We are so grateful for your support of Partners In Health and our work to prevent and treat cholera in Haiti. We are pleased to share a brief update around some of the current successes and challenges that our colleagues are seeing on the ground in Haiti.
Since January, the number of cholera cases and fatalities have decreased across PIH's 11 facilities in Haiti, but the epidemic continues to sicken thousands across the country, hitting the most vulnerable populations the hardest--like malnourished children who have low immunity. With rainy season quickly approaching, the need for basic treatment and prevention tools has never been greater.
Below is an excerpt from a New York Times article authored by Randal C. Archibold and Somini Sengupta, discussing the current situation in Haiti, and citing examples of how PIH's approach is working:
The United Nations raised barely a fourth of the $38 million it needed last year to provide lifesaving supplies, including the most basic, like water purification tablets. Clinics have run short of oral rehydration salts to treat the debilitating diarrhea that accompanies the disease. Some treatment centers in the countryside have shut down as the aid groups that ran them have moved on to other crises. And a growing share of patients are dying after they finally reach hospitals, according to the United Nations’ own assessments.
Josilia Fils-Aime, 11, who lives in this village on an isolated spit of land near the Artibonite River, where the epidemic first began, knows these shortcomings all too well. Her family had run out of water purification tablets, and she drank water from what must have been a polluted stream nearby.
“I felt dizzy and sick,” the girl said. She was struck by sudden vomiting and diarrhea. Doctors diagnosed cholera.
Her predicament has multiplied across Haiti, which has had the most cholera cases in the world for three years in a row.
The United Nations has yet to raise the $5 million necessary to vaccinate 600,000 vulnerable people right away — as the rainy season approaches and the threat of waterborne illnesses like cholera looms — let alone the $2 billion that it promised to raise from rich countries to build Haiti’s water and sanitation infrastructure, which public health experts say is vital to ridding the country of cholera.
Pedro Medrano Rojas, the United Nations secretary general’s newly appointed envoy for the cholera outbreak, attributed the shortfall to global “donor fatigue” in the face of other humanitarian crises.
“Had we had the resources it would have been different,” Mr. Medrano said. “It’s not expensive. No one should be dying from cholera.”
Since the outbreak began in October 2010, 8,562 people in Haiti have died of cholera. New infections have declined, following the typical trajectory of an epidemic, from a peak of more than 350,000 reported cases in 2011 to a little more than 50,000 cases in 2013.
The United Nations is essential to solving the problem because, like many of the country’s institutions since the January 2010 earthquake, Haiti’s own health care system remains in shambles. Clean drinking water and sanitation remain as scarce as when the epidemic began. And where international nonprofit groups, along with the government, once operated 120 cholera treatment centers across the nation, the number has shrunk to barely 40 as aid groups have pulled out.
Perhaps that most troubling measure of all is the rising percentage of cholera patients who die in the treatment facilities that remain. As the United Nations mission said in its report to the Security Council in March, “That reflects weaknesses in the capacity of health centers to provide timely and adequate health services to patients affected by cholera and the longer travel time required for treatment as a result of the closure of many cholera treatment centers.”
Josilia Fils-Aime, for instance, most likely survived because Partners in Health, a nonprofit that has worked in Haiti for years, opened a satellite clinic near her home. The next closest cholera treatment center would have required a two-hour trek, including a boat ride.
“In any other country, you would declare it a humanitarian disaster,” said Dr. Louise Ivers, a health policy adviser for Partners in Health. “What’s going to happen when the rainy season starts?”
By Mr. Medrano’s estimates, as many as 40,000 people could become infected once the clouds break and the rivers swell.
Haiti’s cholera outbreak has spread to three countries across the region: the Dominican Republic, Cuba and Mexico. The fatality rates have been much lower in those countries, which have far better public health systems; it is a measure of how easy it can be to treat the disease.
Three years since cholera broke out in Haiti, prevention and treatment efforts have helped control the epidemic, but the disease is far from gone.
An infectious disease that causes vomiting and diarrhea, cholera can lead to deadly dehydration in as little as 24 hours. In Haiti, where most people lack access to clean water and sanitation, cholera spread rapidly through waterways, accelerated by heavy rains and flooding. Since it appeared on Oct. 19, 2010, it has killed more than 8,000 people and caused about 650,000 cases, sickening approximately one in 15 Haitians.
Haiti’s Ministry of Health and aid groups responded quickly to help control the epidemic. Partners In Health, with our Haitian sister organization, Zanmi Lasante (PIH/ZL), has treated more than 105,000 cases in the Central Plateau, representing almost one-sixth of total cholera cases in Haiti. Cholera has declined since the peak of the epidemic, but persists: Last month, PIH providers treated more than 1,700 cases in clinics and hospitals. Meanwhile, funding for cholera prevention and treatment has diminished since the initial emergency.
“We’re making progress, and we know what we’re doing,” said Dr. Louise Ivers, senior health and policy advisor for Partners In Health, who reported some of the earliest cases of cholera in Haiti. “We need funds to keep a sustained response going.”
