Updated November 17, 2016
Haiti: Cholera, the United Nations, and Hurricane Matthew
Hurricane Matthew hit Haiti on October 4, 2016, causing
widespread damage and flooding and leaving 1.4 million
people in need of immediate assistance. Observers are
concerned that the country might experience a surge in
cholera reminiscent of the 2010 outbreak that claimed the
lives of thousands of people. Prior to the 2010 earthquake,
there had been no cholera cases in Haiti for at least a
century. According to various scientific reports, cholera
was introduced into Haiti by peacekeepers in the United
Nations Stabilization Mission in Haiti (MINUSTAH). Since
then, cholera has infected almost 800,000 Haitians and
killed over 9,000. Although the United Nations (U.N.) has
taken action to control the 2010 outbreak and subsequent
epidemic, numerous groups contend that the agency has not
responded strongly enough. Thousands of victims and their
families have filed legal claims demanding reparations.
In August 2016, U.N. Secretary-General Ban Ki-Moon said
that the U.N. has a “moral responsibility” to the epidemic’s
victims and announced a new program to support them,
though the U.N. continues to claim diplomatic immunity. A
bipartisan group of 158 Members of Congress sent a letter
to Secretary of State John Kerry pressing him to urge the
U.N. to issue an apology to the victims and their families,
set up a fair and transparent process that allows victims to
seek remediation, and take immediate actions to address the
ongoing cholera epidemic in Haiti.
Cholera: Basic Facts
Cholera is a diarrheal infection that is contracted by
ingesting food or water contaminated with the bacterium
Vibrio cholerae. The World Health Organization (WHO)
estimates that there are up to 4 million annual cholera cases
worldwide, causing 21,000-143,000 deaths. The disease is
primarily found in countries with inadequate access to clean
water, sanitation, and hygiene (WASH). Cholera is also
commonly found in urban slums and camps for internally
displaced persons or refugees.
About 75% of people who are infected with cholera do not
exhibit any symptoms, although infected people can spread
the bacterium for up to two weeks should others ingest food
or water contaminated with their fecal matter. Cholera can
cause acute diarrhea and vomiting, which can lead to severe
dehydration and death within hours if not immediately
treated. People with suppressed immune conditions, such as
malnourished children and HIV-positive individuals, are
more likely to die from cholera. Common treatments
include oral rehydration salts and antibiotics. Cholera
vaccines provide protection for three years-five years.
Long-term prevention of the disease requires the
establishment of clean water systems, wastewater treatment
plants, and sanitary facilities.
The Spread of Cholera in Haiti
MINUSTAH was established in 2004 to help restore and
maintain order after the collapse of former President JeanBertrand Aristide’s government. While providing
emergency assistance following the 2010 earthquake, some
MINUSTAH troops inadvertently introduced cholera into
Haiti. In 2011, a team of researchers from France and Haiti
investigated and reported that “contamination of the
Artibonite [River in Haiti] and 1 of its tributaries
downstream from a [MINUSTAH] military camp triggered
the epidemic.” The researchers noted “an exact correlation
in time and places between the arrival of a Nepalese
battalion from an area experiencing a cholera outbreak and
the appearance of the first cases in [the nearby town of]
Meille a few days after.” Other studies have come to the
same conclusion. Vulnerability to disasters—due to a lack
of immunity, overcrowded living conditions, environmental
degradation, poor construction standards, dysfunctional or
lack of sewage and sanitation systems, and political
instability in Haiti—has facilitated the rapid spread of the
disease and led to the largest cholera outbreak in the world.
In 2010 and 2011, roughly 57% of all global cholera cases
and 45% of all cholera deaths occurred in Haiti.
Efforts to Control Cholera in Haiti
In January 2012, the presidents of Haiti and the Dominican
Republic, in cooperation with WHO and the Pan American
Health Organization (PAHO), the United Nations
Children’s Fund, and the U.S. Centers for Disease Control
and Prevention, issued the “Call to Action for a CholeraFree Hispaniola.” The appeal urged donors both to honor
the pledges they made to help Haiti recover from the 2010
earthquake and to provide new funds specifically for
building a sound water supply and sanitation infrastructure
to eliminate cholera. In November 2012, the Haitian
government released the National Plan for the Elimination
of Cholera in Haiti: 2013-2022, which budgeted $2.2 billion
for carrying out the call to action. As of August 2016,
donors had contributed 18% of the funds sought and the
U.N. reported that it had mobilized $307 million in support
of the national plan. The U.N. has used these funds to
vaccinate over 400,000 people against cholera;
build 5,500 household toilets;
improve WASH in over 80 health centers and establish
nearly 700 water and chlorination points;
establish some 250 cholera treatment centers;
construct wastewater treatment plants and build sanitary
facilities in more than 200 schools;
supply more than 9 million cholera prevention and
treatment items, including water purification tablets,
soap, and medical supplies and equipment; and
establish a global stockpile of oral cholera vaccines.
Haiti: Cholera, the United Nations, and Hurricane Matthew
Despite its limitations, the Haitian government has led
cholera prevention and control efforts, with a particular
focus on people displaced by the 2010 earthquake, and
continues to lead coordination and implementation efforts.
