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PORTSIDE  April 2012, Week 1

PORTSIDE April 2012, Week 1

Subject:

In Haiti, Global Failures on a Cholera Epidemic

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Mon, 2 Apr 2012 01:41:37 -0400

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In Haiti, Global Failures on a Cholera Epidemic
By DEBORAH SONTAG
New York Times
March 31, 2012
http://www.nytimes.com/2012/04/01/world/americas/haitis-cholera-outraced-the-experts-and-tainted-the-un.html

MIREBALAIS, Haiti - Jean Salgadeau Pelette, handsome
when medicated and groomed, often roamed this central
Haitian town in a disheveled state, wild-eyed and naked.
He was a familiar figure here, the lanky scion of a
prominent family who suffered from a mental illness.

On Oct. 16, 2010, Mr. Pelette, 38, woke at dawn in his
solitary room behind a bric-a-brac shop off the town
square. As was his habit, he loped down the hill to the
Latem River for his bath, passing the beauty shop, the
pharmacy and the funeral home where his body would soon
be prepared for burial.

The river would have been busy that morning, with
bathers, laundresses and schoolchildren brushing their
teeth. Nobody thought of its flowing waters, downstream
from a United Nations peacekeeping base, as toxic.

When Mr. Pelette was found lying by the bank a few hours
later, he was so weak from a sudden, violent stomach
illness that he had to be carried back to his room. It
did not immediately occur to his relatives to rush him
to the hospital.

"At that time, the word `cholera' didn't yet exist,"
said one of his brothers, Malherbe Pelette. "We didn't
know he was in mortal danger. But by 4 that afternoon,
my brother was dead. He was the first victim, or so they
say."

In the 17 months since Mr. Pelette was buried in the
trash-strewn graveyard here, cholera has killed more
than 7,050 Haitians and sickened more than 531,000, or 5
percent of the population. Lightning fast and virulent,
it spread from here through every Haitian state,
erupting into the world's largest cholera epidemic
despite a huge international mobilization still dealing
with the effects of the Jan. 12, 2010, earthquake.

The world rallied to confront cholera, too, but the
mission was muddled by the United Nations' apparent role
in igniting the epidemic and its unwillingness to
acknowledge it. Epidemiologic and microbiologic evidence
strongly suggests that United Nations peacekeeping
troops from Nepal imported cholera to Haiti,
contaminated the river tributary next to their base
through a faulty sanitation system and caused a second
disaster.

"It was like throwing a lighted match into a gasoline-
filled room," said Dr. Paul S. Keim, a microbial
geneticist whose laboratory determined that the Haitian
and Nepalese cholera strains were virtually identical.

And, as the deaths and continuing caseload indicate, the
world's response to this preventable, treatable scourge
has proved inadequate. Cholera, never before recorded in
Haiti, stayed one step ahead of the authorities as they
shifted gears from the earthquake recovery. While
eventually effective in reducing the fatality rate, the
response was slow to get fully under way, conservative
and insufficiently sustained.

"In the future, historians will look back and say, `Wow,
that's unfortunate,' " said Dr. Paul Farmer, co-founder
of Partners in Health, a nongovernmental organization
that provides health care for the poor. "This unfolded
right under the noses of all those NGOs. And they will
ask, `Why didn't they try harder? Why didn't they throw
the kitchen sink at cholera in Haiti?' "

While the world has dedicated $230 million so far to
combating the unexpected epidemic, the United Nations is
now pleading for an additional $53.9 million just to get
the vulnerable displaced population through the rainy
months ahead.

At the same time, Haitian cholera victims are seeking
compensation from the United Nations, pressing it to
accept responsibility. Early on, protests against the
United Nations hindered the construction of treatment
centers and the delivery of lifesaving supplies. Now
distrust of some cholera programs lingers, and the issue
has strained the peacekeepers' relationship with the
Haitians they are protecting in an eight-year-old
mission to stabilize the politically volatile nation.
So, too, have unrelated allegations that they engaged in
criminally abusive behavior.

"In telling the truth, the U.N. could have gained the
trust of the population and facilitated the fight
against cholera," said Dr. Renaud Piarroux, who led an
early investigation into the outbreak. "But that was
bungled."

