Running head: GLOBAL ESSAY

Global Essay Ashley Wolcott Northwest University

Author Note Ashley Wolcott, Buntain School of Nursing, Northwest University Correspondence concerning this article should be addressed to Ashley Wolcott, Buntain School of Nursing, Northwest University, 5520 108th Ave NE, Kirkland WA 98033. E-mail: Ashley.wolcott11@northwestu.edu

GLOBAL ESSAY Problem Statement The global health problem that will be the main focus of this text is the epidemic of

cholera in Haiti. This is both a regional problem in Haiti, but also has the potential the impact the entire world. Cholera is an infectious disease process caused by the Vibrio cholerae bacteria; it causes diarrhea, dehydration and can lead to death. This bacterium is easily communicable, and is usually transmitted through contaminated water via the fecal-oral route. Water becomes contaminated with feces containing Vibrio cholerae, the contaminated water is then ingested and the bacteria proliferate in the new host, causing sickness. This bacterium has the potential to spread worldwide, as it is easily transmittable. The strain of the Vibrio cholera bacteria that was found in Haiti in the 2010 outbreak was found to be a strain originally found in south Asia, the O1 strain ("Cholera," 2012). The bacterium was thought to have been introduced into the Meye river tributary system in Mirebalais, Haiti at a United Nations base camp. Within weeks the same strain of Vibrio cholerae found in Haiti, was also found in the Dominican Republic the neighboring country to the east. This bacterium was not expected to travel past the neighboring country, but it did. Within a few weeks of the outbreak in Haiti, Vibrio cholerae was found in both Miami, and Boston (Ivers & Walton, 2012). This shows that it a matter of weeks the bacteria was able to travel over 1600 miles. This reinforces how hearty Vibrio cholerae can be, and just how fast it can become a problem not only for the United States, or the Dominican Republic, but for countries all over the world. Currently cholera affects up to 57 countries, this number is believed to be higher but only 57 countries have documented cases of cholera. It is estimated that the number of cases being reported account for much less of the actual population infected the reports account for 10% of the actual cases of cholera (Ali et al., 2011).

GLOBAL ESSAY The magnitude of the health risk of cholera is another concern for global health. The

prevalence of this health problem is vast, there are estimated to be between three and five million cases of cholera each year. One estimate predicted as many as 11 million new cases of cholera each year. Of those incidences it is estimated that 100,000 to 120,000 people die from cholera yearly (Ali et al., 2011). It is important to remember that this estimate is based off of the reported cases of cholera, to which it has been estimated that only 10% of all cholera cases are reported worldwide. Specifically in the country of Haiti there were almost 1,000 new cases of cholera infection reported from February third through the ninth in the year 2013 ("Atlas of Cholera outbreak in La Hispaniola, 2010-2013," n.d.). The estimated cost the country of Haiti has accumulated because of the outbreak of cholera is difficult to estimate because there are many organizations partnering with the country to resolve this illness. The United Nations has been one of the main organizations working to rid the country of Haiti from cholera. It is estimated that the United Nations has spent over $118 million dollars on vaccinations against cholera, improved water and sanitation conditions to prevent the spread of cholera and medical equipment and workers for the treatment of those already infected (Pilkington, 2013). The United Nations had also pledged another 23.5 million dollars in the effort to eradicate cholera from Haiti. Along with the United Nations, the Haitian government has also pledged 2.2 billion dollars to eradicate cholera from its country in the next 10 years (Doucet, 2013). The illness of cholera has a high cost in money as well as in health, directly impacting the lifespan of the people it affects. The average lifespan in Haiti is currently estimated at 62.7 years; in 2010 it was estimated that the average life expectancy dropped down to 52 years because of the cholera outbreak (Whyte, 2010). The people most impacted by this illness where the very young and the

GLOBAL ESSAY elderly because of their lowered immune function. Cholera is an illness that can affect any age group thus every age group had an increase in mortality rate. The reason for stating cholera as a global health problem lies in its mode of transmission and lack of medical care to treat the illness. As previously stated this illness has been found around the world. In the case of the outbreak in Haiti in 2010 the O1 strain was able to travel to multiple countries within a couple of weeks. Cholera is transferred through contaminated water making it more prevalent in underdeveloped and developing countries where access to clean water is not possible. Cholera can also be transmitted through produce that has been watered with unclean water. In undeveloped countries rivers and streams become the water source for

