(2016-11) CRS - Haiti: Cholera, the United Nations, and Hurricane Matthew

Updated November 17, 2016 Haiti: Cholera, the United Nations, and Hurricane Matthew Hurricane Matthew hit Haiti on October 4, 2016, causing The Spread of Cholera in Haiti widespread damage and flooding and leaving 1.4 million MINUSTAH was established in 2004 to help restore and people in need of immediate assistance. Observers are maintain order after the collapse of former President Jean- concerned that the country might experience a surge in Bertrand Aristide’s government. While providing cholera reminiscent of the 2010 outbreak that claimed the emergency assistance following the 2010 earthquake, some lives of thousands of people. Prior to the 2010 earthquake, MINUSTAH troops inadvertently introduced cholera into there had been no cholera cases in Haiti for at least a Haiti. In 2011, a team of researchers from France and Haiti century. According to various scientific reports, cholera investigated and reported that “contamination of the was introduced into Haiti by peacekeepers in the United Artibonite [River in Haiti] and 1 of its tributaries Nations Stabilization Mission in Haiti (MINUSTAH). Since downstream from a [MINUSTAH] military camp triggered then, cholera has infected almost 800,000 Haitians and the epidemic.” The researchers noted “an exact correlation killed over 9,000. Although the United Nations (U.N.) has in time and places between the arrival of a Nepalese taken action to control the 2010 outbreak and subsequent battalion from an area experiencing a cholera outbreak and epidemic, numerous groups contend that the agency has not the appearance of the first cases in [the nearby town of] responded strongly enough. Thousands of victims and their Meille a few days after.” Other studies have come to the families have filed legal claims demanding reparations. same conclusion. Vulnerability to disasters—due to a lack of immunity, overcrowded living conditions, environmental In August 2016, U.N. Secretary-General Ban Ki-Moon said degradation, poor construction standards, dysfunctional or that the U.N. has a “moral responsibility” to the epidemic’s lack of sewage and sanitation systems, and political victims and announced a new program to support them, instability in Haiti—has facilitated the rapid spread of the though the U.N. continues to claim diplomatic immunity. A disease and led to the largest cholera outbreak in the world. bipartisan group of 158 Members of Congress sent a letter In 2010 and 2011, roughly 57% of all global cholera cases to Secretary of State John Kerry pressing him to urge the and 45% of all cholera deaths occurred in Haiti. U.N. to issue an apology to the victims and their families, set up a fair and transparent process that allows victims to Efforts to Control Cholera in Haiti seek remediation, and take immediate actions to address the In January 2012, the presidents of Haiti and the Dominican ongoing cholera epidemic in Haiti. Republic, in cooperation with WHO and the Pan American Health Organization (PAHO), the United Nations Cholera: Basic Facts Children’s Fund, and the U.S. Centers for Disease Control Cholera is a diarrheal infection that is contracted by and Prevention, issued the “Call to Action for a Cholera- ingesting food or water contaminated with the bacterium Free Hispaniola.” The appeal urged donors both to honor Vibrio cholerae. The World Health Organization (WHO) the pledges they made to help Haiti recover from the 2010 estimates that there are up to 4 million annual cholera cases earthquake and to provide new funds specifically for worldwide, causing 21,000-143,000 deaths. The disease is building a sound water supply and sanitation infrastructure primarily found in countries with inadequate access to clean to eliminate cholera. In November 2012, the Haitian water, sanitation, and hygiene (WASH). Cholera is also government released the National Plan for the Elimination commonly found in urban slums and camps for internally of Cholera in Haiti: 2013-2022, which budgeted $2.2 billion displaced persons or refugees. for carrying out the call to action. As of August 2016, donors had contributed 18% of the funds sought and the About 75% of people who are infected with cholera do not U.N. reported that it had mobilized $307 million in support exhibit any symptoms, although infected people can spread of the national plan. The U.N. has used these funds to the bacterium for up to two weeks should others ingest food or water contaminated with their fecal matter. Cholera can  vaccinate over 400,000 people against cholera; cause acute diarrhea and vomiting, which can lead to severe  build 5,500 household toilets; dehydration and death within hours if not immediately  improve WASH in over 80 health centers and establish treated. People with suppressed immune conditions, such as nearly 700 water and chlorination points; malnourished children and HIV-positive individuals, are more likely to die from cholera. Common treatments  establish some 250 cholera treatment centers; include oral rehydration salts and antibiotics. Cholera  construct wastewater treatment plants and build sanitary vaccines provide protection for three years-five years. facilities in more than 200 schools; Long-term prevention of the disease requires the  supply more than 9 million cholera prevention and establishment of clean water systems, wastewater treatment treatment items, including water purification tablets, plants, and sanitary facilities. soap, and medical supplies and equipment; and  establish a global stockpile of oral cholera vaccines. https://crsreports.congress.gov Haiti: Cholera, the United Nations, and Hurricane Matthew Despite its limitations, the Haitian government has led Human rights groups contend that Haitian and international cholera prevention