21 June 2012

Is the UN Off the Hook for Haiti's Cholera Outbreak?

The blame game for Haiti's cholera outbreak took an unexpected turn with the release of a new study. University of Maryland researchers say that "two distinct populations of V. cholerae coexisted in Haiti early in the epidemic." The information comes from sampling people with cholera in 8 towns across eight Arrondissements of Haiti shortly after the October 2010 outbreak. A study published last year attributed a single cholera strain to Nepal, meaning that it was likely carried into the country by UN peacekeepers.

The initial connection to the UN led to public outrage and even a lawsuit filed on behalf of 5,000 Haitians against the UN. In the months since the discovery, the U.N. Stabilization Mission in Haiti (MINUSTAH) has continued to deflect blame. The Daily Beast reported in April:
The spokesman for United Nations Secretary-General Ban Ki-moon, Martin Nesirky, reiterated on Monday that “it was not possible to be conclusive about how cholera was introduced into Haiti … and therefore, at this point, I don’t have any further comment.”
The report by Jonathan Katz is a damning case against MINUSTAH, but the comments from Nesirky that were condemned and criticized back in April may now ring some level of truth given the new information. However, dismissing the UN peacekeepers from any sort of blame is the wrong reaction to the new information.

Study leader Rita Colwell told the NPR Shots blog:
"This suggests that it's very likely that local (Haitian) strains are involved," Colwell told Shots. "Because no one has tested for pathogenic cholera strains in that country before, we have no evidence that it wasn't there already." 
I asked Colwell if she thinks one strain was introduced by the Nepalese soldiers and the other was native to Haiti, or at least predated the current epidemic. 
"The introduction (from Nepal) can't be ruled out but it can't be proven either," she replied. "I think the evidence is at best circumstantial, and it is not sufficient to account for the entire epidemic."
The same post also quotes Johns Hopkins public health researcher Dr. David Sack as the voice of doubt that the MINUSTAH forces are to blame.
He thinks the epidemic exploded too soon after the Nepalese reportedly arrived in Haiti. UN officials tell him that was on October 8, and the first cholera case was recorded on October 12 in a town near the UN camp. 
"Cholera's incubation period is at least 24 hours, sometimes two or three days," Sack told Shots. "Just to have a cholera vibrio floating downstream, and considering the dilution factor – well, it raises questions in my mind. Not that it wasn't imported. I think it was imported. I just question when it was imported."
Colwell describes a sort of 'perfect storm' between the imported cholera strain from Nepal and the local strain that lead to the massive outbreak. No doubt this further complicates the issue of blame, which matters only to the extent of preventing the same mistakes. Invariably, disasters like the earthquake will unfortunately occur in the future. Knowing how to minimize a massive outbreak of cholera will be a vital part of the appropriate response.

The unfortunate sequence of events is also providing an opportunity to learn how to address a cholera outbreak. A year and a half on and the most promising development is a vaccine administered by Partners In Health. The Boston-based global health organization has done a fantastic job sharing information about the ongoing vaccine pilot by dedicating web space to provide the latest updates from the effort. An update on Monday says that phase II of the vaccine has reached 90% of the people who took part in the first phase.

In the end, there no doubt that a foreign strain of cholera made its way into Haiti. The evidence points towards MINUSTAH. Whether or not it was the strain that kicked off the outbreak, the fact that it is detected in Haitians means that the strain has done damage. For that alone, the UN should take responsibility. The Maryland study confirms the UN spokesman's assertion that it is complicated, but skirting admission only delays the much needed learning process that will hopefully prevent this from happening again.