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Baseball and Science in the Time of Cholera

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As a physician working on water security in Haiti, I was moved by the documentary, Baseball in the Time of Cholera. Recipient of a Tribeca Film Festival Special Jury Mention, the film contextualizes and humanizes how the tragedy has destroyed Haitian families. Five percent of Haitians have been infected by cholera. On a global scale, that would be equivalent to the entire United States being infected. The film focuses on one boy, placing his story within the larger question, "How did cholera arrive in Haiti?" Throughout the poignant film, I was struck by how the narrative of the United Nation's role in introducing cholera into Haiti was founded in the science and research I use daily.

The UN military mission in Haiti, MINUSTAH, inadvertently introduced cholera into Haiti through failures in medical screening, sanitation, and waste protocols. With over 7,000 dead in Haiti and cholera spreading to North and South America, the UN continues to deny responsibility.

Cholera is transmitted in water or food contaminated by feces containing the bacterium, Vibrio cholerae. It is an ancient disease of poverty and lack of clean water. Most who experience the up to one liter of "rice-water" diarrhea hourly will require just a simple solution of sugar and salt to survive. In the beginning, hundreds of patients overwhelmed my Haitian colleagues. Those that had fluid to administer ran out of equipment to administer it. Others that had the equipment ran out of fluid. The result was the same for the patient: death.

The world is in the midst of a pandemic, and cholera has been continuously present in the Gulf Coast for nearly 40 years. But Gulf Coast cholera has never caused an outbreak or a single death in the U.S. Most of my U.S. colleagues will never see a case of cholera.

U.S. prevention of water-borne illnesses is based on over 150 years of science. In August 1854, Dr. John Snow described new London cholera cases as "the most terrible outbreak of cholera which ever occurred in this kingdom." Twenty-four hours into the epidemic, Dr. Snow mapped out the nearly 100 deaths and discovered they clustered around a water pump on Broad Street. Seventy-two hours after the first case, he convinced the parish to remove the pump handle. The epidemic subsided shortly afterward. With this data-driven, elegant solution, Dr. Snow became the founder of modern epidemiology. Since then, we know that understanding the origin and transmission of an epidemic is essential to ending it and preventing future outbreaks.

Following the earthquake that devastated Haiti's already struggling infrastructure, the Centers for Disease Control stated that a cholera epidemic was "extremely unlikely" to occur. A cholera epidemic had never been reported in Haiti. In October 2010, after training during a Nepal cholera epidemic, MINUSTAH soldiers were deployed to Haiti. Their base was far from the earthquake's epicenter or any internally displaced person camps. Within days of the soldiers' arrival, Haitians around the base began dying of cholera. The UN denied responsibility. They insisted the open septic tanks leaking waste into a river met international standards. They claimed that focusing on the origin of cholera hindered attempts to understand and control it. They refused to allow Haitian authorities to test the UN soldiers on base for cholera. Two months after the outbreak, the UN declared that "all soldiers had tested negative."

This contradicted earlier reports that no UN soldier was tested before or after the outbreak. It was revealed in the UN report the following year that the UN never tested the soldiers. But science has advanced since the days of Snow. Using methods spanning microbiology, genetics, epidemiology, and hydrology, several research groups independently found a connection between strains of cholera in Haiti and South Asia. The Nepal epidemic strain was an "exact match" to Haiti's cholera strain. First reported by South Korean scientists in the UN report, this was corroborated by Danish researchers. Dr. Daniele Lantagne, a UN report co-author, stated, "Based on the summation of the circumstantial and scientific evidence, the most likely scenario is that someone associated with the UN MINUSTAH facility was the person responsible." Dr. G. Balakrish Nair, also a co-author, said that there was "irrefutable molecular evidence" that the Haitian strain came from the Nepali strain.

To date, the UN has not accepted the findings of their report, nor the statements of the co-authors they appointed. The UN has not changed any of the protocols that allowed cholera to be introduced. A policy allowing untreated waste to leave the base remains in place. Though it has been known for over 40 years that the majority of cholera carriers are asymptomatic, the UN still does not test asymptomatic soldiers from regions that are endemic or have experienced a recent epidemic. They have not created solutions to remain compliant with their own waste and sanitation protocols. In short, the UN has failed to implement a single recommendation of their own report since its publication over a year ago.

Cholera continues to sicken hundreds in Haiti monthly. Toxigenic Vibrio cholerae is found in fresh water systems throughout the country and in its surrounding bays and harbors. Haiti's water security was the worst in the world at the beginning of this century. Diarrheal diseases were the biggest killer of Haitian children under five long before Kreyol had a word for cholera. Cholera worsened the situation.

Haiti needs clean water. The UN's non-military entities that have helped Haiti improve itself could, and should, play a central role in the internationally-supported, nationally-directed efforts to secure clean water for all of Haiti. I admire my UN colleagues who tirelessly strive to create evidence-based solutions, reconciliation, and justice for Haiti, yet the UN's failure to acknowledge data impedes their own staff's progress.

The scientific findings are public record and have been widely reported. Worldwide, people remained unconvinced by the UN's denials. Over 100 U.S. Democrats recently signed a letter urging Washington to push the UN to accept responsibility and respond in more evidence-based ways. During the London premiere of Baseball in the Time of Cholera, someone dressed as a UN soldier put the handle -- painted UN blue -- back on the Broad Street water pump. For those who know the history and science of cholera, it is an arresting, heart-breaking image. For Haiti, the image of the UN introducing cholera and rejecting the science to prevent its spread is reality.

To watch the film and learn more, visit undeny.com.