many things including; laundry, cooking, bathing, drinking, waste elimination, and hydration for crops. Because cholera is transmitted through contaminated water it is easy to understand how it can travel through a country and outside of a country. Any products exported from the country that contain the contaminated water have the potential to cause an infectious outbreak in the country the products were imported to. Another problem is lack of education and lack of healthcare. In a country like Haiti where there is only one physician and almost two nurses per 10,000 people, healthcare and the education that goes along with adequate healthcare is lacking ("Lessons learned during public health response to cholera epidemic in Haiti and the Dominican Republic," 2011). With the introduction of a new bacterium like Vibrio cholerae to Haiti, many people die before the cause of illness is determined. Even when the cause of the illness is determined most countries do not have the antibiotics and clean fluids needed to combat the symptoms of cholera. An estimated two and a half billion people are without access to safe water, this means that cholera has the potential to impact roughly two and a half billion people in the world just from lack of safe water ("Progress on drinking water and sanitation," 2012). It is

GLOBAL ESSAY also estimated that 30% of the world does not have access to essential medicine which accounts for almost two billion people ("Access to essential medicines," 2004). These statistics confirm

that if cholera was to be introduced in these populations they would not have adequate resources for treatment. While this bacterium has the potential to impact the world it has already had an immense impact on the country of Haiti. Since the outbreak of cholera in 2010 over 8,000 Haitians have died and more than 648,000 people have been infected (Doucet, 2013). The damage of cholera has stretched beyond the health of the people, to the economy of Haiti. The biggest exports are produce, coffee and textiles and all were impacted by the outbreak of cholera. When the outbreak of cholera happened in 2010 virtually all exports from the country were stopped because of the fear that surrounded the outbreak. There was a 120% loss on gross domestic products in the country compared to the gross domestic product of 2009 (Castaneda-Alvarez, 2011). Haiti has struggled to regain some of its previous economic standing due to loss of farmers and textile workers and because a lack of interest from other countries in buying Haitian products. With the death of many farmers there was a decrease in both produce and textiles for Haitians to export. After the news of the outbreak of cholera spread many countries were fearful of importing the products because the fear of contaminating their own country was elevated. Also because of the loss of workers Haitians had fewer products to sell because their crops were decreased and the country conserved its products for the people within the country. Current efforts to address this global health threat The biggest responder to the cholera crisis in Haiti has been the United Nations. The United Nations has been the biggest help in containing and treating this illness. It is a common thought that the United Nations has an obligation to help out the people of Haiti because it was

GLOBAL ESSAY reported that it was through a United Nations worker that cholera was introduced into the country in the first place. Regardless the United Nations already had an established presence in the country of Haiti so most of the relief efforts have been funneled in through the United Nations. Directly after the outbreak of cholera the various organizations sent in healthcare

workers under the umbrella of the United Nations. These healthcare workers combined efforts to treat patients infected with choler as well as working to prevent the spread of the illness and further contamination through unsanitary practices. One large campaign the United Nations did in partnership with an organization called DINEPA was a large disbursement , just over seven million, chlorination tablets (Nienaber, 2011). This allowed Haitians to put the tablets into their drinking water to kill Vibrio cholerae bacterium and make the water safe for drinking. The United Nations has also pledged over two billion dollars towards vaccinations against cholera that began in 2012, and will continue through 2020 (Wise, 2012). Education has also been a big effort by the medical staff in Haiti; cholera can be prevented through simple efforts that are inexpensive. The first effort made in education was to teach people about the importance of hand washing, and more sanitary places to dispose of waste. One big problem in Haiti is lack of proper bathroom facilities. Many people will urinate or produce fecal matter into the rivers, which is where they also get their drinking water. Another effort made by multiple non-profit and faith based organizations was the building of clean water wells. These organizations have partnered with the United Nations to build multiple wells and bring access to clean water to over 900,000 Haitians ("Clean water: A health essential," 2011). The current efforts have shown an improvement over the impact that cholera has had on the country of Haiti. When the initial outbreak of cholera happened on October 21, 2010 there were approximately 212,000 new cases of cholera in Haiti reported in the first six months after

GLOBAL ESSAY the initial outbreak ("Atlas of Cholera outbreak in La Hispaniola, 2010-2013," n.d.). Comparing the number of cases in the first six months of the outbreak in 2010, to the last six months in 2012-2013 there were only 58,000 cases of cholera reported. That means that in two and a half

