Haiti: Cholera, the United Nations, and Hurricane Matthew

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. https://crsreports.congress.gov 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 a commission. 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. immunity. Current Situation 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 Affairs 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. https://crsreports.congress.gov IF10502 Haiti: Cholera, the United Nations, and Hurricane Matthew Disclaimer This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material. https://crsreports.congress.gov | IF10502 · VERSION 4 · UPDATED