2010s Haiti cholera outbreak
The 2010s Haiti cholera outbreak was the first modern large-scale outbreak of cholera—a disease once considered beaten back largely due to the invention of modern sanitation. The disease was reintroduced to Haiti in October 2010, not long after the disastrous earthquake earlier that year, and since then cholera has spread across the country and become endemic, causing high levels of both morbidity and mortality.[5] Nearly 800,000 Haitians have been infected by cholera, and more than 9,000 have died, according to the United Nations (UN).[6] Cholera transmission in Haiti today is largely a function of eradication efforts including WASH (water, sanitation, and hygiene), education, oral vaccination,[7][8] and climate variability.[9] Early efforts were made to cover up the source of the epidemic, but thanks largely to the investigations of journalist Jonathan M. Katz and epidemiologist Renaud Piarroux,[10] it is widely believed to be the result of contamination by infected United Nations peacekeepers deployed from Nepal.[11] In terms of total infections, the outbreak has since been surpassed by the war-fueled 2016–2021 Yemen cholera outbreak, although the Haiti outbreak is still one of the most deadly modern outbreaks.[12] After a three-year hiatus, new cholera cases reappeared in October 2022.[13]
Date
Outbreak[edit]
Cholera is caused by the bacterium Vibrio cholerae that when ingested can cause diarrhea and vomiting within several hours to 2–3 days. Without proper treatment including oral rehydration, cholera can be fatal. The suspected source of Vibrio cholerae in Haiti was the Artibonite River, from which most of the affected people had consumed the water.[18] Each year, tens of thousands of Haitians bathe, wash their clothes and dishes, obtain drinking water, and recreate in this river, therefore resulting in high rates of exposure to Vibrio cholerae.[19]
The cholera outbreak began nine months after January 2010 earthquake, leading some observers to wrongly suspect it was a result of the natural disaster.[20][21] However, Haitians grew immediately suspicious of a UN peacekeeper base, home to Nepalese peacekeepers, positioned on a tributary of the Artibonite River.[22] Neighboring farmers reported an undeniable stench of human feces coming from the base, to the extent that local Haitians began getting their drinking water upstream from the base.[23] In response, United Nations Stabilization Mission in Haiti (MINUSTAH) officials issued a press statement denying the possibility that the base could have caused the epidemic, citing stringent sanitation standards.[24] The next day, 27 October 2010, Jonathan M. Katz, an Associated Press correspondent, visited the base and found gross inconsistencies between the statement and the base's actual conditions. Katz also happened upon UN military police taking samples of ground water to test for cholera, despite UN assertions that it was not concerned about a possible link between its peacekeepers and the disease. Neighbors told the reporter that waste from the base often spilled into the river.[25] Later that day, a crew from Al Jazeera English, including reporter Sebastian Walker, filmed the soldiers trying to excavate a leaking pipe; the video was posted online the following day and, citing the AP report, drew increased awareness to the base.[26] MINUSTAH spokesmen later contended that the samples taken from the base proved negative for cholera. However, an AP investigation showed that the tests were improperly done at a laboratory in the Dominican Republic, which had no prior experience of testing for cholera.[27]
For three months, UN officials, the U.S. Centers for Disease Control and Prevention (CDC), and others argued against investigating the source of the outbreak. Gregory Hartl, a spokesman for the World Health Organization (WHO), said finding the cause of the outbreak was "not important". Hartl said, "Right now, there is no active investigation. I cannot say one way or another [if there will be]. It is not something we are thinking about at the moment. What we are thinking about is the public health response in Haiti."[28] Jordan Tappero, the lead epidemiologist at the CDC, said the main task was to control the outbreak, not to look for the source of the bacteria and that "we may never know the actual origin of this cholera strain."[29] A CDC spokesperson, Kathryn Harben, added that "at some point in the future, when many different analyses of the strain are complete, it may be possible to identify the origin of the strain causing the outbreak in Haiti."[23]
Paul Farmer, co-founder of the medical organization Partners In Health, and a UN official himself who served Bill Clinton's deputy at the Office of the Special Envoy for Haiti, told the AP's Katz on 3 November 2010 that there was no reason to wait. Farmer stated, "The idea that we'd never know is not very likely. There's got to be a way to know the truth without pointing fingers."[23] A cholera expert, John Mekalanos, supported the assertion that it was important to know where and how the disease emerged because the strain is a "novel, virulent strain previously unknown in the Western Hemisphere and health officials need to know how it spreads."[23]
