It is impossible to talk about health care in Haiti without mentioning the 2010 earthquake and the subsequent cholera epidemic which so far has affected 630,000 people and taken the lives of 7,500. It would be easy to believe that cholera was a direct result of the devastation of the earthquake and the heavy rains of June, July and August. In fact the media spent much of 2010 speculating on the possibility of a medical epidemic.

Two million people were forced into overcrowded internally displaced camps [IDPs"> where living conditions were appalling. People were traumatized and fearful of further earthquakes and even to mourn the dead was hard as the struggle to live became harder as months passed. Many women and girls in the tent camps especially, were raped and lived with the fear of physical and sexual violence; food and clean water were scarce; latrines dangerously inadequate; and sewers overflowed. So why were so many health care providers and humanitarian aid agencies caught off guard when in October, the first cases of cholera began to appear and not in the IDP as might have been expected? The answer to this question and others, such as why did it spread so rapidly, who was responsible and what has been the response all serve as an excellent lens from which to examine healthcare and the socioeconomic realities of the UN/US occupation of Haiti.

Cholera is an acute dehydrating bacterial infection spread through contaminated water and food. The source of the contamination is human feces and the illness is exacerbated by poor sanitation, limited clean water, heavy rains and associated poor hygiene such as failure to wash hands after going to the toilet. Symptoms can be mild or severe with leg cramps, white watery diarrhea and profuse vomiting. They can appear within hours or over a period of days. However once severe symptoms appear, those most vulnerable such as children, the elderly, pregnant women and those already malnourished and or suffering from chronic illness, rapid dehydration can lead to death in just a few hours. Treatment for most people is surprisingly simple: oral rehydration treatment [ORT"> and in severe cases, an intravenous rehydration with antibiotics.

I visited Haiti in November 2010 and by then cholera was already embedded in Haitian lives. Banners and posters announcing the dangers and prevention of cholera hung from streets and decorated what walls were left standing. Radio and TV jingles blared out similar messages whilst schools, camp committees and women’s organisations reinforced all these messages whilst trying their best to create hygienic environments and most important provide clean water.

A school run by SOPUDEP, a Haitian grassroots movement, did not escape cholera as many parents and students were taken ill. Their priority was to provide clean water through a mix of water treatment tablets and clorox as well as to reinforce basic hygiene regimes - with 700 children it was not an easy task and there were constant school closures as children or their parents were taken ill. Nonetheless they were able to avoid a local epidemic.

In the early hours of one morning, a diabetic friend was rushed to the Médecins Sans Frontières [MSF"> hospital in Martissant 26 which at the time was one of their cholera treatment centers [CTCs">. I arrived in the evening just as dusk was falling to visit my friend. As I waited outside, I watched as cholera patients came and were directed to the side entrance. Some walked, some were carried, frantic parents with a baby wrapped in a bundle but visible enough to know she or he would die very soon; an elderly woman in a wheelbarrow, shrunken and surely at the point of death. In Martissant 26 Cholera was everywhere. It was unavoidable as vendors and customers vied with mountains of rotting refuse and pools of stagnant water lying amidst rubble and buildings destroyed by the earthquake.

Prior to October 2010 there had been no cases of cholera in Haiti for nearly a century. The first hospitalizied case was on the 17 October in Mirebalais, in the region of Haiti’s longest river, the Artibonite. By October 22 cholera was confirmed and the outbreak in the costal areas of St Marc was established. The disease was able to spread rapidly due to initial misdiagnosis, lack of Oral Rehydration Treatment [ORT"> and an already overstretched medical infrastructure.

Cholera was not the epidemic in waiting. The first responders to both the earthquake and the cholera outbreak were the largely ignored by western media, the Cuban brigade, who had been in Haiti since 1998, along with the well established MSF, also in Haiti for many years. At the start of 2013 these are the only two sizable medical teams left from those first 12 to 18 months. From an initial 72 CTCs in 2010/11, MSF which now accepts all cholera referrals as well as walk in patients, has just four CTCs, in Leogane [40 beds"> Delmas 33 [80 beds">, Carrefour [275 beds"> and Cite Soleil/Drouillard [100 beds">.

