Cholera in Present-Day Haiti: Interpretations of and Responses to a Contemporary Enemy

Note: In lieu of an abstract, this is the article's first paragraph. "In his introduction to Epidemics and Ideas, Paul Slack calls to revive the study of social history of epidemics, wanting to show how societies cope with, react to, and interpret crises of disease. He reviews historian Richard Evans’ notion of the “common dramaturgy” to all epidemics, which states that human society responds to mass infection through an inherent response mechanism. Disease presents common dilemmas - including decisions on how the disease is transmitted, whom it infects, who is to blame, and incites common responses. Furthermore, Slack suggests that the society’s understanding of infection, interpreted through different social, cultural, and political contexts, shapes the specificity of these responses. Such variables of understanding include the novelty of the disease, violence of infection, geographical and social incidence, and the ‘disease-environment’ preceding the epidemic."

infection and the infected; (2) identification of disease carriers, followed by stigmatization and labeling as scapegoat; and (3) belief of these scapegoats that the epidemic is a consequence of plots by their enemies. Whereas the cholera epidemic in Haiti has certainly provoked these same questions, the Haitian population has not always responded in the same general manner for which Slack argues. At the same time, the epidemic has not yet finished its scourge in Haiti and such responses may have yet to be fulfilled. 2 Soon after the outbreak was announced, fear of the disease and its sources grew; additionally, so had efforts to separate oneself from the contagion. A Health Cluster Bulletin published by the Pan American Health Organization (PAHO) noted that, around the first month anniversary of the outbreak, people suffering from other illnesses started to refuse hospitals visits in fear of contracting cholera at the facility. 3 Valerie Amos, the UN under-secretary-general for humanitarian affairs, further confirmed these behaviors, quoting, "…people are deeply suspicious, they are deeply worried. Even those who want to seek treatment sometimes are prevented from doing so. They are worried about the response they may get from their neighbors." 4 However, movement away from the infection may be limited as the epidemic progresses if there are few places to relocate. This is a possibility in Haiti for the families living in the more urbanized areas of Haiti. Since the January 12 th earthquake, over 1.5 million Haitians have been displaced from their homes and are living in "refugee" camps. Attempts to flee the disease are futile. Many Haitian sources express the financial limitations and social oppression of the common peoples, especially relating it to the state of politics and recent natural disaster. In contrast, the Dominican Republic has begun to make separations from the disease -not by flight, but by expulsion. Within the fifth week of the epidemic, voices from the Dominican Republic expressed feelings of xenophobia. Reports of Dominican neighborhoods exiling cholera-positive Haitians demonstrate much less tolerance for the disease than is being observed in Haiti. 5 While Slack may have over generalized in his comments by saying that flight from disease was a common response, he may have been more correct by suggesting that populations will respond to disease by distancing themselves from the source of infection -whether by fleeing a location or exiling a population. 2 Slack, "Introduction," 3. 3 Pan American Health Organization, "Situation Overview," Health Cluster Bulletin. 3(19 November 2010): 1--3. 4 Nguyen, Katie. "Haiti election unrest restricts aid operations -UN relief chief." Alertnet, December 9, 2010, accessed December 11, 2010, http://www.trust.org/alertnet/news/haiti--election--unrest--restricts--aid--operations--un--relief--chief/ 5 Rateau, Jackson, "Xenophobie exacerbee des Dominicains contre les Haitiens." 24 November 2010. 4(19) pg 3. Haiti Liberte, November 24, 2010 A second common response to an epidemic is the identification of those infected and a subsequent stigmatization of this population, often foreigners or unpopular minorities. Haiti demonstrates this response with a slight modification. The public readily admits, "the cholera victims come from the destitute slums and huts of peasants -dispossessed, impoverished, and lured by false hopes to work at the capital." 6 However, they place little, if any, blame on the "paupérisée," and instead, seek a source of higher authority to  November 24, 2010, 2. 7 Mission des Nations Unies pour la Stabilisation en Haiti (MINUSTAH). In June 2004, this mission was authorized after the president of Haiti was exiled as a consequence of several armed conflicts occurring in various cities throughout the country. The original goal was to secure a stable environment, promote clean politics, strengthen governmental institutions, and protect human rights. After the January earthquake, however, MINUSTAH forces and goals were expanded to support quick recovery, reconstruction, and stability efforts.   other, threatening the very existence of the nation." 9 Whereas Slack implies that society often assigns the scapegoat label upon the main carriers of the disease, this is not quite the case in Haiti.
