the first two years, the first three years, it certainly would have been a lot easier to address.”

There had been widespread expectations that Mr. Ban would make a statement about the United Nations’ responsibility for the cholera crisis in his recent trip to Haiti in the aftermath of Hurricane Matthew. Instead he spoke more generally about the organization’s cholera eradication plan, which is grossly underfunded.

Epidemiologist Renaud Piarroux of Aix Marseille University offers this prescription in a New York Times op-ed:

To rid Haiti of cholera, the United Nations needs to help reduce the vulnerability of the populations where the disease is rooted. In these areas, priority should be given to projects aimed specifically at improving access to clean drinking water. Only a little more than half of Haitians use a safe water source.

The United Nations must also help Haiti strengthen its ability to detect and control outbreaks. Field teams must respond immediately to cholera alerts, investigate the cause of the outbreak, educate the affected people, and secure clean drinking water through chlorination. The cholera response teams set up three years ago do extraordinary work, but they are too few and poorly equipped, and their funding is not guaranteed.

By admitting that it was involved in the outbreak, the United Nations made only a first and timid step toward a full assessment of its responsibility. The United Nations must continue to open up about what happened in Haiti, rectify the damage, and establish policies that prevent such disasters in the future. Its credibility is still on the line.

At its annual meeting in Denver last week, the American Public Health Association adopted a policy statement on accountability for the Haiti cholera epidemic:

Citing the role of the United Nations’ inadequate sewage precautions in the 2010 Haitian cholera outbreak, which has since killed more than 9,000 people and sickened nearly 790,000, calls on the UN, in coordination with the World Health Organization, the World Bank and other partners, to take responsibility for raising funds and implementing the National Plan for the Elimination of Cholera in Haiti in its entirety. Urges that Haitian workers be hired and paid fairly to build water and sanitation infrastructure in accordance with the national cholera plan, and encourages UN officials to ensure that a diversity of stakeholders oversee the plan’s implementation, including those from Haitian civil society organizations and international nongovernmental organizations that have built up trust with people in Haiti. Also calls on the UN to ensure fair and transparent systems for remedying any harms it may inflict on people and environments during future peacekeeping missions.

It’s the beginning of Haiti’s rainy season, which makes it easier for cholera to spread.  I hope the domestic and international response to cholera in Haiti will not only save lives now, but allow for better health in the future.

Some of our past posts on cholera in Haiti
A 10-year plan to eliminate cholera transmission in Haiti (March 2013)
Cholera, sanitation, and suspicion in Haiti (April 2012)
Clean water and education could outperform vaccines at reducing Haiti cholera epidemic (February 2011)
Vaccination Considered in Haiti as Cholera’s Spread Slows (January 2011)