Project #6629

Help PIH Respond to Cholera Outbreak in Haiti

by Partners In Health (PIH)

Thank you for supporting Partners In Health/Zanmi Lasante and our efforts to end the continuing cholera outbreak in Haiti.

Nearly six years after arriving in Haiti, cholera is still sickening and killing thousands of Haitians. According to recent government figures, over 770,000 Haitians - 7% of the country's population - have suffered from cholera. 9,200 have died. So far in 2016, more than 6,000 have fallen ill, and on average 37 people are dying per month.

Cholera occurs so regularly in Haiti that World Health Organization officials now consider it endemic to the country. Many researchers point out that the cholera bacterium has likely become established in the country's rivers, estuaries and coastal waters, making the illness that much harder to eradicate. Not to mention the fact that only 24% of the population has access to toilets, meaning that adequate sanitation and safe water - keys to beating cholera - are unavailable to the vast majority of Haitians.

Dwindling international support for cholera eradication compounds these issues. In 2010, when cholera first hit Haiti, over 200 international organizations were offering financial and policy assistance. Fewer than 12 of these organizations are still providing these resources, which has slowed relief efforts and helped allow cholera to rage on.

PIH's senior health and policy advisor, Dr. Louise Ivers, commented, "We need to raise our expectations of what's possible to do in Haiti and other countries in terms of these diseases that we've completely eliminated from our own societies."

PIH/ZL continues to fight cholera through treatment and prevention. Our staff of local community health workers accompany cholera patients to treatment at PIH clinics; open rehydtration posts in remote locations; educate communities about santitation; and work to establish adquate sanitation and water systems.

Your support makes this lifesaving work possible, and along the way helps redefine what's possible in global health. From all of us at PIH, thank you!


Photo by Calixte Wilsonn/Partners In Health
Photo by Calixte Wilsonn/Partners In Health

Thank you so much for your generous support of Partners In Health and Zanmi Lasante’s efforts to treat and prevent cholera in Haiti.

Cholera continues to plague Haiti, particularly at the border shared with the Dominican Republic. Political tensions and a consequent migrant crisis have resulted in makeshift camps throughout the region, populated by thousands of Haitian migrants who fled the Dominican Republic among threats of violence and deportation. These camps are overcrowded and lack adequate sanitation – two conditions that have allowed cholera to spread and, according to a December 2015 New York Times report, infect more than 100 people.

PIH and ZL are working to treat cholera within the borderland. In the below excerpt from an article on PIH’s website, Dr. Alexandre Widner (pictured above, left), PIH’s border health activities coordinator in Haiti, comments on this political and medical crisis.

"Despite many signs of brotherhood between Haiti and the Dominican Republic, which share the island of Hispaniola, the binational relationship is worsening each day due to a high peak of migratory tension. According to various sources, more than 500,000 Haitians live in the Dominican Republic, more than 75 percent of whom lack identifying documents (a passport or identity card), which leads to constant marginalization, stigmatization, and discrimination—including torture by some authorities along the border. To make matters worse, on September 23, 2013, the Dominican Republic’s Constitutional Tribunal published Law TC 168-13 with a retroactive clause that eliminates the citizenship of thousands of Dominicans of Haitian descent who have lived in the country since 1929.

Despite the fact that mass deportation would expand the humanitarian crisis in Haiti on top of the impact of the major 2010 earthquake, the Dominican migration office started in August the expulsion of thousands of Haitian migrants and Dominicans of Haitian descent (who are now stateless) out of profound xenophobia. Since then it’s estimated that more than 65,000 people were deported or forced to leave the country, causing an alarming situation at several unofficial and official border points, including Ouanaminthe, Belladère, Malpasse, and Anse a Pitres. In Anse a Pitres, the repatriated and stateless live in open-air camps at high risk of extreme poverty, child malnutrition, juvenile delinquency, and an increase in death due to cholera, malnutrition, and malaria—among other diseases.

Clinicians are providing care to patients primarily for infectious diseases like HIV, tuberculosis, and cholera and for children under 5 suffering from moderate or severe malnutrition. The number of hospital births has increased considerably thanks to a dynamic collaboration between Zanmi Lasante and the Ministry of Health in these remote communities.

While we recognize the right of the Dominican Republic as a sovereign nation to pass laws or create fair and inclusive immigration policies within its territory, we demand justice for the flagrant violation of human rights executed by a brother country towards thousands of stateless Dominican brothers and sisters. Together we shout: “No to violence, no to racism!”

Long live solidarity between the people!"


Rebecca E. Rollins / Partners In Health
Rebecca E. Rollins / Partners In Health

 (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.

Photo by Isaac Benito / Partners In Health
Photo by Isaac Benito / Partners In Health

(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.


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Organization Information

Partners In Health (PIH)

Location: Boston, MA - USA
Website: http:/​/​
Project Leader:
Laura Soucy
Annual Giving Coordinator
Boston, MA United States

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