haiti in the time of cholera · 2019. 3. 19. · haiti in the time of cholera “…expectations...

This case was originally developed by the Harvard Global Health Institute by Suerie Moon, MPA, PhD, Research Director and Co-Chair, Forum on Global Governance for Health, and Rachel Gordon, MBA, Case Studies Manager. It is used and distributed with permission by the Global Health Education and Learning Incubator at Harvard University. Cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management.

This case is licensed Creative Commons Attribution-Non Commercial-NoDerivs3.0Unported [email protected]

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GLOBAL GOVERNANCE REVISED March, 11, 2013

Suerie Moon Rachel Gordon

Haiti in the Time of Cholera “…expectations are lowered for diseases that disproportionately affect poor people.”1

An Earthquake Destroys a Country On January 12, 2010 a 7.0 magnitude earthquake struck and devastated Haiti, the poorest country in the Western

Hemisphere. Located in the Caribbean approximately 700 miles off the coast of the United States (U.S.), approximately 80% of the population lived in poverty.2 (See Exhibit 1 for a map of Haiti and Exhibit 2 for basic indicators.) The quake—considered the worst in the region in over 200 years—occurred six weeks before scheduled presidential elections.3 An estimated 200,000 people died and 2.3 million more (approximately 25% of the population) were displaced. The capital city, Port-au-Prince was severely damaged and in the days following the quake, approximately 580,000 of the city’s residents fled to the surrounding countryside, straining rural resources and communities.4 Of those that stayed in the surrounding urban area, an estimated 1.5 million people eventually resided in over 1,300 tent camps that often lacked adequate water supplies and sanitation facilities.5,a

The earthquake compounded Haiti’s historical lack of physical and human resources making recovery efforts extremely difficult. Haiti’s existing poor infrastructure was weakened as electricity and water suppliesb were interrupted and transportation routes were blocked and damaged. Buildings of all types—homes, hospitals, government, schools and even the presidential palace—were decimated.6 The education minister estimated that the quake damaged approximately half of Haiti’s 15,000 primary schools and 1,500 of its secondary schools.7 Port-au-Prince’s three main universities were devastated practically beyond repair.8 Half of all hospitals as well as the headquarters of the Haitian Ministry of Public Health and Population (MSPP), the government agency responsible for overseeing the public sector of Haiti’s health system were destroyed. The earthquake strained a public health system a A year after quake the U.N. Office for the Coordination of Humanitarian Affairs estimated that 810,000 people still continued to live in 1,150 camps. See “Haiti: One Year Later,” http://www.unocha.org/issues-in-depth/haiti-one-year-later, accessed November 2012. b Even before the quake Haiti had the lowest water and sanitation coverage in the region with only 17% of the population having adequate access to sanitation facilities and 63% having access to suitable drinking water. See “Independent Review of UNICEF’s Operational Response to the January 2010 Earthquake in Haiti,” September 2011, http://www.unicef.org/evaldatabase/files/Independent_Review-UNICEF-Haiti2011_Final.pdf, accessed November 2012.

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Haiti in the Time of Cholera

that an article in The New England Journal of Medicine subsequently characterized “as already the hemisphere’s weakest system” prior to the earthquake.9 Civil service was disrupted and tragically many of those who would have contributed to relief efforts—Haitian government officials and civil servants, international aid workers—were killed. 10

Moreover, the quake disrupted an already weak economy. The U.S. State Department estimated the earthquake caused $11.5 billion in damages and reconstruction costs.11 An assessment conducted by the United Nations (U.N.), European Commission and Inter-American Development Bank and World Bank estimated the quake’s financial impact was $7.63 billion, the equivalent to 120% of Haiti’s 2009 GDP. 12

Following standard practice after major crises, the U.N. created international humanitarian relief sectors to coordinate and facilitate relief planning and priorities. In total 12 different sectors focusing on agriculture, camp coordination and camp management, early recovery, education, emergency shelter and non-food items, emergency telecommunications, food, health, logistics, nutrition, protection, and water, sanitation and hygiene were formed. Responsibilities for each sector went to multilateral organizations such as the International Organization for Migration, UNICEF, World Food Program, and the World Health Organization. 13 In addition to these groups, the U.N. also extended the stay of its peacekeeping force, the U.N. Stabilization Mission in Haiti better known by its French acronym MINUSTAH. (The U.N. Security Council created MINUSTAH in April 2004 after determining the “the situation in Haiti continued to be a threat to international peace and security in the region and acting under Chapter VII of the U.N. Charter.”14) In January 2010 the U.N. Security Council increased MINUSTAH forces by an additional 2,000 troops and 1,500 civilian police to help with earthquake recovery and stability efforts.15 The relief agencies provided technical expertise and carried out international relief campaigns for disaster aid asking for $575 million.16

The U.S. government, which had a long history of supporting Haiti, participated actively in the country’s recovery. Shortly after the quake, the U.S. Secretary of State met with the Haitian President to coordinate the relief effort which involved a short term component of emergency supplies coupled with a longer term plan for rebuilding the communications, electricity and transportation infrastructure.17 A U.S. Congressional Report stated, “Even before the disaster, efforts to alleviate Haiti’s persistent poverty were a top congressional concern as were efforts to promote long-term stability and security, and strengthen democratic processes.”18 Post-quake a U.S. State Department Fact Sheet noted “the country’s geographical proximity to the continental U.S.” as reason to maintain good relations stating “Haiti’s recovery is a strategic imperative for the U.S.”19 In FY2010, as part of those efforts, U.S.’ financial contributions to the region almost tripled to just under $1.7 billion with a significant portion of that aid going Haiti after the earthquake.20 The U.S. also offered technical resources to deal with the quake’s aftermath. For example, the U.S. Center for Disease Control and Control (CDC) sent over 300 technical experts to provide assistance to Haiti after the earthquake.21

It Is Not Likely The public health community anticipated that post earthquake conditions put Haiti at risk for many health threats

but did not consider a cholera outbreak a very real possibility. In March 2010, the CDC posted a pre-decisionc brief to describe what efforts, if any, needed to be taken to prevent the significant spread of cholera. With the approaching rainy season, the brief anticipated that

“current problems with water, sanitation, and hygiene infrastructure will be exacerbated…[but] an outbreak of cholera is very unlikely at this time…cholera is not circulating in Haiti, and the risk of cholera introduction to Haiti is low. Most current travelers to Haiti are relief workers from countries without endemicd cholera, and they

c After natural disasters it was customary CDC practice to post briefs on diseases most likely to become prevalent given post disaster conditions. d Endemic is a condition “present in a community at all times but in relatively low frequency. Something that is endemic is typically restricted or peculiar to a locality or region.” For example, malaria is endemic in parts of Africa. Two closely related but not interchangeable terms are epidemic and pandemic. An epidemic “is a sudden severe outbreak within a region or a group while a pandemic occurs when an epidemic becomes very widespread and affects a whole region, a continent, or the entire world.”

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are likely to have access to adequate sanitation and hygiene facilities within Haiti, such that any cholera organisms they import would be safely contained.”22

On October 15, 2010, the Cuban Medical Brigade reported its first cholera case in the Haitian city of Mirebalais.23 (The Brigade was an international medical mission sponsored by the Cuban government that provided services and assistance throughout the world with a focus on Africa.) The Brigade had worked in Haiti since 1998 but the appearance of cholera was unexpected and surprised the Brigade. One member commented, “We went back to our books to see if this really could be cholera and then reported it right away.”24 Six days later, on October 21st, the Haitian National Public Health Laboratory confirmed the first cholera outbreak in Haiti in over 100 years.25 Speaking of the unlikely possibility of cholera occurring in Haiti, a U.N. spokeswoman from the humanitarian coordination office said, “[cholera was] the one thing we thought we were relatively safe on.”26

Cholera was an infection of the intestine. For a cholera outbreak to occur two conditions had to be met: (1) there had to be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholerae organisms; and (2) cholera had to be present in the population.27 Typically, the majority of those infected did not necessarily exhibit any symptoms or only suffered from mild diarrhea and/or vomiting which did not require medical intervention. Cholera could cause severe dehydration and subsequent death if untreated. With appropriate treatment and public health response the mortality rate for cholera epidemics was below 1%.28

We Have an Epidemic but How? Haiti implemented a nationwide monitoring program that registered all ambulatory patients, hospital admissions

and deaths. The MSPP with technical support from the CDC, Pan American Health Organization (PAHO) and other non-governmental organizations coordinated a response to the epidemic. The cholera strain initially identified in Haiti, Vibrio cholerae O1, typically required treatment at a health facility with rehydration therapy only 7% of the time.29 Two days after the first cholera cases were discovered new cholera patients were being admitted every 3.5 minutes at a hospital located 60 miles away from the first cholera cases.30 During the initial days of the epidemic, mortality rate estimates ranged from 7.7% to 9%.31 By October 27th there were 4,722 recorded cholera cases and 303 deaths.32

The cholera outbreaks began in the region north of the Artibonite River near a MINUSTAH base. Rumors began to circulate that lack of adequate sanitation procedures regarding the removal of human waste had caused the epidemic especially as it was discovered that a new rotation of peacekeepers from Nepal—where cholera was endemic—had recently arrived in Haiti on October 9, 12 and 16.33 Reports of bad smelling, black water from the base trickling into the river had been observed by local residents. An October 28th Associated Press story described base conditions: “A buried septic tank inside the fence was overflowing and the stench of excrement wafted in the air. Broken pipes jutting out from the back spewed liquid. One, positioned directly behind latrines, poured out a reeking black flow from frayed plastic pipe which dribbled down to the river where people were bathing.”34 According to the article, area residents blamed those at the base and used an example of one man to illustrate the community’s general attitude towards MINUSTAH, “a young man walked by its gate laughing and chanting, ‘Co-co-cholera. Cholera MINUSTAH’ – referring to the peacekeeping mission by its French initials.”35 The Mirebalais Mayor blamed the peacekeepers: “They are located exactly where the sickness started.”36 However both U.N. officials and other cholera experts dismissed the idea that the MINUSTAH base was the cholera source. Many cholera experts felt the earthquake’s environmental disturbance caused the spread of a previously dormant cholera organism.37

On November 1st, a CDC lab test indicated that the cholera strain in Haiti was the same as strains found in South Asia. Haiti’s Minister of Health stated, “Although these results indicate that the strain is non-Haitian, cholera strains may move between different areas due to global travel and trade. Therefore we will never know the exact origin of the strain that is causing the epidemic in Haiti. This strain was transmitted by contaminated food or water or an infected

Definitions and examples from MedicineNet.com, http://www.medterms.com/script/main/art.asp?articlekey=3234, accessed December 2012.

