The Culture and Politics of Health Care Work

Cholera and Cover-Up in Post-Earthquake Haiti

Ralph R. Frerichs

• Publisher: ILR Press
• Year: 2016
• ISBN:
  9781501703621
• Topic: Medicine
• Subtopic: Epidemiology

In October 2010, nine months after the massive earthquake that devastated Haiti, a second disaster began to unfold—soon to become the world's largest cholera epidemic in modern times. In a country that had never before reported cholera, the epidemic mysteriously and simultaneously appeared in river communities of central Haiti, eventually triggering nearly 800, 000 cases and 9, 000 deaths. What had caused the first cases of cholera in Haiti in recorded history? Who or what was the deadly agent of origin? Why did it explode in the agricultural-rich delta of the Artibonite River? When answers were few, rumors spread, causing social and political consequences of their own. Wanting insight, the Haitian government and French embassy requested epidemiological assistance from France. A few weeks into the epidemic, physician and infectious disease specialist Renaud Piarroux arrived in Haiti.In Deadly River, Ralph R. Frerichs tells the story of the epidemic—of a French disease detective determined to trace its origins so that he could help contain the spread and possibly eliminate the disease—and the political intrigue that has made that effort so difficult. The story involves political maneuvering by powerful organizations such as the United Nations and its peacekeeping troops in Haiti, as well as by the World Health Organization and the U.S. Centers for Disease Control. Frerichs explores a quest for scientific truth and dissects a scientific disagreement involving world-renowned cholera experts who find themselves embroiled in intellectual and political turmoil in a poverty-stricken country.Frerichs's narrative highlights how the world's wealthy nations, nongovernmental agencies, and international institutions respond when their interests clash with the needs of the world's most vulnerable people. The story poses big social questions and offers insights not only on how to eliminate cholera in Haiti but also how nations, NGOs, and international organizations such as the UN and CDC deal with catastrophic infectious disease epidemics.

1

UPHEAVAL

It all seemed to start in the delta of Rivière de l’Artibonite, the Artibonite River, Haiti’s main watercourse. That morning in Bocozel village, two young boys— we’ll call them Paul and Jean, both primary-school age—followed their usual path to school, crossing the canal bridge over the water that flowed to the nearby rice fields. It was hurricane season, but the weather had been mild for a few weeks. Early mornings were cool, but now the sun warmed the air.

The long, grand Artibonite River originates in the mountains of neighboring Dominican Republic and flows west 240 kilometers (150 miles) through central Haiti and on to the ocean waters of the Gulf of La Gonâve. Along its course, mountains rise on both sides until farmland spreads out fan-shaped closer to the coastal plain. Many who live by the river are subsistence farmers growing rice in the fertile valley.

That particular day, Paul and Jean drank from the canal—just as most area youngsters did—to quench their thirst before beginning the school day. The flowing water looked the same as always, but something was very different that morning. Far too small for the eye to see, deadly microbes floated in the murky water.

The boys arrived at school and settled in to their daily routine of lessons. As the morning wore on, they began to feel queasy and asked their teacher for permission to use the toilet. Both had watery diarrhea but felt no pain—at least at first. By early afternoon, though, their diarrhea intensified. They felt nauseous and began to vomit. They became severely dehydrated, and their heads throbbed with intense pain.

More time passed. The two became very thirsty and progressively weaker. They could feel their hearts beating faster and faster. The afternoon grew warmer, but their feet and hands were very cold. They became lightheaded, dizzy, and increasingly sleepy.

Soon, other children in the school became sick with similar symptoms. The alarmed teacher, sensing something was very wrong, took them all to a small clinic a short distance away. The symptoms grew worse, and right before the eyes of the caregiver young children underwent frightening transformations. Paul and Jean were most severely affected—by then, they were almost unrecognizable. Their breathing was labored. In a few short hours, the bloom of their youth gave way to sunken eyes, grayish wrinkled skin, and a deathly pallor resembling that of the very old. They were thirsty but could not drink. They became unresponsive and lapsed into unconsciousness.

