It's been more than three years since cholera struck Haiti. And the epidemic continues today.
The deadly bacteria have killed more than 8,500 people and infected hundreds of thousands.
Why has the outbreak been so hard to stop, even with more than $9 million in foreign aid pledged to Haiti?
Lack of sanitation, says journalist Jonathan Katz, who has been covering the cholera epidemic since it began.
Haiti doesn't have sewers. Instead, the country relies on what's known as the bayakou: independent, and somewhat secretive, laborers who clean the cesspools under people's latrines.
"Almost all of them are men ... and they work in a very interesting way," Katz says. "The job is done by hand. They climb into the latrines with a bucket. They scoop out the excrement and put it somewhere else."
"The job is incredibly important," he says, "It's basically the only way that people who have underground cesspools — dug under latrines in their backyard — get them clean."
But even a latrine is a luxury in Haiti.
"Most people in Haiti can't afford even that kind of cesspool," Katz says. "So what most people do, especially in the rural areas, is that they look for an open field or they look for a canal. Most people prefer to go at dawn."
And when those choices aren't available, people use an even less sanitary method: the so-called flying toilet.
"You take a plastic bag. You go in the plastic bag. And then you throw it," Katz says. "That's the way the sanitation tends to get done."
After the 2010 earthquake, foreign aid flooded into Haiti. And a major concern was getting clean water and temporary toilets into the country. But nothing has been done to solve Haiti's water and sanitation problems permanently, Katz says.
"There were very, very short-term, Band-Aid type solutions," he says. "For instance, the bladders of water provided to the displacement camps and the porta-potties being installed in big, visible places. They weren't long-term, durable solutions."
And sanitation problems are what kicked off the cholera outbreak in the first place.
Evidence suggests the cholera in Haiti came from a United Nations base where Nepalese peacekeeping troops were living. The cholera strain in Haiti exactly matches one found at the U.N. base. And the sanitation on the base wasn't sufficient to prevent contamination of the adjacent river.
Haitian citizens recently brought a lawsuit against the U.N. They're seeking compensation for the spread of cholera.
"Before these lawsuits were brought forward, U.N. officials were trying to actively deny they were responsible," Katz says. "Since then, the science [supporting the connection] has been so overwhelming that the U.N. basically doesn't even take up the issue of whether it's responsible."
And once cholera establishes itself in a region, the infectious disease doesn't leave easily.
"It's very hard to get out of the environment," Katz says. "That said, there have been many places in the world that have dealt with horrific cholera epidemics over very long periods of time."
What was the solution? Sewers. "Build underground pipes," Katz says. "As long as people continue to drink water that is infected, cholera is going to be a major problem."
LINDA WERTHEIMER, HOST:
It's been almost three and a half years since cholera struck Haiti and that epidemic continues. The deadly bacterial infection has killed more than 8,500 people and infected hundreds of thousands. Evidence suggests this strain of cholera originated at a United Nations base housing peacekeeping troops. The outbreak has been difficult to contain because Haiti lacks working sewers.
In a recent article for the New Yorker, Jonathan Katz writes about cholera and Haiti's independent and somewhat secret laborers who clean the country's cesspools, the bayakou.
JONATHAN KATZ: Almost all of them are men. They're basically independent contractors, although sometimes they kind of organize into groups, and they work in a very interesting way. The job is incredibly important because it's basically the only way that people who have underground cesspools dug under latrines in their backyards can get them cleaned, and the way the job is done is done by hand.
They climb into the latrines with a bucket and they scoop out the excrement and they take it out and they put it somewhere else.
WERTHEIMER: Now, these people are basically cleaning out a sort of a pit designed to catch waste. I mean, wouldn't that be sort of a middle class invention? I mean, they're not really cleaning up after very much of the population, are they?
KATZ: Right. Most people in Haiti can't afford even that kind of cesspool, so what most people do in most parts of the country, especially in the rural areas, is when they have to go, they look for an open field. They look for a canal. There's another practice that's common in Haiti, which is known as the flying toilet. Basically, you take a plastic bag, you do what you need to do in the plastic bag and then you throw it.
That's the way the sanitation tends to get done.
WERTHEIMER: After the 2010 earthquake, there was a lot of aid coming in to Haiti and one element, obviously, was concerns about clean water. Has anything actually been done?
KATZ: Not in a long term sense, for the most part, which is sort of very, very short term band-aid type solutions. So, for instance, the bladders of water that were being provided to the displacement camps, the porta-potties that were, you know, being installed in big visible places, those are the kinds of things that were helpful for as long as they lasted, but they weren't long term institutional durable solutions.
WERTHEIMER: Haitian citizens have actually brought lawsuits against the United Nations, seeking compensation for the spread of cholera. What is the United Nations saying? What are they doing?
KATZ: Before these lawsuits were brought forward, at the very beginning of the epidemic, UN officials were actively trying to deny that they could have been responsible. Since then the science has been so overwhelming that the UN basically doesn't even take up the issue of whether it was responsible.
WERTHEIMER: Could you just lay out for us the case that the UN is responsible for this epidemic?
KATZ: Essentially what has happened is that in October of 2010, a group of Nepalese soldiers were being rotated into the peacekeeping mission and they were coming from Nepal, where there was an active cholera outbreak going on. And effectively there was no medical screening. What has been found is - there's a number of things.
First of all, there's widespread agreement, including from the United Nations, that the sanitation at their base was inadequate to prevent contamination of the adjacent river, and in the words of the scientists who the United Nations itself, under pressure, appointed to review the evidence, they described that strain, the Nepalan strain, in Haiti as being perfect match.
WERTHEIMER: Do you think that after many years of being clear of cholera, that it's now come to Haiti to stay?
KATZ: The most likely scenario is that cholera is now endemic to Haiti. Once you have cholera, it is very, very hard to get out of the environment. But that said, there have been many parts of the world that have dealt with horrific cholera epidemics over a very long period time, but there was a solution. And the solution was actually devised directly in response to those cholera epidemics and that solution was waste and sanitation.
It's doesn't really matter so much if cholera is in the soil, just so long as people aren't getting sick. But so long as people are drinking water that's infected, it's going to continue to be a major problem for a very, very, very long time.
WERTHEIMER: Jonathan Katz, thank you.
KATZ: Thank you.
WERTHEIMER: Jonathan Katz is a freelance journalist. He wrote a book about this situation. It's called "A Big Truck That Went By: How The World Came To Save Haiti And Left Behind A Disaster." Transcript provided by NPR, Copyright NPR.