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Global Health, An Epidemiological Perspective: Strategic Interventions for the Reduction of Cholera in Haiti

A Joint Report Submitted 
Dr. Barbara Goldoftas, Ph.D.
Assistant Professor of Environmental Science and Policy at Clark University
Jenkins Macedo (M.A. 2012)
Lydia Meintel-Wade  (M.S. 2012)
Marcus Pasay (B.S. 2013)
David Safari (M.S. Cand., 2013)

            This chapter focuses on the cholera epidemic that began in Haiti in October 2010. This epidemic has been one of the most severe cholera outbreaks in history due to a variety of factors that promoted the quick and rampant spread of the disease. As of October 14, 2011, just one year after the initial outbreak began, the total numbers of reported cholera cases in Haiti are 437, 649 and still rising (WHO, 2011b).
The Republic of Haiti is situated in the western part of the Island of Hispaniola in the Great Antillean archipelago (WHO, 2011a). Haiti shares its border to the east with the Dominican Republic. Haiti achieved independence from France in 1804 after a long history of colonial rule by both France and Spain.  During its colonial period, Haiti was very productive in sugar and coffee related products, which relied heavily on a slave labor force. The country’s long history of exploitation from colonial powers as well as political instabilities after independence resulted in social, environmental and economic problems (WHO, 2011a). The unsustainable extraction of natural resources during this period  led to deforestation, topsoil depletion and other types of environmental degradation.  These environmental problems persist today, making economic development difficult and exacerbating a number of current risk factors for disease.
This chapter is broken down into five sections including: Section I) Background of cholera and its historical context in Haiti, Section II) Population of study and social/environmental determinants of health, Section III) Short-term/immediate interventions for the cholera outbreak, Section IV) Intermediate stage interventions for the cholera outbreak and Section V) Long-term interventions for the cholera outbreak. Within each section there are subsections that go into detail about specific intervention techniques and how to implement these techniques.
The Disease
Cholera is a water-borne human intestinal disease caused by the bacterium Vibrio cholera. The disease is most often spread through the ingestion of food or water contaminated by the feces of a person infected with cholera. After infection by the bacteria, many people experience symptoms including fever, muscle cramps, diarrhea, and vomiting within hours. Without treatment, these symptoms lead to rapid dehydration that can result in shock or death within hours. Rapid dehydration and electrolyte loss caused by cholera can result in death in up to 50% of untreated cases (Farmer et al, 2011).
Cholera is most often found in areas with limited sanitation, poor water treatment systems or inadequate hygiene, but other environmental factors are also associated with outbreaks. The bacteria Vibrio cholera exists naturally in coastal and freshwater bodies. Under disadvantageous conditions such as low temperatures it enters into a dormant state in which it can remain viable and transmissible, meaning that cholera epidemics can result either from the contamination of a water supply by infected persons or by the transmission of an environmental strain to humans. Studies have shown a positive association between levels of chlorophyll, rainfall and cholera cases in India and Bangladesh (Colwell, 2010). Chlorophyll in water serves as a proxy measurement for the abundance of phytoplankton populations and is used as a proxy because the bacteria live in and on zooplankton, whose populations are directly related to phytoplankton levels (Colwell, 2010).
Reports of cholera-like diseases have been recorded since ancient times, but the first epidemic cholera outbreak that was defined as such began in 1817 in India and Southeast Asia (Reidl & Klose, 2002). In the past cholera was a serious health problem in the developed and wealthy populations of the world, including Europe and North America but increased access to medical care, prevention methods, and technological advancements in water and sanitation infrastructure in these areas has reduced its threat to almost nothing. There has not been an outbreak of cholera in Europe or North America since the early 1900s (CDC, 2011). However, many developing countries still have underdeveloped sanitation, water, and healthcare systems, which increases the danger of possible cholera outbreaks and their subsequent effects on local health and economies. Currently an estimated 3-5 million cases occur around the world each year, resulting in over 100,000 deaths (CDC, 2011). Cholera has been seen as a deadly infection that can be spread rapidly throughout a country if the conditions allow. In the case of Haiti, poor social and environmental conditions have created ideal conditions for the rampant spread of cholera making this one of the most deadly cholera epidemics on record.
Section I: Historical Context of Cholera in Haiti
Haiti has long been one of the poorest countries in the Western Hemisphere, which has greatly affected the health and wellbeing of the Haitian citizens. The health system in Haiti has never been very robust causing the country to have very high maternal and infant mortality rates (Farmer et al, 2011). Having high maternal and infant mortality rates along with weak sanitation conditions and water security indicate that the health system and infrastructure of the country is unstable and poor, making Haiti’s population and great example of a population that is extremely vulnerable to disease outbreaks. Before the cholera outbreak began in October of 2010, diarrheal diseases have been a significant cause of death in Haiti, especially among children.
Before the 2010 earthquake, many Haitians lived in impoverished conditions without access to treated water, adequate housing or sanitary living conditions. The lack of these services left a large portion of the population at risk of contracting both waterborne and airborne diseases. Even before the earthquake diarrheal diseases were a significant concern in Haiti; 22% of deaths of children under five years old were attributed to diarrheal diseases in 2008, making these diseases the second leading cause of death among children (WHO, 2011d). Also, approximately 40% of the population does not have access to latrines, which is a contributing factor to cholera outbreak as water sources become contaminated with human feces (ICM, 2010). The magnitude of the cholera outbreak after the earthquake in 2010 was intensified by the absence of these services.
The last cholera epidemic in that occurred in Latin America was a multi-country epidemic of greater than 1,000,000 reported cases and 10,000 reported deaths during 1991-1994 (Farmer et al, 2011). During this period Haiti and the Caribbean did not record any case of cholera outbreak (WHO, 2011). The first case of cholera reported in October 2010 in the department of Artibonite in the center of the country marked the first cholera epidemic in Haiti in over a century (WHO, 2010). Shortly after the first reported case, many other cases began showing up along the Artibonite River, where the initial spread of cholera was though to begin (Farmer et al, 2011). After the earthquake, a large portion of the population lacked access to clean and safe drinking water and basic sanitation as a result of internal migration, which allowed the disease to spread person-to-person and through contaminated water supplies (WHO, 2011 & IMC, 2010).

