C2 - United Nations Accountability for its Role in the Haitian Cholera Epidemic (Rec. Aug. 2017)

Transcription

1 I. United Nations Accountability for its Role in the Haitian Cholera Epidemic II. Rachel Yantzi, MSN/MPH, RN (primary author) 137 Melrose Avenue North, Hamilton, Ontario, Canada L8L 6X rachel.yantzi@gmail.com APHA Member (# ), International Health and Public Health Nursing Sections Cheryl Conner, MD 1440 S. Wabash Ave, #213, Chicago, IL, connerck@gmail.com APHA Member (# ), Medical Care and International Health Sections III. Sponsors: none IV. Collaborating Units: none V. Endorsements: International Health Section Medical Care Section VI. Summary 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 forces (troops of the United Nations Stabilization Mission in Haiti, or MINUSTAH) 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 9,408 deaths and 801,000 Haitians infected (more than 1 in 16 citizens), as of November Given the role played by United Nations (UN) troops in the Haitian cholera epidemic, the APHA urges the UN Secretary-General and UN Member States to take leadership in guaranteeing that the New Approach to Cholera in Haiti is properly funded and implemented. Without a long-term plan for building a national water and sanitation system, Haiti will remain vulnerable to cholera outbreaks that infect and 1

2 kill Haitians annually during the rainy season and whenever a natural disaster occurs. Hurricane Matthew, which struck Haiti on October 4, 2016, caused a surge in cases more than 1400 new infections in the 2 weeks immediately after the Hurricane. VII. Relationship to existing APHA Policy This policy is an update to the Late-Breaker Policy LB of the same name. The following APHA policies are relevant to the current resolution: Policy : Access to Safe Water, Sanitation, and Hygiene in Developing Countries Policy 20089: Strengthening Health Systems in Developing Countries Policy : Supporting Increased U.S. Investments in Bilateral and Multilateral Programs to Address the Epidemics of HIV/AIDS, Tuberculosis and Malaria Policy : Call to Action To Reduce Global Maternal, Neonatal, and Child Morbidity and Mortality Policy : Preventing Genocide VIII. Rationale for consideration The APHA must be a leader in defending the health of vulnerable populations injured by large institutions. The cholera epidemic in Haiti is an example of a vulnerable population being injured by a large, multinational organization. Protecting health involves demanding accountability from institutions that cause catastrophic public health problems through negligence and mismanagement. The New UN Approach to Cholera presents a critical opportunity to address the cholera epidemic and its victims. Difficulties fundraising to date underline the importance of public health professionals elevating the importance of an effective plan and robust funding to resolve the crisis. IX. Problem Statement Prior to October 2010, there had not been a case of cholera in Haiti in at least 100 years. The undisputed evidence shows that cholera was brought to Haiti by United Nations peacekeeping forces from Nepal. 1 Since the cholera outbreak began in Haiti in October 2010, there have been at least 9,408 deaths and 801,000 Haitians infected (more than 1 in 16 citizens), as of November The origin of cholera in Haiti has been traced to improper waste disposal at the MINUSTAH Mirebalais camp, which allowed infected sewage to flow into the Meye river. 3-4 Cholera broke out shortly 2

