Tuesday, September 17, 2013

Cholera in Haiti By Deborah Sontag

Cholera in Haiti By Deborah Sontag

Posted by K T on September 16th, 2013
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 MIREBALAIS,Haiti— 
Jean Salgadeau Pelette, handsome when medicated and groomed, often roamed this central Haitian town in a disheveled state, wild-eyed and naked. He was a familiar figure here, the lanky scion of a prominent family who suffered from a mental illness.On Oct. 16, 2010, Pelette, 38, woke at dawn in his solitary room behind a bric-a-brac shop off the town square. As was his habit, he loped down the hill to the Latem River for his bath, passing the beauty shop, the pharmacy and the funeral home where his body would soon be prepared for burial.
The river would have been busy that morning, with bathers, laundresses and schoolchildren brushing their teeth. Nobody thought of its flowing waters, downstream from a U.N. peacekeeping base, as toxic. When Pelette was found lying by the bank a few hours later, he was so weak from a sudden, violent stomach illness that he had to be carried back to his room. It did not immediately occur to his relatives to rush him to the hospital.“At that time, the word ‘cholera’ didn’t  yet exist,” said one of his brothers, Malherbe Pelette. “We didn’t know he was in mortal danger. But by 4 that afternoon, my brother was dead. He was the first victim, or so they say.”
In the 17 months since Pelette was buried in the trash-strewn graveyard here, cholera has killed more than 7,050 Haitians and sickened more than 531,000, or 5 percent of the population. Lightning fast and virulent, it spread from here through every Haitian state, erupting into the world’s largest cholera epidemic despite a huge international mobilization still dealing with the effects of the Jan. 12, 2010, earthquake.The world rallied to confront cholera, too, but the mission was muddled by the United Nations’ apparent role in igniting the epidemic and its unwillingness to acknowledge it. Epidemiologic and microbiologic evidence strongly suggests that U.N. peacekeeping troops from Nepal imported cholera to Haiti.
“It was like throwing a lighted match into a gasoline-filled room,” said Dr. Paul S. Keim, a microbial geneticist whose laboratory determined that the Haitian and Nepalese cholera strains were virtually identical.“In the future, historians will look back and say, ‘Wow, that’s unfortunate,”’ said Dr. Paul Farmer, co-founder of Partners in Health, a nongovernmental organization that provides health care for the poor.While the world has dedicated $230 million so far to combating the unexpected epidemic, the United Nations is now pleading for an additional $53.9 million just to get the vulnerable displaced population through the rainy months ahead.
“In telling the truth, the U.N. could have gained the trust of the population and facilitated the fight against cholera,” said Dr. Renaud Piarroux, who led an early investigation into the outbreak. “But that was bungled.”The United Nations maintains that an independent panel of experts determined the evidence implicating its troops to be inconclusive.Questioned for this article, though, those same experts said that Keim’s work, conducted after their own, provides “irrefutable molecular evidence” that Haiti’s cholera came from Nepal, in the words of G. Balakrish Nair, an Indian microbiologist.“When you take the circumstantial evidence in our report and all that has come out since, the story now I think is stronger: The most likely scenario is that the cholera began with someone at the MINUSTAH base,” said another expert, Daniele Lantagne, an American engineer, using the French acronym for the U.N. mission.Even so, Anthony Banbury, a U.N. assistant secretary-general, said last week, “We don’t think the cholera outbreak is attributable to any single factor.”And many health officials consider the cholera response “pretty remarkable,” as John Vertefeuille, the Centers for Disease Control and Prevention’s director in Haiti,said.
A sky-high initial fatality rate of over 9 percent has declined to 1.3 percent (less than 1 percent is considered a well-managed epidemic). And the most recent statistics show new cases dropping to 120 daily.
