Cholera Vaccination in Haiti: Evidence, Ethics, Expedience

By Hinman, Alan R.; Farmer, Paul et al. | Harvard International Review, Fall 2011 | Go to article overview

Cholera Vaccination in Haiti: Evidence, Ethics, Expedience


Hinman, Alan R., Farmer, Paul, Papers, Jean-William, Ivers, Louise C., Leandre, Fernet, Weigel, Jonathan L., Rosenberg, Mark L., Harvard International Review


The cholera epidemic in Haiti will be a year old in October and is far from under control. As cases spiked across the country during the summer rainy season, the ranks of cholera relief workers grew thin. Too few patients reach healthcare facilities with enough time to be sure that treatment--simple rehydration in most cases--can restore them to health. Access to clean water and to modern sanitation is dwindling. We must redouble existing efforts at cholera prevention and care--case-finding and treatment, water and sanitation projects, education and surveillance--while simultaneously integrating vaccination into die ongoing response. Even prior to this epidemic it was clear that waterborne pathogens posed great risks to communities across the country, including those not affected directly by the January 2010 earthquake. All steps to protect Haiti's vulnerable population needed, and still need, to be taken.

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One of these steps is vaccination. Oral cholera vaccines have been proven safe, effective, and deliverable in resource-poor epidemic settings. They can help protect poor communities that lack clean water and modern sanitation, and they bring collective as well as individual benefits. There is no evidence to suggest, as some have warned, that adding vaccination to the cholera response would take resources from other pillars of prevention and care, such as case-finding, treatment, and water and sanitation efforts. Yet, cholera vaccines remain unavailable in Haiti to date. We propose a vaccine demonstration in urban and rural Haiti, with a discussion of ethical considerations and possible objections. The Haitian cholera epidemic is the largest the world has seen in recent history; Haiti deserves nothing less than a comprehensive, integrated response using all of the tools in the armamentarium, including oral cholera vaccine.

Background

Founded in the aftermath of the largest and most successful slave revolt in history, modern-day Haiti is marred by extreme poverty, political unrest, a high burden of disease, and weak infrastructure. Haiti's chronic afflictions were exacerbated when a magnitude 7.0 earthquake devastated its capital, Port-au-Prince, and the surrounding regions on January 12, 2010, killing an estimated 220,000 people and displacing some 1.3 million more. Massive rescue and relief efforts ensued: UN agencies, multilateral organizations, bilateral aid agencies, and nongovernmental organizations rushed from around the world to help. These relief efforts averted substantial suffering and death, and the outpouring of solidarity--an estimated 50 percent of American households donated to the earthquake relief and recovery efforts--was heartening. But acute relief did little to address the profound deficiencies of Haiti's public health infrastructure, and the often chaotic and splintered response to the quake complicated the situation in other ways. To help realize lasting improvements, NGOs and international aid groups must work with and be coordinated by the government, the only institution charged with providing rights to all Haitian citizens.

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As aid workers shifted from immediate rescue and relief to the longer road of reconstruction, challenges such as providing safe shelter, food, clean water, and sanitation in the IDP camps remained. Today, nearly 600,000 people still live in internally displaced persons (IDP) camps, which fill most of the open spaces in the beleaguered capital. Before the earthquake, Haiti had poor health indices, including the highest infant (57/1,000) and maternal mortality (620/100,000) rates in the region, and one of the lowest immunization rates in the world (53 percent). Now, pathologies that often crop up among displaced populations, such as diarrhea and respiratory infections, have become common in the IDP camps and elsewhere in the ruined city. Water is no longer provided for free in most IDP camps, increasing the risk of outbreaks of waterborne disease. …

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