Action Against Hunger leads cholera prevention in areas hardest-hit by epidemic. Photo: Christophe Da Silva for Action Against Hunger
On Tuesday, January 12th, 2010 – almost a decade ago, a 7.0 magnitude earthquake had just destroyed much of Haiti. Over 3 million people were affected by the earthquake.
At that time, Trazillio Mazard a lab technician who worked for Action Against Hunger, remembers the feeling of fear, everywhere. He remembers visiting a health center when six people died of cholera in a single day. He recalls working with a colleague to disinfect homes. Two days later, the epidemic took that co-worker’s life, too.
Cholera appeared in Haiti for the first time just months after the devastating January 2010 earthquake. In the early days, there was so much unknown about the deadly, fast-acting illness.
“We were so vulnerable because we were so ignorant,” says Trazillio.
One of the primary ways the bacteria-borne illness spreads is through contaminated water, which is why the disease is often seen during humanitarian crises, when sanitation and health systems break down. The outbreak exacerbated existing weaknesses in Haiti’s health systems, and this lack of capacity and local expertise to combat a major epidemic led to widespread panic.
Cholera spreads rapidly, crippling access to safe drinking water, adequate sanitation, health services, and education. People associated the sickness with their living environments, and desperate to flee, they moved to different areas and carried the bacteria to other communities.
Between 2010 and 2018, there were more than 800,000 suspected cases and nearly 10,000 identified deaths from cholera in Haiti.
A hygiene education session is held by Action Against Hunger staff. Photo: Christophe Da Silva for Action Against Hunger
“Many people thought cholera was the result of witchcraft and that they could do nothing to protect themselves,” says Véline Sévère, Head of Action Against Hunger’s Water, Sanitation, and Hygiene (WASH) Department in Haiti. “Little by little, they came to understand that this is a ‘real disease’ and that they can protect themselves by adopting better hygiene practices.”
Thankfully, Haitian communities are now better prepared to prevent cases and to quickly deal with any new outbreaks. Their massive efforts to eliminate the disease, together with the dedication of local authorities, Action Against Hunger, and other partners are working: the last confirmed case of cholera in the country was detected in February 2019. If the country goes three years without a new infection, the epidemic will be considered officially eradicated by the World Health Organization (WHO).
“We do not have the same fear, because we are armed with knowledge,” says Trazillio, who is now the cholera project manager for Action Against Hunger. “I am convinced we can eradicate cholera with the knowledge and tools we have now. When it is all over, it will be a huge accomplishment – a dream becoming real.”
An Evolving Approach
Since the outbreak began in 2010, Action Against Hunger with assistance from the Canadian International Development Agency (CIDA), has led eradication efforts in the regions of North-West and Artibonite, where the outbreak hit hardest. At first, whenever a new case was reported, our teams focused on “mass distribution of supplies”: equipping as many people as possible with the tools needed to prevent the spread of cholera. We distributed hygiene kits with water treatment products, soap, and oral rehydration salts to all households in high-risk communities and held education sessions to encourage handwashing, improve sanitation, and teach people how to treat water at home.
“At the beginning, I was afraid. I was shocked, seeing children die in health centers – I felt like I couldn’t do enough to help them. People were so paralyzed by fear, they were afraid to touch each other. There were so many questions about how to face this. We quickly created training materials to sensitize people on how it was transmitted to quell the fear.”
– Véline Sévère, Head of Action Against Hunger’s WASH Department in Haiti
In 2014, together with Haiti’s Ministry of Public Health and Population (MSPP) and UNICEF, we set up a system of surveillance, investigation, and alert in the North-West and Artibonite. Our rapid response teams were tasked with responding to all suspected cases within 48 hours. We started taking a more targeted approach: we established sanitary cordons to investigate suspected cases, distribute hygiene kits, disinfect spaces and water points, and continue education efforts. We also installed decontamination stations to secure hazardous water sources.
Over the last decade, our teams learned from mistakes and adapted. In 2014, there was a suspected case in Bassin Bleu in the North-West region, but health officials in the surrounding areas were not alerted in time, leading to an outbreak. We realized that local officials were not immediately involved in the response and were not systematically sharing case information.
To address this issue, we developed a community relay network and trained several local agents in epidemiologic monitoring. Now, stronger local capacity and skills ensure that alerts are provided and answered within 48 hours, even in remote communities. UNICEF – one of our primary donors – saw improved effectiveness in the areas where we work and dedicated additional funding to support the community relay network.
An Action Against Hunger team member disinfects a home after a suspected case of cholera was reported. Photo: Christophe Da Silva for Action Against Hunger
Today, Action Against Hunger’s approach to addressing cholera and other water-borne diseases is known as the Sword and Shield Technique, which aims to both stop the potential spread of new outbreaks and to maintain prevention efforts in vulnerable communities.
The sooner we react to suspected cases, the more likely we are to stop the spread of the epidemic. That’s why our rapid response teams aim to respond to alert calls within 24 hours, 80% of time, and within 48 hours, 95% of the time. Additionally, now, after sanitary cordons are established around the home of a suspected cholera case and twenty of its neighbors, the rapid response teams transform into community engagement teams, who encourage the adoption of better hygiene practices.
One innovative aspect of our program includes a research project to locally source water treatment products. Right now, many of the products used to prevent water-borne diseases, such as chlorine tablets, are provided for free as part of international aid programs. To stimulate local markets and guarantee sustainability, our teams are assessing how viable the local market for water treatment products would be by interviewing community members to understand at what price they would be willing to buy these products, offer the products at a reasonable price, and promote sales.
An awareness session held at a local market. Photo: Christophe Da Silva for Action Against Hunger
“Now, it feels like we can see the light at the end,” says Véline. “We are no longer afraid, because we are prepared to face this head on and we can see the difference we are making in communities.”
However, even as progress against cholera has been made, international attention on Haiti and its epidemic has dwindled – and so has the funding needed to maintain prevention work and to address the underlying causes for the outbreak. Additionally, recent political unrest shut down roads and blocked access to communities, limiting the capacity of our rapid response teams to mobilize quickly when suspected cases are reported.
“We can eradicate this scourge in Haiti – but it is not inconceivable to say that the fight against cholera could stop now, as we are close to eradication, due to lack of funding,” says Cédric Piriou, Action Against Hunger’s Country Director in Haiti. “With all the progress we have made against this epidemic, it’s as important now as ever to maintain our work to improve sanitation and hygiene, to provide safe, affordable, and reliable access to clean water, and to prevent cholera from resurging.”