A painting commissioned by Oxfam reminds people to purify their water before drinking it. Image by Meghan Dhaliwal. Haiti, 2012.
Graffiti blames UN peacekeepers for cholera outbreak. Image by Meghan Dhaliwal. Haiti, 2012.
A wall outside the construction site for a new cholera treatment center in Verrettes is plastered with flyers from DINEPA, the nation's water supply and sanitation institution. Image by Meghan Dhaliwal. Haiti, 2012.
Graffiti depicts a United Nations plane next to symbols of death. Image by Meghan Dhaliwal. Haiti, 2012.

If you find yourself in Haiti today, chances are you won’t see cholera if you’re not looking for it. You will not see bodies lining the roadside, ready to be buried. You will not watch as the sickest hang limp in the arms of loved ones on the back of moto-taxis as they look for an empty bed at a cholera treatment center. But cholera has not disappeared from Haiti.

Subtle, or not so subtle, reminders sit on concrete walls, scrawled in graffiti: "Aba MINISTA" and "MINISTA=Kolera" (Kreyol for "Against MINUSTAH [UN Peacekeepers]" and "MINUSTAH=Cholera"). Colorful paintings on the sides of buildings commissioned by Oxfam International with the words “Pou Pwotege Nou Kont Kolera” remind people to purify their water before drinking it. Hospitals have broken ground to create permanent cholera treatment centers (CTCs)—the temporary white tents that sprung up in the wake of an unexpected epidemic are almost a thing of the past.

Nearly two years after the initial outbreak, Haitians are adjusting to life with the ominous and ever-present cholera. The panic is subsiding as the disease becomes endemic to the environment—a new fixture in the long list of risks plaguing everyday life in Haiti.

Cholera appeared in Haiti in October 2010 with cases spiking along the banks of the Artibonite, the country’s longest river. The disease spread rapidly through the country, claiming over 3,000 lives and affecting all ten of the country’s departments in the first three months of the outbreak. News coverage showed dramatic scenes of hospitals overflowing with patients, faces gaunt and skin ashen from the extreme dehydration brought on by the water-borne bacteria. The disease, which hadn’t been recorded in Haiti in over a century, caused widespread alarm among both the public and the medical community.

In the rural Artibonite Valley, the staff of Hôpital Albert Schweitzer experienced the devastating effects of the cholera outbreak from the very start. From October 17, 2010 through October 31, 2011, a total of 7,114 patients were admitted to their CTC. According to CTC admission statistics, the hospital treated 7 percent of all estimated cases in the Artibonite region in that year-long span.

Medical Director Silvia Ernst likened the influx of patients during the first rainy season after the outbreak to flipping on a light switch. Because cholera is a water-borne illness, seasonal rains make the disease more mobile. The Schweitzer hospital peaked with a daily admission of 132 new cases per day to its CTC during that rainy season, occurring from June 2011 to August 2011.

This summer marks the second rainy season since the disease made its first appearance in the country, and everyone was braced for the worst. When the rains arrived early, starting in April 2012 instead of May, case numbers began to rise. According to data from Medecins Sans Frontieres (Doctors Without Borders), the most dramatic spike in cases in the Port-au-Prince area occurred from the end of April to the end of May. Numbers rose from 384 cases during the 16th week of the year to 976 during the 18th week, peaking with 1,428 during the 21st week.

At the Schweitzer hospital in early July, just barely a month and a half after a spike in cases in the more urban Port-au-Prince area, their CTC, as well as the CTC in neighboring Verrettes, sits empty. The rains have slowed, almost stopped completely save for a few violent thunderstorms, and thus the spread of cholera has been halted. But this lack of rain is no reason to celebrate—the crops aren’t getting enough water and the farmers in the area are worried.

Dawn Johnson, the technical coordinator of the hospital’s Integrated Community Services Division, works closely with many of these farmers and their families in implementing public health practices, such as hand-washing and drinking purified water to prevent the spread of cholera. However, getting people to stick to these practices proves difficult.

“People have heard the message, but how many of those people have been able to take that message and allocate scarce resources to act on it?” asks Johnson. On the day I visited, Johnson met with a family who has a latrine behind their house that they use diligently. Their neighbors, however, experienced technical difficulties when digging their latrine and abandoned the project before completion—they continue to use the field next to their house as a bathroom.

“Even if people do everything right, someone else might not…so what is the point?” said Johnson, attempting to demonstrate the mindset of so many people in the Artibonite region.

With a complete lack of water and sanitation infrastructure, people in Haiti have long been at risk for contracting water-borne illnesses. But before October 2010, cholera never showed up in the menagerie of diseases endemic to the country. The disease was allegedly introduced to Haiti when a sewage leak from the base of Nepalese United Nations peacekeepers made contact with the Artibonite River. The UN denies responsibility for the outbreak, but laboratory testing has found that the strain of cholera in Haiti is native to Southeast Asia.

Fifteen thousand Haitians who have either had cholera themselves or lost a family member to the disease are pursuing a legal case against the UN. Filed in November 2011, the case is seeking water infrastructure for the country, reparations for the individual victims, and an apology from the UN to the people of Haiti. The UN has not responded to the case yet, but lawyer and director of the Institute for Justice and Democracy in Haiti Brian Concannon hopes this is the case that is “too big to fail.” UN responds, those 15,000 Haitians must continue to go about their lives—some with gaping holes in their family and some with residual health problems from the cholera. They wait in limbo.

Since October 2010, 586,625 people in Haiti have fallen ill with cholera, and 7,490 of them have died according to data from the Haitian Health Ministry. In June 2012 alone, 24,694 people were recorded sick with the disease.

But life in Haiti continues as the country tries to stabilize itself after the unanticipated blow of cholera. Routines are changing—slowly. More water is chlorinated or purified before drinking, more latrines are used, and more hands are washed. The bright Oxfam paintings and chicken-scratch graffiti remain, as does the disease that gave them their raison d’etre.

Project

Before the international response to the earthquake of 2010 one challenge Haiti didn't face was cholera. Now it does, with 7,000 already dead and a continuing challenge for the entire country.

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