Waiting for Helicopters: Cholera, Prejudice, and the Right to Water in Haiti

Cholera is something they sent,” says graffiti on Port-au-Prince walls, “to finish killing off the rest of us.”

Bathing in a drainage ditch – too frequently the only option. Photo: Ben Depp, bendepp.com
Bathing in a drainage ditch – too frequently the only option. Photo: Ben Depp, bendepp.com
Scientists have shown that the cholera pathogen came to Haiti with foreign UN troops who carried the bacteria in their bodies, and whose military base was dumping its sewage into a nearby river. The imported disease has claimed more than 7,000 lives and continues to ravage communities across Haiti. Despite billions in post-earthquake aid dollars and hundreds of humanitarian NGOs, the country still faces a dearth of water and sanitation services, further fueling the epidemic. Nearly half a million internally displaced people (IDPs) still live since the 2010 earthquake in makeshift camps under tarps, torn tents, and pieces of old fabric and cardboard, an ideal environment for cholera. The situation raises serious questions about the humanitarian mechanism and its priorities. Why do so many people still lack the most basic of services? What factors are guiding humanitarian agencies’ decisions to provide or withhold them? Read more about the results of a study answering these questions in this multi-part series. The first article focuses on how neglect of humanitarian standards and lack of commitment to human rights led to deliberate decisions to cut services that left hundreds of thousands without water and sanitation, thus allowing cholera to spike. In the next article, we will examine NGO personnel’s negative perceptions about residents of the displacement camps, and how these perceptions abetted their decisions to deny services. The final piece takes a step back to look at the political dynamics that have historically left large gaps in water and sanitation infrastructure in Haiti, and how these trends continue. Throughout, we highlight grassroots groups that are working towards Haitian-driven alternatives.

Days after a cholera outbreak was announced in October, 2010, local Port-au-Prince organizations Asanblé Vwazen Solino (Solino Neighborhood Assembly) and Bri Kouri Nouvèl Gaye (Noise Travels, News Spreads) scraped together shoe-string budgets, designed a flyer, and plunged into a steam-roller campaign. Says Esaie Jean-Jules, the Information Coordinator with Solino Neighborhood Assembly, “We rented a vehicle, put a sound system on it and printed flyers in Creole explaining how cholera is contracted, and how people can combat the disease by handwashing and treating water. We climbed on top of the truck and used a microphone to tell people these things everywhere we went.”

These groups were driven by the belief that all people deserve to be cholera-free. Now, a year and a half after this first-line response and even the first protests demanding accountability from the UN, recorded cholera deaths have surpassed 7,000, with almost 550,000 people infected.[i] Actual numbers could be much, much higher.

The conditions allowing for this epidemic are human-made. The poor humanitarian response has aggravated the spread of the imported pathogen. We’ve known since 1854 – when the physician John Snow discovered the source of a London cholera epidemic and put a stop to it – that clean water is all it takes to sever the fecal-oral route on which the bacteria depends. However, few of the people still living in hundreds of internal displacement camps have access to clean drinking water. There are more than 4,000 camp residents for every one water source (i.e. a tank or other receptacle) and only 30% of those have an adequate level of chlorination, according to the most recent data. As for sanitation, which is important for keeping fecal matter away from water sources, there are more than 110 camp residents for every toilet.[ii]

The Pan-American Health Organization has stated that cholera could infect 200,000-250,000 this year in Haiti.[iii] In a recent alert, the organization Partners in Health warns us, “When the rains came last year, the number of cholera cases nearly tripled from 18,908 in April to 50,405 in June. This year could be worse, but it doesn’t need to be.” This fear has already become truth, however: with another rainy season drenching the country, cholera is again on the rise.

How could the same pattern – vast under-provision of water and sanitation leading to a rainy-season surge in cholera cases – be repeating itself? To begin answering this question, we must look at the organizations in charge of the humanitarian response and why they have failed to provide the necessary services. Although government is normally, and ideally, the final party responsible for providing services like water and sanitation, circumstances made it virtually impossible for the Haitian government to assume this responsibility. It has longbeen grossly underfunded, particularly for provision of public services, due in part to a history of debt and requirements on foreign aid that included the slashing of social sector budgets. The situation has deteriorated with the earthquake which battered the Haitian government, damaging or destroying every high-level government building, killing thousands of employees, and obliterating infrastructure and records. Exacerbating the government’s current incapacity has been the fact that earthquake relief dollars have overwhelmingly bypassed it. While $6 billion have been disbursed to Haiti, including private donations from more than one in two US households, only one percent has gone to the Haitian government. [iv] Instead, almost all donations have gone straight to large non-governmental organizations (NGOs). These are agencies such as the Red Cross, Save the Children, and CARE, typically headquartered in capital cities of industrialized nations, that one commonly thinks of when donating to crisis-relief.

