Decades of neglect of water and sanitation infrastructure have left the Haitian population vulnerable to outbreaks of waterborne illness. Despite the vulnerability of the population, United Nations (UN) forces (troops of the United Nations Stabilization Mission in Haiti, or MINUSTAH) have failed to take adequate precautions with their sewage, allowing human waste infected with cholera to contaminate the Haitian water supply. Since the cholera outbreak began in Haiti in October 2010, there have been at least 9,229 deaths and 789,242 Haitians infected. Given the role played by UN troops in the Haitian cholera epidemic, APHA urges the UN secretary-general and Department of Peacekeeping Operations to take leadership in guaranteeing that the National Plan for the Elimination of Cholera in Haiti is properly funded. The United Nations’ own special rapporteur released a report in August 2016 urging the secretary-general to take responsibility for the introduction of cholera in Haiti and advising the UN to make financial restitution for this mistake. Following this report, the secretary-general’s spokesperson acknowledged MINUSTAH’s role in causing the cholera epidemic; however, there has been no commitment on the part of the UN to take financial responsibility for the crisis. Without a long-term plan for building a national water and sanitation system, Haiti will remain vulnerable to cholera outbreaks during the rainy season and whenever a natural disaster occurs. Hurricane Matthew, which struck Haiti on October 4, 2016, has already led to a surge in cases, including more than 1,400 new infections in the 2 weeks immediately after the hurricane.
Relationship to Existing APHA Policy Statements
The following APHA policy statements are relevant to the current statement:
- APHA Policy Statement 20026: Access to Safe Water, Sanitation, and Hygiene Promotion in Developing Countries
- APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries
- APHA Policy Statement 200322: Supporting Increased U.S. Investments in Bilateral and Multilateral Programs to Address the Epidemics of HIV/AIDS, Tuberculosis and Malaria
- APHA Policy Statement 201113: Call to Action to Reduce Global Maternal, Neonatal, and Child Morbidity and Mortality
- APHA Policy Statement 200030: Preventing Genocide
Prior to October 2010, there had not been a case of cholera in Haiti in more than 100 years. The undisputed evidence shows that cholera was brought to Haiti by United Nations (UN) peacekeeping forces from Nepal. Between October 2010, when the cholera outbreak began in Haiti, and August 2016, there were at least 9,229 deaths and 789,242 Haitians infected (more than one in 16 citizens).
UN peacekeepers were found to have violated guidelines for proper waste disposal at the MINUSTAH (United Nations Stabilization Mission in Haiti) Mirebalais camp, allowing infected sewage to flow into the Meye River.[3,4] Furthermore, the UN secretary-general and UN Office of Legal Affairs failed to react promptly to rectify the situation and not only delayed investigating the cause of the outbreak but initially attempted to cover up its source, the open septic pit.[2–4]
The Haitian population was and continues to be vulnerable to outbreaks of diarrheal illness due to poor water and sanitation infrastructure. According to the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Joint Monitoring Program for Water Supply and Sanitation, only 64% of Haitians have access to improved water sources, and only 26% have access to improved sanitation. In 2003, the country’s national census showed that 32% of Haitians relied on river water as their primary source of water. Knowledge of the vulnerability of the population should have prompted greater vigilance in preventing contamination. As noted in a civil lawsuit filed by the Institute for Justice and Democracy in Haiti, “humanitarian workers and medical experts also publicly stressed Haiti’s heightened vulnerability to waterborne diseases, including cholera.” These warnings were published in more than 100 articles across a wide array of international media outlets. Despite its knowledge of the vulnerability of the Haitian population, the UN did not investigate the concerns of residents and the mayor of Mirebalais concerning unsanitary conditions at the MINUSTAH base, did not ensure that sewage pipes were intact and in good repair, and did not ensure that sewage disposal sites were fenced off and not allowed to overflow into the river during heavy rains.
