October 2013 marked the 3rd anniversary of the widely-documented 2010 cholera outbreak in Haiti, a small developing Caribbean country which shares the island of Hispaniola with the Dominican Republic. Haiti first reported cases of cholera in October 2010; within one month cholera had spread to all parts of Haiti and the Dominican Republic. “Between October 2010 and August 2013, more than 670,000 people in Haiti were treated for cholera, with around 8,200 deaths attributed to the outbreak.”
Cholera is an intestinal infection, caused by ingestion – usually in contaminated food or water – of the bacterium Vibrio cholerae. Cholera causes diarrhea and vomiting, symptoms that can lead to dehydration and death within hours. Every year, 3-5 million people develop symptoms and 100,000-200,000 people die due to cholera worldwide. Many developed countries, like the United States and Canada, have largely eliminated domestic cholera. However, global cholera incidence has increased since 2005; in 2011, more than 60% of reported cases occurred in the Americas- mostly in Haiti.
As with many other diseases, cholera usually affects vulnerable populations. Those with low immunity are most likely to develop symptoms if exposed, and cholera can spread easily in areas with poor infrastructure and sanitation facilities. While cholera has been largely eradicated in most of the developed world, “cholera remains a global threat to public health and a key indicator of lack of social development. Recently, the re-emergence of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsanitary conditions.”
While many other countries in the Americas dealt with cholera epidemics in recent decades, Haiti had not encountered cholera for 100 years when the 2010 outbreak began. This meant that there was no natural immunity or protection within the Haitian population against this bacterium, which spread quickly. The cholera epidemic also began a mere 9 months after a magnitude 7.0 earthquake hit Haiti, which had destroyed infrastructure and displaced 1.5 million people. 80% of cases can usually be successfully treated with oral rehydration salts, but cholera in Haiti has had a high fatality rate- partially because of limited access to health services.
Three years after the epidemic began, the emergency response is slowly winding down. However, the underlying problems that allowed cholera to spread so quickly – most notably lack of access to clean water, sanitation facilities, and health services – remain unsolved. Haiti has the lowest coverage of improved water and sanitation services in the Western Hemisphere. According to the World Health Organization, in 2010 only 64% of Haitians had access to clean drinking water and only 26% had access to adequate sanitation facilities– and the number of people in Haiti with access to adequate sanitation has since decreased to 17%. But the problems extend beyond merely providing access; one recent survey showed that 50% of improved water sources in rural Haitian households tested positive for e. coli. To meet the Millenium Development Goal of halving the proportion of the world’s population without access to improved water and sanitation facilities by 2015, Haiti would need to achieve 74% and 63% coverage for improved water and sanitation facilities, respectively. Unless the situation quickly improves, these goals likely will not be met.
These unsolved problems in Haiti could represent an international health threat as well. In the years since the beginning of the epidemic in Haiti, cholera has spread to Cuba, most likely through international travel. Health officials in Mexico detected cases of cholera in early September 2013; since then, there have been 171 reported cases in Mexico. 75% of individuals infected with the bacteria do not show symptoms- but can still infect others around them. If cholera remains present in Haiti at current levels, many other countries are then at risk of ‘imported’ cases.
In February 2013, the Haitian government began a National Plan to eliminate endemic cholera in 10 years through improvements in water and sanitation, health care services, epidemiology and surveillance, and health and hygiene promotion. It is estimated that the National Plan will need $2.2 billion to be successful; however, funds and resources are scarce. A recent publication by the Center for Strategic and International Studies, Water and Sanitation in the Time of Cholera: Sustaining Progress on Water, Sanitation, and Health in Haiti, argues that the international community – specifically the United States – must step in and contribute to support these anti-cholera efforts. Improvements in water and sanitation coverage and health care in Haiti could have far reaching effects, such as decreasing the disease burden from other diarrheal and water-born illnesses. The report argues: “failing to adequately support Haiti’s water and sanitation activities threatens the sustainability of other U.S. development investments in the country, including improved population health, economic development, the empowerment of women, and progress toward democratic governance and political participation.”
Cholera is preventable with adequate water, sanitation, and healthcare services and treatable with oral rehydration salts; the most effective anti-cholera campaign in Haiti will combine all these strategies. Three years after the epidemic began, international coverage, attention, and action are beginning to wind down. However, these challenges persist and need permanent solutions to prevent future cases, future unnecessary deaths, and possible future epidemics in other countries. Eliminating cholera in Haiti will require a sustainable and coordinated long-term strategy – and will require participation from a variety of actors, including domestic governments and communities, non-profits, and the international community.