They called him moun fou, a Creole term for a mentally ill person—but what killed him began as a rational act. On a day in October 2010, a 28-year-old man (who happened to have schizophrenia) bathed in a local river in the town of Mirebalais, Haiti. By October 12, the man was sick with diarrhea; less than 24 hours later, he was dead. Some 720,000 of his fellow Haitians have since contracted the same condition—“a tsunami of sick people,” says Louise C. Ivers, a doctor with Haitian NGO Partners in Health—and nearly 9,000 have died. The disease is cholera, and the source of the outbreak, according to a lawsuit initiated by 5,000 of them, is an action by the United Nations.
In 2010, after a massive earthquake devastated Haiti, a battalion of U.N. peacekeepers from Nepal was stationed at a base along the Artibonite, one of the country’s biggest rivers. Within weeks, cholera—a disease never before seen in Haiti—spread nationwide. Months later, scientific investigations would determine that the Nepalese detachment were immune carriers of a strain of cholera bacteria that had recently been found in outbreaks in Nepal. They’d built toilet facilities that released their untreated waste directly into the Artibonite. In Haiti, which lacks sufficient potable water in homes and schools, the bacteria became impossible for millions to avoid. “In the beginning, we were so overwhelmed by the death around us,” Ivers says of the epidemic.*
By 2012, when Haiti’s ministry of public health and population surveyed 13,181 homes, 16 percent reported a household member had fallen ill with cholera, and one in 100 said a family member had died of it. Despite a rapid response from health officials, the epidemic is predicted to continue until 2022. “People in Haiti are still dying every week,” says Ivers, who treats cholera patients.
Can the U.N. be held accountable for its actions, which—despite originating from good intentions—have caused terrible suffering among a population it pledged to protect? A class-action lawsuit currently winding its way through the United States' appeal process could hold the answer. The outcome could have vast implications worldwide, showing whether the world’s most powerless populations can find restitution from the major international powers that often control their fates.
This wouldn’t be the first time cholera has played an outsized role in health history. If necessity is the mother of invention, cholera can be considered the mother of public health. An outbreak in London in 1854, a point when germ theory was still unknown, prompted physician John Snow to use statistics and maps to count cholera victims. Deducing the epidemic’s source was a contaminated water pump on Broad Street, Snow removed the handle, saving lives and ameliorating Londoners’ abject panic. His epidemiological investigation was the first one ever—the founding of modern public health.
For over a century, cholera itself remained nearly untreatable. In an oral history, physician William Greenough recounted working in Bangladesh in the 1960s: “I've been in the field with five thousand cases of cholera when the only thing you could do was ... drag people who were infected into the middle of a field so that they would not infect everyone else.” That changed when doctors perfected oral rehydration therapy, a combination of water, sugar, and salt that could be prepared at home to prevent sufferers’ lethal dehydration. The innovation, which avoided deaths for people too sick and poor to reach hospitals, cut cholera mortality from as high as 50 percent to just one to two percent. Richard Cash, a doctor who helped create oral rehydration therapy (and a former colleague of mine) calls it “a panacea for diarrheal disease.” The victory was an early example of shifting health care into communities, a move health workers still prioritize today.
The current outbreak in Haiti is poised to become the next milestone in cholera’s public health history. By prompting a legal inquiry into health and human rights, the effects will be felt well beyond those who are struck by the illness.
Having exhausted two other attempts at recourse, Haitians and their advocates approached the U.N. in New York in November 2011, seeking “a fair and impartial adjudication of the claim ... compensation to petitioners, monetary reparations to victims of cholera at large, and a public apology including acceptance of responsibility for causing the epidemic,” according to a policy paper by Yale University’s Global Health Justice Partnership. The U.N. rejected the complaint, refusing to admit culpability, and the Institute for Justice and Democracy in Haiti responded with the lawsuit.
In January, a judge dismissed the case, citing the U.N.’s immunity from national laws, which derives from a 1946 U.N. convention. (The IJDH filed an appeal in mid-February.) The immunity rule, which is one of the first U.N. conventions ever passed, is meant to protect the U.N. during its frequent work around armed conflict or other crises where leadership can be dysfunctional or hostile to intervention. This way, the U.N. can operate without spurious legal blocks.
If the U.N. does not ultimately take responsibility for its actions, it would cause “grievous damage to the credibility of the U.N. as a promoter of health and human rights."
But invoking immunity to avert a compensation lawsuit is rare, according to Brian Concannon, an IJDH attorney. “The U.N. is making a much broader immunity claim than it ever has,” he says. The recent ruling cited a precedent, a case in which the U.N. had been found immune from a sex discrimination and retaliation lawsuit brought by Cynthia Brzak, a U.N. employee. “In our case, it’s very different," Concannon says. "Our clients”—the Haitian people included in the lawsuit—“never consented to anything with the U.N. And the U.N. outright refused to provide them with any mechanism for hearing their claims.”
Fran Quigley, a law professor who wrote a court brief in favor of compensation, says that if the U.N. does not ultimately take responsibility for its actions, it would cause “grievous damage to the credibility of the U.N. as a promoter of health and human rights” by “enshrin[ing] the idea that if you’re poor and you’re powerless, then you don’t have rights. And the tragic irony of all this is that the entity that would be dodging responsibility would be the world’s foremost promoter of human rights.”
Quigley says the IJDH legal team had always anticipated the case would get volleyed up to higher courts through the appeals process. Both he and Concannon express cautious optimism about eventual compensation to victims.
Despite the legal wrangling, the U.N. and the U.S. government actually seem to agree that Haitian victims need help. In December, 77 U.S. congresspersons urged U.N. head Ban Ki-Moon to offer assistance. In October 2013, U.N. High Commissioner Navi Pillay said cholera victims should be compensated (although she didn’t say by whom), and even a U.N. fact sheet (PDF) says the epidemic has taken “an unacceptable toll on the lives of Haitian people.”
The block may be more financial than philosophical. In 2013, the Haitian government announced a 10-year, $2.2 billion plan for cholera eradication, but full funding has never been forthcoming from international organizations or private donors. As the Guardian reported at the time, “the U.N. has committed only $23.5m on top of money it has already spent on cholera. This compares with the $650m the U.N. spends annually on the troops that brought the epidemic to Haiti.”
Personal compensation to over 720,000 victims would help right the U.N.’s wrongs. Ivers says that funding should also go to public health needs: “There’s not a lot of funding available ... to take care of patients with cholera," she says. "The water and sanitation system is really quite dire.... For the U.N. to make a larger contribution to that [cholera eradication] plan—that certainly seems to be one part of the way forward.”**
The idea of compensation for massive loss is not new: The U.N. has compensated victims of armed conflicts in Iraq and Kuwait, despite having no culpability for their deaths. But public attention to U.N. irresponsibility is rare, and a ruling in favor of Haitians may set an important precedent for how global resources can and should be distributed to save human lives, especially in the most vulnerable parts of the world. At a time when complex international problems like climate change pose specific threats to the world’s poorest communities, the idea has potent, wide-ranging implications.
*UPDATE — February 27, 2015: We originally implied that U.N. peacekeepers arrived in Haiti after the 2010 earthquake. The U.N. has maintained a presence in Haiti since 2004. Also, in this paragraph, we referred to cholera as being caused by a virus—it is, in fact, a bacterial disease.
**UPDATE — February 27, 2015: Louise Ivers was originally misquoted saying that public health needs could be prioritized above personal compensation. She, in fact, did not say that one should be prioritized above the other.