The United Nations maintains that an independent panel
of experts determined the evidence implicating its
troops to be inconclusive.

Questioned for this article, though, those same experts
said that Dr. Keim's work, conducted after their own,
provides "irrefutable molecular evidence" that Haiti's
cholera came from Nepal, in the words of G. Balakrish
Nair, an Indian microbiologist.

"When you take the circumstantial evidence in our report
and all that has come out since, the story now I think
is stronger: the most likely scenario is that the
cholera began with someone at the Minustah base," said
another expert, Daniele Lantagne, an American engineer,
using the French acronym for the United Nations mission.

Even so, Anthony Banbury, a United Nations assistant
secretary general, said last week, "We don't think the
cholera outbreak is attributable to any single factor."

Many health officials consider the cholera response
"pretty remarkable," as John Vertefeuille, the Centers
for Disease Control and Prevention's director in Haiti,
said.

A sky-high initial fatality rate of over 9 percent has
declined to 1.3 percent (less than 1 percent is
considered a well-managed epidemic). And the most recent
statistics show new cases dropping to 120 daily.

Others, though, believe the bar for success was set too
low and more lives could have been saved. Some critics
bemoan weak disease surveillance and case-tracking,
others inadequate water distribution and latrine
building, and still others what they see as a penny-
pinching reluctance to use antibiotics and cholera
vaccine.

Also, some think cholera could have been stymied, even
eradicated, last winter during the dry season after the
first wave. Instead, it flared with the rains even as
aid groups shuttered or reduced operations. And now,
after another winter without an aggressive prevention
and eradication effort, the health authorities fear a
reprise.

"I think it's going to be another bad year for cholera,"
said Dr. John Carroll, an Illinois doctor who works in
Haiti.

A Rapid Death

Here in the epicenter of the epidemic, all signage
relates to life in the time of cholera. Surrounding the
town square are heart-adorned posters that say, "Living
with cholera: Always wash your hands with clean water
and soap." Banners slung across the streets, in
contrast, bear skulls and crossbones: "Justice and
reparations for all victims of the Minustah cholera."

Inside City Hall, the deputy mayor, crisply dressed in a
chambray shirt and slacks, described how he personally
buried 27 bodies for fear that workers would not take
precautions, how he nearly lost two of his own children
to cholera and how he seethed every time Nepalese troops
entered his offices.

"They were in my face every day, and the feeling inside
me got stronger and stronger," said Ocxama Moise, the
deputy mayor. "A few months ago, I even considered
killing a soldier or two to see what would happen. I
shared the idea with some friends, and they said,
`Don't. You're an official.' But it's only a matter of
time before the population finds a way to get justice."

After the earthquake, when Haitians were living amid
cadaver-filled ruins in the sprawling Port-au-Prince
area, international health officials were concerned that
infectious diseases would rip through the tent camps.

Well before the earthquake, Haiti was fertile ground for
a disease that spreads primarily through fecal
contamination of water: in 2008, only 12 percent of the
population had access to piped, treated water, and only
17 percent to "improved sanitation," which includes the
simplest pit latrines. Haitians' latrine access actually
declined, from 24 percent in 1990.

"For decades we as partners have failed to ensure safe
water and sanitation is provided to every resident of
Haiti," said Dr. Jon Kim Andrus, deputy director of the
Pan American Health Organization.

But Haiti had escaped the cholera that raged through
Latin America in the 1990s, and even the cholera that
struck the Caribbean in the 19th century. It appeared
"extremely unlikely" that cholera would present itself,
a C.D.C. post-earthquake brief said.

"The risk of cholera introduction to Haiti is low," it
said, noting relief workers were "likely to have access
to adequate hygiene and sanitation facilities within
Haiti, such that any cholera organisms they import would
be safely contained."

Seven months later, that assumption would be challenged.

On Oct. 8, 2010, hundreds of Nepalese troops began
arriving in Haiti after a cholera outbreak in their
homeland, where cholera is endemic; the country weathers
outbreaks well, with that one causing nine deaths.

Cholera also affects individuals differently; many
infected develop no symptoms or only mild or moderate
diarrhea.