Section II: Population of study and social/environmental determinants of health
Population of the Study
Haiti’s population as a whole has been affected by the cholera epidemic, however there are several subpopulations within the country that may face elevated risk, including internally displaced people not in camps and those living along the Artibonite river (WHO, 2011). For instance, initially case-fatality rates ranged from 0.8%-7.7% throughout the country illustrating geographic disparities that have shaped the epidemic (Farmer et al, 2011).  Interventions proposed in this paper pertain to the entire Haitian population, but those subpopulations that have been affected more should be specifically targeted with mitigation efforts and treated with more urgency according to their level of risk.
The cholera outbreak in Haiti has been one of the most explosive and deadly outbreaks in recent history with over 250,000 cases and 4,000 deaths within the first six month of the outbreak (Dowell and Braden, 2011). In Haiti’s capital, Port-au-Prince, the disease has been found to have an attack rate of 7.8% compared to a global attack rate of 4.6% (WHO, 2011b). This high attack rate has illustrated the severity of the spread by indicating the amount of persons infected out of the total population exposed.  This outbreak spread rapidly throughout the country and has been most severe in rural areas and large urban slums. This outbreak has been exacerbated by the displacement of thousands of people into slums that have little to no resources following the devastating earthquake that occurred in January 2010. Cholera has been detected in all 10 departments of Haiti and is mostly concentrated in urban areas where population is high. In more rural areas, while populations may be lower, case-fatality rates are extremely high because it is very difficult for this portion of the population to access basic heath care (Farmer et al, 2011). Those who were displaced by the earthquake and reside in makeshift settlements are particularly vulnerable to cholera due to lack of health care, water and proper sanitation.  
The geographic layout of Haiti has had severe implications for the spread of cholera and the associated deaths. The topography of the land has created “hot spots” for cholera due to physical attributes of the land such as elevation and surface water location. For example, departments that boarder the Artibonite River have an increased number of cases compared to departments that do not boarder the Artibonite River because it is thought that this river is the source of cholera (CDC, 2010). Also, seasonality and weather patterns are of particular importance to those who are located in the south and southeast of the country because they are vulnerable to a resurgence of cholera due to an increase in precipitation caused by the rainy season that can create major flooding and enhance the spread of cholera (WHO, 2011b). Mountainous regions are considered to be a “hot spot” for cholera because often times they can only be reached after a half-a-day journey on foot making the entire village susceptible to infection (Butler, 2011).  The mountains in the South East department have made it difficult to reach those affected by cholera resulting in this department having the highest case-fatality rate of 7.7% (Farmer et al, 2011).
Key Environmental and Social Determinants of Health
Environmental and social determinants of health have played a significant role in the way that cholera has spread throughout Haiti. In order to begin mitigating the spread of cholera we must take a closer look at these determinants to better understand their patterns and associations with the spread of cholera on a variety of scales ranging from the household level to the national level. The Haitian population was extremely vulnerable at the time of the cholera outbreak due to a lack of infrastructure for treated water, sanitation, and accessible medical facilities.  From a variety of determinants associated with the spread of cholera, this paper will address access to treated water and sanitation as key social and environmental determinants, respectively.
Social determinants of health are thought to be social and economic conditions of an individual that affects their health and well being as a whole. They are the conditions in which people are born, grow, live, work and age including the health system that individuals have available to them (WHO, 2010). Often social determinants of health are shaped by the distribution of money, power, and resources at the global, national, and local levels that are influenced by policy choices. Haiti has struggled with unequal distribution of money, power, and resources at the national level and internationally since its independence.  The majority of the 77% percent of Haitians currently living below the poverty line do not have consistent access to safe drinking water as a result of their social and economic conditions (World Bank, 2011).
In 2002 Haiti ranked last out of 147 countries for water security according to the water poverty index, thus illustrating the need for clean water and distribution of clean water across the country (Farmer et al, 2011).  The water poverty index is a tool developed to measure water stress at the community level to aid national decision makes to establish priority interventions regarding the water sector (Sullivan et al, 2003). Acute water shortages are thought to be one of the most significant catalysts of the cholera epidemic; political unrest at the time of the outbreak resulted in several roads being blockaded and barriers to equal distribution of treated water and aid (CMAJ, 2011). Even before the January 10 earthquake only about two thirds of the population of Port-au-Prince had access to tap water (Farmer et al, 2011), a proportion which was significantly decreased by the effects of the earthquake. During this time, access to improved water sources was even more limited in rural areas (~50%) (WHO, 2010). Increasing access to clean water for the entire Haitian population should be an immediate priority in order to mitigate the spread and severity of the cholera epidemic in Haiti.
            Environmental determinants of health are closely linked with social determinants of health and are influenced by one another. Environmental determinants of health are often considered to be the physical, biological, and chemical components of the environment that affect the health of individuals and populations. In the case of Haiti and the cholera epidemic sanitation is an important environmental determinant of health because the lack of improved sanitation facilities contributed to the spread of the disease (Dowell and Braden, 2011).           
Sanitation or lack thereof, is another issue that has promoted the spread of cholera in Haiti and is a result of the lack of financial and resource availability to Haiti in the global market. In the case of Haiti, the cholera epidemic will ultimately be controlled when the municipal and rural drinking water systems are effectively protected from contamination by sewage (Dowell et al, 2011). Before the earthquake in 2010, only half of the population in Port-au-Prince had access to latrines and other forms of modern sanitation compared to the rest of the country where only 17% of the population had access to adequate sanitation (Farmer et al, 2011). Proper hygiene associated with the use of soap and water has been thought to reduce the risk of diarrheal illnesses by 47% (Cairncross, 2003; in Farmer et al, 2011). Even though soap is relatively cheap (US$0.50 in Haiti) most Haitians live on only US$1.25 a day, an income that makes the cost of soap a considerable financial burden (Farmer et al, 2011). Improving the sanitation conditions in which Haitians live, specifically targeting solid waste treatment and the separation of drinking and sewage water is of the utmost importance for controlling the cholera epidemic.

