(Above: Dr. Thelisma Heber cares for a patient at the Cholera Treatment Center in Mirebalais, Haiti.)
Thank you for your support of Partners In Health, Zanmi Lasante (our sister organization in Haiti), and the thousands of people who you've helped to receive treatment for cholera, as well as education and resources to prevent it. Below please find an excerpt from a piece posted on our website this past summer. While we've made great progress in the places where we work in Haiti, cholera rages on.
Haiti never knew cholera until 2010. That’s when the United Nations flew in a group of peacekeepers from Nepal, whose capital had recently suffered an outbreak of the disease, and set them up in a camp with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in the country, the 200-mile Artibonite. Since the first person was diagnosed in October 2010, there have been more than 739,000 cases of cholera and 8,900 deaths, according to Haiti’s Ministry of Public Health and Population.
So why does cholera continue to plague Haiti, and PIH/ZL sites, five years after the initial outbreak?
“We haven’t gotten rid of the reasons for the transmission of the bacteria, and that’s because there’s such poor water and sanitation,” says Dr. Louise Ivers, PIH’s senior health and policy advisor. Since the outbreak began, “there have been no transformative water and sanitation activities, and so the underlying problem is still there. I think that’s why the number of cases has started to go up again.”
Ivers also says numbers may be higher where PIH/ZL operates because the Centre region is one of the poorest in the country and, therefore, has limited water and sanitation infrastructure. Plus, staff actively record cholera cases, something that is not true everywhere in the country because human resources are lacking. A full count of the disease could be much higher nationwide.
In response to the epidemic, the governments of Haiti and the Dominican Republic proposed a 10-year, $2.2 billion plan to eliminate cholera, including investments in new water and sanitation systems. But that plan, announced in 2012 and supported by an international community of donors, is only 13 percent funded.
Some advocates believe the U.N. should shoulder more of the burden for cholera in Haiti. Brian Concannon and the non-profit he co-founded, the Institute of Justice and Democracy in Haiti (IJDH), has requested the U.N. accept responsibility for the initial outbreak. The IJDH filed a lawsuit against the U.N. in U.S. federal court in 2013, but a judge dismissed the case in January 2015. The organization is now appealing that ruling.
Meanwhile, Partners In Health/Zanmi Lasante (ZL) staff do what they can to halt the most recent spike in cases, as they’ve done with others in the past. They mobilize a network of community health workers to find patients, open rehydration posts in remote locations, educate people about proper hygiene and sanitation, and diligently work to bring reliable water and sanitation systems to the region.
More comprehensive work needs to be done. In a 2010 article published in The Lancet, Ivers and Dr. Paul Farmer, a PIH co-founder and chief strategist, laid out a detailed roadmap to break the cycle of cholera. They wrote that health care professionals have to aggressively find and treat cholera cases and administer vaccines such as Shanchol, which Ivers and her colleagues found reduced the number of cholera cases by 63 percent among those vaccinated in villages north of St. Marc. Water and sanitation systems need to be improved. Public health care systems have to be strengthened. And global health policy must be crafted to give cholera the level of attention it deserves.
(Eusuze Murat (center), a WASH hygiene promotion supervisor, and Joseph Rolles (right), a WASH engineer intern, walk with health workers to the town of Larang in Cerca-La-Source.)
Thank you for supporting Partners In Health and our efforts to treat and prevent cholera in Haiti, which has enabled us to continue working in partnership to make measurable progress fighting this disease and saving lives.
Cholera is a centuries-old disease, but it’s a relatively young scourge in Haiti. It entered the country in October 2010 when contaminated sewage from a United Nations peacekeepers’ camp leaked into one of the largest water sources, the 200-mile Artibonite. There have since been more than 745,500 cases of cholera and nearly 9,000 deaths, according to Haiti’s Ministry of Public Health and Population.
The disease is a day-to-day battle for health care professionals working with Zanmi Lasante (ZL), Partners In Health’s sister organization in Haiti.
There’s an immediate side to eliminating cholera, which requires identifying and treating patients for a potent diarrheal disease that could kill within 24 hours. And then there’s the long-term side, which requires infrastructural and behavioral change.
