# Professionalism/The U.N. and Cholera in Haiti
## Outbreak
### Background

On January 12, 2010 a magnitude 7.0 earthquake shook Haiti, resulting in a death toll of 220,000+. The quake pummeled Haiti's sanitation grid and devastated the country. Humanitarian organizations, such as the United Nations (U.N.), pledged resources and manpower to rebuild Haiti. On October 20, 2010 one of the most deadly modern cholera outbreaks spread across the country. The Center for Disease Control and Prevention (CDC) reported that by 2014 over 665,000 Haitians were infected and over 9,000 died. The outbreak challenged the modern belief that cholera was a disease of the past. Modern sanitary practices usually prevent fecal water contamination, the main infection vector for the Vibrio cholerae bacterium that releases cholera toxin. In 2002 Haiti ranked last in water security, making it susceptible to rapid spread of the disease Yet, before the outbreak not a single report of cholera was documented in Haiti for at least 100 years.

### Origins of the Outbreak

Two hypotheses on the origin of the outbreak were proposed:
* Climate: Nonpathogenic cholera indigenous to Haitian coastal waters evolved into a pathogenic strain once environmental conditions were met.
* Human Transmission: Foreign agents were infected prior to arrival in Haiti and poor sanitary practices allowed the bacteria to spread.
The climate hypothesis suggested that the earthquake provided optimal conditions for the mutation of a new and virulent strain of cholera. Rita Colwell, a former director of the National Science Foundation, claimed that "the conditions [in Haiti] would lead to a very high probability of an outbreak." She also stated that "the reason we don't know [the cause of the outbreak] is because the medical community is not receptive to climactic causation or correlation."
However, the climate hypothesis was put into question by conflicting evidence. The epicenter of the earthquake was 15 miles from the Haitian capital, but the first cases of cholera appeared in the countryside 45 miles away. It also took over nine months for the outbreak to begin, coinciding with the influx of humanitarian groups.
The disaster encouraged organizations to travel into damaged Haitian territory and some of the countries that sent aid were infected with endemic cholera strains. Neighboring farms in Haiti reported a fecal stench and leaking waste from a Nepalese U.N. peacekeeper base. The troops who inhabited the implicated base trained in the Nepalese capital of Kathmandu experienced a cholera outbreak on September 23, 2010. The troops also arrived on October 8, 2010, only four days before the initial reports of cholera infection. Additionally, the base was located on a tributary of the Artibonite River, a major source of drinking and bathing water for Haitians.
In early 2011 researchers analyzed the Haitian cholera strains using single-molecule real-time DNA sequencing and found that the genomic origin closely matched El Tor strains found in south Asian countries such as Bangladesh. Because of the conclusive genomic evidence and the accusations against the Nepalese base, the U.N. appeared to be implicated in the outbreak.

## Haitian Claims
### Fear of Cholera

Widespread fear of cholera presented numerous obstacles to treatment efforts. Cholera treatment centers were being built to relieve the pressure on overcrowded hospitals. However, Haitians were convinced that treatment centers were responsible for the spread of disease and it became difficult to find locations for clinics. Plans to establish treatment centers were sometimes abandoned due to difficulties in finding clinic locations and violent protests from local communities. Patients were stigmatized and ashamed to even be seen near treatment centers. Some towns "refused to allow outsiders" to seek treatment at local hospitals. Additionally, the spread of disease was facilitated by Haitians seeking refuge in regions without cholera. There were also economic ramifications that stemmed from the fear of cholera. For instance, merchants reported plummeting domestic food sales while investors cancelled forums and meetings that were intended to boost the struggling economy.

