Cholera Outbreak in Haiti after the 2010 Earthquake

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8th Feb 2020 Health Reference this

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Tambri Housen presentation on communicable disease control and the complex nature of humanitarian emergencies was quite interesting. The example on the outbreak of Cholera in Haiti truly reflects on some of the unintended negative consequence that can occur in a humanitarian response and the value of thinking through and preparing for such, as much as possible. Haiti faced one of the largest earthquake documented on January 12, 2010(1) and 10 months after, suffered an outbreak of Cholera, which resulted in over 725,000 infection and 8,000 deaths by the end of 2014 as noted by Tambri. This was an epidemic that spread to neighboring country Dominican Republic with over 21,000 cases and 363 deaths reported(1).

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Prior to this, Haiti had not faced an outbreak in over a century. Unfortunately, the strain of cholera introduced to the region was from South Asia, which further investigation determined the infection and breeding site was a river close to the peacekeeper’s camp(1). The circumstance surrounding the cause of this outbreak, Haiti’s inadequate water and sanitation infrastructure before and especially after the earthquake, as well as the living conditions in displaced person’s camps largely contributed to the rapid spread of Cholera. Although this outbreak was indeed unintended, it sparked many opinions on how this could have been prevented. For instance, screening workers before deployment to the crisis zone. This practice is usually emphasized when workers are returning to their home country especially if it is a high-income country but not as much when they are being deployed out. However, you can argue that for a disease like cholera the process of screening is quite unpleasant, as it involves collecting stool samples, results do not have a quick turn over time as rapid testing isn’t available, the likelihood of contracting it is much higher in conflict environment and the signs and symptoms of cholera can be dominant for months, so if one is infected they very well may be unaware of it.

This outbreak has also given insight on how to perform a rapid outbreak control in the midst of humanitarian crisis.  In this instance, the CDC and Haitian Ministry of Public Health and Population immediately focused on these priorities: Preventing further casualty by providing treatment, oral rehydration solution packets, clinical training and encouraging the sick to seek immediate care(2). They also tackled the spread of the disease by emphasizing safe water storage and use, handwashing and appropriate waste disposal(2). Finally, they identified risk factors, created prevention strategies, surveilled and monitored the spread of cholera in Haiti(2).  

Overall, this outbreak points to a far bigger issue in Haiti, an issue of poverty and a weak health system which was further heightened by the earthquake. This outbreak had great momentum because of the poor health infrastructure in Haiti. This is quite the case in much humanitarian response and as public health professionals, we face the conflict of treating an issue at hand like the cholera outbreak or addressing the underlining cause of the issue like poverty. But then doing something is better than doing nothing.

 

Why are more refugees hosted by low and middle income countries?

One cannot discuss humanitarian emergency without the topic of refugees, displaced persons and asylum seekers coming up. One of the main theme in this course was the issue on refugees and the fact that more low-income countries are hosting the influx of refugees produced from war and disasters. According to the UN Refugee Agency, “68.5 million individuals were forcibly displaced worldwide as a result of persecution, conflict, violence, or human rights violations”, of which 25.4 million were refugees(3). This translates to the current combined population of Australia, New Zealand and Canada or the entire population of the United Kingdom being less than the world’s number of displaced persons(4). Equally as shocking, the countries that are hosting these refugees are some of the least capable countries to do such, with 8 out of 10 top refugee host countries being in developing regions(3). Similarly, the major source countries of refugees are from developed regions with Syria, Afghanistan, South Sudan and Myanmar taking the lead respectively in 2017(3).

More refugees have originated from Syria than any other country, accounting for 6.3 million people(3), and 9.2% of the total global population of refugees. A majority of these refugees end up in Turkey, which is hosting 3.4 million refugees as of 2017 and counting, Lebanon, Jordan, Iraq and Germany(3). While, Syrian refugees were granted asylum in more than 120 countries, yet those listed above host a large proportion of Syrian refugees(3). Likewise, the conflict in South Sudan surged the number of refugees in 2017, resulting in sub-Saharan Africa receiving the largest increase in refugee numbers than any other UNHCR regions(3). The refugee population in Africa increased to 6.3 million by the end of 2017 with about 1 million South Sudanese refugees fleeing to Sudan and Uganda(3).