Section III: Short term/immediate interventions for cholera
The outbreak of cholera in an area requires immediate response to prevent rapid spread of the disease. Rapid response is especially important for this disease, because it can result in mortality within hours of the first symptoms and many people in Haiti cannot access to medical care quickly enough if at all. Within four weeks of the first confirmed in the Artibonite province of Haiti on October 19, 2010, the disease had reached all 10 provinces in Haiti and had spread to the neighboring Dominican Republic on the island of Hispaniola. By December 31st of that year 179,379 persons had contracted cholera and 3,990 of these had died, according to the Haitian Ministry of Public Health (WHO, 2011b).  The remarkable speed of the epidemic’s spread demonstrates that immediate interventions need to be put in place by health officials in order to minimize loss of life.
This section proposes short-term interventions discussed in infectious disease literature with a focus on improving hygiene and sanitation and increasing public awareness to take immediate precautions in order to prevent transmission of cholera. The implementation of short term interventions such as these can enables the Ministry of Health to slow the spread of the epidemic immediately while planning medium and long term interventions to eliminate the disease.
Vaccination of cholera can be administered by injection or oral ingestion. The injectable form although its side effectiveness and limited effectiveness have made it inappropriate for mass vaccinations. Cholera can also be prevented using oral vaccines, which have proved to be more effective and have no side effects. The oral vaccines have two major types (Dukoral and Shanchol) and all the two medicines require two dozes, given two weeks apart. The World Health Organizations has licensed Dukoral vaccine in over 60 countries due to its effectiveness (WHO, 2010a). This vaccine has been shown to provide short-term protection of 85–90% against V. cholerae O1 among all age groups at 4–6 months following immunization. However, Dukoral has to be mixed with a buffer before being swallowed, while Shanchol is just a couple of milliliters of solution that can be dropped into the mouth like a polio vaccine. Logistically, the latter would be easier, and it would be affordable at around $2per dose (Medecins Sans Frontieres, Field News, 2011).
Strengthening surveillance and early warning greatly helps in detecting the first cases and put in place control measures. Health officials needed daily reports to monitor the epidemic spread and to position cholera prevention and treatment resources across the country.  In the first week of the outbreak, Ministère de la Santé Publique et de la Population's director general collected daily reports by telephone from health facilities and reported results to the press. On November 1, formal national cholera surveillance began, and MSPP began posting reports on its website. Reported cases decreased substantially in January, and the national CFR of hospitalized case-patients fell below 1%. As of July 31, 2011, a total of 419,511 cases, 222,359 hospitalized case-patients, and 5,968 deaths had been reported (Tappero and Tauxe, 2011). Surveillance such as this can help in planning for better a better intervention approach.
Water and Sanitation
To achieve better control strategies, all the partners involved should be properly coordinated and water and sanitation should be included as key tools in controlling cholera epidemic. Provision of safe water in areas that experience shortage is critical in preventing emergence of new cases. Affected communities should be encouraged to boil in the short term and keep drinking water in clean containers.  The public should also be directed to wash their hands with soap before eating and after using toilets or pit latrines. Soap kills bacteria on the skin during the process of washing. This stops contamination of food, water and transmission of the bacteria from one person to another.
Oral Rehydration Salts (ORS)
Efficient treatment can be achieved by prompt rehydration using oral rehydration salts (ORS) or intravenous fluids, depending on severity of cases. Due to diarrhoea, cholera patients normally lose a lot of water from their bodies and they require to replace water lost by taking fluids. Very dehydrated patients are treated through the administration of intravenous fluids, preferably Ring lactate. For children aged 5 years and below, supplementary administration of zinc has proven effective in reducing duration of diarrhea (WHO, 2007). The mortality rate of cholera can be reduced to less than 1% by the adequate replacement of fluids and electrolytes. A mixture of glucose and salt solution allows oral replacement of electrolytes and makes treatment of the disease (particular in rural areas) much more effective. Also, the use of any digestible carbohydrate together with NaCl appears to be effective for electrolyte replacement.
Information dissemination and community participation
Health departments should endeavor to make announcements about affected areas so that the public is aware in order to prevent the spread of cholera epidemic. Communication channels such as televisions, radios, newspapers and announcements in schools, churches and other social gathering places helps in taking necessary precautions to reduce the spread of cholera (Keraka and Wamicha, 2003). According to UN-Habitat and Gender Water Alliance (2005), community participation is becoming a central issue in modern times. The participation of both women and men in planning and decision making processes are the key elements for ownership and sustainability of water and sanitation projects at community level. The involvement of volunteers from the affected and surrounding populations plays a vital role in curbing down cholera epidemic. It also supports the health workforce to manage the rapidly spreading epidemic.

