Cholera and Health Care in Haiti

New Media Fellows 2013

By Sokari Ekine

February 20, 2013

Also published at 1804 Caribvoices and at Pambazuka News

It is impossible to talk about health care in Haiti without mentioning the 2010 earthquake and the subsequent cholera epidemic, which so far has affected 630,000 people and taken the lives of 7,500. It would be easy to believe that cholera was a direct result of the devastation of the earthquake and the heavy rains of June, July and August. In fact, the media spent much of 2010 speculating on the possibility of a medical epidemic.

Two million people were forced into overcrowded internally displaced camps (IDPs) where living conditions were appalling. People were traumatized and fearful of further earthquakes; even to mourn the dead was hard as the struggle to live became more difficult as months passed. Many women and girls, especially in the tent camps, were raped, and they lived with the fear of physical and sexual violence. Food and clean water were scarce; latrines dangerously inadequate; and sewers overflowed.

So why were so many health care providers and humanitarian aid agencies caught off-guard when in October 2010, the first cases of cholera began to appear? The answer to this question and others—such as why it spread so rapidly, who was responsible, and what has been the response—all serve as an excellent lens from which to examine health care and the socioeconomic realities of the UN/U.S. occupation of Haiti.

Cholera is an acute dehydrating bacterial infection spread through contaminated water and food.  The source of the contamination is human feces and the illness is exacerbated by poor sanitation, limited clean water, heavy rains and associated poor hygiene such as failure to wash hands after going to the toilet. Symptoms can be mild or severe with leg cramps; white, watery diarrhea; and profuse vomiting. They can appear within hours or over a period of days. However, once severe symptoms appear, rapid dehydration can lead to death for the most vulnerable—children, the elderly, pregnant women and those already malnourished and or suffering from chronic illness—in just a few hours. Treatment for most people is surprisingly simple: oral rehydration treatment [ORT] and in severe cases, an intravenous rehydration with antibiotics.  

I visited Haiti in November 2010 and by then cholera was already embedded in Haitian lives. Banners and posters announcing the dangers and prevention of cholera hung from streets and decorated what walls had been left standing. Radio and TV jingles blared out similar messages. Schools, camp committees and women’s organizations reinforced all these messages, whilst simultaneously trying their best to create hygienic environments and, most importantly, provide clean water. The SOPUDEP school did not escape cholera as many parents and students were taken ill. Their priority was to provide clean water through a mix of water treatment tablets and Clorox as well as to reinforce basic hygiene regimes—with 700 children it was not an easy task, and there were constant school closures as children or their parents were taken ill. Nonetheless, they were able to avoid a local epidemic. 

In the early hours one morning, a diabetic friend was rushed to the Médecins Sans Frontières [MSF] hospital in Martissant 26, which, at the time, was one of their cholera treatment centers [CTCs].  I arrived in the evening just as dusk was falling to visit my friend. As I waited outside, I watched as cholera patients came and were directed to the side entrance. Some walked, some were carried; frantic parents held a baby wrapped in a bundle, but visible enough to know she or he would die very soon; an elderly woman in a wheelbarrow passed by, shrunken and surely at the point of death. In Martissant 26, cholera was everywhere. It was unavoidable as vendors and customers vied with mountains of rotting refuse and pools of stagnant water lay amidst rubble and buildings destroyed by the earthquake.  

Prior to October 2010 there had been no cases of cholera in Haiti for nearly a century. The first hospitalized case was on October 17 in Mirebalais, in the region of Haiti’s longest river, the Artibonite. By October 22, cholera was confirmed and the outbreak spread to the costal areas of St Marc. The disease spread rapidly due to initial misdiagnosis, lack of Oral Rehydration Treatment [ORT], and an already overstretched medical infrastructure. Cholera was not the epidemic in waiting. The first responders to both the earthquake and the cholera outbreak were the Cuban brigade, who had been in Haiti since 1998 and were largely ignored by Western media, along with the well established MSF, also in Haiti for many years. At the start of 2013, these were the only two sizable medical teams left from those first 12 to 18 months.  From an initial 72 CTCs in 2010-11, MSF, which now accepts all cholera referrals as well as walk in patients, has just four CTCs. The CTCs are in Leogane (40 beds); Delmas 33 (80 beds); Carrefour (275 beds); and Cite Soleil/Drouillard (100 beds). 