Some US professors have disagreed with the contention that Nepalese soldiers caused the outbreak. Some said it was more likely dormant cholera bacteria had been aroused by various environmental incidents in Haiti.[30] Before studying the case, they said a sequence of events, including changes in climate triggered by the La Niña climate pattern and unsanitary living conditions for those affected by the earthquake, triggered bacteria already present in the water and soil to multiply and infect humans.[30]
However, a study unveiled in December and conducted by French epidemiologist Renaud Piarroux contended that UN troops from Nepal, rather than environmental factors, had started the epidemic as waste from outhouses at their base flowed into and contaminated the Artibonite River.[31] A separate study published in December in the New England Journal of Medicine presented DNA sequence data for the Haitian cholera isolate, finding that it was most closely related to a cholera strain found in Bangladesh in 2002 and 2008. It was more distantly related to existing South American strains of cholera, the authors reported, adding that "the Haitian epidemic is probably the result of the introduction, through human activity, of a V. cholerae strain from a distant geographic source."[32]
Under intense pressure, the UN relented, and said it would appoint a panel to investigate the source of the cholera strain.[33] That panel's report, issued in May 2011, confirmed substantial evidence that the Nepalese troops had brought the disease to Haiti. The U.S. Centers for Disease Control and Prevention (CDC) utilized DNA fingerprinting to tests various samples of cholera from Haitian patients to pinpoint the specific strain of cholera found in Haiti. During an epidemiological outbreak investigation, DNA fingerprinting of bacteria can be extremely helpful in identifying the source of an outbreak. The results of the CDC tests showed that the specific strain of cholera found in samples taken from Haitian patients was Vibrio cholerae serogroup O1, serotype Ogawa, a strain found in South Asia.[34] This specific strain of cholera is endemic in Nepal, therefore supporting the Haitian suspicion that Nepalese peacekeepers were the source of the outbreak. However, in the report's concluding remarks, the authors stated that a "confluence of circumstances" was to blame.[34]
Rita Colwell, former director of the National Science Foundation and climate change expert, still contends that climate changes were an important factor in cholera's spread, stating in an interview with UNEARTH News in August 2013 that the outbreak was "triggered by a complicated set of factors. The precipitation and temperatures were above average during 2010 and that, in conjunction with a destroyed water and sanitation infrastructure, can be considered to have contributed to this major disease outbreak."[35]
In August 2016, after Katz obtained a leaked copy of a report by United Nations Special Rapporteur Philip Alston,[36] Secretary General of the United Nations Ban Ki-moon accepted responsibility for the UN's role in the initial outbreak and stated that a "significant new set of U.N. actions" will be required to help solve the problem.[2] In 2017, Katz also revealed the existence of emails that showed that "officials at the highest levels of the U.S. government were aware almost immediately that U.N. forces likely played a role in the outbreak". Katz reported that these emails showed "multiple federal agencies, from national security officials to scientists on the front lines, shielded the United Nations from accountability to protect the organization and themselves".[37]
Reactions[edit]
At the beginning of the outbreak, widespread panic regarding the virulence of the disease and the UN's denial of the blame caused increased tension between the UN and the Haitian community. On 15 November 2010, a riot broke out in Cap-Haïtien following the death of a young Haitian inside the Cap-Haïtien UN base and rumours that the outbreak was caused by UN soldiers from Nepal.[38] Protesters demanded that the Nepalese brigade of the UN leave the country.[39] At least five people were killed in the riots, including one UN personnel.[40] Riots then continued for a second day.[41] Following the riots, the UN continued their position that the Nepalese soldiers were not to blame, and rather said that the riots was being staged for "political reasons because of forthcoming elections", as the Haitian government sent its own forces to "protest" the UN peacekeepers.[42] According to one author, rather than confront the inescapable conclusion that the UN was indeed the cause, "the world's preeminent humanitarian organization continued to dissemble."[43] During a third day of riots, UN personnel were blamed for shooting at least five protestors, but denied responsibility.[44] On the fourth day of demonstrations against the UN presence, police fired tear gas into an IDP camp in the capital.[45]