3 after the arrival of a deployment of peacekeepers from Nepal, where cholera is endemic. The peacekeepers were not tested or treated for cholera, and an Independent Panel of Experts appointed by the UN to investigate the source found the camp used piping that was haphazard, with significant potential for cross-contamination and disposed of its untreated waste in unprotected open-air pits with significant risk for overflow. Genetic analysis of the strain in Haiti has found it to be a perfect match to the strain active in Nepal. Based on this and other evidence, the Independent Panel has concluded that MINUSTAH was the most likely source of cholera in Haiti. 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 tried to cover up the source of the outbreak as coming from their open septic pit. 2-4 The Haitian population was and continues to be particularly vulnerable to outbreaks of diarrheal illness due to poor water and sanitation infrastructure. 5 According to the World Health Organization (WHO)/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. 6 In 2003, the national census found that 32% of Haitians relied on river water as their primary source of water. 7 Knowledge of the vulnerability of the population should have prompted greater vigilance in preventing contamination. As cited in the 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 following the 2010 earthquake. 7 These warnings were published in over 100 articles across a wide array of international media outlets. 7 Despite its knowledge of the vulnerability of the Haitian population, the UN did not engage in any of the following measures to prevent contamination: investigation of the concerns of residents and the mayor of Mirebalais concerning unsanitary conditions of the MINUSTAH base, 3 ensuring that sewage pipes were intact and in good repair, 4 ensuring that sewage disposal sites were fenced off and not allowed to overflow into the river during heavy rains. 4 Cholera continues to present a public health emergency. In 2016, cholera cases increased by 32% and deaths increased by 56%. The UN estimates that another 30,000 people may contract cholera in Following the recent tragedy of Hurricane Matthew that struck Haiti on October 4, 2016, 1400 new cholera cases were documented in the two weeks since the hurricane 9. To make matters worse, 34 cholera treatment centers were destroyed in the hurricane. 9 Cholera is transmitted by drinking contaminated water and the torrential rains from the hurricane have spread cholera quickly. Cholera has a 3

4 very short incubation period and so there was a rapid surge in cases in Haiti since the hurricane. Although immediate interventions, including a vaccination campaign, seem to have been successful in containing the surge, without improvements in Haiti s water and sanitation infrastructure, the country will remain vulnerable to large surges in infections with any natural disaster. Legal & Moral Responsibility 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 of water, health and remedy. 12 A report released by the Law and Public Health schools at Yale University entitled: Peacekeeping Without Accountability: The United Nations Responsibility for the Haitian Cholera Epidemic, enumerates in detail the UN role in this situation and also argues for their moral, legal and financial responsibility for the crisis. 12 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. 12 The UN s legal responsibilities to provide remedies to civilians are also contained in UN agreements and treaties, are confirmed by the International Court of Justice. 12 Beyond the UN s legal responsibilities are its moral responsibilities. Haitians anger towards UN peacekeepers for the introduction of cholera and failure to take responsibility has led to calls for MINUSTAH to exit the country, 13 and undermined the UN s credibility in Haiti and internationally. 5,11,14 It is not only the Haitian people that call on MINUSTAH to be accountable: numerous actors within, and affiliated with, the UN have criticized the UN s response to the cholera epidemic. 15 These criticisms range from urging the UN to come clean on cholera, to paying reparations to the people of Haiti. 15 In August 2016, a 19-page report by Philip Alston (Special Rapporteur on Extreme Poverty and Human Rights) reviewing the scientific evidence for UN responsibility for the cholera crisis, and arguments for why the UN must take responsibility was published in the New York Times. Alston provided 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. 16 He also warned 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. 16 4

5 Following the submission of Alston s report, Farhan Haq, deputy spokesman for the secretarygeneral acknowledged in an 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. 17 Haq told reporters at the New York Times that a new response would be publicly presented in the next two months. 17 In a public session of the General Assembly in December 2016, the UN Secretary-General finally issued a public apology for the UN s role in cholera, and launched a New Approach to Cholera in Haiti (the New Approach ), including a commitment to cholera control and elimination efforts, as well as material assistance to those most affected by cholera. In December 2016, the UN General Assembly formally adopted a resolution that welcomes the New Approach, and called on all actors to support it 19. X. Evidence-based Strategies to Address the Problem The New Approach to Cholera in Haiti is divided into two complimentary Tracks. Track 1a focuses on cutting transmission of cholera and improving access to treatment using strategies such as rapid response teams, public health education campaigns, expanded cholera vaccination, and increased capacity to treat acute diarrhea. Track 1b focuses on the medium and long-term goal of improved water, sanitation and health care systems in the country. Finally, Track 2 focuses on providing material assistance to cholera victims 21. The UN estimates that the new approach will require $ million over the next two years. 22 If fully funded and implemented, this New Approach has the potential to effectively control cholera and provide much needed support to families devastated by the epidemic. It is also a significant step towards meeting the recommendations presented by Special Rapporteur Philip Alston in his report, and the demands from victims of 1) water, sanitation and health infrastructure to control and eliminate cholera; 2) compensation for victims; and 3) a public apology. 16 The New Approach supports the Haitian government s priorities and can provide critical capacity building support to local authorities in the areas of health care and water and sanitation. Track 1a of the New Approach is intended to support the implementation of the Haitian government s medium term plan to eliminate cholera in Haiti ( Medium Term Plan ). The Medium Term Plan, which was developed with the support of the Center for Disease Control, UNICEF, Pan American Health Organization and other members of the Regional Coalition to Eliminate Cholera in Hispaniola, complements and updates an earlier 10 year Government of Haiti plan to eliminate cholera from Haiti, which was released in February 2013 and costed at $2.2 billion over 10 years. The Medium Term Plan is costed at $181 million for and focuses on coordinated efforts by the Haitian Ministry of Public 5