In order to place Haiti’s health challenges in a global south context I asked Oliver Schulz, the head of the MSF mission in Haiti, how the country compares to African countries. He gave the example of the eastern Congo, where, in general, there is an existing structure and willingness by the Ministry of Health to get involved. So, within six months of starting a MSF cholera project, the ministry is already ready to take over. However, in Haiti, because the disease is new, and because there is neither the capacity nor the necessary health infrastructure, the government is unable to take over. However, as Schulz pointed out, the situation in Haiti is far more complex than simply pointing a finger at the government, as they simply do not have the necessary resources. In particular, Schulz was critical of the WHO and UN, whose role should be to support the government in developing a comprehensive health care infrastructure, yet despite years of talking, little has actually happened.

Says Shulz, “Even with cholera some of the things we discussed two years ago are still being discussed. I do not know how much they are involved in activities like plans etc but it seems to me that by now we should have a national health plan, and it seems to me normally the WHO supports the government in making such plans as that’s what they do in other countries.”

The problem with healthcare in Haiti is that there is no system, no structures, no plan—at least not one that has been implemented. What healthcare facilities exist are wholly inadequate—medical staff, support staff, equipment, and treatment are insufficient and left to medical NGOs such as MSF, the Cuban Brigade, and a few faith-based and charity clinics to provide. For example, there is one MSF hospital in Carrefour with 275 beds serving about 400,000 people. In Cite Soleil, the figures are similar. In addition to MSF hospital there is a public hospital, St Catherine’s , which like most government hospitals is staffed by excellent Haitian doctors but is rundown and under equipped. The Charity Mission runs a small hospice for HIV/AIDs patients and a few other small clinics that serve at least 250,000 people. Finally there is the Centre de Nutrition et Sante Rosalie Rendu, which has a pediatric clinic and sees up to 300 patients under five years of age per day. Many mothers travel across the city to reach the clinic. The round trip from, for example, Delmas to Cite Soleil can take up to four hours and three tap-taps at a price of about $2 - a long and costly journey. But the Haitian and American doctors are excellent and the clinic includes a nutrition center for malnourished children. The children attend the clinic everyday for six months, or until their weight and overall condition has improved. 

The public hospitals, including the country’s main teaching hospital and clinical and trauma referral center, L’Hôpital Université d’Etat d’Haïti (Haitian State University Hospital or HUEH), are in terrible condition and have effectively been abandoned by all those involved in running the country—the government, the UN, USAID and other country donors, and the NGOs. HUEH was partially damaged in the earthquake—150 nursing students were killed and two-thirds of the buildings destroyed. Even before the earthquake, it was not in great shape, and the rebuilding of HUEH was supposed to be a priority as shown in this 2010 proposal by Partners In Health [PIH].

Significant, strategic, and ongoing improvements to the comprehensive infrastructure, staffing, training, operations, and clinical practice of this central public health facility are investments in the future of all public health throughout Haiti. More immediately, HUEH is in a state of emergency. If conditions at the hospital are not improved in a matter of months, it will become the site of a second round of catastrophic deaths due to disease outbreak or total health system collapse. There has been a vision articulated by the Haitian leadership of the hospital, but they cannot implement it alone. Please join the effort to build Haiti back better by first investing in the health of Haiti’s people.

One medical improvement to HUEH that is exemplary of how things happen in Haiti is the TB clinic set up in 2010 by an American volunteer, Dr Coffee, and a group of Haitian nurses.  Since initially opening in 2010 and operating under tents, the clinic is now housed in a building and has cared for over 1000 patients.

Since 2004, when the Medical School of UNIFA (the University of the Aristide Foundation] was forcibly closed, HUEH has been the sole medical training center in Haiti. President Jean-Bertrand Aristide founded UNIFA in 1996 in order to ‘amply the voices of Haitian people’ by creating an inclusive educational space, providing educational activities from adult literacy to training doctors and nurses. In August 2011, the much-needed medical school reopened with 63 men and 63 women. 