One calamity after another
Here in the epicenter of the epidemic, all signage relates to life in the time of cholera. Surrounding the town square are heart-adorned posters that say, “Living with cholera: Always wash your hands with clean water and soap.” Banners slung across the streets, in contrast, bear skulls and crossbones: “Justice and reparations for all victims of the MINUSTAH cholera.”Inside City Hall, the deputy mayor, crisply dressed in a chambray shirt and slacks, described how he personally buried 27 bodies for fear that workers would not take precautions, how he nearly lost two of his own children to cholera and how he seethed every time Nepalese troops entered his offices.“They were in my face every day, and the feeling inside me got stronger and stronger,” said Ocxama Moise, the deputy mayor.
Haiti had escaped the cholera that raged through Latin America in the 1990s, and even the cholera that struck the Caribbean in the 19th century. It appeared “extremely unlikely” that cholera would present itself, a CDC post-earthquake brief said.But on Oct. 8, 2010, hundreds of Nepalese troops began arriving in Haiti after a cholera outbreak in their homeland, where cholera is endemic.Cholera affects individuals differently; many infected develop no symptoms or only mild or moderate diarrhea.
Falling violently ill in October 2010, Pelette was not one of the lucky ones. Severe cholera causes profuse watery diarrhea, often accompanied by vomiting. Treatment is straightforward: replacing lost fluids and electrolytes, orally or intravenously. But those like Pelette who get no treatment can become so dehydrated that they go into shock and swiftly die.Nobody knows for sure, but people here believe that Pelette was the first Haitian to die of cholera, and, though he was not named, he was presented as the “first case” in the American Journal of Tropical Medicine and Hygiene in January.
Enter the epidemic A couple of hours after Pelette died from what the family priest proclaimed to be a poison of some sort, Rosemond Laurime, 21, a “small-business man” in his family’s description, got sick in nearby Meille. From Meille, the epidemic coursed through the Artibonite River valley, landing with a thump 46 miles northwest, and downstream, in the coastal St. Marc area. On Oct. 19, three children died in rapid succession in a classroom in the rice fields. On Oct. 20, the St. Nicholas Hospital was overrun.Patients sprawled on every surface, doubled and tripled up on beds, in the halls, in the courtyard and even on the sidewalk outside. By nightfall, there were 404. Forty-four died.“At that moment, I felt like I didn’t want to live any longer myself,” said Dr. Yfto Mayette, the hospital director. “It was so sudden and so brutal.”
On Oct. 21, as a brass band accompanied Pelette’s white coffin to the cemetery, the national laboratory completed its analysis of the bacteria.At 11 that night, Dr. Jordan W. Tappero of the CDC got a call in Atlanta from the laboratory’s director: “Jordan,” he said, “It’s positive.”Louise C. Ivers, Haiti mission chief for Partners in Health, had just arrived in Boston for a meeting. “My first thought was, ‘You can’t be serious.’ Everyone was exhausted.”
InPort-au-Prince, Jocelyne Pierre-Louis, a senior Haitian health official, had steeled herself. “We were in a way waiting for the other shoe to drop,” she said. “We had barely picked ourselves up after the earthquake when the cholera fell on us.”Pierre-Louis reported to the large tent that replaced her collapsed office after the earthquake. Ivers took the next plane back, and Tappero flew in, too, with the first of 119 CDC employees who would deploy toHaiti.There was much to do, from treating patients to treating water, from importing personnel to training Haitians, from distributing supplies to distributing basic disease and hygiene information.But there were also fundamental decisions to be made, and nobody was firmly in charge. International health officials deferred to the Haitians — “our partners” — but in reality held the purse strings and know-how. This led to an often awkward collaboration, colored by Haitians’ resentment that cholera had been imported in the first place.Gaetan Drossart, mission chief for Doctors Without Borders-Belgium, said the “health cluster,” a consortium of humanitarian groups, had good intentions, “but there’s a lot of meetings and a lot of blah blah blah.” He said other groups were limited by agreements with donors to working in the earthquake zone and could not redeploy quickly.
