David Nabarro: UN fighting cholera with 'hands tied behind our backs'

As it scrambles to ensure cholera doesn’t surge in Haiti the aftermath of Hurricane Matthew, the United Nations is coming up short on funds.

A $120 million emergency flash appeal for relief and recovery work remains only 28 percent funded, now more than three weeks after the storm hit Haiti on Oct 4. Even more questions linger over how the U.N. will fund a planned $400 million Multi-Partner Trust Fund, half of which would go toward material compensation for victims of cholera and their communities. The fund is meant to complement U.N. Secretary-General Ban Ki-Moon’s acceptance of responsibility for bringing cholera to Haiti following an earthquake in 2010.

Pulled between pressing needs, the U.N.’s moral imperative to end cholera, and inadequate resources, David Nabarro’s job is that of a tightrope walker. He is the U.N. secretary-general’s special adviser leading the response to the Haiti cholera crisis, with previous experience tackling the Ebola outbreak in West Africa, bird flu and a host of other health and development issues. Nabarro is also one of six candidates in the running to lead the World Health Organization.

Following a recent four-day trip to Haiti, Nabarro spoke with Devex about the challenges of tracking cholera in Haiti, funding the crisis and how he’s applying his experiences with Ebola to the job.

Devex also asked him about a report U.N. special rapporteur on extreme poverty and human rights Philip Alston presented Tuesday to the General Assembly, in which he called the U.N.’s lack of assumed responsibility for bringing cholera to Haiti “morally unconscionable, legally indefensible and politically self-defeating.” Our conversation, below, has been lightly edited for length and clarity.

What were the major takeaways from your trip to Haiti?

The hurricane has caused massive destruction in the southwest and damaged people's lives and their lifestyles. It has destroyed homes, crops, plantations and it has affected water supplies, health care and people’s ability to move around.

This is a very unstable situation and I, together with colleagues, concluded that the risk of further spread of cholera is quite high. I have put an emphasis on the need for getting really good information about what is happening in the interior of the country, and secondly, having an extremely strong coordination system, particularly for food, water, health care and for shelter. And, thirdly, trying to make certain that there is effective communication with the public.

You spoke this week about how the U.N. would allocate the $200 million funds it hopes to raise to compensate cholera victims’ families and communities. Half would go to communities and another $100 million would go to the families of victims, resulting in payments of about $10,000 per family. How do you see this money actually being distributed?

This is really an appeal that has two parts to it, and that includes efforts to include water and sanitation in the work, and the other is providing support, payments, to either individuals or communities that have been affected by cholera since the outbreak. The [second] part, Track II, is a version of the reality that people have had quite serious damage to their lives and their livelihoods as a result of cholera. And so what we are trying to do is to enable their families or their communities to have some material support. But the problem is that it is not very helpful to design such schemes if we don’t have any money.

You mentioned that it is “highly unlikely” you would be able raise the necessary $200 million for compensation via donations, and that you might look to U.N. member states, instead. What is your plan for contributions?

People are prepared to give money for things such as cholera treatment and prevention … but, by and large, they are not keen to donate money to us to pay for the problems faced by people who have been sick. There is an alternative. Instead of asking for donations, we ask for what we call member state contributions, making it part of our normal [U.N.] budget. It will take a long time to negotiate, and we do need money in the bank, so we can be talking with Haiti about what sort of support they need. I just don’t want us to start talking to people about support if, at the same time, we have no money in the bank account.

How do these funding gaps impact the work you are trying to execute on the ground? 

Our job is to be very skillful at coordinating a response and running distribution systems. The logistics of our job is to bring in the best possible technical advice on the health challenges, or shelter, and our job is to be supporters to our Haitian friends. Some people say, “If you did better, you would get more money,” but that is just not fair. We don’t run around with lots of reserves and have lots of capacity in terms of our physical and analytic structure. I do feel like we are being asked to fight this one with our hands tied behind our backs and that is a real pity. So our main frustration is the relatively low response and I’m wondering why it is. I can’t explain it.

U.N. special rapporteur on extreme poverty and human rights Philip Alston presented a report Tuesday in which he said the U.N.’s failure to take responsibility for cholera is a “disgrace.” Do you think giving money to victims and families can help ease relations and make up for the U.N.’s role in the outbreak?

My own view is that we do need to provide some support to people whose lives have been affected by this, and I think it will make a huge difference in the relationship for the U.N. and the people of Haiti. If we are in a position to provide the support that I have described, I think it will go a long way to help the people of Haiti to appreciate we really are aware of their distress and that we want to help them as they try to cope with that distress. And, so, this is part of the process of the U.N. seeking an improvement in its relationship with Haitians. This is something that is overdue.

The U.N. secretary-general brought you on to help respond to the Ebola crisis in 2014 and 2015 in West Africa. Do you see any similarities in the challenges Haiti is now facing, and what type of work is needed?

Some of the threats [in Haiti] are quite similar, in that we didn’t have precise information on what was happening in West Africa and we needed to work closely with the people, with strong communication procedures, to make sure they knew the risks they were facing and that we understood the challenges from their point of view. What I learned from Ebola is that communities should always own the response to a disease outbreak — after all, the disease is affecting them, so it is good, if possible, to have them involved. And I learned the importance of mapping where sick people are using GPS. I have that same feeling in Haiti. We need to know who is ill and to get them involved in the response.

Is mapping work happening now in Haiti?

We are in the early stages, but it is not easy to get around. Roads have been damaged and blocked and transportation is difficult. A lot of work is needed to get access.

Do you think that the extent of cholera’s uptick following Hurricane Matthew can be fully understood, or accurately measured?

It’s very difficult. To be sure, there has been an increase. There has not been an extraordinarily dramatic increase, but I think there has been a spike. Why I prefer to talk about the risk [of a further increase] is we haven’t got good enough data to tell us what is going on, because we haven’t got good enough access … it’s frustrating. I never realized the magnitude, the damage that could be caused by a hurricane. It really is like a great, big sanding machine that has gone across the countryside and removed everything.

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