After recently spending 24 hours in Gonaives, Artibonite department, the link between water and health is once again engraved in my mind. The day – spent on the ground with UNICEF partner Action Against Hunger (ACF) in and around the commune of St Michel d’Attalye – illustrated the direct connection between safe water and cholera, between life and death like no infographic or report could.
Gonaives was the first place I visited after arriving in Haiti in September 2014. At the time, it was among the hotspots of the still ongoing cholera epidemic, with over 470 cases that month. Today the situation has calmed down all over the country with a 90 percent reduction in reported cases between 2014 (27,388) and 2011 (350,000). However, with an ambitious target of reaching less than 1,000 suspected cases a year (an incidence of <0.01%) to reach elimination by 2022, each confirmed cholera case is of concern.
This is particularly true in the capital Port-au-Prince and in the departments of North and Center which account for over half of all cases and where over 2,000 cases have already been observed for 2015 (nearly 6,000 in Port-au-Prince alone). In contrast, Artibonite has entered a quiet period, meaning that although cases continue to occur (an average of 55 cases a week), NGO partners can dedicate more attention to prevention and strengthening community-based response mechanisms to cholera alerts.
The Haitian government and its partners, including UNICEF, implement a four-pronged approach to eliminate cholera in the country.
- One: rapid response and investigation of all cholera alerts led by Ministry of Health emergency response teams (EMIRA) and supported by UN and NGO partners.
- Two: complementary investments in the underlying structural causes of the epidemic, in particular access to clean drinking water and adequate sanitation.
- Three: strengthening of epidemiological surveillance (to control an epidemic it is crucial to have timely information about the number and location of cases) and the enhancement of health services at national and local levels.
- Four: sensitization of individuals on good hygiene practices via mass media campaigns and face-to-face community outreach activities. Whenever possible community-based interventions are prioritized
When I visited Gonaives in September 2014 cholera agents of the ACF-team were working hand-in-hand with the EMIRA and other local government agents to ensure a professional response within 48 hours after each cholera alert. Once a patient was registered at a cholera treatment center (CTC) the agents’ task was to disinfect his/her home and to establish a ‘sanitary cordon’ (‘cordon sanitaire’) around the neighboring houses of the cholera patient – usually around ten houses. The latter involves disinfection of neighboring houses if required, sensitization activities, and provision all of cholera kits that contain a month’s supply of soap, water, chlorine tablets (to disinfect drinking water) and oral rehydration salts (to compensate lost minerals in case of diarrhea) to families.
To ensure quick local response capacities, ACF is now benefitting from the relative calm to conduct prevention activities and to refine a mechanism of community-based agents, which may eventually replace the need for external assistance. In high-risk areas, ACF has trained community volunteers called ‘brigadiers’, who know how to prevent cholera and what to do when a case is registered. Besides, they are in charge of keeping their communities attentive to the risk of cholera and encouraging good hygiene practices and other preventative behaviors. This approach has a triple advantage. Being themselves from the communities the brigadiers know the area by heart, they have more credibility than outsiders, and they are on site when an outbreak occurs.
Currently, the cholera epidemic in Haiti remains an emergency with the acute risk of major outbreaks. In particular the current rainy season (which will last until November) makes experts itchy. The spike in cases last November illustrates the need for ongoing vigilance and rapid response. Despite continued progress against the disease, for a large part of the population the risk of cholera remains the same as in 2010. The localized epicenters of cholera outbreaks continue to be characterized by a lack of water and sanitation infrastructure, insufficient social services, and the high mobility of populations.
To break the chain of transmission and get rid of cholera in Haiti, clean water and sanitation together with improved hygiene behaviour are the key. Today’s challenge is to break the chain of transmission and to eliminate the remaining risk, once and for all.
Cornelia Walther is the Chief of Communication at UNICEF Haiti