In order to place Haiti’s health challenges in a global south context I asked Oliver Schulz, the head of the MSF mission in Haiti, how the country compares to African countries. He gave the example of the eastern Congo where in general there is a structure and willingness by the Ministry of Health to get involved. So within six months of starting a MSF cholera project the ministry is ready to take over. However in Haiti, because the disease is new and because there is neither the capacity nor the necessary health infrastructure, the government is unable to take over. As Schulz pointed out, the situation in Haiti is far more complex than simply pointing a finger at the government as they simply do not have the resources. In particular, Schulz was critical of the WHO and UN whose role should be to support the government in developing a comprehensive health care infrastructure yet despite years of talking little has actually happened.

“Even with cholera some of the things we discussed two years ago are still being discussed. I do not know how much they are involved in activities like plans etc but it seems to me that by now we should have a national health plan and it seems to me normally the WHO supports the government in making such plans as that’s what they do in other countries.”

The problem with healthcare in Haiti is there is no system, no structures, no plan - at least not one that has been implemented. What healthcare facilities exist are wholly inadequate - insufficient medical staff, support staff, equipment and treatment, and left to medical NGOs such as MSF, the Cuban Brigade and a few faith-based and charity clinics. For example there is one MSF hospital in Carrefour with 275 beds serving about 400,000 people. In Cite Soleil the figures are similar. In addition to the MSF hospital there is a public hospital, St Catherine’s ,which like most government hospitals, is staffed by excellent Haitian doctors but is rundown and under equipped. The Charity Mission runs a small hospice for HIV/AIDs patients and a few other small clinics serve at least 250,000 people. Finally there is the Centre de Nutrition et Sante Rosalie Rendu which has a pediatric clinic and sees up to 300 under 5s a day, many mothers traveling across the city to reach the clinic. The round trip from for example, Delmas to Cite Soleil can take up to 4 hours and three tap taps at a cost of about $2 - a long and costly journey. But the Haitian and American doctors are excellent and the clinic includes a nutrition center for malnourished children who attend everyday for six months or until their weight and overall condition has improved.

The public hospitals including the country’s main teaching hospital and clinical and trauma referral center, L’Hôpital Université d’Etat d’Haïti (Haitian State University Hospital or HUEH), are in a terrible condition and have effectively been abandoned by all those involved in running the country - the government, the UN, the USAID and other country donors, and the NGOs. HUEH was partially damaged in the earthquake - 150 nursing students were killed and two thirds of the buildings destroyed. Even before the earthquake, it wasn't in great shape and the rebuilding of HUEH was supposed to be a priority as shown in this 2010 proposal by Partners In Health [PIH">.

“Significant, strategic, and ongoing improvements to the comprehensive infrastructure, staffing, training, operations, and clinical practice of this central public health facility are investments in the future of all public health throughout Haiti. ...........More immediately, HUEH is in a state of emergency. If conditions at the hospital are not improved in a matter of months, it will become the site of a second round of catastrophic deaths due to disease outbreak or total health system collapse. There has been a vision articulated by the Haitian leadership of the hospital, but they cannot implement it alone. Please join the effort to build Haiti back better by first investing in the health of Haiti’s people.”

One medical improvement to HUEH and which is exemplary of how things happen in Haiti, is the TB clinic set up in 2010 by an American volunteer, Dr Coffee, and a group of Haitian nurses. The clinic, initially operated under tents, is now housed in a building and has cared for over 1,000 patients TB since 2010.

Since 2004, when the Medical School of UNIFA (the University of the Aristide Foundation"> was forcibly closed, HUEH has been the sole medical training center in Haiti. UNIFA was founded by President Jean-Bertrand Aristide in 1996 in order to ‘amply the voices of Haitian people’ by creating an inclusive educational space from adult literacy to training doctors and nurses. In August 2011 the much needed medical school reopened with 63 men and 63 women.