As cholera targets the poor and over 78% of the population lives on less than $2 a day, the majority of the population are exactly those at risk. 10 Public politicians are hesitant to blame, and even seek to defend, MINUSTAH forces in the dialogues offered by newspapers; yet, they have failed to silence the majority's opinion of placing blame on a group of higher authority. Slack is correct in the latter part of his assertion by saying blame is placed on foreign and/or minority populations, of which the Nepalese MINUSTAH forces are both. \ A third component in Slack's support for a "common dramaturgy" is that the stigmatized party will deny their role in the spread of the disease and, more specifically, will denounce the blame as a conspiracy theory. After deadly riots that protestors threw stones at the Nepalese and verbally assaulted them for the believed infection of the country, the MINUSTAH published a press release that affirmed; "The way events unfolded suggests that these incidents were politically motivated, aimed at creating a climate of insecurity on the eve of elections. MINUSTAH calls the people to remain vigilant and not be manipulated by enemies of stability and democracy in the country." 11 Vincenzo Pugliese, a spokesperson for MINUSTAH, also reflects a similar sentiment, "Someone is hiding behind all this. People do not have the means to communicate and organize things like those questions to which we are witnessing. There is someone who handles it. It is clear; this is part of a plan." 12 Both of these sources demonstrate and support a common response of denial, suggested by Slack.

II.
Slack provides a list of common dilemmas shared by all societies when confronted with a biological epidemic and identifies common responses to such dilemmas, as discussed in Part I.
Through our very brief analysis, we can see that it is difficult to accurately anticipate the response of a unique society on the basis of these generalized guidelines. Slack then presents another idea: collective responses to epidemics develop different profiles, depending on the society's particular  15 The WHO provided a "time--tested management protocol," based off the experience of this international public health agency with past epidemics and outbreaks of cholera. There are cautions that medical practitioners might have been misguided by these protocols and believed them to be the most effective route to treat cholera in Haiti, while ignoring strategies of advanced medical training and community education to decrease the incidence and spread of the cholera bacillus. There is evidence that this, however, is not the case; training programs for Haitian medical practitioners and educational interventions of the community have complemented the strictly biomedical protocols, and are received efficiently by the population. To view the epidemic in a more "three-dimensional" format, Slack argues that it must be placed in the context of the country's "disease-environment" and be related to background levels of morbidity and mortality. Haiti's response to the cholera epidemic receives impetus by its previous and ongoing struggle with disease and public health. 21 The concerns of greatest relevance 16  to the locals are that of premature death, malnutrition, and deadly infectious diseases, as conveyed through this opinion: "While in this country even thousands of children die at birth and thousands more never reach their fifth birthday; while plagued by hunger and death that follows, before the disastrous earthquake." 22 Haitians understand that these issues are caused by deficient sanitation systems, poor nutrition, and inadequate health services, as their country ranking last in the western hemisphere in health care spending. As a result, Haitians interpret their poor disease-environment to be a consequence of national governmental ignorance. They express, "History has bequeathed to Haiti inequality, dictatorship, corruption, and extreme and persistent poverty, which all contribute in their way for the Haitian government's failure to provide clean water to the population." The population, therefore, views cholera as another reason to believe in the failure of the government, expecting that the government will maintain status quo and do little to relieve the symptoms of the populace; "The consequence: a vicious cycle of contaminated water consumption, ineffective public hygiene, health crises and recurrent underlying all the foregoing, chronic poverty and deeply rooted. 23 " Upon recognition of a poor disease-environment and understanding it as the fault of governmental disregard, the population responds with a heightened campaign of popular skepticism that carries criticisms of current politicians and election candidates. A reporter claims that they, the local citizens, have been ignored by the politicians and are "people trampled by leaders who promote their own well-being," and later suggests that, "Maybe other more lucrative targets are being pursued by our leaders, and [this ignorance] contributes to the Haitian genocide." 24 Additionally, a recent anti-imperialism movement, representing large swaths of Haitians, has voiced similar concern. This organization criticizes the corrupt and greedy government of allowing first-world countries to develop neo-colonialist regime within Haiti and to rape it of it's natural resources, while simultaneously preventing development of important infrastructure that would benefit the indigenous population. Furthermore, this movement threatens the imminent presidential election with boycotts, despite the desperate need for it's complete representation if the movement's favored presidential candidate is to win.
