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:


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.


How to Win Friends and Immunize Kids

The ongoing measles outbreak in Southern California has summoned spectres of the scenes that originally motivated me to work on immunization access in the Middle East. Parents so eager to vaccinate their children that the phone would ring off the hook during stock-outs, forcing clinics to reallocate nurses to issue updates. Girls who use their hijabs to cover the trademark swelling of mumps, so they wouldn’t be removed from school. Typhoid breaking out days before a war did the same, forcing thousands into shelters crowded beyond belief with no hygienic systems to speak of.

I wish every teethy news cycle sprung up smack before a long run. My modus operandi in response to implacable rejection of basic facts is to fume – which, while generally useless, makes for good fuel. I’m presently a global health policy student, where this sort of emotional response to public welfare issues is not at all unusual.

Convincing people opposed to vaccination to inoculate their children is nigh-impossible. Evidence presented by people with 12 years of advanced scientific and medical training does not change minds. All the snarky, cathartic Amazon reviews in the world will not change minds. Banning unvaccinated children from schools does not change minds – and for what? To be homeschooled by scientifically illiterate parents, and continue the cycle? Coercion, in fact, births strategic evasion: doctors in California have allegedly begun falsifying immunization records. Hoping that the selectively unvaccinated end up with the more evolutionarily disadvantageous side effects of mumps and breed themselves out of existence is, likewise, an exercise in dangerous futility.

It’s important to remember that failing to change minds about the safety of routine immunization means more than just the failure to win an argument. The negative externalities presented by the selectively unvaccinated directly risk the lives and well-being of the unwillingly immunocompromised. If you think these people are idiots in the first place, you know this. I’m not telling you anything new. But these are the real consequences of backing people into a corner, righteousness be damned.

Doctors, public health officials, and general believers in the power of modern medicine and (yes, okay, including me) need to get their Dale Carnegie on. What we are doing is not working. Allow me to cite some depression-era words of wisdom:

“It is hard to change minds under the best of circumstances; do not handicap yourself by telling people they are wrong.”

“We are incredibly heedless in the formation of your beliefs, but find ourselves filled with an illicit passion for them whenever anyone proposes to rob us of their companionship.”

Amid the volatility and mocking disbelief, there are two instances of success I think we can learn from that illustrate these principles (these articles are both very good, and I encourage anyone interested to read them in full):

  1. Dr. Mohammed Pate tackled polio in Northern Nigeria – a hotbed for infectious disease that makes Disneyland look like, well, Disneyland – by treating the reluctant with unparalleled empathy and patience. Here’s an excerpt from The Art of Eradicating Polio:

For at least a half an hour, the man listened as the boy vented. The vaccinators had been rude, the boy said, insulting his mother as they tried to force their way in.

I would be angry, too, if someone insulted my mother, Muhammad replied.

Why do they bring only polio vaccine when we get no help with all our other problems? And are you going to force us to take it? the boy asked querulously. No, it is your decision. I will not force you, the man assured him. But I hope that you will change your mind. Then he patiently explained that the vaccine is safe—he had vaccinated his own kids—and it would protect them from devastating paralysis. And also, that the world has a once-in-a-lifetime chance to eradicate polio—and the boy, and Nigeria, should not stand in its way.

Then the boy’s older brother, who had been listening from behind the curtain, emerged with one more question: Will you be responsible if the children are harmed? Yes, the man promised, and the brother brought the kids out to receive the polio drops. The crowd that had gathered burst into applause.

  1. While all but a few hundred members of the U.S. public were entirely uninvolved, the U.S. policy response to Ebola confronted a similar form of irrational fear. Dr. Ron Klain, short-term Ebola czar, had this to say in a Politico profile:

“…you have to take the public’s fears seriously, and respect those fears. I don’t think it was a surprise that the country was very concerned about Ebola in the fall. It was a new thing to encounter in America, a frightening disease. Our approach has been to try to deal with those fears, both by putting the right policies in place and communicating with people in an honest and transparent way.”

Ron Klain also brings up the important topic of exposure bias. Once the public saw that Craig Spencer, the infected doctor in New York, did not magically infect his fellow bowlers and subway-commuters (and, grumblegrumble, once election fear-mongering died down), public hysteria passed. With vaccination, this works in reverse: as preventable infectious diseases become increasingly rare, memory of the real danger they present fades. Here, at least, the Disneyland cases have served some purpose, persuading reluctant vaccinators and prompting grassroots movements for policy change in schools.

As for top-down action, I struggle to form ideas for concrete policy interventions, generally beset with unbridled frustration at the knowledge that most tools in my toolbox don’t fit the need. But building broader coalitions in support of vaccination programs is absolutely necessary.  It’s a wonder to me, frankly, that fiscal conservatives don’t cheer mandatory vaccination in droves. Disease eradication eliminates all future costs associated with vaccinating, treating, and monitoring; disease elimination from a country or region dramatically reduces them. Forever. For-ev-er. You do see a bit of this thinking occasionally surface: Rick Perry, bless his heart, issued a promptly-overturned executive order mandating HPV vaccination for sixth grade girls in 2007.  Working across the aisle and encouraging politicians of all stripes to find their district-friendly argument for vaccination could soften the ivory tower.

Respecting fears is hard when you know they are ridiculous. But the outrage cycle is not just ineffectual – it’s dangerous. It’s time to swallow the vitriol and focus on developing new strategies that will produce results.

How to Win Friends and Immunize Kids

Bioterrorism is already here. It just doesn’t look like we expected.

This is a story of unconnected dots.

On October 17 2013, a strain of polio endemic to Pakistan first appeared in Deir al-Zor province, Syria. This virus presumably hitched a ride on a ne’er-do-well from Balochistan who thought supporting the Nusra Front would be a good use of his time and likely had no idea he was infected.

On February 12, the U.S. Department of State launched a new Global Heath Security Agenda. The highlight Secretary Kerry’s op-ed on the launch? The 2003 outbreak of SARS, hyped scourge of Asia, with 8,000 known infections and 775 known deaths. The famed Anthrax attacks of 2001, with 17 infections and five deaths, also made an appearance.

On March 11, an infant in Lebanon presented with paralysis. Unlike Jordan, Lebanon has refrained from establishing formal camps for its refugees in an effort to deter permanent residence — a lesson, perhaps, learned from the influx of Palestinians half a century ago. Continue reading “Bioterrorism is already here. It just doesn’t look like we expected.”

Bioterrorism is already here. It just doesn’t look like we expected.

Burdens of Disease.

People have been asking me lately, as I’ve bounced from place to place, why I find the Middle East an interesting place to pursue global health work. There are about fifty different answers to this, but in short: I think inequality within countries makes for more challenging distribution of resources than inequality between countries, I’m interested in how healthcare can be used as a political tool, and I expect the challenges much of the region faces now to be similar to those some areas of Africa will face in twenty-thirty years. But the easiest explanation is quick and visual.

Continue reading “Burdens of Disease.”