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person.”38 Within a month, the cholera strain in Haiti was present in other countries including the neighboring Dominican Republic, the U.S., Venezuela, Mexico, Spain and Canada.”39

International health officials emphasized the importance of containment and treatment over identifying the epidemic’s origin. The CDC medical epidemiologist leading the agency’s cholera response in Haiti commented, “Our primary focus here is to save lives and control the spread of disease. We realize that it is also important to understand how infectious agents move to new countries. However, we may never know the actual origin of this cholera strain.”40 In a separate press conference, the U.N. Humanitarian Coordinator and deputy head of the U.N. mission referring to a CDC analysis of the cholera strain in Haiti told reporters, “The conclusion was that it would be impossible to ascertain where and how it came in…CDC has said it would be almost impossible to find a precise source….Our emphasis is on trying to contain the number of deaths from what is going to be a very severe outbreak.”41 The CDC chief of the response to the epidemic stated, “Naming individual countries is not productive. We’re focused on this really unacceptable number of deaths.”42 Despite allegations pointing towards MINUSTAH, a U.N. spokeswoman agreed, “From our point of view, it really doesn’t matter [who caused the epidemic].”43

On November 15th, thirteen days before scheduled presidential elections, rioting took place in Haiti’s second largest city, Cap Haitian. MINUSTAH peacekeepers, seen as the source of the cholera epidemic, were the target of the riots.44 A U.N. spokesman said the protesters used the escalating cholera epidemic as an excuse to push the troops out and destabilize the country before the rescheduled presidential election. He explained, “These are not genuine demonstrations. They are using spoilers paid to create chaos.”45 The U.N. also claimed that demonstrations had made it difficult to reach and treat the city’s cholera victims.46 The head of the U.N. mission said, “It's really unfair to accuse the U.N. for bringing cholera into Haiti. We don't want to stigmatize any nation or any people.”47

To Vaccinate or Not? In Haiti, the primary strategy for cholera prevention emphasized public education on good sanitation practices,

but some non-governmental groups argued for a vaccination campaign.48 An effective campaign however had to overcome several challenges.49 Cholera vaccines were in short supply. The manufacturer of the only officially World Health Organization (WHO) approved vaccine (Dukoral) had limited capacity to increase production quickly. Another new cholera vaccine that had recently been developed with the support of the Bill and Melinda Gates Foundation was in the midst of the WHO approval process for widespread distribution. To provide immunity both vaccines required that two doses be administered two weeks apart making efficacy an issue. (A single dose vaccine, Orochol, had existed but its manufacturer had stopped production in 2004 to focus on the production of other vaccines.) Coordinating the logistics of a large scale vaccination campaign was also daunting. Vaccinating Port-au-Prince’s population required managing four million doses. Finally, the earthquake’s lasting impact exacerbated challenges of any large scale vaccination campaign: ensuring data quality, adhering to a standard definition and reporting cases in a timely manner. The PAHO deputy director commented, “Coordinating these groups on a normal day in Haiti would be difficult enough, but in post-earthquake Haiti in the middle of a cholera outbreak, it becomes a huge challenge.”50

The Source is Clear or Is It? In November, French epidemiologist Rene Piarroux arrived in Haiti as an official representative of his

government to assist Haitian officials in determining the cholera outbreak source. Over the course of three weeks Piarroux and his team traveled the countryside and conducted numerous interviews with local Haitians living in the affected areas, Haitian government officials and those working with multi-lateral organizations to determine the factors that caused the epidemic. In December Piarroux completed and submitted his report to the French government which in turn shared copies with the Haitian government and U.N. officials. As Piarroux had been hired by the French government, he did not initially release his report to the general public.

Frustrated with a lack of official response to the report’s findings, Piarroux broke official protocol and French policy and shared a copy with Le Monde, the largest daily newspaper in France, without first seeking permission from the appropriate French officials. The newspaper subsequently published the entire report in early December.

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The report’s conclusions were unambiguous: “In conclusion, the fact finding mission…has revealed the severe and unusual [nature of] this epidemic, whose origins were undoubtedly imported. It started around the camp of MINUSTAH and propagated explosively due to the massive contamination of the water in the Artibonite and one of its tributaries with feces of patients suffering from cholera.”e,51

The international community reacted with a range of responses to the report. Although the U.N. acknowledged the receipt of Piarroux’s report, it did not publicly support his conclusions. A U.N. mission spokesman said, “We have neither accepted nor dismissed his findings, as it’s one report among others. The Nepalese contingent in Mirebalais is just one piece of the cholera puzzle, since there is no conclusive evidence at this point that the Nepalese camp was or was not the source of the epidemic.”52 Additionally, a spokesperson for the Nepalese army called the findings in Piarroux’s report “hypothetical” and told the French news agency AFP, “We strongly condemn the making of such allegations with no firm evidence or facts.”53 Moreover, an editorial published in the December issue of The Lancet, a well-respected medical journal, held the position that: “Although interest in how the outbreak originated may be a matter of scientific curiosity for the future, apportioning blame for the outbreak now is neither fair to people working to improve a dire situation nor helpful in combating the disease.”54

During a U.N. press conference that month, the Under Secretary General for Peacekeeping Operations told reporters “We are calling for an international panel and we are in discussions with WHO to find the best experts to be in a panel, completely independent… [And] have the best investigation on the source of the outbreak.”55 He asserted, however, “There is no consensus among scientists on this issue [the epidemic’s cause].”56 He pointed out that none of the Nepalese peacekeepers had tested positive for cholera or shown any symptoms of the disease, and that repeated analyses of water from their camp had not detected the strain of the disease blamed for the epidemic.57 Two days later at another news conference, U.N. Secretary-General Ban Ki-moon noted that all the tests MINUSTAH and the Haitian government had conducted linking the peacekeepers to the outbreak had been negative. He continued, “But there remain fair questions and legitimate concerns that demand the best answer that science can provide. That is why, pursuant to close consultation with Dr. Margaret Chanf of WHO, I am announcing today the creation of an international scientific panel to investigate the source of the cholera epidemic….We want to make the best effort to get to the bottom of this and find answers that the people of Haiti deserve.”58

In January 2011 the Secretary-General appointed an independent panel of four members with expertise in the areas of microbiology, cholera and water and sanitation to determine the cause of the cholera outbreak in Haiti. The U.N. statement released by the Secretary General’s office declared, “Determining the source of the cholera outbreak is important for both the United Nations and the people of Haiti.” The four experts were “selected based on their global stature, expertise and extensive experience working with cholera in all its aspects.”59 The panel would operate independently of U.N. with access to all U.N. records, reports and facilities.60

The Cholera Epidemic Impacts Haiti and Beyond Even as the panel formation was announced, the scientific and medical communities contended that learning

as much as possible about the epidemic was critical. Piarroux co-authored an editorial in the journal Clinical Microbiology and Infection arguing that understanding the Haitian cholera source was a necessity. First, developing the most effective preventive approach depended on the most detailed epidemiological information available. Second, if an institution had played a role in the epidemic’s spread such knowledge was necessary to change practices to prevent such a tragedy

e Translation by supplied by Google Translate with necessary modifications by casewriter. The original French text is, “En conclusion, la mission d’investigation menée depuis trois semaines a révélé le caractère sévère et inhabituel de cette épidémie, dont l’origine importée ne fait aucun doute. Elle a démarré aux abords du camp de la MINUSTAH et a été propagée de manière explosive du fait de la contamination massive de l’eau de l’Artibonite et d’un de ses affluents par des matières fécales de patients atteints de choléra.” For a complete version of the original report see, http://medias.lemonde.fr/mmpub/edt/doc/20101210/1452027_1b80_cholera_haiti_rapport_pr_piarroux.pdf or http://www.ph.ucla.edu/epi/snow/piarrouxcholerareport_french.pdf. Both accessed October 2012. f Dr. Chan was Director-General of the World Health Organization. The Director-General was WHO's chief technical and administrative officer and oversaw the policy for the organization's international health work.

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from reoccurring. Moreover, understanding if the cholera source had always been present in the environment might indicate whether it could be completely eliminated from Haiti. Finally, knowing the source was “essential to restore trust between populations and humanitarian staff.”61 The president of Médecins Sans Frontières (Doctors Without Borders)—an international humanitarian medical organization and one of the first NGOs (in addition to the Cuban Medical Brigade) to treat Haitian cholera victims called for the appointment of an independent panel of experts to not only investigate the source of the cholera epidemic but also make any findings public. In an online editorial, she rebuffed the MINUSTAH’s assertion that an investigation was unnecessary because the epidemic’s origin would always be uncertain. She characterized such reasoning as “counter-productive to hide epidemiological data and keep investigative reports confidential. Such actions prevent us from establishing a precise diagnosis and can result in misdirected aid efforts…we must identify the source of the epidemic.”62 Finally, the authors of an article entitled, “The Origin of the Haitian Cholera Outbreak Strain,” in the January 2011 issue of The New England Journal of Medicine concluded “our data strongly suggest that the Haitian epidemic began with the introduction of a V. cholerae strain into Haiti by human activity from a distant geographic source…[although] understanding exactly how the South Asian variant strain of V. cholerae was introduced to Haiti will require further epidemiologic investigation.”63 Discussing the policy implications of their conclusions, the authors wrote, “the apparent introduction of cholera into Haiti through human activity emphasizes the concept that predicting outbreaks of infectious diseases requires a global rather than a local assessment of risk factors. The accidental introduction of South Asian variant V. cholerae El Tor into Haiti may have consequences beyond Haiti.” 64

