21 Jan Health citizenship and Haiti…

Mountz (2004) and others (Nagar et al, 2002; Hyndman, 2001) point to the importance in the scalar narratives of globalization, and particularly, in locating the processes of power in relation to the state. In this case, the processes of power are being negotiated and managed across multiple states and supranational organizations. Haiti represents a new place of transnationalized citizenship formation in all of the ways that we imagine citizenship: as a technology of control (Kearns, 1995; Mitchell, 2005), urban citizenship and the role of the city in the development of citizenship (Holston & Appadurai, 1996; Staeheli, 2008), global citizenship and post-citizenship cosmopolitanism (Desforges, 2004; Sassen, 2992; Ong, 2006), and in relation to migration and non-citizenship (Mitchell, 2004; Varsanyi, 2008).  The impotence of the collective health citizenship of Haitians was made manifestly clear during the past 24 months through the massive international mobilization of humanitarian aid, military security, and development programs and people. Perhaps the most striking and startling display of this denationalization of health citizenship has been through the introduction of cholera into Haiti.

Cholera was confirmed in Haiti on 21 October 2010.  The first cases appeared in an area named Meille, on the Meye Tributary of the Artibonite.  More cases followed from Mirebalais which sits directly on the Artibonite Rivier, and quickly spread downriver, reaching the coastal regions within five days of the first hospitalization. Within 10 weeks the cholera outbreak had spread to all 10 departments. The source of the arrival of cholera in Haiti was controversial and blamed on everything from floating on ocean currents from the Gulf of Mexico due to the tectonic plate shifts resulting from the earthquake of 12 January, to evolving from non-pathogenic strains already present in Haiti, to having been inadvertently introduced to the environment from a human host (Cravioto et al., 2011).

Before the earthquake, only 12% of Haitians received their water from a tap and only 17% had adequate sanitation, down from 26% in 1990 (WHO, 2010). No city in Haiti had a functioning sewage system (Grau et al, 2009). The water and sanitation systems in Haiti were already weak, with Haiti ranking dead last in the Centre for Ecology and Hydrology water poverty index (Cho, Ogwang, & Opio, 2010), and the earthquake further reduced the viability of what little infrastructure was in place. Thus, the country, and the Artibonite region, particularly was highly vulnerable to the introduction of any new water-borne infectious disease.

The cholera strain found in Haiti is a “hybrid” strain of the El Tor biotype and the classic toxin biotype. The El Tor biotype is known for its longevity, both in and outside the body, meaning that a single carrier can infect more people than a carrier of the classic toxin. Further, the classic toxin biotype is associated with more severe illnesses (CDC 2010a). Thus, this hybrid was particularly poised to wreak havoc on an already devastated country (Ceccarelli et al, 2011).

While the international target fatality rate is 1% for cholera worldwide, Haiti, in October 2010, was experiencing a 6.4% fatality rate – far higher than acceptable levels. And although the cholera outbreak and death rate were reported to have plateaued in February 2011, that summer, a second peak in cholera case rates occurred. The fatality rate, overall, has fallen to below 1%, but department by department, the fatality rates range from .8% to over 5%. The uneven distribution of mortality rates, and particularly, the consistency of a high death rate in the Sud-Ouest Department and the sudden spike in the region around Pestel and Desreveaux raise intriguing questions about the distribution of aid and services, and the enclaving of health citizenship. I’ll return to this issue later in the paper.

As of January 2012, more than 520,000 cases of cholera, and more than 7,000deaths have been reported by the Haitian government. According to many experts, the reported numbers are exceedingly low (CEPR, 2011). In fact, “decline in cholera prevalence in early 2011 is part of the natural course of the epidemic, and should not be interpreted as indicative of successful intervention. Substantially more cases of cholera are expected than official estimates used for resource allocation” (Andrews & Basu, 2011). As many as another 21,000 have been sickened in the Dominican Republic, with a further 363 deaths in the neighboring country (UN, 2012). And 23 cases linked to the strain in Haiti have been reported in the U.S.

