Catching Up on Cholera in Haiti

When cholera broke out in Haiti in October 2010, reporter Jonathan Katz* was the first to break the story connecting UN peacekeepers from Nepal to the outbreak. Nearly two years later, Haiti is still struggling to address the issue of cholera and the UN has yet to admit that it was to blame for the outbreak.

I caught up with Jonathan to discuss his original reporting, the outbreak and the UN’s response.

Tom Murphy: How did you connect the Nepali peacekeepers and the cholera outbreak?

Reporter Jonathan Katz

Jonathan Katz: Almost as soon as cholera erupted in central Haiti, in mid-October 2010, rumors began flying that U.N. peacekeepers had been somehow involved with sparking the epidemic. A lot of the cholera talk was crazy — white helicopters dropping black powder into a river and such — but nearly all the versions agreed on a few key details: A substance from a U.N. base flowing into the country’s main river, the Artibonite, and making people downriver sick. Then a friend pointed out an article from September 2010, a month before, noting an active cholera outbreak in Kathmandu. The peacekeepers stationed throughout the Artibonite River Valley, where there aren’t many foreigners, were from Nepal.

I’d been living in Haiti since 2007 as the AP correspondent, so I was used to checking out rumors, and on Oct. 27 headed up to the base in question. Long story short, the soldiers’ sanitation was horrendous. It was obvious that some forms of their waste were flowing into the tributary, and that given their sloppy disposal procedures, a much bigger contamination was possible. Most incredibly, I ran into U.N. military police at the base, collecting samples of waste water to test for cholera, the day after MINUSTAH headquarters issued a statement saying there was no reason for concern.

Then I connected some dots: Responders quickly identified the major river system as the primary vector by which the disease was spreading. The base commander confirmed that his contingent had arrived just before the outbreak in Haiti, in the midst of the outbreak in Nepal, and I got a top WHO cholera official on the phone who confirmed that Haiti had never had a documented case of cholera before. Shortly thereafter, the CDC found that the cholera strain in Haiti matched one circulating in South Asia, including Nepal. By Halloween it was obvious that the U.N. peacekeepers were prime suspects. That the WHO, CDC and U.N. were so adamant about not undertaking a serious investigation suggested that they probably thought so too.

TM: In what ways are the earthquake and the cholera outbreak connected? In what ways are they not?

JK: The two disasters were basically a tragic coincidence. It’s possible that ex-urban migration after the quake meant larger concentrations of people to get sick in rural Haiti, but most analyses suggest that by October 2010 nearly everyone who’d fled Port-au-Prince for the countryside after the quake had come back. In fact, the famous earthquake displacement camps, which many responders assumed would be ravaged by cholera, were spared the brunt of the epidemic. Since many of the encampments had been receiving treated water from the NGOs already since the quake, they turned out to be one of the safer places for the urban poor to live.

If there was an underlying connection between the disasters, it was poverty. The Haitian government’s lack of resources to enforce building codes before the quake, along with people’s preferences for cheap construction materials, made that disaster far more deadly than it might have been. A lack of public sanitation, potable water and decent healthcare similarly made the introduction of a virulent cholera strain into the country’s primary river catastrophic. And, of course, poverty was a underlying cause of the instability that made a U.N. peacekeeping mission justifiable in the first place. Also the quake, which tragically killed MINUSTAH’s leadership and many of its soldiers, also prompted the Security Council to increase troop levels by several thousand.

TM: How would you characterize Haitian attitudes in regards to MINUSTAH?

JK: MINUSTAH came to Haiti in 2004, following a U.S.-led peacekeeping force that arrived after a coup deposed President Jean-Bertrand Aristide. Hardcore U.N. opponents and pro-Aristide folks won’t like me saying this, but in its early years there were Haitians happy to have the U.N. around, especially in areas that had been terrorized by gangs of one persuasion or another. (There were also a lot of Haitians who hated them from the beginning.) But after a decade of mission creep, stepped-on toes and the indignity of the second-oldest independent republic in the Western Hemisphere living daily with the presence of foreign soldiers on its streets, even MINUSTAH’s former fans were ready for them to go. Cholera itself was even probably only the second-to-last straw. The dissembling, obfuscating and refusal to even publicly consider accepting responsibility were probably the coup de grâce.

TM: What does the University of Maryland study revealing two strains of cholera in Haiti tell us?

JK: As to whether the U.N. introduced a previously unknown, deadly strain of cholera to Haiti, it has nothing apparent to say at all. It may ultimately point to a more complicated hypothesis about exactly how that imported strain proved to be so deadly, though it’s a bit too early to say.

Significantly, about 48% of the samples the Maryland team chose to test were V. cholerae O1 Ogawa El Tor, which the U.N.’s own panel (one of whose authors participated in the Maryland study) found was introduced by human activity at the site of the U.N. base in October 2010. Just 21% of the Maryland team’s samples, meanwhile — and it’s not clear exactly how those samples were chosen to be tested in the first place, i.e. whether those patients had been diagnosed with cholera — indicated patients only infected by the second strain. Also important: Scientists I’ve talked to about that study have pointed out that the suspected “second strain” is a variety of cholera that’s never been shown to spark an epidemic before.

The study’s primary author, Rita Colwell, has in large part built her career on proving environmental causes of cholera epidemics. She was pushing that hypothesis for Haiti as soon as the first reports of disease were in, before the U.N. connection arose. When one of the world’s leading proponents of the environmental spread of cholera can’t justify such an explanation for half of her own samples, and an outlying one-fifth of the samplesfeatures a strain that doesn’t cause outbreaks, you’ve got a pretty good case for saying that humans caused the epidemic.

