Haiti’s Year of Living Miserably

At the one-year anniversary of Haiti’s tragic earthquake, media scrutiny will focus on the sorry lack of achievement in reconstructing Haiti’s public buildings, private residences, economy, and infrastructure. No doubt a fair amount of finger-pointing will be directed at all players, including NGOs, the U.S. and Haitian governments, the UN peacekeepers and agencies, and a long list of private actors. Most of the homeless remain homeless. Most public buildings and infrastructure remain in shambles, few Port-au-Prince residents have genuine employment, and human rights are a disgrace (especially for women and girls), according to recently released assessments from Oxfam (PDF) and Amnesty International (PDF).

According to Oxfam, "close to one million people are reportedly still displaced. Less than 5 percent of the rubble has been cleared, only 15 percent of the temporary housing that is needed has been built, relatively few permanent water and sanitation facilities have been constructed," and less than half the money pledged last year for Haitian relief has actually been disbursed. "Nobody can pretend that this has been a hugely successful humanitarian response," said Paul Conneally, a spokesman for the International Federation of Red Cross and Red Crescent Societies. "If anything, it demonstrates the limitations of humanitarian action."

UNICEF acknowledges that 380,000 children are living in squalid tent camps in Port-au-Prince and adjacent communities. The Miami Herald asks how such little progress could have been made in a year if, as the UN claims, $1.28 billion of donor funds have been disbursed, or roughly $1,000 per Haitian. (Last week, the office of the UN special envoy to Haiti insisted that 63.6 percent of funds had been distributed in Haiti.)

For public health advocates, the most egregious post-earthquake occurrence has been the emergence of cholera in October and its unrelenting spread and death toll, now causing disease and claiming lives in every part of the country, neighboring Dominican Republic, and Florida. The first identified case was a twenty-year-old man from the village of Meille, treated on October 14 by Cuban physicians. In a matter of days the vibrio (cholera bacteria) spread from the northern Artibonite River region southward, toward Port-au-Prince. Within ten days, according to the U.S. Centers for Disease Control and Prevention (CDC), 4,722 cholera cases were reported, with 303 deaths. Haiti’s National Laboratory of Public Health identified the vibrio as 01 serotype Ogawa, biotype El Tor--a form of cholera never previously seen on the Hispaniola island, where no cholera of any form had surfaced in more than a century.

Given the sickening state of Haiti’s water systems before the earthquake (when only 12 percent of the population had piped water) and post-quake damage to the pipes and pumping stations of Port-au-Prince, it seemed axiomatic that in the absence of heroic public health efforts the vibrio would claim an enormous death toll and become endemic to the Haitian ecology. Indeed, the cholera crisis has deepened. At its peak in late November, the epidemic was claiming eighty lives a day; by December 19 that toll was down to fifty-five daily, raising hope that the outbreak might be waning. That hope was dashed after Christmas, however, when a record number of deaths in a single day were recorded (one hundred), pushing the January 1, 2011, cumulative total of fatal cases to 3,651.

UN officials told reporters in mid-December that the official counts of cases and deaths likely underestimate the true scale of the epidemic, which is likely twice as large as indicated. Moreover, the UN reckons that by May, cholera will have caused 650,000 illnesses in the country and a commensurate increase in deaths.

The mortality rate is very high in Haiti, at about 6 percent of identified cases (as compared to 0.2 percent in Bangladesh with the same strain), sparking speculation that unique conditions in the country may foster worse disease. As bad as the Haitian situation is, it cannot be much worse than the human and ecological setting of cholera’s origins in Bangladesh. A December 10 study in the New England Journal of Medicine, "The Origin of the Haitian Cholera Outbreak Strain," offers powerful genetic evidence that the particular strain afflicting Haiti did indeed originate in Bangladesh sometime between 2001 and 2008.

Knowing Haiti has been hit with a partially drug-resistant and virulent form of the vibrio, and that the populace has absolutely no natural immunity having lived cholera-free for generations, many observers are now calling for mass vaccination. In a recent Newsweek article Drs. Paul Farmer and Jean-Renold Rejouit of Partners in Health argue in favor of such a scheme. On December 17, the Pan American Health Organization (PAHO) cholera expert panel voted in favor of mass vaccinations.

But finding and packaging supplies of the two-dose oral vaccine will probably take three or four months, and there are also questions about the effectiveness of a vaccine campaign. Only two manufacturers are currently in the cholera vaccine business: Sanofi Aventis, which makes vaccine at its subcontractor factory run by Shantha in India, and Crucell, which makes a vaccine in the Netherlands. Until supplies are available, public health workers have time to consider how they will administer two doses of vaccine to some segment of the Haitian population of ten million.