U.N. Panel Releases Findings The U.N. appointed panel conducted three simultaneous in-country investigations that considered the cholera

origins from the perspectives of epidemiology, water and sanitation and molecular analysis. The experts considered the various outbreak sources and presented the three dominant theories about the source of the epidemic: a strain of cholera normally found in the Gulf of Mexico traveled to Haiti via currents as a consequence of the January 2010 earthquake, a previously local strain of cholera found naturally in the Haitian environment mutated into a pathogenic strain or that an infected individual from a country in which cholera was endemic unintentionally brought cholera into Haiti.65

In May 2011, the U.N. appointed expert panel released, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti.”g The report’s final conclusion underscored that humans—not environmental sources—caused the epidemic: “The evidence does not support the hypotheses suggesting that the current outbreak is of a natural environmental source. …the evidence overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type of Vibrio cholerae as a result of human activity...The Independent Panel concludes that the Haiti cholera outbreak was caused by a confluence of circumstances…and was not the fault of, or deliberate action of, a group or individual” [emphasis in the original].66 The authors also acknowledged the other factors that created the epidemic: “the introduction of this cholera strain as result of environmental contamination with feces could not have been the source of such an outbreak without simultaneous water and sanitation health care system deficiencies.”67 At the same time, the report emphasized “the source of cholera in Haiti is no longer relevant to controlling the outbreak. What are needed at this time are measures to prevent the disease from becoming endemic.”68

The report pointed to several reasons for the severity and rapid transmission of cholera in Haiti. The contamination of the Aribonite River and its associated canals meant that the thousands of Haitians who depended on these resources for washing, drinking, recreation and agriculture were susceptible to infection. The Haitian population was especially vulnerable as their previous lack of exposure meant they had little immunity to cholera. Moreover, this strain was particularly virulent. Terrible water and sanitation conditions exacerbated the disease’s transmission. Travel by those leaving affected communities also hastened cholera’s spread. Additionally, the large numbers of people

g To read the complete original report see, www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf, accessed November 2012.

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seeking care overwhelmed health facilities and systems. Finally, an initial lack of proper preventive measures in medical facilities compounded the problem.69

Ultimately the report offered recommendations to the U.N., the Government of Haiti and the international community. Recommendations specific to the U.N. included: vaccinating and/or screening all emergency workers for cholera before they could enter the country, ensuring that fecal waste at all U.N. associated facilities be treated appropriately on site to inactivate any existing pathogens, urging U.N. agencies to “take stewardship in” training health workers, and that the U.N. take full advantage of “microbial techniques to improve surveillance, detection, and tracking of Vibrio cholera, as well as other disease-causing organisms that have the potential to spread internationally.”70 For the international community, the report proposed vaccines should be used even after an epidemic onset as a way to control and manage the disease’s spread. Suggestions to Haiti centered on water improvement measures. In the short term, the government needed to offer potable water supplies and collect fecal waste in dense settlement areas in a timely manner. Long-term the country needed to invest infrastructure to treat and pipe water.

After the report was published the U.N. maintained its position that the epidemic’s cause was unclear. A representative for the U.N. peacekeeping department told reporters that the report “does not present any conclusive scientific evidence linking the outbreak to the MINUSTAH peacekeepers or the Mirebalais camp...Anyone carrying the relevant strain of the disease in the area could have introduced the bacteria into the river.”71 The U.N. Department of Public Information released a statement that thanked the panel, called for the creation of a U.N. Taskforce “to ensure prompt and appropriate follow-up,” reiterated the devastating impact of the epidemic and reminded the media that the U.N. offered ongoing support to the Haitian people and government.72 (To read the entire statement, see Exhibit 3.) The office classified the statement as “for information only” and not as an “official record.”

Effective Intervention and Policy Are Critical The international medical and public health communities continued to press for understanding the cholera

epidemic’s origin on the premise that such knowledge was necessary to develop the most effective treatment interventions in Haiti and to restore Haitian trust in the international community. Moreover, these lessons could also be applied to other epidemics. A July article published by Piarroux reiterated the charges from his report printed in Le Monde that the MINUSTAH peacekeepers had brought cholera into Haiti. This article, unlike his report, did not appear in the popular press but was instead published in the CDC’s well-regarded journal Emerging Infectious Diseases (EID) and specifically written for a scientific audience. It was based on a more complete methodology, followed standard epidemiologic practices and had been peer reviewed. Piarroux argued,

“determining the means of the spread of the cholera epidemic in Haiti was necessary to direct the cholera response, including lasting control of an indigenous bacterium and the fight for elimination of an accidentally imported disease…Putting an end to the controversy over the cholera origin could ease prevention and treatment by decreasing the distrust associated with the widespread suspicions of a cover-up of a deliberate importation of cholera. Demonstrating an imported origin would additionally compel international organizations to reappraise their procedures.”73

Another article, published in mbio, the online-only, open access journal of the American Academy of Microbiology used whole genome sequencing to determine conclusively that the Haitian cholera strain source originated from Nepal. The authors wrote the “results in this study are consistent with Nepal as the origin of the Haitian outbreak.” They continued “this highlights how rapidly infectious diseases might be transmitted globally through international travel and how public health officials need advanced molecular tools along with standard epidemiological analyses to quickly determine the source of outbreaks.”74

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Suing the U.N. On November 3, 2011, lawyers from the organizations of Institute for Justice and Democracy in Haiti

(IJDH) and Bureau des Avocats Internationaux respectively based in the U.S. and Haiti filed a petition with the claims unit of MINUSTAH in Haiti and with the U.N. in New York City, U.S. Representing over 5,000 Haitian cholera victims the suit claimed the “sickness, death, and ongoing harm from cholera suffered by Haiti’s citizens are a product of the U.N.’s multiple failures” 75 and sought $50,000 for each sickened victim and $100,000 for families whose relatives died from cholera. 76 In addition to compensation, the suit demanded the U.N. provide a fair and impartial hearing, redress the situation by creating a fund to establish “a comprehensive sanitation, potable water and medical treatment program” in Haiti, and that the U.N. and MINUSTAH publicly acknowledge their roles in causing the epidemic.

The suit made three allegations against the U.N. First the U.N. was “liable for negligence, gross negligence, recklessness, and deliberate indifference.” Moreover, the U.N. had not followed Haitian civil, criminal and constitutional law even though it was obligated to do so according to its own mandates and statutes. Specifically, “the U.N. has failed to establish a standing claims commission as required by the Status of Forces Agreement (“SOFA”). Under the SOFA, the claims commission is the forum that has jurisdiction to hear civil claims of Haitians injured by MINUSTAH’s actions. The U.N. has yet to establish this commission leaving victims without a clear route to seek accountability and relief.”77 Finally, the U.N. did not follow international law and even violated international human rights law: “the U.N. General Assembly, expanding on principles in the Declaration of the U.N. Conference on the Human Environment, has stated that international organizations have the ‘responsibility to ensure that activities within their jurisdiction or control do not cause damage to the natural systems located within other States.’”78

The suit justified its claims from several perspectives. The legal justification was based on the premise that, “Under the SOFA, the U.N. is responsible for the acts of MINUSTAH, a subsidiary organ of the U.N.”79 Further, immunity of MINUSTAH did not presuppose any legal action and that “international law and jurisprudence recognize that immunity cannot be so absolute as to foreclose all avenues for redress.” 80 Also by not taking responsibility for its actions, the U.N.’s moral stature, creditability and operational effectiveness were in jeopardy. A U.N. response, according to the brief, was “vital to the U.N.’s integrity in promoting human rights around the world…the U.N. is a unique global leader. It leads in setting human rights standards, in reaffirming the dignity and worth of all people, and in ensuring justice…the petitioners simply ask the U.N. to live up to the noble ideals it promotes.”81 Finally, a settlement was practical as it was “in the interest of promoting MINUSTAH’s operational efficiency in Haiti.” (Exhibit 4 shows a schematic of the suit.)

The suit faced legal and practical challenges even though a former U.N. Rights Commission member commented after reading the petition, “one would hope that the Secretary General would address this with great moral seriousness. It's a lot of money but if the facts are alleged as true it's a serious harm.”82 However, no international court or body had jurisdiction over the U.N. and no outside formal enforcement monitoring mechanisms were in place. Moreover, it would be unprecedented for the U.N. to take the action that the lawsuit demanded as it had had never opened a standing claims commission in any country. Nonetheless, in December 2011, the U.N.’s legal counsel officially acknowledged the suit. The U.N. Under-Secretary-General for Legal Affairs, the Legal Counsel, sent a letter to IJDH noting, “Please be advised that the United Nations is in the process of reviewing the claim, and we shall provide you with a response in due course.”83 (Exhibit 5 is a copy of the letter the U.N. General Counsel sent to IJDH.)

Lessons from the Cholera Epidemic The outcome of the suit against the U.N. remained uncertain but cholera’s toll on Haiti continued. The

outbreak had become one of the largest epidemics in the world and cholera was in danger of becoming endemic in Haiti.84 At a January 2012 press conference, the director of PAHO stated, “We have the duty to have our eyes on the elimination of cholera. We should not accept endemic cholera in Hispaniola, and we can use the lessons we learned in eliminating cholera from Latin America and Caribbean in the 1990’s.”85 Yet the conditions—lack of water and proper sanitation facilities—that had made cholera a constant in Haiti since its introduction in October 2010 persisted. An

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estimated “eighty percent of Haitians still ha[d] no access to proper toilets, and many drink and bathe in water near where they defecate.”86 Although the international community agreed that “investments in infrastructure are absolutely essential,”87 to end cholera in Haiti such an undertaking was expensive. Estimates from the Inter-American Development Bank, Office of the Haitian Prime Minister, World Bank to make the necessary improvements in Haiti’s water and sanitation infrastructure ranged from $746 million to $1.1 billion.88