Since the introduction of cholera to Haiti in 2010, the number of reported cases and deaths has been decreasing annually. However, without any improvements in Haiti’s water and sanitation infrastructure, the country is vulnerable to large surges in infections in the event of a natural disaster. This is in fact what occurred with the recent tragedy of Hurricane Matthew, which struck Haiti on October 4, 2016. Initial reports indicated that at least 540 people were killed by the hurricane. Cholera has a very short incubation period, and thus there has been a rapid surge in cases in Haiti since the disaster. Cholera is transmitted by drinking contaminated water, and the torrential rains from the hurricane quickly spread the disease. Because of the lack of access to clean drinking water following the hurricane, the initial reports of more than 1,400 new cholera cases in the 2 weeks subsequent to the disaster are sure to increase. To make matters worse, 34 cholera treatment centers were destroyed, and thus the death rate will likely be much higher than it was prior to the hurricane.
Need for resources for an effective response: While the Haitian Ministry of Public Health and Population (MPHP), the Haitian National Agency of Water and Sanitation, UNICEF, the Pan American Health Organization (PAHO), and a number of nongovernmental organizations (NGOs) are working on short-term management of the cholera epidemic (e.g., vaccinations and temporary clean water stations), a long-term plan is needed to keep cholera from becoming endemic in Haiti. In view of this need, the MPHP has devised the National Plan to Eliminate Cholera in Haiti (hereafter National Plan). The National Plan was developed in consultation with experts from the Centers for Disease Control and Prevention and two UN organizational units, UNICEF and PAHO. The $2.2 billion, 10-year plan focuses on long-term elimination of the disease through large-scale development of the public health and sanitation infrastructure. Given that Haiti is the poorest country in the Western Hemisphere, the MPHP will be unable to fund such an initiative without support from international governmental agencies and NGOs.
Legal and moral responsibility: A report released by the law and public health schools at Yale University, “Peacekeeping without Accountability: The United Nations’ Responsibility for the Haitian Cholera Epidemic,” enumerated in detail the UN role in this situation and argued for its moral, legal, and financial responsibility for the crisis. As articulated by legal scholars from Yale, “in light of the U.N.’s critical role in developing and promoting human rights globally, the U.N. must demonstrate the same commitment to comply with international human rights law that it demands from states and other non-state actors, or risk losing its moral authority to make these demands at all.”
By introducing raw human sewage into a major waterway and failing to provide any recourse for victims, MINUSTAH failed to respect the international human rights for water, health, and remedy. According to the International Court of Justice, the UN does indeed have duties under international law, as long as they do not interfere with the organization’s mandate to promote human rights. It cannot be argued that safely disposing of human waste on a UN military base interferes with this mandate.
Beyond the UN’s legal responsibilities are its moral responsibilities. Although UN agencies, including MINUSTAH, deny legal responsibility for the outbreak due to their immunity agreement with the Haitian government, many of the Haitian people feel that the UN is responsible. In fact, Haitians’ anger toward UN peacekeepers has led to calls for MINUSTAH to exit the country, which will stand in the way of the UN secretary-general’s stated intention of assisting in the country’s 10-year plan to control cholera infections.[4,10,13] It is not only the Haitian people who hold MINUSTAH responsible: a recent report, “International Covenant on Civil and Political Rights Violations in the Context of the Cholera Epidemic in Haiti,” compiled statements from several individuals within and affiliated with the UN who have criticized the organization’s response to the epidemic. In July 2014, UN Secretary-General Ban Ki-moon said that he believed “the international community, including the United Nations, has a moral responsibility to help the Haitian people stem the further spread of this cholera epidemic.”
In August 2016 Philip Alston, the UN special rapporteur on extreme poverty and human rights, published a 19-page report reviewing the scientific evidence on UN responsibility for the cholera crisis and arguments for why the organization must take moral and financial responsibility. He provided a moral and legal rationale as well as pragmatic arguments based on the self-interest of the UN as an institution. He argued that the UN’s handling of the cholera crisis “undermines both the UN’s overall credibility and the integrity of the Office of the Secretary-General.” He also warned that “unless action is taken, the message is that a double standard applies according to which the United Nations can insist that Member States respect human rights, while rejecting any such responsibility for itself even in a particularly egregious situation.”