The governments of Haiti and the Dominican Republic have created a 10-year strategy to eliminate cholera from the island of Hispaniola, which they share. Haiti, which has seen the vast majority of cases, has called for a comprehensive response, including short-term measures such as vaccination, to stay the disease during the long-term work of building latrines and piped water systems.
Still, funding to put the plans into action has come up short. Donors have committed only about $30 million of the proposed $2.2 billion plan.
“We have the opportunity now, as cholera is decreasing, to invest in building water and sanitation systems to prevent the kind of outbreak that we had in 2010,” said Dr. Ralph Ternier, director of community care and support for PIH/ZL. “Cholera has killed so many people these past three years. We shouldn’t forget that.”
Cholera cases have continued to spike throughout the epidemic with increases in rainfall, both during the spring rainy season and in the tropical weather season in the late summer and fall. Just a few weeks ago, heavy rains caused severe flooding in a community near Mirebalais in the Central Plateau. About 120 families lost their homes and crops in the floods. A PIH/ZL team responded the following morning, distributing chlorine and buckets to disinfect drinking water, oral rehydration solution to treat dehydration from cholera, and materials to improve hygiene.
Ternier said the PIH/ZL clinic in Lascahobas has been overwhelmed by cases lately. Many people in that area don’t have latrines, which creates conditions ripe for transmission.
“That shows you the fight is really not behind us,” Ternier said.
Over the course of the epidemic, PIH has monitored cholera cases and deaths to improve care and target vulnerable communities with additional prevention and treatment. Data have shown a decrease in the number of cholera patients who died. In the first two and a half years, about 1 percent of cholera patients that came to PIH clinics died. In the last year, that figure dropped by half to .6 percent, demonstrating that it’s possible to manage cholera with a very low fatality rate in Haiti. PIH’s work to monitor cholera data and use it to improve care will be presented at the annual meeting of the American Public Health Association in November.
Partners In Health has advocated for a comprehensive response to the epidemic since its start, including the use of vaccination, publishing these views in The Lancet. In early 2012, in partnership with the Haitian Ministry of Health, PIH delivered the vaccine to two rural communities hard-hit by cholera in the Artibonite region. The successful results of this project were recently published inThe American Journal of Tropical Medicine and Hygiene.
With evidence from PIH’s vaccination project, the World Health Organization recommended in 2012 to expand access to the vaccine in Haiti and the Dominican Republic. The Haitian Ministry of Health has also conducted targeted vaccination campaigns in the Central Plateau and the north of Haiti.
Vaccination is just one part of a comprehensive response that also includes improvements to water and sanitation systems and health care facilities where people can receive treatment.
“We have to take care of cholera, and we also have to take care of other diarrheal diseases,” Ivers said. “We need to ensure that funding to support cholera treatment and prevention is also used to strengthen the health system as a whole. Only a strong health system is going to be able to deal with cases of cholera as they come.”
Research reporting the results of Partners In Health’s cholera vaccination project in Haiti was released today in a special section of The American Journal of Tropical Medicine and Hygiene.
The journal’s October issue, released just before the third anniversary of the cholera outbreak on Oct. 19, 2010, features a variety of public health research on cholera in Haiti.
As part of the special section, PIH Senior Health and Policy Advisor Dr. Louise Ivers and colleagues discuss the results of PIH’s rural cholera vaccination campaign in early 2012. The demonstration project was executed in collaboration with Haiti’s Ministry of Health and sought to vaccinate two vulnerable communities in the Artibonite region and build support for using the vaccine more broadly.
“Vaccines should not be viewed as a silver bullet that can subdue cholera in Haiti,” Ivers said. “But wider use of them, such as in campaigns targeting particularly vulnerable populations, can play a meaningful role in protecting people from illness and death.”
The journal article explains the project’s design and successful results. A total of 45,417 people in two communities received at least one dose of the two-dose vaccine, representing 77 to 93 percent of the targeted population. Even more, 91 percent of people who received the first dose also received the second, an excellent completion rate.
Another article reports the results of a similarly successful campaign in Port-au-Prince, conducted by the nonprofit health care organization GHESKIO.
These projects proved that delivering the vaccine in the midst of an epidemic was possible in Haiti. The evidence contributed to the World Health Organization’s recommendation in 2012 to expand access to the vaccine in Haiti and the Dominican Republic.
Ivers said that community involvement was critical to the project’s success. In advance of the vaccination, community health workers conducted a census of the community and registered people to receive the vaccine. PIH and our Haitian sister organization, Zanmi Lasante, also worked with community leaders to ensure support of the campaign. Ivers said it wasn’t hard to convince community members to be vaccinated because they knew the danger through personal experience.
“We interviewed people in focus groups before the vaccination campaign and they had very emotional stories to tell about their experience with cholera,” Ivers said. “So it was not a far-off, distant issue, but a real and immediate threat.”
On February 28, 2013, Partners In Health's Executive Director Ophelia Dahl sent an email to supporters sharing the powerful words of Dr. Louise Ivers, the clinician who led the cholera vaccination effort in Haiti. We are excited to share with you Dr. Ivers' op-ed, which was published in the New York Times on February 22nd, prefaced by Ophelia's email:
Since cholera broke out in Haiti more than two years ago, Partners In Health has worked alongside many others to fight the deadly epidemic.