NGOs were thus the only ones endowed with the funding and capacity to carry out the needed relief. And they took on a responsibility towards Haitians to provide services, known in the jargon of the aid world as “the humanitarian imperative.” They also took on a responsibility to the taxpayers in the US and elsewhere who have paid much of their bill. In fact, ‘non-governmental’ is actually a misnomer since many of the agencies, like Save the Children and Catholic Relief Services, get at least half of their funding from the US government.[v]

In assuming these responsibilities, NGOs began coordinating among themselves through the UN humanitarian system, which hosts what are dubbed “cluster meetings.” The group of NGOs involved in water and sanitation meets as a “WASH [water, sanitation, and hygiene] cluster,” which divided the city up into slices of NGO turf, with each NGO agreeing to take responsibility for water and sanitation in certain camps. Although the governmental water agency, DINEPA, co-coordinates the cluster, it’s those with the resources and capacity – the NGOs – that really make the who, what, and where decisions. If they decide not to provide services to particular camps, those camps simply do not receive services. So, as a body vested with authority by the UN, acknowledged by the Haitian government, and run by well-financed NGOs, we can legitimately ask: why did they not deliver? Why were interventions that could have stopped or at least slowed cholera in its tracks not implemented on a mass scale?

Hoping to answer some of these questions through research I was doing as a graduate student of public health, I conducted a study of IDP camps and foreign NGO officials in Port-au-Prince to gauge attitudes towards the humanitarian work being done in the WASH sector in 2011. My research partner, Silvan Vesenbeckh, and I interviewed internally displaced people (IDPs) in 16 camps, 52 individuals working for major NGOs doing WASH work in these camps, and relevant officials with the International Organization for Migration and UN agencies. I analyzed the transcripts of all these interviews, categorizing respondents by type (NGO official, UN official, camp resident, etc.), and used qualitative analysis techniques to identify trends in themes and opinions among each type of respondent. What I’m sharing here are the results of that analysis.*

Overall, the interviews pointed to a lack of commitment to human rights and humanitarian standards that led to NGOs’ deliberate decisions not to provide aid. And, as will be discussed more in the next article, thenegative perceptions about camp residents prevalent among the NGO community were significant factors leading to the relaxation of standards and negligence of human rights. They reflect what is destructive about the overarching ways NGOs interact with recipients of aid and with Haitian society more broadly.

Rights? “Virtually no mention of it”

A commitment to human rights in post-disaster work is important for at least two basic reasons. First, all human beings, particularly in times of catastrophe and extreme poverty, deserve a certain level of basic necessities – such as water, shelter, freedom from violence. Second, people’s poverty and need should not subject them to aid provision that is disrespectful, culturally inappropriate, insufficient, or without their input. In other words, the process of providing aid is just as important as the aid itself. (To translate this to an example we can more likely relate to: it’s not okay for a physician to offer lower quality treatment to her Medicaid or Medicare patients than to her privately insured ones.) A human rights approach requires NGOs to implement policies that make their programs more sensitive to vulnerable groups – such as ensuring that latrines are not set up in a way that aggravates gender-based violence, setting basic standards of quality and quantity in how much water people get, and ensuring that the camp committees they partner with are gender-representative. Human rights also introduces accountability, meaning that although international human rights treaties are usually legally binding only for governments, they also constitute a set of guidelines that NGOs often use as guidance, and that aid recipients can use to hold NGOs to their word.

However, the absence of human rights commitments was evident at all levels of NGO operations in Haiti, beginning with formal project mission statements and plans. My review of the Haiti coverage on the NGOs’ websites, as well as their Haiti progress reports published one year after the earthquake (in the cases where such existed), revealed that only one out of the 14 explicitly mention the right to water or sanitation. Only two of them had any mention of human rights at all.

What about NGO officials? Were they talking about human rights, like the right to water or the right to health? The WASH cluster – composed of NGO representatives discussing water and sanitation – was the perfect place to examine this. When asked about human rights, one aid worker put it bluntly, saying, “There’s virtually no mention of it in the WASH cluster.” The majority of NGO officials we interviewed had the same assessment. Corroborating this, a text search of the WASH cluster mailing list dialogue (which scanned 791 email messages between NGOs from 2010 and 2011), turned up only one message with a mention of “human rights,” and it did not relate to water or sanitation. Given that the cluster is where NGOs coordinate most water and sanitation decisions, the lack of human rights commitments in cluster discourse and NGO consciousness bodes poorly.

“Sphere Standards are not applicable in Haiti”

One way to measure agencies’ commitment to the principles of human rights, even if they are not using the language, is through their adherence to the “Sphere Minimum Standards in Disaster Response.” Commonly known as “Sphere Standards,” these are widely recognized guidelines for provision of basic needs in disaster settings. The Sphere Standards are well-known among the international humanitarian community and often talked about in cluster meetings. They require, for example, that aid-givers provide a minimum of 15 liters of water daily per person, and at least one toilet per every 20 people. While these numbers certainly do not represent achievement of rights, they at least set a floor in moving towards them.

Although the Sphere Standards are used as guidance in humanitarian settings around the world, of the 17 NGO officials in Haiti who discussed Sphere Standards in their interviews, all of them stated that these standards were not applicable or realistic in Haiti. In particular, they said, they would not aim to build one toilet for every 20 people. Why not? Camps are too crowded for toilets, said some. Camp residents have access to toilets in neighborhoods, said others. Camp residents we spoke to disputed both of these claims, with the overwhelming majority saying more toilets were vital, often pointing to spots in the camp where they’d like to see facilities installed. Yes, camps were crowded, they said, but that made proper sanitation all the more necessary.