In the politics of US imperialism in Haiti, the contribution of UNIFA and the Cuban brigade doctors to the health infrastructure have been ignored by western media. I doubt this is by accident given the election of puppet and Duvalierst, Michel Martelly, and the resurgent post earthquake neo-liberal agenda driven by the US, it’s allies and NGOs. Although the rebuilding of the HUEH and other public health clinics has not taken place the new Paul Farmer led, PIH, state of the art University Hospital of Mirebalais [HUM"> has now opened. I asked a number of NGO personnel, doctors and Haitian activists why the HUEH has been abandoned yet the PIH NGO hospital has flourished. The response was always the same - “we ask the same question”. No one would question the importance of HUM to Haiti’s health infrastructure. It is the largest post-earthquake project in the country and has taken three years to build. HUM has 300 beds, plus primary and secondary health care for up to 500 people a day. As a teaching hospital HUM along with UNIFA will provide doctors and nurses for Haiti. However questions remain as to the location and who will have access to the hospital.

There is no doubt that both the earthquake and cholera epidemic played a leading role in the funding and realization of the PIH project. One of the uses of founder, Paul Farmer, is that he is able to raise funds especially since he became a spokesperson for ‘the">http://www.counterpunch.org/2013/01/17/the-uses-of-paul-farmer/">the machine that drives Haiti”. When questioned by journalist Ansel Herz about the stalling of a wage increase from $3 to $5, Farmer, the new voice of the occupiers, also stalled as he seemed to have forgotten his own treatise on ‘pathologies of power’.

The inadequate provision of healthcare for the poor in Haiti and elsewhere, as Farmer himself has written over and over, is due in large part to structural violence and a pathology of greed which has left over 2 million people food insecure, forces women into relationships which are detrimental and often abusive; results in people dying needlessly of cholera or because they couldn't access simple surgery as was the case for Elie Joseph.

In February 2012, Elie Joseph was diagnosed with a heart murmur which is a common congenital heart defect called ventricular septal defect [VSD"> where the blood flows the wrong way, putting stress on the heart and lungs which can lead to infections. The charity Haitian Hearts, which sends children suffering from heart related illnesses to the Dominican Republic or the US, arranged for Elie to travel to the Dominican Republic for the 15-minute procedure which would fix his heart. Elie received his travel documents but not his mother so he was unable to undertake the operation which would have taken some four hours plus the follow up treatment. In December 2012 Elie Joseph died from pneumonia in the tent at Aviation camp where his parents are forced to continue to live three years after the quake. VSD is not an illness to die of and Elie is one child out of thousands who have died needlessly as a result of structural violence.

The violence of poverty is multifaceted so that even when healthcare is accessible there are still other obstacles to overcome. Gladis* lives with her three children aged 6 months, 4 and 9 years in a camp in Delmas 33. She is fortunate because the camp is not too far from both the MSF cholera treatment center in Delmas 33 and the La Paz clinic run by Cuban doctors. Gladis came to Acra camp a few days after the earthquake with her two children. Her home in Tabarre was destroyed in front of her eyes and she wandered the streets for three days disorientated , traumatized, sleeping and walking with the children till eventually she came to Acra. At that time there were no tents and people were sleeping in the open or under whatever makeshift covering they could find. It was about three months before the people at Acra were able to secure tents by searching out various NGOs themselves.

It was a dangerous time for women in particular as sexual violence was rampant, the only food and water was being handed out by NGOS and you had to queue for hours. Three years later, Gladis is hardly coping with her life and its possible that only the support of her neighbours and the camp committee which has kept her going. In October 2011 when she was about 6 months pregnant, Gladis caught cholera. It started in the morning and within a few hours she was unable to walk. Her neighbours gave her water with the RHT salts but these did not help. She had two problems - she would have to leave her children with neighbors and luckily hers were trustworthy. Secondly she had to get to the MSF treatment center. She was in no condition to travel by Tap Tap or motorbike and besides she did not have the money. The only way was by car. Again Gladis was lucky as one of the camp leaders saw she was ill and suspected cholera. He had an old truck that just about ran and its with this that Gladis, near death, was taken to the hospital where she spent 15 days.

