By Anthony Robbins, MD, MPA
I am surely not an expert on cholera. I have never seen a patient with the disease. And I have never been to Haiti. Yet I keep reading about the epidemic in Haiti. The first case reports appeared in October 2010, about 10 months after the powerful earthquake that shook Haiti. Unrepaired damage to hospitals, clinics, and roads made it difficult to bring oral rehydration to patients with cholera. The country lacked potable water and infrastructure to treat human fecal waste. By 2014, at least 700,000 Haitians had been infected and more than 8000 had died. The disease continues to spread.
Cholera had spared Haiti for a century or more, so it was not unreasonable that people asked where did the pathogen come from in 2010. But public health people might have explained that the question was a distraction. Why so? Very simply, knowing how Vibrio cholerae arrived in Haiti would not help control its spread or prevent future outbreaks.
As Declan Butler reported in Nature: “Cholera is a disease of poverty, and spreads rapidly in communities lacking clean water supplies and sanitation.” “Until clean water and sanitation are readily available in Haiti, cholera outbreaks will continue.”
Early this year I realized that this public health message was often shoved off course.
- At a board meeting of the Public Health Advocacy Institute, a lawyer working with Haitian cholera victims told us of his efforts to win compensation from the United Nations. It seems that the strain of cholera afflicting Haiti came from Asia and may have been imported by Nepalese soldiers participating in earthquake relief efforts.
- A similar focus on the source of the Vibrio cholerae received excessive attention in a draft policy statement for the American Public Health Association.
I pulled out my editor's pen and wrote an Editorial for the Journal of Public Health Policy. Now I have been invited to opine on cholera in Haiti on Scientific American's guest blog. In my JPHP editorial, I wrote:
The bottom line is that all low-income countries that lack potable water and sanitation are vulnerable. Haiti presented an ideal environment for cholera to spread. But it might have struck other communities in other countries. The world must invest in the infrastructure that will prevent the kind of epidemics we are witnessing in Haiti. Most of the world, middle- and high-income countries, was made safe from cholera before we could identify the pathogen or treat the disease with oral rehydration fluids.
Anthony Robbins, MD, MPA is co-Editor of the Journal of Public Health Policy. He directed the Vermont Department of Health, the Colorado Department of Health, the U.S. National Institute for Occupational Safety and Health, and the U.S. National Vaccine Program.
From your editorial:
"But how cholera got to Haiti offered little help in ending the outbreak or preventing future ones once the disease was spreading. The source didn’t much matter."
It true that the source didn't much matter .. to the UN, or to the developed world.
One lesson we can learn from the cholera epidemic in Haiti is that it is *clear* that it matters very much to the Haitians.
I think the point is that identifying down the source doesn't help us stop it. We know how to stop it: Safe drinking water and sewers.
Unlike, say, measles, cholera elimination can be robust. Once you've got sanitation systems established, there won't be another epidemic even if it's reintroduced by travel.
How many months' worth of Iraq War budget would it take to build a viable water & sanitation infrastructure in Haiti?
Would it help if there was an Al Qaeda cell in Haiti to trigger a US military response?
If Haiti can't get help from the UN, the gov there could broadcast an appeal to Al Qaeda to let them join. This sounds like a crazy idea, but if it happened, it would instantly go viral and get results.
Think of the old film "The Mouse That Roared."
There are two issues here. One is the value of knowing what started an epidemic (as stated, we already know what causes underlying vulnerability). It's useful to understand that because putting in place screening for foreign peacekeepers can be more cost-efficient than building a water-sanitation system in the middle of a crisis/conflict. But secondly, there is the question of justice and compensation if the outbreak was caused by gross negligence, like dumping untreated sewage into the main water source of a large community.
This post seems to dismiss both of these important perspectives.
Of course it mattered to know the source of the cholera! It was critical to ensure that the latrines of the camp of the Nepalese soldiers were relocated away from the river that was a source of water to the population downstream. I posted a comment in this blog at the time complaining that all I heard in the radio was about how medics were treating the sick people; not one word about educating the people on how to avoid contaming the water. Every refugee camp where there was an outbreak of cholera should have been inspected to ensure latrines were built away from rivers and water wells. It is not expensive to provide water tanks (in the military we called them "water buffaloes") with chlorinated water. It takes a small amount of bleach to chlorinate 500 gallons of water. The military has water purification machines that use diatomaceous earth to filter water for the troops. These machines must be standard part of any emergency response to countries and communities affected by natural disasters. I never heard they were used in Haiti.