Section IV: Intermediate interventions for cholera
When an epidemic strikes, or indeed any disaster, there is often a large influx of foreign aid to help with the emergency. This was the case when Haiti experienced an earthquake and cholera epidemic within ten months and many nations, multinational agencies and nongovernmental organizations rapidly came to the country’s aid.  However, this aid will not last forever: aid is usually aimed at mitigating the acute effects of a disaster and is not generally maintained once the crisis is contained.  Cholera can persist in a region because the bacteria can remain viable in natural water bodies in a dormant state when seasonal conditions are unfavorable and multiply when conditions improve, producing a resurgence of the disease (Colwell, 2010). In Haiti, transmission continued at a reduced rate in 2011 and resulted in at least one large outbreak in the New Year (Tappero & Tauxe, 2011).  Studies have shown a significant relationship between rainfall and cholera cases (Colwell, 2010), which indicates that cholera may continue to increase seasonally in the coming years in Haiti, which it did in Haiti during the rainy season of 2011 (Tappero & Tauxe, 2011). Given the deficit of effective sanitation and medical infrastructure in the country, it is necessary to plan for direct interventions into a variety of sectors of society that will impact health in the period after the epidemic and before Haiti acquires the economic means for significant infrastructure development.
            This section offers suggestions of interventions for the “medium-term,” meaning the time period after the end of the epidemic and continuing until major changes in Haitian infrastructure can be financed and implemented.  It is in this period that we find ourselves now: the cholera transmission rate in Haiti has decreased and a portion of the population has been immunized by natural infection but a large percentage of the population is still at risk (Tappero and Tauxe, 2011). Considering the Haiti’s poor economic state and the fact that the influx of aid experienced at the start of the epidemic can not be expected to continue indefinitely, it is essential that these interventions be very low cost and be implementable on small regional scales at the level of the nongovernmental organization.  The following sections offer interventions for toilets, water treatment, and education, which fit these criteria. 
Sanitation and specifically sewage treatment will continue to be principal concerns during the medium term.  During the year following the earthquake an estimated 13,000 latrines were installed by humanitarian organizations in Haiti, most in IDP camps (Elhofy, 2011).  This intensity of installation should be continued in the wake of the cholera epidemic, but it will be important to expand the focus of sanitation efforts beyond the camps.  Considering that only 24% of Haitians had basic sewage in 2004, long before the earthquake, it seems clear that it is not only internally displaced people who are at risk due to inadequate sewage facilities but a majority of the population (Farmer, 2011).  At this point attention must be given to other populations in need who experience elevated risk and vulnerability, especially the most poor.  Rural areas are less equipped to manage their waste in a sanitary way than urban areas, in which rates of access to improved sanitation facilities are higher (WHO, 2010).  Additionally, the slums of Port-au-Prince are also densely populated with impoverished people, but lack the infrastructural support provided to IDP camps.  Both the number of latrines available and the overall incidence of cholera in these slums is a critical concern that should be addressed (Elhofy, 2011).
Ultimately the construction of permanent underground sewage systems would be the preferred intervention for toilet access as a determinant of health.  However, such systems take a significant amount of funding and time to be constructed and in the medium term Haiti needs to increase the number of sanitary latrines available to the public in order to reduce cholera incidence.  During this period of time, the development of pit latrines would strengthen sanitation infrastructure in rural areas (Farmer, 2011).  This type of toilet consists of a pit dug into the ground and covered with a hole left for excrement to fall through.  It is important for this hole to be left clean and covered at all times when it is not in use, as flies will be attracted to the latrines and can easily spread cholera from infected excrement to human foods (WHO, 2011c).  Building a closed shelter to protect the latrine can further protect against transmission by flies, especially because flies avoid darkness and dark surfaces.  Pit latrines are optimal for rural Haiti because they are the cheapest and most simple intervention for improved sanitation (WHO, 2011c).  Among dense urban populations, above-ground sewage tanks are a more practical solution for the medium-term.  This type of intervention would be mobile and easily transported to target areas such as urban slums, but a safe location for the deposition of the waste collected in these tanks would have to be developed.
