The fight against cholera: “In deep shit?”

Port-au-Prince, Haiti, 24 July 2013 – Lack of financing for a ten-year cholera eradication plan means that the disease will likely be endemic to Haiti for years to come.

Cholera bacteria are spread by contaminated food, water and fecal matter. One of the essential parts of the US$2.2 billion National Plan for the Elimination of Cholera in Haiti is the financing for sanitation systems nationwide.

The majority of Haitians – about eight million people – do not have access to a hygienic sanitation system. They defecate in the open, in fields, in ravines and on riverbanks. The capital region produces over 900 tons of human excreta every day, according to the United Nations Office for Project Services (UNOPS).

“Haiti is the only country in the entire world whose sanitation coverage decreased in the last decade,” said Dr. Rishi Rattan, a member of Physicians for Haiti, an association of doctors and health professionals based in Boston that works with Partners in Health and other Haitian groups.

A pig forages amidst plastic, organic waste and human excreta in one of
Cité Soleil’s canals. Photo: HGW/Marc Schindler Saint Val

“Before the cholera outbreak or the earthquake, diarrhea was the number one killer of children under 5 and the second leading cause of all death in Haiti. Given that cholera is a water-borne illness that relies upon lack of access to clean water, it is highly likely that cholera will become endemic in Haiti without full funding of Haiti's cholera elimination plan by entities such as the United Nations (UN),” Rattan told Haiti Grassroots Watch (HGW) in an email.

Cholera, brought to Haiti in October 2010 by soldiers from the United Nations Stabilization Mission in Haiti (MINUSTAH), quickly spread throughout the country. To date, over 600,000 people have been infected and at least 8,190 have died, according to a government report dated July 21, 2013. Almost 3,000 people are infected each month.

The death rate is on the rise in the countryside. Today, more than four percent of those infected die due to the lack of cholera treatment centers. At the epidemic’s peak, there were 285. Today, there are only 28. Once financing ran out, most humanitarian agencies abandoned the country.

Worse, one of the two large waste treatment facilities built following the earthquake recently went out of service.

The cholera-excrement connection

Written by the Pan-American Health Organization (PAHO), the US and Haitian governments and UNICEF, and published in November 2012, the cholera elimination plan has as one of its chief targets human excrement. The plan sets as its objective that by 2022, “90 percent of the population has access [to] and uses a functional sanitary facility” and that “100 percent of drained excreta are treated before being discharged into the natural environment.”

The sanitation budget alone tops US$467 million.

“According to our figures, less than 30 percent of the population has access to what we might call basic sanitation,” Edwige Petit, head of sanitation for the government’s National Agency of Water and Sanitation (in French, Direction nationale de l’eau potable et de l’assainissement - DINEPA), told HGW. “In neighboring countries, 92 to 98 percent have basic sanitation.”

By DINEPA’s count, about one half of households in the countryside, and 10 to 20 percent in the cities, lack access to a proper toilet or latrine. Everyone else uses rivers, ravines or almost any open space to take care of their needs.

In Cité Soleil, a slum that is part of the metropolitan area, some people are forced to use open patch of ground they can find.

“As far as latrines are concerned, we ‘go’ wherever we can, do you understand?" explained resident Wisly Bellevue, without a blink.

“In other words, we go in the wild, nearby.”

“When our children have to take a poop, we put them on a little bowl,” he added. “We put a little water in there. Once they are done, we throw it into an empty lot.”

A man crosses a bridge over one of Cité Soleil’s waste canals that lead
to the Port-au-Prince harbor. Photo: HGW/Marc Schindler Saint Val

Big institutions with septic systems are serviced by excreta trucks managed by the state, UNICEF or other agencies, or by private companies. In 2010 and 2011, for example, humanitarian agencies emptied the thousands of portable toilets (“Johnny-on-the-spot” or “Porta Potty”) in the refugee camps for the 1.3 million people made homeless by the 2010 earthquake.