Within an hour of arriving at the clinic, the two boys were dead. A third schoolchild from a neighboring hamlet died an hour later. A pained message was sent to the health director of Artibonite département (one of Haiti’s ten administrative units): three children dead from acute watery diarrhea. It was only the beginning of a long list of deaths.

The date was Tuesday, October 19, 2010, and cholera had broken out in Haiti.

Although new in Haiti in 2010, cholera is not a new disease. In the ancient world, it was found mainly on the Indian subcontinent. Toward the middle of the nineteenth century, it began to move around the globe in a series of waves or pandemics.¹ The most recent pandemic—the seventh—began in Indonesia in 1961 and gradually spread throughout Asia and on to Africa.

Researchers had shown the presence of cholera in the Caribbean region three times but only in the 1800s and never before in Haiti itself—at least not in recorded history.² So when the disease was first confirmed in Haiti in 2010, scientists could link the outbreak to the seventh pandemic but knew little more.

Why had Haiti been spared before 2010? Historical investigators had long considered infected travelers the primary mode of cholera introduction,³ but Haiti had not had any such visitors. Haitians had overthrown their French colonizers in what was then called Saint-Domingue in a slave revolt (the Haitian Revolution of 1791–1803), which led to the founding of the Republic of Haiti. With slavery eradicated, the island nation no longer had boatloads of disease-carrying Africans arriving on its shores. And while over time Haiti found itself occupied by foreign troops (including U.S. Marines from 1915 to 1934), it was spared the scourge of invading cholera-ridden troops, a frequent event during the first six pandemics. Finally, Haiti had never been a destination for overseas agricultural or factory workers. No one traveled to the poorest country in the Western Hemisphere seeking work.

What changed that October?

As events unfolded in Bocozel, a small town of about fourteen thousand people some fifteen kilometers southeast also faced a dire situation. Deschapelles, in the agricultural valley where the Artibonite River branches into the Artibonite plain, is near a dam that distributes water from the river to the canals that irrigate downstream lands. It’s also home to Hôpital Albert Schweitzer (Albert Schweitzer Hospital), which was suddenly inundated with an influx of people with similar symptoms. Almost all the patients came from the areas bordering the Artibonite River. Many reported they had drunk from the river. The hospital staff of fourteen doctors and fifty nurses, although fairly well equipped, was about to be overwhelmed that Tuesday afternoon and the next day.

Dr. Ian Rawson, the hospital’s managing director and a medical anthropologist and public health specialist, blogged regularly about the comings and goings at the hospital. That evening and the following day he faced the disease firsthand when he saw dozens of newly arrived diarrhea patients. Late Wednesday evening, October 20, 2010, on the hospital blog Rawson wrote, “The causative organism has not been identified and the initial suspicions have focused on typhoid”—a gastrointestinal disease caused by a bacterium.

Specimens collected from diarrhea cases were sent to the Laboratoire National de Santé Publique (LNSP, National Public Health Laboratory) in Port-au-Prince, Haiti’s capital city. Awaiting the lab’s diagnosis, Rawson’s medical staff focused on hygiene and rehydration. Most patients needed intravenous fluids to replenish what they had lost from the diarrhea and to prevent death from severe dehydration. Some needed daily infusions of ten liters or more. Hospital staff worried supplies might not last very long.

The Albert Schweitzer doctors didn’t even have a dim thought of cholera.

What had spared Haiti before from deadly cholera? Past policies? Good luck? Surely public officials and scientists would soon begin the appropriate investigation to unravel how cholera had come to the country. Scientists who study diseases such as cholera seek out origins so they can inform public officials needing to implement new policies and correct past mistakes so future generations can be spared.

Haiti had experienced many calamities. A devastating earthquake struck its most populated area the afternoon of Tuesday, January 12, 2010. In the aftermath of the earthquake, many predicted the occurrence of epidemics, including cholera. But for nine months, there were no epidemics.

