Cholera in Haiti and Regional Infrastructure
So after my Sunday workout today I opened up the tap and started drinking some water. Looking at the product of my municipal water utility, that I honestly pay close to nothing for, left me feeling very very sad, thinking about the current cost of clean water in Haiti. Especially considering how much it costs to make sure that water is really clean.
A few days ago I got an email forwarded from a friend who was forwarding it from another friend, about a small clinic in a small town of 10,000 people up north in Haiti: "Things are beyond crisis stage now. We have over 100 people in two hangars in Borgne and supplies are scarce and by the time it trickles down to us, there is precious little left." So I did the only thing I could do from the US, I forwarded the email and got contacts and it ended up with PAHO and in a meeting with MSF, and a call went out to move additional supplies and I felt alright about my tiny little connection in the game of telephone. But then I thought about how many more small towns like Borgne were out there and my heart grew heavy. Anybody who knows me knows I treat every drop of water I drink in Haiti. Even bottled. A bit of personal hypersensativity from 1) a really bad bout of giardia a few years ago, and 2) having seen purified water sold on the streets come back in tests as fecal coliform contaminated. The thing which scares me is that I have never been to Haiti for an extended trip of more than a few weeks and not had some kind of stomach issue. With all my treatment, and clorox, and handwashing, and awareness, inevitably somewhere along the path there is fecal oral contamination and my gut gets colonized with some unfamiliar bacteria and I have a few uncomfortable days at the toilet. While not a Watsan expert I have a fair amount of experience with both water treatment and sanitation. I’ve been involved in planning on and execution on systems of various sizes from home to community scale. I can definitely say I know a lot more than the basic principles being provided in prevention training. And I've never had to worry about money for or shortages of soap, or clorox, or iodine, or UV pens, or filters. etc. Yet somewhere in my day to day experience I have always found a fecal oral contamination path. The moral I've taken from this personal experience is I don't care who you are, everybody in Haiti is at risk from Cholera. Haiti is one of the most densely populated nations in this hemisphere. Outside of Port au Prince in the countryside, there are millions of people living in small towns of a few thousand people, with bad sanitation, limited health services and poor road access. My personal opinion in observing disaster response is that response to this epidemic will be a logistic undertaking that outstrips what was needed for the January 12th earthquake response. And I think because this is a slow and creeping crises, we are losing precious time to get ready. A public health practitioner projected to me 70,000 cases in the North, there are under 1500 beds ready in that region. The current death rate seems to be under 10%, but this is in areas with treatment and where treatment services are not overwhelmed, untreated cholera death rates can reach %50-60. 1815-1915 Cholera killed millions globally. What really stops Cholera is modern sanitation. A Cholera infected Nepalese troop transported to UN headquarters in New York, would not spread Cholera in the US. In fact if that troop were asymptomatic nobody would probably ever know. This is because his waste would get flushed to a bond supported locally managed treatment facility, regulated by but not at all managed by the national government. Cholera spreads in Haiti because there is A LOT of open untreated sewage in Haiti because local governments have no municipal utilities. The way to stop Cholera immediately is through a massive aid supported public health campaign. But longer term people need to address the underlying issue of the sewage infrastructure. To truly prevent the recurrence of these outbreaks every few years as they used to happen in the 1800s a massive decentralized effort needs to be made to improve the local regional infrastructure of Haiti and support that infrastructure through the development of regional fee and tax structures. An effort must be put towards the distribution of centralized aid to municipal focused projects.The Haitian national government has been slow at moving forward provisions for the strengthening of municipal governments since they were written into the constitution in 1987. Since 1987 there has been an inconsistent and often incoherent set of laws regarding decentralization. Currently the reality is that there is almost no tax base or fee structure for municipal governments to work from to enact local, and more accountable, improvement projects.
This anti-decentralization mentality, adhering to the legally outdated precepts of the 1982 Municipal Law, is no longer just neglect, it could ultimately lead the death of tens of thousands of Haitians. If this effort to build out regional infrastructure isn’t taken all Haitians will be at risk from Cholera for years to come. My hope is that, after elections today (which are now suspect after 12 candidates announced fraud allegations this afternoon), when the new government is announced in December (or January if election votes are contested) they will undertake regional infrastructure, municipal empowerment and jobs creation as a national priority.
