Cholera

Cholera

By James Stairs

Much like a fingerprint, every country has a unique mix of fragrance. In some places it’s the spices from an outdoor food stand or the blossoms of a particular type of tree. In others it is diesel fuel exhaust or rubbish fires or garbage trucks or a salty breeze off the ocean.
After a while these scents become familiar and travelers come to associate them with a specific place and time. Sometimes they can comfort and sometimes they can disturb but it’s hard to argue that they don’t tell at least a part of the story of a place.
Often, amidst the familiarity, there are smells that don’t quite fit. They are there but can’t quite be placed. They lurk in the shadows, just out of reach, but are strong enough to completely change the way in which a person interprets their surroundings.
In much of Haiti, there is a smell that lurks almost anywhere you go. It is noticeable to the return traveler, often not obvious but always there. It slips under the diesel fumes, garbage fires and the open sewers, carving out its own space.
It’s liquid hand sanitizer- the kind you might find in a public bus station in North America or beside a breakfast buffet at a hotel in Europe. The kind you buy in a little bottle at a pharmacy and keep in the desk drawer in your office during flu season.
Hand sanitizer has bludgeoned its way in to the Haitian sensory landscape for one reason.
Cholera.
The deadly bacterial infection mysteriously appeared in Haiti a few months after the 2010 earthquake had knocked the nation to its knees. Before it arrived, there had been no record of cholera on the Caribbean island for more than a hundred years.
As the disease spread throughout the country with ferocious speed, panic took hold in the exhausted population. Emergency officials scrambled to put together strategies to limit the outbreak but it soon became clear to everyone involved that the lack of basic infrastructure across Haiti would make it almost impossible to contain the spread of the contagion.
In a country reeling from decades of political instability, foreign intrusion, non-existent infrastructure, crushing poverty and unspeakable natural disaster, Haiti was an easy mark for cholera. Hundreds of thousands of people were living in temporary settlements after the earthquake, there were no significant public health facilities and the national government was in disarray.
As the crisis mounted, the last line of defense against cholera in many of the displacement camps became a combination of public information meetings and a mass distribution of alcohol-based hand sanitizer.
It was as if the battle were lost before it even began. First the earthquake that, according to the Haitian government, killed 316,000 people, left hundreds of thousands seriously injured and made upwards of a million people homeless and soon afterwards, the threat of the unimpeded spread of cholera.
Since its appearance, the disease has lived up to its terrible reputation. It has run amok through the densely-populated and impoverished nation of 11 million people. To date, nearly 9000 people have died, over 715,000 rendered so incapacitated and gravely ill that they can barely move.
Official statistics, many say, don’t take in to account that many of the infected who died were undiagnosed or lived off the grid. Undocumented and unnoticed outside of their communities, an unknown number of cholera victims were simply buried.
Today, Haiti is considered the worst cholera epidemic in modern history.
A cholera outbreak usually starts when a bacterium called Vibrio cholerae contaminates a water supply. The bacterium contains a toxin called CTX which attacks the intestinal walls and, in a nutshell, robs the human body of the ability to retain liquid in any form.
As most people who have taken a basic biology course would know, much of the mass of a human being is made up of water- an average adult has up to 40 litres of water in their body. When a person is infected with cholera, they are consumed by violent waves of vomiting and diarrhea.
“Cholera is basically an extreme dehydration of the body,” says Djoen Besselink, the project coordinator for the Carrefour Cholera Treatment Centre for the international medical organization Medecins Sans Frontieres (MSF). If the disease is not treated immediately, he explains, the body rapidly expels every bit of moisture it has until there is nothing left to sustain itself.
After infection, cholera affects people in different ways. For most people living in healthy conditions, the body can naturally fight off the infection and it has little effect. However, the real danger posed by the disease is that, whether an infected person exhibits symptoms or not, it is contagious through their waste.
For populations living in close proximity with a lack of basic sanitation, water sources are easily contaminated. Once a water supply is infected, the bacteria can spread quickly and those without the natural resources to fight off the infection are put at risk. Cholera can also be spread by eating infected seafood.
A person with cholera can lose up to 20 litres of water a day. Depending on the strength and health of the infected person, the disease can cause shock, organ failure and death within hours. Children, who have a higher percentage of water in their bodies, are particularly vulnerable.