So, why are the least capable countries hosting the more refugees? What impact does this have on host countries? and what can be done to assist? These are the questions that have come up in global discussions and as I reflect on this matter. One of the main reason for the massive dwelling of refugees in developing nations is because the highest producing countries of refugees are also in developing regions. Therefore, when individuals flee their countries during conflicts they end up in boarding countries which have been the case for Syria and Lebanon or South Sudan and Uganda. However, if geography is such a huge factor, why has there been a visible absence of refugees in the United Arab Emirates (U.A.E), Saudi Arabia, Qatar, Kuwait and several more(5). These are countries that classify as upper-middle to high income, they have more capacity to host refugees and are geographically close to some of the crisis countries like Syria, Iraq and Afghanistan. These countries are similar in culture, religion and language and would make sense for displaced individuals from Syria, Iraq and Afghanistan to settle and re-establish there, as the transition would be less challenging. Yet we see countries like Turkey and Germany of similar capacity accepting a noteworthy number of refugees.

More than 140 member states are a part of the international treaty on refugees, giving refugees the freedom to enter any country without fear of being deported back to their home countries(5). However, these gulf countries (U.A.E, Saudi Arabia etc.) are not a part of the international treaty and therefore not obligated to take in refugees, although they have donated millions to the UN towards refugee assistance(5). So, for countries that are a part of the treaty, that cannot afford to donate millions but are willing to open their doors get overwhelmed with the demands of hosting such large quantities of refuges. Countries like Uganda, Sudan, Kenya, DR of Congo that already facing economy and development challenges, have received severe burdens, social and economic impact from hosting large populations of refugees. As the demands on health facility, housing, social services and employment increase.  Some solutions and recommendations offered by the UNHCR include voluntary repatriation, resettlement to countries that will grant permanent residence, local integration and the return to home countries if possible(3).  While these solutions are great, they will not happen overnight and the solutions are more realistic for high-income countries that already have stability in their economic, infrastructure and health system. But for countries that are already struggling with the added burden that comes with hosting refugees, considering both refugee and host populations needs is key in developing sustainable solutions that are mutually beneficial to the host countries, their citizen and supporting refugees.

 

Humanitarian Crises and its effects on Mental Health

A crisis, be it a natural disaster, famine, drought, conflicts, or an epidemic can result in great negative impacts on those affected and those in response. About 450 million individuals suffer from mental disorder globally(6), and when a crisis occurs this can cause depression, anxiety, acute or post-traumatic stress disorder on affected individuals and exacerbate pre-existing disorders.

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The major factors in a humanitarian crisis that result in mental health disorders are experiencing a traumatic event, becoming a refugee, becoming a fugitive in your own country, separation from loved ones, hunger, starvation, and persistent insecurity. These often-unavoidable factors result in significant changes in the social and psychological qualities of an individual, family and communities. Therefore, while the basic and fundamental needs of individuals are crucial set priorities in humanitarian response, their mental health needs are also equally as important. Making sure supportive psychosocial response is readily available is key to preventing these disorders from becoming chronic, and making it challenging for those affected to adapt, become resilient and functional in their new realities.

Some of the main interventions mentioned in Tambri Housen’s presentation include developing services in the healthcare system that attends to urgent psychiatric needs, guaranteeing the availability of services and medications, providing outreach support, and educating aid workers and community leaders on the common mental health knowledge. The WHO and UNHCR also developed the mhGAP Humanitarian Intervention Guide as a tool guide that supports providers and aid workers in addressing onsite response and management of mental, neurological and substance use disorders in humanitarian emergencies(7).

