Cholerwhatchagonnadoaboutit.

The curious case of cholera in Haiti has popped up around me three times in the last week, and since I disagree with just about everyone I talk to about it I figured it might be a ripe topic for a blog post.

Long story short: a strain of cholera, a disease previously absent in Haiti, was brought to the country by Nepalese U.N. peacekeepers sent over after the 2010 earthquake. This has infected over half a million people and done some really enormous damage. Cholera isn’t difficult to treat – the dehydration is what kills you – but Haiti’s poor infrastructure in almost every regard has left nearly 9,000 people dead. Human rights activists brought a lawsuit against the United Nations, the actual text of which you may read here. The crux of the argument, as far as this non-lawyer can tell, is focused on seeking condemnation for “the negligent, reckless, and tortious conduct” of the United Nations. In a move that has received widespread condemnation, the case was dismissed just last month, and an appeal is currently pending.

The U.N. has handled the aftermath of the epidemic very poorly. But I remain puzzled by the accusation of criminal negligence. The common refrain that the U.N. should be “held responsible” is also vague – what does that mean in practice? Not to get too Olivia-Pope-advising-a-scorned-woman about it, but exactly what kind of outcome do these plaintiffs want? Let’s explore these one at a time:

Negligence

In areas where cholera is endemic, most cases are asymptomatic; when symptoms are present, they are general, and actual testing is required to distinguish cholera from other diarrhea diseases. The U.N. peacekeeper force is roughly 100,000 strong. The most effective way to avoid negligence might be to test peacekeepers prior to deployment. There’s a new-ish rapid test for cholera that costs $4. Testing every U.N. peacekeeper would cost at least $400,000 and would necessitate a 24-hour delay – potentially quite harmful in a post-disaster setting, where every hour counts. It’s a scenario I could envision prompting complaints of equal fervor if testing had been taken.

This particular test is 91% sensitive and 92% specific, which, depending on how many peacekeepers might be infected, isn’t that bad – it means that 9% of all positive tests are false positives and that 8% of all negatives are false negatives. But the WHO recommends that all positive tests be confirmed via culture, which costs more money.

Furthermore, where is the line? To be non-negligent, must we also test for rotavirus? For polio? That’s another $25 per peacekeeper, eating well into the program’s annual budget. How often do you test – before every deployment?

Another alternative to testing might be mass treatment of U.N. peacekeepers. Mass treatment in the absence of disease confirmation would be cheaper in the short term, but potentially much more costly and deadly in the long term if it tilts the genetic balance in favor of drug resistance.

Holding the U.N. Responsible

Peacekeepers make $1,210 per month. By most western standards, this is paltry; for potential applicants from low- and middle-income countries, it may be the opposite. So it’s no wonder that many peacekeepers may come from areas where infectious diseases are endemic. This isn’t going to change unless wages and recruitment strategies change substantially.

This salary rings true to me (a U.N. department where I conducted research ran out of money almost annually in October, leaving nurses and other clinic staff unpaid). If the U.N. doesn’t have money to conduct mass testing or to raise peacekeeper wages, it’s odd to me that plaintiffs might request some of their limited funds go to this lawsuit. Would the money originally spent on disaster relief operations, or on health and refugee support since, qualify as a portion of potential compensation? If the U.N. proceeds with pre-deployment testing for a portfolio of diseases and some still sneak through (as seems inevitable to me), should they be held further responsible? A claim of responsibility seems more than appropriate given the evidence, but beyond that, all of this seems very murky and possibly counterproductive.

In conclusion: 

While I very much appreciate the role that advocates such as the plaintiffs play in shifting public conception of what is possible and equitable, I really do not see how continued pursuit of this lawsuit benefits anyone (I’m more of a realpolitik gal, as you may have gathered). Let’s take the money that could be spent on continued prosecution and possible mass testing and put it towards preventing future outbreaks by investing in health and sanitation systems in disaster-prone areas.

Cholerwhatchagonnadoaboutit.

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