Preventing cholera in Haiti

In 2016, when a fresh outbreak of cholera began in the mountainside community of Wopisa-Gabriyèl, Haiti, Precius Estilus was among the first to fall ill. Early one morning, he was gathering his tools to work in his garden when he was overtaken by a sudden, extreme weakness.

By 11 a.m., he was vomiting. A friend encouraged him to go to the doctor, and they began the long descent to the nearest cholera treatment center.

The only way out of Wopisa-Gabriyèl is on foot. The descent is steep and covered with loose rocks, and at one point requires climbing down rocks through streaming water in the middle of a waterfall. Despite his friend’s encouragement to hurry, Estilus had to stop every few minutes to recover and gather his strength.

By the time he finally arrived in the town of Verrettes and the cholera treatment center of MCC partner Zanmi Lasante (the Haitian branch of the nonprofit Partners in Health), it was 10 at night. Another patient in the center had just died. Seeing his condition, doctors immediately started him on rehydration solution.

“As the IV dripped, I felt closer and closer to God,” he says. “I knew only God could give me back my life.”

Estilus was 28 years old at the time; his wife was pregnant with their youngest child. Given how quickly severe cases of cholera can progress, even strong young men like him can die in a matter of hours.

Estilus was lucky. After seven days, weak but alive, he was discharged and came back to his community with a supply of water purification tablets from the center.

In Wopisa-Gabriyèl, Precius Estilus was among the first to fall ill with cholera during an outbreak in 2016. With MCC’s help, Estilus built a simple latrine and received a water filtration bucket and hygiene training.

Not long after Estilus returned, MCC staff visited to find out what was most needed in the community, which was lashed by the winds, rains and flooding of Hurricane Matthew in October 2016.

“We assumed that we’d probably be doing a food security project, as this had been the priority issue in most areas we visited,” says Paul Shetler Fast, at the time an MCC representative for Haiti and now MCC’s global health coordinator.

“But they were very clear that no, latrines and stopping cholera was number one, gardens could come next. I remember one older man said something like, ‘What good is food if I’m too sick to eat, what good is a garden if I’m dead?’”

Cholera is a fast-acting bacterial infection that is transmitted from person to person through contact with infected fecal matter, most often when water sources are contaminated by human waste containing the cholera bacterium. It thrives in unsanitary conditions, where people lack the means to purchase bleach or construct adequate toilets.

"I knew only God could give me back my life."

- Precius Estilus  

Haiti’s ongoing cholera epidemic started in 2010, in the aftermath of the earthquake that had devastated the capital city, Port-au-Prince, earlier that year. Infected waste, improperly disposed of by a contingent of United Nations peacekeepers, was released into Haiti’s Artibonite River. Within days, an outbreak of a particularly virulent strain of cholera swept down the course of the river, into surrounding areas in the Artibonite Department (like a province or state) and, eventually, throughout the country. To date, almost 10,000 people have died, and close to a million have gotten sick.

Cilana Louissine, 45, was talking to a community health worker in 2016 when she suddenly felt extremely weak, almost unable to walk. She, too, made the arduous descent from Wopisa-Gabriyèl. Shortly after arriving in the crowded cholera ward at Hospital Albert Schweitzer in the town of Deschappelles, she lost consciousness.

“My family was there with me,” she remembers. “My husband was crying; they all thought I was dead.”

After nine days in the hospital, she returned home to face a long recovery. Even though she was no longer sick, she was weak from the illness and unable to work. Her family suffered financially long after she recovered.

Treating cholera is simple and affordable, but for those like Estilus and Louissine in remote communities hours from medical care, this treatment is often too far away. Prevention is paramount.

MCC worked with the community to develop a project that would eventually result in the construction of 600 latrines in the wider Wopisa-Gabriyèl area.

MCC provides a cement base, tin roof, PVC pipe and nails for each latrine, while residents supply labor and local materials for the walls.

Without latrines, residents had no choice but to defecate outdoors where their waste could contaminate the soil. During the hurricane, heavy rains washed soil — and everything else — down the mountain and into the rivers and streams residents use for drinking and washing. Cholera cases, which had been declining since 2010, spiked.

The idea for prevention is simple: if potentially infected waste is contained and kept away from floodwater and flies, the risk of cholera transmission can be dramatically lowered.

MCC provides basic construction materials — a cement base, tin roof, PVC pipe and nails — and the community provides labor and local materials for the walls.

Alongside latrines, MCC provides water treatment tablets and water filtration buckets, as well as training on the use and maintenance of latrines, techniques for washing fruits and vegetables and techniques for effective handwashing.

Because cholera can be spread by insects that land on fruit and vegetables after coming into contact with infected waste, thoroughly disinfecting produce with water and bleach, as Cilana Louissine is doing here, is a simple and effective way to prevent transmission of the disease. 

The year before this project began in Wopisa-Gabriyèl and in the community of Kabay, health workers reported 291 deaths from cholera in the two communities. In the more than two years since these projects were implemented, there have been zero.

In fact, the work has been so successful that, after Hurricane Irma caused flash floods in the Artibonite Department in September 2017, a scaled-up version of the project was implemented throughout the larger region where Wopisa-Gabriyèl is located. That project, which targets schools and other potential transmission points and supports the local water authority and civil protection volunteers, has seen the same success.

MCC’s cholera work is multifaceted, including providing buckets for handwashing stations and water filtration to 231 elementary schools —only five of which had regular hand washing and clean drinking water available for students before. After 2016’s Hurricane Matthew, MCC also supported the rehabilitation and expansion of a Zanmi Lasante cholera treatment center in Verrettes that was initially constructed as a temporary response to the 2010 outbreak of cholera.

When Estilus thinks about how his life has changed since 2016, latrines are a major component. “Before, we had to take care of our needs outside,” he says. “Cholera almost destroyed us, but now it’s gone. Now we have latrines.”

Louissine is especially thankful for the training she received with her new latrine. She hopes that, as her children grow up and have children of their own, they’ll continue the hygiene practices they learned as part of MCC’s trainings. It’s this knowledge that will ensure that Wopisa-Gabriyèl remains safe and free from cholera into the future.

“We thought our life was finished,” she says, “but now, with MCC’s help, we’re moving forward.”

Getting to zero: Thanks to strategic interventions in Wopisa-Gabriyèl and Kabay, two communities at the heart of Haiti’s cholera epidemic, there have been no cases of cholera in the more than two years since MCC projects began there. Here’s what it took to get to zero.