and control efforts, with a particular law guarantees a victim’s right to an effective remedy. focus on people displaced by the 2010 earthquake, and Several U.N. human rights experts have said an continues to lead coordination and implementation efforts. independent and impartial mechanism to review claims and These initiatives have led to dramatic declines in related ensure adequate reparation is essential. In August 2016, the cases (Figure 1). U.N. Special Rapporteur on Extreme Poverty and Human Rights called the U.N.’s approach “morally unconscionable, Figure 1. Cholera Cases in Haiti: 2010-2016 legally indefensible, and politically self-defeating.” In August 2016, Secretary-General Ban reiterated the U.N.’s immunity but said the U.N. is developing a plan to intensify efforts to treat and eliminate cholera, improve long-term access to clean water and sanitation, and provide about $200 million in compensation to Haitian cholera victims. The program is neither finalized nor funded. Source: Created by CRS from PAHO/WHO, Epidemiological Update: Current Situation Cholera, October 18, 2016. Persistent lapses in access to sanitation and clean water Notes: Cholera cases in 2016 are through September 17, 2016, and threaten efforts to eliminate cholera in Haiti, and Hurricane exclude suspected cases in the aftermath of Hurricane Matthew. Matthew has caused further setbacks. Haiti had made some progress in improving access to sanitation, but access to Hurricane Matthew’s Impact on Spread of Cholera clean water has declined. In 1990, only 18% of Haitians had The first category-4 hurricane to hit the country since 1964, access to sanitation facilities; by 2015, 28% had such Matthew caused flooding and destroyed water systems, access. Access to clean water fell from roughly 62% in creating conditions for the further spread of cholera. WHO 1990 to 58% in 2015. Gaps between rural and urban use of and PAHO report that 5,840 suspected cholera cases sanitation facilities and improved water also strain cholera occurred from October 4 through November 6, 2016. efforts; whereas 34% of urbanites were using improved Roughly one week after Hurricane Matthew hit, the U.N. sanitation in 2015, only 19% of the rural population was issued a $119 million appeal for Haiti, including $9 million doing so. Similarly, 65% of urbanites had access to clean for health services and $15 million for WASH. As of water in 2015, whereas only 48% of rural dwellers were October 20, 2016, roughly 22% of that appeal had been using clean water. funded. The Haitian Ministry of Health is also partnering The loss of international support for cholera control has with WHO/PAHO to vaccinate over 820,000 people against also compromised related efforts. Following the 2010 cholera. The vaccination campaign began November 8, earthquake, hundreds of international actors arrived in Haiti 2016. The U.S. government has provided more than $48 to provide emergency assistance. The groups began to million for Hurricane Matthew response efforts, including leave, however, as funding fell. In 2011, 120 groups were those aimed at controlling cholera. conducting cholera control efforts and had partnered with the Haitian government and U.N. agencies to establish 250 Dispute over U.N. Response MINUSTAH operates under a Status of Forces Agreement, cholera treatment centers (CTCs). As of June 2016, only 30 which provides broad immunity from prosecution. To organizations were working on cholera elimination and as counterbalance that immunity, however, the agreement of October 28, 2016, only 67 CTCs were open. requires the U.N. to establish an independent Standing The Haitian government has been unable to fill the resulting Claims Commission to hear claims and compensate victims gaps. Lacking adequate funds to pay salaries for health and injured by U.N. actions. The U.N. has not established such sanitation workers, the government has closed cholera a commission. treatment centers and reduced the number of staff available Human rights groups therefore filed claims directly to the to carry out cholera surveillance, treatment, and community U.N. in 2011 on behalf of 5,000 cholera victims demanding awareness campaigns, as well as to provide care in health that the U.N. compensate them for their losses, install a facilities and cholera treatment centers. Budget shortfalls national water and sanitation system, and publicly also have prohibited the Haitian government from covering apologize for its role in the outbreak. In 2013, after the the operational costs of newly built sewage treatment U.N. had rejected the claims and rebuffed additional efforts plants, leaving all but one plant inoperable. Funding to resolve the matter out of court, the groups filed a lawsuit constraints have limited the Haitian government’s capacity in U.S. federal court seeking damages for personal injury, to protect the water and sanitation systems from illicit use. wrongful death, loss of use of property and natural The longtime lack of a fully functioning government has resources, and breach of contract. In 2014, the U.S. exacerbated these challenges, as well. government filed a statement claiming that the U.N. has Maureen Taft-Morales, Specialist in Latin American immunity. In 2015, a federal court judge ruled in favor of the U.N. and dismissed the case for lack of subject matter Affairs jurisdiction. In August 2016, an appeals court upheld U.N. Tiaji Salaam-Blyther, Specialist in Global Health immunity. IF10502 Critics from outside of and within the U.N. have called for the organization to take responsibility for the epidemic. https://crsreports.congress.gov Haiti: Cholera, the United Nations, and Hurricane Matthew Disclaimer This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. 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