In 2012, Haiti government officials crafted a 10-year national plan to eliminate cholera by responding to both sides of the epidemic—curing those who are ill and preventing further infections by improving water, sanitation, and hygiene (WASH) in rural and urban areas. To support those efforts, ZL formally began a WASH program in January 2014, applying its nearly three decades of expertise in programs related to health; water, sanitation, and hygiene; and disease control. The WASH team promotes behavioral change and supports the construction and rehabilitation of water and sanitation infrastructure at ZL- and government-supported clinics, hospitals, and schools.
“At the end of the day, if people are dying from preventable water-borne diseases, no amount of medicine or health care access will make a difference,” says Elizabeth Campa, ZL’s senior health advisor and advisor to the WASH program. “Without WASH, we do not have health.”
WASH staff face an uphill climb. Haiti is the most underserved country in the Western Hemisphere in terms of water and sanitation infrastructure, according to a 2012 report by the World Health Organization and UNICEF. Only 69 percent of the population has access to a clean water source and 17 percent had access to improved sanitation facilities in 2010. The latter is comparable to some countries in sub-Saharan Africa and far below the regional average of 80 percent for Latin America and the Caribbean.
The work of the WASH team was critical during the most recent waves of the cholera epidemic, and for the past two years, its rapid response team helped chlorinate water, disinfect homes, provide hand soap, and offer referrals to mobile cholera treatment centers.
WASH is also focused on long-term, community-based programs, such asCommunautes Assainies (Healthy Communities). Its goal is to reduce the prevalence of diarrheal diseases by 25 percent in 20 communities in and around Mirebalais and Cerca-La-Source within a 16-month period.
Since October 2014, the WASH team has supervised and provided technical support for community members who have built nearly 700 household toilets. The goal is to expand that number to 2,000 by January 2016. The team will also oversee the construction of water and sanitation facilities in 20 schools and five health centers over that same period.
A major, yet less visible, part of WASH's work involves improving social norms regarding hygiene and sanitation. The WASH team meets regularly with local leaders to understand common practices. Together they decide when to gather the larger community to inform residents on cholera’s reach in Haiti, its transmission through contaminated water, and its broader economic and social impacts. During those meetings, a volunteer committee is selected and asked to develop a plan for the community’s eventual certification as “open defecation free” (ODF). A local resident is chosen as the WASH community agent, tasked with smoothing neighbors’ transition to a new way of life.
Once activities are in full swing, WASH staff provide advice to community members on the proper location and maintenance of household toilets. Government officials and local representatives assess the community after several months' work and award ODF status once that goal is reached. They also continue to monitor the community to ensure residents remain faithful to their plan.
WASH can already point to success stories. Jeremy, a town in Cerca-La-Source, was certified this month an ODF community, and other towns have built dozens of household toilets and are working to change behavior regarding sanitation and hygiene—arguably the more difficult of the two steps.
Other WASH community projects under way in the Central Plateau include improving water, sanitation, and hygiene facilities in the Belladere hospital and Lacolline School in Lascahobas. And next year, WASH will begin improving facilities at 25 ZL- and government-supported schools.
“All our kids in the ZL network of schools will have a safe place to relieve themselves and access to water points for drinking and washing their hands,” Campa says. “My hope is that this project will plant a seed in our kids’ lives on the importance of sanitation, clean water, and good hygiene behavior.
“Adolescent girls will likely not miss so much school because they'll have a safe place to wash during their menstruation,” she adds. “And our team is striving to target the parents of these kids too in constructing their own household sanitation. The possibilities are endless.”
Thank you for supporting Partners In Health and our efforts to fight Cholera in Haiti. We’re thrilled to share excerpts from an article recently published on our website about the success of the Cholera vaccination campaign—made possible with the support of generous people like yourself.
When a cholera epidemic exploded in Haiti less than a year after the devastating earthquake in January of 2010, the staff at Partners In Health/Zanmi Lasante responded immediately and aggressively. We mobilized thousands of community health workers, opened cholera treatment wards, ran sanitation and hygiene initiatives, and more. A proposal to administer the new, World Health Organization-approved vaccine Shanchol was also floated.
