Peace and Pestilence https://www.foreignaffairs.

com/print/1114755

Home > Peace and Pestilence

Sunday, June 21, 2015

Peace and Pestilence
Lessons on Peacekeeping and Public Health from the Haitian Cholera Epidemic
Adam Houston

ADAM HOUSTON is CIHR Fellow in Health Law, Ethics & Policy 2015-2016. He works
with the Institute for Justice & Democracy in Haiti (IJDH).

For centuries, war and disease have gone hand in hand. Smallpox served as vanguard for
the Spanish forces in their conquest of the Americas, and yellow fever and typhus finally
turned the tide—in Haiti and Russia, respectively—against the strategic genius of Napoleon.
In fact, it wasn’t until World War I that a major conflict saw more soldiers perish on the
battlefield than from disease—yet those soldiers’ comrades played a key role in spreading
the 1918 flu pandemic, which claimed far more lives worldwide than the war.

Not long after the United Nations was formed in the aftermath of World War II, the world
came to the novel conclusion that soldiers could be used not to wage war but to promote
peace, resulting in the creation of United Nations Peacekeeping. Although peacekeeping has
changed the role of the soldier, however, it has not severed the connection between soldiers
and the spread of disease. The Haitian cholera epidemic, which has resulted in more than
730,000 infections and 8,900 deaths since 2010, originated with UN peacekeepers. This
tragedy serves as a warning, as yet largely unheeded, about preventing those sent to help
vulnerable populations from becoming a vector for disease.

Until peacekeepers brought Vibrio cholerae to Haiti, the country had not recorded a case of
cholera in at least a century. Conclusive scientific proof about the origins of the epidemic
—Nepalese peacekeepers stationed at a base in Mirebalais, from which human waste was
negligently allowed to enter the rivers that serve as the primary water source for tens of
thousands of Haitians—has not spurred the United Nations to take effective action to end the
epidemic, compensate the victims, or even simply admit responsibility. This is despite the fact
that the risks of cholera transmission were well known, and that its introduction easily
avoidable; effective screening of troops before deployment would have helped, as would
have adhering to basic principles of sanitation on the base.

Left with no other options, victims of the epidemic have turned to the courts to enforce their
rights; the UN has responded to their claims by declaring itself immune from suit. This
litigation thus raises important questions around the boundaries of UN immunity and about
the organization’s legitimacy in promoting human rights and the rule of law. Determining the
UN’s obligations to the victims of the cholera epidemic is important. So too, however, is
examining how current UN practices leave other vulnerable populations at risk. Despite the
scale of the Haitian tragedy, it has spurred surprisingly little action on the part of the UN to
prevent such a tragedy from happening again.

UN peacekeeping constitutes a uniquely high-risk activity in this regard. Peacekeepers are dispatched to war-torn
areas, where existing health and sanitation infrastructure has frequently been damaged. Once there, they
regularly interact with displaced persons and other populations whose circumstances make them particularly
vulnerable to disease.

1 de 3 22/06/2015 12:31
Peace and Pestilence https://www.foreignaffairs.com/print/1114755

Compounding the risk is the current model of UN peacekeeping, which increasingly relies on
large troop contributions from countries which themselves face high burdens of infectious
disease. A CDC briefing eight months before the Haitian epidemic highlighted the
vulnerability of post-earthquake Haiti to waterborne disease, but noted that cholera
importation was unlikely given that “most current travelers to Haiti are relief workers from
countries without endemic cholera.” Peacekeepers were almost certainly the single biggest
exception to this statement.

Given this potent mix of risk factors, the cholera epidemic in Haiti is not even the worst-case
scenario. That distinction would likely go to the spread of drug-resistant malaria. Most
current UN peacekeeping missions take place in sub-Saharan Africa, the region that
accounts for the vast majority of global malaria morbidity and mortality. The region’s malaria
burden has been rolled back in recent years, in large part due to the availability of effective
artemisinin-based drugs. Given their importance, it is extremely worrying that artemisinin
resistance has emerged in Southeast Asia.

