21-27 February 2014 #695

Cholera in the time of peacekeeping

Haiti’s cholera epidemic may have ebbed, but the controversy over its links to Nepal refuses to go away
Naresh Newar

Four years after the cholera outbreak in earthquake-devastated Haiti, genetic analysis has traced the strain of the microbes that caused the epidemic to Nepal, but the authorities here continue to deny that Nepali UN peacekeeping troops were responsible.

“It is easy to blame Nepali soldiers as they contribute a lot to UN peacekeeping missions and they happened to be in Haiti right at the time when the epidemic occurred, but it is dangerous to pinpoint a group of nationals,” said Babu Ram Marasini, Director of the Epidemiology and Disease Control Division of Nepal’s Department of Health Services (DOHS).

The issue resurfaced late last year when lawyers representing families of the victims in Haiti filed a lawsuit in New York against the United Nations, charging the outbreak had been triggered when sewage from infected Nepali peacekeepers was discharged into the water system.

Following the devastating 7.0 magnitude earthquake on 12 January 2010 that killed more than 200,000 people, Haiti suffered an outbreak of cholera for the first time in over a century. From 2010-2013, the total number of cholera cases reached 682,573, of which 379,870 were hospitalised and 8,330 died.

Scientists initially linked the origin of the cholera outbreak to a rise in temperature and salinity in a river in western Haiti. This hypothesis was backed by cholera experts in a 2012 epidemiology article.

However, reports by international news agencies sparked debate among observers when they suggested the epidemic had links to unsanitary conditions and inconsistent medical exams at a UN peacekeeping military camp, where 1,280 Nepali troops were living at the time.

A cholera epidemic in Nepal’s Jajarkot district in 2009 killed 300 people, many of them children, but according to Nepal’s DOHS the epidemic was under control by the time of the Haiti outbreak. Protestors in Haiti blamed Nepali troops in 2010 for bringing cholera to the island.

The Nepal Army, which provides soldiers for UN peacekeeping missions, denied the allegations and insisted personnel were given regular health checks. Each soldier is properly vaccinated while serving domestically and when travelling abroad, officials said.

“The UN has already made it clear that our Nepali soldiers had nothing to do with the epidemic and that is also our official position,” Nepal Army spokesperson Brig Gen Jagdish Chandra Pokhrel said.

But the UN’s position is not quite so categorical, stating instead that the source of the outbreak cannot be identified with total certainty and that its development into an epidemic was caused by a range of factors including the poor state of sanitation and health infrastructure.

According to the UN’s 2011 Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti, ‘The precise country from where the Haiti isolate of Vibrio cholerae O1 arrived is debatable,’ noting, however, preliminary genetic analysis indicate that the strains isolated during the cholera outbreak in Haiti and those circulating in South Asia, including Nepal, at the same time in 2009-2010, are similar.

“This kind of blame game is dangerous because now again the Nepali connection in Haiti’s epidemic is [being] published in media stories across the world,” public health expert Resam Lamichanne from the DOHS said, pointing out that cholera has been successfully controlled in Nepal and there were zero cases in 2013.

But a 2013 report published by the Global Health Justice Partnership at Yale Law School in the US claims the cholera strain in Haiti has been scientifically linked to a single origin in Nepal and that the troops ‘inadvertently carried the disease [to Haiti].’

“Citing deep anger over the outbreak among the Haitian public, the report calls on the UN to ‘re-establish its institutional legitimacy’ in Haiti by taking concrete steps to apologise publicly and ensure such outbreaks never occur again.

The world is not blaming the Nepali peacekeepers,” said Daniele Lantagne, a cholera specialist from the US, who co-authored a report by an independent panel formed by the UN Secretary-General to investigate the source of the 2010 outbreak.

She said the outbreak resulted from a confluence of events, which included someone infected with cholera being in Haiti, the person’s faeces being disposed of inappropriately, and cholera proliferating in the environment, compounded by a lack of transmission prevention once the bacteria were in the open. “All four [factors] were required to start the current Haitian outbreak,” Lantagne said.

Four years after the outbreak, people in Nepal are still reacting to the claims against the country’s soldiers. Shiva Yadav, a community health worker at a government health post in Banke district, 500km west of Kathmandu, agreed: “I really feel sorry about the situation in Haiti and we are ready to offer our help because of our own success in controlling the epidemic.”

According to Nepal’s Ministry of Foreign Affairs, the country is the seventh largest provider of peacekeeping troops in the world, with more than 4,000 soldiers active in 2012.


Read also:

Keeping the peace

Cholera choler

A history of maladies

The first recorded instance of cholera in Nepal was 1823. And although it had probably happened before, the water-borne disease began to be detected with regularity ever since. A British doctor in Kathmandu did a study of the 1885 epidemic, revealing there were worse outbreaks in 1831, 1843, 1856, 1861 and 1876.

‘Nepali’ cholera became infamous when an outbreak in Haiti was alleged to have come from Nepali peacekeepers who were stationed upriver from major coastal settlements. Because Jajarkot had an epidemic in 2009, it was automatically assumed that Nepali soldiers carried the disease with them to Haiti.

Although scientists are still debating, reports in the western media have questioned the UN and its waste management contractor’s efficiency in disposing waste from the MINUSTAH camp.

Sameer Mani Dixit of Centre for Molecular Dynamics Nepal says it is impossible to establish three years later what really happened in Haiti.

“They could have found out what happened and how if samples from Haitians were compared with samples from Nepali peacekeepers in 2011,” he says. “But to compare two outbreaks that occurred two years apart and affected two groups of people isn’t scientific, let alone conclusive.”

Dixit says strains of cholera are very closely related and mutate easily over a short period of time. An upcoming research paper co-authored by his organisation reveals that strains found in Nepal in 2012 also matched strains found in Bangadesh and Haiti in 2012. They conclude that closely related strains are undergoing global dissemination.