The idea was doubted and criticized by many, but the community wanted the vaccine, and PIH/ZL was determined to provide the best care available. With the blessing of the Haitian Ministry of Health, PIH/ZL pushed ahead, and after overcoming all sorts of obstacles in distributing the tiny vials—training legions of staff, fighting the axle-gripping mud of rainy season, working around a simultaneous polio vaccination campaign, ensuring 45,417 patients swallowed two doses of the drug two weeks apart—the campaign finished in June 2012.
This past February, Dr. Louise C. Ivers and colleagues published a paper showing exactly how much the vaccine Shanchol slowed the spread of cholera in villages north of St. Marc, Haiti, in 2012. Writing in The Lancet Global Health online, the senior health and policy adviser at Partners In Health finds that Shanchol was widely effective when administered to thousands of adults and children in the region. “We found that there were about 65 percent fewer cholera cases among people that were vaccinated than there were in those that were unvaccinated,” she says.
It’s fantastic news, and not just for the obvious reason that fewer cholera cases means fewer cholera fatalities. ”Effectiveness of reactive oral cholera vaccination in rural Haiti: a case-control study and bias-indicator analysis” also reminds us of the importance of a vaccination campaign that almost never happened. And it paves the way for even stronger efforts to end the epidemic that has killed 8,800 Haitians and infected 20,000 last year alone. “It’s a huge victory,” says Dr. Ralph Ternier, director of community care and support at Partners In Health's (PIH) sister organization Zanmi Lasante (ZL).
“Our study contributes to mounting evidence that oral cholera vaccines have an important role to play as a component of comprehensive, integrated cholera control efforts in Haiti,” the study concludes.
As Dr. Ivers hints, the results of the study aren’t as earth-shattering as might be expected, but rather put a fine point on a cholera-fighting strategy that has become, well, standard. Since the vaccination campaign, the Haitian Ministry of Health, with the support of their partners, administered the vaccine to 300,000 citizens, and the World Health Organization has begun stockpiling the drug for use in future outbreaks.
In 2010, Partners In Health responded to the devastating 7.0 earthquake that struck Haiti, as well as the subsequent cholera outbreak. Above, community health workers conduct public outreach as part of the cholera vaccination campaign.
Thank you for supporting Partners In Health and our work to eradicate cholera in Haiti. Below is a reflection written by PIH/Haiti staff member Ralph Ternier, 5 years after the earthquake and subsequent cholera outbreak. Your support enables us to continue making progress and saving lives in Haiti.
Ralph Ternier is director of community care and support at Zanmi Lasante, Partners In Health’s sister organization in Haiti. Here he reflects on his experiences during the country’s earthquake in 2010—and the five years since.
A few days ago we celebrated the 211th anniversary of the famous Haitian Independence Day. This tiny land of contradiction has witnessed stunning and unfortunate events over the last two centuries. Some people keep saying the nation is damned; others who are attached to the country speak of hope, solidarity, and compassion, especially after having faced one of history’s most destructive and deadly earthquakes.
In a few days we will remind ourselves how fragile and precious life can be. For many years into the future we will tell our grandchildren about that day of sorrow. Some might refuse to believe such a narrative. Even I was incredulous toward what the Dominican taxi driver told me that Tuesday evening five years ago.
I had left Haiti to go to the Dominican Republic at 4:30 p.m. on January 12—20 minutes before my people plunged into the deepest desperation. I returned to Haiti two days later in a small airplane with two Partners In Health colleagues. From the sky I could watch the chaos on the ground—people with their belongings running away from death, an abyss of curse.
From that day on, we spent the whole year rescuing, saving, and relieving as many as possible, guided by one label: TNTC (too numerous to count). Then the first cholera epidemic in the country’s history hit, stressing and weakening the health system further.
But always there is opportunity.
We have learned particularly in this last decade that all these unfortunate events and disasters must be a platform to revitalize the health system. Five years after the terrible earthquake, it is important for us to reflect on our major achievements, impediments, and perspectives.
In addition to the roughly 1 million people that received emergency and general health care, we pride ourselves on the legacy of the teaching hospital in Mirebalais that came from all the international support. During 2010, Zanmi Lasante (ZL) understood that this massive contribution to the public health sector wouldn’t be productive without sustaining the community health structure. Therefore we formalized all ZL community activities through the new department of community care and support.