Falling violently ill in October 2010, Mr. Pelette was
not one of the lucky ones. Severe cholera causes profuse
watery diarrhea, often accompanied by vomiting.
Treatment is straightforward: replacing lost fluids and
electrolytes, orally or intravenously. But those like
Mr. Pelette who get no treatment can become so
dehydrated that they go into shock and swiftly die.

Nobody knows for sure, but people here believe that Mr.
Pelette was the first Haitian to die of cholera, and,
though he was not named, he was presented as the "first
case" in The American Journal of Tropical Medicine and
Hygiene in January.

Some details in that widely cited article, like Mr.
Pelette's age and date of death, did not match those on
his death certificate, obtained by The New York Times.
Also, Mr. Pelette does not offer an example of untreated
mental illness, as the article contended; he had
received care at a hospital for chronic mental diseases,
his brother said.

"When he took his pills, he was calm," Malherbe Pelette
said, speaking on the porch of his sundry store. "He
would come here every day, stand at the door waiting for
a soda or cookies, and give a fist bump to everybody who
came in. Sometimes, he showed up completely naked. He
had a terrible speech impediment, and when he was
agitated, it was really hard to understand him.

"Still, my friend, I cried when he died - a lot, a lot."

Enter the Epidemic

A couple of hours after Mr. Pelette died from what the
family priest proclaimed to be a poison of some sort,
Rosemond Laurimé, 21, a "small businessman" in his
family's description, got sick in nearby Meille.

In Haiti, small businesses are minuscule, selling mangos
or charcoal today to survive tomorrow. Mr. Laurimé
peddled soap at a stand outside the Nepalese base, which
sits on the banks of a fly-specked stream that flows
into the Latem and then into Haiti's longest river, the
Artibonite.

Around 6 p.m. on Oct. 16, when he returned to his shack
near the base, he was clutching his stomach. Soon,
doubled over from violent diarrhea and vomiting, he
begged for help.

His grandmother, 70-year-old Marie-Jean Ulysse, did her
best, finally summoning a moto-taxi at daybreak to take
Mr. Laurimé to the hospital in Mirebalais, run by a
Cuban medical brigade.

By the time he got there, it was too late: "His body had
lost all its water," Ms. Ulysse said.

On Oct. 17, Mr. Laurimé became the first to die of
cholera at a hospital in Haiti. The next day the Cuban
doctors, who had seen five dozen cases of acute diarrhea
in preceding days, notified the Haitian Health Ministry
that something was terribly wrong.

Mr. Laurimé's grandmother also fell ill and, hovering
near death, witnessed the frightening explosion of the
epidemic as she lay absorbing fluids intravenously on a
hospital cot. She saw a chain of sick prisoners stripped
of clothing and handcuffed one to the next. She watched
an endless parade of patients carried in, bodies carried
out.

"I said to my children, `Please do your best to take me
home because I don't want to end up in the big hole
where they're dumping all those bodies,' " she said.

While she is fine now, Mr. Laurimé's mother is not.
Yverose Fleury wears a cloth binding her midsection in
an effort to contain her sorrow. She said neighbors had
ripped up her son's photograph because she keened over
it incessantly.

"Nothing is the same with us after the cholera," she
said. "My husband is weak and cannot work, my remaining
son has a mass on his neck, my little daughter can't
hold down food, and I am sick in the head."

From Meille, the epidemic coursed through the Artibonite
River valley, landing with a thump 46 miles northwest,
and downstream, in the coastal St. Marc area. On Oct.
19, three children died in rapid succession in a
classroom in the rice fields. On Oct. 20, the St.
Nicholas Hospital was overrun.

Patients sprawled on every surface, doubled and tripled
up on beds, in the halls, in the courtyard and even on
the sidewalk outside. By nightfall, there were 404.
Forty-four died.

"At that moment, I felt like I didn't want to live any
longer myself," said Dr. Yfto Mayette, the hospital
director. "It was so sudden and so brutal."

On Oct. 21, as a brass band accompanied Mr. Pelette's
white coffin to the cemetery, the national laboratory
completed its analysis of the bacteria.

At 11 that night, Dr. Jordan W. Tappero of the C.D.C.
got a call in Atlanta from the laboratory's director:
"Jordan," he said, "It's positive."

