Haiti After the Earthquake

by Paul Farmer

  To continue the conversation after the call, we began work on a “consensus statement,” as we’d done for AIDS a decade previously. We learned a lot about the minutiae of cholera prevention and care and about the importance of sparking greater public concern about the epidemic. The cholera experts were the most helpful: they shook the public health minimalists out of their torpor. No one working in the western hemisphere had seen anything like the Haiti epidemic in decades. “This is not your grandmother’s cholera,” David Sack had said.29 He didn’t specify whether he meant this in terms of virulence or infectiousness, but we feared it was both.

  We weren’t sure we’d be able to complete a consensus document in short order, although we had committed to trying. The maximalists among us decided that, rather than languishing in the bitter debates over the origins of cholera in Haiti and the role of prevention “versus” treatment, we would write our own pieces for medical journals and for the popular press. Within a month, Louise Ivers, David Walton, and our Haitian colleagues had written pieces in the Lancet and the New England Journal of Medicine.30 A few days after these pieces appeared, on December 10, 2010, Partners In Health hosted a press call. By then, we’d developed treatment capacity at all our sites in the rural Lower Artibonite and Central Plateau, and set up a fiftybed cholera treatment center in Parc Jean-Marie Vincent. We were also carrying out intensive education and prevention campaigns. We’d already spent a million dollars and planned to spend more than twice that amount again by the end of the fiscal year. The United States had, by some reports, committed more than $57 million to fight cholera. The idea that it was impossible to launch a comprehensive, integrated response, including ramping up vaccine production (or even building a new factory to manufacture vaccine) in the face of such investments was absurd. The Haitian cholera outbreak also afforded us the long-overdue chance to build a global stockpile of vaccine that could be deployed during this epidemic and the next.

  The conference calls seemed to have positive effects. Jonathan Katz reported a growing consensus about the need for vaccines in Haiti, for example. He noted that I hadendorsed broader use of the vaccine [in Haiti], and called for creating emergency stockpiles of millions of doses to keep cholera from spreading to other countries. He endorsed measures like searching Haiti’s central mountains for people too sick to reach clinics, using antibiotics even in moderate cases, and rebuilding the water and sanitation networks shattered by January’s earthquake. Other cholera experts [also on the conference call], including a different team from Harvard Medical School, where Dr. Farmer teaches, have also called for stockpiling millions of doses to stop outbreaks, as is now done with measles vaccine and the flu drug Tamiflu.”31

  For a time it didn’t seem that we were alone. The New York Times ran a piece suggesting that some of the people from the Pan-American Health Organization, who had initially opposed large-scale vaccination as impractical, had changed their minds. For example, PAHOʹs John Andrus was quoted as saying, “We recognize that it’s time to rethink our position. We don’t want to miss an opportunity.”32

  But as 2010 drew to a close, it seemed that the opportunity had slipped away. The consensus statement was underway, but the minimalists and the maximalists were often deadlocked. We went to friends in the popular press, and managed to get a piece into the December 20 edition of Newsweek:Cholera demands … fully integrated prevention and care, using all the tools available and raising our goals. Twelve years ago we argued that AIDS treatment using antiretroviral therapy was possible even in rural Haiti—and the results have justified that approach. The Haitian cholera epidemic exposes the fallacy of setting goals based on a country’s GDP. Pathogens like HIV, cholera, and dengue move within a complex web of global social connections, binding the richest and the poorest countries together in vulnerability. But while those microbes jet around the world, their remedies remain stuck in customs. There’s no excuse for allowing Haiti’s cholera disaster to escalate. We already have preventive measures—from improved sanitation to vaccines—and effective treatments: rehydration, replacement of electrolytes, and antibiotics. We must move swiftly, aggressively, and together. If we insist that prevention and care are complementary, and we draw on any and all means available globally, we can beat this emergency—and whatever problem comes next.33

  The week before Christmas, I visited a few of the cholera treatment centers in central Haiti. Our colleagues were doing stellar work. They followed strict infection-control procedures, spraying our shoes with chlorine solutions that made our eyes burn and filled the air with an unforgiving scent. But these procedures suggested that no transmission would occur in these sites. We also knew that almost all those seeking care there would survive: in Mirebalais, the case-fatality rate—the percentage of people presenting with cholera who died—had essentially fallen to zero. These centers were run by Haitians from Zanmi Lasante and by members of the Cuban medical brigade (one of whom was Bolivian). The numbers of new patients were dropping, but the tents were still full.