Field trials of oral cholera vaccines (whole-cell and B-subunit forms) conducted in Bangladesh during the 1990s demonstrated 50 to 85 percent rates of protection against the El Tor strain. But perhaps the most relevant study (PDF), conducted by WHO in a northern Uganda refugee camp in 1997, yielded decidedly mixed results with a two-dose mass vaccination effort.

The WHO team assessed the logistic and cost requirements for a mass campaign among one hundred thousand refugees--in conditions akin to those seen in Port-au-Prince’s tent cities. About a third of the population accepted vaccination, with second dose uptake considerably lower than first. Significant personnel and logistics were required to track and administer the vaccines. In addition, costs were incurred in transport and cold-chain storage. Clean water supplies had to be mobilized for people to swallow their vaccine, at considerable expense. Total costs came to about $3 per vaccine dose plus $10 per dose in logistic and personnel costs--a hefty sum. Worse, in this specific case many costs were offset by donated services, such as the storage and refrigeration of the actual vaccines. Extrapolating from the WHO refugee experience, vaccinating the entire Haitian population could cost $300 million to $500 million dollars.

Farmer and Rejouit argued in Newsweek that some costs could be offset by giving Haitians both doses of vaccine, with instructions regarding when and how to take the second dose on their own. But they fail to explain how Haitians will safely store their second dose, which requires refrigeration, or where safe water will be found to swallow down the vaccine. These are precisely the sorts of issues Haitian officials, PAHO, and NGOs ought to be working out at this time.

If money and vaccine supplies can’t be mustered until late April, as PAHO now projects, what can be done to save lives in the interim? The major responder at present is the U.S. government, through USAID and a host of supported NGOs. To date the United States has committed $28 million to a three-pronged effort:

1. Clean water promotion involving thirty metric tons of chlorine for urban water purification and fifteen million Aquatabs for individual water purification use;

2. Sanitation and hygiene education, involving 7,500 trained community health workers deployed in rural areas;

3. Oral rehydration salt therapy, featuring a December shipment of five thousand ORT packs.

Global experience with cholera outbreaks shows that case fatality rates above 4 percent, coupled with a burst of rapid spread of the vibrio, are the norm. Case fatality rates come down to 1 percent or less when local medical workers become familiar with methods of rapid identification and hospitalization of acutely ill individuals, and rehydration treatment. It is dehydration that kills cholera victims, and rehydration that saves lives. A single dose of the very inexpensive antibiotic doxycycline can both shorten the length of illness and decrease vibrio shedding, thereby reducing the amount of bacteria in local water supplies. But antibiotics do not save lives. Only rehydration (with cholera-free fluids) can slow the case fatality rate.

Haiti cannot bring that case fatality rate down without considerable help from the outside. About 80 percent of the medical facilities in Port-au-Prince were destroyed or severely damaged in the earthquake, and cholera patients are undergoing IV drip rehydration treatment in tents and street-side makeshift clinics. In the Christmas issue of the Lancet, Farmer and colleagues from Harvard and Haiti offer a five-step plan for controlling the cholera outbreak, including prevention efforts focused on safe water and encouraging existing health programs to work to strengthen the Haitian health system.

The more protracted the epidemic, the greater the probability that the vibrio will become endemic to waterways not only throughout Haiti but also in the neighboring Dominican Republic. It is not alarmist to assume a high probability that the El Tor vibrio could still haunt Haiti and neighboring Dominican Republic a decade from now. That fear has already prompted a secondary food crisis, according to the UN Food and Agriculture Organization, as frightened rice farmers are refusing to plant their watery fields. CDC investigators reported on December 24 that just three of the then-identified cholera cases in the Dominican Republic involved individuals that had acquired their infections in Haiti. Clusters found in impoverished parts of the Dominican Republic, such as the El Dique slum of Santo Domingo and the Navarre district, are linked to now-contaminated local water sources.

Safe water equals infrastructure; infrastructure equals governance, and Haiti has little that could be characterized as "governance." The State Department cables released recently by WikiLeaks include unflattering assessments of Haitian President René Préval, characterized as stubborn and corrupt. Haiti’s national elections found Préval’s hand-picked successor, Jude Celestin, the winner, but a report from an international panel found that Celestin came in third (WSJ). A second runoff election is pending. Without a genuinely accepted and duly elected leader, Haiti will be hard-pressed to execute the necessary governance to end its cholera epidemic, much less rebuild the ravaged country.