The Big Truck That Went By

Epidemiologist vs. Epidemiologist

Here’s some reaction to that new study from Maryland, which says a second, environmental strain of cholera contributed to the epidemic that started in Haiti two years ago.

Renaud Piarroux, a French epidemiologist whose studies showed the UN base was the likely source of the epidemic, writes in to say he’s not sold:

“The contamination of the Artibonite River by human fecal waste from UN soldiers … is really the only explanation I found after spending weeks in investigating the epidemic in Haiti and additional months in searching for other evidences that could complete this investigation. Conversely, I never heard that Rita Colwell’s opinion was the result of an extensive field investigation in Haiti. I really would have preferred to be convinced by the ‘non-UN evidences,’ but they were really not convincing.”

I invited Dr. Colwell to comment on my previous post, but I haven’t heard back from her. Or as we used to say at the org: Colwell did not immediately respond to requests for comment.

By the way, an answer to one question from yesterday: The samples Colwell’s team examined were collected from eighteen towns and cities over three weeks in November 2010. That’s three to seven weeks after the outbreak began in the Central Plateau.

New (non-UN) cholera evidence?

NPR’s Richard Knox reports on a new wrinkle in the story of how cholera got to Haiti. A team based in Maryland has published a study that found 21 percent of cholera patients in Haiti were infected with a non-Nepalese strain of the disease.

Dr. Rita Colwell says her team’s findings support a hypothesis that the epidemic was caused, at least in part, by environmental factors other than UN soldiers recently arrived from an outbreak in Nepal leaking excrement into a river. For corroboration, NPR’s Knox goes to Dr. David Sack at Johns Hopkins, who agrees the new study casts doubt on the “UN” hypothesis. Sack concludes we will probably never know where the epidemic, which has now killed some 7,500 people and infected more than half a million, came from.

A few thoughts:

1. Colwell and Sack have been arguing for an environmental cause of cholera since the first week of the epidemic in October 2010. After the UN evidence came to light, they have reliably pooh-poohed the UN-cholera connection. In fact, when the UN mission in Haiti started searching for answers in late 2010 and wanted someone to present a hypothesis that something other than the Nepalese soldiers were responsible for the outbreak, my sources inside the mission confirmed at the time, they called in David Sack.

You can make a similar argument against the big names backing the currently dominant hypothesis as well. Whenever you ask French epidemiologist Renaud Piarroux, he is likely to tell you that all the important evidence supports the UN being responsible for the outbreak. Piarroux being convinced by non-UN evidence, or Sack being persuaded that the UN was responsible, would be far more notable. (Disclosure: I try to keep an open mind, but you could probably say the same thing about me.)

2. According to Knox, the Colwell team’s findings don’t actually dispute that Nepalese cholera was a cause of the epidemic — just that it was the only cause. In fact, the study found the Nepalese strain in more than half of samples taken. Additionally, NPR says the non-Nepalese strain “has never been known to cause an epidemic.” To my untrained eye, that would seem to weaken the case for this other strain’s importance, but I don’t know. (Side note: According to the numbers in the NPR piece, only about 78 percent of the samples are accounted for: Half Nepalese, 21 percent non-Nepalese, 7 percent mixed. What happened to the other 22 percent? Maybe that’s in the full journal article, which I’ve reached out to Colwell to get.)

3. It’s not clear from the NPR piece when these samples were taken. That’s important, because we know that cholera can and does evolve once it has been introduced.

4. Some key parts of Colwell’s “perfect storm” hypothesis don’t make sense to me. She says:

“You have this massive earthquake in January 2010 … Then Haiti had one of the hottest summers on record … That was followed by a hurricane that skirted Haiti, causing heavy rain and flooding … With all the river systems churned up with nutrients and warm water, and proper alkalinity, it would be ideal for the organism to become quite dominant.” 

Hurricane Tomas hit on November 5, 2010, three and a half weeks after the epidemic began. At that point more than 500 people were known to have died and at least 7,000 had been infected — both likely undercounts. Tomas skirted the far edge of Haiti’s peninsulas, missing the region where the outbreak occurred. The storm made headlines in the states but didn’t actually cause all that much damage in Haiti. In fact, articles at the time noted that it was not clear if the storm was having an effect on cholera at all.

The earthquake, meanwhile, struck ten months before and was over 50 miles from the outbreak zone, which is probably why Colwell was quoted at the time in a Richard Knox article titled “Earthquake not to blame for cholera outbreak in Haiti.”

Neither the hurricane nor the earthquake explain how “01 serotype with close resemblance to the Nepalese strain” ended up in Haiti, whether as the whole of the early epidemic or “in about half the patients sampled.” 

