Haiti cholera outbreak response 'inadequate', says MSF

Associated Photo Press, 20.11.2010

 

PORT-AU-PRINCE, Haiti (AP) — It began as a rumor that farmers saw waste from a U.N. peacekeeping base flow into a river. Within days of the talk, hundreds downstream had died from cholera.

 

The mounting circumstantial evidence that U.N. peacekeepers from Nepal brought cholera to Haiti was largely dismissed by U.N. officials. Haitians who asked about it were called political or paranoid. Foreigners were accused of playing "the blame game." The World Health Organization said the question was simply "not a priority."

 

But this week, after anti-U.N. riots and inquiries from health experts, the top U.N. representative in Haiti said he is taking the allegations very seriously.

 

"It is very important to know if it came from (the Nepalese base) or not, and someday I hope we will find out," U.N. envoy Edmond Mulet told The Associated Press.

 

The answer would have implications for U.N. peacekeeping missions around the world, he said.

 

It would affect the relationship between the U.N. and Haiti: If its peacekeepers misled, it could lose credibility for tasks such as helping oversee next week's election. It could affect the job of U.N. humanitarian workers, who work separately from the peacekeepers.

 

It would help answer scientific questions: Is the source still out there? How does this cholera strain spread? Does it pose a threat to the region, including the southern United States?

 

When riots broke out across northern Haiti this week, the U.N. blamed them on politicians trying to disrupt the upcoming vote. But observers say the U.N.'s early stance fanned the flames.

 

"If the U.N. had said from the beginning, 'We're going to look into this' ... I think that, in fact, would have been the best way in reducing public anger," said Brian Concannon, director of the Institute for Justice & Democracy in Haiti. "The way to contribute to public anger is to lie."

 

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Before last month, there had never been a confirmed case of cholera in Haiti.

 

In March, the U.S. Centers for Disease Control and Prevention said cholera was "extremely unlikely to occur" in Haiti. There were no cholera bacteria there. Most foreigners were relief workers with good sanitation who come from countries where cholera is not an issue.

 

Then it did happen. There are now more than 1,100 dead; experts say hundreds of thousands will fall ill as the disease haunts Haiti for years.

 

Even more surprisingly, it did not first appear in a major port, an earthquake tent camp or an area where foreigners are concentrated, but instead along the rural ArtiboniteRiver.

 

Speculation keeps returning to that river and a base home to 454 U.N. peacekeepers from Nepal. They are perched on a babbling waterway called the Boukan Kanni, part of the MeilleRiver that feeds into the Artibonite.

 

People living nearby have long complained about the stink in the back of the base and sewage in the river. Before the outbreak began they had stopped drinking from that section of the river, depending instead on a source farther up the mountain.

 

The latest Nepalese deployment came in October, after a summer of cholera outbreaks in Nepal. The changeover at the base, which guards the area south of the central plateau town of Mirebalais, was done in three shifts on Oct. 9, 12 and 16.

 

The U.N. says none of the peacekeepers showed symptoms of the disease. But 75 percent of people infected with cholera never show symptoms but can still pass on the disease for two weeks — especially in countries like Nepal where people have developed immunity.

 

The CDC has said the strain of cholera in Haiti matches one found most prevalently in South Asia.

 

"It very much likely did come either with peacekeepers or other relief personnel," said John Mekalanos, HarvardUniversity microbiology chair. "I don't see there is any way to avoid the conclusion that an unfortunate and presumably accidental introduction of the organism occurred."

 

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Haiti runs on rumors, like a 10 million-player game of broken telephone. Last year it was the local woman said to have given birth to a fish. This year it was cholera — all too true, even if the news came from the same places: in a group taxi, from a cousin, from the guy on the next farm over.

 

On Oct. 20, the news crackled over Haitian radio: 19 people had died after fever, vomiting and severe diarrhea at a hospital in St. Marc near the mouth of the ArtiboniteRiver. Most were children.

 

A day later, the disease was confirmed to be cholera.

 

Tele-djol — "the mouth channel" — lit up. Some said helicopters had dropped a black powder in the river, or that they heard poison was poured into a dam in the Dominican Republic. Others said the epidemic was linked to the Nepalese base.

 

The rumors were easy to ignore. Mulet said the U.N. did not address them right away because it did not know the situation would turn into a crisis.

 

"It was such a minor thing, like we have every day," Mulet said. "We didn't know this was going to be an epidemic."

 

But the rumors got stronger in the mouths of politicians. Even the health minister, whose government depends on the U.N. for protection, told the nation it was suffering from an "imported disease."

 

On Oct. 26, U.N. spokesman Vincenzo Pugliese put out a short statement saying that the base's septic tanks are built to U.S. Environmental Protection Agency standards, that the waste is dumped 820 feet (250 meters) from the river, and that the U.N. unit for environmental compliance periodically checks waste management.

 

Sanitation at the base is handled by a private company, Sanco Enterprises SA, which won the contract over the summer by underbidding a rival. The U.N. said the septic tanks were to be emptied once a week.

 

But when the AP visited on Oct. 27, a tank was clearly overflowing. The back of the base smelled like a toilet had exploded. Reeking, dark liquid flowed out of a broken pipe, toward the river, from next to what the soldiers said were latrines. U.N. military police were taking samples in clear jars with sky-blue U.N. lids, clearly horrified.