The international medical community continued to find valuable lessons from the cholera epidemic that had public health implications beyond Haiti. A study conducted by Children’s Hospital Boston and Harvard Medical School documented that social media had tracked the epidemic’s spread faster than traditional sources. The authors believed that such findings offered opportunities to better manage disease outbreaks especially in resource-limited settings. While they conceded that some limitations existed when using informal data, they concluded that “at the early stages of an outbreak informal sources can be indicative not just that an outbreak is occurring, but can highlight disease dynamics…social and news media…are a cost effective data source.”89 Another article documented the spread of the disease by tracking one of the first cholera cases in Haiti and argued that the cholera epidemic in Haiti was an example “that globalization has important impacts on public health.” The article noted that first victim had been a resident of Mirebalais and that the road between the city and Port-au-Prince had been newly paved. A mere forty-five minutes linked the two cities offering easy fluidity of movement between city residents displaced by the earthquake and the country side. The modernization of roads without simultaneous modernization of other modern amenities had unintended and unforeseen consequences for Haiti: “The conflagration of a small rural town with poor infrastructure, no decent sanitation or clean water, and these factors of a new improved road—a compelling reason to move back and forth from the capital and increased movement of international visitors—is globalization at the micro level.”90

There Was No One Cause In March 2011 the former American president Bill Clinton toured a new Haitian hospital in his capacity as the

U.N. special envoy to the country. Speaking with reporters, Clinton offered his thoughts on the cause of the cholera epidemic, “I don't know that the person who introduced cholera in Haiti, the U.N. peacekeeper, or soldier from South Asia, was aware that he was carrying the virus. It was the proximate cause of cholera. That is, he was carrying the cholera strain. It came from his waste stream into the waterways of Haiti, into the bodies of Haitians. [However] I think it's better to focus on fixing it.”91

A day later during a noon briefing for reporters, the spokesperson for the U.N. Secretary-General Ban addressed the cholera issue. He reminded reporters that in the final report commissioned by the U.N. the authors had concluded that it was impossible to know how cholera had been introduced in Haiti and that “the outbreak was caused by a confluence of factors, and was not the fault of, or deliberate action of a group or individual.”92 Addressing President Clinton’s remarks, the spokesperson observed that that the president had emphasized focusing on improving Haiti's sanitation system and that the U.N. still considered Haiti’s situation a priority. Finally, when asked about the establishment of a standing commission to address the suit filed against the U.N., the spokesperson noted that the U.N. had received the cholera related claims in Haiti, and was in the process of studying them.93

Measurable Progress? With the approach of the 2012 rainy season in Haiti, the U.N. and other organizations braced themselves for

a resurgence of the epidemic. WHO estimated that there could be 20,000 cholera cases in the spring.94 Partners In Health, a U.S. based health care non-profit with a long history of providing medical services in Haiti, began a cholera vaccination pilot program with the goal to immunize 1% of the population and to demonstrate that the necessary conditions for successful treatment—two doses over two weeks—could be achieved even for those living in hard to reach rural areas.95 Although a national plan and strategy had been put in place to deal with cholera, the U.N. humanitarian coordinator acknowledged that little progress had been made. Haiti still depended on international actors and partners to treat the disease. He conceded,

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As humanitarian actors facing cholera, what we are doing is sort of patchwork, band-aid work on a fundamental problem. The fundamental problem is when cholera broke in Haiti there was no experience of it and the conditions were ripe for it to spread quickly. Only less than two-thirds of Haitians have access to safe, protected drinking water and only 17 percent, that is not even one in five, of Haitians have access to latrines and safe waste management, which means people go to the toilet wherever – waste matter is mixed often with drinking water sources, so already we have very high [rates of] diarrhoeal diseases and once cholera was introduced and given these poor sanitary conditions, it spread like wild fire. What we are doing in the short-term, in terms of treatment, education [and] oral rehydration is necessary, but we all agree that the long-term solution is investment in improved drinking water sources and in waste management. 96

By the summer of 2012, cholera’s impact on the country was still being felt—the disease had become endemic. Disagreement still continued on the source of the epidemic. Dr. Rita Colwell, a distinguished University Professor both at the University of Maryland at College Park and at Johns Hopkins University Bloomberg School of Public Health and a prominent global infectious diseases, water, and health expert posited, “the introduction (from Nepal) can’t be ruled out but it can’t be proven either. I think the evidence is at best circumstantial, and it’s not sufficient to account for the entire epidemic.”97 At the same time, the Nepalese MINUSTAH soldiers had been replaced by personnel from Uruguay. U.N. officials characterized this move as part of its overall reduction of troops in Haiti and unrelated to the cholera issues.98 The U.N. had also begun installing new water treatment centers at all 28 of its bases in Haiti.99

Even as the U.N. remained silent on the cause o the Haitian cholera epidemic, there were calls for the institution to acknowledge its role. A former U.N. Human Rights Commission member commented, “At the very least they [the U.N.] should require medical records for all peacekeepers. We don’t want someone with a contagious disease to enter a different biosphere and start an epidemic.” 100 The U.S. U.N. Ambassador received a letter signed by 104 members of the U.S. House of Representatives urging, “As cholera was brought to Haiti due to the actions of the U.N., we believe that it is imperative for the U.N. to now act decisively to control the cholera epidemic.”101 For the lawyers who had brought the suit against the U.N. the issue was one of fairness. The plaintiffs’ lead lawyer commented, “In many ways, cholera is more a justice issue than a medical issue. You don’t get cholera unless you are poor—unless you don’t have access to clean water.”102

Haiti November 2012 By November 2012, an estimated 7,600 people had died and 600,000 had become ill.103 Officials worried that

the recent Hurricane Sandy would cause a rise in cholera cases even as cholera treatment continued to overwhelm the Haitian government and hospitals. Public hospitals typically referred cholera patients to NGOs or refused to treat them. Foreign NGOs were overburdened just as foreign aid continued to drop. One worker with Médecins Sans Frontières described the situation, “If we are overcapacity, it is because of the health ministry. They refer all cases to NGOs, but with the fall in international funding, there is a struggle. In May we treated 70% of the cholera cases in Port-au-Prince…Two years after the start of an epidemic, that’s not normal. The ministry of health should take responsibility. We shouldn’t be a substitute.”104

Indeed even as over 289 organizations continued to work in Haiti in 11 different areas105 international aid workers remained pessimistic. (Exhibit 6 shows how many NGOs by sector remained in Haiti.) The Partners In Health Clinical Director in Haiti who had worked in there for many years summarized how little progress had been made in eradicating cholera. She remarked, “Haiti had never seen a case of cholera before October 2010, yet somehow needless cholera deaths are beginning to be accepted as the new norm. That is an outrage we cannot accept.”106

The IJDH director believed that the U.N. would be forced to take responsibility for its role in bringing cholera to Haiti. He predicted, “There is general agreement that this wall of impunity is going to come down at one time or another. If any case should do it, this would be the case as it is so clear. We are on the right side of the tide of history.”107 While the director waited for a U.N. response, IJDH was preparing to expand its lawsuit to include other

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victims. Moreover, the organization had contingency plans to file a national lawsuit in the U.S. or Europe if the U.N. continued to ignore the pending lawsuit.

Although the U.N. still had not responded to the lawsuit,108 the U.N. head of humanitarian affairs in Haiti wished for resolution. He commented, “Obviously we are aware of the latest reports and analysis. Unfortunately, we have to leave this in the hands of the legal process until they have worked that through. I hope that is sooner rather than later. We'd all like to put that issue behind us so we can contain the continued epidemic.”109

In December 2012, the Haitian government announced a ten year plan to improve water and sanitation facilities throughout the country. Developed with the backing of the CDC, PAHO and UNICEF, the ten year initiative was expected to cost U.S.$2 billion but as of November 2012 was largely unfunded. A CDC official explained, “This is the greatest public health intervention that could be implemented in Haiti, but it is a long-term strategy, it’s not a fix tomorrow. Our goal is to eliminate the transmission of cholera.”110

However, some were critical of this initiative noting that it was not a new effort but merely a renaming of aid monies already allocated in January 2012 by various U.N. agencies. In an opinion piece for the magazine Foreign Policy, Jonathan Katz, the Associated Press reporter who initially reported on the unsanitary waste disposal practices at the MINUSTAH camp in Haiti, wrote,

“Shifting around aid money – making the same promises over and over without fulfilling them – is an old game in the development world. But in this case it's especially bold. Donors have been hammered for failing to live up to their pledges for post-quake rebuilding in Haiti. Nearly half the funds pledged after the earthquake for 2010-12 have not been delivered… By relaunching an existing Haitian-Dominican effort under the guise of a U.N. initiative, the world body can once again claim to be too busy saving Haitian lives to comment on how those lives were put in danger in the first place. It took no time for this to happen. When an AP reporter asked on Dec. 11 whether humanitarian coordinator Nigel Fisher thought the U.N. caused the cholera epidemic, he refused to comment, saying: ‘My focus is on today.’”111

“The Claims Are Not Receivable” On February 21, 2013, the U.N. officially responded to the legal claims brought against it by the IJDH on

behalf of the Haitian cholera victims. Responding to questions during that day’s noon briefing, the spokesperson for the Secretary-General said, “I can confirm that we have informed counsel for the claimants that the claims are not receivable. Consideration of the claims would necessarily involve a review of political and policy matters. Accordingly, the claims are not receivable pursuant to Section 29 of the Convention on the Privileges and Immunities of the United Nations, adopted by the General Assembly on 13 February 1946.”112 (Exhibit 7 shows the spokesperson’s talking points verbatim from the U.N. website and Exhibit 8 is the full text for Section 29 from the Convention on the Privileges and Immunities Treaty, No. 4.) In keeping with U.N. practice regarding suits filed against the U.N., it offered no other decision details. However, according to a statement released on the U.N. website, the Secretary-General personally telephoned Haiti’s president to inform him of the U.N.’s dismissal of the suit while also “express[ing] his profound sympathy for the terrible suffering caused by the cholera epidemic, and calls on all partners in Haiti and the international community to work together to ensure better health and ha better future for the people of Haiti.”113

The Boston Globe newspaper’s national security and foreign policy columnist (who was also a faculty member at Harvard University’s Kennedy School of Government and a former Assistant Secretary for Intergovernmental Affairs at the Department of Homeland Security of the United States) wrote about the U.N.’s decision. The columnist categorized, “the case [as] historic; the [U.N.] organization rarely asserts immunity for itself but merely enforces the privileges for member nations.”114 In the same column, the reporter, while acknowledging there could be room for debate about the U.N.’s lack of sympathy towards the Haitian cholera victims, about testing peacekeepers before deployment and even if a moral obligation had existed for the U.N. to help Haiti, stated, “This case is about disaster management, not public health….Ban’s decision will protect all relief efforts in the future. It is the only outcome that provides the necessary protections to those who are asked to work voluntarily in dangerous situations. Most