Crisis can also affect the mental health of aid workers and the response team. This course has provided the opportunity to listen to various speakers from different fields, experiences and roles in dealing with a crisis and among them all, there is no denying that working in the field is extremely difficult. The conditions and circumstances are challenging, and some of the decisions that are made are even harder. Having to witness such hardships takes a toll on those sent to be a part of the solution. So, while mental health of the affected is important, the same holds true for those sent to assist. Humanitarian emergencies affect us all, whether those directly impacted, those assisting the affected-on ground or those witnessing the effects miles away from a television set or a news article. 

References:

1. Fisher M, Kramer A. An Epidemic after an Earthquake: The Cholera Outbreak in Haiti, Part 1 Center for Strategic and International Studies (CSIS): Center for Strategic and International Studies (CSIS); 2012 [Available from: https://www.csis.org/blogs/smart-global-health/epidemic-after-earthquake-cholera-outbreak-haiti-part-1.

2. 2010 Haiti Cholera Outbreak & CDC Response Center for Disease Control and Prevention: Center for Disease Control and Prevention; 2014 [Available from: https://www.cdc.gov/cholera/haiti/2010-outbreak-response.html.

3. Global Trends. UNHCR: UN Refugee Agency; 2017.

4. Kuo L. The world’s least developed countries are also the ones hosting the most refugees Quartz Africa2016 [Available from: https://qz.com/africa/711387/the-worlds-least-developed-countries-are-also-the-ones-hosting-the-most-refugees/.

5. Yan H. Are countries obligated to take in refugees? In some cases, yes CNN2015 [Available from: https://edition.cnn.com/2015/09/08/world/refugee-obligation/index.html.

6. World Health Report: Mental disorders affect one in four people World Health Organization [Available from: https://www.who.int/whr/2001/media_centre/press_release/en/.

7. Ventevogel P, van Ommeren M, Schilperoord M, Saxena S. Improving mental health care in humanitarian emergencies. Bulletin of the World Health Organization. 2015;93(10):666-A.

Tambri Housen presentation on communicable disease control and the complex nature of humanitarian emergencies was quite interesting. The example on the outbreak of Cholera in Haiti truly reflects on some of the unintended negative consequence that can occur in a humanitarian response and the value of thinking through and preparing for such, as much as possible. Haiti faced one of the largest earthquake documented on January 12, 2010(1) and 10 months after, suffered an outbreak of Cholera, which resulted in over 725,000 infection and 8,000 deaths by the end of 2014 as noted by Tambri. This was an epidemic that spread to neighboring country Dominican Republic with over 21,000 cases and 363 deaths reported(1).

Prior to this, Haiti had not faced an outbreak in over a century. Unfortunately, the strain of cholera introduced to the region was from South Asia, which further investigation determined the infection and breeding site was a river close to the peacekeeper’s camp(1). The circumstance surrounding the cause of this outbreak, Haiti’s inadequate water and sanitation infrastructure before and especially after the earthquake, as well as the living conditions in displaced person’s camps largely contributed to the rapid spread of Cholera. Although this outbreak was indeed unintended, it sparked many opinions on how this could have been prevented. For instance, screening workers before deployment to the crisis zone. This practice is usually emphasized when workers are returning to their home country especially if it is a high-income country but not as much when they are being deployed out. However, you can argue that for a disease like cholera the process of screening is quite unpleasant, as it involves collecting stool samples, results do not have a quick turn over time as rapid testing isn’t available, the likelihood of contracting it is much higher in conflict environment and the signs and symptoms of cholera can be dominant for months, so if one is infected they very well may be unaware of it.

This outbreak has also given insight on how to perform a rapid outbreak control in the midst of humanitarian crisis.  In this instance, the CDC and Haitian Ministry of Public Health and Population immediately focused on these priorities: Preventing further casualty by providing treatment, oral rehydration solution packets, clinical training and encouraging the sick to seek immediate care(2). They also tackled the spread of the disease by emphasizing safe water storage and use, handwashing and appropriate waste disposal(2). Finally, they identified risk factors, created prevention strategies, surveilled and monitored the spread of cholera in Haiti(2).  