Water Treatment
As has been discussed, the primary mode of transmission for cholera is through contaminated water supplies.  More than 50% percent of both urban and rural Haitian populations are without reliable access to potable water; only 11% of have water in the home, 42% access water from public fountains and more than 30% acquire water from an unprotected supply (Global Development Alliance, 2008).  Many studies in developing countries have shown that even in impoverished circumstances it can be realistic to develop effective interventions into water treatment.  According to Agrawal and Bhalwar, “There is now conclusive evidence that simple, acceptable, low cost interventions at the household and community level are capable of dramatically improving the microbial quality of household stored water and reducing the risks of diarrheal disease (2009).”  In their article about low-cost water treatment interventions the provided the following table, which presents a comparison of various treatment options on the basis of availability and practicality, cost, and efficiency at microbial removal:
(Agrawal & Bhalwar, 2009)
            To reduce cholera transmission among the Haitian population, the majority of which cannot afford expensive private treatment systems, those interventions that this study and other published papers have considered to be low cost should be considered most realistic.  Unfortunately, considering efficacy as the only priority will result in the selection of expensive interventions to which most Haitians will not be able to achieve access. 
As shown in the table above, both exposure to sunlight and plain sedimentation are low-cost interventions.  However, the low efficacy of plain sedimentation methods at removing bacteria makes it a sub-optimal choice.  Boiling, the cost of which depends on fuel type, is a very popular solution to water quality problems in developing countries and results in the removal of a high percentage of biological contaminants.  Boiling is simple and a method of sanitation that is already culturally accepted. However, it is not the best intervention for Haiti because fossil fuels are expensive and fuel wood burning—the most popular method of heating water in Haiti—would result an increase in the rate of deforestation which could be detrimental to the environment and economy.  It would be appropriate to advise the public to boil water at the beginning of an outbreak before they could be trained in less familiar treatment methods, but disinfection by boiling is not sustainable for the medium or long term. Water treatment through the effects of solar radiation and temperature, listed as “exposure to sunlight” above, remains the most appropriate medium term intervention for the economic and ecological realities of Haiti.  Additionally, in-home disinfection using chlorine products is a proven method that could be economically practical for Haiti in the interim (Tappero & Tauxe, 2011), especially if low concentrations of household bleach were used rather than expensive chlorine tablets. 
            Education of Haitian community members and community health workers is important both during the outbreak and following it. The initial educational response included trainings-of-trainers by the Center for Disease Control on cholera treatment, the training and support of about 10,000 community health workers by the Haitian government and other organizations to support treatment and prevention efforts (Tappero & Tauxe, 2011). These community health workers were educated about triage for people showing symptoms of cholera, making and using ORS, prevention by disinfection and water treatment methods. Similar information was posted on the CDC website and educational posters and radio and television announcements were produced to educate the public about basic prevention, detection and treatment methods. 
            In the medium term it is important that information about cholera become common knowledge. This not be difficult to achieve if treatment and santitation education are incorporated into childhood education and efforts to inform the public through print, radio, television and community outreach programs is continued.  Making cholera education a mandatory part of primary and secondary education will reinforce alternative education efforts and raise a generation better equipped to deal with the continued presence of the disease.  Although the education of thousands of health workers was a significant feat, it is important that education continue in order to dispel misconceptions and bring knowledge to the most marginalized of Haitians.  Lastly, it is very important that educational materials going forward be produced both in French and Creole as well as being represented in a visual form on posters and signs so that francophone, creole-speaking and illiterate segments of the population can be reached.