After the submission of Alston’s report, Farhan Haq, deputy spokesman for the secretary-general, acknowledged in an e-mail to the New York Times that “over the past year, the UN has become convinced that it needs to do much more regarding its own involvement in the initial outbreak and the suffering of those affected by cholera.” Haq told reporters at the New York Times that a new response would be publicly presented in the next 2 months. As of yet, however, no such response has been presented to the public.
Evidence-Based Strategies to Address the Problem
In February 2013, the MPHP proposed a plan for the eradication of cholera. As noted above, the estimated budget for the 10-year plan is $2.2 billion. Given MINUSTAH’s role in introducing cholera in Haiti, the UN secretary-general and the UN Department of Peacekeeping Operations should assume responsibility for funding and/or coordinating the funding of the National Plan in its entirety.
In recent months, several international human rights and development experts have made similar recommendations as to how the UN should respond. In his August 2016 report to the UN secretary-general, Special Rapporteur Alston recommended that the secretary-general issue an apology, accept responsibility for the cholera crisis in Haiti, and provide compensation to cholera victims and their families.
After the submission of Alston’s report and the UN secretary-general’s response in the New York Times, the internationally recognized NGO Partners in Health made a renewed call for the UN to take responsibility for its role in the cholera crisis. In a letter to Samantha Power, the US permanent representative to the United Nations, Partners in Health wrote that “we respectfully request the United States Mission to the UN to press that body to take responsibility for the cholera epidemic by funding a comprehensive plan to eliminate this devastating scourge.” Partners in Health is continuing to gather support through a petition currently available on the organization’s Web site.
The Independent Panel of Experts on the Cholera Outbreak in Haiti offered an opposing argument to UN accountability in its final report, contending that “the source of cholera in Haiti is no longer relevant to controlling the outbreak.” It is true that UN acceptance of responsibility for its actions will not reverse the suffering and death experienced by the Haitian people since October 2010. However, efforts to rid the island of Hispaniola of cholera come at a price. The MPHP’s National Plan is projected to cost $2.2 billion, and as Philip Alston argued in his report, cholera and its response have “diverted scarce resources in an already impoverished country.” If the UN does not ensure that the National Plan is funded, the plan will not come to fruition, and cholera will remain endemic in Haiti.
In his report, Alston refuted a number of common arguments in opposition to UN accountability. In response to the assertion that the UN cannot be held accountable owing to its legal immunity, Alston maintained that the 1946 convention that grants immunity to the UN does not preclude the organization from providing remedy to victims of wrongdoing. In fact, he noted that “the provision of remedies for wrongdoing is an essential dimension of the law relating to immunity.” He further argued that by refusing to provide remedy to victims, the UN is exposing itself to a growing number of demands that it be stripped of legal immunity. Therefore, it is in the secretary-general’s best interests to respond to victims’ demands in a just and transparent manner.
- Urges the UN secretary-general to prioritize, in coordination with WHO and the World Bank, fundraising to assist the Haitian government in implementing the National Plan , ensuring that the plan is funded in its entirety.
- Urges other UN agencies such as PAHO, UNICEF, and the General Assembly, as well as international NGOs, to support the UN secretary-general in funding the National Plan.
- Urges the United States Mission to the UN to petition that body to fund the National Plan.
- Recommends to the Haitian government and development partners carrying out the National Plan that Haitian workers be hired and paid fairly to construct water and sanitation infrastructure.
- Urges the UN secretary-general, in coordination with WHO, the World Bank, and other partners, to assist the Haitian government in ensuring that a variety of stakeholders oversee the implementation of the National Plan, including Haitian civil society organizations and international NGOs trusted by the Haitian people.
- Urges the UN secretary-general, the Department of Peacekeeping Organizations, and the Office for the Coordination of Humanitarian Affairs to implement prevention strategies during future deployments (e.g., water and wastewater treatment); to ensure timely, fair, and transparent processes to assess accountability; and to consider provision of remedies for harms caused to people and environments in the course of peacekeeping missions in the future.
