10.24.11

Haiti's Deadly Cholera Fiasco

Cholera cases are spiking again in earthquake-ravaged Haiti, and humanitarian agencies are woefully unprepared despite warnings. Eve Conant talks to Haiti’s president about the crisis.

On the walls of earthquake-battered buildings in Port-au-Prince, Haitians have scrawled their frustration and contempt in black paint. “Minustah=Kolera," the graffiti reads. It's an unmistakable message to the United Nations, whose peacekeepers—some sent to assist Haiti after last year's massive quake—may have inflicted the scourge threatening to sweep the country again.

The world’s worst outbreak of cholera in decades threatens to ravage Haiti anew this fall, and the bacterium—which had not afflicted the island for a century, if ever—has been traced by epidemiologists to a camp where a battalion of U.N. peacekeepers from Nepal arrived a year ago.



On the one-year anniversary of the first reported cases, medical workers at treatment centers in the capital earlier this month reported threefold spikes in patients suffering from the horrific intestinal infection. Cholera has killed 6,600 and sickened 470,000, and the U.N.’s World Health Organization estimates infections could top half a million within months.

“This is far and away the biggest epidemic in the world right now. It’s not unreasonable to worry about 10,000 deaths by the end of the year,” says Paul Farmer, cofounder of the NGO Partners In Health, a nonprofit consortium that provides medical care inside impoverished countries.

Experts long feared a third wave of cholera would strike when Haiti’s fall rainy season arrived and would spread bacteria through runoff and overflowing canals and sewers. Yet humanitarian agencies were unable to mount an effective defense despite months of encouragement from medical professionals to begin a massive vaccination program.

Now Partners In Health, along with another nongovernmental organization called GHESKIO and the Haitian Health Ministry, are searching for funding for their own response: a vaccine program that might reach 100,000 residents beginning in January, in a country where 10 million are threatened.


Finger-pointing, confusion, rumors, and lack of funds seemingly have conspired to ward off common-sense action inside the Caribbean island just 90 minutes from Miami.

“If I were offered the vaccine I would take it today, definitely,” Michel Martelly, the hip-hop star turned new Haitian president, tells The Daily Beast. “Anything that can get us out of this situation is welcome.”



The problem is, nobody made the command decision to order large amounts of the vaccine, which has a limited shelf life and isn’t stockpiled. If doses had been ordered earlier, millions might be available to administer this fall. But that didn’t happen. A WHO cholera expert says the U.N. organization is still examining whether a large-scale vaccination effort would be possible.

Now, resources and attention are dwindling. The number of organizations helping with cholera has nosedived from 128 in January to 40 today. And makeshift camps that were once relatively safe can offer only 7 percent of residents clean water, down from nearly 50 percent just this past March. Farmer attributes this to the “ADD (Attention Deficit Disorder) of humanitarian” operations in Haiti.



Those who have lent their money, reputation, and time to relief efforts are mortified by the tepid response to what could be a devastating resurgence of the deadly disease.

“The idea that you can die of cholera one and a half hours from Miami is f--king insane,” says Sean Penn, the outspoken American actor and head of the J/P Haitian Relief Organization. 
“Death by cholera is a poverty death—it’s just access to clean water and education.”



With Haiti’s long history of crises and calamities—hurricanes, flooding, civil unrest, political upheaval, and longstanding poverty—the cholera epidemic was the last thing the country needed after a 7.0 earthquake leveled large parts of the country in January 2010.



Yet it appears to have come from one of the very institutions that meant to help the country. When rumors first surfaced last year that U.N. peacekeepers from Nepal carried cholera to the island and contaminated a local river with overflowing camp latrines, protests—some of them violent—followed.

The U.N. commissioned an independent investigation, and its final report published in May acknowledged the Nepalese base could have been the source, though it focused on a “confluence of factors” responsible for cholera’s spread—including poor water sanitation. Other reports, including those from the U.S. Centers for Disease Control, European researchers, and geneticists involved in tracking down the anthrax attacks in 2001, strongly suggest that no other source but the Nepalese camp could have introduced the disease.


When the epidemic began last October, some aid groups opposed vaccinations, fearing it would steal resources from urgent rehydration treatments and emergency sanitation measures. On the eve of a controversial election, the then-Haitian government feared civil strife if only a chosen few were vaccinated. Soon after, the Pan American Health Organization recommended a limited number of doses, but no action was taken.



Even new President Martelly says he knows little about the vaccines or how they could be used. “Cholera is a new thing for us,” he concedes.

Already, 5 percent of Haiti’s population has been infected with a disease that afflicts the stomach and intestines and can lead to death quickly in vulnerable populations that can’t get treatment.

A few weeks ago, 27-year-old Haitian Maurice Jonel’s bellyache quickly turned to cholera. He had been careful—he washed his hands often and drank only treated water. He knows he’s lucky to have survived and fears for poorer Haitians who lack even his limited resources.

“Some people can't get to the doctor in time. And especially for people living in the streets, for the crazy people who drink from the gutter—they should get a vaccine. It would be beautiful if Haiti had a vaccine,” he said.


"It’s not unreasonable to worry about 10,000 deaths by the end of the year."

Frustration is growing, with some human-rights leaders calling for reparations or at least an acknowledgment of culpability from the U.N. President Martelly also wants the U.N. to clarify what happened and pitch in more.

“We want to see how it was introduced, and to have them give us medical and technical assistance. I am getting into discussions with them but it will take a few more weeks,” he says.

But fighting cholera in Haiti will require a host of weapons. A vaccine certainly wouldn’t be a cure-all: the two primary ones are 85 percent and 67 percent effective, require two doses, and last about two years. It would take time for manufacturers to increase production, but estimates show it would cost only about $20 million to purchase the vaccine for everyone in Haiti (except children under a year old). Compare that to the U.S. government’s longtime investment to maintain a stockpile of anthrax vaccine or to ramp up production of bird- and swine-flu vaccines, which threatened to become pandemics but petered out.



While little is known about effective vaccination strategies for epidemic cholera, a study this past April found that concentrating 1 million doses in high exposure areas, enough for 5 percent of the population, would reduce cases by 11 percent and vaccinating 30 percent of the population could reduce cases by 55 percent, saving 3,320 lives. The independent U.N. report also recommended that U.N. personnel and emergency responders should receive antibiotics and be immunized using the vaccines in order to protect themselves and others.


With a limited shelf life, and no clear source of funding, vaccine makers won’t ramp up production until the doses are ordered.

“That is the catch-22,” says David Sack, a world-renowned cholera expert now at Johns Hopkins. “With no demand they won’t make a vaccine they can’t sell.”



Eric Mintz, leader of the CDC’s Global Water, Sanitation, and Hygiene Epidemiology, says Haiti could gain from a vaccination program if it was “well organized and targeted a particular population or age group where it could have more impact than, say, a random lottery.”



Experts say the international community—which has been responsible for the delay—should bear the burden to get the vaccinations started.

“It’s officialdom, us in the international community,” says Farmer, the Harvard professor and cofounder of Partners in Health. “If we can’t move this forward, then we’re as much to blame as a feckless Haitian bureaucrat.”



With Pooja Bhatia, who is a writer in New York.