01.28.12

A Call for U.N. Accountability for Cholera in Post-Earthquake Haiti – Part III: Raising U.N. Disease Prevention Standards

By | Leave a Comment

In response to the second anniversary of Haiti’s January 12, 2010 earthquake, this post is the third in a four-part series examining the implications of ongoing efforts to establish U.N. accountability for allegedly causing Haiti’s deadly cholera epidemic in the months following the events of January 12, 2010. This post was authored by O’Neill Institute Research Associate, J.P. Shuster, with support from O’Neill Institute Law Fellow, Ana Ayala.

The second anniversary of Haiti’s devastating 7.0-magnitude earthquake passed earlier this month, perhaps expectedly, without it receiving a fraction of the global media attention and international support that accompanied the sufferings experienced on January 12, 2010. Yet the aftermath of that traumatic event and the harrowing days that followed remain a reality for Haitians. Included in the litany of those miseries is an ongoing cholera epidemic that started just ten months after the earthquake. The epidemic has now killed nearly 7,000 people, infected 520,000 others and continues to cause 200 infections per day. What is more, multiple scientific investigations have demonstrated that U.N. peacekeepers with MINUSTAH, the peacekeeping mission in Haiti, likely exposed Haitians to the water-born illness inadvertently via negligent maintenance of sewerage facilities at a Nepalese camp. Based on that evidence, a Haitian non-governmental organization, the Bureau des Avocats Internationaux (BAI), and its U.S. partner, the Institute for Justice and Democracy in Haiti (IJDH), filed on November 3, 2011, a petition with the Claims Unit of the Office of the United Nations Secretary-General in Haiti on behalf of 5,000 victims of cholera and their families.[1] Yet the U.N. has refused to accept responsibility for transporting the disease to Haiti or provide compensation to victims of the epidemic. 

This series has primarily considered the problem of U.N. accountability for the international spread of disease. Part I of this series explored the mounting evidence against the U.N. that suggests the international body negligently, if unintentionally, transported cholera to Haiti through infected Nepalese peacekeeping personnel. Part II of this series took a close look at the immunity provisions that could pose a major challenge to Haiti’s cholera victims from obtaining effective judicial relief from the U.N.

Aside from accountability concerns, however, the U.N.’s standards for preventing and timely responding to the international spread of disease that ostensibly led to Haiti’s first outbreak of cholera in a century – and, importantly, from a South Asian strain of the disease previously unknown to Haiti – remain unimproved. More specifically, U.N. peacekeeping operations (UNPKO) pre-deployment protocol creates the potential for further inadvertent transmissions of disease across borders while the dubious leadership roles of U.N. peacekeeping missions allow the U.N., as a non-state actor, to skirt critical surveillance and response obligations that the World Health Organization (WHO) has imposed on states for the effective response to incidents of international spread of disease.

 On the prevention side, UNPKO deployments constantly create new potentially disastrous routes for pathogens to travel by regularly recruiting personnel from resource-poor and biogenetically diverse contexts to staff its missions. In Haiti, peacekeepers arrive to serve in MINUSTAH from Guatemala, Sri Lanka, Bangladesh, Burkina Faso, Burundi, Rwanda, Sierra Leone and Yemen,[2] which constitute only a portion of the fifty-seven countries that comprise the evolving international security force. Around the world, the U.N. continues to deploy over one hundred thousand personnel, often from countries experiencing their own political conflicts and public health challenges, to man its sixteen peacekeeping missions around the world.

Dr. Louise Ivers of Partners In Health recently warned in the American Journal of Tropical Medicine and Hygiene, “The risks of globalization must not be seen just as the south to north “spread of disease” or “reintroduction of disease” but also of the inverse—the introduction of deadly pathogens through routes previously not traveled.”[3] The deployment of uniformed personnel from one impoverished, institutionally-weakened or conflict-beleaguered country to another for purposes of carrying out peacekeeping operations should be seen as creating an entire network of previously untraveled “south-south” routes for infectious diseases.  

When taken that globalized diplomacy creates the potential for fast-tracking pathogens between vulnerable populations, the U.N.’s pre-deployment protocol appears entirely inadequate to prevent the inadvertent spread of disease. In particular, UNPKO regularly deploys new peacekeepers to missions like MINUSTAH as often as every six months but does not require that uniformed personnel undergo laboratory testing for infectious diseases, including cholera, unless the personnel present active symptoms. Such standards do not account for important circumstantial indicators, such as the fact that cholera was known to be endemic to Nepal and that approximately 75 percent of Nepalese cholera carriers do not show active symptoms. The pre-deployment screening standards also did not take caution of the fact that shortly before the outbreak of cholera in Haiti, a surge in cholera infections was reported in the Kathmandu valley where Nepalese peacekeepers train for three months before departing to Haiti.

Therefore, if the U.N. is going to continue relying on individuals from poor countries to staff its peacekeeping missions, the international body must account for epidemiological and circumstantial realities in its pre-deployment screening procedures to prevent the transporting of known contagions from those countries.   