Louise C. Ivers, Haiti mission chief for Partners in
Health, had just arrived in Boston for a meeting. "My
first thought was, `You can't be serious.' Everyone was
exhausted."

In Port-au-Prince, Jocelyne Pierre-Louis, a senior
Haitian health official, had steeled herself. "We were
in a way waiting for the other shoe to drop," she said.
"We had barely picked ourselves up after the earthquake
when the cholera fell on us."

Dr. Pierre-Louis reported to the large tent that
replaced her collapsed office after the earthquake. Dr.
Ivers took the next plane back, and Dr. Tappero flew in,
too, with the first of 119 C.D.C. employees who would
deploy to Haiti.

"It was a herculean effort at the time, people working
18, 20 hours a day, trying their best to make a
difference," Dr. Tappero said.

There was much to do, from treating patients to treating
water, from importing personnel to training Haitians,
from distributing supplies to distributing basic disease
and hygiene information.

But there were also fundamental decisions to be made,
and nobody was firmly in charge. International health
officials deferred to the Haitians - "our partners" -
but in reality held the purse strings and know-how. This
led to an often awkward collaboration, colored by
Haitians' resentment that cholera had been imported in
the first place.

It did not help that the initial projection used by
international officials for planning purposes - 200,000
cases in six months - was an underestimate. There would
be that many cases in three months' time, with a daily
death toll of more than 100 by mid-December.

As the epidemic took off, the players who operated
outside the "health cluster," a consortium of
humanitarian groups, were able to react most nimbly.

At first, Doctors Without Borders and the Cuban medical
brigades, both self-financed, handled the overwhelming
majority of cases. "We felt quite lonely at the
beginning," said Yann Libessart, spokesman for Doctors
Without Borders. "It made no sense. Everybody was in
Haiti. It was the biggest density of humanitarian actors
in the world, and we two organizations were dealing with
80 percent of the cholera."

Gaëtan Drossart, mission chief for Doctors Without
Borders-Belgium, said the health cluster had good
intentions, "but there's a lot of meetings and a lot of
blah blah blah." He said other groups were limited by
agreements with donors to working in the earthquake zone
and could not redeploy quickly.

Also, everybody initially worried most about the
epidemic's arrival in Port-au-Prince. But Haiti's meager
health care resources have always been concentrated in
the capital, and after the earthquake humanitarian
personnel and supplies were, too. That would eventually
increase the cholera survival odds in Port-au-Prince,
which would have a 0.7 percent fatality rate compared
with 4.5 percent in the southeast.

But it took several deadly weeks for the disease to
forcefully strike the capital, where rehydration
solutions were warehoused; water, latrines and medical
professionals were more plentiful; and organizations had
had time to set up proper treatment centers.

Proper treatment centers maintain rigorous infection
control to keep from becoming cholera contamination
centers: chlorine sprayers to disinfect shoes, hand-
washing stations, cots with holes and buckets
underneath, disposal systems for waste and bodies.

None of this was in place at the start. Doctors Without
Borders sent a team to the St. Marc hospital. "It was
really, really awful," Mr. Drossart said. "There were an
enormous number of cases, it was totally disorganized,
the cholera patients were not isolated, and they were
not being treated correctly."

Even four months later, that hospital did not have
cholera cots; patients defecated in bed or risked a
potentially fatal drop in blood pressure by getting up,
United Nations investigators found.

"Hospital staff reported walking on feces in cholera
units," they added.

Understaffed hospitals sometimes discharged patients too
soon, sending them home to their deaths. They deputized
relatives as caretakers although many patients arrived
so dehydrated that they needed intravenous lines and
nurses to watch over them. Pregnant women were a
particular challenge.

"Our greatest heartbreak is that while the women
survived, we only saved one pregnancy," said Ian Rawson,
managing director of Albert Schweitzer Hospital in
central Haiti.

Truth vs. `The Blame Game'

Within a week of the outbreak, officials in Mirebalais
were pointing fingers at the United Nations base, and
United Nations officials were trying to stifle what they
portrayed as rumors. The struggle began between those
who thought that determining the epidemic's origin was
important and those who lamented "the blame game."

At first, the United Nations said the base's handling of
its waste met international standards - that it used
sealed septic tanks, which were regularly emptied by a
Haitian contractor, with the waste buried in a proper
landfill.