Among the quake’s casualties were three of the top commanders of MINUSTAH. They died when the headquarters in Port-au-Prince collapsed. MINUSTAH’s presence in the country for the past six years—with about nine thousand military personnel and nearly four thousand police—was a source of comfort for some but anger and frustration for many others, and it spurred periodic protests and unrest. From time to time, those feelings spilled into the streets, as they did in September 2010 when protesters rallied against MINUSTAH after a teenage boy was found hanging from a tree at a MINUSTAH base.

In October, as fear of cholera increased and the mysteries of origin and transmission remained unsolved, people raised questions and spread rumors that in turn stimulated social tensions and violence. Fear, panic, and anger set in. Who was to blame for cholera’s arrival? Haitians wanted to know. Who was causing the disease to spread? Who was telling the truth? Lying? Who was saving lives? Causing deaths? Answers were not forthcoming.

Later, when more rumors began to spread that linked UN peacekeepers to the outbreak, cities and villages in some regions of Haiti erupted in protests. On Monday, November 15, as the epidemic continued to rage through the country, street protests broke out in Cap-Haïtien, the country’s second-largest city. When a Haitian protester was shot dead, MINUSTAH officials insisted that peacekeepers had shot in self-defense.⁴ Since the violence was occurring in the midst of a campaign for the nation’s presidency and parliament, a MINUSTAH spokesperson insisted it had been provoked by political forces “that do not want elections to happen” and that UN forces providing logistical support for the upcoming vote were being targeted as a “way of hampering the electoral process.”⁵ He made no mention of the UN cholera rumor, nor did he acknowledge the bitter frustration of people exposed to a terrible disease who had to live without the benefit of toilets and safe water.

Throughout that fateful Wednesday, October 20, Dr. Rawson maintained contact with a colleague, Dr. Scott Dowell, a hospital board member and prominent physician at the United States Centers for Disease Control and Prevention in Atlanta, Georgia. CDC had people in Haiti who would soon be investigating the sudden outbreak and offering medical assistance to those in need.

“We are waiting to see what the morning brings,” Rawson blogged late that evening, likely weary from work and probably without the warm smile he had in almost every photograph. But before morning, word came that Bocozel and Deschapelles were not the only areas affected by the violent outbreak of enteric disease. By Wednesday evening, the emerging epidemic was overwhelming people at an unprecedented level, striking all communities along the banks and delta of the Artibonite River. The fifty-two hospitals and clinics serving the lower river communities were overwhelmed with cases—thousands appeared at health facilities, and hundreds were dying. Local medical staff had never seen such a wave of patients. Throughout the region, people were suddenly experiencing explosive diarrhea, quickly becoming dehydrated, and suffering intense headaches, dizziness, and lethargy.

Diarrheal diseases in tropical countries typically affect the very young, but patients in Haiti spanned all ages. What they had in common was living near the Artibonite River. Most bathed in river water and drank from the river, either directly or through household water containers. They ate food splashed with river water or handled by family members who had touched the river but then left their hands unwashed.

The worst of the epidemic’s early days occurred at Hôpital St. Nicolas (Saint Nicolas Hospital), a major referral hospital in the coastal town of Saint-Marc. As at clinics in the surrounding regions, the rush of patients began on Tuesday afternoon. A typical day brought a few patients needing urgent care, but soon Saint Nicolas was seeing hundreds. Throngs of sick people and family members choked the hospital’s main entrance trying to get inside for medical attention. Explosive vomitus and diarrhea flowed from the infirm in the crowded courtyard outside; many died waiting. Those who managed to get in found conditions even worse. The stricken were everywhere, filling hospital wards, corridors, and even the spaces between buildings.

Cholera seemed to strike people at random. Some had seizures and died within hours. Others suffered acute dehydration and became dried-up caricatures of their former selves. Respiratory difficulties increased as death approached, the lack of oxygen turning the skin of black Haitians a grayish color. Neurological symptoms among some gave the impression of demonic possession. Panic, fear, and the face of death were all haunting realities. Because of the explosive nature of the epidemic and the fear of cholera symptoms and deaths, many Haitians reacted as did Europeans during nineteenth-century epidemics, when fear of la peur bleue— the blue skin of cholera—terrorized many and riots were all too frequent.⁶

By Thursday, the emerging epidemic had reached an unprecedented scale, involving many communities along the riverbanks and delta of the Artibonite valley. The main Haitian river had always been a life source, but now it had become a source of death.