Regarding the need for improved response standards, the U.N.’s initial uncooperative reactions to reports that an outbreak of cholera may have spread from its base in Meille ran contrary to the purpose of clearly defined detection, assessment, and communication standards to which countries are currently expected to adhere for proper surveillance of and response to the international spread of disease. In particular, WHO has developed over a period of half a century a series of regulations to manage the control of the international spread of disease. Currently, the International Health Regulations (2005) provides a global regime to “prevent, protect against, control and provide a public health response to the international spread of disease” based on consideration of growths in international travel and trade, as well as “the emergence or re-emergence of international disease threats.”[4] Importantly, Article 5 of IHR (2005) requires that countries develop and maintain the capacity to “detect, assess, notify and report events” of international concern while Article 4 also requires states to establish a National IHR Focal Point (NFP) to communicate with WHO contact points in cases of suspected threats to international health.

The Government of Haiti’s (GOH) original response to a potential cholera outbreak essentially adhered to the objectives and purpose of IHR (2005). According to the investigative report of Renaud Piarroux, who examined the situation at the requests of the Haitian and French governments, Haiti’s Ministère de la Santé Publique et de la Population (MSPP) had sent a Haitian investigation team to the Mirebalais region (near Meille) “immediately” after Cuban medical teams working in the region reported cases of acute watery diarrhea on October 18, 2010.[5] MSPP also alerted the U.N.’s regional health body, the Pan-American Health Organization (PAHO), in Port-au-Prince, of the outbreak of acute diarrhea within 24 hours of dispatching the investigation team. Both responses accorded with Haiti’s IHR (2005) Article 6 duties to notify proper international authorities of a potential outbreak. At that point, Haiti’s MSPP began consistently reporting information to WHO/PAHO’s comprehensive event management system in conformity with its Article 7 information sharing duties. On October 22, 2010, Haiti’s National Public Health Laboratory verified the presence of V. cholerae and shared its findings with WHO/PAHO pursuant to Article 10 verification duties. Within days of sharing those results, the Government of Haiti publically outlined its priorities for a multi-sector humanitarian response in a National Epidemic Response Strategy.[6]

Considering that Haiti was still reeling from the January 12, 2010 earthquake, which had killed scores of Haiti’s talented medical professionals and physically destroyed 50 percent of MSPP institutional resources just ten months earlier, the GOH mounted a highly admirable response to the cholera outbreak. In contrast, the U.N.’s refusal to draw on available resources that could have helped determine and communicate the source of the outbreak directly undermined Haiti’s interest in leading an informed response effort, and consequently, frustrated the purpose of IHR (2005) surveillance and response provisions. Despite the October 22, 2010, confirmation of the presence of V. cholerae, as well as popular press accounts on October 27, 2010, of the poorly maintained sewerage facilities at the MINUSTAH base in Meille, the U.N. categorically refused to examine its facilities as a potential source of the outbreak. When cholera experts, including chairman of Harvard University’s microbiology department, John Mekalanos, on November 3, 2010, submitted that the genetic makeup of the cholera strain found in Haiti implied that it “very much likely [came]” with the Nepalese peacekeepers,[7] the U.N. still resisted testing its facilities in Meille for V. cholerae. By the end of November, the outbreak had become a full-blown epidemic, having already killed 1, 344 people and causing 57,000 new infections. Yet WHO continued at that time to insist that investigating the source of the outbreak was “not a priority,”[8] and even claimed that taking time to examine the source of the outbreak would be harmful to Haitians insofar as it “would distract from efforts to fight the disease.”[9] In fact, the U.N. did not carry out an independent investigation of the outbreak’s source until January 6, 2011.

It cannot be overlooked that shortly after the confirmed outbreak of cholera, the U.N. committed itself to working with Haiti’s Ministère de la Santé Publique et de la Population (MSPP), international partners and non-governmental organizations to significantly reduce cholera deaths and the transmission of new infections. More recently, PAHO, UNICEF and the U.S. Centers for Disease Control (CDC) commendably pledged to work together with the governments of Haiti and the Dominican Republic to eradicate cholera from their shared island of Hispaniola.[10]

However, the U.N.’s initial refusal to investigate the source of the cholera outbreak did run contrary to Haiti’s IHR (2005) surveillance duties insofar as restricting knowledge of the potential source of the outbreak threatened the effectiveness of MSPP’s response. As John Mekalanos asserted the week following the National Public Health Laboratory’s verification of cholera, “it is important to know exactly where and how the disease emerged because it is a novel, virulent strain previously unknown in the Western Hemisphere — and public health officials need to know how it spreads.”[11] Moreover, limiting information about the outbreak’s source also frustrated the purpose of IHR (2005) as global health regime intended to control the international spread of disease by leaving open the possibility of even further outbreaks of the particular strain of cholera in the Western Hemisphere. Ralph R. Frerichs, Professor Emeritus of Epidemiology at UCLA, upon analyzing the multiple epidemiological studies conducted on Haiti’s cholera outbreak, specifically noted the importance of investigating the source of the outbreak for preventing future incidents: “Public health officials must first deal with the raging epidemic, containing the spread and bringing it under control. But then the focus should again be on the origin, to find out why the outbreak or epidemic look place, thereby gaining insights to prevent future occurrences.”[12] Considering the vast global human and institutional resources available to the U.N., the international body could have ably worked with public health officials to contain the disease while also making the investigation of the outbreak’s source a high priority.

