Ana S. Ayala, O’Neill Institute
May 10, 2012
In October of 2010, less than ten months after being hit by a devastating earthquake, Haiti experienced a cholera epidemic that quickly spread throughout the small nation. The waterborne disease has now killed at least 7,050 Haitians and sickened over 531,000 others. Meanwhile, nearly half a million earthquake victims remain without adequate housing, and Haitians continue to face one of the most challenging clean water and sanitation situations in the world. As the rainy season sets in, the country is experiencing a notable increase in the number of deaths attributed to cholera, according to the UN.
On April 18, 2012, the O’Neill Institute for National and Global Health Law and the Center for Economic and Policy Research (CESCR) co-sponsored a U.S. Congressional Briefing that examined U.S. and international efforts to address what has become the world’s worst active cholera epidemic. With U.S. Representative John Conyers, Jr. (D-MI) giving introductory remarks and U.S. Representative Maxine Waters (D-CA) giving concluding remarks, the panel of speakers was composed of Dr. Luiz Augusto Galvão, Manager of Sustainable Development and Environmental Health Area at the Pan-American Health Organization/World Health Organization; Donna Barry, Director of Policy and Advocacy at Partners In Health; Brian Concannon, Jr., Director of the Institute for Justice and Democracy in Haiti; Mario López-Garelli, Senior Human Rights Specialist at the Inter-American Commission on Human Rights (Inter-American Commission); and Mark Weisbrot, Co-Director of CESCR. The briefing was organized and moderated by J.P. Shuster, research associate at the O’Neill Institute. The group of panelists discussed urgent measures needed to contain the spread of the disease and the longer-term proposals for preventing cholera from becoming endemic to Haiti, as well as the role of international legal mechanisms for protecting health and human rights violations in Haiti’s greater post-earthquake context.
Public Health Perspective
Donna Barry set the context of the discussion by recalling that health and water are basic human rights and that it is the government’s responsibility to provide access to both, which is why Partners In Health’s work in focuses on strengthening government systems. Barry emphasized the importance of recognizing that, prior to the earthquake, Haiti had the worst health indicators and worst access to clean water in the Western Hemisphere and had one of the world’s worst sanitation systems. Barry also highlighted Partners in Health’s recently launched Haiti Cholera Vaccine Project. The project aims to reduce incidence of disease and transmission and starts with the vaccination of 50,000 individuals in a rural community in Saint-Marc. The vaccination project is intended as a complementary measure to prevention and treatment efforts and is part of Partners in Health’s recommended five-point comprehensive response to combat cholera in Haiti: 1) strengthen water and sanitation infrastructure; 2) identify and treat all those with cholera symptoms; 3) role out a safe, affordable, and effective cholera vaccine; 4) strengthen Haiti’s public health system; and 5) improve effectiveness of foreign assistance to Haiti.
Echoing Barry’s description of Haiti prior to the earthquake, Dr. Luiz Augusto Galvão described the epidemic as “the perfect storm.” Galvão emphasized that, before the earthquake, only 17% of Haitians had access to improved sanitation, only 69% had access to drinking water (compared to 88% in Bolivia, the second poorest country in the Western Hemisphere after Haiti), and Haiti had not experienced a cholera outbreak for over 100 years. Galvão explained that an adequate sanitation system is important for recovery from a cholera outbreak and that Haiti’s population has demonstrated a strong willingness to participate in the efforts taken to stop the epidemic.
In response to the earthquake, PAHO/WHO and Haiti’s Ministry of Public Health and Population (MSSP) led the Health Cluster, a humanitarian response mechanism for the coordination of agencies, institutions, and organizations working in the health sector. As the first cholera cases were detected, the Health Cluster coordinated efforts for the storage and distribution of medicines (one of the biggest problems Haiti faced), treatment, and health promotion, including hygiene and water safety. The Health Cluster also developed messages aimed at helping communities understand the problem and the solutions involving hygiene, use of water, and water safety. Galvão also underscored PAHO’s focus on improving water quality and its participation in the Water and Sanitation Cluster, which is led by UNICEF. PAHO’s current processes include ministerial meetings involving the Haiti and the Dominican Republic, as well as the development of national plans. PAHO has also proposed an international coalition to help Haiti that would be composed of PAHO, UN-WATER, UNICEF, the Centers for Disease Control and Prevention (CDC), the World Bank, Agencia Española de Cooperación Internacional para el Desarrollo (AECID), Canada, France, and Brazil, among others. The coalition is to be launched in June 2012.
Galvão also recalled the recent Call to Action for a Cholera-Free Hispaniola, sponsored by PAHO/WHO, the CDC, and UNICEF, together with governments of Haiti and the Dominican Republic that outlines four key lines of action: 1) improve water, sanitation and hygiene infrastructure; 2) create a task force for water, sanitation, and hygiene infrastructure; 3) develop detailed plan and timeline for water, sanitation and hygiene infrastructure; and 4) honor pledged post-earthquake funds and recruit new partners, which Galvão emphasized as a “fundamental solution” to control cholera in Haiti.
