Cholera, Water, and Recovery in Haiti

Haiti is in the midst of a cholera outbreak, the origin of which is and may remain unclear.  We live in a mobile world and the source could be Africa, Asia, South America, or it may have already been in the environment.  Where it came from is less important than the fact that Haiti, and especially the poorest of the poor, will always be vulnerable without clean water, adequate sanitation, and good hygiene.  This is an update on the current cholera emergency and a reflection on actions that can prevent this from happening again.

The United Nations Children’s Fund (UNICEF), an authority on water, sanitation, and hygiene (WASH), reports that before the earthquake, only four out of ten Haitian children had access to sanitation—one in ten in rural areas.  Only one in five drank from safe water piping systems within their homes—one in twenty-five in rural areas.  Sanitation coverage stood at an alarmingly low 17%, a decrease from 1990.  Few schools had proper water and sanitation facilities, half of the rural population practiced open defecation, and household sanitation (where it existed) was largely limited to rudimentary latrines.  Clearly, this is a context in which a water-borne disease can spread like wildfire.  In post earthquake Haiti, UNICEF acknowledges improved access to safe drinking water and sanitation for 1.2 million people, but without investing in infrastructure and improving local capacity, these gains are not sustainable – particularly when results stem from water-trucking, portable latrines and daily latrine desludging.

So what is cholera?  Cholera is an acute diarrheal infection caused mainly by ingestion of food of water contaminated by a bacterium called “Vibrio cholera 0:1”.  Each year, there are an estimated 3–5 million cholera cases and 100,000–120,000 deaths due to cholera.  Far more people (mostly children) die from other forms of diarrhea each year, but cholera is especially dramatic given the speed with which it can spread and through which people can die without treatment.  Something important to keep in mind is that approximately 75% of individuals infected with the bacterium will be asymptomatic but can still transmit.  Of those with symptoms, approximately two percent will be severely affected.  After a short incubation period of from one to five days, severe symtpoms could include watery diarrhea and/or vomiting that causes severe dehydration.  With prompt and proper treatment, the case fatality rate (the number of people who have it and die) should be less than one percent.  According to the World Health Organization (WHO) the death rate from the cholera outbreak in Haiti has been much higher, although it is getting better, decreasing from 10% at the beginning of the outbreak to about 7.7% now.  This may be due to increased awareness of the importance of seeking care as early as possible.  For 80% of cases, oral rehydration salts (ORS) to replace lost fluids is enough.  For severe cases, intravenous administration of fluids and other forms of treatment are necessary. 

A county can’t treat its way out of a cholera epidemic.  Prevention is key. What is most important is to ensure, as soon as possible, that people have access to clean water, adequate sanitation, and are able to practice good hygiene.  Vulnerable populations should also be advised to not eat raw food, eat only cooked food, and to avoid washing cooking utensils in and/or bathing in potentially contaminated water.  Bathing in rivers and streams is very common in Haiti.  Community mobilization is critical, especially in a context like this where there has not been a cholera outbreak for decades.  Health care providers were unaccustomed to seeing and treating cholera, and families may have mistaken it for run of the mill diarrhea, which if you’ve spent any amount of time in Haiti, you probably have a personal understanding of how common it is.  While it is true there are cholera vaccines, they are not very practical for responding to outbreaks.  Multiple doses are required 7-14 days apart, and effectiveness is only 70% after the second dose.  Whether vaccination will be part of a long term control strategy is up to the Haitian government. 

Acute diarrhea and vomiting were first reported on October 19 in Saint Marc, a medium sized city in the  Artibonite Valley.  As of October 27, almost 5,000 cholera cases and over 300 deaths had been reported.  Other cases were later confirmed on the Central Plateau, in the North, the Northeast and in the West.  Why are the majority of cases occurring in the Artibonite?  Given poor WASH conditions around the country, this could have started anywhere.  But the fact that the Artibonite received the highest number of returns after the earthquake, without comparable investments in the water and sanitation infrastructure, could have been a contributing factor.  The fact that people bathe and wash clothes in the Artibonite River is not unusual.  What may have been different here is the extent to which people were drinking out of it for lack of other options.  To any extent, cholera will be in Haiti for year to come.