Overall, this outbreak points to a far bigger issue in Haiti, an issue of poverty and a weak health system which was further heightened by the earthquake. This outbreak had great momentum because of the poor health infrastructure in Haiti. This is quite the case in much humanitarian response and as public health professionals, we face the conflict of treating an issue at hand like the cholera outbreak or addressing the underlining cause of the issue like poverty. But then doing something is better than doing nothing.

 

Why are more refugees hosted by low and middle income countries?

One cannot discuss humanitarian emergency without the topic of refugees, displaced persons and asylum seekers coming up. One of the main theme in this course was the issue on refugees and the fact that more low-income countries are hosting the influx of refugees produced from war and disasters. According to the UN Refugee Agency, “68.5 million individuals were forcibly displaced worldwide as a result of persecution, conflict, violence, or human rights violations”, of which 25.4 million were refugees(3). This translates to the current combined population of Australia, New Zealand and Canada or the entire population of the United Kingdom being less than the world’s number of displaced persons(4). Equally as shocking, the countries that are hosting these refugees are some of the least capable countries to do such, with 8 out of 10 top refugee host countries being in developing regions(3). Similarly, the major source countries of refugees are from developed regions with Syria, Afghanistan, South Sudan and Myanmar taking the lead respectively in 2017(3).

More refugees have originated from Syria than any other country, accounting for 6.3 million people(3), and 9.2% of the total global population of refugees. A majority of these refugees end up in Turkey, which is hosting 3.4 million refugees as of 2017 and counting, Lebanon, Jordan, Iraq and Germany(3). While, Syrian refugees were granted asylum in more than 120 countries, yet those listed above host a large proportion of Syrian refugees(3). Likewise, the conflict in South Sudan surged the number of refugees in 2017, resulting in sub-Saharan Africa receiving the largest increase in refugee numbers than any other UNHCR regions(3). The refugee population in Africa increased to 6.3 million by the end of 2017 with about 1 million South Sudanese refugees fleeing to Sudan and Uganda(3).

So, why are the least capable countries hosting the more refugees? What impact does this have on host countries? and what can be done to assist? These are the questions that have come up in global discussions and as I reflect on this matter. One of the main reason for the massive dwelling of refugees in developing nations is because the highest producing countries of refugees are also in developing regions. Therefore, when individuals flee their countries during conflicts they end up in boarding countries which have been the case for Syria and Lebanon or South Sudan and Uganda. However, if geography is such a huge factor, why has there been a visible absence of refugees in the United Arab Emirates (U.A.E), Saudi Arabia, Qatar, Kuwait and several more(5). These are countries that classify as upper-middle to high income, they have more capacity to host refugees and are geographically close to some of the crisis countries like Syria, Iraq and Afghanistan. These countries are similar in culture, religion and language and would make sense for displaced individuals from Syria, Iraq and Afghanistan to settle and re-establish there, as the transition would be less challenging. Yet we see countries like Turkey and Germany of similar capacity accepting a noteworthy number of refugees.

More than 140 member states are a part of the international treaty on refugees, giving refugees the freedom to enter any country without fear of being deported back to their home countries(5). However, these gulf countries (U.A.E, Saudi Arabia etc.) are not a part of the international treaty and therefore not obligated to take in refugees, although they have donated millions to the UN towards refugee assistance(5). So, for countries that are a part of the treaty, that cannot afford to donate millions but are willing to open their doors get overwhelmed with the demands of hosting such large quantities of refuges. Countries like Uganda, Sudan, Kenya, DR of Congo that already facing economy and development challenges, have received severe burdens, social and economic impact from hosting large populations of refugees. As the demands on health facility, housing, social services and employment increase.  Some solutions and recommendations offered by the UNHCR include voluntary repatriation, resettlement to countries that will grant permanent residence, local integration and the return to home countries if possible(3).  While these solutions are great, they will not happen overnight and the solutions are more realistic for high-income countries that already have stability in their economic, infrastructure and health system. But for countries that are already struggling with the added burden that comes with hosting refugees, considering both refugee and host populations needs is key in developing sustainable solutions that are mutually beneficial to the host countries, their citizen and supporting refugees.