There are also some key errors in the paper. For instance, it presents Hurricane Tomas as a major cause of the epidemic, but that storm hit on November 5, three and a half weeks after the epidemic began — and the storm didn’t even strike the area where the epidemic was centered. I think we should be open to the idea that there are huge gaps in our understanding. Maybe someday someone will come along with a study that proves cholera traveled to Haiti through some heretofore unimagined route, or emailed itself into the Artibonite River. Much of the Maryland paper was pretty dense for a layman, so maybe such proof is buried in there. But there’s no indication that is the case, and certainly not enough to invalidate all the other studies out there, including the U.N.’s own, which point to the U.N. base as the source of the epidemic.

TM: How has the humanitarian response to the outbreak been over the past year and a half? Does anything stand out in terms of things done well or poorly?

JK: Responders acted quickly and heroically to combat the disease. Doctors Without Borders and Partners in Health, to name two of many organizations, mobilized quickly, set up treatment centers and got out important education to a population that had never seen this disease before, much of which had just been traumatized by the deadliest earthquake ever recorded in the Western Hemisphere. That was impressive work. That the epidemic is at a low tide right now is in large part due to those efforts.

But the U.N. cover-up, and I think we can call it that now, was a bigger hindrance than many responders would like to admit. First of all, we have no idea whether finding the point source quickly might have helped stem the spread of the disease, but it might have — it’s a standard epidemiology for a reason. Second, the U.N.’s persistent dissembling infuriated thousands of Haitians who had no patience for differentiating between one group of foreigners and another. Attacks on cholera treatment centers by frightened people were a problem from the start, and the anti-U.N. riots that broke out in northern Haiti in mid-November were literal roadblocks toward stopping the spread of disease. The U.N. blamed political actors for the protests, and there were definitely people stirring those riots up, but the U.N.’s attitude made those protests possible, if not almost inevitable.

Ultimately it’s hard to get away from the evidence that, after months of openly worrying that the Haitians themselves were going to spark a post-quake epidemic, the responders themselves caused the worst one imaginable and then tried to cover it up. “Other than that, Mrs. Lincoln,” as they say.

TM: External pressure from members of congress, documentaries and new reports are putting the UN in the hot seat. If the UN admits guilt, what will that mean for MINUSTAH, the victims and the response?

JK: Depending on how it goes down, an admission of guilt that leads to legal or punitive action could have huge implications for U.N. and other peacekeeping missions around the world. MINUSTAH is protected by a standard status of forces agreement that prevents prosecution in the country where it operates. If the U.N. is held responsible for malfeasance in Haiti, it could open the door for similar actions in DR Congo, the Balkans, you name it. That’s something to watch. For the victims of the epidemic, a mere admission may be a kind of vindication or comfort, but for most I’d guess it will feel empty unless it’s accompanied by restitution and a significant investment in water and sanitation infrastructure. Many Haitians I’ve talked to about this note that nothing will bring back the dead, butthat action can be taken to help the living. As for its effects on the overall foreign response — to the quake, the epidemic and Haiti’s poverty in general — an admission of guilt could embolden the U.N.’s opponents and be a boost for craven nationalism. Even so, it will be like removing a fat splinter. It’ll hurt like hell, but the longer it stays in, the worse the infection is going to be. But then again, if you learn one thing in Haiti, it’s not to make predictions.

TM: What is the current state of the cholera outbreak in Haiti?

JK: It’s still terrible. In less than two years an estimated 584,000 people have been sickened and, officially, 7,497 people have died — all from a strain of bacteria that had never been seen in Haiti before. Infections appear to be at a low point, but while the rate ebbs and flows, the epidemic isn’t going away. A pilot project to vaccinate about 1% of the population appears to have been a success in terms of distribution, and there’s talk about scaling it up. The great tragedy is that people in Haiti who already had so much to deal with now have to contend with this new threat. They’ll know how successful mitigation efforts have been after the next big set of floods.

TM: Why is this story important to Americans?

JK: I’m not sure it is yet, but it could be. The U.S. paid 27% of last year’s U.N. peacekeeping budget, which in MINUSTAH’s case meant that U.S. taxpayers provided $215 million of a $793 million operation. (The overall budget is down a bit this year.)  A major reason the U.N. peacekeeping mission is in Haiti is that the State Department and Pentagon want it to be there — it’s a far cheaper option than keeping U.S. troops stationed in Haiti full-time, for instance. Moreover, given our incredible continued globalization, and how widely troops and other large groups are moving around the world, it would be worth our while to stop and consider how this happened, and to think up ways to prevent it from happening again to another vulnerable nation, or even to us.

So many Americans gave time, their compassion and their money after the 2010 earthquake, hoping to mitigate the effects of the disaster and prevent more people from needlessly suffering and dying. If the U.N. accidentally caused an epidemic that has sickened over half a million people and killed 7,500 — and again, by all current evidence, it did — then a force that Americans are partially responsible for undid that effort and goodwill by failing to maintain basic standards of hygiene and professional conduct. If Americans cared about needless suffering in Haiti two and a half years ago, it would make sense if they cared about it now.

*Jonathan Katz was the Associated Press chief correspondent in Haiti from 2007 to 2011. He left AP this year to write a book about the 2010 earthquake and response, The Big Truck That Went By: How the World Came to Save Haiti and Left Behind a Disaster, due next year from Palgrave Macmillan. The book won the 2012 J. Anthony Lukas Work-in-Progress Award from Columbia Journalism School and the Nieman Foundation at Harvard.

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About Author

Tom Murphy

Tom Murphy is a New Hampshire-based reporter for Humanosphere. Before joining Humanosphere, Tom founded and edited the aid blog A View From the Cave. His work has appeared in Foreign Policy, the Huffington Post, the Guardian, GlobalPost and Christian Science Monitor. He tweets at @viewfromthecave. Contact him at tmurphy[at]humanosphere.org.