02.06.12

A Call for U.N. Accountability for Cholera in Post-Earthquake Haiti – Part IV: Capitol Hill Considers Future of Cholera in Haiti

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In response to the second anniversary of Haiti’s January 12, 2010 earthquake, this post is the fourth and final in a four-part series examining the implications of ongoing efforts to establish U.N. accountability for allegedly causing Haiti’s deadly cholera epidemic in the months following the events of January 12, 2010. This post was authored by O’Neill Institute Research Associate, J.P. Shuster, with support from O’Neill Institute Law Fellow, Ana Ayala.

Concern for the outbreak of cholera in Haiti, which has now killed 7,001 Haitians and infected over 522,000 others since it began in late October of 2010, reached the U.S. Congress late last month. Members of the Congressional Black Caucus, including Representatives Barbara Lee (D-CA), Yvette Clarke (D-NY) and Donald Payne (D-NJ), as well as a collective of concerned non-governmental organizations, known as the Haiti Advocacy Working Group (HAWG), sponsored a briefing entitled “Health and Cholera” in conjunction with the second anniversary of Haiti’s devastating 7.0-magnitude earthquake on January 12, 2010. Panelists at the briefing included Ambassador Eric Goosby, the U.S. Global AIDS Coordinator; Dr. Jon Andrus, the Deputy Director of the Pan American Health Organization (PAHO); Dr. Jordan W. Tappero, Director of the Health Systems Reconstruction Office at the Centers for Disease Control and Prevention (CDC); Dr. Ralph Ternier, the Director of Community Health at Zanmi Lasante (ZL); the Haitian sister organization of Partners in Health (PIH); and Dr. Mark Weisbrot, the co-director of the Center for Economic and Policy Research (CEPR).

The majority of presenters at the Congressional briefing focused their remarks on two ambitious proposals to curb Haiti’s cholera epidemic. First, PIH/ZL and another public health non-profit located Port-au-Prince, GHESKIO, have launched a large-scale vaccination campaign with the daring goal of immunizing all Haitians to the strain of cholera that is quickly becoming endemic to the population. The chosen drug, Shanchol, has a proven effectiveness of upwards of 80 percent. The organizations have now started two pilot projects – one in a community in Haiti’s Artibonite Valley and another in a slum in Port-au-Prince – to test implementation of the vaccine in Haiti in both rural and urban contexts, respectively. Some experts had questioned the efficacy of the particular vaccination campaign, drawing attention to the limited dosage currently available from the vaccine’s manufacturer, Shantha Biotechnics (about 200,000 doses, enough to vaccinate 100,000 people), as well as the fact that essentially all nine million Haitians remain vulnerable to infection. Nevertheless, the organizations have vowed to find the financing to roll out the vaccine across Haiti. Moreover, the Government of Haiti (GOH) has supported the vaccination strategy, and international organizations originally reluctant to embrace the campaign have now joined the effort, including the CDC, which has agreed to participate in site assessments of the two pilot projects.

The second major response activity that participants detailed at last week’s panel was a plan for a $1.1 billion collaboration between PAHO, UNICEF and the CDC that will seek to comprehensively improve water and sanitation facilities for at least two-thirds of the Haitian population by 2015. According to the CDC’s Dr. Tappero, the Governments of Haiti and the Dominican Republic have endorsed the organizations’ “Call to Action,” and the CDC has begun recruiting an expert task force to develop and cost a strategy, which it plans to present at the International Congress on Water and Sanitation and at the UN “Rio+20” Conference on Sustainable Development, both slated to occur in Brazil in June 2012.

The large-scale vaccination campaign and the massive water and sanitation overhaul that the Congressional panelists outlined constitute two bold steps necessary to contain Haiti’s cholera epidemic and eventually eradicate the disease from the island of Hispaniola. As the relevant organizations attempt to roll out these life-saving initiatives, focus must also remain on how cholera arrived in Haiti to provide victims the opportunity to obtain compensation and to prevent future incidents from occurring. At present, the U.N. stands accused of transporting cholera to the island of Hispaniola inadvertently via negligent maintenance of sewerage facilities at a Nepalese camp of the U.N. peacekeeping mission in Haiti, MINUSTAH. (See Part I of this series).[1] However, the international body has resisted taking action on a complaint on behalf of 5,000 victims and their families while powerful immunities afforded to U.N. personnel in its Convention on Privileges and Immunities pose a major challenge to proper adjudication of such claims. (For more detail on the issue of U.N. immunity, see Part II of this series).

