Health as Peace

Structural Violence and Cholera in Haiti

March 12, 2013, Mirebalais, Haiti, The Cholera Treatment Center is busy with patients even in the dry season. Most of the patients come to the CTC from areas well outside of Mirebalais. Dr. Thelisma Heber, 40, has been caring for patients at the ZL CTC for 2 years. Belizaire Selfanord is 8 years old and severely dehydrated. He was brought to the CTC from Labastille by his mother, Sentane Pierre. Credit: Rebecca Rollins, Partners in Health

Jean Jean Joseph lies on the cot, an arm draped over his forehead, shielding his eyes. The roof of the temporary medical ward is made of green plastic, casting everything in a sickly tint. His feet are broad and flat, with widespread toes and thickly calloused skin, cracked at the heels—79 years of much barefoot walking.

The bed is a wooden cot, with plastic sheet-coating nailed along its length. In the middle of the cot is a circular hole. A bucket sits beneath the hole to catch the watery stools as they evacuate from his body due to an infection with Vibrio cholerae—the bacteria that causes cholera. The correct size of the hole in a cholera cot (for such cots are routinely needed in some areas of our world, therefore specifications are required) should be about eight inches, and the bed should be high enough, but not too high. Guidelines instruct: “If the bed is over 70 cm [28 inches] high, there is a risk of the excreta splashing,” as if the indignity of painful cramping and life-threatening purging of fluids through vomiting and diarrhea are not already enough.

Patients are treated at the Cholera Treatment Center in Mirebalais, Haiti, on Nov. 8, 2012.

Although there is no person directly committing a physically violent act on Jean Jean, and in fact the staff are doing their utmost to care for him with dignity, I feel my own sense of nausea in this moment as his doctor, a feeling in my gut as though I have been punched in the stomach. It is the kind of wrenching that occurs in the sensation of being a hapless witness to a violent act. It is not the same kind of violence, of course, as the atrocities that abound in Port-au-Prince and increasingly throughout the country of Haiti these days—where a recent report confirmed 115 murders as a gang moved to control the town of Pond Sondé±—a crossroads town, filled with ‘ti machann’ (small commerce) and food stops for tired truck drivers en route from the northwest to Port-au-Prince. It’s not the same kind of violence as the gunfire that struck a commercial flight approaching to land on the runway of the Toussaint Louverture International Airport in November, forcing flights to be cancelled, the airport closed, and the US federal aviation authority to ban air traffic over the region. However, amongst the interlocking issues of societal unrest and physical brutalities faced by the Haitian people in these times, cholera is a disappointing cruelty, predictably and avoidably added to the turmoil.

Johan Galtung frames aspects of peace and violence and offers practical considerations for researching and studying peace in a 1961 article “Violence, Peace, and Peace Research.” Galtung labels forms of violence including indirect violence or structural violence, where the actor of the violence is not explicitly an individual. He wrote, “There may not be any person who directly harms another person in the structure. The violence is built into the structure and shows up as unequal power and consequently as unequal life chances.”

The late Dr. Paul Farmer, a physician, medical anthropologist and Harvard professor who began working in Haiti in 1983 and co-founded Partners In Health, popularized the framing of medical inequities and clinical injustices in terms of structural violence. (Paul was my mentor). Rural Haitians who shared their detailed experiences with my team and me in 2011 demonstrated a resonance with this idea of violence by frequently describing their lived experiences of cholera in militaristic terms— sharing how the outbreak “attacked” individuals, “ravaged” communities and induced fear. Structural violence was not an abstract academic notion in these communities and while they did not use this term, time and time again our rural Haitian participants vividly described the structural vulnerabilities that put them at risk of illness and at risk of death from cholera.

PIH staff carry a case containing the cholera vaccine Sanchol in the Artibonite region of Haiti in April 2012. Credit: Rebecca Rollins, Partners in Health

“It was a bit difficult at the time because of frequent rains. And the roads to get to the upper 5th section are not good at all. So, taking someone to [a health center] was very hard.” (Male community representative)

“We don’t currently have a health center in the lower 5th section…[And] when it [cholera] first arrived…if someone didn’t see a doctor within 4 hours, he could die. That’s why a lot of people died.” (Male community leader)

Cholera first became a public health problem for Hispaniola in 2010, when a major outbreak was triggered by the introduction of the bacteria Vibrio cholerae by international soldiers rotating through a United Nations peacekeeping barracks in the Central Department of Haiti. Whereas the individual solider(s) may have been unaware they were shedding cholera—as reports said no one was sick—the sanitation infrastructure in the UN base was insufficient, permitting the deadly pathogen to be released into the local water system. The result was a catastrophe. Having never been faced with this pathogen before, Haitians had no natural immunity. A lack of investment in clean water and sanitation over the prior one hundred years meant that simple preventative measures like using latrines and drinking clean water were materially impossible for many. Desperate poverty in some regions—including where I have worked for more than 20 years with Zanmi Lasante/Partners In Health—meant that families had to make merciless choices such as whether to buy food or to buy soap for handwashing, or to pay school fees.

Oral cholera vaccine – Shanchol – distribution Credit: Jon Lascher / Partners in Health (PIH)

For eight and a half years following the initial outbreak, cholera raged: first in a major country-wide outbreak, then in ebbs and flows of hotspots of disease, until finally in 2019 cases became quiescent. After major efforts from civil society, non-governmental organizations and government entities, and perhaps a degree of immunity from both the intense natural exposure as well as some cholera vaccination campaigns, no major diarrheal outbreak was reported in Haiti by the spring of 2019, and then no stool culture identified the presence of Vibrio cholerae for the following two years. All breathed a sigh of relief and some even believed (and officially celebrated) that the disease had been eliminated from Haiti.

