The writer is president of the International Council of Doctors Without Borders
Haiti: Where Aid Failed
By Unni Karunakara, The Guardian (UK), Online comment, December 28, 2010
(See also related news story below, "Experts Call for Cholera Vaccine Stockpile")
Why have at least 2,500 people died of cholera when there are about 12,000 NGOs in the country?
Haiti should be an unlikely backdrop for the latest failure of the humanitarian relief system. The country is small and accessible and, following last January's earthquake, it hosts one of the largest and best-funded international aid deployments in the world. An estimated 12,000 non-governmental organisations are there. Why then, have at least 2,500 people died of cholera, a disease that's easily treated and controlled?
I recently went to Haiti's capital, Port-au-Prince, and found my Médecins Sans Frontières (MSF) colleagues overwhelmed, having already treated more than 75,000 cholera cases. We and a brigade of Cuban doctors were doing our best to treat hundreds of patients every day, but few other agencies seemed to be implementing critical cholera control measures, such as chlorinated water distribution and waste management. In the 11 months since the quake, little has been done to improve sanitation across the country, allowing cholera to spread at a dizzying pace.
Ten days after the outbreak hit Port-au-Prince, our teams realised the inhabitants of Cité Soleil still had no access to chlorinated drinking water, even though aid agencies under the UN water-and-sanitation cluster had accepted funds to ensure such access. We began chlorinating the water ourselves. There is still just one operational waste management site in Port-au-Prince, a city of three million people.
On the one hand, Haitians were deluged with text messages imploring them to wash before eating, while on the other they had to bathe their children in largely untreated sewer water. Before the quake, only 12% of Haiti's 9.8m people received treated tap water, according to the US Centres for Disease Control (CDC).
The road to controlling a cholera epidemic has been paved by hundreds of previous outbreaks worldwide. Yet, in Haiti, there are vast gaps in the deployment of well-established control measures. Now the epidemic is nationwide, making more than 120,000 people sick and killing at least 2,500.
In the face of this ferocious outbreak, investigations into its origin have not been released publicly, even though this information is fundamental to understanding the epidemic's behaviour.
Hypotheses of cholera's origin range from the contamination of the river Artibonite by UN peacekeepers, through climate change to voodoo. In the absence of transparency, fear and suspicion have provoked violence. The population's anxiety is only amplified by catastrophic epidemic projections by the Pan American Health Organisation (PAHO), a sister of the World Health Organisation.
PAHO's epidemic modelling has not led to effective aid deployment. Huge amounts of aid are concentrated in Port-au-Prince, while scant support has been provided to inexperienced health workers in rural areas, where cholera is flourishing. MSF teams have found health centres with shortages of life-saving oral rehydration solution, and clinics that were simply shut.
It is against this backdrop that many non-governmental agencies have launched fundraising appeals, even while their post-earthquake coffers remain filled. The UN's Office for the Co-ordination of Humanitarian Affairs (OCHA) has repeatedly claimed that underfunding of its $174m cholera appeal, launched primarily to benefit private groups, is hampering the response – despite the fact that Haiti is the top-funded UN appeal for 2010. As nearly a million Haitians remain homeless in the face of a full-blown public health emergency, arguments that existing funds are tied up in longer-term programmes ring hollow.
The inadequate cholera response in Haiti – coming on the heels of the slow and highly politicised flood relief effort in Pakistan – makes for a damning indictment of an international aid system whose architecture has been carefully shaped over the past 15 years.
Throughout the 1990s, the UN developed a significant institutional apparatus to provide humanitarian aid through the creation of the Department for Humanitarian Affairs in 1992, later renamed OCHA, all the while creating an illusion of a centralised, efficient aid system. In 2005, after the Asian tsunami, the system received another facelift with the creation of a rapid emergency funding mechanism (CERF), and the "cluster" system was developed to improve aid efforts.
The aid landscape today is filled with cluster systems for areas such as health, shelter, and water and sanitation, which unrealistically try to bring aid organisations – large and small, and with varying capacities – under a single banner. Since the earthquake, the UN health cluster alone has had 420 participating organisations in Haiti.
Instead of providing the technical support that many NGOs could benefit from, these clusters, at best, seem capable of only passing basic information and delivering few concrete results during a fast-moving emergency. Underscoring the current system's dysfunction, I witnessed the Haitian president, René Préval, personally chairing a health cluster meeting in a last-ditch effort to jump-start the cholera response.
Co-ordination of aid organisations may sound good to government donors seeking political influence. In Haiti, though, the system is legitimising NGOs that claim responsibility for health, sanitation or other areas in a specific zone, but then do not have the capacity or know-how to carry out the necessary work. As a result, people's needs go unmet.