Treating cholera is a simple and inexpensive process. An infected person is given strong doses of antibiotics, while the medicine attacks the bacteria; the patient is kept hydrated with clean water and electrolytes. In severe dehydration cases, an intravenous solution is needed. The disease, if treated properly, can be cured quickly in 99 percent of cases with no long-term health repercussions.
The devastating irony is that, in a country like Haiti that is so poor and with a population with access to so few resources, even the simplest tasks become complicated. Even if treating the infection is a straightforward process at a clinic, patients are not always aware of how to treat the infection, they may have trouble finding a health professional or they might not have the resources to travel to a treatment facility, even if the consequences can be fatal.
Public health experts agree that the spread of cholera is linked both to endemic poverty and to a lack of basic infrastructure. Cholera is predominantly a developing world disease, affecting up to five million people worldwide per year. Infection rates and fatalities drop as the level of income of a country rises.
In Haiti, catching a water-borne disease is a very real and constant threat because there are no sewers to transport human waste away from people’s homes. In addition, there are no water filtration facilities to filter out bacteria in the water supply. There is only one sewage treatment plant in the country, built in 2011.
Like many chronically poor countries, the vast majority of homes don’t have running water. Unless you can afford a private septic system, human waste is collected in the open sewers that run alongside roads and down hills, using gravity to pull the waste towards the bay below.
Throughout the country, it is not hard to find points where open sewers and places where people find the water they need to cook and clean, intersect.
Port-au-Prince, the country’s largest city, is a perfect example of the problem. Sitting in a beautiful bay on the Caribbean Sea, the city is striking for travelers flying in. Steep slopes, completely covered with houses, rise up from the bay, the view also throws the devastation caused by the 2010 earthquake in to plain view. Even if you weren’t there at the time, it’s easy to visualize how houses just collapsed and slid down the hills on to each other.
Like many cities around the world, there is a cultural reality in Port-au-Prince where, as a rule, the wealthier you are, the higher up the hills you live. Slums cover the lowlands surrounding the bay while the modern neighbourhood of Petionville, home to the country’s business and political elite as well as a sizeable expatriate community, perches at one of the highest points overlooking the city.
In the age of cholera, living up the hill holds a distinct advantage. When it rains in Port-au-Prince, water rushes down the hill and through the densely-populated towns and villages below. Houses and open sewers flood, spreading sewage-infected water throughout neighbourhoods.
“[The rate of the spread of cholera] really depends on the seasons,” Besselink explains. “There are two peak infection seasons in Haiti- the rainy season in May and June and the Hurricane season which usually arrives in October and November. Two or three days after it rains, we almost always see a significant increase in the number of cholera cases. “
The crisis is not contained to the city. Flooding is a threat in the countryside, people living in rural regions often have limited access to medical care and, in most cases, have to travel long distances to get it. With a time-sensitive infection like cholera, delays in getting treatment can prove fatal.
Solutions to curb the epidemic have proven elusive. The Haitian government has come under fire for botching the relief effort and the international donor community, despite billions of dollars allocated to rebuilding the shattered nation, is struggling to find an effective way forward.
The reality is that, in order to effectively address the problem, country-wide infrastructure, complete with sewage treatment systems, proper housing and water filtration facilities, would have to be built.
To that end, the United Nations launched an international appeal for funding in 2012 for the implementation of a 10 year, 2.2 billion dollar cholera eradication plan that would address the absence of water and sanitation infrastructure in the country.
Until a lasting solution is found, the only real respite for ordinary Haitians comes during seasonal dry periods. The constant threat of infection has injected perpetual fear in to an already fragile population and public anger has grown. When a conversation turns to cholera in Haiti, even the most diplomatic seethe with anger.
“It’s just so wrong,” one man angrily exclaims as he sits under a tree at a motorcycle taxi stand on a side street off of a main boulevard near the middle-class Delmas 18 neighbourhood. “Despite all of our problems, I used to want my children to grow up here. I used to be optimistic. No more.”
A group of men listening in to the discussion nod in unison, and, for the next hour, the conversation centres around how, as they see it, an injustice has been inflicted on Haiti as a whole. They want the international community to know how cholera came in to their lives and they want the people who they see as being responsible for the epidemic to own up to it.
To make his point, one of the men points to a message scrawled in red spray paint on a huge concrete block nearby. It’s a message seen on walls and bits of rubble across Haiti.
