Haiti After the Earthquake
Page 23
Their numbers weren’t small. In Mirebalais and elsewhere in central Artibonite Haiti were thousands of peacekeepers, some hundreds of them recently arrived, and within a few hours, accusations were flying. Some of the rumors were, as usual, absurd. But it was not unreasonable, epidemiologically, to assume a connection between the large and relatively new presence of people from South Asia and a new, externally derived epidemic—even before the infecting strain had been genetically typed and before it was known that waste management at the Nepalese base, managed by a private Haitian contractor, left much to be desired. In those first days of the epidemic, the chief task was to figure out where the epidemic had come from and to cut its spread by any and all means possible.
That’s why, less than ten days after news of the first cases, I spoke to journalist Jonathan Katz, who was investigating how cholera had been reintroduced to the Americas. One of my suggestions was to identify the source of the Haitian epidemic and to study, genetically and epidemiologically, the introduced strain. On November 9, Katz wrote the following for the Associated Press:Public health experts, including UN Deputy Special Envoy to Haiti Paul Farmer, who co-founded Partners In Health, have called for an aggressive investigation into the origin of the outbreak. They say that should include looking at the unconfirmed hypothesis that cholera was introduced by UN peacekeepers from Nepal, a South Asian nation where the disease is endemic. Those peacekeepers are at a UN base on a tributary of the Artibonite River, which has been found to be contaminated with cholera.11
All this was technically correct, but it was certainly not my intention to fan the blame game. Still, it seemed important to understand the biosocial complexity of this rapidly changing epidemic. This meant understanding both the origins and genetic fingerprint of this particular strain, which would help predict its speed of spread, its appropriate treatment, and even its case-fatality rate. My Harvard colleague John Mekalanos, chair of the department of Microbiology and Molecular Genetics and a genuine cholera expert, made the same point even as we were studying the genetic fingerprint of the cholera strain: “It very much likely did come either with peacekeepers or other relief personnel. I don’t see there is any way to avoid the conclusion that an unfortunate and presumably accidental introduction of the organism occurred.”12
The popular press contained vivid accounts of the likely source of contamination. Katz did yeoman’s work trying to figure out what was going on. This required him to visit the Nepalese base closest to Mirebalais, where I’d been received previously with great courtesy.13 But Katz wasn’t there to have a meal and a chat with the officers. He came to inspect latrines and septic tanks:When the AP visited on October 27, a tank was clearly overflowing. The back of the base smelled like a toilet had exploded. Reeking, dark liquid flowed out of a broken pipe, toward the river, from next to what the soldiers said were latrines. UN military police were taking samples in clear jars with sky-blue UN lids, clearly horrified. At the shovel-dug waste pits across the street sat yellow-brown pools of feces where ducks and pigs swam in the overflow. The path to the river ran straight downhill. The UN acknowledged the black fluid was overflow from the base, but said it contained kitchen and shower waste, not excrement.14
The circumstantial evidence was damning. Within days of the first cases, photos of raw human waste from the camps being dumped directly into one of the rivers connecting the camp to Mirebalais (and Mirebalais to Saint-Marc) covered the newspaper pages.
But the initial response of the UN was to deny any connection between the epidemic and the burgeoning presence of their troops from cholera-endemic regions. Katz put it this way:The mounting circumstantial evidence that UN peacekeepers from Nepal brought cholera to Haiti was largely dismissed by UN officials. Haitians who asked about it were called political or paranoid. Foreigners were accused of playing “the blame game.” The World Health Organization said the question was simply “not a priority.” But this week, after anti-UN riots and inquiries from health experts, the top UN representative in Haiti said he is taking the allegations very seriously. “It is very important to know if it came from (the Nepalese base) or not, and someday I hope we will find out.”15
Umbrage was taken on all sides. The mayor of Mirebalais attacked the UN for introducing “yet another epidemic” to Haiti, echoing the views of many of his constituents. The Nepalese troops and the UN issued epidemiologically implausible, but socially and politically predictable, denials and hired a private Dominican laboratory to see if indeed any of their troops were sick.16 Fortunately, they were not sick, but those who knew a bit about the microbiology of the causative organism, Vibrio cholerae, knew that it wasn’t easy to grow in lab. They also knew that, as with most infectious pathogens, many of those shedding viable cholera bacteria would remain asymptomatic. As we would later learn, the South Asian strain of cholera active in Haiti has been shown to cause greater numbers of asymptomatic cases, to persist longer in the environment, and to exist in higher concentrations in feces.17
But political responses to the mounting epidemic ignored such clinical details. As the Haitians continued to demand explanations, the UN, and especially the Nepalese, continued to issue denials: “Nepal’s UN office said in a statement Friday that its peacekeepers have never been linked to a communicable disease, and that tests done by the United Nations, Haiti’s government, and independent groups prove that none of its peacekeepers now in Haiti has cholera. Nepal firmly rejects such baseless, malicious, and unfounded reports put out by some media and individuals without any regard to the specific evidence to the contrary.”18
Political protests against the peacekeepers occurred well before any of us spoke to the press. Categorical UN denials were only making the situation worse, we feared. Louise Ivers, the person I trusted most on this score, thought that an independent inquiry was needed. We began calling for strain identification to learn what antibiotics would be needed to kill the organism, predict the speed of spread, and estimate the chance of endemicity—settling in for the long term to plague an immunologically naïve population. Above all, pinpointing the source of the outbreak might have, early on, helped to stop its spread. But with many infected people traveling around the country, it seemed by mid-November that this window had closed.