1. Hendriksen RS, Price LB, Schupp JM, et al. Population genetics of Vibrio cholerae from Nepal in 2010: evidence on the origin of the Haitian outbreak. mBio. 2011;2:e00157–e001511.
2. United Nations. Cholera response fact sheet. Available at: http://www.un.org/News/dh/infocus/haiti/CholeraFactsheetAugust2016.pdf. Accessed November 30, 2016.
3. Institute for Justice and Democracy in Haiti. Cholera litigation. Available at: http://ijdh.org/cholera-accountability/cholera-litigation. Accessed November 30, 2016.
4. Cravioto A. Final report of the Independent Panel of Experts on the Cholera Outbreak in Haiti. Available at: http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf. Accessed November 30, 2016.
5. Robbins A. Lessons from cholera in Haiti. J Public Health Policy. 2014;35:135–136.
6. WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation. Estimates on the use of water sources and sanitation facilities. Available at: http://www.wssinfo.org/documents/?tx_displaycontroller%5Btype%5D=country_files. Accessed November 30, 2016.
7. Institute for Justice and Democracy in Haiti. Class action complaint. Available at: http://www.ijdh.org/wp-content/uploads/2013/10/Cholera-Complaint.pdf. Accessed November 30, 2016.
8. Pan American Health Organization/World Health Organization. Hurricane Matthew situation report 19. Available at: http://reliefweb.int/report/haiti/hurricane-matthew-situation-report-no-19-date-18-october-2016-1800-est. Accessed November 30, 2016.
9. Inter Press Service. Without funding, Haiti faces endemic cholera. Available at: http://www.ipsnews.net/2013/07/without-funding-haiti-faces-endemic-cholera. Accessed November 30, 2016.
10. Republic of Haiti, National Directorate for Water Supply and Sanitation, Ministry of Public Health and Population. National Plan for the Elimination of Cholera in Haiti 2013–2022. Available at: http://www.lessonsfromhaiti.org/download/Report_Center/nat-plan-cholera-en.pdf. Accessed November 30, 2016.
11. Global Health Justice Partnership of the Yale Law School. Peacekeeping without accountability: the United Nations’ responsibility for the Haitian cholera epidemic. Available at: http://www.law.yale.edu/documents/pdf/Clinics/Haiti_TDC_Final_Report.pdf. Accessed November 30, 2016.
12. Schuller M. Haitian people want UN troops to leave. Available at: http://www.counterpunch.org/2012/02/13/haitian-people-want-un-troops-to-leave/. Accessed November 30, 2016.
13. UN Department of Humanitarian Affairs. Haiti moving forward step by step. Available at: http://www.un.org/en/peacekeeping/missions/minustah/documents/UN-factsheets-2012-en.pdf. Accessed November 30, 2016.
14. UN Human Rights Committee. International Covenant on Civil and Political Rights violations in the context of the cholera epidemic in Haiti. Available at: http://tbinternet.ohchr.org/Treaties/CCPR/Shared%20Documents/HTI/INT_CCPR_CSS_HTI_18250_E.pdf. Accessed November 30, 2016.
15. New York Times Magazine. Philip Alston’s draft report on the UN and the Haiti cholera outbreak. Available at: http://www.nytimes.com/interactive/2016/08/19/magazine/document-Alston-Haiti-Cholera-Report.html?_r=0. Accessed November 30, 2016.
16. Katz JM. UN admits role in cholera epidemic in Haiti. Available at: http://www.nytimes.com/2016/08/18/world/americas/united-nations-haiti-cholera.html?_r=0. Accessed November 30, 2016.
17. Partners in Health. United States should press UN to fund cholera campaign in Haiti. Available at: http://www.pih.org/press/united-states-should-press-u.n.-to-fund-cholera-campaign-in-haiti. Accessed November 30, 2016.
18. Partners in Health. Tell the UN: fight cholera in Haiti. Available at: http://act.pih.org/page/s/tell-the-un-now. Accessed November 30, 2016.