Cholera, Global Health, Public health concern

Questioning Ban Ki Moon’s plan to address cholera in Haiti

Lately, a spotlight has been placed on the United Nations in Haiti. Outgoing Secretary-General, Ban Ki-Moon has delivered pivotal statements at the General Assembly and via the Miami Herald concerning the UN’s response to the cholera epidemic in Haiti. Right now is as good a time as any to remember the critical work that has already been done to eliminate the disease, long before Ban Ki-Moon’s big statement.  Right now is as good a time as any to remember the fact that Haiti’s future lies only in our own hands.

Before 2010, cholera, which mostly affected Asia and Europe centuries ago, did not exist in Haiti. It was imported from Nepal in October 2010 because of the continuous dumping of feces into a river by UN peacekeepers based in Meyes, near Mirebalais, in central Haiti. Weak hygiene and sanitation conditions since the beginning of the last decade, partly due to political instability, facilitated the rapid spread of the disease to the rest of the country. This shows the UN’s direct responsibility in the emergence of the disease in Haiti, a claim which epidemiologists have backed, and which the UN has fiercely denied and hidden over the last few years.

In 2016 the United Nations has suddenly changed their posture in regards to their role in the spread of cholera in Haiti and their response to the epidemic. The first hint at this change of heart came in a report by Philip Alston, a UN adviser criticizing the organization for its disastrous response. “The UN’s explicit and unqualified denial of anything other than a moral responsibility is a disgrace,” he stated. In early December this year, 6 years and thousands of deaths later, Ban Ki-Moon apologized to the Haitian people for the role his organization played in bringing cholera to Haiti.

In his Miami Herald Op-Ed, Ban Ki-Moon revealed the outline for what he called a “new approach to right a wrong” in Haiti. This approach revolves around intense response to outbreaks, reparations to the victims’ families, and long term development strategies to provide safe water to the population. As a physician familiar with the Haitian government’s already laid out plan to eliminate cholera by 2022 and the ongoing instrumental work of human rights advocates to hold the UN accountable, I struggled to find what was new about this proposal. Is the UN simply publicly parroting the existing national plan to eliminate cholera, or are they finally heeding the victims’ unceasing call for justice?

At the beginning of 2013, while the United Nations was still denying responsibility for the outbreak, the Haitian government with support from various international partners, initiated a 10-year cholera elimination plan, with a short-term component ending in 2016. At the time, many criticized this plan as being too broad. Among other things, it aimed to guarantee access to drinking water for 80% of the population. That was quite impossible in the planned timespan, given the lack of resources.

In fact, in 2014, Haiti came close to eliminating cholera. Were it not for repeated cases of vandalism on water systems in several regions among other factors, the strategies put in place would have been successful. The Ministry of Public Health and Population (MSPP) and the National Direction for Drinking Water and Sanitation (DINEPA) have learned from these experiences, and launched the mid-term part of the plan in August 2016 (before the UN’s change of stance ) with support from partners including UNICEF. This part focuses on axes similar to what Ban Ki-Moon introduced as the UN’s new approach: water and sanitation, healthcare services and management, epidemiological surveillance, health promotion, hygiene and nutrition.

While he did acknowledge the ongoing efforts against the cholera epidemic, the public health orientation Ban Ki-Moon outlined in his op-ed is not different from what has been laid as the basis for every actor in the national plan. His proposal uses the language and solutions proposed by advocates that the UN spent the last 6 years denying. Looking back, the path we have traveled in this fight is paved with lessons for Haiti as well as for the world. The General Assembly has agreed to support the new plan to eliminate cholera in Haiti, but I will not forget where the crucial work began and continues. As I continue my travels through various Haitian communities as a Haitian public health researcher or for personal activities, the notion that Haiti’s future lies only in our hands will remain a dear mantra.

Many thanks to Nathalie Cerin for the fantastic editing of this article.

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Cholera, Global Health, Public Health, Public health concern

A Path to Fighting Cholera in Haiti After Hurricane Matthew

The rain was pouring as the car rolled towards Hinche. Kal and I were leading a team of doctors and researchers on a week-long investigation of factors related to the cholera epidemic in Haiti’s Center department a few weeks ago. As we went along the road, we could only look as far as five meters ahead due to heavy rainfall. I vaguely recalled hearing of a Hurricane Matthew forming in the Atlantic Ocean a few days before. The rain beating down on the area known as the “Bas Plateau” (Southern region of the Center) gave me a glimpse of the massive environmental and health consequences such a hurricane would bring to Haiti. My anxiety increased knowing that this specific department was the first, and one of the most severely, affected by the cholera epidemic ever since it was introduced in Haiti in 2010 due to improper waste management by UN peacekeepers.