As the disease began to infect more people and desecrate previously untouched regions, the Haitian population started to associate cholera with characteristics of violence and aggressiveness, and continue to do so presently. Such belief is observed through short excerpts of various  biases the disease holds against certain populations. In the case of Haiti, cholera has inflicted pain upon the poor of both the urban slums and the rural hinterlands. As cholera has become understood as a disease of the masses -a disease of the poor, the squalor, and the dirty -the population has come to the recognition that they cannot rely on their national government to provide them with necessary resources. In response, the population has taken up the response to rely on international governmental organizations and aid groups to provide them with the financial and provisional resources to combat this disease. 28 In the blogs released from hospitals within Port-au-Prince, there are constant pleas for assistance, specific requests of supplies, and unceasing thanks for donations already made. A recent blog states, "It takes about $22 to save the life of a child from cholera… I think you will agree that $22 is not very much money to keep a child alive and give her back to her mother… Let's splurge. It's the right thing to do." 29 It is obvious these pleas for help are not being made to the Haitian population, as $22 is about half of the average Haitian's monthly salary; instead, such requests reflect a desperate hope that outside donors are their only source of materials. Haiti not only expresses an expectation of individual philanthropy, but also of the supply of medical professionals, whether through non-governmental institutions or informal volunteer networks. They have expected, and since received, a large battalion of Cuban doctors who treat 40% of all cholera cases and "make benefit not only to patients, but also the Haitian medical staff, [the Cuban doctors] having their medical skills at the highest level. They are even helping the campaign of prevention of disease, held in schools by the government and in collaboration with UNICEF." 30,31 Ironically, and almost hypocritically, it is this response that delivers Haiti into a perpetual cycle of international reliance, although the population simultaneously demands independence from colonial and neo-colonial bounds.
While evaluating sources that expressed the current opinions of the Haitian population, I noticed a reoccurring variable that influenced their response of which Slack did not include within his guidelines. The physical environment and, more specifically, the occurrence of natural 28 In the previous paragraphs about other variables, the inequalities experienced by the cholera epidemic have already shown to implicate a multitude of responses. It has contributed to political discontent, to violent responses against international forces, and has limited the implementation of educational messages. Clearly, the social incidence of cholera does not insinuate one specific response. In this paragraph, I seek to offer a novel response of the population that derives from the unequal incidence of cholera and has not yet been discussed within the framework of previous variables. 29 Frechette, Rick. "Cholera andRiots." NPH Saint Damien Hospital Haiti. November 22, 2010. Accessed December 11, 2010. http://saintdamienhospital.nph.org/ 30 Busseien, Tony. "Haiti: jusqu'ou ira l'arrogance des Etats--Unis?" Haiti Liberte. December 8, 2010. 7. 31 On November 14 th , 2010, Cuba provided 800 additional doctors and nurses to Haiti, in addition to the medical forces already present in response to the January 12 th earthquake. Taken from: Auken, Bill Van. "Manifestants abattus en Haiti." Haiti Liberte. November 24, 2010. 8. disasters have also appeared to hold influence over the general response of the Haitian majority.
The chilling memory of the January 12 th earthquake, which killed over 230,000 citizens and displaced 1.5 million, is frequently recalled within the Haitian dialogue. The more recent hurricane Tomas also inflicted a great deal of damage upon an already hurting population. A Haitian reporter suggests there is an "inability of the Haitian popular consciousness to understand and explain the phenomenon of the earthquake as being purely natural and not the expression of the will of any spirit of a god or God Almighty who punishes sinners in general (emphasis added)." 32 The repeated occurrences of natural disasters have imposed a fatalistic mood upon the population and called into question their belief of an otherworldly deity. Their dialogue and questions reveal a sense of defeat, doubt, and pessimism; "Haiti still unable to get up, to cope with the unleashing of nature… How is it that a country like Haiti can never get out, rain or shine, and that we have the distinct impression that the country is regressing rather than moving forward?" 33 The population had been primed with a fragile sense of confusion and upon invasion of the cholera bacilli, the stability of the public's consciousness fractured. As a result, the response of the population oscillates between anger and despair, resignation and rage, all while trying to place blame and find security. The unprecedented magnitude of the previously discussed reactions, such as malcontent with national governance and violence directed towards international force, has been the direct response of a population primed with fatalistic views and a brittle spirit incurred by repeated natural disasters.