  We also visited the nearby Mirebalais construction site. David Walton and Jim Ansara were there and showed us around their ambitious project. The site was nothing if not inspiring: acres of buildings were going up. But we were only a few hundred yards from a site where young people and old were lying on stiff cholera cots. They weren’t dying, thank God, but they were still suffering from an eighteenth-century illness.

  We also visited the cholera treatment unit our teams were running in Lascahobas. Almost no one was dying from cholera there, either. But the beautiful courtyard garden was brown and shriveled by the chlorine solution that had been used for infection control.

  On the flight back to Boston, I shared my anxieties about Haiti’s long-term challenges with an American family with whom we’d been traveling. (They’d been strong supporters of Partners In Health’s efforts in the past.) Although the entire family had been to Rwanda, their eighteen-year-old son had never been to Haiti before this trip. It was a lot to take in: the cholera centers, the crowded hospitals, the capital still strewn with rubble, an accident in which a cyclist had been fatally struck minutes before we drove by.

  I was worried about the five Haitian students heading to the Rwandan National University. Their tuition would be free, courtesy of the Rwandan government, but we hadn’t purchased their plane tickets yet; nor had we obtained visas so they could travel through the United States. And the Rwandan academic year started in January—less than a month away. As I discussed these issues with the family, the young man—a senior in high school—said quietly that he wanted to sell some stocks he’d been given years ago to help buy the tickets. It turned out that he owned enough stock to purchase all five of them.

  So one anxiety was allayed when I headed back to peaceful Rwanda with my brother-in-law, an obstetrician, who’d helped write the Newsweek article. It was a joy to be reunited with our children—my three and his two made five. It was a merry Christmas dinner. But it was clear, as the evening wore on, that Haiti was on our minds. A handful of us were still up at two in the morning, arguing heatedly about what should be done about cholera and about reconstruction. We didn’t get very far, except as regards annoying our non-Haitian hosts and friends.

  The consensus statement on cholera was still stuck on the differences between the minimalists and the maximalists.34 How to integrate vaccination into the response was the chief sticking point. The minimalists argued that there was insufficient data to show that vaccine would confer protection in a “setting like Haiti” (whatever that meant: either that its population was immunologically naïve or that infrastructural obstacles doomed the effort in advance). Nor was there sufficient stock in the world, they said. But without consensus, who would begin ramping up production?

  Cholera case-fatality rates were still highly disparate. In Mirebalais, there hadn’t been a cholera death in several weeks; in other stations, one out of ten cholera patients diagnosed with the disease died. By early 2011, almost two hundred thousan
d cases and four thousand deaths had been reported.35 One modeling exercise under review suggested that cholera would not peak in certain regions till almost a year after the first cases were reported in October. For example, the model predicted that the epidemics in the Grand’Anse, Nippes, and Sud departments would peak in December 2011, with an incidence of 200 cases per 100,000 population.36 That would mean, in just three departments, almost 3,000 people would become ill with cholera in a single month. A Lancet study conducted by Jason Andrews, a young researcher at Harvard Medical School who had helped us in Petite Rivière de l’Artibonite, predicted at least 779,000 cases and 11,000 deaths by the end of 2011.37 As we rang in the New Year in Rwanda, it was hard to feel triumphant about our efforts in Haiti, because the cholera epidemic was, in our view, completely out of control. Other experts (most of them trained in public health) disagreed: we were being alarmist and counterproductive, they said.