With the support of our partners, we have treated tens of thousands of patients. Last year, we delivered Haiti's first cholera vaccination campaign along with our partner in Port-au-Prince, GHESKIO. On Friday, the clinician who led that vaccination effort, Dr. Louise Ivers, published an op-ed in The New York Times in which she called on the United Nations to make a significant financial contribution to a multilateral plan to eliminate cholera in Haiti. Partners In Health supporters have stood resolutely by us as we have fought cholera through all the means at our disposal, integrating prevention, treatment, and efforts to increase access to clean water and sanitation. Today, I invite you to read Louise's powerful words:
Published February 22, 2013, in The New York Times:
A Chance to Right a Wrong in Haitiby Louise C. Ivers
On Thursday, the United Nations secretary general, Ban Ki-moon, rejected a legal claim for compensation filed in 2011 on behalf of cholera victims in Haiti. Through a spokesperson, Mr. Ban said the claims, brought by a nongovernmental organization, were “not receivable” because of the United Nations’ diplomatic immunity.
Regardless of the merits of this argument, the United Nations has a moral, if not legal, obligation to help solve a crisis it inadvertently helped start. The evidence shows that the United Nations was largely, though not wholly, responsible for an outbreak of cholera that has subsequently killed some 8,000 Haitians and sickened 646,000 more since October 2010. The United Nations has not acknowledged its culpability.
Now, as the cholera epidemic appears to worsen, Mr. Ban and the United Nations have an opportunity to save thousands of lives, restore good will — and, yes, fulfill the mandate that brought the organization to Haiti in the first place: stabilizing a fragile country. The United Nations should immediately increase its financial support for the Haitian government’s efforts to control the epidemic. While that may not satisfy everyone, it will go at least some way toward compensating the people of Haiti for the unintentional introduction of the bacteria that caused the epidemic.
Before October 2010, cholera — a diarrheal illness caused by consuming water or food contaminated with the bacterium Vibrio cholerae — had never been reported in the country. In the epidemic’s first year, the striking loss of life attracted international media attention. Even in its third year, the outbreak continues to sicken thousands.
There were 11,220 cases nationwide during the month of December — significantly more than the 8,205 cases seen during December 2011. Our clinic in St. Marc treated more people with the infection last month than in the previous eight months combined.
That soldiers at the United Nations camp were responsible for introducing the bacteria seems apparent. After local and national protests and an Associated Press investigation, Mr. Ban empaneled a group of international experts to determine the disease’s source. Their report stated that evidence “overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type Vibrio cholerae as a result of human activity.” The strain was not indigenous to Haiti.
The report also found that sanitation conditions at the United Nations camp were not sufficient to prevent contamination of the local waterway with human waste. Investigators found that the potential existed for feces to enter the tributary from a drainage canal in the camp and from the open septic disposal pit that was used to handle the waste.
A research study published in January 2011 in The New England Journal of Medicine lent further support to the claim that the cholera came from the United Nations camp, as did an August 2011 study in another scholarly journal.
The interplay of biosocial factors inherently involved in epidemics make it difficult to pinpoint causality. If Haitians had better access to clean water and sanitation, of course, the cholera epidemic would have had a smaller impact and thousands of deaths might have been averted. (By comparison, there were few, if any, deaths from cholera in countries with effective water and sanitation systems where the organism appeared as part of this same epidemic — including the United States.)
But all of this is background to the urgent matter at hand. The United Nations recently started a 10-year initiative to eliminate cholera in Haiti and the Dominican Republic, based on a plan that was developed with multiple partners, including the governments of both countries. It is a collaborative and comprehensive approach that aims to eliminate transmission of the disease with substantial investments in water and sanitation infrastructure, as well as through prevention and treatment.
On Feb. 27, Haiti’s minister of health will introduce one important component of this plan — an initiative to expand access to cholera vaccination.
If the United Nations were to finance this initiative, along with the rest of the government’s anti-cholera program, it could have a significant and immediate impact on stemming this epidemic. As of now, however, the United Nations plans to contribute just 1 percent of the cost. That is not enough.
Meanwhile, the organization’s stabilization mission in Haiti is budgeted for $648 million this year — a sum that could more than finance the entire cholera elimination initiative for two years.
It’s time for the United Nations to rethink what true stabilization could be: preventing people from dying of a grueling, painful — and wholly preventable — disease is a good start.
Louise C. Ivers, a senior health and policy adviser at Partners In Health and associate professor at Harvard Medical School, has been leading cholera treatment and prevention activities in Haiti.
Project Reports on GlobalGiving are posted directly to globalgiving.org by Project Leaders as they are completed, generally every 3-4 months. To protect the integrity of these documents, GlobalGiving does not alter them; therefore you may find some language or formatting issues.
If you donate to this project or have donated to this project, you will get an e-mail when this project posts a report. You can also subscribe for reports via e-mail without donating or by subscribing to this project's RSS feed.
Annual Giving Coordinator