As Hurricane Matthew churned off the coast of Haiti earlier this month public health officials and aid groups issued warnings not just about the dangers from the storm itself but what could follow: a cholera outbreak.
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In 2010, a devastating cholera outbreak infected hundreds of thousands in Haiti just months after a severe earthquake left more than 100,000 dead. Prior to the outbreak, there were no reported cases of cholera in Haiti.
This summer, the United Nations finally acknowledged that it was involved in the initial outbreak and the profound suffering that has followed.
Cholera is a bacterial infection that can lead to potentially serious symptoms of watery diarrhea, nausea, vomiting and muscle cramps, according to the CDC. Often spread through contaminated water or food, the incubation period of the disease can be as short as two hours, meaning it can move quickly through a densely populated area. As the mucus membrane of the intestinal wall is affected, it can lead to diarrhea that can cause severe dehydration.
The disease appeared in Haiti in October 2010 and spread quickly, causing an estimated 770,000 infections in the years since and approximately 9,200 related deaths, according to a 2016 report in the American Medical Association Journal of Ethics.
Within days of the first diagnosis, the AP reported that local politicians and other residents suspected the source of the outbreak was the human waste entering a river system from a military camp for the United Nations Stabilization Mission in Haiti. A group of peacekeeping soldiers had recently arrived there from Nepal, where cholera is endemic. AP reporters found U.N. investigators testing samples for cholera and a septic tank that was overflowing with broken pipes.
At the time U.N. officials strongly denied the base was linked to the outbreak and reportedly told the AP that no Nepalese soldiers had the disease and that the liquid being tested was from kitchens and showers and not from human waste.
On November 1, 2010, the CDC, working with Haitian public health experts, announced that the strain of the disease was similar to one seen in South Asia.
John Mekalanos, a cholera expert and chairman of Harvard University's microbiology department, told the AP in a November 3 news report that early evidence suggested military UN members likely brought the disease to Haiti from Nepal where an outbreak had recently been reported.
Dr. Renaud Piarroux, an epidemiologist at the University of Aix-Marseille, then worked on the ground in Haiti with Haitian and French experts in the days and weeks that followed to confirm the source of the outbreak. They quickly identified the U.N. camp as the likely cause of the outbreak.
Piarroux and his co-authors later published a study about the source of the outbreak in Emerging Infectious Diseases medical journal in 2011. The study’s findings “strongly” suggested that the United Nations camp led to the contamination of the Artibonite river and one of its tributaries, which helped to trigger the cholera epidemic. The tributary system was a source of water for bathing, drinking and cooking for those living downstream from the camp. Early findings from Piarroux’s report were published by the AP, in 2010 putting additional pressure on the U.N. to investigate the source of the outbreak.
However, confirmation by officials was hampered since, in the weeks after the outbreak began, officials at the CDC, UN and the World Health Organization said finding the source was not a priority.
"Our primary focus here is to save lives and control the spread of disease," CDC medical epidemiologist Dr. Jordan Tappero, who was leading the CDC cholera response team in Haiti, said in its that Nov. 1, 2010, press release. "We realize that it's also important to understand how infectious agents move to new countries. However, we may never know the actual origin of this cholera strain."
A WHO spokesman told the AP in November 2010 that the question of whether U.N. peacekeepers from Nepal were to blame was “not a priority." Riots broke out after the U.N. dismissed the allegations about the peacekeeping camp, saying its sanitation was airtight, according to the AP. By December, however, the AP reported that the U.N had relented, calling for a probe into the cause of the outbreak.
In February 2011, independent investigators sent by the United Nations finally arrived in Haiti to examine the possible cause of the outbreak.
Their report, released in May 2011, acknowledged that members of the United Nation Stabilization Mission in Haiti arrived in the country after working in Nepal, where the disease is endemic. They also found that the water system at the camp was “haphazard,” and that human waste was being disposed of near a tributary where the early cholera cases were reported. Furthermore, local hospital staff reported to the U.N. researchers that the first severe cases of cholera came from an area named Meye, which is located 150 meters downstream from the U.N. camp where the soldiers had been staying.
