Fighting Cholera amid Haiti's Debris

EDITOR’S NOTE: Averting a wider spread of cholera that now plagues some sections of Haiti is simple and not expensive, Laurie Garrett, senior fellow for global health at the Council on Foreign Relations, tells’s deputy editor, Deborah Jerome. What needs to be done is for pledged aid to turn into hard cash and have sufficient funding for debris removal and infrastructure development in the earthquake-devastated country, she adds. A few excerpts:

If cholera becomes endemic in Haiti, what does that mean in terms of Haiti’s redevelopment efforts?

It puts a lot of urgency on getting the infrastructure developed much more rapidly than has been the case so far. In particular, separate sewage and drinking water systems. The nature of what needs to be done is not exotic and frankly not all that expensive. We know how to separate our pipe systems and how to do sewage treatment, and we know how to get vibrio cholerae and other dysentery-causing diseases out of the water supply. It’s just been a slow pace in Haiti and one that is frustrating everybody.

Why? There’s aid money flowing into Haiti, and people have known about the deplorable sanitation and water systems in Haiti for a long time.

Actually, money isn’t flowing in. Senator Tom Coburn (R-OK) has held up more than $1 billion dollars for Haiti because he is unhappy with the State Department appointment for an individual who will play a key role in relief operations. So while dollars have been committed, they’ve not flowed at a rate that would allow us to feel comfortable that there is sufficient funding. Bulldozers and heavy lifting equipment to deal with the debris and to destroy shattered buildings only started moving really in the last couple of weeks on a major scale.

It’s shocking how far down the road we are without doing what you would do in any American city in a similar situation–mow down anything that would have been declared unsuitable for habitation and then start rebuilding. But most of Port-au-Prince is still debris, and it’s hard to build plumbing systems, sewer systems, water treatment systems when the debris is sitting in the way. However, I have to say that it’s my understanding that most of the water being distributed in the form of drinking water in Port-au-Prince is actually coming from specifically pumped water stations. That may actually protect Port-au-Prince from a serious outbreak.

Will the cholera outbreak affect the November 28 presidential and legislative elections?

I don’t see any reason why this should affect the elections more than any five or six hundred other things going on in Haiti at the moment. Actually, the really scary thing is that we now have confirmation of deaths due to cholera, the same strain, in Pakistan in the flooded areas. It is probably the case that a widespread cholera epidemic in Pakistan would have more impact politically in that country than the fairly limited outbreak of cholera in Haiti at this time.

The long-awaited Quadrennial Diplomacy and Development Review (QDDR) is due soon. What do you want to see in there?

As far as we can tell, from the hints out of the State Department, most of the development community will be pretty happy with the QDDR. The global health community may have more quibbles. The Global Health Initiative is finding resistance in the HIV/AIDS community. That community is not happy with most of the way that the initiative is structured, so you have some grumblings among the troops on the ground and the advocacy communities.

What are the issues?

From the point of view from the folks dealing with HIV/AIDS, there’s really only one issue: “Give us more money and more independence to spend that money the way we want to.” The Obama administration has really had to rein that in and say, “Look, there’s got to be a structure, there’s got to be accountability, there’s got to be demonstrated outcomes.” It’s created quite a bit of tension between the HIV/AIDS community and the White House, to a degree that at the international AIDS meeting in Vienna [in July] there were posters stuck up all over the meeting by Americans that showed a split view of half of President Bush’s face and half of President Obama’s face smooshed together like a single face and it said underneath, “Which one was better for HIV/AIDS?” The answer was implicit that it was George Bush, mainly because of the scale of the dollars committed.

Are these complaints legitimate?

The scale of growth, the pace of growth, [and] the financing for HIV/AIDS has slowed. It is still growing, but at a much slower pace. If that’s the primary metric by which you judge success or failure of U.S. foreign policy vis-à-vis AIDS, then yeah, you’d be grumbling. I don’t think that’s the appropriate metric.

The irony is that more people in Africa in particular, but developing countries generally, have been able to acquire HIV treatment thanks to PEPFAR [U.S. President’s Emergency Plan for AIDS Relief] in the Obama years than PEPFAR in the Bush years. Programs are maturing, so during the Bush administration this was all brand new and people were trying to figure out what they were doing. Also, a big shift that the Obama administration executed was to get away from contracting out so much of HIV/AIDS efforts in developing countries. Now more of the burden of caring for people with HIV/AIDS, and of prevention programs, is being carried by the ministries of health and their own country programs. This is with the goal of eventually leaving these countries self-sufficient.

One of the big challenges is to look forward on this pandemic, out ten years, and try to imagine how we are going to deal with this if we don’t have a vaccine. Nobody can figure out how this is a sustainable effort unless you can get the countries to embrace the majority of the burden themselves, absorb it into their national governments with assistance from the outside, bring down the prices of generic formulations of the key drugs–both first line and second line–and get serious prevention efforts going that bring down the burden of the numbers of newly infected that will require treatment down the road.

The Obama administration’s global health initiative, in conjunction with changes going on in some of our partner donors is to begin to integrate things so there’s a whole battery of front-line primary care that people get all from the same facility. It would include HIV workups, tuberculosis workups, education about malaria and bed-net distribution. To get back to Haiti, one of the hopes that has been voiced repeatedly by [former] president [Bill] Clinton, who’s acting as our chief ambassador on this whole Haitian recovery, has been: We’ve got to take advantage of this moment to build those kinds of integrated approaches to bringing health into people’s lives.

Re-published with permission by the Council on Foreign Relations. Visit the original article.

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