To make amends, the U.N. must provide funds to fight cholera in Haiti

Regarding the Aug. 19 editorial “The U.N. finally faces facts in Haiti”: The United Nations conceded that it played a role in a devastating cholera epidemic in Haiti six years ago and admitted that it should do “much more.” Contrition was long overdue. International experts reviewing the evidence (including a panel appointed by the United Nations) long ago concluded that the cholera outbreak was triggered by a lack of adequate sanitation at a U.N. peacekeeper’s base. In a country that is extremely vulnerable to disease outbreaks and that has limited capacity to respond to them, the introduction of cholera resulted in a major and ongoing disaster, with more than 10,000 deaths and 800,000 people sickened. The U.N. can save lives, restore goodwill and stabilize the country by financing a plan to control cholera in Haiti. The Haitian government, international agencies and nongovernmental organizations, including Partners In Health, know how to eliminate cholera transmission in Haiti. Partners In Health supports an ambitious plan to interrupt and stop the spread of the disease using a combination of mass vaccination and household water treatment. If the U.N. follows words with financing, it will be taking very strong steps toward making amends to a country whose people it has harmed. We call on it to do just that. ****Louise Ivers** , Boston** The writer is a senior health and policy adviser   with Partners In Health.

‘Really quite disastrous’

AS THE WORLD’S worst outbreak of cholera continues to ravage Haiti, international donors have averted their gaze. Humanitarian relief groups, short of cash, are folding their tents. A pilot project to vaccinate Haitians against the disease, recently undertaken at a cost of $400,000, reached only 1 percent of the population, with no immediate prospect of expansion. Of the 100 or so cholera treatment centers that sprang up around the country after the disease was detected 19 months ago, fewer than a third remain. The United Nations’ humanitarian coordinator for Haiti, Nigel Fisher, said this month that donors have so far met just 9 percent of the $230 million U.N. appeal for 2012 — not only for cholera but for a range of relief programs including flooding, tent cities and food insecurity. “It’s really quite disastrous,” he said. Meanwhile, cholera’s deadly toll has mounted in the Western Hemisphere’s poorest country. Unknown in Haiti for a century before the first cases appeared in October 2010, cholera has now killed 7,100 people, infected more than 550,000 and hospitalized nearly 300,000. It has also spread across the border to the Dominican Republic, killing more than 400 people there. Five percent of Haiti’s 10 million people have already been infected, and health experts estimate that 200,000 could contract the disease this year. Epidemiologists now believe that cholera was unwittingly introduced in Haiti by Nepalese troops in the U.N. peacekeeping force, whose encampment lacked adequate sanitation facilities. After that, there was no mystery about the conditions that enabled the disease to flourish. Spread by water or food that has been contaminated by fecal matter, it raced through a country where just a third of the population has safe drinking water and fewer than one in five people have access to latrines and modern sanitation. The tragedy is that the solution is equally well known but costly. Haiti needs modern water and sanitation infrastructure, an undertaking that might cost $1 billion. But while donors tend to respond generously to emergencies, such as the earthquake that devastated Haiti in early 2010, they lose interest in long-term fixes of the sort that would deal decisively with cholera. Groups representing thousands of Haitian cholera victims have demanded millions of dollars of reparations from the United Nations, citing the disease’s introduction by the peacekeepers. But the United Nations’ money, if it manages to raise any, would be more profitably spent on a much more aggressive cholera vaccination program. It would take just $40 million to administer oral vaccines to every person in Haiti. That’s about the same amount a U.S. presidential campaign collects in a month or a footwear manufacturer recently agreed to pay to settle charges that it exaggerated the fitness benefits of its shoes. But until recently, international health organizations dragged their feet on vaccines, worrying they might be too expensive or difficult to administer. They preferred a systemic infrastructure fix. That’s simply indefensible. It may take many years to provide adequate water and sanitation systems in Haiti, but a two-dose vaccine that costs $4 per person can be manufactured right now. Granted, there will be logistical hurdles to overcome in procuring the vaccine, distributing it and ensuring it is properly ingested by a poorly educated, widely dispersed and largely rural population. But to do nothing in the interim is immoral. **More on this topic:** The Post’s View: Haiti’s terrible idea Paul Farmer: How to save 10 million lives The Post’s View: ‘Sweet Micky’ takes the stage