These initiatives have led to dramatic declines in related
cases (Figure 1).
Figure 1. Cholera Cases in Haiti: 2010-2016
Human rights groups contend that Haitian and international
law guarantees a victim’s right to an effective remedy.
Several U.N. human rights experts have said an
independent and impartial mechanism to review claims and
ensure adequate reparation is essential. In August 2016, the
U.N. Special Rapporteur on Extreme Poverty and Human
Rights called the U.N.’s approach “morally unconscionable,
legally indefensible, and politically self-defeating.”
In August 2016, Secretary-General Ban reiterated the
U.N.’s immunity but said the U.N. is developing a plan to
intensify efforts to treat and eliminate cholera, improve
long-term access to clean water and sanitation, and provide
about $200 million in compensation to Haitian cholera
victims. The program is neither finalized nor funded.
Source: Created by CRS from PAHO/WHO, Epidemiological Update:
Cholera, October 18, 2016.
Notes: Cholera cases in 2016 are through September 17, 2016, and
exclude suspected cases in the aftermath of Hurricane Matthew.
Hurricane Matthew’s Impact on Spread of Cholera
The first category-4 hurricane to hit the country since 1964,
Matthew caused flooding and destroyed water systems,
creating conditions for the further spread of cholera. WHO
and PAHO report that 5,840 suspected cholera cases
occurred from October 4 through November 6, 2016.
Roughly one week after Hurricane Matthew hit, the U.N.
issued a $119 million appeal for Haiti, including $9 million
for health services and $15 million for WASH. As of
October 20, 2016, roughly 22% of that appeal had been
funded. The Haitian Ministry of Health is also partnering
with WHO/PAHO to vaccinate over 820,000 people against
cholera. The vaccination campaign began November 8,
2016. The U.S. government has provided more than $48
million for Hurricane Matthew response efforts, including
those aimed at controlling cholera.
Dispute over U.N. Response
MINUSTAH operates under a Status of Forces Agreement,
which provides broad immunity from prosecution. To
counterbalance that immunity, however, the agreement
requires the U.N. to establish an independent Standing
Claims Commission to hear claims and compensate victims
injured by U.N. actions. The U.N. has not established such
Human rights groups therefore filed claims directly to the
U.N. in 2011 on behalf of 5,000 cholera victims demanding
that the U.N. compensate them for their losses, install a
national water and sanitation system, and publicly
apologize for its role in the outbreak. In 2013, after the
U.N. had rejected the claims and rebuffed additional efforts
to resolve the matter out of court, the groups filed a lawsuit
in U.S. federal court seeking damages for personal injury,
wrongful death, loss of use of property and natural
resources, and breach of contract. In 2014, the U.S.
government filed a statement claiming that the U.N. has
immunity. In 2015, a federal court judge ruled in favor of
the U.N. and dismissed the case for lack of subject matter
jurisdiction. In August 2016, an appeals court upheld U.N.
Persistent lapses in access to sanitation and clean water
threaten efforts to eliminate cholera in Haiti, and Hurricane
Matthew has caused further setbacks. Haiti had made some
progress in improving access to sanitation, but access to
clean water has declined. In 1990, only 18% of Haitians had
access to sanitation facilities; by 2015, 28% had such
access. Access to clean water fell from roughly 62% in
1990 to 58% in 2015. Gaps between rural and urban use of
sanitation facilities and improved water also strain cholera
efforts; whereas 34% of urbanites were using improved
sanitation in 2015, only 19% of the rural population was
doing so. Similarly, 65% of urbanites had access to clean
water in 2015, whereas only 48% of rural dwellers were
using clean water.
The loss of international support for cholera control has
also compromised related efforts. Following the 2010
earthquake, hundreds of international actors arrived in Haiti
to provide emergency assistance. The groups began to
leave, however, as funding fell. In 2011, 120 groups were
conducting cholera control efforts and had partnered with
the Haitian government and U.N. agencies to establish 250
cholera treatment centers (CTCs). As of June 2016, only 30
organizations were working on cholera elimination and as
of October 28, 2016, only 67 CTCs were open.
The Haitian government has been unable to fill the resulting
gaps. Lacking adequate funds to pay salaries for health and
sanitation workers, the government has closed cholera
treatment centers and reduced the number of staff available
to carry out cholera surveillance, treatment, and community
awareness campaigns, as well as to provide care in health
facilities and cholera treatment centers. Budget shortfalls
also have prohibited the Haitian government from covering
the operational costs of newly built sewage treatment
plants, leaving all but one plant inoperable. Funding
constraints have limited the Haitian government’s capacity
to protect the water and sanitation systems from illicit use.
The longtime lack of a fully functioning government has
exacerbated these challenges, as well.
Maureen Taft-Morales, Specialist in Latin American
Tiaji Salaam-Blyther, Specialist in Global Health
Critics from outside of and within the U.N. have called for
the organization to take responsibility for the epidemic.
Haiti: Cholera, the United Nations, and Hurricane Matthew
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