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    This blog highlights effective ideas in the fight against poverty and exclusion, and analyzes the impact of development projects in Latin America and the Caribbean.
  • When Cholera Strikes: A Coordinated Emergency and Longer-Term Response



    by Meri Helleranta

    A rapid response and partnerships between the Haitian Government and key institutions, including the IDB, helped to curb the cholera epidemic, decreasing the number of new cases per week from 14,000 in January 2011 to fewer than 1,000 a year later.

    colera haiti cholera

    Image: IDB

    Five years ago, in October 2010, Haiti was hit by a serious  cholera epidemic. Coming only nine months after the traumatic earthquake, the fast-spreading diarrheal disease—with the ability to kill its victims in just 24 hours—prompted panic.  Within a month, there were over 11,000 confirmed cases and 180 casualties, and those numbers were growing exponentially.

    Cholera is mostly spread by digesting water or food contaminated with excrement that contains the cholera bacteria. Modern epidemiology is considered to have started with a successful experiment to stop the spread of cholera over 150 years ago. Long before microorganisms such as bacteria were known to cause disease, the physician John Snow convinced authorities to close off the wells that had been used by the households where people fell ill in London.

    Following the first confirmed cases in Haiti in 2010, hundreds of relief organizations returned to the country just months after dealing with the devastation of the earthquake.  At the time, the Ministry of Health and DINEPA (National Agency for Potable Water and Sanitation) were overwhelmed by both the emergency health demands and the need to coordinate massive external support.

    Recognizing that time was of the essence, the government requested support from the Inter-American Development Bank (IDB) to scale up its response to the epidemic.  Efforts focused on designing a project with the ability to deliver relief quickly and at the same time, to build local capacity. The resulting 18-month-long project had to deal with the immediate health needs and the challenge of preparing the country to control cholera altogether—a battle expected to last more than a decade.

    Within six weeks of receiving the government’s request, the IDB Board and the Spanish Cooperation Fund for Water and Sanitation in Latin America and the Caribbean had approved an emergency project of US$20 million. The project focused on strengthening treatment capacity, as well as scaling up preemptive actions through the use of community outreach units. At the same time, systematic efforts to chlorinate water, and thereby kill the cholera bacteria, were put in place, at both the production and distribution levels, targeting water kiosks serving the low-income neighborhoods as well as households directly.


    Emergency action in a time of cholera

    To strengthen the government’s stewardship, the Ministry of Health and DINEPA were tasked with serving as the executing agencies, while the UNICEF coordinated the emergency health response and related procurement processes.  In the months that followed, the project built 1,008 oral-rehydration posts and 77 cholera treatment units, and trained 2,780 community outreach agents to deliver key preventive health messages.

    Nearly 140,000 people were treated at the supported facilities, patient-discharge records indicate. As many as 2 million people were reached with core messages on the need to chlorinate household water, the role of hand washing, and the importance of access to oral rehydration solution  at the first onset of symptoms, UNICEF estimated.

    The Ministry of Health set up a national surveillance system during the first two months of the epidemic to track the spread of the disease. Data revealed that mortality rates started drastically declining, from the initial 2.7 percent of patients, to reach lows of less than 1 percent by the ninth month of the epidemic.

    The number of people who fell ill with cholera also began to fall: from 14,000 new cases per week in January 2011 to fewer than 1,000 a year later. During the 18-month span of the project, the epidemic was downgraded to an endemic state. Although the bacteria are not fully eliminated from the environment, the situation is now considered under control.

    All in all, the project was quite successful in achieving favorable results and dealing with the emergency. Even at the height of Haiti’s cholera epidemic in 2010, up to 97 percent of the infected patients made a full recovery from the dehydration caused by the bacteria.

    The sheer numbers of those afflicted testify to the tragic impact this epidemic had on the country. Two years after cholera was introduced to the Artibonite River, there were 590,856 recorded cases and 7,758 causalities.  The fight is not over, as the bacteria continue to affect the population.  Of the 65,000 new cases recorded in 2013, 550 people died.  Thus further steps were needed.


    A medium-term solution through improvements in water and sanitation

    The most critical behavior changes that can help curb cholera are related to household water treatment, hand-washing, home treatment of diarrhea, and the use of latrines as opposed to open defecation.

    It is in these areas that DINEPA is playing a key role in the longer-term response. The project helped significantly strengthen the agency’s regional network. Communal water and sanitation technicians (the TEPAC network) have been established as a permanent presence in communes. These professionals perform routine analyses of water quality, both at the water posts and in homes, and are capable of quickly informing authorities of a potential outbreak of water contamination. Rural regional units (URDs), which supervise engineering works in the area of water and sanitation,have gained very important experience. Their analytical capacity has been strengthened through the establishment of the portable laboratories that can monitor water quality.

    The Haitian population has also learned how to treat water better.  The experience of Altidor, an 8 year-old student in the northern town of Milot, is typical. She explains what she has learned from the home visits of her local TEPAC: “My older brother and I go fetch the water. And when we come back with the gallons, we put a drop of Clorox in it.”

    At the same time, various infrastructure investments have focused on critical areas, such as assuring the level of residual chlorine and functioning of the water networks, upgrading water and sanitation systems in health centers, and providing sanitary blocks to schools. These investments can be expected to be sustained with appropriate maintenance.

    Fortunately, even as challenges continue, the cholera epidemic has been contained for the most part, and the dreaded escalation of the epidemic to other regions has not occurred. To avoid future water-borne tragedies, Haiti will benefit from a solid early detection system and sustained local capacity in both the prevention of disease and curative care.

    This is one of a series of articles in this blog on effective development that highlights the lessons and experiences of IDB projects and evaluations.

    These are some of the posts of the series:

    – Knowledge without borders

    Empowering communities helps reducing crime in Trinidad and Tobago

    – Opening a world of opportunities for small- and medium- size companies

    What does energy efficiency have to do with hotels in the Caribbean?

    Winds of Change in Uruguay

    Learn more about this project and others in the Bank’s 2014 Sustainability Report.


    Meri Helleranta is a Social Protection Specialist at the IDB.

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