Cholera Continues to Spread as Response and Surveillance Weaken

The latest data from the MSPP (Ministry of Health) shows that the number of cholera cases and resulting deaths continues to rise. As of August 2, there have been a total of 583,871 cases and 7,497 deaths reported since October 2010 and this almost certainly is an underestimate. While the number of cases this summer has not spiked as high as it did last year, there have still been 377 deaths and nearly 45,000 cases reported in just the last three months.

The MSPP attributes the slower rate of infection this summer to unusually dry weather; however they predict an increase in the coming months as the hurricane season begins. The Pan American Health Organization estimates that Haiti could see up to 170,000 new cases this year, which would mean an average of about 20,000 cases per month over the next five months. Over the previous three months, the average number of cases has been over 15,000. Despite this, funding for the cholera response, as well as for the infrastructure needed to stem the spread of the disease, has been inadequate. At the end of July, the Comite de Coordination des ONGs Internationales en Haiti (CCO Haiti), which is made up of many international NGOs operating in Haiti, released a statement on the situation:

The cholera outbreak that has already claimed thousands of lives all over the country remains a major threat to public health. Cholera prevention and response should be a key priority for the Haitian Government.

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Furthermore, many public health workers in the Cholera Treatment Center (CTCs) have not received salaries for several months and there are reports of strikes by front line medical staff to redress this situation. This is a serious issue negatively affecting the effectiveness of the cholera response and it needs to be urgently addressed. In addition, there is evidence that the MSPP struggles to carry out its work efficiently due to poor logistics and inefficient fleet maintenance. This seriously hinders the material distribution within the CTCs, Cholera Treatment Units (CTUs) and Acute Diarrhea Treatment Centers (ADTCs), and affects the appropriate collection of cadavers. Necessary arrangement should be made to correct the situation. Overall, the MSPP must once again reinforce its leadership and coordination roles at both central and departmental levels.

Donors must provide sustained and adequate funding to support a comprehensive and integrated approach to cholera prevention and care.

Although less severe than the cholera outbreak last year, the current situation on the ground is much worse than statistics portray. And yet, a shortage of funding has translated into fewer health partners and created serious gaps in coverage. From August, 2011 to May, 2012, the number of Cholera Treatment Centers (CTCs) has declined from 38 to 20, and the number of Cholera Treatment Units from 205 to 74.

In their latest humanitarian bulletin, the UN Office for the Coordination of Humanitarian Affairs (OCHA) noted that, “national capacity to respond to potential outbreaks, especially during the rainy season, remains very weak. The country has only 468 beds for cholera admissions, with 233 of these already occupied. At the height of the epidemic in June 2011, 2500 beds were available.” Despite this, OCHA notes that “significant progress has been made especially in the surveillance and reporting of the epidemic as well as in the integration of cholera care in the national healthcare system.”

Despite OCHA’s positive assessment of strengthening the national health care system, as CCO Haiti pointed out, MSPP is still facing serious issues in their response to cholera. One reason why the Haitian government has had a hard time leading the response is that the international community largely bypassed the government in their provision of funding for cholera. The government of Haiti received only $4.9 million in funds for the cholera response, while the Red Cross alone received $6.1 million. While CCO Haiti calls for increased funding from donors, it is imperative that this money not simply be channeled to international NGOs, but through the MSPP. As the UN Special Envoy has noted, “aid is most effective at strengthening public institutions when it is channelled through them.”

Infrastructure

While the short-term cholera response has reportedly diminished, the only long term solution to stemming cholera’s spread is through investment in water and sanitation infrastructure. This is a key demand of the 15,000 plus Haitians who filed a complaint with the United Nations seeking compensation. Three weeks ago 104 congressional Democrats made a similar demand of the United Nations in a letter to Susan Rice, the US ambassador to the UN.

Thus far, the UN has failed to accept responsibility and the 104 Members of Congress have yet to receive a reply from Ambassador Rice. In the meantime, little money has been dedicated to improving the water and sanitation infrastructure throughout Haiti. As CEPR Co-Director Mark Weisbrot writes today for McClatchy:

But controlling and putting an end to the epidemic is the least that the U.N. can do for Haiti, having caused this disaster. We know that it can be done, too - as it has in many other countries - by building the necessary infrastructure so that Haitians can have access to clean drinking water. The cost has been estimated at $800 million - or the amount that the U.N. spends on keeping its soldiers there for a year.

Surveillance System

Tracking the evolution and spread of cholera is key to an efficient response. Health actors must know where to focus efforts and where to allocate resources. Nevertheless, there have been increasing complaints about the national surveillance system. There are often long delays in publishing information and often there are unexplained jumps in the number of cases and deaths. In May, Doctors Without Borders (MSF), one of the leading responders to the epidemic called the surveillance system “dysfunctional,” later adding that “the numbers are incomplete and unreliable.” In their statement, CCO Haiti adds:

Further efforts need to be made to improve the quality and reliability of data collection systems. Thorough evaluations are needed to identify and address the problems in the epidemiological surveillance system. According to MSPP, only 57.8 % of the 341 daily cholera reports were submitted by departments during the period from March 27 to April 26, 2012. This lack of accurate reporting seriously impacts the capacity to effectively respond.

This trend appears to be continuing as the recent daily reports published by the MSPP are consistently missing data from numerous departments. Without a clear picture of what the disease is actually doing, responding to it will continue to be hampered.