Those seeking to deliver services—to diagnose and treat cholera, a disease about which they were learning, and to prevent it whenever possible—were of course affected by these social responses, which soon became violent. Within weeks of the first cases, the papers contained reports—some unconfirmed—of crowds throwing stones at UN peacekeepers’ armored personnel carriers and, in one case, at UN helicopters seeking to land medical supplies in northern Haiti:Protesters have targeted the United Nations, as well as Nepal, all week. The world body claims demonstrators have attacked its peacekeepers, as well as prevented the movement of humanitarian aid and medical help by blocking roads, bridges and airports. “If this situation continues, more and more patients in desperate need of care are likely to die, and more and more Haitians awaiting access to preventive care may be overtaken by the epidemic,” Edmond Mulet, the UNʹs special representative in Haiti, said in a statement. Small-scale skirmishes—involving rock-throwing and burning tires, then tear gas in response—erupted Friday in Port-au-Prince, relatively sporadic confrontations that paled in comparison with earlier violence. And eyewitnesses said that traffic was again moving in Cap-Haïtien, a northern Haitian city that’s the center of the outbreak, after four days of gridlock caused by massive protests.19
After returning from Rwanda, I wanted to discuss with Edmond Mulet why it might be prudent to investigate the source of the outbreak, and also to call for aggressive measures to prevent, detect, and treat cholera cases. Mulet wasn’t at the UN log base when I arrived, so I left him a book I wrote more than a decade ago, which describes the predictable responses to epidemic disease that we were seeing with cholera. When I returned a few days later, Mulet had read most of the book, highlighting passages with a yellow marker.
He was much taken by the similarities between the social responses to cholera and those registered in the eighties and nineties to AIDS and tuberculosis. Mulet estimated that half of all countries contributing troops to MINUSTAH (UN Stabilization Mission in Haiti) experienced regular outbreaks of cholera, and was disturbed by the focus on the Nepalese battalion. I understood his point and promised him that my comments were (to use the words of another UN friend, who had narrowly survived the quake), “eminently technical.” We needed to identify the strain, get an idea of what it was likely to do in Haiti, and deploy every tool in the international arsenal against it. Mulet agreed. On November 20, he told the Associated Press, “We agree with him that there has to be a thorough investigation of how it came, how it happened, and how it spread … There’s no differences there with Dr. Paul Farmer at all.”20
Gratified as I was by Mulet’s clarification and support, we weren’t seeking validation. We wanted to work together to strengthen efforts against a transnational epidemic. I was en route to Mirebalais to check on the hospital’s progress, which had slowed after some of the Dominican engineers and contractors we’d hired left central Haiti during the cholera outbreak. But our Partners In Health and Zanmi Lasante teams had nowhere to go; we expanded our cholera work as we sought to keep the Mirebalais hospital on schedule.
The rural hinterlands and slums outside the quake zone suffered more than the camps, but all those unable to buy clean, filtered water would suffer. Although some found it perplexing that cholera largely spared the camps and instead laid waste to central Haiti, it was no surprise to those of us at Partners In Health and Zanmi Lasante. Our own small water projects over the years had humbled us about our ability to stave off epidemics of waterborne disease. We could protect certain villages, but the great majority of the rural population still lived without ready access to potable water and modern sanitation. Without a massive and coordinated scale up of such projects to help strengthen municipal water and sanitation systems, there was no way we could keep pace with cholera in rural Haiti.
Although prompt rehydration—simple fluid resuscitation with a well-known solution—could save almost anyone with cholera, most health providers were unprepared for the waves of people who walked, or were carried, into clinics and hospitals throughout central Haiti. The Cubans got right to work, as did some of the Médecins Sans Frontières groups. (There were so many borders between these doctors without borders that it was hard to figure out who was who.) Stefano Zannini, chief of a Médecins Sans Frontières mission in Haiti, called for more helpers and more collaboration: “More actors are needed to treat the sick and implement preventative actions, especially as cases increase dramatically across the country … There is no time left for meetings and debate—the time for action is now.”21
Working with the Ministry and other health-focused NGOs, my colleagues erected cholera treatment centers (or smaller treatment units) at each of our dozen hospitals and clinics across central and Artibonite Haiti. These sites were soon deluged with people standing, or trying to stand, in line for intake into these centers. Such rapid treatment responses saved lives, probably thousands of them. But thousands more would be lost, we feared, in what was likely to be a long struggle against cholera in Haiti.