But on Oct. 27, Al Jazeera filmed peacekeepers with
shovels "working furiously to contain what looks like a
sewage spill." Latrines appeared to be emptying black
liquid directly into the river, a reporter said, and the
air smelled foul with excrement.

That same day, The Associated Press observed an
overflowing septic tank at the base and discovered the
landfill to be open pits in a residential area uphill
from the community's bathing stream.

Even four months later, the United Nations' own experts,
examining the base's supposedly improved sanitation,
discovered haphazard piping with "significant potential
for cross-contamination" between toilets and showers.

They also noted the "potential for feces to enter and
flow from the drainage canal running through the camp
directly" into the tributary. Contaminants would have
been distributed throughout the river delta in two or
three days - a timeline consistent with epidemiological
evidence tracing the cholera trail, the experts said.

Before long, hundreds of Haitians were marching on the
base, with demonstrations spreading to Port-au-Prince
and riots developing in Cap Haitien.

Edmond Mulet, then head of the United Nations
stabilization mission, complained that it was "really
unfair to accuse the U.N. for bringing cholera into
Haiti." United Nations officials believed that agitators
were taking advantage of the issue to sow unrest before
November elections. But many Haitians were genuinely
incensed - and fearful. Some wanted an explanation,
others a scapegoat. Voodoo priests were being lynched
for their supposed role in bringing the curse of cholera
on Haiti, the government said.

In early November, the C.D.C. said that Haitian cholera
samples matched strains commonly found in South Asia.

Dr. Piarroux, an infectious diseases specialist and
parasitologist from Marseilles, arrived to lead a three-
week French-Haitian investigation. He and his colleagues
built a database of cases, identified geographic
clusters and mapped the epidemic's movement.

His conclusion: the only explanation for an outbreak of
South Asian-style cholera in a rural area of Haiti home
to a Nepalese Army base with a faulty sanitation system
had to be infected soldiers on the base itself.

In early December, Dr. Piarroux's mission report was
posted on the Web site of the newspaper Le Monde.
Eventually his findings would be peer-reviewed and
published in the C.D.C.'s Emerging Infectious Diseases
journal.

But at that point, he said, he was considered "a
renegade and a mythomaniac." A leading medical journal,
The Lancet, rejected his study after publishing an
editorial that said, "Although interest in how the
outbreak originated may be a matter of scientific
curiosity for the future, apportioning blame for the
outbreak now is neither fair to people working to
improve a dire situation, nor helpful in combating the
disease."

Nonetheless, Ban Ki-moon, the United Nations secretary
general, announced an independent panel "to get to the
bottom of this and find answers the people of Haiti
deserve."

Money and Lives

From the start, financial concerns colored the response
to the epidemic, which had killed more than 3,600
Haitians by the first anniversary of the earthquake. It
was partly a question of getting money flowing. Some
donors hesitated, given the plodding pace of the
earthquake reconstruction; others had to wait for a new
budgetary year. Some institutions had time-consuming
grant or contracting processes.

It was also a question of philosophy.

Some health officials wanted to use the least expensive
prevention and treatment strategies and to marshal
resources for the long battle ahead.

Others wanted to employ every available weapon at once,
from free drinking water and antibiotics to aggressive
case-tracking, mass vaccination, and water and sewer
system building.

If that meant spending more upfront, so be it, they
said. A year after the earthquake, many organizations
were sitting on donations that remained unspent. The
American Red Cross, for one, still had nearly half of
the $479 million it had raised; it would ultimately
dedicate $18 million directly to cholera prevention and
treatment. Doctors Without Borders would spend $45
million.

Dr. Farmer of Partners in Health, who calls himself "a
maximalist," said he wanted "health equity" - for the
developed world to respond to cholera in Haiti as it
would at home.

His organization initially requested potable water be
trucked into the Haitian heartland so that a traumatized
population would not have to filter and treat its water.
Purification tablets were delivered instead because it
was considered cheaper and simpler, he said.

"There was a fetishization of the simple," Dr. Farmer
said. "But there's nothing simple about the introduction
of a new pathogen or stopping its spread in a water-
insecure place. There's nothing cheap about it, either."

