Haiti After the Earthquake (32 page)

Or perhaps this diagnosis was wrong, and the outbreak was not caused by cholera. Perhaps we'd have a chance to pursue water and sanitation projects more effectively. But late that October night, Louise called me to say that, although the laboratory work had not been completed, the news would be bad. After a century of reprieve, cholera had returned to Haiti.

If the first nine months of the year were dominated by the earthquake, the last two seemed to consist of nonstop cholera. The earthquake laid down the conditions for an epidemic of waterborne disease but by no means made it inevitable. Some conditions predated the quake; some became recognizable only in retrospect. Cholera was the latest acute reminder of Haiti's integration into the global economy and its paradoxical privation—of its place in a vast transnational web and of its exceptional dearth of public services. In the Republic of NGOs, private initiative could not conjure functioning municipal water systems and decent sanitation infrastructure out of thin air. Without all the medical equipment, facilities, or medication we needed, without rapid integration of all necessary preventive measures and treatment, we would be in trouble.

By the last week of October we knew that four things were likely to happen in short order. First, the epidemic would spread rapidly across the country, since Haiti was fertile ground for any waterborne disease caused by a bacterium that could survive, even briefly, outside a human host.

Second, effective means of treatment and prevention would be quite limited in many areas and almost nil in others: those with ready access to clean water would be spared, and those without
would not. Those with access to prompt diagnosis and proper care would survive, but many thousands without access to care would die. There was every reason to believe, from the first cases documented, that this would be a devastating epidemic that could not be limited to central Haiti, or limited to Haiti at all.

Third, we knew from previous epidemics that loss of life, especially among the young and previously healthy, would trigger cycles of accusation and counteraccusation. Blame was, after all, a calling card of all transnational epidemics, including the AIDS epidemic.
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As with AIDS, the introduction to an island of a previously unknown infectious pathogen would implicate transnational spread. Cholera had to have come from somewhere.

The press to discover whence this new malady hailed would reflect the desire to know whose fault it was. Anthropologists often trace modern Haitian ways of explaining misfortune to the slave plantations from which Haiti was born. A wonderful essay about folk healing by Karen McCarthy Brown puts it this way: for the early Haitians, “natural powers such as those of storm, drought, and disease paled before social powers such as those of the slave holder.”
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Although explanations for the earthquake were natural (except among well-nourished American TV pastors), social responses would include local cycles of accusation, drawing on village-level feuds. Other accusations would be vaguely nationalist: Social turbulence around these themes would, predictably, complicate responses to the epidemic. Instead of “
What
brought this latest misfortune down upon us?” I expected to hear, “
Which foreigners
brought this latest misfortune down upon us?”

Fourth, expert opinion on cholera would be divided. Prevention experts would focus on their methods of protection (from water filtration to chlorination to vaccination) and treatment experts on their means of treatment (from oral rehydration to antibiotic therapy). There would be disagreements about priorities and investments. I'd seen these arguments during the Peruvian epidemic and read about them during the Zimbabwean one.
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Conflicts of this kind seemed less to do with cholera than with long-standing divisions between medicine
and public health. We'd encountered these same divisions when responding to AIDS and tuberculosis and malaria and cancer: instead of efforts to integrate prevention and care, there was brisk competition between those working in prevention and those seeking to provide care.

Some—like the Cuban brigade, GHESKIO, and, I think it's fair to say, Partners In Health—have long advocated the integration of prevention and care as leading to better prevention and more comprehensive care. But others pushed for their own areas of expertise and favorite solutions, leading to competition rather than cooperation; prevention versus care; water protection versus vaccination (or even chlorination versus filtration); regional versus national plans; oral rehydration versus antibiotic therapy; hand washing and small waterprotection projects versus municipal water projects. This, in any case, is what we feared.

All four of these predictions came to pass. The cholera epidemic hit central Haiti—even more water insecure than the internally displaced persons camps—like a bomb, spreading from town to town and then into villages far from any clean or filtered water source. As for the rapidity of spread, the numbers spoke for themselves. No cholera epidemic stays local for long, and the Haitian one moved fast. I had heard of the outbreak in the third week of October from colleagues in Mirebalais and Saint-Marc, two cities connected by a river. It reached Port-au-Prince by November 9 at the latest, when cholera was diagnosed in a child who had not traveled outside the city.
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Soon cases were reported across the nation. By the close of the year, almost two hundred thousand cases were registered in Haiti's ten departments, and nearly four thousand of those afflicted had died.
¹⁰
Given weak reporting capacity, these estimates were probably low. The Haitian epidemic is the most devastating the hemisphere has seen in decades.