For me, the fourth predicted struggle—that between experts—was the most enervating. Although I’m trained in infectious disease management (and the social responses to epidemics), and although I was one of the few doctors in Haiti who’d ever seen a case of cholera, I’m no cholera expert. But several of my colleagues, including John Mekalanos and one of my classmates from Harvard Medical School (Ed Ryan), were world-renowned cholera experts. Their genetic analysis of the Petite Rivière strain revealed an El Tor biotype of Vibrio cholerae serogroup 01, which had, in other parts of the world, proven virulent and hard to slow down.22 If the history of a similar El Tor strains in Bangladesh and Nepal offered any indication, the disease would likely become endemic in Haiti. These academics who mapped the strain were also strong proponents of rapid implementation of both prevention (from clean water to roll-out of vaccine) and care (from rehydration to antibiotic therapy).
It was the public health experts, Haitian and especially transnational, who were in discord. In keeping with widespread pessimism about the potential for health delivery in post-quake Haiti, many argued that it would be too difficult to launch comprehensive prevention and care efforts in Haiti. Vaccination was especially discouraged. 23 These “minimalists” were often the leading figures in international health. Others—and we were in this group—argued that there was no time to waste. In about forty days, cholera had caused more than two thousand deaths in Haiti, almost half the number reported during Zimbabwe’s year-long epidemic.24 There would, of course, be implementation challenges to rolling out vaccine in Haiti. But Zanmi Lasante had achieved a 76 percent completion rate for a three-dose course of HPV vaccine in rural Haiti. That is almost twice the rate of completion for similar courses in U.S. settings. Moreover, the earthquake occurred between the second and third dose for many of the girls enrolled.25
The battle lines were well worn: on the one hand, the minimalists favored heavy investment in health education and massive distribution of chlorine tablets for drinking-water disinfection. On the other hand, the “maximalists” argued that, although there might be no way to stop cholera in its tracks in Haiti, all the tools for preventing its spread (from improved sanitation, including chlorine tablets, to effective and safe vaccines) and for treating those already stricken (from rehydration and replacement of electrolytes to antibiotics) needed to be promptly integrated with the more restrained public health responses. Interventions such as exhorting people to drink clean water and wash their hands, or distributing chlorine tablets, were necessary but would never stop the epidemic. Having watched with horror as cholera ripped through the Mirebalais prison, killing five young detainees in as many days, we also wanted to review the evidence for antibiotic prophylaxis in certain instances.26
Three weeks after the first cases came to light, Jeffrey Sachs called, as he had more than a decade previously regarding AIDS: “Why aren’t we responding to this epidemic more aggressively, with integrated prevention and care? Aren’t there vaccines and also antibiotics? Isn’t this a bacterial disease? Why aren’t we bringing in the private sector, including companies that can help us get filtered drinking water and soap and antibiotics scaled-up more widely?”
Why indeed, I thought, as I often did during discussions with Sachs. He was well aware of the politicization of water aid that had occurred between 2001 and 2004, when the quality of the Haitian water supply was held hostage to the United States’ displeasure with President Jean-Bertrand Aristide. He’d been one of the few aid experts willing to testify before Congress regarding this sorry affair.27
Sachs had already contacted Unilever, a company with significant production capacity in the Caribbean, which made soap, hand sanitizer, and water filtration units. We agreed to set up a conference call with Unilever by the third week of November, and then another with cholera experts at the start of December. The first promised to be uncontroversial: the company pledged to donate many of its products and also some expertise on clean water and sanitation.
The second conference call, including the academics and the public health experts, was harder. It seemed that the latter were reluctant to commit the necessary resources; it also turned out that they had underestimated the dimensions of the Haitian cholera epidemic. On November 25, a Wall Street Journal article, “Cholera Spreading in Haiti Faster than Thought,” noted that official projections about the peak size of the epidemic had more than doubled. Nigel Fisher, a smart humanitarian and a top UN official in Haiti, summed up the revised estimates: “When we were in the initial stages of planning, we had said there would be 200,000 cases over six months. Today the figures are 425,000 over six months, of which 200,000 will be before year’s end, with a peak before Christmas.”28 I was grateful for Fisher’s candor.
The close of November, between the two calls, found me back in Haiti. In Mirebalais, the Cubans and Zanmi Lasante teams were managing to save almost all patients who showed up to the cholera treatment center there. The great worry was for all those falling ill far from towns with cholera treatment capacity such as Mirebalais. My colleagues from Zanmi Lasante spoke of scores of deaths in rural hamlets. “These deaths aren’t even counted,” they told me.
So the second conference call really mattered. The agenda was modeled on the effort we tried to engineer a decade previously, when the same sort of arguments—pitting AIDS prevention against AIDS care—were dominant. Back then, Jeff Sachs, still at Harvard, had helped bring us together. Now based at Columbia, he insisted that I take charge and try to assemble a group of cholera experts. We thought perhaps a few dozen specialists would join, but more than eighty people called in from Haiti, across the United States, Geneva, and as far away as Korea (where John Clemens, one of the world’s leading cholera vaccine experts, was working). Our Partners In Health and Zanmi Lasante teams were present, as was Bill Pape. We discussed the ranking problems facing cholera prevention and care, and also the priorities for the coming months and years. Disagreement surfaced about the problems and the priorities, but the debate seemed constructive.