For a preview of the consequences of losing an effective and affordable drug, look to the
spread of chloroquine-resistant malaria, which emerged in the same region in the 1950s and
1960s before spreading to Africa beginning in the late 1970s, where it caused a two- to
three-fold increase in mortality. Soldiers from multiple countries where artemisinin resistance
has been detected—Cambodia, Thailand, and Vietnam—have participated in current African
missions. Nevertheless, the UN has failed to implement an effective process to prevent the
introduction of artemisinin-resistant malaria.

In contrast to cholera, whose spread could have been halted by proper sanitation even after
infected personnel had entered Haiti, once drug-resistant malaria is recorded it may already
be too late. UN forces, no matter their country of origin, regularly contract malaria while on
mission; in some troop-contributing countries, such as Jordan, returning peacekeepers
account for the bulk of all imported cases. Once bitten, a soldier already infected with a
drug-resistant parasite could in turn introduce that parasite into the local mosquito
population, and from there into local humans. The historical failure of malaria eradication
efforts in the very African countries currently hosting peacekeepers underscores the virtual
impossibility of reversing the damage of drug resistance once it has been introduced. The
only solution is preventing it from arriving in the first place. Effort needs to be put into
determining the most effective methods of doing so, such as appropriate pre-deployment
testing and treatment.

This has not been the United Nations’ approach thus far. Existing guidelines on
peacekeeping and disease focus on protecting peacekeepers from local diseases,
overlooking the risks to locals from imported ones. Although the UN accepted a number of
the recommendations put forward by the independent panel of experts it charged with
investigating the Haitian cholera epidemic, such as taking steps to improve sanitation on
bases, it remains to be seen how effectively they will be implemented. At the same time,
victims of the epidemic are still without a remedy and the UN-endorsed plan to eradicate
cholera from Haiti remains grossly underfunded, even as the ongoing peacekeeping mission
in the country costs over half a billion dollars per year. And while some countries, such as
Cambodia, have recognized concerns around peacekeepers and artemisinin resistance, the
UN itself remains silent on the issue.

Inaction in the face of grave public health risks is unfortunate given that peacekeeping is not
only a particularly high-risk activity but one especially well suited to mitigating those risks.
Peacekeeping missions, and who participates in them, are defined in detail. They are subject
to oversight by a single centralized organization with both the expertise and capacity to craft

2 de 3 22/06/2015 12:31
Peace and Pestilence https://www.foreignaffairs.com/print/1114755

effective policies to address risks as they arise. And once those decisions have been made,
the military structure of UN peacekeeping makes it easier to directly implement and enforce
new policies.

In this case, although participation by a broad spectrum of countries in UN peacekeeping

missions is something to be welcomed, the UN must take steps to address the attendant
risks. Doing so would require relatively little change in how peacekeeping is managed. The
current method of financing peacekeepers ensures that peacekeepers from lower-income
countries are in effect subsidized by the UN; the relative cost of appropriate screening and
prevention measures could readily be incorporated into this subsidy. In turn, such an
investment could also help build domestic capacity—particularly in areas like laboratory
diagnostics—that would have positive spillover for public health programs within troop-
contributing countries.

Political inertia can be overcome; for instance, as Ebola hit the headlines, the UN agreed to
suspend rotations of African soldiers to Haiti over concerns about the virus, even though the
practical risk of introducing the disease was far lower than it ever was for cholera. The UN
has access to the expertise necessary to develop effective policy, and a structure that is well
suited to its implementation. It also has a duty to ensure that peacekeepers protect the most
vulnerable not only from war but from pestilence as well.

Copyright © 2015 by the Council on Foreign Relations, Inc.

All rights reserved. To request permission to distribute or reprint this article, please fill out
and submit a Permissions Request Form. If you plan to use this article in a coursepack or
academic website, visit Copyright Clearance Center to clear permission.

Source URL: https://www.foreignaffairs.com/articles/haiti/2015-06-21/peace-and-pestilence

3 de 3 22/06/2015 12:31