years the reported number of cases in Haiti has decreased by 154,000, a 73% decrease ("Atlas of Cholera outbreak in La Hispaniola, 2010-2013," n.d.). This shows sufficient evidence that the current efforts in Haiti have been effective. However with that stated 58,000 new cases of cholera in the last six months is still a considerable number of cases, which may indicate that there is a better way to decrease the cases of cholera. The current efforts in Haiti have made substantial impact on the infection of the nation. While there has been a significant decrease of cholera cases since the 2010 outbreak, there still remain a high number of cases being reported in the current months. This could be caused from a lack of resources, as it is obvious that not everyone will be reached by the United Nations, or the funded aide programs of the Haitian government. More likely though is that the efforts which have been made have not been the most culturally appropriate efforts. There is a long standing history of mistrust between the United Nations and the people of Haiti. This stems from the United Nations occupancy in the country despite the wishes of the Haitian people for them to leave. There have also been many instances in which the United Nations has lauded their power, wealth, and status over the Haitian people. These factors have led to a mistrust of the United Nations and the efforts they try to make in the country. This tension has led to mistrust, of not only the United Nations but of outsiders in general. With most of the medical workers being foreigners there is a mistrust that keeps many Haitian from receiving help from the United Nations efforts. Currently the education focus is primarily aimed at a target audience of women, because they are usually the care providers of the family and perform domestic chores (Nybo,

GLOBAL ESSAY 2013). Education has been offered in both French and Creole, which are the two primary languages of Haiti. However with a literacy rate of 52.9% this is sometimes ineffective ("Haiti," 2013). The United Nations has also worked with medical personnel to emphasize the need for proper hygiene, and to demonstrate proper techniques for hygiene. The United Nations has funded the supplies needed to perform demonstrations on correct hygiene. One of the problems with this method is that Haitian people generally do not come to seek medical treatment from sources like those present in the United States. When Haitians are sick they tend to go to witch doctors for healing. Trying to convince Haitians to come to a medical clinic and not go to the witch doctor is a hurdle that the United Nations did not consider. Another factor that has not been considered from a cultural standpoint is that Haitians are independent people, this stems from fighting for their independence in 1803, since gaining independence the people resist change ("Haitian independence proclaimed," n.d.). Recommendations

The first recommendation I would implement to decrease the risk of cholera worldwide is a worldwide education program for undeveloped and developing countries, on the importance of boiling water to kill the bacterium Vibrio cholera. In the country of Haiti the goal would be to vaccinate all the people within 5 years. The vaccine against cholera costs about $1.85 per dose and two doses are needed for each person, with both doses the protection percentage is 60%-85% (Knox, 2012). This would decrease the amount of cholera infection that is happening specifically in the country of Haiti but this would not stop the chance of a global problem from cholera. The next thing that I would propose would be to build latrines in every village, at least one latrine should be built for every ten people and the latrines should not be built by any kind of water source, where cross-contamination would be possible, this way it will reduce the chance of

GLOBAL ESSAY cholera getting into water sources and contaminating food, water or traveling to other countries. The last change I would recommend would be for clean water wells to be built in every village. Cholera can be prevented through having a clean water source. By building clean water wells, people will have close access to clean water and will be able to safely cook, clean, and water crops. A person should not have to walk more than 10 miles to get clean water so enough wells will have to be built to accommodate this, all wells should be built within 5 years. The last implementation I would suggest is education. Simple education on signs, symptoms, and prevention of cholera should be available to all people. Haitian culture is a very proud culture that holds independence as a virtue. The best way to implement the changes mentioned above would be to respect their independence and to work with people of the country because as already stated above Haitians do not have a good history with foreigners, especially those that force change. The way that I would implement these changes is by respecting their culture and religion through the use of witch doctors. Witch

doctors are respected in Haiti because of the rich Voodoo culture. The witch doctor is believed to have special communication with the spirits that cause all things considered negative. By working through witch doctors the plan can be implemented through people within the country and of native origin, as well as gaining respect for the new plans because the witch doctor has approved and is proposing the ideas to the general public. The trouble comes when trying to motivate the witch doctors; because most of them live below the poverty line I think money would be a good motivator to gain support from the witch doctors. Another way to gain the support is to employ Haitian workers in the building of wells, and latrines. This will help to gain favor with the general public because over 40% of the country is unemployed, and the population living below the poverty line is 80%. Another big hurdle is education about cholera and disease

GLOBAL ESSAY transmission in general. The first thing that would have to happen would be to offer a free education to anyone who is willing to work for my organization for at least a year once they