 

At the shovel-dug waste pits across the street sat yellow-brown pools of feces where ducks and pigs swam in the overflow. The path to the river ran straight downhill.

 

The U.N. acknowledged the black fluid was overflow from the base, but said it contained kitchen and shower waste, not excrement.

 

The U.N. said it is up to the private contractor and local mayor to ensure its dump sites are safe. Sanco Vice President Marguerite Jean-Louis said it is up to the mayor and the U.N. Mirebalais Mayor Laguerre Lochard, who is running for Senate on Sunday, said he complained several times to the U.N. that the site was not safe but never received a response.

 

Jean-Louis said her company emptied the septic tanks on Oct. 11, after the first shift of Nepalese troops arrived, and did not return again until after the outbreak began. At some point in mid-October, neighbors said a new Sanco driver they did not recognize came one day and dumped outside of the usual pits.

 

Sanco returned to the base after the AP had been there for hours. There was more waste than usual, Jean-Louis said, possibly because the soldiers overlapped during their rotations.

 

Following protests at the base days later, the U.N. opened the compound to the AP. The Nepalese soldiers acknowledged, after repeated questions and revised statements, that the base had undergone an extensive clean-up and that they had replaced the broken pipe. Aboveground pipes from uphill latrines ran over a drainage canal to the river. The U.N. spokesman acknowledged what looked like human waste at the bottom.

 

The U.N. is now reviewing all sanitation systems at its military, police and civilian installations, officials told the AP this week.

 

The U.N. said none of the Nepalese soldiers had shown signs of cholera, which some news outlets misreported as saying the soldiers had specifically tested negative for it. Pugliese confirmed on Oct. 30 that they had not been tested for the disease.

 

The U.N. also tested environmental samples the soldiers took from the base. It says they came out negative at an independent laboratory in Santo Domingo.

 

But the Santo Domingo lab, Cedimat, has been under contract to MINUSTAH, the U.N. mission's name in French, since 2004, said Dr. Maximo Rodriguez, the doctor whose name appears on the tests. Rodriguez is a general medicine doctor whose specialty is treating obesity. Cedimat is a patient-treatment facility. In fact, the test results were written on forms meant for people: The results provided to the AP by the U.N. had the "patient's" name listed as "Minustha Minustha (sic)" — age 40, male.

 

Rodriguez said "any well-equipped laboratory" can do tests for cholera. But epidemiologists say examining environmental samples for cholera takes extra expertise, because the disease can be hard to isolate.

 

"A positive test is informative, a negative test doesn't really prove anything," said Dr. Arthur Reingold, chairman of Global Public Health and Infectious Diseases at the University of California-Berkeley School of Public Health. He is an adviser to the World Health Organization and a former CDC epidemiologist.

 

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The idea that cholera was imported to Haiti by the U.N. carries unique implications.

 

For decades, and especially since the Jan. 12 earthquake, Haiti has depended on foreign governments, aid groups and the U.N. for everything from rebuilding to basic services. The U.N. has had five peacekeeping missions in Haiti since 1993, the current one arriving six years ago.

 

Some Haitians see the peacekeepers as the only hope for security in a nation where towns are ruled by drug lords and coups d'etat are more common than elections. Others resent heavily armed foreign armies on their soil and see the soldiers as a threat to national sovereignty and pride.

 

The peacekeepers have saved lives in floods and defeated kidnapping gangs. They have also killed people in protests and accidents and had an entire unit dismissed for paying for sex, many with underage Haitian girls.

 

Earlier this month, Dr. Paul Farmer, who founded the medical aid group Partners in Health and is U.N. deputy special envoy for Haiti, called for an aggressive investigation into the source of the cholera, saying the refusal to look into the matter publicly was "politics to me, not science."

 

The CDC acknowledges politics played a role in how the investigation unfolded.

 

"We're going to be really cautious about the Nepal thing because it's a politically sensitive issue for our partners in Haiti," said CDC commander Dr. Scott Dowell.

 

The CDC agrees that the movement of pathogens from one part of the world to another is an important public health issue. Its scientists are working on samples of bacteria from 13 infected Haitians to sequence the cholera strain's genome, the results of which will be posted on a public database.

 

But the U.S. government agency has several caveats. First, it has not taken environmental samples or tested the Nepalese soldiers. Second, it will not go public with its analysis until all its studies are complete. And third, it may not get enough information to say exactly how cholera got into the country.

 

"The bottom line is we may never know," Dowell said.

 

The WHO has repeatedly said the same.

 

"At some time we will do further investigation, but it's not a priority right now," WHO spokeswoman Fadela Chaib said this week.

 

But Mulet now says Farmer was right all along, and that he is consulting with experts, including a French epidemiologist who met with him this week to discuss how to investigate the Nepalese base.

 

"We agree with him 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."

 

As recently as Nov. 10, the mission's spokesman told Haitian reporters that the U.N. was not undertaking any other investigations because the concerns were not "well-founded." The head of the mission said that is not the case today.

 

"One thing I can assure you: There has been no cover up — there has been no cover up from our side — and we have done everything we can to investigate," Mulet said. "Eventually we will find out what happened and how it happened."

 

Associated Press writers Michael Stobbe in Atlanta and Edith Lederer at the United Nations contributed to this report.