Cholera arrived in Haiti this month with a vengeance. Since the first case was identified on October 19, 4,764 people have been hospitalized and 337 deaths have been counted.

The actual numbers may be much higher; early in the epidemic, over half the people counted as deceased arrived at health centers already dead, indicating that many were dying without accessing services. The outbreak is centered in the rural Artibonite and Central Plateau regions, where health centers are few and far between and transportation to the centers can take hours.

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In the rural village of Delande, numerous residents reported deaths in their families. There are no toilets in Delande, and locals have historically bathed in and drunk the river water. When the disease hit, the basic sanitary conditions necessary to control cholera were simply not in place.

Early on, people died and were buried at home. "There are many who haven't had time to go to the hospital and died," said local pastor Solomon Thomas. No government or NGO workers have come to the village, so it is almost certain those deaths were not counted. Now the community is scared and taking the sick to the hospital--a process that requires carrying the ill across the Artibonite River and over a small mountain, then finding a motorcycle or car. 

Hand washing as a last resort

"The solution to the sickness is in your hands," said Haitian president Rene Preval at a meeting with leaders of affected areas last Sunday. The gathering was labeled a disaster response meeting, but in reality it was a three-hour public health lesson. The attendees learned that cholera is a bacterial infection. Because it causes extreme diarrhea and vomiting, the disease evacuates the body of almost all its water and leads to severe dehydration that can kill within hours. 

The leaders also learned that cholera is easily preventable through proper sanitation and health practices. It is not spread from person to person; one has to ingest the bacteria through contaminated water or food. 

During the meeting, Preval called upon leaders one by one to "test" them on what cholera is and how it can be prevented and treated. Guerrier Fisnal, a public administrator for the commune of Crete-Brulée, admitted he "learned a lot from the discussion." He can now share the news with his community that people need to wash their hands and boil drinking water. 

Public health messages have also been disseminated on the radio, in the newspaper, and via informational text messages sent by Voila and Digicel, Haiti's two major cell phone companies. But the issue goes deeper than individual hygiene. In a country where, according to UNICEF, less than forty percent of the population has access to latrines and potable water is scarce, many are forced into daily contact with contaminated water.

Gabriel Timothee, director general of the public health, ministry acknowledged, when probed, that a better sanitation system would have lessened the impact of the disease. "But in any case," he continued, "it's a sickness of dirty hands." In the areas without toilets, where feces run in the open sewers, he suggested that people wash their hands more frequently.

As the crisis continues, the government and international institutions are distributing Clorox as widely as possible. And their efforts have diminished the number of new cases and deaths. But in Haiti, cholera is here to stay. Even if the epidemic can be contained in the near term, infected bodies buried without being sanitized will contaminate ground water. This can "bring back the malady at any time, even in five or six years," warned Alex Larsen, the minister of health.

Dr. Jean William Pape, director of the highly respected Haitian health organization GHESKIO, hoped the epidemic would "create an incentive" for the government to provide "what we have needed for a long time: adequate sanitary conditions for the population."

Where did it come from?

Meanwhile many Haitians are furious at the "importation" of the illness and are seeking a culprit. Cholera has not been present in Haiti for as long as data has been collected. Currently, blame is centered on a battalion of Nepalese MINUSTAH (the French acronym for the United Nations mission in Haiti) peacekeepers based in Mirebalais. 

Hundreds of protesters marched at the Nepalese base on Friday chanting "down with MINUSTAH, down with imported cholera." The Nepalese peacekeepers came to Haiti shortly before the outbreak occurred, and not long after their arrival, a resurgence of cholera cases was reported in Nepal. Their base is situated next to a tributary for the Artibonite River, which is believed to be the primary source of the epidemic. 

MINUSTAH distributed a press release October 26 defending the sanitation system at the base. But Dubuisson Pierre, a Mirebalais resident, said, "We've been complaining for months, asking them to block the leaks. Dirty water was leaking into the river. It's only after they sent out the communiqué that they blocked it off to cover the evidence."

So far, no tests have been done on the peacekeepers because none were ill, MINUSTAH spokesperson Vincenzo Pugliese told the Associated Press. But 75 to 85 percent of people with cholera display no symptoms and are simply carriers. "There need to be some serious studies," said Abel Descollines, a protester and candidate for a local governmental post in Haiti's upcoming elections.

Anxiety in Port-au-Prince

Back in the capital, health officials are building treatment centers and distributing water, anxiously waiting for the epidemic to hit. It may already be present--Al Jazeera reported one case of cholera symptoms in a little girl from the slum of Cité Soleil who had not traveled to the affected regions. In any case, experts are sure that the outbreak is coming. Doctors Without Borders press officer Claude Richard Accidat explained, "It would be very difficult to stop the propagation of cholera in Haiti. You can't prohibit people from going to visit family [in affected zones] or taking a bus to Port-au-Prince."

Most of the NGOs in Port-au-Prince work in the tent camps that still house 1.3 million people displaced by the January 12 earthquake. But areas like Cité Soleil where people live packed together, with few or no toilets and minimal access to clean water, are likely more vulnerable. 

Haiti is still in the international spotlight because of the earthquake, which killed as many as 300,000 people. But the cholera epidemic is highlighting broader structural issues. The earthquake was a natural disaster, but its heavy toll has been attributed to poor construction practices and urban planning. Similarly, cholera is a health crisis, but it is hitting Haiti with particular force because of the country's poor management and its lack of health and sanitation services. It may take more than Clorox for Haiti to scrub this epidemic away.

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