Section: IV: Long-term interventions for cholera
The purpose of this long term intervention strategies is to reduce and control the spread of the disease. Cholera is a diarrheic illness caused by a toxigenic bacterium of the Vibrio cholerae species (Jouravlev 2004). The outbreak of the disease in Haiti has caused thousands of deaths within few months since its introduction. Direct infection from person to person is probably very rare, although this may occur in close contacts within the home or as a result of contacting waste excrement of infected persons (Jouravlev 2004). Specific to the Haitian case, improved sanitation, access to clean drinking water and health resources were non-existent before the earthquake (Njoh 2010). Studies have found that the disease was introduced by UN Volunteers from Nepal (Chao 2011; Chin et al. 2011). Our goal in this long term intervention is to prevent the continuous spread of the disease nationally.
Improved sanitation and water facilities
Haiti is ranked 142 as one of the poorest countries in the developing world with poor health and sanitation infrastructures (Nielsen 2011). As such, Haiti qualifies as one of the Heavily Indebted Poor Countries (HIPC) to receive monetary assistance from International Financial Institutions (IFIs) to address issues related to poverty reduction, good governance and improving the living standards of its citizens (IMF 2009). Before the earthquake in 2010, the country’s social, economic, environmental and political systems were degraded. It is estimated that as of 2010, about 80% of the total population of Haiti’s 10 million people live without access to improved sanitation facility; whereas, about 40% of the total population were without access to clean drinking water (WHO 2010). These statistics point to why developing and implementing long-term cholera intervention strategy is significant for the control of Cholera.
The proper disposal and management of solid waste is a problem in almost all countries most especially in developing countries where the lack improved sanitary infrastructure is a challenge. Water-borne diseases related to inadequate water supply and sanitation is among others as the leading cause of deaths in the developing world (Fewtrell et al. 2004). The establishment and implementation of modern sanitation facilities in solid waste disposal and management throughout the country assist decrease the spread of the disease.
Solid waste disposal and management is crucial in controlling the spread of cholera because the bacterium that causes the disease lives in decomposing waste materials. When solid wastes are not properly disposed and managed in facilities where they are treated, it causes the bacterium of the disease to spread. In this way, solid waste becomes environmental drivers for the spread of the disease. Our improved sanitary strategy proposed in this section will allow us to address the issue of solid waste as environmental drivers for the spread of the disease. This will allow us to develop provide dumpsters throughout every community to properly collect, dispose and manage solid waste. Collected waste will be dumped at a designated landfill where it will undergo mechanical and chemical treatments. This method will decrease significantly the amount of disease carrying pathogens in water sources and thereby decreasing the future outbreaks of cholera and other water-borne diseases (Kremer et al. 2005). In the extreme case, we will design and develop a waste incinerator that will be used to burn waste to generate electricity for the country, thus reducing the amount of waste disposed in the designated landfills.
Also, a sanitation police will be set up by the Ministry of Environment to routinely patrol in urban and rural communities to ensure that environmental safety procedures are followed. The sanitation police will work with local authorities to ensure that wastes are not openly dispose. A fine will be imposed on individuals or communities that are found violating these standards and regulations.
Improved toilet facilities
It is estimated that about 50% urban and 80% rural communities in Haiti lack access to improved sanitation facilities, which include improved toilets facilities (WHO 2010b). As a result, these isolated communities use the outskirts of their communities as toilet areas for the disposal of human excrement, which in turn could serve as potential environmental risk factors for the spread of illness. To address these issues, we’ve decided to design implement a nationwide project to build a robust toilet facilities in communities to reduce the immediate and long-term impacts of disposing human excrement on the environment. It is our goal to work with the Ministry of Health and Population as well as Public Works of Haiti to design strategies on how to convert the human excrement into useable goods such as manure and fertilizers to boost local agriculture.  
Water treatment and distribution
