After a magnitude 7.0 earthquake rocked Haiti in January, many experts worried that devastating outbreaks of infectious diseases would soon invade the region. In a nation where a large part of the population already lived without access to reliable sanitation and clean water, a disaster that further disrupted infrastructure seemed likely to lead to widespread infections, such as cholera, which spreads through feces-contaminated water. Although more than a million people are still living in tent encampments following the disaster, it was not until late last week that news of a potential cholera outbreak first emerged.
Some 259 people have died from the bacterial infection so far and another 3,342 have been sickened, according to Haiti's Ministry of Health, the BBC reports. Officials fear that the outbreak, which seems to have started around the Artibonite and Plateau Central regions, north of the capital, Port-au-Prince, could become endemic to the city, where about 89 percent of residents live in slums or slum-like conditions. Five people there have been diagnosed with the disease, according to the World Health Organization (WHO), but they likely contracted the illness before arriving in the capital.
"There are limited ways you can wash your hands and keep your hands washed with water in slums like we have here," Michel Thieren, an official from the Pan-American Health Organization, told the Associated Press.
The cause of the disease is the bacterium Vibrio cholerae, which releases a toxin that triggers severe diarrhea and rapid dehydration; both effects can quickly prove deadly. Cholera might sound like an ailment that was dispatched in 19th century, but it still infects some three million to five million people worldwide and kills at least 120,000 each year, mainly in India and sub-Saharan Africa.
Although the number of people who have died from the disease in Haiti is lower so far today than it had been over the weekend, the country is still bracing for further spread. "We are preparing ourselves for the worst case scenario, which is a cholera outbreak in the whole country," Michel van Herp, of Doctors Without Borders, told BBC News.
But why is the outbreak just now emerging in Haiti, and how is cholera still a global concern? Scientific American spoke with David Sack, a professor in Global Disease Epidemiology and Control at Johns Hopkins Bloomberg School of Public Health, to learn more about the disease and what is being done to control it.
[An edited version of the transcript follows.]
Why do you think this outbreak is happening now, more than nine months after earthquake?
I wish I knew more about the events that led to this outbreak. From what I can gather, the outbreak did not start in the area of the earthquake, so it's not clear that it is directly related to the earthquake. We don't know whether it was introduced or if the bacteria was indigenous to the area and had never been spread before.
Is the current outbreak likely linked to long-term use of these tent-based refugee camps?
The refugee situation makes it much more dangerous, but I'm not sure that's what started the outbreak. You need to have the organism there circulating first. And of course we haven't seen cholera in Haiti for many, many years. Even in the 1990s outbreak in Latin America, it did not jump across to the Caribbean islands.
So how is cholera usually spread?
It is fecal-oral. So the feces get into the food or water supplies, though mainly the water. There is also an environmental reservoir, so it usually starts in the environment.
Cholera can kill within a matter of hours. Who is most at risk for getting—and dying from—cholera?
Anybody can be at risk—it's one that can kill healthy people quickly. We usually think a lot of these diseases will preferentially hit the malnourished or otherwise vulnerable. But cholera is something that can affect anybody.
The main risk factors are people whose stomachs, for whatever reason, are not making the normal amounts of gastric acid—if someone has recently had stomach surgery or is taking drugs that inhibit the production of gastric acid. The other risk factors are genetic, which unfortunately there isn't much you can do about. If your blood type is O, you're at higher risk. When cholera struck Peru, the indigenous people there virtually all have blood type O, and they were at higher risk.
In terms of risk for death, it is people who don't have treatment available. If they don't get treatment in a very short amount of time, they have a very high risk of dying.
Are rehydration therapy and antibiotics the best treatments out there?
Yes. But what I have not seen is what the sensitivity pattern is for the antibiotics. We've seen in previous outbreaks that people don't know what the patterns are and they ship the wrong antibiotics.
So different antibiotics are needed to treat different strains of cholera?
Yes. That's why it's important to know the sensitivity of this strain. And you have to keep monitoring it because it could change in the future.
What are the best ways to keep the disease from spreading to more people? Is it mostly an issue of clean water?
There are different ways of making your water clean. One thing I haven't seen out there so far is consideration of the vaccine, which is available now. It has only been since March this year that the World Health Organization has recommended the use of the cholera vaccine on a wide scale. I think this is a situation where it might be considered.
From the numbers that have come out so far, it seems that there's been a mortality rate of roughly eight percent. Is that a pretty standard number of expected deaths?
Standard mortality should be zero. I've worked in Bangladesh for many years, and in our hospital, we treated thousands of patients, and nobody died of cholera. So no deaths are inevitable if you provide the right treatment.
Nobody's had much experience with it in Haiti, so case mortality rates become very high at first, but as facilities become more experienced and people learn where to get treatment, the case mortality rates should come down very quickly.
Cholera seems like a disease of the past—will it ever be eradicated?
No, because of its environmental reservoir. I don't see any way we could eradicate it like eradicating polio or smallpox. As long as you have an environment, you will have cholera.
How does Haiti's outbreak compare with others in recent years?
In Bangladesh, we have thousands of cases every year, but it doesn't make it into the newspapers because we have it every year.