But what happens when a violent epidemic of preventable, treatable diarrheal disease finally subsides in a country? Can we consider this a kind of “peace”? Although stabilizing the future of the country was not an overt goal of the international humanitarian assistance offered to Haiti during the cholera crisis, the connections between international development aid, humanitarian response and reducing the fragility of nations is quite well described. Investment in health is seen by governments as an important diplomacy tool and studies suggest that health investments, in addition to their humanitarian function, also reduce the “fragility” of states. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), is oft cited as one of the most effective global health programs of all time, having saved 26 million lives globally and, according to a bipartisan analysis has also improved global security, stability and governance.

Campaign against cholera Credit: Jon Lascher / Partners in Health (PIH)

However, having pledged to transform water and sanitation in Haiti as a component of responding both to the epidemic of cholera and to a major earthquake earlier in 2010, no such revolution in water and sanitation ever happened and many international development dollars actually failed to materialize. Consequently, the inhumane conditions in which cholera thrives did not abate in Haiti even during its conspicuous microbiologic absence between 2019-2022. In fact, social conditions in many areas worsened as the sociopolitical context continued to reach new levels of urgency – most recently described as “collapse.”

Conflict is intertwined with health—through mechanisms such as described by Graeme MacQueen and Joanna Santa-Barbara as direct violence, disruption of economic and social systems, famine and diversion of economic resources to military ends, rather than health needs. It seems clear that conflict leads to ill-health in many ways and not always as inadvertent consequences. Yet the role of good health, the protection of health, the promotion of health or even of health-workers in peace-building is less well studied, and at sometimes extremely controversial.

Between March and June of 2012 an an oral cholera vaccine – Shanchol – was distributed in two doses, two weeks apart in the Artibonite Valley region of Haiti. About 50 thousand people were vaccinated. Another 50,000 were vaccinated in Port-au-Prince by GHESKIO, working in conjunction with PIH, ZL and the Ministry of Health. Credit: Jon Lascher / Partners in Health (PIH)

Since 2011, our team’s qualitative and quantitative research as well as deep engagement with impacted communities, offering services providing care to patients, education, training, supplies and vaccination – consistently shows that very quickly after the diagnosis of the outbreak in 2010, Haitians knew what they should do to prevent cholera, but they regularly lack the material means to do it. This fact remained true in 2018 when our observations and household surveys showed that 27% of homes had someone in the household with diarrhea in the previous two weeks, 35% used spring or surface water as their main water source, and almost two thirds experienced moderate or severe food insecurity. Despite having high “knowledge scores” about cholera, people remained frustratingly vulnerable to cholera and other diarrheal disease in structural ways. Despite their individual best efforts, they were avoidably at risk of illness and death—at risk of Galtung’s and Farmer’s “structural violence.” The public health “peace” in the time without cholera was not reflected in a structural alleviation, structural peace-building that would be befitting a more sustained absence of the disease.

Clean water, safe sanitation and safe food practices eliminated the threat of cholera in most of Europe and North America by the early 1900s, and Latin America by the 1990s. The disease caused such havoc and major outbreaks that it was a driving force for public health and investments in water and sanitation infrastructure in many areas of the world. Oral cholera vaccines that were developed in the 1980s and refined in the 1990s have good effectiveness in protecting those who are at risk of the disease but have been vexingly scarce in supply. Our modeling study, undertaken by four research groups in collaboration with Haitian Ministry of Health experts proposed the positive impact of vaccinating broadly against cholera in Haiti during the lull period, hoping to build upon the major successes of the programs and offer a bridge to greater infrastructure and social development. However, the findings, including a prediction that cholera would re-emerge if the status quo remained, fell largely on deaf ears in the global public health community—or at least amongst those with the power and resources to intervene.

Waiting in line for the cholera vaccine Credit: Jon Lascher / Partners in Health (PIH)

In late September 2022, a young child was brought to a health center in a densely populated neighborhood of Port-au-Prince. Despite the best efforts of healthcare workers, she succumbed to her severe watery diarrhea. Within days a new outbreak of cholera was confirmed. As the illness spread around the neighborhood and then disseminated—once again around the country, anecdotes, as well as our research in collaboration with the US Centers for Disease Control and the Haitian National Laboratory, identified that gang violence, having obstructed the movement of fuel, triggered an acute on chronic lack of access to clean water in a densely populated urban community that became the initial locus of this resurgence. Community members described to our research team that no water trucks could enter the area, so they turned to different water sources, even if they knew that they may not be safe. What choice did they have? Once again on the surface of cholera outbreaks, individual behavior seems to be at fault whereas in fact it is often materially impossible to surmount the structural factors—the structural violence—that stand between the community member, the physical violence of guns and bullets, the opportunity to have agency over one’s own health. Could health-building, reliable safe water, reliable food access (and education and other basic services) have prevented the preponderance of violence that has emerged in under-served and impoverished communities in Haiti? Would better national health-building in the years since Haiti’s first cholera outbreak have stemmed a social discontent? It’s unknowable for the current crisis in Haiti—and arguably not a major factor—but health insecurity is surely a destabilizing force, and if peace is “not just about incentivizing criminals to give up the game; it’s also about giving communities a reason to trust the state,” as Jake Johnston wrote, then health-building, water, sanitation and even cholera vaccinations are a pathway to sustained health for communities and at least offer the promise of contributing to future peace.

Louise C Ivers MD, MPH is faculty director of the Harvard Global Health Institute and director of the Massachusetts General Hospital Center for Global Health. She provides care for patients in the United States, Haiti and Uganda and works on the design, implementation and evaluation of public health programs. (Her patient’s name was changed for privacy).