 

Humanitarian Crises and its effects on Mental Health

A crisis, be it a natural disaster, famine, drought, conflicts, or an epidemic can result in great negative impacts on those affected and those in response. About 450 million individuals suffer from mental disorder globally(6), and when a crisis occurs this can cause depression, anxiety, acute or post-traumatic stress disorder on affected individuals and exacerbate pre-existing disorders.

The major factors in a humanitarian crisis that result in mental health disorders are experiencing a traumatic event, becoming a refugee, becoming a fugitive in your own country, separation from loved ones, hunger, starvation, and persistent insecurity. These often-unavoidable factors result in significant changes in the social and psychological qualities of an individual, family and communities. Therefore, while the basic and fundamental needs of individuals are crucial set priorities in humanitarian response, their mental health needs are also equally as important. Making sure supportive psychosocial response is readily available is key to preventing these disorders from becoming chronic, and making it challenging for those affected to adapt, become resilient and functional in their new realities.

Some of the main interventions mentioned in Tambri Housen’s presentation include developing services in the healthcare system that attends to urgent psychiatric needs, guaranteeing the availability of services and medications, providing outreach support, and educating aid workers and community leaders on the common mental health knowledge. The WHO and UNHCR also developed the mhGAP Humanitarian Intervention Guide as a tool guide that supports providers and aid workers in addressing onsite response and management of mental, neurological and substance use disorders in humanitarian emergencies(7).

Crisis can also affect the mental health of aid workers and the response team. This course has provided the opportunity to listen to various speakers from different fields, experiences and roles in dealing with a crisis and among them all, there is no denying that working in the field is extremely difficult. The conditions and circumstances are challenging, and some of the decisions that are made are even harder. Having to witness such hardships takes a toll on those sent to be a part of the solution. So, while mental health of the affected is important, the same holds true for those sent to assist. Humanitarian emergencies affect us all, whether those directly impacted, those assisting the affected-on ground or those witnessing the effects miles away from a television set or a news article. 

References:

1. Fisher M, Kramer A. An Epidemic after an Earthquake: The Cholera Outbreak in Haiti, Part 1 Center for Strategic and International Studies (CSIS): Center for Strategic and International Studies (CSIS); 2012 [Available from: https://www.csis.org/blogs/smart-global-health/epidemic-after-earthquake-cholera-outbreak-haiti-part-1.

2. 2010 Haiti Cholera Outbreak & CDC Response Center for Disease Control and Prevention: Center for Disease Control and Prevention; 2014 [Available from: https://www.cdc.gov/cholera/haiti/2010-outbreak-response.html.

3. Global Trends. UNHCR: UN Refugee Agency; 2017.

4. Kuo L. The world’s least developed countries are also the ones hosting the most refugees Quartz Africa2016 [Available from: https://qz.com/africa/711387/the-worlds-least-developed-countries-are-also-the-ones-hosting-the-most-refugees/.

5. Yan H. Are countries obligated to take in refugees? In some cases, yes CNN2015 [Available from: https://edition.cnn.com/2015/09/08/world/refugee-obligation/index.html.

6. World Health Report: Mental disorders affect one in four people World Health Organization [Available from: https://www.who.int/whr/2001/media_centre/press_release/en/.

7. Ventevogel P, van Ommeren M, Schilperoord M, Saxena S. Improving mental health care in humanitarian emergencies. Bulletin of the World Health Organization. 2015;93(10):666-A.

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