The Haitian Cholera Outbreak and its Implications on Global Health Equity: A Conversation with Dr. Louise Ivers

Interview by Beier nelson

https://doi.org/10.56927/239586

HHPR Senior Editor Beier Nelson interviewed Dr. Louise Ivers, MD, MPH. She is the director of the Harvard Global Health Institute as well as the director of Massachusetts General Hospital’s Center for Global Health. Dr. Ivers has spent much of her work in Haiti, initially improving HIV treatment access, and in the last decade supporting the medical response to the cholera outbreak in the nation after the 2010 earthquake.

To ensure clarity, the interview below has been minimally edited.

Beier Nelson (BN): Thank you for your time today, Dr. Ivers. Can you give an introduction on your interests in medicine and especially global health?

Dr. Louise Ivers (LI): I'm an infectious disease physician by training. I’m drawn to both the intellectual side of science and the service side of caring for patients. I also love the aspects of public and global health, taking that proximity to a patient and bringing that up to a bigger level to address policy issues on a larger scope. I think of global health as promoting the health of all, so it is both a domestic and an international issue. Personally, I have focused a lot of my own work on the international side; when I first became involved in global health, I was working a lot in the HIV space, promoting access to treatment in Haiti.

BN: Thank you. A substantial part of your work was devoted to the cholera epidemic in Haiti after the 2010 earthquake. Could you provide a brief description of cholera, how it can be so deadly as well as how it can be treated and prevented?

LI: Cholera is a highly infectious bacteria causing secretory diarrhea when it enters the body. Patients can lose up to 10 liters of fluid a day, and even very healthy people can go from being well to dead in hours. Cholera is 100% preventable and 100% treatable. It can be prevented by handwashing, having access to clean water and effective sanitation systems. Cholera can also be prevented by an oral vaccine that is taken with two doses. The treatment for cholera is very simple: fluids. The most effective way to receive fluids is through oral rehydration solution, which is a finely balanced mixture of salts, sugars, and water that facilitates absorption in the gut. The end goal is to maintain the fluid balance in the body relative to the amount of fluid being lost in the diarrhea. Unfortunately, most of the places where cholera actually is most rampant are places that don't have access to the right prevention or the right treatments fast enough and that's where we see the highest mortality rates.

BN: What was your role in the medical relief effort in Haiti?

LI: At the time of the cholera outbreak, I had been working in Haiti with an organization called Partners in Health in Haiti for seven years, supporting my Haitian colleagues in their expansion of HIV, TB treatment and primary health care. In January of 2010, a major earthquake struck near the capital Port au Prince, displacing 1.2 million people and killing hundreds of thousands. We were very involved in the humanitarian response by providing food, water, shelter, and emergency medical care. By October of 2010, the situation was still critical as there were still a lot of displaced people. Then, the cholera outbreak started. When the disease arrived, it was so devastating, killing people very quickly as there was already a lack of access to safe water and sanitation prior to the earthquake. Our initial response was to set up cholera treatment centers, caring for the sick and then training community health workers to go out into villages with the oral rehydration solution. A few weeks later, I started working with my colleagues to advocate for the use of cholera vaccines, but the vaccines have never been used in an outbreak before, so we advocated for using them as part of a comprehensive approach. So, we just focused on trying to help with that response at the patient level and then at the system's level, advocating for better ways to address the disaster of a cholera outbreak.

BN: As you touched on earlier, there was a lack of pre-existing sanitation infrastructure in Haiti before the earthquake. Furthermore, the destruction of health infrastructure from the earthquake, as well as Haiti's history of political instability, are also factors that exacerbated the cholera epidemic. These issues seem so out of control of the teams of medical personnel that work to treat the patients. How can these healthcare workers work best to treat patients even amid all these circumstances?

LI: I believe these are the tensions between clinical care and public health. Despite the challenges on the public health side, you can still dedicate your time to the care of the patient in front of you. As a physician myself, I love that connection with another human. I love to sit at the end of the bed and spend time with my patient. You can do that regardless of what's happening. Meanwhile, that knowledge of caring for the patient is very informative when you think about the policy structure. Because if you have a policy that is too far removed from reality, you can risk making theoretical solutions that don't address the problem at hand. If I'm caring for a patient with cholera, but I've run out of oral rehydration solutions, that informs me in my advocacy of increasing access to resources. So being on the front lines is very much something I love to do as a doctor, and it also helps to inform both the research that I do and also the positions that I take in advocating around policy.