The outbreak of cholera became an issue for Haitian candidates to answer in the 2010 general election.[46] There were fears that the election could be postponed. The head of MINUSTAH, Edmond Mulet said that it should not be delayed as that could lead to a political vacuum with untold potential problems.[47]
In November 2011, the UN received a petition from 5,000 victims for hundreds of millions of dollars in reparations over the outbreak thought to have been caused by UN members of MINUSTAH.[48] In February 2013, the United Nations responded by invoking its immunity from lawsuits under the Convention on the Privileges and Immunities of the United Nations.[49] On 9 October 2013, Bureau des Avocats Internationaux (BAI), the Institute for Justice & Democracy in Haiti (IJDH), and civil rights lawyer Ira Kurzban's law firm Kurzban Kurzban Weinger Tetzeli & Pratt, P.A.(KKWT) filed a lawsuit against the UN in the Southern District of New York.[50] The lawsuit was dismissed, but an appeal was filed in the Second Circuit.[51] In October 2016, the Second Circuit Court of Appeals upheld the United Nations' immunity from claims.[52] On 11 March 2014, a second lawsuit was filed, Laventure v. United Nations, in the Eastern District of New York, on behalf of more than 1,500 victims of the disaster.[53] In an opinion piece in the Wall Street Journal, an attorney for the plaintiffs wrote:
"Imagine if the United Nations killed thousands on the streets of New York. Or London. Or Paris. And sickened nearly a million more. Would the U.N. claim it was not liable? Of course not. The international community wouldn't allow it."[54]
A lead lawyer for the plaintiffs also noted that the lawsuit was different from the one filed by the IDJH, in that it alleged that liability had been accepted by the U.N. in the 1990s. The lawyer stated that immunity: "should not be a shield to hide behind because the United Nations (or the U.S. government) doesn't like the price tag that comes with the U.N.'s indisputable gross negligence in this case."[55]
This case, too, was dismissed by the U.S. District Court,[56] and the Court of Appeals.[57] The appeal is currently before the United States Supreme Court.[58]
In December 2016, the then UN Secretary-General Ban Ki-moon finally apologized on behalf of UN, saying he was "profoundly sorry" for the outbreak.[59] The Secretary-General promised to spend $400 million to aid the victims and to improve the nation's crumbling sanitation and water systems. As of March 2017, the UN has come through with only 2 percent of that amount.[60]
Morbidity and mortality[edit]
Domestic[edit]
On 21 October 2010, the Haitian Ministry of Public Health and Population (MSPP) confirmed the first case of cholera in Haiti in over a century.[5] The outbreak began in the rural Center department of Haiti,[34] about 100 kilometres (62 mi) north of the capital, Port-au-Prince. By the first 10 weeks of the epidemic, cholera spread to all of Haiti's 10 departments or provinces.[61] It had killed 4,672 people by March 2011[62] and hospitalized thousands more.[18] The outbreak in Haiti was the most severe in recent history prior to 2010; the World Health Organization reported that from 2010 to 2011, the outbreak in Haiti accounted for 57% of all cases and 45% of all deaths from cholera worldwide.[63]
By January 2013, more than 6% of Haitians acquired the disease.[64] The highest incidence of cholera occurred in 2011 immediately following the introduction of the primary exposure. The rate of incidence slowly declined thereafter, with spikes resulting from rainy seasons and hurricanes. As reported by the Haitian Health Ministry, as of August 2012, the outbreak had caused 586,625 cholera cases and 7,490 deaths.[65] According to the Pan American Health Organization, as of 21 November 2013, there had been 689,448 cholera cases in Haiti, leading to 8,448 deaths.[66] While there had been an apparent lull in cases in 2014, by August 2015 the rainy season brought a spike in the number of cases. At that time more than 700,000 Haitians had become ill with the disease and the death toll had climbed to 9,000.[67] As of March 2017, around 7% of Haiti's population (around 800,665 people) have been affected with cholera, and 9,480 Haitians have died.[68] Latest epidemiological report by WHO in 2018 indicate a total of 812,586 cases of cholera in Haiti since October 2010, resulting in 9,606 deaths.[69]
However, a 2011 serological survey indicated that a large number of patients may have not been diagnosed: while only 18% of over a 2,500 respondents in a rural commune reported a cholera diagnosis, 64% had antibodies against it.[70][71]
International[edit]
The first case of cholera was reported in the Dominican Republic in mid-November 2010,[72] following the Pan-America Health Organization's prediction.[73] By January 2011, the Dominican Republic had reported 244 cases of cholera.[74] The first man to die of it there died in the province of Altagracia on 23 January 2011.[74][75] The Dominican Republic was particularly vulnerable to exposure of cholera due to sharing a border with Haiti, and a large Haitian refugee population displaced following the 2010 earthquake. As of the latest epidemiological report by WHO in 2018, there has been a total of 33,188 cases of cholera in the Dominican Republic resulting in 504 deaths.[69]