III.
It is evident that the current Haitian cholera epidemic has initiated a reaction characterized as violent, intense, and largely as a conduit to exhibit distaste of national and international governance. Slack proposes that these epidemic profiles are unique to every society and are reliant on how the disease interacts with the populace. He continues to state that variables of novelty, disease-environment, geographical and social incidence, and violence of the disease are significant in the profiling the society's response. Although Slack's offerings are not quite complete, as he does not use society's previous experience with natural disasters within his examples, his methods of analysis can be used to support the presumption that a society's unique response to disease 32 Michel, Herve Jean. "Le cholera poursuit ses ravages en Haiti!" Haiti Liberte. December 9, 2010. 14. 33 Lanctot, Jacques. "Vivement une revolution a Haiti!" Haiti Liberte. 15 November, 2010. 8. arises from its ability to explain the infection when informed by the present-day socio-cultural context. In truth, Slack may have been limited by the length of his volume to be fully comprehensive, as I have experienced the same dilemma in trying to qualify a complex process within a finite space.
Using a variety of primary sources, I have attempted to make sense of the Haitian response to the recent cholera epidemic by observing the ways the disease interacted with the social, cultural, and historical background of this country. 34 During this, I have struggled to associate one response with only one variable. For example, violence perpetrated against MINUSTAH forces was not solely a reflection of the violence that cholera wrecks on an individual's body -it was also a result of historical bitterness held against imperialist forces and, although not discussed, of the current day abuses that MINUSTAH has inflicted upon Haitian citizens. Responses do not delineate from one specific variable, nor can one response be separated from another, just as the social, political, cultural, and historical factors of a country do not function as separate entities.
Instead, the dynamic relationships between the suggested variables constructed a unique perception of cholera, specific to Haiti, and initiated a complexity of responses interdependent on one another.
Additionally, I compared Haiti's experience with the 'common dramaturgy' of events that Paul Slack had proposed. Again, I discovered that any attempt at generalization could never be met with full success. A society's experience with disease -or any conflict in general -is a multidimensional process that cannot be reduced to two dimensions of cause-and-effect or to a linear sequence of events.
In his article Cholera and Colonialism, David Arnold presents: "Like any other disease, [cholera] has in itself no meaning: it is only a micro-organism.
It acquires meaning and significance from its human context, from the ways in which it infiltrates the lives of the people, from the reactions it provokes, and from the manner in which it gives expression to cultural and political values." 35 In conclusion, the Haitian experience has demonstrated how historical and present-day governmental rule (or lack thereof), combined with inherent poverty and sickness, exacerbated 34 This affair has been especially interesting to observe because it is the first time cholera has encroached upon Haitian borders and new meaning is being given to the epidemic each day. It should be recognized that that profile of the disease established in this essay may be entirely different than the profile it will possess at the end of its reign, whenever that may occur. 35 Arnold, David. Cholera and Colonialism in British India. Past and Present. 1986;113(1): 118--151. with recurrent and abusive natural disasters, and a diversity of other contextual variables has endowed a certain profile upon the cholera bacilli. The responses to this disease have included a failed uptake of educational hygiene messages, not limited by traditional beliefs but by deficient resources; violent episodes between the Haitian majority and UN forces; a continued reliance on international aid; a criticism of nation government; and an unstable, victimized social consciousness.

Index.
Cumulative cholera cases reported as of epidemiological week Dec 5-11. Number of reports cases are represented from highest-lowest by a red to yellow gradient, respectively. Total cases as of December 11 th is 106,610. Blue dots represent cholera treatment facilties and green circles represent a 5 km radius (1 hour walking distance) from cholera treatment center. Data from Ministere de la Sante Publique et de la Population.
Cumulative cholera deaths reported as of epidemiological week Dec 5-11. Number of total reported deaths are represented from highest-lowest by a dark-green -light green gradient, respectively. Total reported deaths as of December 11 th is 2,276. Blue dots represent cholera treatment facilities and green circles represent a 5 km radius (1 hour walking distance) from cholera treatment center. Data from Ministere de la Sante Publique et de la Population.

Number of new cases and overall fatality rate from
October 20 th to December 15 th . Number of cases represented on left-hand axis and percent fatality represented on right-hand axis. Data from Ministere de la Sante Publique et del la Population.