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importantly, it will maintain an incentive for nations to support U.N. efforts for assistance or peacekeeping missions that have, by any measure, done far more good than harm.” 115,h

The IJDH, however, did not plan to drop its lawsuit against the U.N. and even argued that a legal basis continued to exist for its suit. In a press release, the director stated, “The U.N. says that our claims concern policy. Our case is about the U.N. dumping contaminated sewage in Haiti’s waters that has caused thousands of deaths. Under this definition, any harm that the U.N. does to anybody would be a matter of policy.”116 Additionally, the director’s co-counsel still believed the U.N. to be morally culpable and declared “We will win this case. Regardless of what the U.N. says, it has already been found guilty in the court of public opinion. This is a missed opportunity for the U.N. to do the right thing and demonstrate its commitment to justice and human rights, with deadly consequences,”117 The IJDH and co-sponsoring organizations planned to proceed with the lawsuit and appeal through a national court in Haiti, the United States or Europe.118

In addition to the moral and scientific arguments, others criticized the U.N.’s recent sanitation efforts in Haiti as inadequate and called for a reevaluation of U.N. priorities. In a New York Times Op-Ed the Partners in Health Clinical Director, wrote

“If the United Nations were to finance this initiative, along with the rest of the government’s anti-cholera program, it could have a significant and immediate impact on stemming this epidemic. As of now, however, the United Nations plans to contribute just 1 percent of the cost. That is not enough.

Meanwhile, the organization’s stabilization mission in Haiti is budgeted for $648 million this year – a sum that could more than finance the entire cholera elimination initiative for two years.

It’s time for the United Nations to rethink what true stabilization could be: preventing people from dying of a grueling, painful – and wholly preventable – disease is a good start.”119

As of January 2013, cholera still continued to impact Haiti. A January 2013 PAHO Epidemiological Update estimated from the cholera epidemic’s start in October 2010 through to January 7, 2013 “the total number of cholera cases reached 638,511, of which 353,532 (55%) were hospitalized and 7,943 died.”120

h To read the entire column see http://bostonglobe.com/opinion/columns/2013/02/28/decision-claim-diplomatic-immunity-for-cholera-outbreak-haiti-was-cold-but-correct/MxeER5UM6aWzZB2WNJtjgI/story.html accessed March 2013.

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Exhibit 1 Map of Haiti

Source: Courtesy of the University of Texas Libraries, The University of Texas at Austin, http://www.lib.utexas.edu/maps/haiti.html, accessed December 2012.

Exhibit 2 Haiti: Basic Country Statistics (2009)

Total population 9,993,000

Gross national income per capita (PPP international $) 1,180

Life expectancy at birth male/female (years) 60/63

Probability of dying under five (per 1,000 live births) 70

Probability of dying between 15 and 60 years m/f (per 1,000 population) 278/227

Total expenditure on health per capita (Intl $, 2010) 76

Total expenditure on health as % of GDP (2010) 6.9

Source: World Health Organization, http://www.who.int/countries/hti/en/index.html, accessed December 2012.

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Exhibit 3: U.N. Response to Expert Panel Report

4 May 2011

Secretary-General SG/SM/13543

Department of Public Information • News and Media Division • New York

Secretary-General, Upon Receiving Experts’ Report on Source of Haiti

Cholera Outbreak, Announces Intention to Name Follow-up Task Force

The following statement was issued today by the Spokesperson for U.N. Secretary-General Ban Ki-moon:

The United Nations has today made public the report of the Independent Panel of Experts to investigate the source of the cholera outbreak in Haiti, which was presented to the Secretary-General on 3 May. The Special Representative of the Secretary-General in Haiti presented a copy of the report to the Government of Haiti earlier today.

The Secretary-General expresses his gratitude to the Independent Panel of Experts for its efforts and will carefully consider its findings and recommendations. To that end, the Secretary-General intends to convene a task force within the United Nations system, to study the findings and recommendations made by the Independent Panel of Experts to ensure prompt and appropriate follow-up.

The cholera outbreak has caused significant loss of life and widespread infection throughout the country. On behalf of the United Nations family, the Secretary-General reiterates his deepest sympathies to the victims of the epidemic and their loved ones.

The Secretary-General reaffirms the continuing commitment of the United Nations to stand shoulder to shoulder with the Government and people of Haiti in the ongoing fight against the cholera epidemic and expresses his gratitude to the many countries and organizations that have helped to combat the disease.

* *** *

For information media • not an official record Source: U.N. Website, http://www.un.org/News/Press/docs/2011/sgsm13543.doc.htm accessed October 1, 2012. Original text, formatting altered by casewriter.

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Exhibit 4: Schematic Overview of the Petition for Relief Filed Against MINUSTAH

Statement of Facts

A. Background B. Nepal’s Peacekeeping Forces in Haiti C. Cholera Outbreak in Haiti D. U.N.’s Response to Questions over its

Role in Bringing Cholera to Haiti E. Findings of the Independent Panel F. Recommendations of the Independent

Panel G. Conclusion

Petitioners—Over 5,000 Haitians filing a claim

A. For their own injuries from cholera B. As parents on behalf of their minor

children who contacted cholera C. Next-of-kin on behalf of family

members who died from cholera.

Jurisdiction

A. The SOFA mandates that the United Nations settle Petitioners’ third-party claim for their cholera related illnesses and deaths

B. This Petition is filed within the statue of limitations

General Allegations

A. The U.N. is liable for negligence, gross negligence, recklessness, and deliberate indifference for the health and lives of Haitian people resulting in petitioners’ injuries and deaths from cholera.

B. The U.N. failed to represent Haitian civil, criminal, and constitutional law as mandated by the SOFA.

C. The U.N. failed to comply with international law and violated Petitioners’ fundamental rights under international human rights law.

The United Nations Must Act to Protect Victims’ Right To An Effective Remedy Under International Law

A. The U.N. is legally bound to respect victims’ right to an effective remedy as guaranteed under international human rights law.

B. Providing the Petitioners Access to an Effective Judicial Remedy is in the Interest of the United Nations.

C. The United Nations must make reparations available to the Petitioners.

Request for Relief

A. Fair and Impartial Adjudication of the Claim

B. Compensation to the Petitioners C. Reparations to victims of cholera at

large

Source: Casewriter based on Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, (November 3, 2011) http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf accessed January 2013.

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Exhibit 5: Copy of Letter U.N. General Counsel Sent to Institute for Justice and Democracy in Haiti

Source: Institute for Justice and Democracy in Haiti, Cholera Litigation, Letter from Office of Legal Affairs, http://ijdh.org/cholera-accountability/cholera-litigation. Copy of letter accessed September 2012 at http://ijdh.org/wordpress/wp-content/uploads/2012/08/petition-for-releif-Claim-for-Compensation.jpg.

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Exhibit 6 Number of NGOs Working in Haiti Broken Down by Sector (November 2012)

Presence per Type Number of Partners

Government 14

U.N. Agencies 10

International NGOs 179

International Organizations 12

National Partners 74

Total 289

Note: Number of partners based on those who reported their activities to the appropriate cluster.

Area of Expertise National Partners

International NGOs

Total Number of Partners

Camp Coordination Camp Management

2 15 17

Early Recovery 6 53 59

Education 14 38 52

Food Security 30 35 65

Gender Based Violence 2 3 5

Health 24 51 75

Nutrition 8 33 41

Protection 9 24 33

Shelter 0 32 32

Water and Sanitation 16 72 88

Note: Partners may work in more than one area so total number of partners is significantly greater than 289.

Source: U.N. Office for the Coordination of Humanitarian Affairs, November 2012, http://reliefweb.int/map/haiti/haiti-cluster-and-sector-partners%E2%80%99-presence-who-what-where-nov-2012 accessed December 2012.

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Exhibit 7 Highlights of the Noon Briefing (verbatim from U.N. website)

HIGHLIGHTS OF THE NOON BRIEFING BY MARTIN NESIRKY,

SPOKESPERSON FOR SECRETARY-GENERAL BAN KI-MOON

THURSDAY, 21 FEBRUARY 2013

HAITI: U.N. SAYS CHOLERA CLAIM NOT RECEIVABLE, SECRETARY-GENERAL REITERATES SYMPATHY FOR SUFFERING

• In November 2011, a claim for compensation was brought against the United Nations on behalf of victims of the cholera outbreak in Haiti. Today, the United Nations advised the claimants’ representatives that the claims are not receivable pursuant to Section 29 of the Convention on the Privileges and Immunities of the United Nations. The Secretary-General telephoned Haitian President Michel Martelly to inform him of the decision, and to reiterate the commitment of the United Nations to the elimination of cholera in Haiti.

• Since the outbreak began in 2010, the United Nations and its partners have worked closely with the people and Government of Haiti to provide treatment, improve water and sanitation facilities, and strengthen prevention and early warning. In December 2012, the Secretary-General launched an initiative for the Elimination of Cholera in Haiti, which aims to strengthen Haiti’s own National Cholera Elimination Plan through significant investments and the use of an oral cholera vaccine.

• The Secretary-General again expresses his profound sympathy for the terrible suffering caused by the cholera epidemic, and calls on all partners in Haiti and the international community to work together to ensure better health and a better future for the people of Haiti.

• In response to questions, the Spokesperson said, “I can confirm that we have informed counsel for the claimants that the claims are not receivable. Consideration of the claims would necessarily involve a review of political and policy matters. Accordingly, the claims are not receivable pursuant to Section 29 of the Convention on the Privileges and Immunities of the United Nations, adopted by the General Assembly on 13 February 1946.”

• The Spokesperson added that he was not in a position to provide any further details. It is not the United Nations’ practice to discuss in public the details of, and the response to, claims filed against the Organization.

Source: U.N. website, http://www.un.org/sg/spokesperson/highlights/index.asp?HighD=2/21/2013&d_month=2&d_year=2013, accessed March 2013.

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Exhibit 8 Excerpt from Convention on the Privileges and Immunities of the United Nations, Article 8, Settlement of Disputes, Section 29 (in its entirety)

Source: U.N. website, http://www.un.org/en/ethics/pdf/convention.pdf, accessed March 2013.