BN: What do you think is the role of outside organizations when providing medical relief to a population in need in a foreign country like Haiti? How can we make sure we are not falling into a savior complex, but providing care that is culturally appropriate and sensitive?

LI: Generally speaking, what needs to happen is that more local organizations need to be supported. If we invested more in community organizations, they would have more capacity to manage a disaster situation, because the talent is there. This idea needs to be paramount in international development, but unfortunately that doesn't happen very much. If you look at how the U.S has historically approached international development policies, the support goes around the government and U.S-based organizations in the area, but not to local organizations. In Haiti, the American Red Cross received over a billion dollars of donations from people in the US. But, in the end a majority of that money never ended up in Haiti or in the hands of Haitians.

The issue of “saviors” going to help poor people is a whole area of discussion. In the organization I worked with, all of the staff except for three were Haitian, and the leadership was Haitian. When the cholera outbreak happened, yes, the team needed some assistance, but they were in charge; indeed, they're still there now. When providing assistance, it’s important to think about your positionality, but don’t disengage for fear of doing the wrong thing. You will make mistakes, and I've certainly made mistakes, but approach the work with a true sense of humility and be willing to learn from those around you. Haitian health workers are world-leading experts in tracking, documenting, and treating cholera cases. There is a difference between cultural competence and cultural humility; I don't know that one can ever truly fully understand another culture, but having humility puts you in a position of being a constant learner and not making assumptions. So have humility, but act. Being paralyzed by the fear of doing the wrong thing is in some ways a luxury.

BN: Cholera has recently returned to Haiti for the first time in three years. Do you think Haiti is able to more effectively manage this issue now then in 2010?

LI: Yes, I do. Because, in 2010, the whole country was still devastated from the earthquake. Health institutions had collapsed and many health workers were killed. The Ministry of Public Health building had totally collapsed in that January earthquake. Cholera was a brand new disease in Haiti in 2010, and there was no knowledge on how to respond. This time around, the country has had a decade of experience in controlling cholera and the workforce is very dedicated. I honestly don't know people who work harder than the Haitian health workers and public health officials, constantly being chased by outbreak after outbreak: Cholera, Zika, Chikungunya, COVID, etc. The bigger challenge at the moment in Haiti is the security situation in the country. It is very hard to move around the country, and a lack of available fuel has caused an access issue. The problem with many global health issues is that we know what to do, but we just aren't able to do it, whether that is a lack of funding, restrictive legislation, or lack of political will. In this situation, the challenge will be getting to the patients.

BN: In your article, “Cholera in Haiti, the Equity Agenda and the Future of Tropical Medicine,” in collaboration with the late Dr. Paul Farmer, you questioned why Cholera has ravaged Haiti when our world has made so many advancements to eradicate the disease. In that article, you stated that “expectations are lower for diseases that disproportionately affect poor people,” which has led to a decrease in investment into sanitation systems, as well as a lack of vaccine access to people in Haiti.” How can we work to change this viewpoint into making sure that the resources available fall into the hands of those who need it the most?

LI: Another way of phrasing this question is: how can we keep equity at the top of the agenda? Equity never happens by chance; it only happens by choice. If you don't think about the most impacted people first, the historically oppressed and marginalized, and those who have borne the brunt of racist and exploitative policies, you will always have your innovations, policies, and medical discoveries be disproportionately applied. What we've always seen in public health is that new discoveries and policies don't trickle down to the poorest people. If you look at HIV/AIDS, for years there was access to treatment for HIV in the U.S and in Europe, but not for people who needed it in Africa or in Haiti. In the case of cholera, an equity agenda might mean focusing your energy on the rural population first, knowing that people in urban settings have more resources in terms of treatment - it will depend on the specific context. Don't just think that if you do things the way we always do them, eventually the poor will also benefit because it usually doesn’t happen that way.