Dr. Mark Weisbrot, the co-director of CEPR, raised the issue of U.N. accountability for spreading cholera to Haiti at last week’s panel. In his comments, Dr. Weisbrot mentioned the significant scientific evidence that all but confirmed that U.N. peacekeepers with MINUSTAH inadvertently exposed Haitians to the particular strain of cholera.[2] Dr. Weisbrot also reiterated his prior statement that U.N. has attempted to intentionally mislead the public about its role in generating Haiti’s cholera outbreak. During the panel, Dr. Weisbrot suggested that the U.S. Congress could pressure the U.N. to acknowledge its responsibility for the epidemic and commission its own report to investigate the incident.

While Dr. Wesbrot’s recommended actions for the U.S. Congress are undoubtedly essential to achieving U.N. accountability in Haiti, they face major hurdles. Congressional interest in demanding U.N. payouts is naturally low considering the U.S. Government remains the largest voluntary contributor to the U.N.’s annual budget, contributing roughly 22 percent of the international organization’s regular budget and up to 27 percent of the UNPKO annual budget.[3],[4] In addition, even those who may support increased accountability from the U.N. may be hesitant to call for U.N. compensation to Haiti’s cholera victims out of concern that such accusations of malfeasance can have the undesirable result of providing fodder to those who wishing to reduce U.S. overall contribution to the U.N.

Consequently, a valid legal judgment from a U.N. claims mechanism or a domestic court would provide one of few cogent means for obtaining justice for Haiti’s cholera victims and ensure that U.N. Peacekeeping Operations (UNPKO) sufficiently and transparently improve its standards for the prevention and response to the international spread of disease. Part II of this series considered the prospects for obtaining relief and found significant challenges to requesting the U.N. to voluntarily produce a costly judgment against its own interests. Additionally, it remains unclear whether UNPKO has improved the inadequate pre-deployment screening standards that likely failed to prevent Haiti’s current epidemic and may still pose the risk of further deadly outbreaks in the sixteen countries in which UNPKO operates missions. (See Part III of this series for UNPKO prevention and response standards).

More specifically, UNPKO must have proper inducement to fully adopt the recommendations that its own Independent Panel of Experts provided in their May 2011 report.[5] Specifically, the expert panel recommended that UNPKO provide prophylactic doses of appropriate antibiotics and screen all personnel for the absence of V. Cholerae prior to mission deployments. To prevent contamination in UNPKO host countries, the panel recommended that missions treat fecal waste using on-site systems that inactive pathogens before disposal. Such improvements require minimal time, effort and funding in comparison to the costs of a deadly outbreak. Importantly, it also remains uncertain whether UNPKO, which draws significant numbers of its uniformed personnel from resource-poor and biogenetically diverse settings, has implemented the protocol recommendations for all deployments to each of its sixteen peacekeeping missions around the world. Without agency-wide integration of the recommended improvements, UNPKO may continue to create global “south-south” paths for diseases to travel by placing vulnerable populations in direct contact with harmful pathogens known to UNPKO prior to personnel deployments.

Furthermore, a successful vaccination campaign and the construction of a comprehensive water and sanitation system will require significant financial and human resources. At present, the U.S. Government has contributed only 12 percent of its pledged $11 billion in relief and reconstruction since the earthquake. A judicial finding of fault could lead to penalties that fill the gaps in unilateral foreign contributions to large-scale infrastructure programs.

This series has attempted to call attention to the destructive outbreak of cholera in Haiti in conjunction with last month’s second anniversary of Haiti’s devastating January 12, 2010 earthquake. In particular, this series has focused on examining the scientific evidence demonstrating U.N. responsibility for the cholera outbreak, as well as the logistical and legal barriers to obtaining effective relief from the U.N. and the legal instruments and mechanisms intended to protect persons from the international spread of disease.

Importantly, calling for a justified U.N. response to complaints filed on behalf of Haiti’s cholera victims, including especially the complaint on behalf of 5,000 cholera victims mentioned above, should not be construed as an attack on MINUSTAH’s Nepalese peacekeepers. After all, the peacekeepers’ own poverty and vulnerability to disease caused them to contract the deadly water-born illness, and their willingness to serve the cause of international peace and security in the wake of Haiti’s earthquake contributed to the inadvertent transmission of the disease in that country. Nor should the call of this series for compensation from the U.N. to Haiti’s cholera victims be seen as a mean-spirited attack on an institution that has boldly championed the cause of global peace, promoted the rule of law and protected the vulnerable from social and economic harm since its inception in the wake of the World War II.

Nevertheless, international peace and security stands to benefit from a sincere evaluation of the claim currently before the Claims Unit of the Office of the United Nations Secretary-General in Haiti, or if necessary and feasible, a domestic court adjudication of such claims. As mentioned in the opening of this series, anti-U.N. sentiment continues to fester dangerously in Haiti. The U.N.’s evasion of responsibility for malfeasance and extraordinary harm will only increase mistrust and resentment among the Haitian population and promises to lead to further protests and even violence.