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Endnotes 1 Farmer, Paul E., et. al., “Perspective: Cholera in Haiti: the Equity Agenda and the Future of Tropical Medicine,” American Journal of Tropical Medicine and Hygiene, 86(1), 2012. 2 “Haiti,” CIA World Factbook, https://www.cia.gov/library/publications/the-world-factbook/geos/ha.htmlCIA Factbook, accessed November 2012. 3 “Haiti,” CIA World Factbook, https://www.cia.gov/library/publications/the-world-factbook/geos/ha.htmlCIA Factbook, accessed November 2012. 4 “Haiti two years after the earthquake,” U.N. Department of Public Information Fact Sheet, January 6, 2012, http://www.un.org/apps/news/infocusRel.asp?infocusID=91, accessed September 2012 and Background Note Haiti December 2010,” U.S. Department of State, December 7, 2010, www.state.gov/outofdate/bgn/haiti/170279.htm accessed August 2012. 5 “Haiti: One Year Later,” United Nations Office for Coordination of Humanitarian Affairs,” http://www.unocha.org/issues-in-depth/haiti-one-year-later, accessed November 2012. 6 “Haiti two years after the earthquake,” U.N. Department of Public Information Fact Sheet, January 6, 2012, http://www.un.org/apps/news/infocusRel.asp?infocusID=91 and Margesson R, Taft-Morales M. “Haiti Earthquake: Crisis and Response,” Congressional Research Service, February 2, 2010, http://www.fas.org/sgp/crs/row/R41023.pdf both accessed September 2012. 7 Cawthorne, A, “Interview with Joel Jean-Pierre, Haiti Education Minister: Haitian education system ‘totally collapsed,’” Reuters-AlertNet, January 18, 2010, http://reliefweb.int/sites/reliefweb.int/files/reliefweb_pdf/node-341149.pdf, accessed November 2012. 8 Cawthorne, A, “Interview with Joel Jean-Pierre, Haiti Education Minister:Haiti: Interview-Haitian education system ‘totally collapsed,’” Reuters-AlertNet, January 18, 2010, http://reliefweb.int/sites/reliefweb.int/files/reliefweb_pdf/node-341149.pdf, accessed November 2012. 9 Dowell Scott F. and et al., “Public Health in Haiti–Challenges and Progress,” New England Journal of Medicine, 364;4, January 27, 2011 accessed August 2012. 10 Margesson R, Taft-Morales M. “”Haiti Earthquake: Crisis and Response,” Congressional Research Service, February 2, 2010, http://www.fas.org/sgp/crs/row/R41023.pdf and “Haiti two years after the earthquake,” U.N. Department of Public Information Fact Sheet, January 6, 2012, http://www.un.org/apps/news/infocusRel.asp?infocusID=91, both accessed September 2012.. 11 “Background Note Haiti December 2010,” U.S. Department of State, December 7, 2010, www.state.gov/outofdate/bgn/haiti/170279.htm accessed August 2012. 12 “Background Note Haiti December 2010,” U.S. Department of State, December 7, 2010, www.state.gov/outofdate/bgn/haiti/170279.htm accessed August 2012. 13 Margesson R, Taft-Morales M. “”Haiti Earthquake: Crisis and Response,” Congressional Research Service, February 2, 2010, http://www.fas.org/sgp/crs/row/R41023.pdf, accessed September 2012. 14 Margesson R, Taft-Morales M. “”Haiti Earthquake: Crisis and Response,” Congressional Research Service, February 2, 2010, http://www.fas.org/sgp/crs/row/R41023.pdf, accessed September 2012. 15 “Background Note Haiti December 2010,” U.S. Department of State, December 7, 2010, www.state.gov/outofdate/bgn/haiti/170279.htm accessed August 2012. 16 Gronewold, N. “earthquake in Haiti Shattered Efforts to Restore Resources, Boost Agriculture,” The New York Times, Janaury 18, 2010, http://www.nytimes.com/gwire/2010/01/18/18greenwire-earthquake-in-haiti-shattered-efforts-to-restore-596.html?pagewanted=all, accessed September 2012. 17 Llana, S. M., “Haiti earthquake: Angry crowds bemoan lack of government response,” The Christian Science Monitor, January 17, 2010, http://www.csmonitor.com/World/Americas/2010/0117/Haiti-earthquake-Angry-crowds-bemoan-lack-of-government-response, accessed 2012. 18 Meyer Peter J. and Sullivan Mark P., “U.S. Foreign Assistance to Latin America and the Caribbean: recent Trends and FY2103 Appropriations,” Congressional Research Service, June 26, 2012, available at Federation of American Scientists website, http://www.fas.org/sgp/crs/row/R42582.pdf accessed October 2012. 19 “Country Fact Sheet: Haiti June 2012,” U.S. Department of State, June 7, 2012, www.state.gov/r/pa/ei/bgn/1982.htm accessed August 2012. 20 Meyer Peter J. and Sullivan Mark P., “U.S. Foreign Assistance to Latin America and the Caribbean: recent Trends and FY2103 Appropriations,” Congressional Research Service, June 26, 2012, available at Federation of American Scientists website, http://www.fas.org/sgp/crs/row/R42582.pdf accessed October 2012.

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21 Dowell Scott F. and et al., “Public Health in Haiti–Challenges and Progress,” New England Journal of Medicine, 364;4, January 27, 2011 accessed August 2012. 22 “Acute Watery Diarrhea and Cholera: Haiti Pre-decision Brief for Public Health Action,” CDC Emergency Preparedness and Response Brief, March 2, 2010, http://emergency.cdc.gov/disasters/earthquakes/haiti/waterydiarrhea_pre-decision_brief.asp accessed August 2012. 23 Archibold Randall C., “Cuba Takes Lead Role in Haiti’s Cholera Fight,” The New York Times, November 7, 2011, http://www.nytimes.com/2011/11/08/world/americas/in-haitis-cholera-fight-cuba-takes-lead-role.html?pagewanted=all accessed September 2012. 24 Dr. Jorge Luis Quiñones, a member of the Cuban medical mission as quoted in Archibold Randall C., “Cuba Takes Lead Role in Haiti’s Cholera Fight,” The New York Times, November 7, 2011, http://www.nytimes.com/2011/11/08/world/americas/in-haitis-cholera-fight-cuba-takes-lead-role.html?pagewanted=all accessed September 2012. 25 “Update: Outbreak of Cholera—Haiti 2010,” CDC Morbidity and Mortality Weekly Report (MMWR), December 8, 2010, 59(48);1586-1590, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5948a4.htm?s_cid=mm5948a4_w, accessed September 2012. Piarroux, R. et al., “Understanding the Cholera Epidemic, Haiti,” Emerging Infectious Diseases, CDC Vol17 No.7, July 2011 accessed July 2012. 26 Imogen Wall as quoted in, Sontag, D., “In Haiti, Capital Braces for a Cholera Outbreak,” The New York Times, October 24, 2010, http://www.nytimes.com/2010/10/25/world/americas/25haiti.html, accessed October 2012. 27 “Frequently Asked Questions About the Haiti Cholera Outbreak,” CDC, June 8, 2011, www.cdc.gov/haiticholera/cholera_qa.htm 28 Butler, D. “Cholera tightens grip on Haiti,” Nature, November 25, 2010, Vol 468, p.483 29 “Defeating Cholera: Clinical Presentation and Management for Haiti Cholera Outbreak, 2010,” CDC, December 2010. 30 Richard Knox, “After Bringing Cholera to Haiti, U.N. Plans to Get Rid of It,” NPR, January 12, 2013, http://www.npr.org/blogs/health/2013/01/12/169075448/after-bringing-cholera-to-haiti-u-n-plans-to-get-rid-of-it accessed January 2013. 31 Butler, D. “Cholera tightens grip on Haiti,” Nature, November 25, 2010, Vol 468, p.483 and “high death rate in Haiti cholera epidemic slows,” Reuters, October 27, 2010, http://www.reuters.com/article/2010/10/27/us-haiti-cholera-idUSTRE69L21520101027, accessed October 2012. 32 Butler, D. “Cholera tightens grip on Haiti,” Nature, November 25, 2010, Vol 468, p.483 33 Piarroux, R. et al., “Understanding the Cholera Epidemic, Haiti,” Emerging Infectious Diseases, CDC Vol17 No.7, July 2011 accessed July 2012. 34 Katz JM. “UN probes base as source of Haiti cholera outbreak,” Associated Press, October 28, 2010, http://www.thejakartapost.com/news/2010/10/28/un-probes-base-source-haiti-cholera-outbreak.html accessed November 2012. 35 Katz JM. “Haiti Cholera Outbreak: UN Investigates Epidemic’s Origin,” The Associated Press/Huffington Post, October 28, 2010, http://www.huffingtonpost.com/2010/10/28/haiti-cholera-outbreak-un_n_775182.html accessed November 2012. 36 Katz JM. “Haiti Cholera Outbreak: UN Investigates Epidemic’s Origin,” The Associated Press/Huffington Post, October 28, 2010, http://www.huffingtonpost.com/2010/10/28/haiti-cholera-outbreak-un_n_775182.html accessed November 2012. 37 For example see Enserink, M.”Despite Sensitivities, Scientists Seek to Solve Haiti’s Cholera Riddle,” Science, January 28, 200 vol.331, www.sciencemag.org, accessed September 2012., Knox R. “Earthquake not to blame for cholera outbreak in Haiti,” National Public Radio, October 26, 2010, http://www.npr.org/blogs/health/2010/10/26/130832317/earthquake-had-nothing-to-do-with-cholera-outbreak-haiti accessed September 2012. 38 Dr. Alex Larsen as quoted in “Press Release,” CDC, November 1, 2010, www.cdc,gov/media/pressrel/2010/r101101.html, accessed August 2012. 39 Chunara R., et. al., “Social and News Media Enable Estimation of Epidemiological Patterns Early in the 2010 Haitian Cholera Outbreak,” American Journal of Tropical Medicine and Hygiene, 86(1), 2012, pp.39-45. 40 Dr. Jordan Tappero as quoted in, “Press Release,” CDC, November 1, 2010, www.cdc,gov/media/pressrel/2010/r101101.html, accessed August 2012. 41 Nigel Fisher as quoted in, “Haiti’s cholera cases likely to increase significantly, UN relief official says,” United Nations News Centre, November 15, 2010, http://www.un.org/apps/news/story.asp?NewsID=36765&Cr=haiti&Cr1=cholera&Kw1=haiti&Kw2=&Kw3=#.UIMDe2eKXTo accessed October 2012. 42 Dr. Scott F. Dowell McNeil Jr. as quoted in ,Donald G., “Cholera’s Second Fever: An Urge to Blame,” The New York Times, November 20, 2010, http://www.nytimes.com/2010/11/21/weekinreview/21mcneil.html, accessed October 2012.

