The State of Cholera, and Water, in Haiti

The orderlies' urgent shuffling broke the grim quiet of the cholera treatment center in Mirebelais, near the origin of the outbreak, as they rushed seventy-year-old Clercius Vileus in on a stretcher. A subsistence farmer, Vileus draws his water from a well near the Artibonite River. He knew it might be tainted, said the young man who brought him in, but it was the only water they had to drink. Vileus grew sick. But he was accustomed to stomach bugs, so he waited a day before coming into town for help. His eyes had an otherworldly glow, and the skin on his taught stomach stayed puckered into a wrinkly fold after Dr. Wesler Lambert reached out to pinch it: he was severely dehydrated. Without help, the doctor said, Vileus would probably be dead within hours.

This was in late November and we were a few hours drive from Port-au-Prince, where the spreading epidemic had added fuel to the fires of civil unrest then erupting. In the weeks ahead, a presidential election marred by widespread fraud would touch off more protests and riots that would shut down the city, which would prevent the clinics in the countryside from getting more supplies of IV fluid and antibiotics, which would later trigger a rush on supplies and new shortages in the capital when the protests ended.

At the time, the official death toll was around 1,000 people with more than estimated 20,000 infections. Health officials had tentatively announced the situation might be stabilizing. But that was misleading. Dr Lambert thought the numbers were low and would likely rise, because the assessment overlooked all those who never even made it to a clinic, and also because cholera appeared in cycles– plateaus followed by spikes, plateaus then more spikes – which would be the trend for months. Humanitarian agencies were rushing to expand their operations around the country—a job they later received a lot of credit for. They were asking for donations of supplies and money, trying to distribute chlorine and water purification tablets, and broadcasting instruction that cholera could be prevented by washing hands thoroughly and boiling water. The organization that Lambert works for, Partners in Health, joined Doctors Without Borders in criticizing a slow initial response from the humanitarians.

It was, he said, a case of too little, too late.

Today, the disease has killed more than 5,800 people.

That sentiment was reflected in a study by American researchers, published earlier this year in the medical journal The Lancet, which concluded that UN projections on the epidemic were too low because they failed to account for cholera transmission rates and trends, and various intervention measures have been debated without comparative estimates of their impact.

Consequently, the cholera epidemic is much bigger and likely to be much longer lasting than initially expected. Using mathematical models, the study predicts there could be nearly 800,000 cholera infections and 11,100 deaths between March and November of this year. That's nearly twice the estimate that the United Nations had put forward. They also concluded that recent decline in cases is a normal ebb and flow of the disease, not "indicative of successful intervention."

But the study predicted that a gradual improvement in access to clean water, along with distributing more antibiotics and vaccinating 10 percent of the population, could prevent some 3,700 more deaths.

The question of how cholera came to Haiti was still up for debate. Many Haitians blamed leaking pipes from a septic tank on a UN base near along the Artibonite River, just upstream from Mirebelais. The UN spokesman told me that an investigation had turned up no trace of cholera at the site, but that the link could not be conclusively proved or disproved. But there was plenty of circumstantial evidence. When I visited the base, which is inhabited by peacekeepers from Nepal, a major said he wasn't authorized to speak on the matter. Around the back of the base, there was a strong chemical odor beneath the pipes at the bank of the Artibonite. My driver said that, a few weeks before, there was a filthy stream running from the pipes into the water. Yves German, who owns the land the base is on, told me he had seen pigs rooting around in the muck there two years ago and had complained to the local mayor. People had been getting sick periodically for years, he said. But the first cases appeared downstream only days after a new contingent of peacekeepers arrived. The Center for Disease Control in Atlanta found that the strain is endemic in South Asia.

In May, a special UN panel commissioned by Secretary General Ban Ki Moon concluded that the "sanitation conditions at the Mirebalais [peacekeepers'] camp were not sufficient to prevent contamination of the Meye Tributary System with human fecal waste." Their report outlined clear recommendations for UN reform: all personnel and emergency responders coming from cholera endemic countries should get a prophylactic dose of antibiotics/be carefully screened for cholera; UN installations worldwide should treat waste on site before it is disposed; since cholera will be in Haiti for a long time, the UN should train health workers and expand distribution of rehydration salts to prevent deaths before victims can reach treatment centers; the UN and Haitian government should prioritize investment in piped, treated drinking water and sanitation throughout the country. In the meantime, they should expand chlorine treatment and waste removal, and continue to deliver clean water and remove waste in high-density population centers, including the homeless camps.

Still, the epidemic was not the fault of any one group or individual, according to the report, but a perfect storm of vulnerabilities in a country without water and sanitation infrastructure in many places. Developing that infrastructure around the entire country will be critical to combating cholera and other waterborne diseases; cholera will be killing Haitians until that happens. It's a long-term process, but one that experts and aid organizations say has been undermined by delays or all-out failures of international donors to pony up promised reconstruction funds, and by the expense of the relief effort itself.

Dr. Lambert agreed that the spread of the disease reflected a long history of neglect, including the government's health and sanitation failures, but also the gaps of an international relief effort that told people not to drink from the river without providing a realistic alternative. "One of the problems with NGOs is sometimes they like to work in an enabling environment where they have everything," he said. "But the reality is different." Just as the earthquake had exposed how little had been done to develop basic water and sanitation infrastructure in Haiti, especially outside the capital, the spread of cholera reflected the limits of relief efforts concentrated mostly in quake-impacted areas in Port-au-Prince.

"It's a common failure," he said. "It's my failure because I'm Haitian. I do as much as I can from a healthcare perspective. But it's [also] a failure of the international community. Since 1991, even since Jean Claude Duvalier, we have received billions from the international community. Look!" He wanted to know how the US and Canada could tolerate such a situation in Haiti, just "one and a half hours from Miami," he said. "We're the only country living in such conditions in the Caribbean.

Now the rainy season, which peaks in August and September, has brought a flood of new victims– often carried by relatives for hours on stretchers– streaming into treatment centers in rural areas. Partners in Health reported a fourfold increase in patients at their clinics in April and June, a timeframe in which 86,000 new cases appeared (a quarter of all the cases since the epidemic began).