However, that 2011 U.N. report stopped short of putting blame specifically on that camp, going only so far to say there was an “hypothesis” that the source was the soldiers from a cholera-endemic country was “a commonly held belief in Haiti”. The report went on to say that the country of origin of the strain was “debatable” and instead cited multiple factors for the spread of the disease, including the widespread use of the tributary system by Haitians, their lack of immunity to cholera, and the conditions within medical facilities treating the victims.
"The Independent Panel concludes that the Haiti cholera outbreak was caused by the confluence of circumstances as described above, and was not the fault of, or deliberate action of, a group or individual," the report said.
The United Nations refusal to accept responsibility for the outbreak led to continued demonstrations in Haiti. Members of the medical community also railed against the U.N. for shirking responsibility.
In 2013, researchers from the Yale Law School and the Yale School of Public Health released a report called “Peacekeeping without Accountability” to analyze the actions of the U.N.
“By causing the epidemic and then refusing to provide redress to those affected, the U.N. has breached its commitments to the Government of Haiti, its obligations under international law, and principles of humanitarian relief,” the report authors wrote.
That same year, a number of advocacy groups filed a class-action lawsuit on behalf of five U.S. and Haitian citizens affected by the cholera outbreak against the U.N. and certain U.N. officials alleging they were responsible. A United States District Judge found that the U.N. had immunity from prosecution, according to court documents.
The decision was appealed this year but the original decision was affirmed. The plaintiffs have until mid-November to decide whether to appeal to the U.S. Supreme Court.
Then, this past August, The New York Times broke the news of a confidential report from New York University law professor and U.N. special rapporteur, Philip Alston, to U.N. Secretary-General Ban Ki-moon. In his report, Alston wrote, “The fact is that cholera would not have broken out but for the actions of the United Nations.”
Shortly after that report was made public, the United Nations finally acknowledged that its personnel likely played a part in the Haitian cholera outbreak. "Over the past year, the U.N. has become convinced that it needs to do much more regarding its own involvement in the initial outbreak and the suffering of those affected by cholera," Farhan Haq, deputy spokesman for the U.N. secretary-general, told reporters on August 18.
The following day, Haq said, "The Secretary-General deeply regrets the terrible suffering the people of Haiti have endured as a result of the cholera epidemic.” "The United Nations has a moral responsibility to the victims of the cholera epidemic and for supporting Haiti in overcoming the epidemic and building sound water, sanitation and health systems."
Piarroux, the lead author of the 2011 study published in Emerging Infectious Diseases, wrote an op-ed in The New York Times in September, decrying the United Nations for taking so long to acknowledge its role and respond to the crisis.
“By admitting that it was involved in the outbreak, the United Nations made only a first and timid step toward a full assessment of its responsibility,” he wrote. "The United Nations must continue to open up about what happened in Haiti, rectify the damage, and establish policies that prevent such disasters in the future. Its credibility is still on the line.”
A spokesman for the U.N. secretary-general told ABC News a full presentation on the assistance and support to combat the Haitian cholera outbreak will be presented later this month.
Today, the U.N. camp at the center of the outbreak controversy is no longer fully functional and has no military members, according to a spokesperson for the U.N.’s Departments of Peacekeeping and Field Support.
Since the 2010 outbreak, the U.N. Stabilization Mission in Haiti has pursued a multi-pronged course of action to adequately deal with the waste management of its peacekeeping forces. It was not until October, 2015, that the U.N.’s oversight services department found the Mission to be in compliance with all of the recommended procedures.
In addition, as of late 2013, the peacekeeping forces have been supporting the Haitian government in its long-term plan to eradicate cholera.
In the meantime, in Haiti today, cholera remains stubbornly endemic. This week, the Pan American Health Organization reported there have been 1,351 suspected cases of cholera identified since Hurricane Matthew hit the country. PAHO has identified the disease as a main priority in the storm’s aftermath.
EDITOR'S NOTE: This report replaces an earlier story on the same subject.