Article from our Water, Sanitation and Hygiene Barometer 2021
By Renaud Piarroux, epidémiologist.
Renaud Piarroux is head of the parasitology and mycology department at the Pitié-Salpêtrière hospital in Paris, and professor at the Sorbonne University Faculty of Medicine. An internationally recognized specialist in cholera epidemics, he is actively involved in fighting Covid-19*, and has agreed to give SOLIDARITÉS INTERNATIONAL his analysis of the current health crisis. As he sees it, lessons learned from fighting cholera in Haiti can serve us in the ongoing battle against Covid-19 in France.
It may seem surprising to compare the cholera epidemic in Haiti to the outbreak of Covid-19 in Paris. At first, these two situations seem to have nothing at all in common: the causes of infection (bacterium versus virus), clinical symptoms and treatments are different, as are the ways these two diseases spread, except for the common denominator that they are transmitted via contaminated hands. Above all, the context is completely different. On the one hand, a disease associated with underdevelopment, which broke out in a context of political, economic and social collapse; on the other, an epidemic affecting a rich European city where the social context is indeed tense, but not enough to threaten overall social stability. And yet, despite these intrinsic differences, there are many similarities between the two catastrophes.
The Haitian controversy
The cholera epidemic broke out in Haiti in October 2010, while the country was still reeling from the effects of a particularly deadly earthquake (between 100,000 and 300,000 lives lost) that had hit eight months earlier. In the space of a few days, cholera cases exploded along the length of Haiti’s largest river, the Artibonite. Although epidemiological investigations quickly identified the disease’s point of origin right next to a camp of UN peacekeepers freshly arrived from Nepal, where there was an ongoing cholera epidemic, experts from the Pan American Health Organization (PAHO) and various UN agencies immediately ruled out the theory that these soldiers had imported the dangerous microbe.
American academics then rushed to second this conclusion, claiming that the epidemic was linked to global warming and the emergence of the offending bacteria in the brackish waters of the Artibonite delta. However, as time went by, this hypothesis was refuted by epidemiological studies and by comparing the genomes of the vibrio cholerae strains identified during the Nepalese and Haitian epidemics. As scientific evidence of the UN forces’ responsibility continued to mount, rendering the climate hypothesis more and more implausible, the arguments put forward by PAHO experts and supported by academics grew weaker and weaker, as did the official UN position denying any responsibility for this catastrophe. It took another six years before Ban Ki-moon, then UN Secretary-General, implicitly acknowledged the organization’s responsibility and offered his apologies to the Haitian population.
With no political or scientific consensus, it took years to organize action to fight cholera
This controversy over the origin of the epidemic, coupled with many Haitians’ distrust of both the United Nations and their own successive governments, meant that a trusting environment could not be established, thus impeding the implementation of cholera control activities. With no political or scientific consensus on which strategy to pursue, it took years to adequately organize and implement action to fight cholera, especially the intervention of mobile teams every time a new case was detected.
As a result, the epidemic continued year after year, as successive outbreaks alternated with relatively calm periods. It was only at the end of 2016 that this struggle finally took a turn for the better, when Ban Ki-moon’s apology put fighting cholera back on the international community’s political agenda. Two years later, in February 2019, the last cholera outbreak was extinguished near the Artibonite delta. Since then, not a single case of cholera has been diagnosed in Haiti.
The need to build trust and involve populations
A deadly disease characterized by several successive waves of infection, against a backdrop of public distrust for political authorities; a scientific controversy over the origins and the future of the epidemic, as well as on how to put an end to it; experts who have lost credibility because they are suspected of hiding the truth and not seeking to inform objectively; and lastly, great difficulties in establishing a coherent strategy and setting up an effective response. It is clear that the health and social crisis caused by Covid-19 in France has many similarities with the cholera epidemic in Haiti. In this respect, two points merit emphasis since they will determine the success or failure of the Covid-19 response in the coming months, at least until the population has been vaccinated.
Firstly, it is absolutely essential to establish a trusting relationship between the general public and the scientific and political authorities that are involved in designing and implementing activities to fight the epidemic. Clearly, in France as in Haiti, this relationship was very quickly damaged by the inconsistent and sometimes even false declarations made by certain experts and politicians over the course of the epidemic.
Faced with a case of health misconduct that, in one situation, caused an epidemic (introduction of cholera in Haiti) and, in the other, compromised the response to an epidemic (lack of preparation and protective equipment to tackle Covid-19 in France), there was a great temptation to hide the truth and look to pseudoscientific explanations as a means of skirting the issue. In Haiti, the focus turned to the environmental context, poverty within the country and the population’s failure to observe personal hygiene measures. In France, the general public was told that they did not need masks or any other form of protection—not even fabric masks that could have been produced very quickly. It seems that in politics, it is never advisable to acknowledge your mistakes. This allows you to maintain your advantage over the enemy. However, let us note that when the enemy is a virus, this attitude has a phenomenal cost, measured in human lives.
Moreover, since these errors cannot be concealed indefinitely, disguising them leads to controversy, which in turn fuels conspiracy theories and undermines trust among a growing proportion of the population. This means that instructions to prevent the epidemic spreading are not always followed, and the situation gets worse. The epidemic takes hold.
When fighting cholera or Covid-19, it is people themselves who decide whether or not to observe good hygiene and protective measures
The second point concerns the population’s central role in controlling epidemics. When fighting cholera or Covid-19, it is people themselves who decide whether or not to observe good hygiene and protective measures. They also decide whether or not to seek medical attention, especially when they have moderate symptoms of the disease. Finally, they are the ones that choose whether or not to open their doors to epidemic response teams. And, where Covid-19 is concerned, these same people are asked to provide the names of their contacts, which is an essential step to break the chains of transmission surrounding each confirmed case.
Mobile teams: a valuable asset
In Haiti, mobile teams gradually gained the population’s trust by travelling throughout the country and providing everyone with the materials they needed to protect themselves against cholera. Our supervisory rounds enabled us to check that people understood and were observing hygiene guidelines, insofar as conditions permitted. The mobile teams acquired specific skills and earned a good reputation, which increased the impact of their operations. In France, the mobile team strategy to visit patients and their families in their homes is still in its very early stages. Initially deemed too complex to apply, it has only been implemented in Paris (COVISAN), Cayenne (YANACOV) and Marseille (CORHESAN). For the moment, it only covers limited areas within these three cities. And yet these teams are a valuable asset to help the population get organized to fight the epidemic, especially as people are weary of the crisis and mistrust the government, whom they consider detached from reality.
Cholera in Haiti and Covid-19 in Paris are not so dissimilar after all. There is even a direct link between the mobile team strategies in Haiti and in Paris: the first COVISAN hub, which was launched last April at the Pitié-Salpêtrière Hospital in Paris, is based on the Haitian cholera response model and was set up with the assistance of a former Country Manager at SOLIDARITÉS INTERNATIONAL.
*Renaud Piarroux has written two books: Choléra. Haïti 2010-2018, histoire d’un désastre (2019) and La vague. L’épidémie vue du terrain (2020).
Photo © Gwenn Dubourthoumieu / SOLIDARITÉS INTERNATIONAL