On Jan. 10, 2010, a 7.0 magnitude earthquake struck the heart of Haiti, displacing millions of people, destroying much of the country’s infrastructure and ultimately creating nearly inhabitable conditions — a common recipe for a disease outbreak to take hold. It was not unexpected when Haiti then experienced the worst cholera outbreak in modern history.
Through the combined efforts of Haiti’s Ministry of Health, Weill Cornell and GHESKIO, a Cornell-affiliated, world-class Haitian clinical treatment and research facility, the country recently celebrated its 3rd year anniversary of the last documented case of cholera on Feb. 4, 2022.
The World Health Organization utilizes a three year benchmark to declare that a country has eliminated cholera. The proclamation has become a monumental milestone, not just for Haiti, but for global epidemic mitigation procedures as well.
Weill Cornell and GHESKIO have been affiliated with one another since 1979. Weill graduate Dr. Jean Pape serves as co-founder of GHESKIO and has since become a Weill Cornell professor.
“The mission is to provide clinical care to the most vulnerable, conduct clinical research and share the knowledge through training at the national model,” said Dr. Vanessa Rouzier, a Weill Cornell trained pediatrician and faculty member with a specialty in infectious disease.
Cholera is caused by the water-borne pathogen Vibrio cholerae and is characterized as a disease born from poverty. Poor sanitation and limited waste-management strategies allow for fecal-contaminated water sources that contain the bacteria to spread disease.
Vibrio cholerae, which contains the cholera toxin, acts by altering the ionic balance in the gut, leading to fluid build up in the intestines and causing the massive diarrhea that is popularly associated with the disease. Dehydration is the normally lethal consequence of catching cholera.
Between 2010 and 2014, there were 699,579 cases and 8539 deaths due to the cholera outbreak in Haiti. The earthquake destroyed 80 percent of downtown buildings in the capital Port-au-Prince, displacing 1.5 million people. Just 2 hours north of Port-au-Prince, one of the largest rivers in Haiti became contaminated with cholera and it quickly spread.
Rouzier, born and raised in Haiti, returned to work there in 2009 after the earthquake-induced cholera epidemic. Seeing the action first hand, she described the aftermath as “chaos.”
“[A]s we’ve seen with COVID, there’s a lot of fear associated with the new introduction of a disease panic,” Rouzier said.
Haiti, with its limited healthcare infrastructure, became quickly overwhelmed. Rouzier explained that improving sanitation and access to clean water is the first step to eradicating cholera.
However, such plans at the time were unaffordable for a country like Haiti. The transition to a proper sewage system, access to potable water and an economy where people can buy disinfecting materials would have cost an estimated $2 trillion. This is the long term goal, but midterm strategies were necessary as well.
Rouzier and her team started to implement these strategies, starting with a single slum. Working with leaders in the community, they improved water sanitation by developing a chlorine factory, established a public trash system to reduce litter and worked with schools to build a biodigester — a mechanism to decontaminate feces. The effort as a whole demonstrated the capacity to enact change at the local level.
“We don’t have to wait for the multimillion investments in the country,” Rouzier explained. “[it showed] we can do things locally”.
The last strategy was introducing a vaccine. Back in 2010, there were only two cholera vaccines approved by the WHO. Both were limited in supply and only distributed to people traveling to areas with cholera outbreaks.
After battling the WHO, CDC and partners, Rouzier and her team convinced the Red Cross to buy 100,000 doses of one of the cholera vaccines for a trial run. The first of the pilot programs officially vaccinated 50,000 people with the oral cholera vaccine in 2012. A Haitian organization called Partners in Health vaccinated an additional 50,000 in the area where the outbreak started.
“People at the time were saying, ‘Oh, this is impossible. You’re in a post earthquake situation, the country is in disarray. It’s not feasible, you’re not going to get people to come back for the second dose!’ We heard the same arguments with COVID,” Rouzier said. “It’s funny how history repeats itself. But from April to June 2012, nearly two years after the outbreak, we vaccinated 100,000 people and we showed that it was feasible.”
The monumental success led WHO to begin advocating to include the OCV in cholera outbreak scenarios.
Though the health and sanitation of Haiti has still not improved greatly, the country has effectively eradicated the transmission of cholera in a population that remains very poor and has little access to water and basic sanitation.
“To me, this is a remarkable story because it really shows that you can be faced with [amazingly] overwhelming circumstances, take [it] one step at a time, don’t stop when they say no and [still] turn the tide around,” Rouzier said.