Truth vs. ‘The Blame Game’
 Within a week of the outbreak, officials in Mirebalais were pointing fingers at the U.N. base, and U.N. officials were trying to stifle what they portrayed as rumors. The struggle began between those who thought that determining the epidemic’s origin was important and those who lamented “the blame game.”
 At first, the United Nations said the base’s handling of its waste met international standards — that it used sealed septic tanks, which were regularly emptied by a Haitian contractor, with the waste buried in a proper landfill.
 But on Oct. 27, Al-Jazeera filmed peacekeepers with shovels “working furiously to contain what looks like a sewage spill.” Latrines appeared to be emptying black liquid directly into the river, a reporter said, and the air smelled foul with excrement.
 Even four months later, the United Nations’ own experts, examining the base’s supposedly improved sanitation, discovered haphazard piping with “significant potential for cross-contamination” between toilets and showers.
 They also noted the “potential for feces to enter and flow from the drainage canal running through the camp directly” into the tributary. Contaminants would have been distributed throughout the river delta in two or three days — a timeline consistent with epidemiological evidence tracing the cholera trail, the experts said.
 Before long, hundreds of Haitians were marching on the base, with demonstrations spreading to Port-au-Prince and riots developing in Cap Haitien.
 Edmond Mulet, then head of the U.N. stabilization mission, complained that it was “really unfair to accuse the U.N. for bringing cholera into Haiti.” U.N. officials believed that agitators were taking advantage of the issue to sow unrest before November elections. But many Haitians were genuinely incensed — and fearful. Some wanted an explanation, others a scapegoat. Voodoo priests were being lynched for their supposed role in bringing the curse of cholera on Haiti, the government said.
 In early November, the CDC said that Haitian cholera samples matched strains commonly found in South Asia.
 Money and lives
 From the start, financial concerns colored the response to the epidemic, which had killed more than 3,600 Haitians by the first anniversary of the earthquake. It was partly a question of getting money flowing. Some donors hesitated, given the plodding pace of the earthquake reconstruction; others had to wait for a new budgetary year. Some institutions had time-consuming grant or contracting processes.
 It was also a question of philosophy.
 Some health officials wanted to use the least expensive prevention and treatment strategies and to marshal resources for the long battle ahead.
 Others wanted to employ every available weapon at once, from free drinking water and antibiotics to aggressive case-tracking, mass vaccination and water and sewer system building.
 If that meant spending more upfront, so be it, they said. A year after the earthquake, many organizations were sitting on donations that remained unspent. The American Red Cross, for one, still had nearly half of the $479 million it had raised; it would ultimately dedicate $18 million directly to cholera prevention and treatment. Doctors Without Borders would spend $45 million.
 Farmer of Partners in Health, who calls himself “a maximalist,” said he wanted “health equity” — for the developed world to respond to cholera in Haiti as it would at home.
 His organization initially requested potable water be trucked into the Haitian heartland so that a traumatized population would not have to filter and treat its water. Purification tablets were delivered instead because it was considered cheaper and simpler, he said.
 There was also a reluctance to use antibiotics, which can reduce diarrhea, spare suffering and potentially limit the disease’s spread.
 The Cubans alone dispensed antibiotics to all cholera patients and preventively to their relatives.
 World health authorities, concerned with cost and drug resistance, initially said antibiotics should be reserved for severe cases. Nearly three months later, the CDC recommended antibiotics for moderate cases, too.
 Delay and disbelief
 In February 2011, nearly four months after the outbreak, the United Nations’ independent experts arrived inHaiti.
 The secretary-general’s office wanted them to move quickly but not too quickly; it did not want the findings released until the Nepalese contingent had concluded its six-month rotation, Lantagne said.
 The panel said not only that the cholera had come fromSouth Asiabut that it originated in the tributary behind the Nepalese base.
 Yet the U.N. experts noted that “the introduction of this cholera strain as a result of environmental contamination with feces could not have been the source of such an outbreak without simultaneous water and sanitation and health care system deficiencies.”
 And they diplomatically concluded that the epidemic was “not the fault of, or deliberate action of, a group or individual.”