The cycles of accusation and counteraccusation started, as predicted, on day one. Louise Ivers and David Walton had given me a heads-up, as I paced about in Rwanda. Although the world became aware of the epidemic when it reached Saint-Marc, there had almost
surely been cases several days earlier far from the coast, in the region closest to the Nepalese peacekeepers whose base sits on the banks of the Meille River. Because that river flowed by the Nepalese encampment into the city of Mirebalais, a causal link was quickly posited, and not just by epidemiologists: much of the local citizenry believed that a new pathogen had been introduced by the foreigners in their region. Most of the foreigners in Mirebalais were UN peacekeepers, the great majority, in fact, from cholera-endemic countries.

Their numbers weren't small. In Mirebalais and elsewhere in central Artibonite Haiti were thousands of peacekeepers, some hundreds of them recently arrived, and within a few hours, accusations were flying. Some of the rumors were, as usual, absurd. But it was not unreasonable, epidemiologically, to assume a connection between the large and relatively new presence of people from South Asia and a new, externally derived epidemic—even before the infecting strain had been genetically typed and before it was known that waste management at the Nepalese base, managed by a private Haitian contractor, left much to be desired. In those first days of the epidemic, the chief task was to figure out where the epidemic had come from and to cut its spread by any and all means possible.

That's why, less than ten days after news of the first cases, I spoke to journalist Jonathan Katz, who was investigating how cholera had been reintroduced to the Americas. One of my suggestions was to identify the source of the Haitian epidemic and to study, genetically and epidemiologically, the introduced strain. On November 9, Katz wrote the following for the Associated Press:

All this was technically correct, but it was certainly not my intention to fan the blame game. Still, it seemed important to understand the biosocial complexity of this rapidly changing epidemic. This meant understanding both the origins and genetic fingerprint of this particular strain, which would help predict its speed of spread, its appropriate treatment, and even its case-fatality rate. My Harvard colleague John Mekalanos, chair of the department of Microbiology and Molecular Genetics and a genuine cholera expert, made the same point even as we were studying the genetic fingerprint of the cholera strain: “It very much likely did come either with peacekeepers or other relief personnel. I don't see there is any way to avoid the conclusion that an unfortunate and presumably accidental introduction of the organism occurred.”
¹²

The popular press contained vivid accounts of the likely source of contamination. Katz did yeoman's work trying to figure out what was going on. This required him to visit the Nepalese base closest to Mirebalais, where I'd been received previously with great courtesy.
¹³
But Katz wasn't there to have a meal and a chat with the officers. He came to inspect latrines and septic tanks:

The circumstantial evidence was damning. Within days of the first cases, photos of raw human waste from the camps being dumped directly into one of the rivers connecting the camp to Mirebalais (and Mirebalais to Saint-Marc) covered the newspaper pages.

But the initial response of the UN was to deny any connection between the epidemic and the burgeoning presence of their troops from cholera-endemic regions. Katz put it this way:

Umbrage was taken on all sides. The mayor of Mirebalais attacked the UN for introducing “yet another epidemic” to Haiti, echoing the views of many of his constituents. The Nepalese troops and the UN issued epidemiologically implausible, but socially and politically predictable, denials and hired a private Dominican laboratory to see if indeed any of their troops were sick.
¹⁶
Fortunately, they were not sick, but those who knew a bit about the microbiology of the causative organism,
Vibrio cholerae
, knew that it wasn't easy to grow in lab. They also knew that, as with most infectious pathogens, many of those shedding viable cholera bacteria would remain asymptomatic. As we would later learn, the South Asian strain of cholera active in Haiti has been shown to cause greater numbers of asymptomatic cases, to persist longer in the environment, and to exist in higher concentrations in feces.
¹⁷

But political responses to the mounting epidemic ignored such clinical details. As the Haitians continued to demand explanations, the UN, and especially the Nepalese, continued to issue denials: “Nepal's UN office said in a statement Friday that its peacekeepers have never been linked to a communicable disease, and that tests done by the United Nations, Haiti's government, and independent groups prove that none of its peacekeepers now in Haiti has cholera.
Nepal firmly rejects such baseless, malicious, and unfounded reports put out by some media and individuals without any regard to the specific evidence to the contrary.”
¹⁸

Political protests against the peacekeepers occurred well before any of us spoke to the press. Categorical UN denials were only making the situation worse, we feared. Louise Ivers, the person I trusted most on this score, thought that an independent inquiry was needed. We began calling for strain identification to learn what antibiotics would be needed to kill the organism, predict the speed of spread, and estimate the chance of endemicity—settling in for the long term to plague an immunologically naïve population. Above all, pinpointing the source of the outbreak might have, early on, helped to stop its spread. But with many infected people traveling around the country, it seemed by mid-November that this window had closed.