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43 Imogen Wall, United Nations spokeswoman as quoted in, McNeil Jr., Donald G., “Cholera’s Second Fever: An Urge to Blame,” The New York Times, November 20, 2010, http://www.nytimes.com/2010/11/21/weekinreview/21mcneil.html, accessed October 2012. 44 Desvarieux J. and Padgett T., “Haiti’s Cholera Riots: A Plot to Stop the Elections?,” Time, November 16, 2010, www.time.com/time/printout/0,8816,2031665,00.html accessed September 2012. 45 Vincenzo Pugliese as quoted in Archibold, Randal C., “Officials in Haiti Defend Focus on Cholera Outbreak, Not Its Origins,” The New York Times, November 17, 2010, http://www.nytimes.com/2010/11/17/world/americas/17haiti.html?scp=9&sq=cholera%20Haiti&st=cse, accessed October 2012. 46 Archibold, Randal C., “Officials in Haiti Defend Focus on Cholera Outbreak, Not Its Origins,” The New York Times, November 17, 2010, http://www.nytimes.com/2010/11/17/world/americas/17haiti.html?scp=9&sq=cholera%20Haiti&st=cse, accessed October 2012. 47 Edmond Mulet, head of U.N. mission in Haiti, as quoted in Desvarieux J., “At the Heart of Haiti's Cholera Riots, Anger at the U.N.,” Time, November 22, 2010, http://www.time.com/time/printout/0,8816,2032437,00.html#, accessed September 2012. 48 Unless otherwise noted the rest of this paragraph based on Butler, Declan. “Stopping An Epidemic: Would cholera vaccines have helped in Haiti?” Nature, Vol. 468, November 25, 2010. 49 Grady, D., “In Haiti, Rush to Stem the Spread of Cholera,” The New York Times, October 25, 2010, http://query.nytimes.com/gst/fullpage.html?res=9E0DE0DD1F3AF935A15753C1A9669D8B63&ref=earthquakes, accessed October 2012. 50 Jon Andrus as quoted in Butler, D., “Cholera tightens grip on Haiti,” Nature, Vol.486, November 25, 2010. 51 Piarroux R., “Mission on the cholera epidemic in Haiti,” December 2010, http://medias.lemonde.fr/mmpub/edt/doc/20101210/1452027_1b80_cholera_haiti_rapport_pr_piarroux.pdf accessed October 2012. 52 Vincenzo Pugliese as quoted in, Katz, Jonathan M., “Strong evidence links peacekeepers from Nepal to disease outbreak,” Associated Press, December 10, 2010, http://www.msnbc.msn.com/id/40553068/ns/health/t/haiti-cholera-likely-un-troops-expert-says/#.UIMLe2eKXTo, accessed October 2012. 53 Raminda Chhetri, Nepalese army spokesperson as quoted in “Haiti cholera: UN peacekeepers to blame, report says,” BBC News, December 10, 2010, http://www.bbc.co.uk/news/world-latin-america-11943902, accessed November 2012. 54 “As cholera returns to Haiti, blame is unhelpful,” Lancet, Vol 10 December 2010, p.813 55 The Under-Secretary-General for Peacekeeping Operations (DPKO), Alain Le Roy as quoted in “UN in talks to set up independent panel of experts to probe origin of cholera in Haiti,” U.N. Press Release, U.N. News Centre, December 15, 2010, http://www.un.org/apps/news/story.asp?NewsID=37084&Cr=haiti&Cr1=&Kw1=haiti&Kw2=cholera&Kw3=#.UGRnta6KXTo accessed September 2012. 56 The Under-Secretary-General for Peacekeeping Operations (DPKO), Alain Le Roy as quoted in “UN in talks to set up independent panel of experts to probe origin of cholera in Haiti,” U.N. Press Release, U.N. News Centre, December 15, 2010, http://www.un.org/apps/news/story.asp?NewsID=37084&Cr=haiti&Cr1=&Kw1=haiti&Kw2=cholera&Kw3=#.UGRnta6KXTo accessed September 2012. 57 “UN in talks to set up independent panel of experts to probe origin of cholera in Haiti,” U.N. Press Release, U.N. News Centre, December 15, 2010, http://www.un.org/apps/news/story.asp?NewsID=37084&Cr=haiti&Cr1=&Kw1=haiti&Kw2=cholera&Kw3=#.UGRnta6KXTo accessed September 2012. 58 “Haiti: Ban appeals for more funds to fight cholera, set up panel to probe its origins,” U.N. Press Release, U.N. News Centre, December 17, 2010, http://www.un.org/apps/news/story.asp?NewsID=37106&Cr=haiti&Cr1=&Kw1=haiti&Kw2=cholera&Kw3=#.UGRnvq6KXTo, accessed September 2012. 59 “Haiti: Ban appoints four top medical experts to probe source of cholera epidemic,” Press Release, U.N. News Service, January 6, 2011 http://www.un.org/apps/news/story.asp?NewsID=37216&Cr=haiti&Cr1#.UGRm066KXTo accessed May 2012. 60 “Haiti: Ban appoints four top medical experts to probe source of cholera epidemic,” U.N. Press Release, U.N. News Centre, January 6, 2011 http://www.un.org/apps/news/story.asp?NewsID=37216&Cr=haiti&Cr1#.UGRm066KXTo accessed May 2012. 61 B. Faucher and R. Pairroux, “The Haitian cholera epidemic: is searching for its origin only a matter of scientific curiosity?” Clinical Microbiology and Infection, Vol. 17 No.4, April 2011. 62 Allié, Marie-Pierre, “Le Monde Op-Ed: Why It’s Important to Know How the Cholera Epidemic in Haiti Began,” Medicins Sans Frontieres website, January 4, 2011, http://www.msf.org.au/resources/editorials/editorial/article/le-monde-op-ed-why-its-important-to-know-how-the-cholera-epidemic-in-haiti-began.html accessed August 2012.

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63 Chin, Chen-San et. al., “The Origin of the Haitian Cholera Outbreak Strain,” The New England Journal of Medicine, 2011; 364:32-42. 64 Chin, Chen-San et. al., “The Origin of the Haitian Cholera Outbreak Strain,” The New England Journal of Medicine, 2011; 364:32-42. 65 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011, p.8. 66 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011 P29 67 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011 68 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011. http://www.un.org/apps/news/infocusRel.asp?infocusID=91&Body=Haiti&Body1= accessed June 2012. 69 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011. 70 Cravioto, A., Lanata, C., Lantagne, D., and Nair, B, “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti,” U.N. Commissioned Report, May 4, 2011. 71 Michel Bonnardeaux, a spokesman for the U.N. peacekeeping department as quoted in, “UN Haiti cholera panel avoids blaming peacekeepers,” Reuters, May 5, 2011, http://www.reuters.com/article/2011/05/05/us-haiti-cholera-panel-idUSTRE74457Q20110505 accessed November 2012. 72 “Secretary-General, Upon Receiving Experts’ Report On Source of Haiti Cholera Outbreak, Announces Intention To Name Follow-Up Task Force,” U.N. Department of Public Information, News and Media Division, New York City, May 4, 2011, http://www.un.org/News/Press/docs/2011/sgsm13543.doc.htm, accessed May 2012. 73 Piarroux, R. et al., “Understanding the Cholera Epidemic, Haiti,” Emerging Infectious Diseases, CDC Vol17 No.7, July 2011 accessed July 2012. 74 Hendriksen R. et. al., “Population Genetics of Vibrio cholera from Nepal in 2010: Evidence on the Origin of the Haitian Outbreak,” mBio, July/August 2011, Vol.2, Issue 4. 75 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) accessed January 2013. 76 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) accessed January 2013. 77 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) pages 18, 21, 23 and 24 accessed January 2013. 78 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) p. 2accessed January 2013. 79 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) p. 18 accessed January 2013. 80 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) p. 18 accessed January 2013. 81 Brief of Petitioner, Institute for Justice and Democracy v. United Nations (“U.N.”) and its subsidiary, the United Nations Stabilization Mission in Haiti, http://ijdh.org/wordpress/wp-content/uploads/2011/11/englishpetitionREDACTED.pdf (November 3, 2011) p. 2accessed January 2013. 82Associated Press, “Haiti group demands UN pay for cholera outbreak,” The Guardian, November 11, 2011, http://www.guardian.co.uk/world/feedarticle/9942669, accessed October 2012. 83 Letter addressed to Brian Concannon Jr., “Re:Petition for Relief—Claim for Compensation-Outbreak of Cholera in Haiti,” December 21, 2011, office of the Under-Secretary-General for Legal Affairs, http://ijdh.org/wordpress/wp-content/uploads/2012/08/petition-for-releif-Claim-for-Compensation.jpg, accessed September 2012.