While many reports in news and other media cautiously stated that cholera has not been seen in Haiti “in decades” (Leinwand, 2010),  “in 50 years” (Archibold, 2010), or even “in the last century” (As cholera returns, 2010), a careful examination of health histories and of 19^th and 20^th century newspapers conducted at the Duke University Haiti Laboratory at the John Hope Franklin Humanities Institute, revealed that Haiti has, in fact, never experienced a cholera outbreak. Their research consisted of a close combing of newspapers throughout the Americas, as these are the most reliable source for any outbreak as all port towns had to report all disease outbreaks. Ships could not dock at ports experiencing major disease outbreaks, and those in port at the time of an outbreak had to be quarantined until the disease was under control as a way to manage the spread of infectious diseases (Jenson, 2011). When cholera first appeared in the Americas in 1832, president Jean-Pierre Boyer immediately set about on a hygiene program and worked to strengthen the public health system (Jenson, 2010). At that time, in the rest of the Americas, cholera was able to spread easily through slave quarters and through military barracks. Haiti had neither as slavery had been abolished in the Revolution nor the military lived at their own homes (Jenson, 2011). And while cholera came as close as the Dominican Republic in 1868, it never crossed the border.

The original outbreak in October occurred just 150 meters down river from a Nepalese MINUSTAH camp within days of the peace keeping troops’ arrival. Immediately, both the Nepalese military and MINUSTAH denied any responsibility, stating that the troops had all been tested before deployment, including stool samples where clinically indicated. But 75% of El Tor strain carriers are asymptomatic (Enserink, 2010). Further, what they did not tell the press was that those same troops were sent home for 10 days’ leave after testing, before reassembling in Kathmandu for deployment between October 8^th and 10^th (CITATION). In September 2010, Nepal reported an outbreak of cholera in Kathmandu, which prompted a notice to American citizens on the US Embassy website.

On November 1, the CDC announced that preliminary results of biotype, serotype, antimicrobial susceptibility testing and by pulse-field gel electrophoresis of the strain of V. Cholerae indicated that it was a South Asian strain of the El Tor biotype which is distinctly different rom the strain that had been present in Latin America since the 1991 Peruvian outbreak, and that the cholera strain had been introduced by a single event (CDC, 2010b; Chin et al, 2011).

A joint Haitian-French investigative origin study, not unlike John Snow’s original report on London’s Broad Street Pump Outbreak in 1854, was conducted between 19 and 24 October and again between 7 and 27 November, led by the epidemiologist Professor Renaud Piarroux, from the Universite de la Mediterranee in Marseille, an acknowledged expert in cholera (Piarroux et al, 2011).  Piarroux concluded that the origin of the cholera break was around the camp of the Nepalese MINUSTAH forces. Several doctors and local people reported seeing a “nauseating liquid pour[ing] from the base.” The Department of Epidemiology Centre also reported the presence of a pipe from a septic tank at the MINUSTAH camp “pouring a dark liquid in the river” during the preliminary investigation conducted in October, but the pipe was gone by the time Piarroux arrived in November (Piarroux, 2010).

Further, Al Jazeera reporter, Sebastian Walker, filmed Nepalese soldiers trying to clean up what appeared (and smelled) to be a sewage leakage flowing from the toilets on the base on October 27^th (“UN Investigates”, 2010). And BBC reporter, Stephen Katz, while filming the base, became overwhelmed with the stench of raw sewage, even as the camp commander insisted that there was no leakage (CITATION). Further investigation found that grey and black water drainage pipes were haphazardly constructed with several areas for cross contamination. While grey water is piped into drainage pits on the campsite, black water is piped into containers that are picked up on demand and trucked across the street from the camp and up a hill to be dumped into an open septic pit that is in an area prone to flooding.  The Meye Tributary System is just down the hill from the septic pit.

The Meye Tributary system is the site of significant human activity, including washing clothes, bathing, and children playing. Further, the Mirabalais municipal water supply system closed for a few weeks in October 2010, leading people to rely on alternate water sources, including water collection from the Meye Tributary. What is not clear, as no written records are kept, is exactly what two weeks the municipal water system was closed, leaving the question of its impact on the outbreak open to interpretation.