### Distrust of the U.N.

The United Nations Stabilisation Mission in Haiti (MINUSTAH) was established in Haiti in response to the turbulent political climate of 2004. Numerous scandals in the period between the 2004 Haitian coup d'état and the earthquake led to tensions between the U.N. and Haitians, who viewed the peacekeeping mission as an "occupying force." Consequently, there was an overall distrust of international aid.
Haitian speculation on the origins of the cholera outbreak often traced back to a Nepalese U.N. Peacekeeper base. Theories circulated that U.N. helicopters had dumped a black powder, which some Haitians believe leads to zombification, into the Artibonite River. Others reported seeing a "putrid smelling mess" leaking from the base into the river. Locals claimed that MINUSTAH had been transporting waste from the base to the neighboring village. Due to improper maintenance, the waste had been overflowing from the disposal sites towards homes and into the river. Haitian frustrations increased as the U.N. claimed ignorance, denied accusations, and claimed immunity from all liability concerning the outbreak. Eventually, violent protests erupted against the U.N. In response, the U.N. ceased international aid flights and a water-sanitation campaign. The U.N. also claimed that the riots had nothing to do with cholera, and were instead a result of the upcoming 2010-11 Haitian general election.

### The 2010-11 Election

The 2010-11 presidential election was only the third democratic election in Haitian history and was viewed as crucial to achieving stability after the earthquake and outbreak. Public discontent was high during the election, which sometimes resulted in violent protests. Though the general election occurred in November 2010, the official results were not determined until April 2011 due to accusations regarding corruption and credibility of the results. Other criticisms suggested that interference from the U.N. and United States manipulated the outcome by forcefully excluding popular candidates from the election.
Candidates' platforms revolved around fighting corruption, boosting the economy, and responding to natural disasters. Mirlande Manigat, a front-runner in the election, also advocated for decreasing Haitian dependence on non-governmental organizations (NGOs). The ultimate winner of the election, Michel Martelly, promised to restore Haiti's military.

## U.N. Responses
### Lawsuits

Following accusations that the outbreak originated from Nepalese peacekeepers, the first lawsuits against the U.N. were filed. In November 2011, human rights lawyers from the Boston-based Institute for Justice & Democracy in Haiti (IJDH) sued for a national water and sanitation system, a public apology, and compensation for 5000 victims. The Secretary-General of the U.N., Ban Ki-moon, "expressed his sympathy for the terrible suffering caused by the cholera epidemic," but claimed no responsibility. In 2013, the lawsuit was thrown out on the basis of the United Nations' legal immunity from the Convention on the Privileges and Immunities of the United Nations, which states: "Disputes involving any official of the United Nations... enjoys immunity, if immunity has not been waived by the Secretary-General." An appeal filed by the IJDH in 2015 and a 2017 class-action suit, Laventure v. United Nations, were also both dismissed on the basis of legal immunity.

### U.N. Actions

In July 2013, Emergency Relief Coordinator Valerie Amos announced the additional allocation of $1.5 million from the Central Emergency Response Fund (CERF). With this, annual CERF funding increased to $4 million. However, at that point in mid-July, only $5.7 million out of the $34.5 million requested by humanitarian organizations for cholera relief was funded. Furthermore, engagement had dropped from 107 humanitarian organizations to 43.
In August 2016, the Deputy Spokesman for the Secretary-General, Farhan Haq, said in a confidential email that "over the past year, the United Nations has become convinced that it needs to do much more regarding its own involvement in the initial outbreak and the suffering of those affected by cholera." However, Secretary-General Ban stopped short from admitting responsibility and stated: "We simply did not do enough with regard to the cholera outbreak and its spread in Haiti. We are profoundly sorry about our role." Before retiring in 2016, Ban proposed a "new approach to cholera in Haiti" that his successor, Antonio Guterres, implemented. Out of the $400 million required for the plan's success, only $10 million has been raised.
In October 2017, MINUSTAH was retired with no mention of the cholera outbreak in the official announcement.