Hurricane Matthew mostly devastated Haiti’s Deep South, affecting nearly 80% of homes in Jeremie, a coastal town in Grand Anse. Crops, livestock and drinking water systems also perished. As foreseen by health authorities and the population, outbreaks of cholera, which is endemic in Haiti seem to have quickly risen in several localities of the South peninsula. In light of my experience on the field in the Center, I propose a few strategic insights pertaining to cholera elimination in the aftermath of this disaster.

Decision making and public health interventions are more likely to be successful when they include members of the community served.

That is to say, the people from there who hold an attachment to that particular region, who maintain hope in the face of adversity and challenges as in post-Matthew Haiti. In my opinion, the water and sanitation technicians of the municipalities known as TEPACCs embody this idea. They are residents of the respective communities they serve. Oftentimes university students or local professionals, they are responsible for listing water sources and oversee the management of sanitation structures in the most remote areas of the country. The TEPACCs are widely responsible for the safety of the water consumed by most of the population and ensuring that waste is properly disposed.

These workers are familiar with all the localities and their physical and structural characteristics. During our time in Mirebalais, the TEPACCs Grandin and Cameau,  guided us to the remote areas, and informed us on the unspoken truths of these places where cholera has remained for 6 years. The cholera efforts and results all around the country would be far more effective if they were provided the necessary equipment they often lack such as, motorcycles so they can access remote areas easier, computers and cellphones to facilitate communication. In the aftermath of Hurricane Matthew because so many water sanitation structures have been destroyed, offering more resources to the TEPACCs is crucial.

The epidemic situation in the Center also reveals the vulnerability of specific regions where cholera persists in Haiti. Floods may have worsened the contamination of water sources in the South, as shown by more than four hundred suspected cholera cases, unconfirmed as of this writing. However, the focus should not be taken off previously identified zones of cholera persistence such as specific towns or regions in the North, Center, Artibonite and West even when they were not the strongly affected by Hurricane Matthew. Studies show that these zones of persistence play an important role in re-emergence of cholera during the rainy season because the transmission lingers even during the dry season. The increased cases during the rainy season such as the situation in Randel (South) right now- where an outbreak erupted even before the hurricane- is nothing but a mere consequence of cholera enduring in Haiti for 6 years. So, in addition to the added risk that Hurricane Matthew brought, these preexisting persistence zones remain the pressure points on which our attention should remain if we hope to eliminate Cholera on the island.

The reconstruction of water systems and protection of sources should indeed take into account these towns whose vulnerability have not decreased after Matthew. In Mirebalais, I visited a Cholera Treatment Centre (CTC) where there were more than a hundred cases in the last three days at the time of my visit. An officer of an international organization working with outbreak response teams on the field reminded me that the epidemic had been raging long before the hurricane. It is imperative that we do not forget that.

 

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La Theme River. Photo credit: Karolina Griffiths

In such a context, I do not share the opinions of some of my colleagues who dismiss the importance of vaccination, thinking it would be a waste of time, money and energy. As a matter of fact, the World Health Organization pledged one million vaccine doses to Haiti that 500,000 people could benefit from. Vaccinations may not the cure to the epidemic, but they can help save precious time and resources while we focus on strengthening our response capacity to outbreaks, improving access to safe water and sanitation, and educating at-risk populations especially in a post-disaster context. Education is crucial for behavior change, because many still believe that “cholera is spread through the air.” One man told us these words right before he nonchalantly dove in the Artibonite River that visibly contains dirt and sewage from the marketplace, the slaughterhouse and the prison.

The effects of Hurricane Matthew will be long term. The challenges of eliminating cholera by 2022 are uncountable. Based on my experience in research on the determinants of the cholera epidemic in the Center department alone, I foresee the benefits of strengthening the TEPACCs in their role, keeping epidemiologic surveillance in known areas of cholera persistence in Haiti and seizing this opportunity to vaccinate at-risk populations to prevent new cholera infections. This will be a heavy task, but this is a time where we, as a people, cannot afford to sink into fatalism or complacency. Hurricane Matthew is surely a step back, but it is also an opportunity to push Haiti forward towards progress and sustainability.

