How the Cholera Outbreak In Haiti Began... MSF

Le Monde Op-Ed: Why It's Important to Know How the Cholera Epidemic in Haiti Began

DECEMBER 23, 2010

By Dr. Marie-Pierre Allié, President, Médecins Sans Frontières in France

Two months after the cholera epidemic began in Haiti, nearly 2,000 people have died and 100,000 have become ill. Médecins Sans Frontières has treated more than 51,000 people to date. The illness surprised observers both because of its breadth and the initial speed with which it spread. It raised important questions that remain unanswered today. Basic data about the source of the illness and the daily case count are among the unknowns that need to be answered in order to understand the course of the epidemic.

The monitoring and information system established by the World Health Organization (WHO) is critical for directing the response, but it has gaps. In addition to lacking specific data on the initial type of contamination, it took nearly two months to finally obtain the figures allowing responders in the field to answer, region-by-region, the questions raised by the development of the epidemic. When did it begin in this region? What are its dynamics? Should we fear a rebound of the disease?

The U.S. Centers for Disease Control has officially refused to investigate the source of the illness. Contrary to its founding principles, the U.S. government's epidemiological investigative and monitoring agency states that "the answer to that question makes no difference in efforts to prevent the disease from spreading."

In fact, the lack of investigations and documentation leaves the field wide open to multiple theories. Briefly, there are two conflicting hypotheses as to the source of the epidemic on the island. One is based on global warming and the other points to a cholera strain imported from Asia.

Johns Hopkins University professor David Sack endorses the "green" hypothesis. He and some of his colleagues believe that rising water temperatures and increased salinity created conditions favorable to the growth of plankton that serve as hosts for cholera vibrio. According to this theory, vibrio can survive long-term in brackish, stagnant water and may thus trigger new epidemic peaks.

Harvard University microbiologist John Mekalanos, working with other researchers, offers a different explanation. Advocates of the "Nepalese" hypothesis have concluded that cholera was brought to Haiti in early October with the arrival of a contingent of U.N. blue helmets (Minustah forces), including soldiers from Kathmandu. In fact, a strain of cholera similar to the one circulating in Haiti today hit Kathmandu last summer. French professor Renaud Piarroux, of Nice University Hospital, conducted an on-site investigation for the French and Haitian governments and supports this hypothesis. He places the first cases close to the Minustah camp in Mirebalais, in the center of the country and far from water that might carry plankton.  This theory may also explain the suddenness with which cholera struck in Haiti.

These two explanatory models imply very different courses of development for an epidemic, so priority should be given to assembling an independent, multidisciplinary team that can confirm or reject one or the other. However, the United Nations' Office for the Coordination of Humanitarian Affairs (OCHA) continues to repeat that "the issue of the origin of the epidemic is actually not important." Minustah has long challenged the need for any investigation, asserting that "experts have emphasized the difficulty, if not the impossibility, of determining precisely how cholera came to Haiti."

MSF cannot support such statements. It is counter-productive to hide epidemiological data and keep investigative reports confidential. Such actions prevent us from establishing a precise diagnosis and can result in misdirected aid efforts. For example, the WHO says that the epidemic continues to worsen, basing those statements on the number of cumulative cases (which, by definition, continue to increase until the epidemic ends). However, based on its activity figures, which correspond to more than half of the number of patients, MSF notes that the number of new daily cases has stabilized over the last two weeks, with the exception of certain disease centers in the Northern Department.

The alarmist—and unconfirmed—predictions of the WHO and the U.N. Secretary-General of up to 650,000 cases serve only to increase fears. Even worse, the refusal to answer Haitians' questions about the source of the cholera reinforces a climate of distrust and suspicion toward foreigners. Confidence is critical to obtaining the population's support for and cooperation with the systems that international NGOs have established.

For these reasons, we must identify the source of the epidemic. The results of the epidemiological investigations must be published and a commission of independent experts must be appointed.

—Dr. Marie-Pierre Allié, President, Médecins Sans Frontières in France