In the politics of US imperialism in Haiti, Western media has ignored the contribution of UNIFA and the Cuban brigade doctors to the health infrastructure. I doubt this is by accident given the election of the puppet and Duvalierst, Michel Martelly, and the resurgent post earthquake neo-liberal agenda driven by the US, it’s allies, and NGOs. The rebuilding of the HUEH and other public health clinics has not taken the place of the new, state of the art Paul Farmer-led PIH University Hospital of Mirebalais [HUM], which has now opened. I asked a number of NGO personnel, doctors and Haitian activists why the HUEH has been abandoned yet the PIH NGO hospital has flourished. The response was always the same—“We ask the same question.”

No one would question the importance of HUM to Haiti’s health infrastructure. It is the largest post-earthquake project in the country and has taken three years to build. HUM has 300 beds, plus primary and secondary health care for up to 500 people a day. As a teaching hospital HUM along with UNIFA will provide doctors and nurses for Haiti. However, questions remain as to the location and who will have access to the hospital.  

There is no doubt that both the earthquake and cholera epidemic played a leading role in the funding and realization of the PIH project. One of the strengths of PIH founder Paul Farmer is that he is able to raise funds, especially since he became a spokesperson for “’the machine that drives Haiti.” When questioned by journalist Ansel Herz about the stalling of a wage increase from $3 to $5, Farmer, the new voice of the occupiers, also stalled, as he seemed to have forgotten his own treatise on ‘pathologies of power.’

The inadequate provision of healthcare for the poor in Haiti and elsewhere, as Farmer himself has written over and over, is due in large part to structural violence and a pathology of greed which has left over 2 million people food insecure; forces women into relationships which are detrimental and often abusive; and results in people dying needlessly of cholera or because they couldn't access simple surgery, as was the case for Elie Joseph

In February 2012, Elie Joseph was diagnosed with a heart murmur: a common congenital heart defect called ventricular septal defect [VSD] where the blood flows the wrong way, putting stress on the heart and lungs which can lead to infection. The charity Haitian Hearts, which sends children suffering from heart-related illnesses to the Dominican Republic or the US, arranged for Elie to travel to the Dominican Republic for the 15-minute procedure that would fix his heart. Elie received his travel documents but his mother did not, so he was unable to undertake the operation that would have required a four-hour surgery plus the follow-up treatment. In December 2012, Elie Joseph died from pneumonia in the tent at Aviation camp, where his parents still live three years after the quake. VSD is not a terminal illness, and Elie is one child out of thousands who have died needlessly as a result of structural violence.

The violence of poverty is multifaceted, so that even when healthcare is accessible, there are still other obstacles to overcome. Gladis* lives with her three children aged 6 months, 4 and 9 years, in a camp in Delmas 33.  She is fortunate because the camp is not too far from both the MSF cholera treatment center in Delmas 33 and the La Paz clinic run by Cuban doctors. Gladis came to Acra camp a few days after the earthquake with her two children. Her home in Tabarre was destroyed in front of her eyes and she wandered the streets for three days disorientated and traumatized, sleeping and walking with the children till eventually she came to Acra. At that time, there were no tents and people were sleeping in the open or under whatever makeshift covering they could find. It was about three months before the people at Acra were able to secure tents by reaching out to various NGOs themselves.

It was a dangerous time for women in particular as sexual violence was rampant; the only food and water was being handed out by NGOS; and residents had to queue for hours for supplies. Three years later, Gladis is hardly coping with her life, and its possible that only the support of her neighbors and the camp committee has kept her going. In October 2011 when she was about six months pregnant, Gladis caught cholera. It started in the morning and within a few hours she was unable to walk. Her neighbors gave her water with the RHT salts but these did not help. She had two problems. First, she would have to leave her children with neighbors – luckily her neighbors were trustworthy. Secondly, she had to get to the MSF treatment center. She was in no condition to travel by tap-tap or motorbike, and besides, she did not have the money. The only way was by car. Again, Gladis was lucky, as one of the camp leaders saw she was ill and suspected cholera. He had an old truck that just about ran and it was in this truck that Gladis, near death, was taken to the hospital, where she spent the next 15 days. 