 After the U.N. panel dispersed, Danish and American scientists collaborated to scrutinize the Haiti-Nepal connection using the most comprehensive type of bacterial genetic analysis — whole-genome sequence typing.
 Dr. Rene S. Hendriksen ofDenmarkpersuaded the Nepalese to provide samples from their outbreak. Keim’s Translational Genomics Research Institute inArizonasequenced the DNA, comparing it with Haitian samples already sequenced by the CDC.
 The Haitian and Nepalese strains were virtually identical.
 Citing this study and other evidence, a legal claim was submitted to the United Nations in November on behalf of Haiti’s cholera victims.
 The victims’ lawyers have asked the United Nations to establish a commission to hear the claim. Banbury of the United Nations says the claim is “under serious review by the legal affairs department.”
 “The U.N.’s choice is simple,” the lawyers wrote in a legal article. “It can rise to the occasion and demonstrate that the rule of law protects the rights of poor Haitians against one of the world’s most powerful institutions, or it can shrink from the challenge and demonstrate that once again in Haiti, ‘might makes right.”’
 A breather, and then disaster
 It is tempting now when reported cholera cases are at a low for Haitians to relax their guard and for health officials to take a breather.
 “We are no longer 24/7 cholera,” Pierre-Louis said. The same thing happened last year. Then the rains hit andPort-au-Prince, like other places, experienced more cases — 24,000 — during a 42-day period than at the epidemic’s start. It was a scramble to deal with the surge; many grants had expired, emergency workers had gone home and treatment centers were closed.
 “We had supplies and structures prepositioned but it wasn’t simple,” said Drossart of Doctors Without Borders. “We couldn’t keep mobilizing staff forHaiti. There are other things going on in the world.”
 Vertefeuille of the CDC said a key focus now was making the response sustainable without a large international presence. But the government health system, weak and underfinanced, will be hard-pressed to assume greater responsibility.
 Vertefeuille also said cholera was likely to persist inHaitiabsent the development of water and sanitation systems, the cost of which has been estimated at $800 million to $1.1 billion.
 A singular achievement was the opening of Haiti’s first wastewater treatment site last fall. But humanitarian groups fret that short-term water and sanitation solutions are not being pursued aggressively, and that tent camps have lost the free water and, in some cases, the latrine services that gave them a buffer against cholera.
 Many also express keen frustration that the dry season is not being used for aggressive case tracking — chasing the disease into pockets where it flares, investigating and chlorinating the water source and mobilizing the community.
 “You can’t wait with your arms crossed until the rain falls again,” Piarroux said. “You have to go after these areas like firemen trying to extinguish every last burning ember of a forest fire.”
 ‘Would have burned it down’
 In Meille, the walled gate at the U.N. base is freshly painted now with the insignia of Uruguayan peacekeepers. The Nepalese are gone.
 The mission itself is reducing its forces nationwide.Nepal’s troop strength is being cut by two-thirds, more than any other country’s. U.N. officials said that this was unrelated to tensions over cholera.
 But people here think otherwise: “If they hadn’t left, we would have burned it down,” Moise, the deputy mayor, said of the base.
 Behind the base, the stream where the epidemic began bustles with life now as it did before the outbreak; many who live and work beside it have no other access to free water.
 Recently, just behind the base’s barbed-wire periphery, Dieula Senechal scrubbed exuberantly colored clothes while a 6-year-old girl, Magalie Louis, splashed into the water to brush her teeth.
 Approaching with a machete on his way to hack some cane, her father, Legenord Louis, said Magalie had contracted cholera late last year but after four days of “special IVs” was restored to health. He knew the river water was probably not safe, he said, but, while they brushed their teeth in it, they did not swallow.
 For drinking water, Louis said, his family relies on a local well. But he lives from hand to mouth and cannot afford water purification tablets; the free supply he got in 2010 ran out long ago. So he gambles.
 “If you make it to the hospital,” he said, “you survive the cholera.”

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