  If the public health and clinical experts couldn’t agree, it’s not difficult to imagine the discord among NGOs and other implementers. Just before the dawn of the new year, a disgruntled doctor from Médecins Sans Frontières (the home base of disgruntled doctors, some might say) lamented in the Guardian the poor coordination among groups trying to respond to cholera. I quote the piece at length because it was a pretty apt, if dismal, description of the problems we faced:Ten days after the outbreak hit Port-au-Prince, our teams realised the inhabitants of Cité Soleil still had no access to chlorinated drinking water, even though aid agencies under the UN water-and-sanitation cluster had accepted funds to ensure such access. We began chlorinating the water ourselves. There is still just one operational waste management site in Port-au-Prince, a city of three million people. On the one hand, Haitians were deluged with text messages imploring them to wash before eating, while on the other they had to bathe their children in largely untreated sewer water. Before the quake, only 12% of Haiti’s 9.8m people received treated tap water, according to the US Centres for Disease Control (CDC) … Throughout the 1990s, the UN developed a significant institutional apparatus to provide humanitarian aid through the creation of the Department for Humanitarian Affairs in 1992, later renamed OCHA, all the while creating an illusion of a centralised, efficient aid system. In 2005, after the Asian tsunami, the system received another facelift with the creation of a rapid emergency funding mechanism (CERF), and the “cluster” system was developed to improve aid efforts. The aid landscape today is filled with cluster systems for areas such as health, shelter, and water and sanitation, which unrealistically try to bring aid organisations—large and small, and with varying capacities—under a single banner. Since the earthquake, the UN health cluster alone has had 420 participating organisations in Haiti. Instead of providing the technical support that many NGOs could benefit from, these clusters, at best, seem capable of only passing basic information and delivering few concrete results during a fast-moving emergency. Underscoring the current system’s dysfunction, I witnessed the Haitian president, René Préval, personally chairing a health cluster meeting in a last-ditch effort to jump-start the cholera response.38

  On one hand, we could point to certain successes. We’d been able to reduce case-fatality rates to zero wherever we had the tools of our trade and the ability to pay the nurses and doctors and infection-control staff we’d trained in preceding months. On the other hand, some public health experts had underestimated the dimensions of the cholera epidemic and had actively discouraged more aggressive interventions. Estimates of two hundred thousand cases had once been decried as hyperbole; some still denied the need for vaccine. As noted, almost a million new cases have been predicted by the end of 2011. It was impossible to know if this was an overestimate, but we maximalists faced the New Year with nothing less than shame. If our goal had been to scale up on integrated and comprehensive cholera response using all available interventions, including vaccine, we had failed miserably.

  I found myself talking about cholera every day and mostly lamenting our failure to bring all the tools of our trade to bear on the epidemic. My eldest daughter, Catherine, reminded me that my sorrow bordered on obsession: “Dad, can we not talk about cholera at the dinner table?”

  No, not yet.

  As the anniversary of the quake approached, it was difficult not to stop and take stock of the situation: How much had been accomplished, and how much remained to be done? What would Port-au-Prince look like on January 12, 2011? The medical metaphor of acute-on-chronic seemed still useful when considering these questions. I’ve argued that the early rescue and relief efforts described in these pages were not a failure. Although too few were saved from the rubble and too many were still living in squalid camps almost a year after the quake, there was, until cholera hit, no second spike in what epidemiologists call “crude mortality rate.”

  Humanitarians often took credit for averting secondary waves of mortality, and justly so in some circumstances. Haiti’s well-managed internally displaced persons camps were a good example: such camps saw fewer cases of cholera because their residents had access to clean water and modern sanitation (especially compared to many rural regions outside the quake zone and outside the realm of modernity). But cholera was far from under control.