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have been medically trained. Haitians know that education is a good thing and fight to make sure their children get educated. By allowing older students to become medically trained they can ensure a free education, and allow people of the country that understand and appreciate the history of the Haitian people to teach the people of Haiti. To evaluate the effectiveness of these implementations it would be expected that globally the strain found in Haiti, the O1 strain would not spread to other neighboring countries. It would also be expected that the incidence rate of cholera worldwide would decrease; this would be measured in the same manner that current statistics are measured. Specifically for the country of Haiti it would be expected that after the entire country had been vaccinated that within six months the number of cholera cases should drop drastically getting down to less than 10,000 cases. This would continue to be monitored in the same fashion that statistics were being measured now. Annual testing of all clean water wells would be done to ensure that the water was staying safe and uncontaminated. A crew of Haitians would have to be employed to go around and make sure that latrines were also in good order. This would have to be overseen by a foreman and then reported to the organization. To evaluate the education the medical staff was getting and to ensure their teaching methods were accurate they would be subject to annual progress reports, much like job evaluations. Overall for this population there should be an increased lifespan, fewer cases of illness caused by cholera, and better sanitary conditions to prevent water contamination.

GLOBAL ESSAY References Access to essential medicines. (2004). World Health Organization. Retrieved April 21, 2013, from http://apps.who.int/medicinedocs/en/d/Js6160e/9.html

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Ali, M., Lopez, A. L., You, Y. A., Kim, Y. E., Sah, B., Maskery, B., & Clemens, J. (2011, July 14). The global burden of cholera. WHO. Retrieved April 21, 2013, from http://www.who.int/bulletin/volumes/90/3/11-093427/en/ Atlas of Cholera outbreak in La Hispaniola, 2010-2013. (n.d.). Pan American Health Organization. Retrieved April 21, 2013, from http://new.paho.org/hq/images/Atlas_IHR/CholeraHispaniola/atlas.html Castaneda-Alvarez, N. P. (2011, September 22). Haiti: What comes after the quake. DAPA: Haiti What Comes after the Quake Comments. Retrieved April 21, 2013, from http://dapa.ciat.cgiar.org/what-comes-after-the-quake/ Cholera. (2012, July). WHO. Retrieved April 21, 2013, from http://www.who.int/mediacentre/factsheets/fs107/en/index.html Clean water: A health essential. (2011). International Action. Retrieved April 21, 2013, from http://haitiwater.org/why/why-clean-water Doucet, I. (2013, February 28). Haiti launches 10-year plan to eradicate cholera yet UN funds fall short. The Guardian. Retrieved April 21, 2013, from http://www.guardian.co.uk/global-development/2013/feb/28/haiti-plan-cholera-un-funds Haiti. (2013, March). CIA - The World Factbook. Retrieved April 22, 2013, from https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html Haitian independence proclaimed. (n.d.). History.com. Retrieved April 22, 2013, from http://www.history.com/this-day-in-history/haitian-independence-proclaimed

GLOBAL ESSAY Ivers, L. C., & Walton, D. A. (2012, January 1). The "first" casse of Cholera in Haiti: Lessons for global health. The American Journal of Tropical Medicine and Hygiene. Retrieved April 21, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3247106/ Knox, R. (2012, August 17). WHO calls for emergency stockpile of cholera vaccine. NPR. Retrieved April 22, 2013, from http://www.npr.org/blogs/health/2012/08/17/159014069/who-calls-for-emergencystockpile-of-cholera-vaccine Lessons learned during public health response to cholera epidemic in Haiti and the Dominican Republic. (2011). Center for Disease Control and Prevention, 17(11). Nienaber, G. (2011, February 16). Haiti: Clean water is a human right. Ezili Danto Haiti News Haiti Clean Water Is a Human Right Comments. Retrieved April 21, 2013, from

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http://www.ezilidanto.com/zili/2011/02/clean-water-is-a-human-right-if-you-can-find-it/ Nybo, T. (2013, February 26). At a glance: Haiti. UNICEF. Retrieved April 22, 2013, from http://www.unicef.org/infobycountry/haiti_68000.html Pilkington, E. (2013, February 21). UN will not compensate Haiti Cholera victims, Ban Ki-moon tells president. The Guardian. Retrieved April 21, 2013, from http://www.guardian.co.uk/world/2013/feb/21/un-haiti-cholera-victims-rejectscompensation Progress on drinking water and sanitation. (2012). Unicef. Retrieved April 21, 2013, from http://www.unicef.org/media/files/JMPreport2012.pdf Whyte, S. (2010, January 14). Health care in Haiti: A battered system is dealt another blow. CBCnews. Retrieved April 21, 2013, from http://www.cbc.ca/news/health/story/2010/01/13/f-haiti-earthquake-health-care.html

GLOBAL ESSAY Wise, C. (2012, December 12). Fighting cholera, a dose at a time. PBS. Retrieved April 21, 2013, from http://www.pbs.org/newshour/rundown/2012/12/fighting-cholera-in-haitione-dose-at-a-time.html

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