According to other officials, Sphere Standards “don’t apply in urban settings.” This is patently false according to Sphere’s own published guidance and a Sphere Standards expert we consulted. Moreover, it has not been standard practice in other countries to change the rules in urban areas. No one cited examples of the standard being changed in this way anywhere else.

Regardless, the WASH cluster took these officials’ opinions to heart, and, in mid-2010 adopted a modified standard for toilet provision, declaring that 100, instead of 20, people per toilet was an acceptable goal for NGOs. That’s one port-a-potty for 100 people to use as their primary bathroom, and an overfilled, under-maintained one at that. In actuality, the average number of people per toilet among the camps I sampled was 177.

Moreover, a few months after the cholera outbreak, the WASH cluster announced the termination of free water distribution to camps by the end of March 2011 – just as cholera cases were making a resurgence with the rainy season.[vi] Free provision of water was simply “not sustainable,” wrote the cluster in its announcement.

Today, as a result of these intentional decisions on the part of foreign NGO and UN officials, the overwhelming majority of camps have no water or sanitation. As of March 2012, two percent of IDPs had access to water trucked into the camps (down from 48% in March 2011). There were 3991 functional latrines for the camp population of nearly half a million.[vii] With the deluge of new rain in 2012, camp residents trudge through often ankle-deep mud and water that snakes its way into the plastic shelters worn down from more than two years of facing the elements. According to the most recent statistics from the WASH cluster, in half of all camps people are forced to defecate in open air. This means people often tie up human waste in plastic bags and toss it into a nearby drainage ditch. Children, being children, don’t always bother with the plastic.

These ingredients for a renewed upsurge in cholera have already proved their potency. Doctors Without Borders issued urgent appeals this April, reporting that admissions to its cholera treatment centers in Port-au-Prince and a neighboring city tripled in less than a month. Yet treatment is hard to come by. Half the NGOs working in the Artibonite region, where the disease was introduced, have now reportedly left. A letter is circulating in the US Congress demanding that the UN and international community step up the response.

At the end of a typical day in a camp, residents scrape up what food they have been lucky enough to find that day while aid workers retire to leafy restaurants to shake off the heat over a fish filet or cocktail. One has to wonder whether this is the kind of disconnect that makes conceivable the decision to cut off water to a camp, or to treat bathrooms as optional luxury items. But what do officials themselves have to say about this? Why the neglect of humanitarian standards and human rights guidance? In the next article, you’ll hear quotes from NGO officials suggesting that their detachment from local populations and skepticism of camp conditions led to beliefs that IDPs were exaggerating their desperation, systematically trying to con the system. This often overtook officials’ genuine concern for IDPs’ well-being. We’ll also get a glimpse of Haitian groups working towards the health and leadership of their fellow Haitians and in particular, the most vulnerable, driven by their underlying belief in human rights.

*Respondents’ names are not given as interviews for the study were conducted anonymously.

Sign these petitions telling the UN to take responsibility for introducing cholera into Haiti and to help stop the epidemic: Just Foreign Policy Petition & Baseball in the Time of Cholera Petition.

The study described was part of a Master’s thesis at the Harvard School of Public Health. For a copy of the full paper, contact deepa.otherworlds@gmail.com. Special thanks to Professor Stephen Marks and Silvan Vesenbeckh at the Harvard School of Public Health, Professor Mark Schuller at the City University of New York, and Ben Depp for sharing his remarkable photography.

[i] Just Foreign Policy, “Haiti Cholera Counter,” May 30, 2012, http://www.justforeignpolicy.org/haiti-cholera-counter.

[ii] DINEPA, “Présentation des résultats Enquête EPAH / WASH,” April 2012.

[iii] “Haiti’s Cholera Crisis,” New York Times, May 12, 2012, http://www.nytimes.com/2012/05/13/opinion/sunday/haitis-cholera-crisis.h…

[iv] Vijaya Ramachandran and Julie Walz, “Haiti: Where Has All the Money Gone?” Center for Global Development, Policy Paper 004, May 2012, http://www.cgdev.org/content/publications/detail/1426185.

[v] Including grants, contracts, and in-kind donations such as commodities and services from the US government. KPMG, LLP, Save the Children Federation, Inc Financial Statements (December 31, 2010), 3, http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/FINANCIAL%20STATEMENT%2012.31.2010.PDF; and Catholic Relief Services, 2010 Annual Report (2010), 40, http://crs.org/2010-annual-report/.

[vi] WASH Cluster Situation Report, Haïti. March 23, 2011.

[vii] DINEPA, “Présentation des résultats Enquête EPAH / WASH,” April 2012.

Deepa Panchang is the Education and Outreach Coordinator for Other Worlds. She has worked in advocacy for human rights in Haiti since the 2010 earthquake. You can access all of Other Worlds’ past articles regarding post-earthquake Haiti here.