Remembers Gladis, “I didn’t know what was happening until after some days. I saw they had put me in the last room where many people were dying and I thought I would die too. So many people died, I don't know how many, but every day they were dying…When I started to get better, I was able to eat. They gave us food sometimes three times a day.“

Although Gladis was released after 15 days, she was still suffering from headaches and running a fever. But for the MSF, her cholera had been treated and they needed the beds as new patients were arriving all the time. Gladis survived but she remains unwell, fearful, and hardly able to breast-feed her baby. Again this is just one story. Although I have heard many complaints from women about the public hospital and clinics, I have only ever heard good things about both the Cuban doctors, MSF, and the pediatricians at Sante Rosalie Lendu. 

The cholera epidemic is not over by far and once the rains start the numbers are expected to rise again. The estimates for 2013 are 118,000 cases of cholera.  To put these numbers in a global context, there were 160,000 cases in the whole of Africa in 2010 in a population of one billion people, compared to the 10 million in Haiti. I asked Oliver Schulz of MSF for his thoughts on the year ahead:

“My personal fear is that things will get worse before they get better. The structures are weaker today than in 2011/2012. Every year the structures deteriorate. There is no plan for cholera and without a WHO-supported comprehensive national health care plan with clear directives, clear action plans and milestones, it will not get better. Also, many of the big agencies have left and there are too many unknown NGOs, charities and faith groups”

Within weeks, suggestions began to appear that the origins of the cholera epidemic lay with the UN; specifically, with a Nepalese contingent based near the Artibonite river and spread through base toilets. Initially, the UN denied being responsible, however, there has been mounting evidence of  the UN being the source.  By October 2012, two years after the outbreak, the evidence against the UN was irrefutable.

"We can now say," Dr Lantagne said, "that the most likely source of the introduction of cholera into Haiti was someone infected with the Nepal strain of cholera and associated with the United Nations Mirabalais camp."    

In the hope of obtaining justice and reparations for the thousands of cholera victims, the Bureau des Avocats Internationaux [BAI] and the Institute for Justice and Democracy in Haiti [IJDH] filed a groundbreaking suit against the UN on behalf of 5,000 cholera victims.  In addition to insisting on accountability the suit makes the following demands on the UN:

•           Install a national water and sanitation system that will control the epidemic;

•           Compensate for individual victims of cholera for their losses; and

•           Issue a public apology from the United Nations for its wrongful acts.

The UN role in introducing cholera is one more abuse in a long list of violent acts against the Haitian people. From sexual abuse, rape, and cholera to the killing of innocent civilians, the UN is not held accountable. UN-appointed Special Envoy of Occupation Paul Farmer suggested, as early as December 2010, a vaccination program as part of a five-point intervention to halt the cholera epidemic. However, Haitians had little reason to trust a UN-led initiative even if it was supported by a world renowned physician. Three years later, the only evidence of improvement in Haitian healthcare is the teaching hospital at Mirebalais. More than anything, Haiti needs clean water—not just for cholera but also for a range of illnesses—and because everyone has a right to clean water. Provision of clean water however does not make money for pharmaceutical companies: being well does not make money for pharmaceutical companies. But a cholera vaccine every three years is highly profitable disaster capitalism at work. Rashid Haider explains the case against vaccination:

“The vaccines Shanchol and Dukoral contain large amounts of killed cholera bacteria, the latter having an additional component known as the recombinant B subunit of cholera toxin (rCTB). Both vaccines are two-dose oral vaccines that are taken with an interval of two weeks, and are meant to cause development of protection against cholera one week after the second dose.”

Harmon’s assumption that these vaccines are sixty to ninety percent protective for a period of two to three years does not concur with facts. The vaccine Shanchol, which is intended for field-testing soon in Haiti, offered a poor protection rate of only forty-five percent during the first year of surveillance in a large-scale field trial in India in 2006. Dismal results were also obtained in a large-scale field trial in Peru in 1994 when the two-dose vaccine Dukoral was tested.

The alternative argument for a national water and sanitation system is a far more sustainable and realistic solution to ending the epidemic and preventing new outbreaks. It is long-term, benefits everyone and responds to a range of preventable illness and improves the overall quality of lives.  

Sokari Ekine is a 2013 IRP New Media Fellow reporting from Haiti.

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