The U.N. finally owns up to its role in Haiti’s cholera outbreak

LIKE CLIMATE change deniers, the United Nations for years has stood virtually alone against the weight of scientific opinion on its own peacekeepers’ responsibility for the outbreak of cholera six years ago in Haiti, which continues to suffer from the world’s worst epidemic of that deadly disease. That stance, regarding an epidemic that has killed more than 10,000 people and infected hundreds of thousands, is “morally unconscionable, legally indefensible and politically self-defeating,” according to a new report from a top adviser to the organization. Not to mention scientifically obtuse. Spurred by the report from Philip Alston, a New York University law professor who is a human rights adviser to the organization, the U.N. is finally acknowledging its complicity in Haiti’s cholera crisis. Breaking a steely silence, a spokesman for Secretary General Ban Ki-moon told the New York Times that the organization “needs to do much more regarding its own involvement in the initial outbreak and the suffering of those affected by cholera.” A new policy will be prepared after consultations with Haitian officials and other governments. It is difficult to overstate the damage the U.N. has done to its own prestige and moral standing by its pig-headed denialism. The disease, absent from the country for at least a century, struck soon after the arrival in 2010 of several hundred peacekeeping troops from Nepal, which at the time was struggling with a cholera outbreak. Untreated waste from the peacekeepers’ base was discharged into an adjacent river and, in short order, Haitians in nearby villages began to get sick and die. In a nation with paltry infrastructure and an anemic public health system, the disease spread quickly. Epidemiologists soon traced the outbreak, and even the specific strain of cholera, to the U.N. base, concluding there was no other plausible source of the disease. Despite that, U.N. officials adopted a three-monkeys policy: They saw nothing. They heard nothing. They said nothing. That tone-deaf stance appeared driven by U.N. lawyers, loath to crack the shell of legal immunity they insisted was the U.N.’s birthright. Doubtless, they feared any admission that might expose the organization to billions of dollars of claims in lawsuits arising from deaths and infections, not to mention from people affected in the future. That lawyerly posture was heedless of the U.N. charter, whose preamble affirms its commitment to human rights, “better standards of life” and other goals at odds with a flat refusal to own up to the facts in Haiti. The reality, which the U.N. at last seems ready to accept, is that the organization must recognize its responsibility and renew its commitment to combat cholera in Haiti and strengthen the nation’s public health infrastructure, which the organization has previously pledged to improve, to little effect. That may be difficult and costly; the alternative was untenable. **Read more about this topic:** The Post’s View: Cholera’s fresh attack in Haiti The Post’s View: United Nations must admit its role in Haiti’s cholera outbreak The Post’s View: The United Nations’ duty in Haiti’s cholera outbreak

The U.N. isn’t Haiti’s biggest problem

The Post was right to stress in the April 17 editorial “The U.N.’s debt to Haiti” the dishonor brought to the U.N. mission in Haiti by its careless introduction of cholera and reported sexual abuse. Yet the ravaging of the Haitian people has been done not primarily by the United Nations, but by the Haitian political class whose childish infighting and coup-plotting has made Haiti too risky for economic development. Highly disruptive presidential overthrows were common before the United Nations’ arrival and have been prevented by its presence. The mission’s end, cholera guilt notwithstanding, will expose Haiti to the ambitious spoilers who deride electoral results and have the armed gangs to back up their words. The editorial might have better called for a sound spanking of the U.N. mission, along with a renewal of its mandate for another year. ****James Morrell** , Washington** The writer is director of the   Haiti Democracy Project.