  Vulnerability to cholera and other stuttering secondary catastrophes remained extreme in urban Haiti. On September 24, a month before the first cases of cholera, a violent thunderstorm lasting less than thirty minutes killed six people and ripped down the flimsy shelters of almost twenty thousand families.39 It tore through the General Hospital, laying waste to the fragile tents sheltering tuberculosis patients. If a thirty-minute storm caused such damage, what would happen if a larger one struck?

  Some reconstruction was underway, and more was promised. The day after the thunderstorm ripped apart the tuberculosis ward in the General Hospital, Bernard Kouchner, the French Foreign Minister, announced a twenty million euro rehabilitation and reconstruction project at the hospital.40 Our colleagues at the General Hospital, including Alix Lassègue and Miss Thompson, were grateful for France’s help but were holding the applause until the work began in earnest. (It was our worry that the Mirebalais hospital would be completed first, becoming the de facto national referral hospital.)

  Major infrastructure rebuilding proposals were heartening but slow to get moving. The grace and comity that had animated the Haitian and international response efforts immediately after the quake had largely evaporated even before cholera struck. Every day the press reported stories of struggles over scarce resources, within the camps and without. People in the camps were frustrated: persistent vulnerability frayed nerves. They complained about the lack of services, especially the lack of schools available for displaced children. Dramas occurred as a few landowners tried to push the displaced out from under their tarps, tents, and beat-up sheets of tin or plywood. At the close of September, the New York Times ran a long report about efforts to enforce property rights instead of sheltering homeless people. On the leafy grounds of one church mission, foreign and homegrown clergy seemed set on pushing refugees out of the camp that was set up there immediately after the quake. “‘This used to be a beautiful place, but these people are tearing up the property,’ said . . . a Church of God missionary living at the site. ‘They’re urinating on it. They’re bathing out in public. They’re stealing electricity. And they don’t work. They sit around all day, waiting for handouts.’”41 Surely the missionary intended no irony by applying a phrase like “tearing up the property” to people displaced by an earthquake that quite literally tore up the Haitian capital, their homes, and their lives.

  The cholera outbreak created yet another set of obstacles on the rubble-strewn road to reconstruction, and made the persistent lack of readily available funds for large infrastructure projects such as municipal water systems ever more crippling.42 Although the United States, Cuba, and many other government and nongovernmental groups had invested in cholera treatment and prevention, none of us mistook these frantic efforts for re
construction. An Associated Press story documented the slow pace of reconstruction:Not a cent of the $1.15 billion the United States promised for rebuilding has arrived. The money was pledged by Secretary of State Hillary Rodham Clinton in March for use this year in rebuilding. The United States has already spent more than $1.1 billion on post-quake relief, but without long-term funds, the reconstruction of the wrecked capital cannot begin.43

  Other accounts disputed the exact numbers and the causes of delay. (Some simply invoked the word “bureaucracy” as an explanation.) But one thing seemed certain: the holdup stemmed from fundamental weaknesses in the machinery of foreign assistance, often having more to do with donor-country problems than Haitian ones. The $1.15 billion the United States pledged in March for reconstruction had stalled because of partisan politics in Congress.44 In its sluggish delivery on aid promises, the United States was far from alone. The Associated Press reported that, as of September 29, less than 15 percent of all reconstruction pledges had arrived: $696 million compared to the almost $10 billion in pledges.45 And of the money that had been disbursed according to official reports, some was a phantasm born of bookkeeping wizardry (retooled aid dollars, debt relief, or tardy delivery of already promised loans to the government of Haiti).

  When funds were, at last, released from the bureaucratic snares of foreign assistance, there was no guarantee that they would reach the most deserving projects. There was stiff competition for contracts, from the quake’s immediate aftermath to the long road of reconstruction, and as noted, the Haitian companies seemed to be losing these fights.46 Unless the rules of the road for foreign aid were changed, the anemia of reconstruction projects in terms of creating local jobs and strengthening Haitian capacity (including that of small construction firms) seemed likely to persist.47