Dr. Farmer said he kept thinking about the many water
stations at the New York City Marathon: "That's for a
sport, for heaven's sake. You're telling me the giant
humanitarian aid machine can't do that in an epidemic?"

Mark Henderson, a Unicef official, said water trucking
was done inside the town of St. Marc. "I don't know if
it would have been logistically possible to send a water
truck to every village in the Artibonite," he said. "And
I'm not sure it would have yielded better results than
getting water, which is available locally, and applying
chlorine."

There was also a reluctance to use antibiotics, which
can reduce diarrhea, spare suffering and potentially
limit the disease's spread.

The Cubans alone, who claimed in a report that without
their help "another 1,000 Haitians would have died at
Haitian Health Ministry institutions," dispensed
antibiotics to all cholera patients and preventively to
their relatives.

World health authorities, concerned with cost and drug
resistance, initially said antibiotics should be
reserved for severe cases. Nearly three months later,
the C.D.C. recommended antibiotics for moderate cases,
too.

The fiercest disagreement was over vaccination. Again,
citing cost as well as limited supplies and logistical
challenges, world health officials initially did not
endorse it. Some worried aloud that Haitians could get a
false sense of security and become lax about hygiene.

Also, one of the two oral vaccines available - Shanchol,
the cheaper one - was still under review by the World
Health Organization.

But proponents argued that vaccines could save lives and
buy time until long-range solutions like water and waste
systems were put in place. They called for fast-tracking
approval for Shanchol and increasing vaccine production
by offering manufacturers purchase commitments. In mid-
December, after a C.D.C. analysis indicated that using
the available vaccine doses could reduce the caseload by
22,000, the Pan American Health Organization agreed a
pilot vaccination project would be useful.

Influenced by arguments against vaccination, though, the
Haitian government said no. Choosing a small group to be
immunized would inflame tensions, it said; at least
500,000 needed to be vaccinated, said Jean Ronald Cadet,
Haiti's vaccination chief. "They brought us cholera,
they have to take responsibility for taking care of it,"
he said.

Delay and Disbelief

In February 2011, nearly four months after the outbreak,
the United Nations' independent experts arrived in
Haiti.

The secretary general's office wanted them to move
quickly but not too quickly; it did not want the
findings released until the Nepalese contingent had
concluded its six-month rotation, Ms. Lantagne said.

When the experts revealed their findings in May, the
secretary general's staff members were surprised, Ms.
Lantagne said. Early theories had proposed environmental
and climatological explanations for the outbreak. "I
believe they fully expected our results to be that there
was no possibility cholera was imported into Haiti," she
said.

Instead, the panel said not only that the cholera had
come from South Asia but that it originated in the
tributary behind the Nepalese base.

Yet the United Nations experts noted that "the
introduction of this cholera strain as a result of
environmental contamination with feces could not have
been the source of such an outbreak without simultaneous
water and sanitation and health care system
deficiencies."

And they diplomatically concluded that the epidemic was
"not the fault of, or deliberate action of, a group or
individual."

The panel had examined the Nepalese base's infirmary
logs and found no reports of severe diarrhea in
September or October of 2010. Many took that to mean
that the soldiers were probably unwitting, asymptomatic
carriers of cholera. But Dr. Piarroux did not think that
asymptomatic carriers would have shed enough bacteria to
have caused such a sudden, marked contamination of the
river. He believed that many soldiers must have had
diarrhea - even if it was only mild or moderate diarrhea
that, being military men, they did not report to the
infirmary.

Testing the soldiers would have been the only way to
learn the truth, Dr. Piarroux said. But Haitian health
officials were not permitted onto the base to examine
the soldiers.

After the United Nations panel dispersed, Danish and
American scientists collaborated to scrutinize the
Haiti-Nepal connection using the most comprehensive type
of bacterial genetic analysis - whole-genome sequence
typing.

Dr. Rene S. Hendriksen of Denmark persuaded the Nepalese
to provide samples from their outbreak. Dr. Keim's
Translational Genomics Research Institute in Arizona
sequenced the DNA, comparing it with Haitian samples
already sequenced by the C.D.C.