Mario López-Garelli presented on how the Inter-American Commission has used the mechanisms at its disposal to aid post-earthquake Haiti. While the Commission has been monitoring the general human rights situation in Haiti for over forty years, since the earthquake, the Commission has worked with the government and civil society organizations to promote the use of a human rights approach for the reconstruction of Haiti. Based on the information received, the Commission has primarily focused on the living and security conditions at the camps of internally displaced persons (IDPs), sexual violence against women and girls in these camps, and forced evictions. The Commission has used a number of its mechanisms to address these issues, including public hearings, working meetings, press releases, reports, working visits by the Commission’s Rapporteur for Haiti, and the issuance of precautionary measures (requests to the government to take the necessary measures to prevent irreparable harm to persons involved in a pending petition or case before the Commission).
López-Garelli explained that women and girls in IDP camps faced conditions that put them at risk of rape, beatings, and threats. Through the precautionary measures granted to protect women and girls in these camps, the Commission expressed to the Haitian government its concern over the lack of intervention and monitoring of the situation by state agencies that has exacerbated the situation. Moreover, among other requests, the Commission requested that victims of sexual violence receive mental and psychological services, access to medical services, privacy during examinations, access to female medical and culturally sensitive providers with experience with rape victims, issuance of medical certificates, HIV prophylaxis, and emergency contraception. In response to the lack of security in the camps, the Commission requested that proper lighting, the presence of women police officers, patrolling, training of appropriate responses by police forces, creation of special units within judicial police of Haiti to investigate cases of rape and other forms of sexual violence, and the full participation of grassroots and women groups in the planning and implementation of these policies.
According to López-Garelli, while the Commission has since received encouraging information pointing to some improvement in the conditions that put girls and women at risk of sexual violence—improved lighting near toilets (where these attacks are most frequent), better treatment by police officers during investigations, and the drafting of necessary legislation—there are still recommendations that require implementation. The Commission continues to monitor the situation and is eager to continue utilizing all its mechanisms to help protect human rights in Haiti.
Brian Cocannon emphasized that while it is important to address the medical and public health issues of the problem, there is also a need to discuss the legal aspects of the situation, particularly that the cause can be explained in legal terms. Along with Bureau des Avocats Internationaux (BAI) in Port-au-Prince, Cocannon’s organization, Institute for Justice and Democracy in Haiti, filed a complaint in November 2011 on behalf of 5,000 cholera victims against the United Nations before both the United Nations Stabilization Mission in Haiti (MINUSTAH) Claims Unit and U.N. Secretary-General for allegedly acting recklessly and allowing the introduction and spread of cholera in Haiti. According to Concannon, U.N. accountability was clear. By failing to test Nepalese troops coming in as U.N. peacekeepers, who the U.N. knew were coming from a place with a cholera epidemic, and recklessly disposing waste at the Nepalese peacekeeper’s camp, the U.N. violated the law. The U.N. has denied fault, claiming that the cholera outbreak was a result of a “confluence of factors,” including poor water and sanitation systems in Haiti. However, Concannon explained that while a confluence of factors play an important role in the epidemic, such factors gave the U.N. even more reason for being more careful.
The complaint filed asks that the U.N. 1) provide clean water and the sanitation necessary to control the epidemic, 2) compensation for the victims, and 3) an apology. Concannon described this lawsuit as an opportunity for the U.N. to “make things right” for the people in Haiti because, should the U.N. provide the necessary clean water and sanitation requested, the U.N. would help Haiti prevent the spread of other waterborne diseases in the future and be able to save thousands of lives lost every year to these diseases. The lawsuit is also an opportunity for the U.N. to help advance the rule of law. Finally, the lawsuit is an opportunity for the U.N. to garner public support by living up to its ideals.
Mark Weisbrot, an economist, described Haiti’s situation as a misallocation of resources. Weisbrot pointed out that the U.N. had spent $1.5 billion on MINUSTAH, the peacekeeping forces, while the needed infrastructure would cost $746 million, $230 million has been spent on cholera (not even a sixth of what has been spent on MINUSTAH), and the cost of the vaccination campaign is equivalent to a half-day’s budget of MINUSTAH. Therefore, Weisbrot saw Congress as potentially playing an important role in influencing the U.N. and other international actors to ensure the proper allocation of resources and placing political pressure on the U.N. to provide the resources needed for the improvement of water and sanitation system.
Moreover, Weisbrot emphasized the urgency of making sure that the necessary resources are deployed now and not misinterpret a decline of the epidemic as necessarily successful intervention. Last year, the international community reduced its efforts upon observing a decline before the rainy season and incorrectly interpreted it as a result of successful intervention. The decline was followed by a spike during the rainy season, during which more lives were lost. The international community should not make the same mistake.
For more background on the legal aspects of the cholera epidemic in Haiti, see our four-part series “A Call for U.N. Accountability for Cholera in Post-Earthquake Haiti” (see related posts below).
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