Water is a fundamental aspect of human existence. However, access to clean drinking water continues to be a global phenomenon as climate change and global warming continue to impact our natural systems of clean and fresh water sources (Thompson 2003). It is estimated that about1.1 billion people in developing countries have inadequate access to water. Almost two in three people lack access to clean water and survive on less than $2 a day (UNDP 2006). In Haiti, 59% of the entire population lives without access to improved water system (WHO 2010b), which is a challenging problem and contributing factor to the widespread of infectious diseases. This proposed intervention will include the establishment of a national water treatment and purification plant that will make clean water available to every household. The public and private sectors will collaborate to ensure that purified water are freely distributed and accounted for. Local communities will be involved in this process at community levels to ensure that the available water resource is used wisely and efficiently.
Improved health care system
As part of our long term intervention, we are established a comprehensive health care system, which will involve the public and private health sectors. The emphasis of this comprehensive system is such that, with the involvement of both groups in addressing the health needs of Haitians, we will be using a holistic approach in tackling the disease. This will include the provisions of funds for the education and training of community health workers. This is important because Haiti is in drastic need of medical personnel. Investment in the health care sector will not only produce a productive and healthy workforce, but also create a vigorous system in which access to information, prevention, and treatment will be ensured.
Furthermore, access to advance medical supplies is a challenge in Haiti. We will invest in this sector by working closely with state and non-state actors in providing medical supplies. These medical supplies and equipment will include the provision of emergency response vehicles, medicines, and storage facilities. We will work closely with international institutions such as the World Health Organization (WHO), the International Committee of the Red Cross (ICRC) and the American Red Cross (ARC) for assistance in providing medical supplies and equipment.
National education and awareness
Education is considered as the vehicle of change, which can lead a transformative society at all spectrum of the development discourse if implemented in response to the needs of the population it seeks to target. On this note, as development practitioners as well as medical experts, we will work closely with the Ministry of Education in collaboration with the Ministry of Health and Population to design, strategize and structure a curriculum framework that will incorporate cholera education. This curriculum will be taught at all levels in primary and secondary schools to reinforce our campaign in eliminating cholera and other infectious diseases.
We will also provide funding to teachers who are willing to pursue professional development courses or a degree in the health sciences and who in term will serve by teaching after their completion. This will be carefully administered so that other areas of the economy cannot be impacted by the influx of teachers in the health science sector. There will be a limited intake of teachers per year as to be determined by both the Ministry of Education and the Ministry of Health and Population. Applicants that will benefit from this scheme will have to conduct an academic research in the field of health science upon completion to contribute to the academics on health issues in the region.
National disaster preparedness and response
The 2010 earthquake and its aftermath generated sufficient evidence why our proposal for national disaster preparedness and response is essential. The government of Haiti before the earthquake lack substantial resources and this was partly due to the lack of good governance, corruption, and instabilities. We are proposing that the institutionalization of a national disaster preparedness and response unit is essential to address immediate emergency issues.
Our plan to this approach of emergency preparedness and response will include the construction of bunkers throughout major cities that will have the capacity to host thousands of displaced people during the event of a disaster or emergency. This will assist in reducing the spread of the disease. Our plan also envisage a system of training, professional development and public education about disaster preparedness and response.
Furthermore, we will work with the state, local and international organizations to fund and train Crisis Counselors with the appropriate skills in conducting psychological first aid (PSA) with communities and individuals impacted by disaster. These crisis counselors will work with local and international agencies to counsel victims and direct them to resources where they can access further help if needed. Those who need further mental health counseling caused by the death of love ones, friends, or the loss of properties will be referred to the appropriate mental health counselor in their area.
Financial Investment for Long-Term Interventions
The design, organization and implementation of these strategies in our long-term cholera intervention wouldn’t be achieved if we don’t mention how we seek to fund it. We will work with local, international, and government agencies to raise awareness and the need to act. Specific monetary appears will be made to international financial institutions such as the International Monetary Fund (IMF), the World Bank and other leading agencies and foundations that are concern with health and sanitation issues. Funds generated through donations and foreign aid will be deposited into a specialized bank account created specifically for this project.