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84 “Experts Call for Major Investments in Water and Sanitation to End Cholera in Haiti and Dominican Republic,” PAHO Press Release, January 11, 2012, http://new.paho.org/hq/index.php?option=com_content&view=article&id=6320&Itemid=1, accessed September 2012. 85 “Experts Call for Major Investments in Water and Sanitation to End Cholera in Haiti and Dominican Republic,” PAHO Press Release, January 11, 2012, http://new.paho.org/hq/index.php?option=com_content&view=article&id=6320&Itemid=1, accessed September 2012. 86 Wise, C. “On Second Anniversary of Earthquake, Cholera Continues to Cripple Haiti,” PBS Newshour: The Rundown, January 12, 2012, http://www.pbs.org/newshour/rundown/2012/01/on-second-anniversary-of-the-earthquake-cholera-continues-to-cripple-haiti.html accessed September 2012. 87 Sanjay Wijesekera, head of UNICEF’s water and sanitation program as quoted in “Experts Call for Major Investments in Water and Sanitation to End Cholera in Haiti and Dominican Republic,” PAHO Press Release, January 11, 2012, http://new.paho.org/hq/index.php?option=com_content&view=article&id=6320&Itemid=1, accessed September 2012. 88 “Experts Call for Major Investments in Water and Sanitation to End Cholera in Haiti and Dominican Republic,” PAHO Press Release, January 11, 2012, http://new.paho.org/hq/index.php?option=com_content&view=article&id=6320&Itemid=1, accessed September 2012. 89 Chunara R., et. al., “Social and News Media Enable Estimation of Epidemiological Patterns Early in the 2010 Haitian Cholera Outbreak,” American Journal of Tropical Medicine and Hygiene, 86(1), 2012, pp.39-45. 90 Ivers, Louise C., et. al., “The ‘First” Case of Cholera in Haiti: Lessons for Global Health,” American Journal of Tropical Medicine and Hygiene, 86(1), 2012, pp.36-38. 91 Associated Press, “Clinton: U.N. soldier brought cholera to Haiti,” USA Today, March 7, 2012, http://usatoday30.usatoday.com/news/world/story/2012-03-07/haiti-cholera/53402748/1, accessed October 2012. 92 Martin Nesirky, “Highlights of the Noon Briefing, March 8, 2012,” March 8, 2012, http://www.un.org/sg/spokesperson/highlights/index.asp?HighD=3/8/2012&d_month=3&d_year=2012, accessed October 2012. 93 Martin Nesirky, “Highlights of the Noon Briefing, March 8, 2012,” March 8, 2012, http://www.un.org/sg/spokesperson/highlights/index.asp?HighD=3/8/2012&d_month=3&d_year=2012, accessed October 2012. 94 “Interview with Nigel Fisher, U.N. Resident and Humanitarian Coordinator for Haiti,” U.N. News Centre, May 3, 2012, http://www.un.org/apps/news/newsmakers.asp?NewsID=50 accessed October 2012. 95 Richard Knox, “Vaccination Against Cholera Finally Begins In Haiti,” NPR, April 12, 2012 http://www.npr.org/blogs/health/2012/04/12/150493770/vaccination-against-cholera-finally-begins-in-haiti accessed January 2013. 96 “Interview with Nigel Fisher, U.N. Resident and Humanitarian Coordinator for Haiti,” U.N. News Centre, May 3, 2012, http://www.un.org/apps/news/newsmakers.asp?NewsID=50 accessed October 2012. 97 Konx, Richard., “Scientists Find New Wrinkles in How Cholera Got to Haiti,” National Public Radio, June 18, 2012, http://www.npr.org/blogs/health/2012/06/18/155311990/scientists-find-new-wrinkle-in-how-cholera-got-to-haiti, accessed August 2012. 98 Sontag, D., “In Haiti, Global Failures on Cholera Epidemic,” The New York Times, March 31, 2012, http://www.nytimes.com/2012/04/01/world/americas/haitis-cholera-outraced-the-experts-and-tainted-the-un.html?pagewanted=all, accessed May 2012. 99 Katz, Jonathan M., “United Nations Still Denies its Troops Brought Cholera to Haiti,” The Daily Beast, April 4, 2012, http://www.thedailybeast.com/articles/2012/04/04/united-nations-still-denies-its-troops-brought-cholera-to-haiti.html, accessed October 2012. 100 Klarreich, K., “Will the United Nations’ legacy in Haiti be all about scandal?,” The Christian Science Monitor, June 13, 2012, http://www.csmonitor.com/World/Americas/2012/0613/Will-the-United-Nations-legacy-in-Haiti-be-all-about-scandal, accessed August 2012. 101 Sontag, Deborah, “US Lawmakers Press for Action on Cholera in Haiti,” The New York Times, July 21, 2012, http://www.nytimes.com/2012/07/21/world/us-lawmakers-press-for-action-on-cholera-in-haiti.html, accessed September 2012. 102 Brian Concannon, Director of the Institute for Justice and Democracy in Haiti as quoted in , Hayes, Jason, “In Haiti, Cholera Case Needs a Court,” Pulitzer Center, July 11, 2012, http://pulitzercenter.org/reporting/haiti-cholera-united-nations-peacekeepers-artibonite-lawsuit-mugess, accessed October 2012. 103 Weisbrot, M., “The United Nations must cure Haiti of the cholera epidemic it caused,” The Guardian, November 12, 2012, http://www.guardian.co.uk/commentisfree/2012/nov/12/united-nations-haiti-cholera-epidemic accessed December 2012.

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104 Mathieu Fortoul as quoted in Watts, J., “Haiti seeks $2bn for cholera epidemic ‘introduced by UN peacekeepers,” The Guardian, November 29, 2012, http://www.guardian.co.uk/world/2012/nov/29/haiti-appeal-cholera-nepal-peacekeepers, accessed November 2012. 105 “Haiti: Cluster and Sector Partners Presence Map,” OCHA Updated November 2012, http://reliefweb.int/map/haiti/haiti-cluster-and-sector-partners%E2%80%99-presence-who-what-where-nov-2012, accessed November 2012. 106 Dr. Louise Ivers as quoted in, “Haiti seeks $2bn for cholera epidemic ‘introduced by UN peacekeepers,” The Guardian, November 29, 2012, http://www.guardian.co.uk/world/2012/nov/29/haiti-appeal-cholera-nepal-peacekeepers, accessed November 2012. 107 Unless otherwise noted quotes and background from this paragraph based on Watts, J., “Haiti seeks $2bn for cholera epidemic ‘introduced by UN peacekeepers,” The Guardian, November 29, 2012, http://www.guardian.co.uk/world/2012/nov/29/haiti-appeal-cholera-nepal-peacekeepers, accessed November 2012. 108 Richard Knox, “After Bringing Cholera to Haiti, U.N. Plans to Get Rid of It,” NPR, January 12, 2013, http://www.npr.org/blogs/health/2013/01/12/169075448/after-bringing-cholera-to-haiti-u-n-plans-to-get-rid-of-it accessed January 2013. 109 Nigel Fisher as quoted in Watts, J., “Haiti seeks $2bn for cholera epidemic ‘introduced by UN peacekeepers,” The Guardian, November 29, 2012, http://www.guardian.co.uk/world/2012/nov/29/haiti-appeal-cholera-nepal-peacekeepers, accessed November 2012. 110 Dr. Jordan Tappeo, director of the Health Systems Reconstruction Office for the CDC as quoted in, Trenton D. and Martha Mendoza, “Haiti, DR to eliminate cholera with $2.2 billion,” The Washington Times, November 28, 2012, http://www.washingtontimes.com/news/2012/nov/28/haiti-dr-to-eliminate-cholera-with-22-billion/print/ accessed November 2012. 111 Jonathan Katz and Tom Murphy, “The U.N.'s Haitian Shell Game,” Foreign Policy, December 18, 2012, http://www.foreignpolicy.com/articles/2012/12/18/the_uns_haitian_shell_game?page=0,1, accessed January 2013. 112 Martin Nesirky, Spokesperson for Secretary-General Ban Ki-Moon, as quoted from, UN Office of the Spokesperson website, “Highlights of the Noon Briefing By Martin Nesirky, Spokesperson for Secretary-General Ban Ki-Moon, Thursday, 21 February 2013, Haiti: U.N. Says Cholera Claim Not Receivable, Secretary-General Reiterates Sympathy for Suffering,” February 21, 2013, http://www.un.org/sg/spokesperson/highlights/index.asp?HighD=2/21/2013&d_month=2&d_year=2013, accessed March 1, 2013. 113 News & Media United Nations Radio, “UN works to eliminate cholera in Haiti; ‘claims not receivable,’” February 21, 2013, http://www.unmultimedia.org/radio/english/2013/02/un-works-to-eliminate-cholera-in-haiti-claims-not-receivable/ accessed March 1, 2013. 114 Juliette Kayyem, “UN’s cold, but correct, call on Haiti,” The Boston Globe, February 28, 2013, http://bostonglobe.com/opinion/columns/2013/02/28/decision-claim-diplomatic-immunity-for-cholera-outbreak-haiti-was-cold-but-correct/MxeER5UM6aWzZB2WNJtjgI/story.html, accessed March 2013. 115 Juliette Kayyem, “UN’s cold, but correct, call on Haiti,” The Boston Globe, February 28, 2013, http://bostonglobe.com/opinion/columns/2013/02/28/decision-claim-diplomatic-immunity-for-cholera-outbreak-haiti-was-cold-but-correct/MxeER5UM6aWzZB2WNJtjgI/story.html, accessed March 2013. 116 Brian Concannon, co-counsel, as quoted in, Press Release, “United Nations Denies Justice to Haiti Cholera Victims,” Institute for Justice & Democracy in Haiti and Bureau des Avocats Internationaux, February 21, 2013, Institute for Justice & Democracy in Haiti website, http://ijdh.org/archives/31035 accessed March 2013. 117 Ira Kurzban, co-counsel, as quoted in, Press Release, “United Nations Denies Justice to Haiti Cholera Victims,” Institute for Justice & Democracy in Haiti and Bureau des Avocats Internationaux, February 21, 2013, Institute for Justice & Democracy in Haiti website, http://ijdh.org/archives/31035 accessed March 2013. 118 Edith M. Lederer, “UN Won’t Compensate Haiti Cholera Victims,” The Huffington Post, February 21, 2013, http://www.huffingtonpost.com/2013/02/22/un-haiti-cholera-victims_n_2743367.html, accessed March 2013. 119 Louise C. Invers, “A Chance to Right a Wrong in Haiti,” Op-Ed, The New York Times, February 22, 2013, http://www.nytimes.com/2013/02/23/opinion/a-chance-to-right-a-wrong-in-haiti.html?_r=0 accessed March 2013. 120 “Epidemiological Update: Cholera,” PAHO, January 15, 2013, http://new.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=19785&Itemid=&lang=en, accessed March 2013.

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