PORT-AU-PRINCE, Haiti — When Haiti’s leading infectious disease specialist heard that cholera, the deadly waterborne disease that he and others had spent nearly a decade trying to eradicate in the impoverished country, was back, he was angry.
But Dr. Jean William “Bill” Pape, who runs the Caribbean’s largest HIV/AIDS research center and most recently helped lead Haiti’s COVID-19 response, was not surprised.
The disease is just part of the latest wave of ills to plague the country. Malaria is on the rise in Haiti, and so too is acute malnutrition in children under 5 and in pregnant women. HIV/AIDS patients can’t get their medication and Haitians in need of medical care often can’t get it because it requires crossing through gang strongholds, risking their lives to reach a hospital or clinic that may or may not be open.
And then, there is the fuel problem. Diesel and propane were already in short supply even before a powerful coalition of gangs began blocking tanker trucks from accessing the country’s principal fuel terminal, Varreux, last month. The situation has left Haitians with no access to potable water, waste collection or health facilities.
“We are really in a very, very catastrophic situation,” said Pape, founder and director of the Haitian Study Group on Opportunistic Infection and Kaposi’s Sarcoma.
Pape has opened two of the country’s 16 Cholera Treatment Centers, and the one in downtown Port-au-Prince is getting filled quickly.
“Many people have died at home before the epidemic was recognized because they could not get to a health center for lack of public transportation,” he said.
Pape recently met with leaders from some of the neighboring slums. They complained that mud and debris is flowing into homes and that the Bois de Chêne canal that separates the Village de Dieu from Cité Éternel slums hasn’t been cleaned in over four years because workers in the Ministry of Public works are afraid of coming face-to-face with gangs.
“It is inhumane to let our fellow Haitians live in such horrible conditions,” Pape said.
Among the cholera dead are children and at least 16 inmates inside Haiti’s overcrowded National Penitentiary in Port-au-Prince.
In the city of Jeremie in the Grand’Anse region, a nurse said that 550,000 people who live in the town and its coastal communities haven’t had electricity since before last year’s deadly earthquake.
“Surgical instruments cannot be sterilized if the hospital cannot run the generator,” she added.
Crisis wipes out health gains
For years, Haiti’s kidnapping gangs and the wave of violence they’ve unleashed have been steadily wiping out health gains in HIV/AIDS, infant mortality, maternal deaths, tuberculosis, malnutrition and waterborne diseases like cholera, while robbing Pape and the country’s crippled health system of their best doctors, lab technicians and other medical professionals.
“I’ve lost 93% of my best staff, people that have been trained at Cornell,” said the physician, himself a 1975 graduate of Cornell University in New York, where he teaches at Weill Cornell Medical College. “I can’t blame them. They have kids, there is no future for them; there is insecurity.”
With several confirmed deaths and scores of suspected cases traced to cholera during the crippling fuel blockade now headed into its fifth week, Pape is helplessly watching all that Haiti has built with the aid of the United States and others in the international community fall apart amid “a complex human tragedy.”
“It’s really, really sad. All the gains that we’ve made have really reversed back to where they were before and this is likely to go down even further,” he said. “And now on top of that, we’ve got cholera and unfortunately for us, it’s in many locations.”
The resurgence of cholera couldn’t have come at a worse time for Haiti, and yet all the conditions were ripe for an outbreak. The disease spreads rapidly in areas without adequate treatment of water and sewage, which is a continuing problem in Haiti. Garbage hasn’t been picked up for weeks in many places because of gang violence and the lack of gas and diesel. In Brooklyn, the neighborhood in the sprawling Cité Soleil slum where the first cases were reported 10 days ago and a violent clash between warring gangs in July left over 470 victims, residents haven’t seen waste collection since mid-August, when the gang conflict also stopped water trucks from entering.
Clean water is key to containing deadly disease, but public and private production of treated water has now ground to a halt. This has led to many Haitians being forced to drink water from contaminated wells and other suspect sources like waterholes placed too close to a latrine.
“Here what we have is a pile of garbage sitting within a few meters of food that’s going to be used for consumption. All you need are flies that go from one area to another,” Pape said. “We also have daily rains, so we have flooding. This is the best way to spread any kind of infectious agent.”
Different kinds of ills
Before the gang problem, the ills plaguing Haitians were related to poverty, AIDS, tuberculosis and malnutrition among them, public health experts say.
“We were dealing with the extreme manifestation of illnesses because of poverty,” said Dr. Richard Frechette, the founder of St. Damien’s Pediatric Hospital and St. Luke Foundation in Port-au-Prince. “Over these 30 years now, there has been a lot of variation of that. There have been ... disasters, earthquakes, hurricanes and also social revolutions, which change everything.”
Today, with the reign of gangs who are preying on and terrorizing the population, Haitians and the physicians treating them are confronting different kinds of ills, all rooted in the violence.
“We have so many trauma cases now: people hurt while running from gunfire, or jumping over walls to get away from gunshots, and of course those with gunshot injuries,” said Frechette. “There have been hundreds of trauma patients. There are illnesses related to being displaced as internal refugees, especially among children. Malnutrition, scabies, impetigo, pneumonia, gastroenteritis from bad water, worms, etc.”
Vast areas of the capital are now deserted because of violence, including Martissant, parts of Cité Soleil, Croix-des-Bouquets, Pernier and Torcelle.
Sitting in the yard of his hospital complex not far from the U.S. Embassy and the strongholds of several gangs, Frechette said he now spends a lot of his time dealing with the fallout from the horrors of kidnappings, sexual violence and trauma.