In late January 2011, more than 20 Venezuelans were reported to have been taken to hospital after contracting cholera after visiting the Dominican Republic.[76][77] 37 cases were reported in total.[74] Contaminated food was blamed for the spread of the disease.[78] Venezuelan health minister Eugenia Sader gave a news conference which was broadcast on VTV during which she described all 37 people as "doing well".[74] The minister had previously observed that the last time cholera was recorded in Venezuela was twenty years before this, in 1991.[74]
In late June 2012, Cuba confirmed three deaths and 53 cases of cholera in Manzanillo;[79] in 2013 there were 51 cases of cholera reported in Havana.[80] Vaccination of half the population was urged by the University of Florida to stem the epidemic.[81][82]
Vulnerabilities[edit]
Infrastructure[edit]
Before the outbreak, Haiti suffered from relatively poor public health and sanitation infrastructure. In 2002, Haiti was ranked 147th out of 147 countries for water security.[83] As of 2008, 37% of Haiti's population lacked access to adequate drinking water, and 83% lacked improved sanitation facilities.[84] As such, families often obtain their water from natural sources, such as rivers, that may be contaminated with V. cholerae. Poor sanitation infrastructure allows cholera bacterium to enter these waterways. Persons are subsequently infected via the fecal-oral route when the water is used for drinking and cooking, and poor hygiene often contributes to the spread of cholera through the household or community.[85] There is also a chronic shortage of health care personnel, and hospitals lack adequate resources to treat those infected with cholera— a situation that became readily apparent after January 2010 earthquake.[86] Insufficient water and sanitation infrastructure, coupled with a massive earthquake in 2010, made Haiti particularly vulnerable to an outbreak of waterborne disease.[87]
Physiological[edit]
Malnutrition of the population, another pre-existing condition that was exacerbated by the earthquake, may have also contributed to the severity of the outbreak.[16] Research from previous outbreaks shows that duration of diarrhea can be prolonged by up to 70% in individuals suffering from severe malnutrition.[88] Furthermore, Haitians had no biological immunity to the strain of cholera introduced since they had no previous exposure to it. Therefore, physiological factors including malnutrition and lack of immunity may have allowed cholera to spread rapidly throughout the country.[8]
Information[edit]
Lack of information and limited access to some rural areas can also be a barrier to care. Some aid agencies have reported that mortality and morbidity tolls may be higher than the official figures because the government does not track deaths in rural areas where people never reached a hospital or emergency treatment center.[89] Limitations in the data from Haiti stem from a lack of pre-outbreak lack of surveillance infrastructure and laboratories to properly test samples and diagnose cases.[90] Haiti was tasked with developing surveillance systems and laboratories after the 2010 earthquake and cholera outbreak which caused difficulties tracking the progression and scale of the outbreak. Because of the lack of established surveillance, much of the case report data is anecdotal and potentially underestimated. Also, because of lack of laboratory confirmation for the vast majority of cases of cholera, it is possible that other diarrheal diseases were being falsely classified as cholera.[16]
Environmental[edit]
Rainy seasons and hurricanes continue to cause a temporary spike in incident cases and deaths. Moreover, as a result of global warming and climate change, Haiti is at an increased risk of cholera transmission. The Intergovernmental Panel on Climate Change (IPCC) advances that global warming between 1.5–2 degrees Celsius will very likely lead to an increase in frequency and intensity of natural disasters and extreme weather events.[91] Resource-poor countries are poised to be affected more so than more developed and economically secure countries.[91]
Environmental factors such as temperature increases, severe weather events, and natural disasters have a two-fold impact on the transmission potential of cholera in Haiti: 1) they present conditions favorable to the persistence and growth of V. cholerae in the environment, and 2) they devastate a country's infrastructure and strain public health and health care resources.[9] An exhaustive study into environmental factors influencing the spread of cholera in Haiti cites above average air temperatures following the earthquake, "anomalously high rainfall" from September to October 2010, and damage to the limited water and sanitation infrastructure as likely converging to create conditions favorable to a cholera outbreak.[9]