Even with all of this damning evidence taken together, why did the UN refuse to take responsibility for the outbreak? Imogen Wall, United Nations spokesperson to Haiti went so far as to state, “From our point of view, it really doesn’t matter” (McNeil, 2010).

Several editorials and even commentary from the United Nations cited concerns for deepening political and social frictions and delegitimization of the UN occupying force, not only in Haiti, but also across the globe as a reason to not further investigate the cause of the outbreak. For instance, Mark Leon Goldberg, author of the UN Dispatch op-ed of 16 November stated, “It is hard to identify a single villain when poor living conditions are to blame. But the fact is, cholera became epidemic because of the combustible combination of a weak government, poverty, crowded and unsanitary living conditions — all made worse by the earthquake and then, Hurricane Tomas” (Goldberg, 2010). Donald G. McNeil, New York Times science and health reporter “specializing in plagues and pestilences” (2010) went so far as to state, “And the “fault” — if that’s the word — often lies just as much with the victims as with the vectors, since, as in syphilis’s case, they are careless about whom they cavort with, and with cholera, they must lack good sanitation for it to spread” (emphasis add).

Within weeks, Haitians responded to the preliminary epidemiological reports with deepening distrust of humanitarian workers which sparked renewed frustrations over the continued occupation of Haiti by MINUSTAH troops, in residence since 2004 following the coup d’etat of Jean-Bertrand Aristide (Faucher & Pirraoux, 2011). By mid-November, full-scale protests had broken out with Haitians blocking roads in Cap-Hatien and Port-au-Prince with burning tires and makeshift barricades (Watson, 2010; Herz, 2010). Stones were hurled at UN troops and gunshots were exchanged, killing two and wounding 12 Haitians and wounding six UN personnel (Pitts, 2010). Protestors demanded that the UN leave their country.

In response, the UN announced that the protests were politically motivated, driven by the rising tensions around the upcoming elections, stating, ““MINUSTAH calls the people to remain vigilant and not be manipulated by enemies of stability and democracy in the country,”  (UN Deplores violence, 2010; MINUSTAH, 2010). Interestingly, the elections were not put off and were held on 28 November, just five weeks after the first confirmed death from cholera, even as the disease ravaged several parts of the country sickening 10’s of thousands and as more than 1,000 people had died from cholera at the time of the elections. For many Haitians, this was insult upon injury as they questioned the squandering of $500 million a year spent to keep the peacekeeping forces in their country (CIATION). But that’s for another paper. (or is it?)

To be sure, this is not about playing the “blame game,” as so many involved in those first few months of denial put it; however, there are multiple geopolitical processes that were given precedence over the Haitian people’s desire to know and to understand how this calamity could have befallen them.  Further, several epidemiologists have pointed to the importance of understanding the cause of the outbreak in militating against future, similar outbreaks.  Alice Dautry, Director General of the Institut Pasteur, in the forward to the edited volume, Influenza and Public Health: Learning from past pandemics, states, “It is important, I think, that we examine the political and economic dilemmas and decisions that guided attempts to manage these epidemics, and to investigate both the ethical implications of these decisions and the social response to them” (2010, xv).

Among the issues is one of testing and vaccination protocols for peacekeeping troops coming in from areas where diseases are endemic. The lack of and the unwillingness to deploy cholera vaccine doses in Haiti pointed to two major problems. 1. That there were only 400,000 cholera vaccine doses available at the cost of $2 a dose. 2. That deployment was decided against as a) the vaccination takes two doses (3 for small children) to be effective and managing who has and has not had the vaccine would be difficult to manage – not to mention, 75% of cholera carriers are asymptomatic, so choosing who would or would not get the vaccine would be difficult; b) the vaccine takes three weeks to become active; c) it was decided that education and outreach for cleaning water and hygiene are effective enough to slow the spread (Borkowski, 2010; Knox, 2010; Waldor et al, 2010). Yet several epidemiological studies since last October have found quite the opposite to be true (Clemens, 2011; Chao, Halloran & Longini, 2011; Stacks, 2011).