Haiti has a way of forcing public health questions. A decade ago people debated whether it would work to treat AIDS in the poorest nation in the Western Hemisphere.
Turned out the answer was yes. Thousands of lives have been saved and the size of Haiti's AIDS epidemic has been cut in half by linking HIV treatment and prevention.
Now there's a new question. Could a cholera vaccine slow the spread of the disease in Haiti and the neighboring Dominican Republic?
Yes, say some veterans of the Haitian public health wars. They argue in The Lancet that a relatively cheap oral cholera vaccines could slow the epidemic, which could become entrenched on the island of Hispaniola for years to come.
"Although large-scale vaccination might not prevent cholera from becoming endemic in Haiti," they write, "it would save thousands of lives…. Production of these vaccines should be ramped up, as cholera experts have argued for the past decade."
The authors are Drs. Paul Farmer, Louise Ivers, Patrick Almazor and Fernet Leandre of Partners in Health, an organization that's been delivering care and promoting public health in Haiti for 30 years.
They also argue for much wider antibiotic treatment of cholera. Right now it's recommended only for the most severe cases. "Treatment needs to be much more aggressive," Farmer told reporters in a Friday teleconference. "We're arguing for antibiotics for all comers."
Few medical people would forego antibiotic treatment if they got cholera, the group pointedly notes.
Recall that Farmer spearheaded the campaign to bring HIV treatment to Haiti. He's also behind a current campaign to put cholera vaccination on the global public health agenda.
On December 3, Farmer convened a teleconference on the cholera question. It included 80 of the world's leading cholera experts and public health heavy-hitters, including Dr. Jon Andrus, deputy director of the Pan American Health Organization.
Andrus had been among those reluctant to deploy cholera vaccination in the the current Caribbean outbreak. Why? Not enough vaccine, not enough resources, and too distracting from the urgent tasks of treating cholera victims.
But Andrus has reconsidered. He's now convinced that cholera vaccination should be seriously considered. Late next week, he plans an emergency meeting of experts at PAHO.
Still, it's far from clear how this will work out. Farmer says he understands there may be a couple million doses of cholera vaccine in manufacturer's vats. If so, that wouldn't go very far on an island that contains nearly 20 million people between Haiti and the Dominican Republic -- even allowing for the fact that you don't have to vaccinate everybody to reduce cholera transmission.
Farmer favors a vaccine called Shanchol made by an Indian company because its production cost is only a dollar a dose, and it's simpler to administer – it doesn't require reconstitution in water, for instance. But the World Health Organization hasn't certified Shanchol as safe, a serious obstacle in getting it paid for and widely distributed.
Asked about the obstacles, Farmer says:
These things take time, they take procurement experts, they take capital for manufacturing for transport. But if this is a regional public health emergency it just doesn't seem to much to ask that we start doing this as soon as we can.
Farmer also has influential friends. He's an advisor to Bill Clinton, the UN's special envoy to Haiti .
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