Very often we ask ourselves how we would adequately fight cholera without these tireless workers who still go door to door to raise awareness of the epidemic and ensure that community members are safe and protected. In many narratives we’ll frequently link cholera and the earthquake: they happened the same year, they created panic and chaos, and they took away so many lives.
But we have become stronger in the wake of these disasters. Our network of community health workers has grown to 350 members, and we now have several thousand accompagnateurs—compared to fewer than 100 before 2010.
Challenges, however, persist. The earthquake destroyed most of the important public health facilities in several departments, especially in West, where the needs of the surrounding population dramatically increased. To respond to these needs, the community network stepped up to expand services, such as rehab and mental health care in the communities.
A few days ago, I drove into the so-called downtown of Port-au-Prince. At points I felt as if I was living in 2010 as rubbles is still piled on many avenues. One of my friends in the car from the diaspora asked me how I kept morale and stayed in the country. With a beaming smile I responded with what someone had told me the day I came back: “This country cannot be worse; it can only be better.”
After five years, everything that we are doing for the health system, for the patients, must be better, better than what it was before 2010, better than what it was during the cholera outbreak—better for the sake of our beloved lost during these tragedies.
Photo: Carline, 29, received treatment for cholera at a Partners In Health cholera treatment center in Mirebalais, Haiti, in March.
We thank you for supporting Partners In Health and our work to treat and prevent cholera in Haiti. Below is an overview of our work since the outbreak began, as reported by Cate Oswald, Senior Program Manager for Parters In Health in Haiti. Your continued support allows us to address the ongoing needs of patients across Haiti. Often it is a very small amount of money that is required to save the life of someone infected with cholera.Comprehensive Cholera Response in HaitiCate Oswald, April 2014
Since cholera was introduced to Haiti in October 2010, it has killed more than 8,500 people, sickened more than 700,000, and become one of the world’s largest epidemics in recent history. To date, Partners In Health (PIH) and our Haitian sister organization Zanmi Lasante (ZL) have treated more than 105,000 cases in the Central Plateau, representing almost one-sixth of total cholera cases in Haiti. PIH/ZL has also worked in partnership with the nonprofit GHESKIO to vaccinate nearly 100,000 people in the first-ever oral cholera vaccine campaign in Haiti.
As it is clear that cholera is in Haiti for the long term, PIH/ZL remains committed to a comprehensive strategy for cholera prevention and treatment. With a main focus on providing high-quality treatment and care, our strategy has incorporated public education; aggressive case finding; oral cholera vaccine implementation; improved access to clean water and proper sanitation; and advocacy of stronger international policies and funding accessibility for cholera treatment and prevention in Haiti.
PIH/ZL is deeply committed to doing whatever it takes to stem the tide of cholera in Haiti. Each day, our community teams distribute chlorine solution so that people can treat their water, and our staff of dedicated doctors, nurses, cooks, cleaners, and infection control specialists work to prevent new infections and deaths from cholera. PIH/ZL maintains a level of preparedness, in the form of clinical staff and treatment supplies, to respond to spikes in cholera cases within our service area and ensure that all new cases are diagnosed and treated. We continue to provide cholera treatment services in the form of acute diarrheal disease units at each of the public hospitals where we work in conjunction with the MSPP.
Truly bringing an end to cholera in Haiti will require a coordinated effort: the government, private sector, and public sector must invest together in a comprehensive response, including long-term improvements in water and sanitation. PIH/ZL is dedicated to continuing advocacy efforts with governments and multilateral organizations to work toward a long-term solution for water security and infrastructure in Haiti, as well as disseminating far and wide the news of our successful efforts to comprehensively combat cholera. Research reporting the resultsof PIH’s cholera vaccination project in Haiti was recently published in The American Journal of Tropical Medicine and Hygiene.
Despite the fact that international funding for cholera prevention and treatment has diminished, we anticipate that health facilities will continue to see more cases and more deaths from cholera, particularly in rural areas. PIH/ZL continues to seek dedicated funding to ensure that we are able to maintain our comprehensive approach, prevent unnecessary deaths, and build on the progress Haiti has made in combating the cholera epidemic.
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