The Haitian and Nepalese strains were virtually
identical - a conclusion the Nepalese were reluctant to
accept. "They were trying to fish around for whether our
analysis was properly conducted," Dr. Hendriksen said.
"But finally they gave up simply because our data was
valid. We agreed we would balance the paper and not get
into the blame game."

Citing this study and other evidence, a legal claim was
submitted to the United Nations in November on behalf of
Haiti's cholera victims.

Anticipating compensation, thousands flooded treatment
centers seeking medical certificates attesting to their
cholera. Doctors Without Borders set up a special unit
to process the requests, and has asked the United
Nations to clarify whether a legal proceeding is even
moving forward.

The victims' lawyers have asked the United Nations to
establish a commission to hear the claim. Mr. Banbury of
the United Nations said the claim is "under serious
review by the legal affairs department."

"The U.N.'s choice is simple," the lawyers wrote in a
legal article. "It can rise to the occasion and
demonstrate that the rule of law protects the rights of
poor Haitians against one of the world's most powerful
institutions, or it can shrink from the challenge and
demonstrate that once again in Haiti, `might makes
right.' "

A Breather, and Then Disaster

It is tempting now, when reported cholera cases are at a
low, for Haitians to relax their guard and for health
officials to take a breather.

"We are no longer 24/7 cholera," Dr. Pierre-Louis said.
The same thing happened last year. Then the rains hit,
and Port-au-Prince, like other places, experienced more
cases - 24,000 - during a 42-day period than at the
epidemic's start. It was a scramble to deal with the
surge; many grants had expired, emergency workers had
gone home, and treatment centers were closed.

"We had supplies and structures prepositioned, but it
wasn't simple," said Mr. Drossart of Doctors Without
Borders. "We couldn't keep mobilizing staff for Haiti.
There are other things going on in the world."

Dr. Vertefeuille of the C.D.C. said a key focus now was
making the response sustainable without a large
international presence. But the government health
system, weak and underfinanced, will be hard-pressed to
assume greater responsibility.

Dr. Vertefeuille also said cholera was likely to persist
in Haiti absent the development of water and sanitation
systems, the cost of which has been estimated at $800
million to $1.1 billion.

A singular achievement was the opening of Haiti's first
wastewater treatment site last fall. But humanitarian
groups fret that short-term water and sanitation
solutions are not being pursued aggressively, and that
tent camps have lost the free water and, in some cases,
the latrine services that gave them a buffer against
cholera.

Many also express keen frustration that the dry season
is not being used for aggressive case tracking - chasing
the disease into pockets where it flares, investigating
and chlorinating the water source, and mobilizing the
community.

"You can't wait with your arms crossed until the rain
falls again," Dr. Piarroux said. "You have to go after
these areas like firemen trying to extinguish every last
burning ember of a forest fire."

Those who now find the official response sluggish -
"daily" epidemic surveillance is posted after a delay of
weeks - point to what happened recently in Pestel in
southwest Haiti.

On Dec. 10, a severely dehydrated man showed up at the
cholera treatment unit. The man was too far gone to be
resuscitated, said Dr. Seneque Philippe, the physician
in charge.

Dr. Philippe's cholera unit had been inactive because
the government had not paid the staff's salaries. He was
not ready for another outbreak.

Within two weeks, however, Dr. Philippe believed that he
was in the midst of one. People were dying during the
long journey down from the rugged mountains to his
coastal hospital.

He said that he alerted Health Ministry officials on
Dec. 24, and that they were unresponsive. So he
contacted an American missionary who had been working in
Pestel for decades. She, in turn, tapped into an
Internet network of health professionals involved in
Haiti and gathered volunteers, supplies and money to pay
Dr. Philippe's nurses.

They arrived Jan. 10 to find the cholera treatment unit
overflowing. Most patients were coming from the
mountains, so the volunteers, bolstered by other
recruits, set up remote treatment tents. They also
conducted a door-to-door census in the villages.
Including treatment records, too, they calculated 278
suspected cholera cases and 62 deaths in December and
January, with most deaths occurring before the ad-hoc
group of foreigners arrived.

In Port-au-Prince, Dr. Pierre-Louis of the Health
Ministry maintained that the reported outbreak in Pestel
had been a "false alarm," with only 65 cases and three
deaths. She said that "the local doctor" had rebutted
the larger numbers.