The severity and rapid spread of the recent cholera epidemic in Haiti was influenced by a number of determinants of health in the impoverished country.  Sanitation and access to treated water were key determinants which both influenced the risk experienced by individuals and limited the ability of the population to slow transmission of the disease.  In Haiti, where access to clean water and sanitation are extremely limited, it is expected that endemic transition of the disease could continue for years and result in an even greater loss of life (Tappero & Tauxe, 2011).  A large variety of public health interventions have been and can be implemented to contain the epidemic and work towards eradicating endemic cholera, especially those which will improve sanitation and water treatment infrastructure.  Knowledge pertaining to the introduction, amplification and eventual reduction of the cholera epidemic in Haiti can contribute to sanitation and disease management policies domestically and in other countries to reduce the frequency effect of such epidemics.  Additionally, the infrastructure improvements implemented in response to this outbreak can reduce deaths due to other common diarrheal diseases after the epidemic is contained and contribute to improved public health in Haiti. 

Works Cited

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Butler, Decan. 2011. “No Quick Fix for Cholera in Haiti”. Nature. no. 478, 295-296          doi:10.1038/478295a

Center for Disease Control and Prevention. 2011 "Center for Disease Control and Prevention                   General Information."

Center for Disease Control and Prevention. 2010 "Acute Watery Diarrhea and Cholera: Haiti        pre-decision brief for public Health."

Chao, D. L., Hallorana, M. E., Longini, Jr., I. M. . 2011. "Vaccination strategies for           epidemic cholera in Haiti with implications for the developing world." Proceedings of the                   National Academy of Sciences of the United States of America no. 108 (17):7081-5. doi:               10.1073/pnas.1102149108.

Chin, C. S., J. Sorenson, J. B. Harris, W. P. Robins, R. C. Charles, R. R. Jean-Charles, J.   Bullard, D. R. Webster, A. Kasarskis, P. Peluso, E. E. Paxinos, Y. Yamaichi, S. B.    Calderwood, J. J. Mekalanos, E. E. Schadt, and M. K. Waldor. 2011. "The origin of the        Haitian cholera outbreak strain." The New England journal of medicine no. 364 (1):33-      42. doi: 10.1056/NEJMoa1012928.

Colwell, Rita. 2010. "The intricate connection of cholera, climate and public health." On the          Water Front no. 9:1-8.                                                  

Dowell, Scott, and Christopher Braden. 2011. "Implication of the introduction of cholera to          Haiti." Emerging Infectious Diseases no. 7 (17): 1299-1300.

Elhofy, Ashraf. 2011. “Understanding the cholera epidemic in Haiti: Comparing disease focused, with a complex adaptive systems [CAS] approach.” Resilience: Interdisciplinary    Perspectives on Science and Humanitarianism no. 2: 94-106.

Farmer, Paul, Almazor CP, Bahnsen ET, Barry D, Bazile J, et al. 2011 “Meeting cholera's            challenge to Haiti and the world: a joint statement on cholera prevention and care”. PLoS       Negl Trop Diseases no. 5 (5): 1-13.

IMF. 2009. "Haiti: Enhanced Initiative for Heavily Indebted Poor Countries Completion Point   Document." IMF Country Report no. 9 (28).

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Keraka, Margaret Nyanchoka and Wamicha, W. N. 2003. “Child Morbidity and Mortality           in Slum Environments along Nairobi River.” Eastern Africa Social Science    Research Review Project MUSE”

Lorna Fewtrell, and Jr. John M. Colford. 2004. "Water, Sanitation and Hygiene: Interventions      and Diarrhoea: A Systematic Review and Meta-analysis."

Medecins Sans Frontieres. 2011 “Haiti: Cholera Vaccines One Possible Option For           Preventing More Outbreaks” Field News

Nielsen, Lynge. 2011. "Classifications of Countries Based on Their Level of Development: How it is Done and How it Could be Done." IMF Working Paper.

Njoh, Malange Ernest. 2010. "The Cholera Epidemic and Barriers to Healthy Hygiene and            Sanitation in Cameroon: A Protocol Study." Medical Research.

Reidl, Joachim and Karl Klose. 2002 “Vibrio cholera and cholera: out of the water and                               into the host.” FEMS Microbiology Reviews. 26. no. 2. (26): 125-139. Sullivan, C.,            Meigh, J. and Giacomello, A. 2003, The Water Poverty Index: Development and   application at the community scale. Natural Resources Forum, no 27: 189–199.          doi: 10.1111/1477-8947.00054

Tappero, J. and R. Tauxe. 2011. “Lessons Learned during Public Health Response to Cholera       Epidemic in Haiti and the Dominican Republic.” Emerging Infectious Diseases 17, no.            11: 2087-2083.

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