In July, when the population of Brooklyn that is now dealing with a cholera outbreak came under fire from warring gangs, the work of St. Luke Foundation was excruciatingly difficult.
“People are afraid, depressed and terrorized; they’re living under gunfire, children are growing up under their beds, hiding from bullets, sleeping flat on the floor under what should be a place for rest. It’s a plague,” Frechette, who is also a Roman Catholic priest, said.
“We have doctors who have been kidnapped doctors, we have nurses who have been kidnapped, and when they’re freed, they get out of Haiti as fast as they can,” he added. “We have doctors who are afraid of being kidnapped, we have nurses who are afraid of being kidnapped, and they are leaving Haiti in large numbers. And if they can’t go to the States, they go to the Dominican Republic or to Brazil or somewhere else. So we’re losing the strength of knowledge, of history, of experience, of capacity.”
Making the situation more dire, the prices of food and fuel keep going up. Meanwhile, in a country where most people live on less than $2 a day, gasoline is selling for $32 a gallon on the black market. Inflation is at a record high 31%, leaving less and less money to pay for food.
USAID health-supported facilities closed
A U.S. State Department spokesperson said the U.S. government, including the U.S. Agency for International Development and the Centers for Disease Control and Prevention, is working closely with Haiti’s Ministry of Public Health and Population’s Cholera Response Task Force and the Pan American Health Organization to determine the extent of the outbreak and how to help.
USAID, which has been a leading funder of health initiatives in Haiti, currently has nearly $4.2 million in active water, sanitation and hygiene assistance in Haiti and nearly $5.2 million for ongoing health programs being administered by partners, several of them in Port-au-Prince. The CDC also has $3.4 million in existing health agreements.
“An organized criminal group’s blockade of Port Varreux is preventing fuel distribution throughout the country. This lack of fuel exacerbates the spread of cholera by inhibiting the transportation of samples to laboratories and patients to hospitals, the production and delivery of potable water, and the ability of hospitals to continue to operate,” the spokesperson said. “The combination of the fuel and security crises has resulted in the temporary closure of 25 percent of USAID-supported health facilities in Port-au-Prince.”
Unlike during the previous cholera epidemic in 2010 and 2011, the Haitian government today has the experience to respond to the outbreak. But the State Department spokesperson said Haiti’s health ministry today “faces serious headwinds, which hinder faster response. These include difficulty getting into the cholera affected areas, and lack of resources including the lack of fuel.”
Cholera strain under investigation
Haiti and U.N. officials say they are still trying to determine if the current outbreak of cholera is the same strain as the one in 2010 that was introduced into Haiti 10 months after the country’s devastating earthquake left more than 300,000 dead.
That particular cholera outbreak was responsible for the deaths of more than 10,000 Haitians, while infecting another 800,000, until its last confirmed case in February 2019. Ulrika Richardson, the U.N.’s leading humanitarian coordinator in Port-au-Prince, said because the local lab doesn’t have the capacity to determine the strain, it is being investigated outside of Haiti.
But the more immediate issue is getting fuel flowing again.
“Without fuel, there is no clean water; without clean water there will be more cases and it will be very difficult to contain this outbreak,” she said.
Gangs have shown no signs, however, of loosening their grip. Over the past weekend armed gangs with access to a vessel attacked a flour mill owned by two major U.S. firms as well as the adjacent Port Lafito. The Haitian Coast Guard succeeded in pushing them back, but more than three dozen heavily armed gang members now patrol the outer perimeter of both, two sources confirmed to the Herald.
‘We have a national emergency’
The last time Haiti’s fuel problems shuttered businesses, schools and hospitals and brought life to a screeching halt, Pape decided to create a contingency plan that eventually required having two months’ worth of fuel reserves to run his two clinics in Port-au-Prince and in Tabarre.
The plan worked until the G-9 gang coalition, led by a former cop, Jimmy “Barbecue” Cherizier, decided to block access to the port again. With overturned trailers, trenches and burning tires blocking the road to the port and fuel running out, Pape has ended all nonessential services, and is asking people leaving the country if he can purchase their last bit of diesel to keep his laboratory and coolers full of vaccines running.
Those staffers who can walk to work still show up, he said, but many patients are unable to make it.
“At the downtown center we see 2,000 patients normally, every single day. Those people cannot get there, because they need public transportation,” Pape said.
On the morning Pape was speaking to a Herald reporter, a patient was brought in with life-threatening vomiting and diarrhea. It was cholera. She lived across the street at Village de Dieu, which Pape said his staff can still get to despite the slum’s reputation as a kidnapping lair.
“I’ve never had any dealings with any gang leaders. But I can tell you, they let us work and that’s all I asked for because my job is not to get into the politics of what puts us there, but it’s to try to help the population as best as we can,” he said. “At our center, we receive all kinds of people, the majority from the slum population, and this is where cholera is going to create the most victims.”
But while Pape can still get to Village de Dieu, he can’t say the same for Cité Soleil, where many children are showing up infected at a small dispensary. After they are stabilized, they are transferred to a Cholera Treatment Center run by Doctors Without Borders in Port-au-Prince.
“I do not think we have the capacity and I will not send my staff to risk their lives in those places,” Pape said.
Gang members, he said, are just as vulnerable to contracting cholera as anyone else in Haiti, including “people in the government, people in the opposition. Cholera doesn’t discriminate,” he said.
“We have to understand we have a national emergency. This is not the time to do politics, this is the time to prevent people from dying. We have no excuse. We cannot say it’s the U.N. who introduced cholera,” Pape added. “Cholera is here and we can do something because we know what to do.”
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