No cases have been confirmed in the Dominican Republic yet.  The Dominican Ministry of Health has been on high alert and activated a response plan that includes limiting border crossings to individuals with official documentation and a health exam.  The Dominican military has significantly increased its presence along the border.  The concern of the Dominican Ministry of Health is understandable but it is unfortunate that border restrictions will negatively impact trade between the two countries and limit access to medical clinics just on the other side of the Dominican Republic – at least at far as the three formal border crossings go.  The rest of the border remains highly porous.  The Dominican Government is assisting the Haitian Government with water purification and is bolstering medical facilities along the border.

The Haitian Government is ultimately responsible for addressing the health needs, emergency and otherwise, of its people.  In this case, the Haitian Ministry of Health (Ministère de la Santé Publique et de la Population or MSPP) and the National Direction for Potable Water and Sanitation (Direction Nationale de l'Eau Potable et de l'Assainissement or DINEPA) are particularly important.  Both Ministries lack resources and have limited capacity but are doing what they are supposed to be doing – taking the outbreak seriously, developing plans, and attempting to coordinate many different responders. President Preval, Prime Minister Bellerive, and Minister of Health Alex Larsen have made public statements acknowledging the extent of the outbreak and providing information on prevention.  For his part, President Préval has agreed to lead a national emergency task force to coordinate the response.  Mario Andresol, the Director General of the Haitian National Police (HNP) has offered up his staff to assist the Haitian Ministry of Health.  Many Presidential candidates have spoken out about cholera while on the campaign trail.

MSPP has set in place a National Response Strategy which prioritizes protecting families at the community level, strengthening primary health care centers across the nation, and establishing a network of special Cholera Treatment Centers (CTCs) and designated hospitals for treating severe cases.   According to WHO, the MSPP is sending community health agents into poor and densely populated areas, including temporary settlement areas created after the earthquake, to actively seek out and refer the sickest people to the CTCs, while at the same time giving them a first dose of oral rehydration salts. MSPP also will be establishing a network of community health posts to treat diarrhea.  DINEPA has a National Action Plan in place that emphasizes: (1) Distribution of water purification tablets to local water distribution points and kiosks; and (2) chlorination of as many water sources around the country as possible.

Given that the Cluster Approach is active in Haiti, three clusters are playing leading roles in the response: (1) Health; (2) WASH; and (3) Logistics.  These clusters include government officials, international organizations, non governmental organizations, and local groups.  The WASH Cluster members are working with Logistics Cluster members to distribute chlorine throughout the country.  DINEPA is also working with the WASH cluster to distribute soap and to carry out awareness campaigns. MINUSTAH is providing security and logistical support.

The WHO/Pan American Health Organization (PAHO) has been working closely with the Ministries of Health from both Haiti and the Dominican Republic. PAHO’s Caribbean Epidemiology Center (CAREC), located in Trinidad, is also working with other countries in the Caribbean to prepare for and response to any suspected cases.  At the request of each government, the U.S. Centers for Disease Control and Prevention (CDC) has deployed experts to assist with the response and are now on both sides of the border.  The United States Agency for International Development (USAID), also present in both countries, is playing a very active role in the response and is funding the efforts of international and non governmental partners.  France has deployed medical staff to Haiti while the Brazilian Ministry of Health has sent medicines and supplies.  

UNICEF is distributing medical supplies in the most heavily affected areas of the Artibonite. Radio is the most trusted media in Haiti and the prevention message has been reinforced by IOM nationwide radio programming on commercial and community radio stations. In addition, the International Organization for Migration (IOM) and the Red Cross Movement are using SMS text and voice messages to reach people in the with SMS information on cholera prevention, treatment and hygiene.  Over 80 specialized IOM staff with hygiene training have been deployed for direct outreach to displaced persons in camps across Port-au-Prince. They are broken into teams of 10, each one with 2 Haitian Red Cross health and hygiene specialists, targeting over 60 camps identified by IOM’s WASH team as the most vulnerable. The International Committee of the Red Cross (ICRC) is currently focused on supporting prisons and will dispatch supplies.  The Canadian Red Cross has been sending convoys of trucks up to Artibonite. The Haitian Red Cross is actively involved in information and awareness campaigns. The American Red Cross has deployed emergency response teams and provided supplies such as cots.