## Conclusions

Though most evidence suggests the U.N. was responsible for the cholera outbreak, it took the organization six years and thousands of Haitian deaths to acknowledge that it played a role. Accepting responsibility at the time of the outbreak would have pierced the U.N.'s cloak of immunity and opened the gates for numerous lawsuits that may have crumbled the existing system. By denying responsibility, the U.N. escalated pre-existing tensions with the Haitian people. Retrospective action likely does not offset the suffering of the Haitian people, but perhaps a public apology from the U.N. would have been appreciated, much like in the case of Thalidomide and Grünenthal.

### Future Actions

The U.N. states its mission as:
   The United Nations came into being... with one central mission: the maintenance of international peace and security.
Organizations that aim to promote peace and provide relief must strictly stick to that agenda. In the case of the cholera outbreak, the U.N.'s denial of responsibility came at the cost of forfeited health and security. Instead of allowing politics and public image to drive humanitarian efforts, organizations must collaborate with countries and their peoples to work towards global security and safety.
Although the U.N. could have accepted responsibility and provided more relief, preventing the spread of cholera would have been nearly impossible due to Haiti's water sanitation issues. According to the WHO/UNICEF Joint Monitoring Programme (JMP) report, 2.1 billion people around the world do not have access to clean water. Organizations like charity: water attempt to tackle this global issue. In 2019, charity: water raised over $300 million to bring clean drinking water to more than 8.4 million people around the world. Its founder, Scott Harrison, left his job as a promoter in New York City, to found the organization in 2006. The U.N. provides worldwide relief, but individually taking action and supporting endeavors like these are integral to helping countries like Haiti become more developed and preventing cases like this in the future.