But Dr. Philippe, the local doctor, while saying he is
"personally aware of only about 15 deaths," said he knew
of 300 cases - a significant outbreak.

"I felt abandoned to handle the problem myself," he
said.

Farther north, one effort to use the dry season to
establish a bulwark against the disease was running into
other problems.

Late last fall, the new government of President Michel
Martelly had authorized a vaccination campaign. It was
to start small, immunizing 50,000 residents of a Port-
au-Prince slum and 50,000 rural residents in the St.
Marc area.

The organizers, wishing they could have begun a year
earlier and more broadly, were nonetheless relieved to
have secured the new administration's cooperation; it
helped that Shanchol, the cheaper vaccine at $1.85 a
dose, had been approved.

The organizers - Partners in Health and the Haitian
group Gheskio - were also pleased to be starting well
before the rains; the vaccine, considered nearly 70
percent effective, is administered in two doses two
weeks apart and takes another week to take effect.

In February, Djencia Augustin, 25, a petite, vivacious
law student, was racing from mud hut to mud hut in the
rice fields of Bocozel to register residents. She wore a
T-shirt with a wordy slogan - "We are fighting cholera
with Shanchol vaccine without forgetting the other
principals of hygiene" - and, in the shade of breadfruit
trees, gathered barefoot villagers in threadbare
clothing around her as she recorded their information on
a computer tablet.

"Some people think cholera is not in our country
anymore," Ms. Augustin told them. "That's not true.
Cholera will come to visit when the rains arrive, so you
need to be prepared."

Bocozel seemed eager. Chavan Dorcelus, 58, said: "It's a
real bonus for us. Plus it's free, and it can't hurt."

Told that pregnant women were ineligible, Fada Joseph,
24, patted her belly. "That's not really fair. I'm very
scared of cholera," she said. "And if I got an abortion,
would that help?"

But in mid-March, radio reports characterized the
project as an experiment on Haitian guinea pigs. With
$370,000 of vaccine sitting in coolers, a government
bioethics committee took up the issue. The campaign
appeared in peril. Dr. Farmer said last Thursday,
however, that the Haitian health minister had just
promised him that she would resolve the issue in the
coming week.

`Would Have Burned It Down'

In Meille, the walled gate at the United Nations base is
freshly painted now with the insignia of Uruguayan
peacekeepers. The Nepalese are gone.

The mission itself is reducing its forces nationwide.
Nepal's troop strength is being cut by two-thirds, more
than any other country's. United Nations officials said
that this was unrelated to tensions over cholera.

But people here think otherwise: "If they hadn't left,
we would have burned it down," Deputy Mayor Moise said
of the base.

In February, an Uruguayan advance guard was there,
removing latrines and generally "sanitizing the
operation so previous problems do not repeat
themselves," as one soldier said.

Across the street, the open pits where the base's waste
used to be deposited were fenced. "They stopped dumping
the foreigners' poo there after the cholera," said
Ludner Jean-Louis, a farmer, his two cows tied to trees.

Mr. Jean-Louis, who had survived the disease himself,
added, "I don't guess you can be mad at Minustah for the
cholera. Only for the poo."

Behind the base, the stream where the epidemic began
bustles with life now as it did before the outbreak;
many who live and work beside it have no other access to
free water.

Recently, just behind the base's barbed-wire periphery,
Dieula Sénéchal squatted with her skirt hiked up,
scrubbing exuberantly colored clothes while a naked 6-
year-old girl, Magalie Louis, defecated by the bank,
gnawed on a stalk of sugarcane and then splashed into
the water to brush her teeth.

Approaching with a machete on his way to hack some cane,
her gap-toothed father, Légénord Louis, said Magalie had
contracted cholera late last year but after four days of
"special IVs" was restored to health. He knew the river
water was probably not safe, he said, but, while they
brushed their teeth in it, they did not swallow.

For drinking water, Mr. Louis said, his family relies on
a local well. But he lives from hand to mouth and cannot
afford water purification tablets; the free supply he
got in 2010 ran out long ago. So he gambles.

"If you make it to the hospital," he said, "you survive
the cholera."

André Paultre contributed reporting from Port-au-Prince,
Haiti.

___________________________________________

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