“Padon pa geri maleng” (“Sorry doesn't heal the scars”)
Am. J. Trop. Med. Hyg.
The Tropical Bookshelf “Padon pa geri maleng” (“Sorry doesn't heal the scars”)
Disasters, discord, poverty. What hardened heart doesn’t
ache for Haiti? Fifty years after Columbus’s arrival, Hispaniola’s
natives were decimated by disease; by the mid-1700s, French
overlords were exploiting Haiti’s African slaves. Then came
revolution, independence, and more upheaval. Finally, in
2004, after its first democratically elected president was
ousted by a coup, the United Nations sent an international
force to Haiti.
Six years later came the double whammy from hell. In
January 2010, an earthquake killed or injured half a million
Haitians; in October 2010, a massive fecal spill sowed
Vibrio cholerae in the Artibonite River.
Today, no one denies that Haiti’s modern epidemic
stemmed from that tragic leak of sewage from a UN
peacekeepers’ camp. But it was not until August 2016 that
UN Secretary General Ban Ki-moon admitted the fact.
When he did, retired University of California, Los Angeles
epidemiologist Ralph Frerichs was ready. Having recently
published Deadly River—Cholera and Cover-up in
PostEarthquake Haiti, Frerichs wrote in the Boston Globe: “It is
not enough that the United Nations is finally beginning to
acknowledge its involvement in the lethal cholera epidemic
in Haiti. Now it must urgently do everything in its power to
eliminate cholera in Haiti before thousands more die.”
(The comments were sadly prescient. In the wake of
Hurricane Matthew, cholera’s grisly toll of withered, gray corpses
can only continue to rise.)
In Deadly River, Frerichs largely channels Renaud
Piarroux, a French infectious diseases doctor who
previously battled cholera in Comoros and the former Zaire. Days
after cholera’s Caribbean touchdown, Piarroux flew from
Marseille to Port-au-Prince at the request of the Haitian
government. And here the story begins.
In addition to Piarroux’s personal investigations and
uncensored thoughts, what distinguishes Deadly River is its
deep dissection of cholera and the bond of its two main
spokesmen. With equal parts of compassion, analysis, and
sometimes strident outrage, Frerichs and Piarroux present
timelines, maps, and reports illuminating the truth. Yes, it
really was “a large septic plume” emanating from the Nepalese
camp near Mirebalais, they show us time and again, that first
sullied the Artibonite and later, due to Haiti’s woeful lack of
sanitation, engulfed the entire country—“not,” as others at the
time proposed, an influx of free-living Vibrios from brackish
waters near the port of Saint Marc. By the end of the book,
we are also convinced that several key actors and pundits
conveniently sidestepped this truth. For readers who long to
see the underside of a fast-moving epidemic including sins of
omission and realpolitik, Deadly River does not disappoint.
Which is not to say it is perfect. For one thing, it
contains a lot more “woulda, coulda, shoulda” than empathy
for health workers coping with chaos. Some of the good
guys are members of the Brigada Médica Cubana who
rehydrated thousands at the height of the crisis; the Centers
for Disease Control and Prevention (CDC), World Health
Organization (WHO), and respected nongovernmental
organizations (NGOs) receive far fewer plaudits. Also missing
are voices of everyday Haitians.
Looking back with 20/20 hindsight, of course it would
have been smart to screen Nepalese troops for cholera
before they ever set foot in Haiti, just as it would have been
prudent to better control their compound and sewage. “The
UN meant well but boy did they screw up and has the world
learned its lesson . . . .” is one commonly held sentiment
Deadly River never quite concedes.
That said, no scientific history can speak for every opinion
or stakeholder. In its quest for justice for Haiti, Deadly River
serves a virtuous cause. In its staunch pursuit of truth, it also
feels heroic. And talk about timing! Now that the United
Nations has finally said it will strengthen its anti-cholera
efforts in Haiti and compensate victims, that Portugal’s
Antonio Guterres has succeeded UN Secretary General
Ban Ki-moon, and that a new natural disaster has seized
our attention, what better moment to reexamine the past
and push for redress?
For further perspective on cholera in Haiti, the American
Journal of Tropical Medicine and Hygiene (AJTMH) turned
to Louise Ivers, senior health and policy advisor for
Partners in Health (PIH). Following the 2010 earthquake, Ivers
oversaw PIH’s on-the-ground cholera operations and also
partnered with GHESKIO (a Haitian NGO) in pioneering
studies of oral cholera vaccine, a new, cost-effective tool
that is rapidly gaining adherents. Ivers now divides her
time between Haiti and Boston, where she is a faculty
researcher in the Division of Global Equity at Harvard
Medical School and a practicing infectious diseases clinician at
Brigham and Women’s Hospital.
FIVE QUESTIONS FOR LOUISE IVERS
Please share some of your earliest memories of the
2010 cholera outbreak in Haiti. Where were you? What
were you doing? And how did cholera affect PIH? The
day the outbreak exploded was very memorable. Early that
morning, we had a meeting in Mirebalais, which included
our CEO and cofounder. All of our Haitian leaders were
present except for one colleague. When I texted to ask
why he was late, he said he had been up all night dealing
with 400 cases of diarrhea. Exhausted, he finally arrived
and gave us a harrowing description of what was going on.
After that, everything moved quickly. Our hospital staff
alerted the authorities; a few days later, our teams were
seeing patients with diarrhea in all 12 of our clinics. The
communities were afraid—hundreds of people were dying—
everywhere I went there were sick people and funerals. One
afternoon, we went in an ambulance to pick up one patient
and returned with five more we collected along the way.