Conversely, a willingness to respond swiftly and transparently to complaints will increase the trust necessary to effectively collaborate for the eradication of cholera from Haiti. In addition to affording Haiti’s cholera victims just and humane recourse, such a response will serve the U.N.’s interest in increasing the authority of U.N.-led efforts to protect health and human rights, including the International Health Regulations (2005), the Charter of the World Health Organizations, and critical health-related international instruments. Tragically, cholera is now poised to become endemic to Haiti. Lack of U.N. accountability for the resulting harm should not be.


[1] Pet. for Relief, filed with Chief, Claims Unit, Office of the United Nations Secretary-General, Nov. 3, 2011. Available at, http://ijdh.org/archives/22916.

[2] See the following reports: Renaud Piarroux, et al., Understanding the Cholera Epidemic, Haiti, 17:7 Emerging Infectious Diseases J.1161, available at, http://wwwnc.cdc.gov/eid/article/17/7/11-0059_article.htm#suggestedcitation; Centers for Disease Control, Press Release: Laboratory Test Results of Cholera Outbreak Strain in Haiti Announced, Nov. 1, 2010, available at, http://www.cdc.gov/media/pressrel/2010/r101101.html; Chen-Shan Chin, et al., The Origin of the Haitian Cholera Outbreak Strain, 364 N.E. J. Med. 33-42.

[3] See, Assessment of Member States’ Contributions to the United National Regular Budget for the Year 2009, U.N. Doc. ST/ADM/SER.B/755 (Dec. 24, 2008), available at, http://www.un.org/ga/search/view_doc.asp?symbol=ST/ADM/SER.B/755.

[4] See, U.S. Funding to the U.N., Better World Campaign, available at, http://www.betterworldcampaign.org/issues/funding/us-dues-and-contributions.html (last accessed Feb. 2, 2012).

[5] Alejando Cravioto, et al., Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti, May 2011, at 25, available at, http://www.scribd.com/doc/54653594/UN-Cholera-Report-Final.

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Comments

Renaud PIARROUX says:

Even if many experts stated that cholera is in Haiti for years or even decades, this is not evidence. Haiti is located in an island and there are many examples showing that cholera can be eliminate from islands. Currently, according to the Ministry of Health, the number of new hospitalized cases is dropping dramatically, with 50 to 60 new cases a day and only seven new deaths recorded from January 1st through January 20th. Apparently, there is only one large active focus nowadays. It is located around Cap Haitian in the North of Haiti. An assessment, which was done last week, showed that nothing special was done in Cap Haitian to put out cholera and stop the transmission. Similarly, in December, it took weeks before the source of the cholera outbreak in the village of Pestel (South of Haiti) could be identified and the transmission stopped. I acknowledge that other small outbreaks might remain undetected, especially if no specific attention is paid for epidemic surveillance while cholera is quiet. It is nonsense to wait for the coming back of rain and not to try to detect and tackle the remaining foci. It is also nonsense to expect a result from an immunization campaign done in the Artibonite valley, an area where cholera transmission stopped since several weeks. The immunization of 200,000 people in Haiti, a country hosting ten million inhabitants, will never prevent a relapse in the cholera epidemic. By contrast, targeting all available resources to detect the areas where cholera transmission is still active and to combat it meanwhile the epidemic declines might raise the hope of eliminating it before the rainy season. Then, it will be of paramount importance to set up a challenging program aiming to substantially improve access to safe water and sanitation all over the country. This is indeed the best strategy to avoid a recurrence of such disaster.

J.P. Shuster says:

Dr. Piarroux,
Thank you for your comment on my analysis, as well as for the important work you have done regarding Haiti’s cholera outbreak. I apologize for my delayed response. Just to clarify one point regarding the vaccination campaign: The relevant authorities are using the first 200,000 doses of Shanchol secured thus far for the specific purpose of demonstrating adherence levels in the selected rural and urban settings. According to the panelists at last month’s briefing, demonstrating the ability to effectively administer the vaccine in both environments will help garner the support necessary to procure the actual number of doses required to roll out the campaign across Haiti. If the parties can accumulate the necessary vaccine stores, it seems that such a campaign would not be at odds with your desire to see that officials target all available resources on locations with known foci. More specifically, perhaps experts could encourage MSPP to focus available vaccines on villages like Pestel and those surrounding Cap Haitian, as you suggest, but with the aim of also vaccinating populations in Haiti’s numerous isolated rural communities that pose the threat of undetected transmissions. I also strongly agree that, if possible, any such efforts should be done as quickly as possible to avoid complications from the rainy season.
JPS

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