Remarks by Paul Farmer, Special Adviser to the Secretary-General Delivered by Assistant Secretary-General Pedro Medrano
On the Occasion of the World Bank Meeting on Cholera
April 11th, 2014
Dear colleagues and friends,
I’m sorry I cannot be here today but am grateful for the opportunity to share these remarks. And I’m so grateful that Dr. Francois, Dr. Adrien and Mr. Duvalsaint are with you so you can hear directly from Haiti’s public health authorities.
Those gathered here today share a long commitment to health equity whether in Haiti and across borders. I know that many of you have accompanied the Ministry of Health and DINEPA with determination and have asked, as I do, how we might best strengthen national and local capacity efforts to eliminate cholera. In other words, how might we best support our Haitian partners as they seek to implement the 2013 – 2015 National Plan for the Elimination of Cholera launched in February 2013 by Minister Florence Guillaume?
There is much to be done in the immediate term, long before the goal of elimination might be met. While much progress has been made, the case fatality rate among cholera patients in Haiti is still too high; of course, no one should get cholera. But no one, once sick, should die from it. In our efforts to eliminate this disease, we need to improve case-finding and the quality of treatment. These are two of the goals of the national plan, which requires responding rapidly to the “red zones,” where cholera cases crop up most frequently. Cholera is a disease for which we have tools for both prevention (from improved sanitation to vaccines) and effective care (from oral rehydration and replacement of electrolytes to antibiotics.)
To eliminate cholera, we must move swiftly, aggressively, and together; marshalling not only the tools needed to slow the epidemic in Haiti and its neighborhood, but also the political will of global health authorities and funders and large-scale implementers. Debates regarding the relative role of prevention and care are as senseless in the midst of an epidemic as are arguments for conserving water in the midst of a fire. We can accept nothing less than complementary prevention and care as clearly outlined in the national plan. This integrated and comprehensive plan needs to be fully supported and fully financed.
I know from my conversations with Minister Guillaume - and I’m sure Dr. Francois and Mr. Duvalsaint can confirm this – that there is a sense that, while progress has been made, we need to renew our sense of urgency. The red zones still are vulnerable. While funding for strengthening water and sanitation and health systems has been pledged, we need to accompany the Haitian authorities as we work towards disbursement and implementation. In doing so, we cannot lose sight of these red zones. And, while as donors we ask for transparency from our Haitian counterparts, our partners in Haiti deserve the same level of accountability from us. We need to be fully transparent with our funding so that Minister Guillaume, Dr. Francois, Mr. Duvalsaint and their colleagues are clear about who is doing what where; about which pledges have been disbursed, to whom, and when. We are all anxious for the creation of the high level committee which should make this sort of genuine partnership a top priority. While it is being established it is incumbent upon us to continue the accompaniment of our Haitian partners.
“Accompaniment” means implementing the following five strategies that Minister Guillaume used as a basis for the national plan.
First, we must diagnose and treat all those with symptomatic cholera.
• This effort requires both the capacity to identify and refer those with symptoms, and the existence of centers equipped and trained to treat them. Community health workers must play a critical role as first responders in the epidemic.
Second, top priority should be placed on remedying Haiti’s water insecurity and improve sanitation.
• Prevention in this context means doing everything we can to remedy Haiti’s water insecurity and improve sanitation. At every step, efforts focus on improving access to clean drinking water through public works projects, point-of-use water-purification systems, and other proven means.
Third, we must make a concerted eﬀort to make oral cholera vaccine available.
• Logistics and cost are often cited as reasons to not provide the vaccine.
• Research in Bangladesh and India suggests that, when the eﬃcacy of the vaccine is added to a substantial herd eﬀect, protection rates can climb to over 90% and protection can last for up to three years.
• Based on findings from the demonstration conducted in Haiti with the Ministry of Health and findings from previous OCV studies, PAHO recommended targeted OCV campaigns as an intermediate bridge to reduce cholera transmission in Haiti while improvements in water and sanitation infrastructure are implemented.
Fourth, “vertical” health programs must be dedicated, at least in part, to strengthening Haiti’s health system.
• Health projects, whether focused on AIDS, cholera, nutrition, women’s health, or any other endeavor, must be dedicated at least in part to strengthening Haiti’s health system. Only a third of Haiti’s health services are currently being delivered in the public sector, but it’s important that we work in an integrated, coordinated fashion.
Fifth, we must raise the bar on our goals and strategies.
• Cholera demands not simply a “harmonization” of global health policy, but also raising the bar on our goals and strategies. Fifteen years ago, we argued that AIDS treatment with antiretroviral therapy was possible even in rural Haiti, and pressed for adequate funding of integrated prevention and care programs. This has come to pass in Haiti as elsewhere. Let’s repeat this successful approach in responding to cholera.
Thank you again for your time, and for this opportunity.