Staff were exhausted, but they were absolute champions.
We also partnered with other organizations. By November,
there were cases in the displaced persons camps we were
supporting in Port-au-Prince, including one camp with
45,000 people where we were the lead agency.
THE TROPICAL BOOKSHELF
When did everyday Haitians know or suspect that
cholera had been imported by UN peacekeepers, and
what happened next? People in Haiti quickly started
reporting that the UN was responsible for the outbreak.
Even before the news broke in international newspapers,
there were protests in Mirebalais. At the peacekeepers’
base, people were carrying placards and shouting slogans
against the UN. As for me . . . you know, in the first days and
weeks we were just so busy trying to take care of thousands
of people in our clinics, setting up treatment facilities,
distributing water products, getting community health workers
trained, lining up staff, etc., I did not pay a lot of attention to
the protests except to instruct that we not stage a big
shipment of buckets at the UN base as we had planned; I did
not want people to think that our activities and the UN’s
activities were related. We already had our hands full trying
to uphold peoples’ trust in our management of the disease.
During that time and continuing to the present, PIH worked
with the community. We held focus groups, met with local
leaders, and participated in many meetings and discussions.
For me, this is the real benefit of being fluent in Haitian
Creole. The stories I heard were humbling. There was so
much suffering and so much fear. People lost whole
families to cholera in a wave of illness that they (and we) had
never before experienced. Hougans (local Voudou priests)
joined our discussions—we like to engage them in our
work so they refer certain patients to the hospital. In large
part, the hougans I spoke with quickly realized that cholera
was a “maladi dokte”—an illness for doctors to treat—and
referred many patients to the clinics.
Please discuss some major lessons you learned from
your work with oral cholera vaccine. The biggest lesson I
learned is that it is absolutely necessary to challenge the
status quo in public health. If something does not make
sense you have to ask why. In 2010, many experts were
saying that OCV was too expensive, that it would not work
in Haitians, that they would not come back for their second
dose, that it would distract from WASH activities, and that
“they” would stop washing their hands. Bottom line: these
attitudes were very dogmatic and anti-poor. It was so hard
to convince the powers-that-be that we only wanted to
“add” vaccination to the toolkit. In high-level meetings, we
were shamed when people called our solution “gold plated”
or “too expensive” or “unrealistic,” but we and GHESKIO
persisted in our advocacy.
Then, a year after the outbreak started, Haiti’s Minister
of Health transitioned; the new Minister immediately called
us and said she wanted to move forward with the idea.
In December, she called a meeting of partners to formally
request a pilot campaign. The night before—it was a big
risk as it cost us almost half a million dollars—PIH found its
own funding and purchased all available doses. We were not
permitted to use CDC funds—WHO created obstacles—
some unknown person even called a local radio station and
said we were experimenting on Haitians (since the vaccine
was already WHO approved and had previously tested safe
and effective in other populations, it was not true, of course).
Finally, after we halted our campaign for a number of weeks
and testified at a national bioethics committee, we were
able to proceed. The American Red Cross gave us 1 million
U.S. dollars for the vaccination campaign, a very tangible
and forward-thinking investment for Haiti.
In sum, my view is neither pro- nor anti-vaccine, but it is
“pro-poor,” and “pro-evidence” and
“pro-using-all-the-toolsyou-have.” If we had a cholera epidemic in Boston (which
would never happen, but let’s just say . . . .), we would use
all available tools to stop it. But when certain people say
that something is too hard or too expensive or not worth it,
they tend to be people who are not truly affected. No one
discussing oral cholera vaccine in the Minister’s office was
ever at risk of dying of cholera. But to save their families,
the people who were at risk of dying were eager for any
possible solution; that is no exaggeration.
Now the tone has changed a lot. Not only is oral cholera
vaccine recommended by WHO, many countries are using
it in outbreaks.
Going forward, what are the implications of the United
Nation accepting responsibility and paying reparations
for a disaster caused by their own negligence; is this a
good precedent or not? I think it was critical that the UN
accept responsibility. The UN caused a disaster in Haiti
and their mandate is to help. I do not blame an unfortunate
single soldier, but the military base should have been
constructed [in such a way] to ensure a safe environment;
human waste should not have leaked or been dumped into
the river. From a legal standpoint, Haitians deserve justice.
However, since I am not a lawyer myself, I have always
focused on the moral argument, namely, that the UN should
help to fix the problem they started. At times, their annual
budget for Haiti has been as high as 650 million U.S.
dollars, although it is less now. So it is not that the UN cannot
afford to address the problem; it is a case of member states
agreeing that Haiti is a priority. Not only have lives been
lost, the epidemic has placed a huge economic burden on
families and the health system. Haitians should also be
compensated for that as well as for their suffering.
What do you and PIH see as a realistic cholera
elimination strategy in Haiti and the respective roles that civil
society versus government might play in achieving that
goal? In Haiti, the central government does not have the
resources to do everything that is needed and often
changes, but local and regional technical managers and
directors are more stable. And civil society is extremely
strong. If PIH accomplishes anything it is only by staying
engaged with civil society and the communities we serve. We
believe that the combined, integrated approach to cholera
control—in other words, combining household water and
sanitation interventions with oral vaccination as an urgent
means of stopping transmission—could prove successful in
the next 2–5 years. In the long term, say 10 or 20 or 30 years,
achieving universal access to water and sanitation would
eliminate cholera altogether.
Addendum: At the time of e-publication, AJTMH learned
that a million doses of oral cholera vaccine are now in Haiti
for use in a new, innovative, single-dose campaign.
This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the
original author and source are credited.