While co-ordination is important, it should not be an end in itself. It must be based on reality and oriented towards action to ensure that needs are covered.
In Haiti, the cholera outbreak will continue to claim lives for the foreseeable future. What is clear, though, is that the aid community at large has failed to prevent unnecessary deaths, in a population already so tragically affected by one catastrophe after another.
Unni Karunakara is the president of the International Council of Médecins Sans Frontières
Experts Call for International Cholera Vaccine Stockpile
PAHO/WHO urged to design a pilot project to use available vaccine in Haiti
http://new.paho.org/hq/index.php?option=com_content&task=view&id=4569&Itemid=1926
Washington D.C., 17 December 2010 (PAHO) -- A group of experts convened by the Pan American Health Organization/World Health Organization (PAHO/WHO) today urged the creation of an international stockpile of cholera vaccine and called for the use of current vaccines in a pilot project in Haiti that would be expanded as more vaccine becomes available. The recommendations were based on considerations including the limited supplies of available vaccine, studies of the vaccines' safety and efficacy, and WHO recommendations on cholera vaccination, as well as conditions on the ground in Haiti.
"In the short term, we should make use of the limited amount of vaccine we have," said Dr. Roger Glass, director of the Fogarty International Center and associate director for international research at the U.S. National Institutes of Health. "In the long term, we need to make sure we have adequate supplies to respond to cholera in Haiti, in the Americas, and around the world."
PAHO/WHO convened today's meeting in response to renewed interest in cholera vaccination following reports that more vaccine might be available than previously believed. Information shared during the meeting indicated that 100,000 doses of cholera vaccine are currently ready for shipment, but an additional 200,000 doses could become available in the next three months and up to 1 million doses in the second half of 2011. Two doses of vaccine are needed to confer protection against cholera.
"While the increased availability of a vaccine is certainly good news, it should be recognized that over 10 million people live in Haiti and over 10 million live in the Dominican Republic," said Dr. Jon K. Andrus, PAHO's deputy director and a leading vaccine expert. "Under no circumstances could there be enough vaccine-over 40 million doses-to vaccinate all the inhabitants of the island of Hispaniola over the next year."
Participants said the situation in Haiti clearly demonstrates the need for an international stockpile of cholera vaccine, which would stimulate vaccine production and guarantee vaccine supplies. Toward that end, "We have asked PAHO/WHO to dialogue with suppliers to see how much more vaccine they can produce and to dialogue with organizations who would be willing to finance the purchase of vaccine," said Dr. Ciro de Quadros, executive vice-president of the Sabin Vaccine Institute. Dr. de Quadros, who chaired the meeting, also heads the Technical Advisory Group of PAHO's immunization program.
At the same time, the experts urged the development of a pilot project in Haiti that would utilize the immediately available vaccine and also provide lessons on how to introduce cholera vaccine effectively in a country that not only has an ongoing epidemic but also is recovering from a major earthquake. The group urged PAHO/WHO to design such a project and to seek funding for it.
Since mid-October, Haiti's cholera epidemic has sickened at least 112,000 people and claimed at least 2,400 lives. PAHO/WHO experts believe the true toll of the epidemic is probably significantly higher than these official numbers, because of gaps in surveillance.
PAHO/WHO and other U.N. agencies as well as nongovernmental organizations have been supporting Haiti's Ministry of Health in the response to the epidemic. Their efforts have focused on ensuring treatment and prevention, with an emphasis on prompt administration of oral rehydration salts or, for severe cases, intravenous fluids and antibiotics. Prevention efforts have focused on ensuring access to safe drinking water, improving sanitation and waste disposal, and promoting safe food handling and personal hygiene practices.
While these efforts continue to be critical to minimizing the spread of the disease and the number of deaths, Andrus noted that it was important to consider vaccination as well.
"As we go along and new opportunities arise, it behooves us to consider those if they can help us save more lives," said Andrus. "This is a disease that has a foothold in Haiti and will be causing disease in Haiti for some years to come."
Other participants in today's meeting included Matthew Waldor of Harvard University, Peter Hotez of the Sabin Vaccine Institute, Eric Mintz of the U.S. Centers for Disease Control and Prevention (CDC), Myron Levine of the University of Maryland, John Clemens of the International Vaccine Institute, Bruce Gellin of the U.S. Department of Health and Human Services, and William Pape of GHESKIO in Haiti.
Contacts:
Donna Eberwine-Villagran, email: eberwind@paho.orgThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it , tel. +1 202 974 3122 or Daniel Epstein, Public Information Officer, email: epsteind@paho.orgThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it , mobile +1 202 316 5679 Knowledge Management and Communication Area, PAHO/WHO.