5. All that said, I agree with Colwell and Sack that the evidence to date against the UN peacekeepers has been largely circumstantial, if also overwhelming. I discuss this in my upcoming book, which you will please be sure to buy.

6. Watch this closely going forward. The UN peacekeepers have been referring to heretofore unspecified evidence for other hypotheses since they were first fingered as the cause of the outbreak. Considering the UN is now facing a lawsuit on behalf of cholera victims that has gotten recent support on the editorial pages of the New York Times and Washington Post, I’d expect to hear more about the Colwell article being cited as counter-evidence in the weeks and months to come.

(Edited 1/19/12 at 1:33 p.m. to clarify the UN was previously referring to unspecified evidence in its favor)

Worst Logic of the Year, Cholera Division

Nigel Fisher, United Nations Resident & Humanitarian Coordinator, January 2012:

“As you know, more than 6,700* Haitians have succumbed to the cholera epidemic so far and almost 500,000* have been infected. If we can take any encouragement, it is that: National cholera response and alert systems are now in place in a country that had no such infrastructure before the cholera outbreak….”

The reason Haiti had no national cholera response and alert system in place was that there was no cholera. In fact there had never been a laboratory-confirmed case of cholera in Haiti, ever, until it appeared in October 2010, almost certainly introduced by United Nations peacekeepers from Nepal.

Please no one set up a national bubonic plague response system.

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* As of April 2012, the official death toll is 7,091 and case load over 534,000.

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UPDATE 5/13/12: 

Fisher made a more important statement earlier this month in an interview posted by the UN News Centre:

“As humanitarian actors facing cholera, what we are doing is sort of patchwork, band-aid work on a fundamental problem. The fundamental problem is when cholera broke in Haiti there was no experience of it and the conditions were ripe for it to spread quickly.*”

Instead, he called for:

“… a massive investment in everything, from food hygiene to water and sanitation to education. It’s long-term and we are working out the details of that.”

Those comments were cited in an editorial which ran in this morning’s Sunday New York Times, which did something Fisher still will not — put them in context of the direct responsibility Fisher’s own organization has for creating the mess in the first place:

“The United Nations bears heavy responsibility for the outbreak: its own peacekeepers introduced the disease through sewage leaks at one their encampments.”

The Times editorial cites a CDC estimate that putting in adequate water and sanitation systems will cost $800 million to $1 billion. That would exceed the Haitian government’s one-year revenues, but is commensurate with the UN peacekeeping mission’s annual budget.

Stay tuned.

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Fisher quote h/t @HaitiJustice

Clinton’s Statement on the Political Situation in Haiti

Some people are having trouble finding Bill Clinton’s statement calling for the quick ratification of Haiti’s new prime minister, which came hours before the new prime minister was ratified. So I’ve pasted the text below.

The new prime minister, Laurent Lamothe, is an old friend of President Martelly who set aside his business providing telecom services to African governments to join the interim reconstruction panel after the 2011 election. Martelly later put him in his cabinet, then nominated him to replace previous Prime Minister Garry Conille after the latter abruptly resigned in February.

Lamothe’s nomination was held up for months. Then, a few hours after Clinton’s  statement, Lamothe was approved by parliament, and then installed by presidential decree the next day. 

Clinton has a lot of potential roles to play in this story: He was the co-chair of the reconstruction panel (along with the prime minister) that Lamothe joined; and the ex-PM, Conille, had been his former chief of staff at the UN Office of the Special Envoy for Haiti. Whether his call to “establish a functional government within the week” (see below) helped speed the process along, reflected an outcome he knew was coming or was totally coincidental is a matter for debate. Feel free to have it in the comments below.

Here’s the text:

REVISED: Statement by President Bill Clinton on the Current Political Situation in Haiti

May 03, 2012 | New York, NY | Bill Clinton | Statements

I call on the Haitian Parliament and the Martelly administration to expedite the ratification process of the Prime Minister, and establish a functional government within the week.

I believe that the Haitian people deserve better from their leaders. The current political crisis disrupted progress towards a more prosperous Haiti for too long. While I am pleased by much of what has been achieved since President Martelly took office, Haiti’s rebuilding efforts have been delayed far too many times. Haiti must have a government with strong and transparent leadership working alongside a parliament that understands its economic, political and social challenges.

Haiti’s leaders have a responsibility to put the Haitian people first, above political differences and self interests, and to show the world that Haiti is on the right path to ensure democracy, and the rule of law, fight corruption, and restore confidence in the Haitian institutions so that donor funds can flow again and attract new investment. I stand ready to continue to assist President Martelly, Prime Minister Designate Lamothe, the parliament and Haiti’s friends in the international community to achieve this provided Haiti’s leaders act now in the best interests of the Haitian people.