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Cholera, Public Health

Improving Haiti’s Healthcare System

Haiti’s public hospitals serving the country’s poorest have gone on strike twice in the last 12 months, in the midst of a deadly epidemic. The media was still reporting on the distressing aftermath of the earthquake, when an outbreak of cholera broke in Haiti’s Center and Artibonite departments. As of last year, six years since its outbreak, approximately 40,000 people have fallen ill. In September, I visited a cholera treatment center in Belladeres, a border town in Haiti’s Central-east which was home to many cases. During this trip and our visits, I was reminded how much of a burden such outbreaks are on an already weak healthcare system. The impact is heavier in isolated towns and villages, where resources are often scarce. The route, from the epidemic’s very start to the current phase where the incidence is the lowest since 2014, has been paved with lessons that could benefit the entire system.

Improving leadership and management. As a medical student back in 2012, I found myself hanging onto every word of Dr. Junot Felix addressing an inquisitive audience during a conference. As a senior public health professional, he stated that “the biggest obstacle facing Haiti’s healthcare system is a lack of competent managers”. As both management and leadership are vital to progress, his statement hinted that Haiti needs more people who are willing to highlight the best in each other and organize to provide the best possible care to the population.

Large and inclusive conversations need to happen between actors from public, private and NGO sectors- regardless of their many differences and priorities- to create liaisons, learn from each other about what has worked in the past, how to handle the current reality and bring forth solutions for the future. This is the type of collaboration that took place in elaborating and executing the plan to battle cholera.

Multi-sector workshop on cholera in Mirebalais, Haiti

Multi-sector workshop on water and sanitation and cholera in Mirebalais, Haiti

Gather and share timely information. When I started working as a practitioner, in a private clinic, I was forced to work while in the dark about crucial information. National health data was either unavailable to me or outdated. I could not accommodate my practice effectively to special trends, especially when it comes to transmissible diseases. This is also the case for State institutions and many NGOs, entities charged with gathering and sharing information at different stages of their programs to contribute to the management of prevalent health issues in Haiti.

Such weaknesses have also affected the war on cholera, where sharing timely information is oftentimes as crucial as setting an IV line. But thanks to the cooperation between the actors in charge of responding to the epidemic, the situation is slowly improving. Were it not for constant efforts to initiate and preserve this synergy, project management and delivery of care and services would be ineffective and resources, used inadequately.

Monitoring sheet, provided by the Haitian Health Ministry, to report new episodes of diseases in hospitals and health centers

Develop an entrepreneurial culture. I have been following Daniella Bien-Aime, a blogger who strongly advocates for an entrepreneurial culture to counterbalance the aid perspective in Haiti. In my opinion, this would also benefit the health sector which is almost entirely funded by international donors. Although international aid has been pivotal to improve health indicators in Haiti in recent past, it is not sustainable for an autonomous healthcare system. International aid leaves little to no place for innovation and competition, and kills local initiatives at an embryonic stage. This is in part why doctors, nurses, midwives, pharmacists and laboratory scientists seek NGOs jobs, abandoning State hospitals and local clinics, or simply leave the country.

Promoting local initiatives either in Port-au-Prince and outside is the first step in instilling this paradigm shift. Raising awareness is one thing but proper training and support programs intended for local healthcare professionals could also breathe new life into Haiti’s healthcare system.

Improve health literacy. Health literacy affects every element of the health care system. This observation brought my colleagues and I to create integrAction, a project dedicated to health literacy which led online campaigns during the Chikungunya and Zika epidemics in Haiti. Health literacy is the ability to obtain, understand and master the health information necessary to make advised decisions. The goal is to make the complicated health system easier to navigate, through health promotion, communication and literacy.

Such initiatives might be largely helpful to the future of Haiti as they help lower the burden of preventable diseases, deaths and consequently lower the amount of money spent on these issues.

The cholera epidemic remains an unprecedented challenge as we work towards its elimination. Almost seven years past its introduction in Haiti, Haitians can use their experiences to look at the future with tenacity and a clearer vision. “We are here, fighting…” a drinking water technician said as we left Belladeres. My short visit there did not allow me the opportunity to implement any lasting change. Neither will any quick fix resolve the problems that lead to the recurring public hospital strikes,  as they are a mere symptom of a deeper issue. As I lay down these recommendations of mine, to anybody reading this, I hope that the seeds will take root to bring forth a brighter future because of our common engagement.

This post, published in 2015, has been updated and edited to appear on Woy Magazine

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