6 Health and Population (MSPP), National Agency of Water and Sanitation (DINEPA) and international actors to control cholera through vaccinations, improved medical care, rapid response interventions in cholera affected households and water and sanitation infrastructure improvements in select high risk areas. 23 Track 1b of the New Approach will support the longer-term goals of building nationwide water and sanitation infrastructure systems. Nationwide water and sanitation would not only eradicate cholera, but also eliminate other waterborne diseases in Haiti and significantly contribute to the country s development. Track 2 is also critical to addressing the problem, as it would provide much needed material assistance for those most affected by cholera. Because cholera sickens and kills those who lack access to clean water, sanitation and healthcare, it disproportionately impacts the most vulnerable and marginalized. Such financial support would help cover burial costs as well as lost income from the death of breadwinners. The benefits of direct financial support are well documented as a key tool that has been used successfully in humanitarian and development contexts to reduce poverty, improve livelihoods, and support community development. It would also provide a critical measure of justice and recognize the injuries of those who have died and been sickened by cholera. 24 Given that Haiti is the poorest country in the Western Hemisphere, 5 the Haitian Government will be unable to implement the Medium Term plan and 10-year plan to eradicate cholera plan without support from international governmental and non-governmental agencies. This must include funding support for the agencies tasked with implementing the Haitian government s plans, notably the MSPP and DINEPA. Unfortunately, this evidence-based strategy will only be funded if UN Member States, UN agencies, or other funders, contribute to the budget. XI. Opposing Arguments/Evidence Some observers have noted concern that the UN has limited resources in its budget to fund the New Approach. Indeed, fundraising efforts as of February 2017 had only generated $2 million out of the $400 million needed for Yet in the broader context of UN budgets, the total amount sought is relatively modest for example, MINUSTAH has by comparison spent $4.4 billion since cholera broke out in 2010, 25 and the UN system mobilized $166 billion to fund the UN response to the Ebola outbreak in West Africa, which killed a comparative number of people to the deaths to date from cholera in Haiti alone. 26 6

7 On the other end of the spectrum, some cholera activists and advocates have argued that the New Approach does not go far enough, and in particular that $400 million is inadequate to cover robust cholera response and material assistance. In order to achieve the goal of cholera eradication in Haiti, UN funding for long-term water and sanitation infrastructure in Haiti must continue even after the goals of the Mid- Term Plan have been achieved. XII. Action Steps demand Therefore the APHA: 1. Urges the UN Secretary-General to prioritize raising funds to assist the Haitian government to implement the New Approach on Cholera in Haiti, ensuring that it is funded in its entirety; 2. Urges UN Member States, UN agencies such as PAHO and UNICEF, as well as international financial institutions and International NGO s, to provide funding for the New Approach; 3. Urges the United States Government to provide funds to support the New Approach; 4. Urges the UN Secretary-General to ensure that funding for the New Approach continues beyond the initial $400 million over the next two years in order to address long-term water and sanitation needs; 5. Recommends to the Haitian Government and development partners carrying out the New Approach on Cholera in Haiti, that Haitian workers be hired and paid fairly to construct water and sanitation infrastructure; 6. Recommends that resources the UN brings to Haiti be used to build the longer term capacity of the Government of Haiti, specifically the Haitian Ministry of Health (MSPP) and water and sanitation agency (DINEPA); 7. Urges the UN Secretary General in coordination with WHO, the World Bank and other partners to assist the Haitian Government to ensure that a variety of stakeholders are engaged to oversee the development and implementation of the New Approach, including Haitian civil society organizations and international NGO s trusted by cholera victims; 8. Urges the UN Secretary-General, the Department of Peacekeeping Organizations (DPKO) and the Office of Legal Affairs to ensure timely, fair and transparent processes to assess accountability and provide remedies for harms caused to the people and environments it comes in contact with in the course of peacekeeping missions in the future