Often the best indicator of public mood in a country with a history of violent political repression, the graffiti pulls no punches- “Minista= Kolera,” says the Creole slang.
The words on the cement slab are like an open sore in the country. The men insist that United Nations peacekeepers, known by their acronym, MINUSTAH, brought cholera to Haiti.
MINUSTAH was formed in 2004 when a peacekeeping force was sent to Haiti with a mandate to restore order and support a new government during the political crisis that arose following the removal of then-president Jean-Bertrand Aristide. The stabilization force was initially welcomed in the country but a series of scandals and missteps gradually eroded popular support.
Today, despite having lead the massive humanitarian effort in the aftermath of the earthquake, the mission is unpopular with large swathes of the Haitian population who see them as agents of a foreign occupation and as a waste of money. There are currently 8690 UN soldiers and police staff in the country as well as 1900 civilian employees.
When cholera first appeared in Haiti in 2010, a frantic search began to discover the source of the outbreak. As infections mounted, images spread around the world of trucks roaming the countryside collecting emaciated bodies. Grieving relatives spoke in shock about the rapid death of their loved ones and international humanitarian groups scrambled to implement emergency plans to curb the spread of the disease.
Soon after the outbreak was reported in October, 2010, a news crew from the Qatar-based Al Jazeera network filmed a team of workers trying to contain a sewage leak behind a row of toilets inside a United Nations base outside Mirebalais, 60 kilometres from Port-au-Prince. The reporter pointed, on camera, to what appeared to be human waste flowing down a hill and in to a passing river. People living downstream from the base, the report said, were getting sick.
The United Nations was quick to deny the allegations, saying that they had tested the water and that it showed that the outbreak hadn’t come from the base. They also argued that finding the source of the outbreak wasn’t as important as containing it.
Three weeks later, an analysis of the bacteria showed that it originated in South Asia and specifically, Nepal. For many Haitians, the coincidence was too much- the soldiers at the base with the overflowing toilets were from Nepal.
As the evidence mounted, anger rose across the country. Riots broke out, reports were commissioned and United Nations representatives went in to damage control. A panel of experts, commissioned by the United Nations, released a report that concluded that, while it appeared the bacteria was introduced by the peacekeepers, Haiti’s poor infrastructure, the locals’ use of watercourses for bathing, working and drinking, the composition of river itself and the lack of natural immunity to the cholera strain contributed to the epidemic.
Blame for the outbreak, the United Nations report concluded, fell on a “confluence of circumstances,” and that no one group or person could be considered at fault.
Independent reports would soon be released that would contradict the findings of the panel of experts. A group of human rights lawyers in the United States filed a compensation claim on behalf of 5000 cholera victims, saying that the United Nations failed to screen the Nepalese peacekeepers, cut corners on sanitation at the Mirebalais base and that they failed to act quickly enough once the outbreak had been discovered.
The United Nations responded by invoking legal immunity based on a 1946 convention, rejecting claims for compensation. Many who had followed the events were outraged.
In October, 2013, another lawsuit was launched in the United States, demanding that the United Nations apologize to victims of the outbreak and that they provide compensation. The case is currently before the courts.
As lawyers quibble over the language of guilt and compensation in New York, cholera continues to spread. The strain of cholera that invaded Haiti has since jumped borders, with cases found in Cuba, the Dominican Republic and in September 2013, an outbreak in Mexico was traced back to the outbreak at Mirebalais.
In Haiti, despite the international attention, much remains the same. Whenever it rains, cholera cases spike.
With so many problems, the Haitian government doesn’t have the resources to deal with the front-line care for victims of the epidemic so international aid organizations have had to step in.
When it comes to the spread of cholera, one of the highest-risk locations in the country is Carrefour, a sprawling, impoverished suburb of Port au Prince.
Behind a sheet-metal gate, metres away from the stalls and shacks of the teeming suburb’s main road, there is a vast compound run by Medecins Sans Frontieres (MSF), filled with staff, tents and equipment with no other purpose but to treat cholera.
Inside the gate, a gentle-faced doctor sits at a registration station filling out forms. To her left, workers mill around the opening of the tent. A couple of people sit on chairs and benches beside the desk.
No one reacts as a young man sitting on a bench suddenly lurches forward and begins to vomit in to a white plastic bucket, his body convulsing violently. Very little comes up- cholera is a disease that still tries to take even if there is nothing left to give. Beside him, another man about his age cradles the stricken patient’s arm in his.