Perhaps part of the challenge of obtaining full cooperation for adequate disease prevention and response on the part international peacekeeping missions lies in the dubious governance role that the mission takes on, which allows the missions to assert quasi-political functions of countries in social distress without assuming liability for performing the obligations called for in international agreements. If the missions are presumably present because of the weakened capacity of the domestic government, it is not logical to expect the state to possess the authority to require the international body to conform to a unified incident response. In the case of disease prevention and response instruments like IHR (2005), the peacekeeping mission may operate independently of the responding government, enabling the international entity to place its own concerns before those of the greater population it aims to serve without any consequence to the mission. This becomes particularly problematic when an effective response may require international organizations to investigate activities within its domain, and in the case of Haiti, even require an entity to investigate its own negligence.

Haiti’s cholera epidemic has demonstrated that the global politics behind peacekeeping missions has created unprecedented opportunities for the international spread of infectious diseases between vulnerable populations. Consequently, UNPKO should improve its pre-deployment screening procedures to account for known pathogens in countries contributing uniformed personnel, especially if UNPKO continues to draw its personnel from resource-poor and biogenetically diverse country contexts. Furthermore, as countries work to unify standards for the prevention of and response to the international spread of disease, international organizations should undertake to cooperate with the disease surveillance and response requirements that IHR (2005) currently imposes on WHO member countries, or at the very least, commit to not undermining the provisions of such global health regimes. Specifically, the U.N. should require its agencies to adhere to IHR (2005) standards for the timely detection, assessment and reporting of any and all events that may contribute to knowledge of a suspected outbreak of disease, as extending such investigation and disclosure requirements to U.N. agencies would better ensure the coordination of an early and informed response to outbreaks of novel, virulent strains of diseases in UNPKO host-countries. After all, such a response should be made with the full cooperation of – and not in spite of – U.N. agencies.


[1] Pet. for Relief, filed with Chief, Claims Unit, Office of the United Nations Secretary-General, Nov. 3, 2011. Available at, http://ijdh.org/archives/22916.

[2] See, MINUSTAH Facts and Figures, available at, http://www.un.org/en/peacekeeping/missions/minustah/facts.shtml. (Last accessed Jan. 18, 2012).

[3] Louise C. Ivers, et al., The “First” Case of Cholera in Haiti: Lessons for Global Health, 86(1) Am. J. Trop. Med. Hyg. 36, 38. Available at, http://www.ncbi.nlm.nih.gov/pubmed/22232448.

[4] World Health Organization, International Health Regulations (2005), 2nd ed., available at, http://www.who.int/ihr/en/.

[5] Renaud Piarroux, et al., Understanding the Cholera Epidemic, Haiti, 17:7 Emerging Infectious Diseases J.1161, available at, http://wwwnc.cdc.gov/eid/article/17/7/11-0059_article.htm#suggestedcitation.

[6] Cholera Inter-Sector Response Strategy for Haiti Nov. 2010 – Dec. 2011 (National Epidemic Response Strategy), Ministère de la Santé Publique et de la Population and Direction Nationale de l’Eau Potable et de l’Assainissement, available at, http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0CDQQFjAC&url=http%3A%2F%2Fbusiness.un.org%2Fen%2Fassets%2F67b50158-4751-4b72-9638-85eb8cdf1289.pdf&ei=X7QYT5bzHJCd0gH3h6mWCw&usg=AFQjCNGPnhh9Rb2IIOghogeLZtaYjUiFLA.

[7] Jonathan Katz, Experts Ask: Did U.N. Troops Infect Haiti?, Associated Press, Nov. 3, 2010, available at, http://www.msnbc.msn.com/id/39996103/ns/health-infectious_diseases/t/experts-ask-did-un-troops-infect-haiti/#.TxiIq0pOXgo.

[8] Jonathan Katz, Cholera Confirmed for Resident of Haiti’s Capital, Associated Press, Nov. 9, 2010, available at, http://www.physorg.com/news/2010-11-cholera-resident-haiti-capital.html.

[9] Katz, supra note 7.

[10] See, David Morgan, International Groups Launch Haiti Cholera Alliance, Reuters, Jan. 12, 2010, available at, http://in.reuters.com/article/2012/01/11/haiti-cholera-usa-idINDEE80A0IF20120111.

[11] Katz, supra note 7.

[12] Ralph R. Frerichs, Origin of Cholera in Haiti – Epilogue, UCLA School of Pub. Health, Jul. 20, 2011, available at, http://www.ph.ucla.edu/epi/snow/origin_cholera_haiti_epilogue.html.

Posted in Global Health, uncategorized ; Tagged: , , .

Comments are closed.

Stay Informed

Signup for our mailing list and stay up to date on the latest happenings at The O’Neill Institute

Or sign up for our RSS Feed

The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

See the full disclaimer and terms of use.