8 XIII. References 1. Hendriksen RS, et al. Population genetics of Vibrio cholerae from Nepal in 2010: Evidence on the Origin of the Haitian Outbreak. mbio [serial online]. 2011;2(4):e doi: /mbio United Nations Office for the Coordination of Humanitarian Affairs. Haiti: Cholera figures (23 December 2016). 3. Institute for Justice and Democracy in Haiti. Cholera litigation. Available at: 4. Cravioto A, et al. Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti. May Available at: 5. Robbins, A. Lessons from cholera in Haiti, Journal of Public Health Policy (2014) 35, doi: /jphp ; published online 6 March World Health Organization/UNICEF Joint Monitoring Program for Water Supply and Sanitation. Estimates on the use of water sources and sanitation facilities. April, 2013 Available at: Accessed July 10, Institute for Justice and Democracy in Haiti. Class Action Complaint. October 9, Available at: 8. United Nations Office for the Coordination of Humanitarian Affairs 2017 Humanitarian Needs Overview. Available at 9. PAHO/WHO Hurricane Matthew Situation Report No.19. Date: October 18, Available at: Inter Press Service. Without funding, Haiti faces endemic cholera. July 26,2013. Available at: Accessed October 19, 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 , 8

9 February. Available at: Accessed July 17, Global Health Justice Partnership of the Yale Law School and the Yale School of Public Health. Peacekeeping without Accountability: The United Nations Responsibility for the Haitian Cholera Epidemic. Available at: Schuller M. Survey Reveals Popular Perceptions of MINUSTAH: Haitian People Want UN Troops to Leave. Counterpunch. February 13, Available at: UN Department of Humanitarian Affairs. Haiti Moving Forward Step by Step Available at: UN Human Rights committee (October 2014): International Covenant on Civil and Political Rights (ICCPR) s Violations in the Context of the Cholera Epidemic in Haiti. Available at: 250_E.pdf 16. Philip Alston s Draft Report on the U.N. and the Haiti Cholera Outbreak. August 19, Available at: Cholera-Report.html?_r=0 Accessed on October 18, Katz, JM. U.N. Admits Role in Cholera Epidemic in Haiti. August 17, Accessed October 18, United Nations General Assembly. 71 st Session/620. A new approach to cholera in Haiti: Report by the secretary-general. November 25, United Nations General Assembly. 71 st Session/161. The new United Nations approach to cholera in Haiti. January 13 th, United States Should Press U.N. to Fund Cholera Campaign in Haiti. Press release August 29, 2016 from Partners in Health. Available at: United Nations Multi-Partner Trust Fund Office. UN Haiti cholera response multi-partner trust fund: Fact sheet. Available at 9

10 United Nations. New UN system approach on cholera in Haiti Available at Republique D Haiti. Ministere de la Sante Publique et de la Population, Direction National de L Eau Potable et de l Assainissement. Plan National D Elimination Du Cholera. Development du Moyen Terme: Juillet 2016-Decembre Institute for Justice and Democracy in Haiti. Rationales for Individual Compensation for Haiti s Cholera Victims. 25. United Nations Advisory Committee on Administrative and Budgetary Questions. MINUSTAH United Nations Stabilization Mission in Haiti. Available at United Nations Multi-Partner Trust Fund Office Gateway. Ebola Response MPTF. Available at 10