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Will Lessons from Cholera in Haiti Be Applied to COVID-19?

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In recent weeks, the United Nations Department of Peace Operations announced a series of protocol changes to reduce the risk that peacekeepers will introduce COVID-19 into vulnerable countries. As the introduction of cholera to Haiti in 2010 by UN peacekeepers demonstrates, such preventative measures are critical. Yet there is cause for concern that the lessons from cholera in Haiti have not translated into adequate action to protect peacekeeping host communities from the preventable transmission of disease.

Peacekeeping presents a unique risk of introducing diseases into the world’s most vulnerable places. Since the World Health Organization (WHO) first declared the novel coronavirus a Public Health Emergency of International Concern in January, peacekeepers from over 120 countries have been involved in UN missions, traveling in and out of extremely fragile states. As Under Secretary-General for Peace Operations Jean-Pierre Lacroix observed, “the places where [UN] peacekeepers operate—vulnerable civilians there are the most at risk… [they are] fragile political environments, where individuals are living in conflict-affected or post-conflict societies with little to no infrastructure or social and sanitary safety nets.”

This risk posed by peacekeeping is not merely hypothetical. In Haiti, over 10,000 people died and close to a million were infected with cholera following the introduction of the disease from a UN compound in 2010. Cholera broke out there for the first time in the country’s history after the UN Stabilization Mission in Haiti (MINUSTAH) failed to effectively screen peacekeepers before their deployment from Nepal—a cholera-endemic country in the midst of its own outbreak—and allowed contaminated waste from its base’s toilets to enter the waterways many Haitians rely on for drinking, washing, and growing crops.

While the UN is making efforts to apply lessons from the cholera epidemic, there are reasons to question whether the reforms are adequate. Audits conducted by the Office of Internal Oversight (OIOS) and other UN memoranda have documented alarmingly widespread recurrence of waste mismanagement on UN bases globally, including in Côte d’Ivoire, Sudan, Somalia, the Central African Republic, Abyei, Liberia, Lebanon, and the Democratic Republic of the Congo. The most recent audit of peacekeeping waste management, carried out during the closure of the African Union-United Nations Hybrid Operation in Darfur (UNAMID) and published in December 2019, found that that mission was spilling untreated wastewater into the surrounding environment at several locations, exposing both UNAMID personnel and the local community to health risks. Even in Haiti itself, an initially withheld audit showed that the UN’s problems with waste management continued for five years while the epidemic was ongoing.

Changes to the UN’s medical support manual following the cholera outbreak have also been inadequate. The updated manual acknowledges that “the United Nations should also be mindful of the danger inherent in the introduction of diseases into the host country’s environment, particularly where such diseases are assumed to be non-existent prior to peacekeeping.” However, it offers little guidance on how to actually put this principle into practice in the field to address existing risks, let alone effectively adapt it to a novel disease like COVID-19.

In turn, even specific changes to protocols may not always reflect best practices. For instance, while the manual now requires vaccinations for cholera prior to deployment, this may not be the most effective evidence-based intervention to prevent cholera transmission. A study by scientists at Yale University suggests that vaccines are only 60 percent effective, whereas prophylaxis and screening measures, which UN-appointed experts recommended implementing in Haiti’s aftermath, were estimated to prevent transmission 90 percent of the time. Those measures were rejected by an opaque task force appointed by the secretary-general in 2011, however, without providing justification or supporting scientific evidence.

As the COVID-19 pandemic has made clear, transparent and coordinated decision-making is critical in addressing public health crises. The fact that UN peacekeeping has been slow to implement changes in this regard to its public health and pandemic response after the deadly cholera outbreak should alarm experts and the general public alike.

Today, questions as to whether the UN has learned its lessons from Haiti are coming into focus in South Sudan, where the first three confirmed COVID-19 cases were all foreign UN personnel. The fourth—a local UN staffer—marked the first known case of local transmission. While it is possible that the UN’s superior access to testing meant it was merely the first to identify a disease otherwise circulating in South Sudan, activists are also accusing the UN of delays both in testing and quarantining the first individual, and in notifying South Sudanese authorities of the first case.

Furthermore, the South Sudanese government’s coronavirus task force has strongly criticized the UN over another staffer who fled the country while under quarantine after being exposed to one of the infected staff. Although UN peacekeeping said the individual tested negative for the virus in their home country and disciplinary action will be taken, it remains unclear what such action will entail or what measures they have taken to prevent similar events. At the very least, the UN’s approach thus far falls short of effectively meeting its stated objectives in the COVID-19 response, including to “help contain and mitigate the spread of the virus, ensuring that UN personnel are not a contagion vector” and to “support national authorities in their response to COVID-19.”

As we approach the ten-year anniversary of the preventable cholera disaster in Haiti, the COVID-19 pandemic underscores the urgent need for the UN to demonstrate not only that it has learned crucial lessons on peacekeeping and public health, but that it is actually applying them on the ground.

*Adam R. Houston is a PhD Candidate in the Faculty of Law and Member of the Human Rights Research and Education Centre (HRREC) at the University of Ottawa. He tweets at @HealthLawAdamH. **Beatrice Lindstrom is a Clinical Instructor in the International Human Rights Clinic at Harvard Law School. She was previously Legal Director of the Institute for Justice & Democracy in Haiti, where she led advocacy for accountability for the cholera epidemic in Haiti.*

Originally published in the Global Observatory