Haiti After the Earthquake (33 page)

Those seeking to deliver services—to diagnose and treat cholera, a disease about which they were learning, and to prevent it whenever possible—were of course affected by these social responses, which soon became violent. Within weeks of the first cases, the papers contained reports—some unconfirmed—of crowds throwing stones at UN peacekeepers' armored personnel carriers and, in one case, at UN helicopters seeking to land medical supplies in northern Haiti:

After returning from Rwanda, I wanted to discuss with Edmond Mulet why it might be prudent to investigate the source of the outbreak, and also to call for aggressive measures to prevent, detect, and treat cholera cases. Mulet wasn't at the UN log base when I arrived, so I left him a book I wrote more than a decade ago, which describes the predictable responses to epidemic disease that we were seeing with cholera. When I returned a few days later, Mulet had read most of the book, highlighting passages with a yellow marker. He was much taken by the similarities between the social responses to cholera and those registered in the eighties and nineties to AIDS and tuberculosis. Mulet estimated that half of all countries contributing troops to MINUSTAH (UN Stabilization Mission in Haiti) experienced regular outbreaks of cholera, and was disturbed by the focus on the Nepalese battalion. I understood his point and promised him that my comments were (to use the words of another UN friend, who had narrowly survived the quake), “eminently technical.” We needed to identify the strain, get an idea of what it was likely to do in Haiti, and deploy every tool in the international arsenal against it. Mulet agreed. On November 20, he told the Associated Press, “We agree with him that there has to be a thorough investigation of how it came, how it happened, and how it spread … There's no differences there with Dr. Paul Farmer at all.”
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Gratified as I was by Mulet's clarification and support, we weren't seeking validation. We wanted to work together to strengthen efforts against a transnational epidemic. I was en route to Mirebalais to check on the hospital's progress, which had slowed after some of the Dominican engineers and contractors we'd hired left central Haiti during the cholera outbreak. But our Partners In Health and Zanmi Lasante teams had nowhere to go; we expanded our cholera work as we sought to keep the Mirebalais hospital on schedule.

The rural hinterlands and slums outside the quake zone suffered more than the camps, but all those unable to buy clean, filtered
water would suffer. Although some found it perplexing that cholera largely spared the camps and instead laid waste to central Haiti, it was no surprise to those of us at Partners In Health and Zanmi Lasante. Our own small water projects over the years had humbled us about our ability to stave off epidemics of waterborne disease. We could protect certain villages, but the great majority of the rural population still lived without ready access to potable water and modern sanitation. Without a massive and coordinated scale up of such projects to help strengthen municipal water and sanitation systems, there was no way we could keep pace with cholera in rural Haiti.

Although prompt rehydration—simple fluid resuscitation with a well-known solution—could save almost anyone with cholera, most health providers were unprepared for the waves of people who walked, or were carried, into clinics and hospitals throughout central Haiti. The Cubans got right to work, as did some of the Médecins Sans Frontières groups. (There were so many borders between these doctors without borders that it was hard to figure out who was who.) Stefano Zannini, chief of a Médecins Sans Frontières mission in Haiti, called for more helpers and more collaboration: “More actors are needed to treat the sick and implement preventative actions, especially as cases increase dramatically across the country … There is no time left for meetings and debate—the time for action is now.”
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Working with the Ministry and other health-focused NGOs, my colleagues erected cholera treatment centers (or smaller treatment units) at each of our dozen hospitals and clinics across central and Artibonite Haiti. These sites were soon deluged with people standing, or trying to stand, in line for intake into these centers. Such rapid treatment responses saved lives, probably thousands of them. But thousands more would be lost, we feared, in what was likely to be a long struggle against cholera in Haiti.

For me, the fourth predicted struggle—that between experts—was the most enervating. Although I'm trained in infectious disease management (and the social responses to epidemics), and although I was one of the few doctors in Haiti who'd ever seen a case of cholera,
I'm no cholera expert. But several of my colleagues, including John Mekalanos and one of my classmates from Harvard Medical School (Ed Ryan), were world-renowned cholera experts. Their genetic analysis of the Petite Rivière strain revealed an El Tor biotype of
Vibrio cholerae
serogroup 01, which had, in other parts of the world, proven virulent and hard to slow down.
²²
If the history of a similar El Tor strains in Bangladesh and Nepal offered any indication, the disease would likely become endemic in Haiti. These academics who mapped the strain were also strong proponents of rapid implementation of both prevention (from clean water to roll-out of vaccine) and care (from rehydration to antibiotic therapy).

It was the public health experts, Haitian and especially transnational, who were in discord. In keeping with widespread pessimism about the potential for health delivery in post-quake Haiti, many argued that it would be too difficult to launch comprehensive prevention and care efforts in Haiti. Vaccination was especially discouraged.
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These “minimalists” were often the leading figures in international health. Others—and we were in this group—argued that there was no time to waste. In about forty days, cholera had caused more than two thousand deaths in Haiti, almost half the number reported during Zimbabwe's year-long epidemic.
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There would, of course, be implementation challenges to rolling out vaccine in Haiti. But Zanmi Lasante had achieved a 76 percent completion rate for a three-dose course of HPV vaccine in rural Haiti. That is almost twice the rate of completion for similar courses in U.S. settings. Moreover, the earthquake occurred between the second and third dose for many of the girls enrolled.
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The battle lines were well worn: on the one hand, the minimalists favored heavy investment in health education and massive distribution of chlorine tablets for drinking-water disinfection. On the other hand, the “maximalists” argued that, although there might be no way to stop cholera in its tracks in Haiti,
all
the tools for preventing its spread (from improved sanitation, including chlorine tablets, to effective and safe vaccines) and for treating those already stricken (from rehydration and replacement of electrolytes to antibiotics)
needed to be promptly integrated with the more restrained public health responses. Interventions such as exhorting people to drink clean water and wash their hands, or distributing chlorine tablets, were necessary but would never stop the epidemic. Having watched with horror as cholera ripped through the Mirebalais prison, killing five young detainees in as many days, we also wanted to review the evidence for antibiotic prophylaxis in certain instances.
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Three weeks after the first cases came to light, Jeffrey Sachs called, as he had more than a decade previously regarding AIDS: “Why aren't we responding to this epidemic more aggressively, with integrated prevention and care? Aren't there vaccines and also antibiotics? Isn't this a bacterial disease? Why aren't we bringing in the private sector, including companies that can help us get filtered drinking water and soap and antibiotics scaled-up more widely?”

