By Paul Farmer1,2,3*, Charles Patrick Almazor4, Emily T. Bahnsen1,3, Donna Barry2,3, Junior Bazile4, Barry R. Bloom5, Niranjan Bose6, Thomas Brewer6, Stephen B. Calderwood7,8,9, John D. Clemens10, Alejandro Cravioto11, Eddy Eustache4, Gregory Je ́roˆme4, Neha Gupta1, Jason B. Harris9,12, Howard H. Hiatt1,2, Cassia Holstein1,3, Peter J. Hotez13,14,15,16, Louise C. Ivers1,2,3, Vanessa B. Kerry1,17, Serena P. Koenig1,2,3, Regina C. LaRocque9, Fernet Le ́andre3,4, Wesler Lambert4, Evan Lyon3, John J. Mekalanos8, Joia S. Mukherjee1,2,3, Cate Oswald4, Jean-William Pape18,19, Anany Gretchko Prosper4, Regina Rabinovich6, Maxi Raymonville4, Jean-Renold Re ́jouit4, Laurence J. Ronan17, Mark L. Rosenberg20, Edward T. Ryan7,9,21, Jeffrey D. Sachs22, David A. Sack23, Claude Surena24, Arjun A. Suri1, Ralph Ternier4, Matthew K. Waldor25, David Walton1,2,3, Jonathan L. Weigel1,3

Introduction

Cholera in Haiti: Acute-on-Chronic

Long before the devastating earthquake on January 12, 2010, Haiti struggled beneath the burdens of intractable poverty and ill health. The poorest country in the Western Hemisphere, Haiti also faces some of the highest rates of maternal and infant mortality—widely used indicators of the robustness of a health system—in the world ([S1] in Text S1; [2,3]). The October 2010 cholera outbreak is the most recent of a long series of affronts to the health of Haiti’s population; it is yet another acute symptom of the chronic weakness of Haiti’s health, water, and sanitation systems.

Water and sanitation conditions high- light these systemic weaknesses. In 2002, Haiti ranked last out of 147 countries for water security [4,5]. Before the earthquake struck, only half of the population in the capital, Port-au-Prince, had access to latrines or other forms of modern sanita- tion, and roughly one-third had no access to tap water [6]. Across the country, access to sanitation and clean water is even more limited: only 17% of Haitians had access to adequate sanitation in 2008, and 12% received treated water [7]. Not surprising- ly, diarrheal diseases have long been a significant cause of death and disability, especially among children under 5 years of age [6].

The cholera outbreak began less than a year after a 7.0-magnitude earthquake took the lives of more than 300,000 people and left nearly 1.5 million homeless [6]. Almost 1 million Haitians still live in spontaneous settlements known as inter- nally displaced persons (IDP) camps [8]. While post-earthquake conditions in Haiti were ripe for outbreaks of acute diarrheal illness, cholera was deemed ‘‘very unlikely

source or piped from rivers and streams constitutes the principal supply of drinking water in rural Haiti. The lack of adequate piping, filtration, and water treatment systems (including chlorination) made these rural regions vulnerable to the rapid spread of waterborne disease. While most IDP camps have been supplied with potable water, large urban slums have had to rely on existing water sources— some of them containing Vibrio cholerae—

and have therefore been vulnerable to rapid disease spread. Most slums also have poor sanitation infrastructure. Since the first cases were reported in Saint-Marc and Mirebalais, cholera has spread to every department in Haiti, and to other countries, too [S3] [12–14].

Public suspicion (ultimately validated by genomic sequence analyses [15]) of the strain’s link to South Asia, home to a group of United Nations peacekeepers stationed in central Haiti, triggered blame and violence that interfered with response efforts. As we have learned from the global AIDS pandemic and other infectious dis- ease epidemics, cycles of accusation can continue for years, diverting attention and resources from the delivery of care and prevention services [16]. Systemic prob- lems that brought cholera to epidemic levels in Haiti will (unless addressed) continue to facilitate its spread. As a disease of poverty, cholera preys upon the bottom of the social gradient; international trade, migration, and travel—from South Asia or elsewhere—open direct channels for path- ogens that follow social fault lines.

Read more