Those who cannot pay for the luxury provided by the trucks have to hire a more economical service: the men called “bayakou” in Haiti, who empty latrines and septic systems by hand.

The bayakou work at night. Most of them do not take their excreta to the DINEPA’s new waste treatment centers, and instead dump their cargos in rivers, canals and ravines. The workers sometimes even dump their human output on the ground nearby if the rising sun catches them at work, because, at all costs, they try to avoid being identified by the population.

Before the cholera epidemic, even the trucks used to dump their “black water” (feces mixed with urine) into the ravines that drain into the Caribbean Sea. Since the outbreak, the government and other authorities have been trying to convince all the sanitation actors to empty their loads at locations that do not put people’s health in danger.

In late 2010, DINEPA and UNICEF opened a giant temporary site in Trutier, north of the capital, to receive all of the material collected from the refugee camp portable toilets as well as from other locations. At the time, a DINEPA representative told HGW that the giant pool of excreta was “the start of at least some form of excreta management” for Haiti.

Advances and Challenges

Since then, DINEPA and its partners have made considerable advances in sanitation. With assistance from the Spanish government, UNICEF and others, DINEPA built two treatment centers for the capital region’s black water, and hopes to build 22 others for a total budget of US$159 million. To date however, only three have been started: near St. Marc, in Les Cayes in the south, and in Limonade in the north.

Trucks empty “black water” at DINEPA’s Morne à Cabri waste treatment center,
shortly after it was opened in late 2011. Source: DINEPA

One of the three waste treatment pools at DINEPA’s Morne à Cabri site. This photo taken
just after the site opened in late 2011. Source: DINEPA

The impressive Morne à Cabri waste treatment center, costing about US$2.5 million and inaugurated in September 2011, “has the capacity to treat 500 cubic meters of excreta per day, which is the equivalent of what 500,000 produce,” according to DINEPA.

But there is already a problem.

Today, the center is closed down. The excreta are not being delivered. The gates are locked. Lack of financing is one reason. The fees paid by excreta trucking companies don’t generate enough revenue.

Also, after the humanitarian agencies stopped managing the refugee camps, because they said they had no more financing, deliveries from the portable toilets became problematic.

“We went from having latrine matter being made up of 10 to 20 percent trash, to 70 to 80 percent,” Petit explained. “The treatment center was not built to handle trash. It was built to handle water and fecal matter. The pools collapsed, blocked with trash.”

Latrines at the Pax Villa camp in Tabarre, in the capital region, on July 23, 2013.
Photo: HGW/Marc Schindler Saint Val

Even though it is struggling financially, DINEPA is determined to get things working again.

“We are going to use government equipment. If we can get US$40,000 or US$50,000 we will be able to clean it,” she said. 

Of course, the other treatment center is working, but one key challenge remains: how to convince everyone to deliver his or her loads?

And even if the excreta are delivered, financing will remain problematic. The excreta trucking companies can pay, but the same is not guaranteed for the bayakou. Perhaps this is why observers say the journeymen continue to dump their loads wherever they can.

Frantz François is responsible for sanitation and the gardens at a Cité Soleil community center.

“The bayakou do a bad job… right now, at this moment, if you walk up and down the canal you will see it is clean. But tomorrow, it will stink. They throw their latrine loads wherever they want to,” he said.

Another part of the national cholera plan is an education campaign aimed at combatting “poor defecation and hygiene practices.” According to Petit, many rural families don’t bother building latrines any longer; they merely concentrate on building homes.

“Over the past 30 years, a certain mentality has developed, where people know that it’s quite possible somebody else [like a foreign agency] will give them toilets,” Petit explained.

Rather than giving out free toilets and latrines, DINEPA hopes to set up a US$120 million fund that will allow families to borrow the money necessary to do their own construction.

An Alternative

DINEPA is not the only organization working on the sanitation issue in Haiti. The US-based Sustainable Organic Integrated Livelihoods (SOIL) treats and transforms human excrement into compost that can be used as fertilizer.