Haitian newspapers immediately understood the seriousness of the situation. The diagnosis was not official, but the press still wrote of cholera,⁷ reporting the official death toll at 49 but unofficially telling of 1,500 cases and 135 deaths—so far. The figures came from the president of the Haitian Medical Association, who may have heard it was cholera from Haitian epidemiologists and scientists at LNSP.

Dr. Gabriel Thimothé, director general of the Ministry of Public Health and Population (MSPP), focused reporters on the dire situation in coastal Saint-Marc. He said experts were seeking the point of the river’s contamination. Dr. Alex Larsen, minister of health, pinpointed the affected area as Artibonite département and upriver Centre département. “The causative organism was likely an imported microbe that flowed in the Artibonite River,” he explained. When a reporter asked whether the imported microbe could be cholera, Larsen said it was doubtful but advocated caution.

The reporter’s question was answered officially when a cholera diagnosis was confirmed. On October 19 and 20, stool specimens from patients in health facilities in Artibonite and Centre départements had been brought to LNSP, where rapid tests—typically not as good as regular laboratory tests but useful for immediate diagnosis—were conducted on eight specimens found positive for V. cholerae O1.⁸ LNSP further analyzed three of the specimens and, on October 22, provided a more complete identification of the organism as toxigenic V. cholerae serogroup O1, serotype Ogawa, biotype El Tor.

In Washington, D.C., the Pan American Health Organization (PAHO) was immediately told of the outbreak, was closely monitoring the situation, and issued a press release on Thursday, October 21 informing the world that cholera had come to Haiti.⁹ It confirmed the cholera diagnosis by Haiti’s national laboratory and presented the epidemiological situation. The report focused on Artibonite département but mentioned other areas, including Mirebalais in Centre département.

After drawing attention to the need for immediate medical care (without rehydration, fatalities reach close to 50 percent), PAHO’s statement briefly addressed the epidemic’s cause, focusing on a possible link between the spread of cholera and an environmental cause: the terrible January earthquake, noting that in its aftermath “more than 1.5 million Haitians were settled in temporary sites throughout Port-au-Prince and beyond.”

But why would an earthquake nine months earlier cause cholera in Haiti? PAHO offered only a vague response: cholera transmission is “closely linked to inadequate environmental management.” Risky areas include urban slums and camps for internally displaced persons, the release stated. The lack of “clean water and sanitation” is a major risk factor.

PAHO did not speculate further about how cholera might have arrived in the country.

The people of Haiti were increasingly eager to identify the source of their new misery. And when public officials showed no interest in the quest for that particular truth, Haitians felt disrespected and devalued. They wondered whether their suffering meant anything to anyone. Not surprisingly, anger, suspicion, and social unrest followed. As many European populations did during the nineteenth-century cholera epidemics, people in Saint-Marc became violent. Doctors and nurses of Médecins Sans Frontières (MSF, Doctors without Borders), were there to provide medic...

Table of contents

• Preface
• Introduction
• 1. Upheaval
• 2. Vibrio Cholerae
• 3. Rumors
• 4. Stealth
• 5. Hypotheses
• 6. Maps
• 7. Altered Reality
• 8. Journalists
• 9. Secrecy
• 10. Obfuscation
• 11. Speculation
• 12. Pandemics and South Asia
• 13. Report
• 14. Vodou and Cholera
• 15. Inquiry
• 16. Politics before Science
• 17. Nepal
• 18. Concealed in the Field
• 19. Quarantine and Isolation
• 20. The Wall Cracks
• 21. Answers
• 22. Sanitation, Water, and Vaccination
• 23. Struggles and Elimination
• 24. Rapprochement
• Epilogue
• Notes
• Bibliography
• Index