## References

* ↑ CNN. (2018, December 26). Haiti Earthquake Fast Facts. Retrieved from https://www.cnn.com/2013/12/12/world/haiti-earthquake-fast-facts/index.html
* ↑ Grad, Y. H., & Waldor, M. K. (2013). Deciphering the Origins and Tracking the Evolution of Cholera Epidemics with Whole-Genome-Based Molecular Epidemiology. MBio, 4(5). doi:10.1128/mbio.00670-13. Retrieved from https://mbio.asm.org/content/4/5/e00670-13
* ↑ CNN. (2010, January 13). U.N. chief calls on world to help crisis-hit Haiti. Retrieved from http://edition.cnn.com/2010/WORLD/americas/01/13/haiti.quake.world.reaction/
* ↑ Center for Disease Control and Prevention. (2014, November 7). Cholera in Haiti. Retrieved from https://www.cdc.gov/cholera/haiti/index.html
* ↑ George, R. (2015, July 7). Why we still haven't stopped cholera. Retrieved from https://mosaicscience.com/story/cholera-haiti/
* ↑ Center for Disease Control and Prevention. (2018, May 11). General Information. Retrieved from https://www.cdc.gov/cholera/general/index.html
* ↑ Lawrence, P., Meigh, J., & Sullivan, C. (2003). The Water Poverty Index:an International Comparison. University of Keele. Department of Economics. Retrieved from https://ideas.repec.org/p/kee/kerpuk/2002-19.html
* 1 2 3 Katz, J. M. (2013, January 11). In the Time of Cholera. Retrieved from https://foreignpolicy.com/2013/01/10/in-the-time-of-cholera/
* 1 2 3 Orata, F. D., Keim, P. S., & Boucher, Y. (2014). The 2010 cholera outbreak in Haiti: how science solved a controversy. PLoS pathogens, 10(4), e1003967. doi:10.1371/journal.ppat.1003967. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974815/#ppat.1003967-Parker1
* 1 2 Parker, A. A. (2010, November 11). Cholera in Haiti - The Climate Connection. Circle of Blue. Retrieved from https://www.circleofblue.org/2010/world/hold-cholera-in-haiti-the-climate-connection/
* ↑ CNN. (2010, January 14). Aid begins flowing to Haiti. Retrieved from http://www.cnn.com/2010/WORLD/americas/01/13/haiti.aid.response/index.html
* ↑ Ali, M., Nelson, A. R., Lopez, A. L., & Sack, D. A. (2015). Updated global burden of cholera in endemic countries. PLoS neglected tropical diseases, 9(6), e0003832. doi:10.1371/journal.pntd.0003832. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455997/
* ↑ The Australian. (2010, October 29). UN base focus of Haiti cholera epidemic. Retrieved from https://www.theaustralian.com.au/news/world/un-base-focus-of-haiti-cholera-epidemic/news-story/fa1953fc8f60254b59aa010741b8227c
* ↑ National Public Radio. (2012, April 12). Water In The Time of Cholera: Haiti's Most Urgent Health Problem. Retrieved from https://www.npr.org/sections/health-shots/2012/04/13/150302830/water-in-the-time-of-cholera-haitis-most-urgent-health-problem
* ↑ Chin, C., Sorenson, J., Harris, J. B., Robins, W. P., Charles, R. C., Jean-Charles, R. R., . . . Waldor, M. K. (2011). The Origin of the Haitian Cholera Outbreak Strain. New England Journal of Medicine,364(1), 33-42. doi:10.1056/nejmoa1012928. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMoa1012928
* 1 2 3 Neel, J. (2010, October 27). Chaos In Haiti As Cholera Patients Seek Treatment. NPR. Retrieved from https://www.npr.org/sections/health-shots/2010/10/27/130862138/chaos-at-haiti-hospital-as-patients-seek-treatment
* 1 2 3 4 5 Katz, J. M. (2013, January 10). In the Time of Cholera. Foreign Policy. Retrieved from https://foreignpolicy.com/2013/01/10/in-the-time-of-cholera/
* ↑ Carroll, J. (2011, December 5). Cholera in Rural Haiti: Interview with Father Andre Sylvestre of Robillard, Haiti (north). Retrieved from https://canada-haiti.ca/content/cholera-rural-haiti-interview-father-andre-sylvestre-robillard-haiti-north
* 1 2 3 Politics in the time of cholera. (2010, November 18). The Economist. Retrieved from https://www.economist.com/the-americas/2010/11/18/politics-in-the-time-of-cholera
* ↑ United Nations. (n.d.). MINUSTAH. Retrieved from https://peacekeeping.un.org/en/mission/minustah
* ↑ Mendoní§a, M. L. (2008, January 21). UN Troops Accused of Human Rights Violations in Haiti. Retrieved from https://www.globalpolicy.org/component/content/article/186/34495.html
* 1 2 VICE News. (2014). Investigating a Mysterious Cholera Outbreak in Haiti: Correspondent Confidential. Retrieved from https://www.youtube.com/watch?v=Xx4sQ0oeU9Q
* ↑ Al Jazeera English. (2016). Haiti in a Time of Cholera - REWIND. Retrieved from https://www.youtube.com/watch?v=02MgwqJk95Y