Many different NGOs throughout the county implement WASH programs and many are now responding to emergency health needs.   Population Services International (PSI) has donated all of its regional stock of water purification tables to Haiti.  ACTED has distributed water purification tablets as well.  Save the Children (STC) is carrying out a health information campaign.  Medecins Sans Frontieres (MSF) has deployed medical teams to cholera affected areas.  The International Medical Corps (IMC) is working closely with the Albert Schwetizer Hospital in Deschapelles, the largest in the Artibonite Valley.  The International Rescue Committee (IRC) is carrying out prevention activities in 37 settlements in Port au Prince.   Food for the Hungry is training staff and communities on cholera prevention and response in 30 settlement sites.  The Center for International Studies and Cooperation (CECI) is distributing soap, ORS and other supplies.

The present emergency highlights the importance water plays in Haiti’s long term recovery.  When I think about water from my time in Haiti, I first recall all the rusted out water pumps throughout the country which worked at one point, but no longer do.  Inevitably, they broke down and the community lacked either the means to buy new parts or the expertise to fix the equipment.  I think of rural communities where people collect water from streams and rivers, often in the same places where they water livestock.  I think of communities on the Central Plateau where generations had lived on the same piece of property without realizing water was only ten feet below them.  With cement, tools, some technical assistance, and a lot of sweat, they were able to construct a reasonably good well.  Finally, I can’t help but think of all the times I contracted a water-borne disease myself, of which giardia was the most frequent culprit.

The Haitian government does not have a long tradition of investing in the basic needs of its people.  There have been administrations that could have but chose not to do so and those that wanted to but did not have the means to do so.  Investments in water yield rich dividends as it is necessary for health, agriculture, and security.  These dividends are maximized by complementary investments in sanitation and hygiene.  It is up to the Haitian government to plan, to coordinate, and to build WASH partnerships – not just for Port au Prince but for every department in Haiti.  Building the capacity of both DINEPA and MSPP are a long term, indispensable part of the solution. For its part, UNICEF plans to continuously build the capacity of DINEPA to extend its presence throughout Haiti’s ten departments.  DINEPA has no shortage of partnerships it can build on including the United Nations Development Program (UNDP), Inter American Development Bank (IDB), USAID, the French Development Agency (AFD), The Spanish Development Agency (AECID), the European Union (EU) and many others.  Donors should assist DINEPA and MSPP to bolster its human and financial resources.  They should also hold each accountable for demonstrating leadership and results.

One size won’t fit all in each of Haiti’s departments.  Boreholes may be drilled in some areas, while wells might be dug manually in others.  Piped water may be expanded into some areas but not others.  Chlorination may be possible in some places while point of use methods better in others.  A long term commitment to WASH is needed by both the Haitian government and the international community.  Expanding water networks will require tackling Haiti’s ever thorny land tenure issues. Concerning sanitation, UNICEF notes that communities need to be empowered to take ownership, eliminate open defecation, and to manage their own sanitation facilities.  National plans and strategies should be just that, including rural as well as urban areas.   At the highest levels, the Haitian government has expressed a desire to decentralize – this will take both a legislative framework to do so and a lasting commitment to improve access to basic services.

One of the main coordination mechanisms in Haiti right now is the Interim Haiti Reconstruction Commission (IHRC) which is co-led by Haitian Prime Minister Bellerive and former U.S. President Bill Clinton.  To date, the IHRC has approved only one WASH project, designed to expand public water supply in Port au Prince.  The cost is 200 million over five years, but is reportedly only 57% funded.   Were the IHRC to articulate WASH as a priority and to secure support for the implementation of nationwide programs, it would be a step in the right direction.

The current cholera emergency is unfortunate as the poorest of the poor are most at risk.  My hope is that the present situation will encourage a lasting committment to promote WASH - not just to respond to cholera, but as an integral part of Haiti's recovery and long term development.  Please feel free to post your thoughts on WASH related issues in Haiti below.

Thanks!
Bryan