Why indeed, I thought, as I often did during discussions with Sachs. He was well aware of the politicization of water aid that had occurred between 2001 and 2004, when the quality of the Haitian water supply was held hostage to the United States' displeasure with President Jean-Bertrand Aristide. He'd been one of the few aid experts willing to testify before Congress regarding this sorry affair.
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Sachs had already contacted Unilever, a company with significant production capacity in the Caribbean, which made soap, hand sanitizer, and water filtration units. We agreed to set up a conference call with Unilever by the third week of November, and then another with cholera experts at the start of December. The first promised to be uncontroversial: the company pledged to donate many of its products and also some expertise on clean water and sanitation.

The second conference call, including the academics and the public health experts, was harder. It seemed that the latter were reluctant to commit the necessary resources; it also turned out that they had underestimated the dimensions of the Haitian cholera epidemic. On November 25, a
Wall Street Journal
article, “Cholera Spreading in Haiti Faster than Thought,” noted that official projections about the peak size of the epidemic had more than doubled. Nigel Fisher, a smart humanitarian and a top UN official in Haiti, summed up the
revised estimates: “When we were in the initial stages of planning, we had said there would be 200,000 cases over six months. Today the figures are 425,000 over six months, of which 200,000 will be before year's end, with a peak before Christmas.”
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I was grateful for Fisher's candor.

The second call, set for December 3, would bring together academic cholera experts, vaccine researchers and manufacturers, clinical trial gurus, and several implementing bodies working in Haiti. We agreed that Harvard Medical School, rather than the UN Office of the Special Envoy, should host the call, in part because of the clear policy disagreements and in part because of the fractious relations between the MINUSTAH troops and Haitians in cholera-affected regions.

The close of November, between the two calls, found me back in Haiti. In Mirebalais, the Cubans and Zanmi Lasante teams were managing to save almost all patients who showed up to the cholera treatment center there. The great worry was for all those falling ill far from towns with cholera treatment capacity such as Mirebalais. My colleagues from Zanmi Lasante spoke of scores of deaths in rural hamlets. “These deaths aren't even counted,” they told me.

So the second conference call really mattered. The agenda was modeled on the effort we tried to engineer a decade previously, when the same sort of arguments—pitting AIDS prevention against AIDS care—were dominant. Back then, Jeff Sachs, still at Harvard, had helped bring us together. Now based at Columbia, he insisted that I take charge and try to assemble a group of cholera experts. We thought perhaps a few dozen specialists would join, but more than eighty people called in from Haiti, across the United States, Geneva, and as far away as Korea (where John Clemens, one of the world's leading cholera vaccine experts, was working). Our Partners In Health and Zanmi Lasante teams were present, as was Bill Pape. We discussed the ranking problems facing cholera prevention and care, and also the priorities for the coming months and years. Disagreement surfaced about the problems and the priorities, but the debate seemed constructive.

To continue the conversation after the call, we began work on a “consensus statement,” as we'd done for AIDS a decade previously. We learned a lot about the minutiae of cholera prevention and care and about the importance of sparking greater public concern about the epidemic. The cholera experts were the most helpful: they shook the public health minimalists out of their torpor. No one working in the western hemisphere had seen anything like the Haiti epidemic in decades. “This is not your grandmother's cholera,” David Sack had said.
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He didn't specify whether he meant this in terms of virulence or infectiousness, but we feared it was both.

We weren't sure we'd be able to complete a consensus document in short order, although we had committed to trying. The maximalists among us decided that, rather than languishing in the bitter debates over the origins of cholera in Haiti and the role of prevention “versus” treatment, we would write our own pieces for medical journals and for the popular press. Within a month, Louise Ivers, David Walton, and our Haitian colleagues had written pieces in the
Lancet
and the
New England Journal of Medicine
.
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A few days after these pieces appeared, on December 10, 2010, Partners In Health hosted a press call. By then, we'd developed treatment capacity at all our sites in the rural Lower Artibonite and Central Plateau, and set up a fiftybed cholera treatment center in Parc Jean-Marie Vincent. We were also carrying out intensive education and prevention campaigns. We'd already spent a million dollars and planned to spend more than twice that amount again by the end of the fiscal year. The United States had, by some reports, committed more than $57 million to fight cholera. The idea that it was impossible to launch a comprehensive, integrated response, including ramping up vaccine production (or even building a new factory to manufacture vaccine) in the face of such investments was absurd. The Haitian cholera outbreak also afforded us the long-overdue chance to build a global stockpile of vaccine that could be deployed during this epidemic and the next.