* ↑ Fraser, B. (2010). Haiti still gripped by cholera as election looms. The Lancet, 376(9755), 1813–1814. https://doi.org/10.1016/S0140-6736(10)62151-4
* ↑ Haiti: Seismic Election. (2010, November 18). Al Jazeera. Retrieved from https://www.aljazeera.com/programmes/peopleandpower/2010/11/20101117839903761.html
* ↑ Delva, J. G. (2010, October 27). Analysis: Cholera, tensions contaminate Haiti’s path to polls. Reuters. Retrieved from https://www.reuters.com/article/us-haiti-elections-cholera-analysis-idUSTRE69Q55F20101027
* ↑ Watson, I. (2010b, November 27). Haiti gears up for elections amid reports of violence. CNN. Retrieved from http://www.cnn.com/2010/WORLD/americas/11/27/haiti.election.violence/index.html
* ↑ P.B. (2010, November 29). As bad as advertised. The Economist. Retrieved from https://www.economist.com/americas-view/2010/11/29/as-bad-as-advertised
* ↑ Haiti runoff vote to be delayed. (2011, January 4). Al Jazeera. Retrieved from https://www.aljazeera.com/news/americas/2011/01/201114234022990732.html
* ↑ Archibold, R. C. (2010, November 27). Haiti Election, Set for Sunday, Marred by ID Card Problems. The New York Times. Retrieved from https://www.nytimes.com/2010/11/28/world/americas/28haiti.html?ref=americas
* ↑ Weisbrot, M. (2011, January 10). Haiti’s election: a travesty of democracy | Mark Weisbrot. The Guardian. Retrieved from https://www.theguardian.com/commentisfree/cifamerica/2011/jan/10/haiti-oas-election-runoff
* ↑ Edmonds, K. (2010, August 23). The Assault on Haitian Democracy. Retrieved from https://nacla.org/news/assault-haitian-democracy
* ↑ Watson, I. (2010, November 26). Haiti prepares for presidential elections amid cholera outbreak. CNN. Retrieved from http://www.cnn.com/2010/WORLD/americas/11/26/haiti.elections.preview/index.html
* ↑ Padgett, T., & Desvarieux, J. (2010, November 15). Former First Lady Mirlande Manigat Could Be Next Haitian President. TIME. Retrieved from http://content.time.com/time/world/article/0,8599,2031412,00.html
* ↑ Haiti confirms Martelly victory. (2011, April 21). BBC News. Retrieved from https://www.bbc.com/news/world-latin-america-13163550
* ↑ Archibold, R. C. (2011, October 25). President Michel Martelly Seeks to Re-create Haiti’s Army. The New York Times. Retrieved from https://www.nytimes.com/2011/10/26/world/americas/president-michel-martelly-seeks-to-re-create-haitis-army.html
* 1 2 "Cholera Litigation". The Institute for Justice and Democracy in Haiti.
* ↑ Ki-moon, B. (2013, February 21). Statement Attributable to the Spokesperson for the Secretary-General on Haiti. https://www.un.org/sg/en/content/sg/statement/2013-02-21/statement-attributable-spokesperson-secretary-general-haiti-please
* ↑ Assembly, U. G. (1946). Convention on the Privileges and Immunities of the United Nations. https://www.un.org/en/ethics/pdf/convention.pdf
* ↑ Laventure v. United Nations (United States District Court, E.D. New York. August 23, 2017) (Casetext, Dist. file). https://casetext.com/case/laventure-v-united-nations-1
* ↑ United Nations, Office for the Coordination of Humanitarian Affairs. (2013, July 18). United Nations Releases New Funds To Support Cholera Response in Haiti During Rainy Season [Press release]. https://reliefweb.int/sites/reliefweb.int/files/resources/OCHA Press Release Funding for Cholera in Haiti 18Jul2013.pdf
* ↑ Katz, J. M. (2016, August 17). U.N. Admits Role in Cholera Epidemic in Haiti. The New York Times. https://www.nytimes.com/2016/08/18/world/americas/united-nations-haiti-cholera.html
* ↑ Sengupta, S. (2016, December 1). U.N. Apologizes for Role in Haiti’s 2010 Cholera Outbreak. The New York Times. https://www.nytimes.com/2016/12/01/world/americas/united-nations-apology-haiti-cholera.html
* ↑ Ki-moon, B. (2017, May 3). New approach to cholera in Haiti (Rep.). https://undocs.org/A/71/895
* ↑ U.N. Development Group. (n.d.). UN Haiti Cholera Response Multi-Partner Trust Fund. http://mptf.undp.org/factsheet/fund/CLH00
* ↑ U.N. Stabilization Mission in Haiti. (n.d.). MINUSTAH Fact Sheet. https://peacekeeping.un.org/en/mission/minustah
* ↑ Water, Sanitation and Hygiene. (n.d.). Retrieved May 6, 2019, from UNICEF website: https://www.unicef.org/wash/
* ↑ charity: water. (2019). Water changes everything. Retrieved from https://www.facebook.com/watch/?v=541207736356229