SOIL supplies people and institutions who pay a small monthly fee with special latrines. Every two weeks, the “Poopmobile” collects the excreta. So far, SOIL says their “Eco-san” toilets serve 24,000 people around the country.

SOIL’s compost installation is located at Trutier, north of the capital, not far from one of the two DINEPA waste treatment centers. Three people work there. One empties the Poopmobile drums into the piles that become usable compost after six months, while the others clean and disinfect the drums so they can be reused.

SOIL’s Baudeler Magloire stands next to a pile of sugarcane bagasse mixed
with excreta at the SOIL compost center near Truitier, Haiti. After six months or so,
the material will be compost. Photo: HGW/Marc Schindler Saint Val

“A lot of countries use this system,” said Baudeler Magloire, project manager at SOIL. “Many in West Africa. It is a new approach, a kind of ecological sanitation.”

The approach is not completely “new.” Human fecal matter has been used as fertilizer since the ancient Chinese and Roman civilizations. The Aztec and Inca peoples also used human excreta in their fields.

SOIL is not opposed to the waste treatment “lakes” being used by DINEPA, but the objectives are different, Magloire noted.

“Our mission is to allow for the material to be recycled, transformed and then sent to places in the country where it is needed. People can buy it, sell it, and use it in agriculture,” he said.

Anti-cholera plan “in deep shit?”

While the Poopmobile collects fecal matter from 24,000 latrines in a country of 10 million, three-quarters of the population is still using non-hygienic practices and systems.

The National Plan for the Elimination of Cholera in Haiti requires US$2.2 billion, and a plan for the neighboring Dominican Republic needs US$77 million more. For the years 2013 and 2014 alone, the two countries are seeking a total of US$521 million: US$443.7 for Haiti and US$33 for her neighbor.

The World Bank, PAHO and UNICEF recently promised US$29 million, and UN agencies have offered another US$2.5 million. But, as of May 31 2013, the pledges had not topped more than US$210 million, less than half of what is needed.

“Investments in water and sanitation are absolutely essential to eliminate cholera transmission,” said PAHO Deputy Director Jon K. Andrus at a Washington meeting where the grant was announced.

Andrus’ supervisor pleaded for all donors to make commitments.

“We must challenge governments and partners to come up with the funds that are needed to get the job done,” said PAHO Director Carissa F. Etienne. “The goal is not just eliminating cholera. It is to ensure that every man, woman and child has access to safe water and sanitation. This is basic to the dignity of every human being.”

Dr. Rattan of Physicians for Haiti believes the UN should give the majority of the funding needed, as soon as possible.

“They have decreased the amount of money they initially pledged and it has yet to actually be disbursed,” Rattan wrote in a July 17 2013 email to HGW. “This is crippling the Haitian government's ability to implement their lifesaving cholera elimination plan.”

A woman receives serum at the cholera treatment center at the Centre Hospitalier
Eau de Vie in Fonds Parisien, Haiti, on May 10, 2013. Photo: HGW/Marc Schindler Saint Val

In Cité Soleil, Michelène Milfort knows very well that there will be no plan implemented any time soon. She lives in a tent with nine others. Her camp has 38 deteriorating temporary shelters, tents and shacks. These earthquake victims only have three SOIL latrines to take care of their needs. Before SOIL’s assistance, they used a nearby empty lot.

John Abniel Poliné is a neighbor.

“Some people have no regular place to take care of their needs. Sometimes a person has to use a little plastic bag, that he then throws into a canal,” he admitted. “It is not always the fault of the individual. You need to understand that if the person had a place to go, he would not be forced to that extreme.”

Poliné said he wonders about the priorities of the Haitian government and of international actors, especially MINUSTAH.

“They just keep giving MINUSTAH thousands of dollars, while the people of Cité Soleil live in subhuman conditions,” he said.

MINUSTAH’s 2012-2013 budget is US$638 million, over US$200 million more than what is needed by the Haiti and the Dominican Republic for the first two years of their cholera elimination plans.

See also our Dossier #4