“I didnt know what was happening until after some days. I saw they had put me in the last room where many people were dying and I thought I would die too. So many people died, I don't know how many but every day they were dying......When I started to get better, I was able to eat. They gave us food sometimes three times a day.“

Although Gladis was released after 15 days she was still ill suffering from headaches and a fever. But for the MSF her cholera had been treated and they needed the beds as new patients were arriving all the time. Gladis survived but she remains unwell, fearful and hardly able to breastfeed her baby. Again this is one story. Although I have heard many complaints from women on the public hospital and clinics, I have only ever heard good things about both the Cuban doctors, MSF the pediatricians at Sante Rosalie Lendu.

The cholera epidemic is not over by far and once the rains start the numbers are expected to rise again. The estimates for 2013 are 118,000 cases. To put these numbers in a global context, there were 160,000 cases in the whole of Africa in 2010, that is in a population of nearly 1 billion people compared to the 10 million population in Haiti. I asked Oliver Schulz of MSF his thoughts on the year ahead.

“My personal fear is that things will get worse before they get better. The structures are weaker today than in 2011/2012. Every year the structures deteriorate. There is no plan for cholera and without a WHO supported comprehensive national health care plan with clear directives, clear action plans and milestones then it will not get better. Also many of the big agencies have left and there are too many unknown NGOs, charities and faith groups”

Within weeks suggestions began to appear that the origins of cholera lay with the UN and specifically a Nepalese contingent based near the Artibonite river and spread through the base toilets. Initially the UN denied being responsible however there has been mounting evidence of the UN being the source. By October 2012, two years after the outbreak, the evidence against the UN was irrefutable.

"We can now say," Dr Lantagne said, "that the most likely source of the introduction of cholera into Haiti was someone infected with the Nepal strain of cholera and associated with the United Nations Mirabalais camp."

In the hope of obtaining justice and reparations for the thousands of cholera victims, the Bureau des Avo­cats Inter­na­tionaux [BAI"> and Institute for Justice and Democracy in Haiti [IJDH"> filed a groundbreaking suit against the UN on behalf of 5,000 cholera victims. In addition to insisting on accountability the suit demands that the UN

• Install a national water and sanitation system that will control the epidemic;
• Compensate for individual victims of cholera for their losses; and
• Issue a public apology from the United Nations for its wrongful acts.

The UN role in introducing cholera is one more abuse in a long list of violent acts against the Haitian people with no accountability. From sexual abuse, rape, cholera to the killing of innocent civilians. UN appointed special Envoy of Occupation, Paul Farmer, suggested as early as December 2010, a vaccination programme as part of a 5-point intervention to halt the epidemic. However Haitians had little reason to trust a UN-led initiative even if it was supported by a world renowned physician.

Three years later the only evidence of improvement in the healthcare is the teaching hospital at Mirebalais. More than anything Haiti needs clean water, not just for cholera but for a range of illnesses and because everyone has a right to clean water. Provision of clean water however does not make money for pharmaceutical companies - being well does not make money for pharmaceutical companies. But a cholera vaccine every three years is highly profitable disaster capitalism at work. Rashid Haider explains the case against vaccination:

“The vaccines Shanchol and Dukoral contain large amounts of killed cholera bacteria, the latter having an additional component known as the recombinant B subunit of cholera toxin (rCTB). Both vaccines are two-dose oral vaccines that are taken with an interval of two weeks, and are meant to cause development of protection against cholera one week after the second dose.

“Harmon’s assumption that these vaccines are 60 to 90 percent protective for a period of two to three years does not concur with facts. The Shanchol that is intended for field testing soon in Haiti had offered a poor protection of 45 percent during the first year of surveillance in a large-scale field trial in India in 2006. Dismal results were obtained in a large-scale field trial in Peru in 1994 when the two-dose vaccine Dukoral was tested.”

The alternative argument for a national water and sanitation system is a far more sustainable and realistic solution to ending the epidemic and preventing new outbreaks. It is long term, benefits everyone and responds to a range of preventable illness and improves the overall quality of lives.

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