Theoretically, governments and health ministries are supposed to report cases to WHO, but in general many of them don't do it at all. Cholera is a very sensitive subject. Many countries just don't want to report it for fear of its impact on trade and travel—and that used to be a reasonable fear, but I'm afraid now that they haven't been reporting it because it's become a tradition.
In the past we used to assume that cholera outbreaks would arise quickly then go away quickly—and by "quickly" I mean one to two months. But the outbreak in Zimbabwe a year ago has taught us that cholera outbreaks can persist for a year. I think it's becoming harder to predict how long we can expect this outbreak to persist.
Is that because we have a better understanding now about the outbreaks, or has there been a change in the disease spread itself?
It seems to be a difference in how it's transmitted, not so much our understanding. It's behaving differently now than it did in the past. Clearly it keeps changing its genetics. So, for example, recently the toxin that the organism produces has changed genetically, and it appears that the change has resulted in a more severe illness. But this organism is in the environment, and its genes are exchanged frequently with the environmental strains, so there's a lot of re-sorting that's going on. And when people get infected, the people themselves act as the amplifier and selector of the most virulent strain.
Independent human-rights experts who work for the United Nations and some academics allege that the UN is liable for the outbreak of the disease in Haiti in 2010. Here, a victim that year.
In September 2014, four United Nations human-rights experts wrote to Secretary-General Ban Ki-moon alleging that the UN had violated human rights through the cholera epidemic in Haiti, which broke out in October 2010. This is the first time that an allegation letter — a formal complaint procedure typically used against governments — has been filed against the UN. The letter and the UN’s response have, finally, been leaked to the public.
The 34-page response from the UN is the longest and most substantive explanation that the world body has provided so far on the cholera epidemic, despite years of questions from the media and rights groups on the UN’s responsibility on the matter.
It appears that the UN is much more willing to engage with and respond to human-rights experts than it is with the cholera victims and their legal representatives. In many respects, that is the most shocking discovery of the entire process: the UN feels more obliged to respond fully to independent experts than it does to the individuals affected by the epidemic.
Since October 2010, 731,880 cholera cases and 8,741 related deaths have been recorded through February 2015. The national cumulative death rate remains at 1.2 percent.
The four human-rights experts who wrote to Ban are part of the special procedures system in the UN human-rights machinery. Special procedures mandate holders are human-rights experts who are unpaid and undertake their duties part time; their independence from the UN and from states enables them to have legitimacy and credibility in their fact-finding, reporting, recommendations and other functions. The independence of mandate holders, combined with their significant expertise, makes them the crown jewel of the UN human-rights mechanisms.
The letter was written and signed by the experts on adequate housing (Leilani Farha); safe drinking water and sanitation (Catarina de Albuquerque); health (Dainius Puras); and Haiti itself (Gustavo Gallon). All four experts raised serious concerns and questions about the violations of Haitians’ human rights caused by the outbreak and failure to eradicate cholera in their country. All four also raised serious concerns and questions about the UN actions and failures to remedy the situation or provide redress to victims.
Ban, despite producing a lengthy response to the letter, failed to adequately address many of the crucial issues raised by the experts and by legal experts acting on behalf of the cholera victims. In particular, the UN has still not addressed the issue of victims’ right to a remedy and continues to insist that it was not responsible for systemic weaknesses and failures that took place on its watch.
The facts are well known. Cholera was introduced by Nepalese peacekeepers who had been inadequately tested for the disease despite the high incidence of cholera in Nepal. Cholera spread through raw feces flowing from a UN peacekeeping camp directly into a tributary of the Artibonite River in Haiti — a river that hundreds of thousands of people rely upon daily for drinking water and for bathing. The UN failed to contain the disease, with vaccination attempts occurring too late and not in sufficient numbers.
Not only have thousands of people have died and hundreds been infected, infections are still being recorded today. The number of cases and deaths registered in 2015 so far are actually higher than those recorded in the same period of 2014 and of 2012, says the World Health Organization.
The UN has steadfastly refused to set up commissions or boards to hear victims’ claims and has relied on absolute immunity as a shield from such claims being brought before the New York District Court.
It is clear from this latest leak of information that the UN is widely viewed as being not only liable for private law claims but also for human-rights violations. When the UN acts as a hybrid sovereign power in a country through a peacekeeping mission that is assuming state functions or roles, it must and should be held liable for human-rights violations in the same way that a state would be held liable. As cutting-edge legal academics are also insisting, the UN was for all intents and purposes the sovereign power (in all but name) during that time.
The allegation letter provided by the four independent human-rights experts demonstrates that the UN is in over its head if it thinks it can continue to ignore calls for justice for Haiti’s cholera victims. Just as an abusive government will eventually be held to account for violating rights and subjugating people, so too will the UN be held accountable for doing the same in Haiti.
[This essay was updated on April 23 to add the names of the four rights experts.]
Tags: Catarina de Albuquerque, cholera and Haiti, Dainius Puras, Gustavo Gallon, human-rights violations in Haiti, Leilani Farha, MINUSTAH, UN human-rights letter Haiti, UN response to cholera allegations, UN Secretary-General and cholera in Haiti, UN special rapporteurs, World Health Organization cholera rates