In behind, a middle-aged woman sits on a cot with a round hole cut in the middle of it. She is expressionless as waste streams, like cloudy water from a faucet, in to a chlorine-treated bucket below.
This is what the everyday face of cholera looks like. Everyone at the clinic is used to it.
Despite its unfortunate existence, the clinic is a paradoxically uplifting place. To anyone there, the misery being felt by the patients is tempered by the knowledge that, by simply being there, the patients have a good chance of a full recovery.
It’s those outside the walls, the ones who can’t get to the clinic, the ones who wait too long, hoping to just ride it out, the ones who don’t know what to do when someone gets sick, that are the real face of the tragedy.
The cholera centre is there to stem the tide while others tackle the systemic problems that are driving the spread of the contagion. To the outside observer, it’s like the health workers at the clinic are sticking their fingers in to the holes of a bursting dam, hoping that what they are doing works long enough until someone comes to fix the whole thing.
Oliver Shultz, MSF head of mission for Haiti, walks around the facility. “At this facility we are responsible for treating anywhere between 500 and 800,000 people. “
As part of its treatment program, MSF also runs another dedicated clinic out of a hospital in downtown Port-au-Prince as well as outreach programs and mobile rapid response teams to reach people in the countryside
Mirroring the simplicity of the infection that they treat, the clinic is an uncomplicated operation- a maze of tents, toilets, chlorine sanitation stations, waste disposal sites and medical consultation stations. There are 300 beds for in-patients, 45 international staff and 300 local people working from the compound.
As you pass from section to section in the facility, every person and everything they carry gets sprayed down with a chlorine solution to kill any bacteria that might have been picked up.
“We basically take care of people here. We rehydrate the patients, get them some food and help them recover. If there are any medications necessary, they get them free of charge,” Schulz explains.
Djoen Besselink, the Dutch psychologist in charge of the facility, joins the tour. He laughs as he moves a bare mattress that is blocking the doorway as he heads up to the roof of the compound for an aerial view of the operation. His colleagues jokingly chastise him for having a messy bedroom.
It’s where he sleeps at night. He eats at the communal kitchen below and social life centres around the plastic lawn chairs on the roof. Like the neighbourhood his work has brought him to, life at a cholera treatment centre doesn’t offer many frills.
As he speaks on the roof, a white United Nations transport helicopter flies over the compound towards the city. It’s flying low and no one knows who’s on the flight- maybe it’s another politician coming to view the emergency first-hand or another cholera eradication plan in the works.
Regardless of who is on the helicopter, it’s just another day in a nation of perpetual crisis, a place where there’s always work to be done for the humanitarian aid community.
What everybody who lives and works in Haiti knows is that the real question is not how to fix a damaged system, it’s more how to build something that never existed. The view from the roof- the miles of poverty, the shacks and open sewers- shows the sheer scope of the reconstruction challenge of a small corner of the country.
Skeptics say that until a stable government is elected with the trust of the people, no plan will ever really work. They argue that the lessons from the misery thrown at Haiti over its history have to be heeded or the pain and frustration of the people in the cholera tents will be repeated over and over.
What the 2010 earthquake showed was that the country needed homes that wouldn’t collapse during an earthquake. The biggest lesson from the worst cholera epidemic in modern history is clear- everyone, regardless of where they live, needs clean water and basic sanitation.
Back in Carrefour, it hasn’t rained in a while so the facility isn’t overwhelmed on this day but everyone knows that the next wave of people coming to the sheet metal gates isn’t too far down the road.
“We treated 15,000 people last year, and seven thousand in the first half of this year,” Besselink explains, focusing his eyes on to downtown Port-au-Prince, way off in the distance. He is in his tenth MSF mission over 30 months and looks tired.
The motorcycle taxi ride back to the city centre is a wild ride of roundabouts and whistles through the sea of humanity that is a Haitian intersection. As traffic congests, the taxi grinds to a halt and both driver and passenger throw their legs out to stabilize the motorcycle. An open sewer flows down the side of the road beneath their feet.
The ride ends outside the front gates of now-razed presidential palace at Champs de Mars which collapsed during the earthquake, a humanitarian worker greets a friend as he hops off the back of the motorcycle.
“I know where you’ve been,” she laughs. “I can smell the chlorine on your clothes.”