The United Nations’ duty in Haiti’s cholera outbreak

IT IS now all but certain that Haiti’s cholera epidemic, which has killed more than 8,000 people and sickened more than 600,000, is directly traceable to a battalion of U.N. peacekeeperswho arrived in the country after the 2010 earthquake. The United Nations and its peacekeepers have done immeasurable good in Haiti and elsewhere, but in this instance they bear responsibility for unleashing one of the world’s most devastating recent epidemics. The peacekeepers, from Nepal, where cholera is endemic, established their base on the banks of a tributary that feeds one of Haiti’s main sources of drinking water, the Artibonite River. Owing to the base’s slapdash sanitation system — drainage sites containing human feces that flooded and overflowed in the rain — waste water flowed into the tributary and contaminated the river. In a country where no cases of cholera had been recorded in more than 150 years, the disease spread so fast that within nine months of the battalion’s arrival in late 2010, the number of cholera-infected Haitians surpassed all recorded cholera infections in the rest of the world combined. Hundreds more will continue to die annually for years to come in a nation whose anemic health, hygiene and sanitation infrastructure is no match for the ravages of a water-borne disease. A report from researchers at the Yale School of Public Health and Yale Law School details the convincing epidemiological evidence, as well as the United Nations’ stubborn disavowal of responsibility. Initially, a panel of independent experts enlisted by the United Nations said that the evidence pointing to the peacekeepers was mainly circumstantial. Now the experts have reversed themselves, saying that the Nepalese peacekeepers were “most likely” the cause of the epidemic. Still, the United Nations refuses to accept legal, financial or moral responsibility. Until now, the United Nations has asserted and enjoyed what amounts to blanket immunity from claims arising from its peacekeepers’ actions. There is a basis in law and logic for its stance. Given the range of nations, conflicts, disasters and chaotic environments in which U.N. personnel are deployed, the institution needs some protection from lawsuits and other claims for damages arising from its operations. Otherwise, it might never enter a risky place, thereby rendering itself useless. Still, immunity in the courts, which the United Nations has enjoyed, does not justify a policy of institutional indifference. In the case of Haiti’s epidemic, U.N. officials have a moral obligation to right a wrong that has killed thousands. That obligation goes beyond the legally tangled question of paying reparations to thousands of potential claimants in Haiti and the obvious need to ensure that U.N. installations and contractors meet higher standards of hygiene and sanitation. It involves the United Nations and its major donors, including the United States, adding resources to help Haiti build lasting improvements to its feeble public health system. Haiti needs sewage treatment plants and municipal water facilities, as well as an effective primary health-care system accessible to people in rural areas as well as towns. Through UNICEF and the Pan American Health Organization, the United Nations should redouble its efforts to establish modern infrastructure in a country where 90 percent of the population lacks running water. That’s not just part of the United Nations’ mission. It’s a matter of accountability and responsibility. **Read more at PostOpinions:** Charanya Krishnaswami and Muneer I. Ahmad: U.N. hypocrisy in Haiti Amy Wilentz: Helping Haiti by aiding one earthquake victim

Cholera outbreak in Haiti in 2010 tied to U.N. peacekeepers, report says

UNITED NATIONS — A group of scientists who investigated the source of a cholera epidemic in Haiti that killed thousands of people has concluded that U.N. peacekeepers from Nepal probably introduced the strain into the Haitian population. In a report, the scientists concluded that the 2010 outbreak was not the result of “deliberate action” and was caused by a “confluence of factors.” The findings marked a major retreat by the experts, who were part of an independent panel appointed by the United Nations and who had concluded just two years ago that incomplete evidence and the myriad factors in the epidemic’s spread — including inadequate water and sanitation infrastructure — made it impossible to assign responsibility for the introduction of the strain. Since then, the experts said, they have obtained new evidence, including microbiological samples. “The exact source of introduction of cholera into Haiti will never be known with scientific certainty, as it is not possible to travel back in time to conduct the necessary investigations, and those on the ground at the time focused on outbreak response not source introduction,” the panel wrote in its new report. “However, the preponderance of the evidence and the weight of the circumstantial evidence does lead to the conclusion that personnel associated with the . . . MINUSTAH facility were the most likely source of introduction of cholera into Haiti.” MINUSTAH is the acronym of the French translation for the U.N. Mission in Haiti. The U.N. peacekeeping mission was established in 2004 to help bring security and stability to Haiti. In 2010, after a deadly earthquake, the United Nations expanded its presence in the Caribbean nation. In trying to identify the introduction of the cholera strain, the U.N. panel’s new report tracks the arrival of a contingent of Nepalese peacekeepers from Kathmandu to a U.N. encampment in the village of Mirebalais in October 2010. Within days, hospitals in the region registered a dramatic increase in deaths from diarrhea and dehydration, signature symptoms of cholera. The illnesses marked the opening chapter in an epidemic that quickly spread across the country. The report stated that the United Nations had constructed a “haphazard” system of pipes from the U.N. camps’ showers and toilets to six fiberglass tanks. The “black water waste,” which included human feces, was then transferred to an open, unfenced, septic pit, near where children and animals frequently roamed. The system presented “significant potential” for contamination, the report said. The members of the U.N. panel — who no longer work for the world body — defended their initial findings, saying that the “majority of evidence” at the time of their first report was “circumstantial.” The latest findings will increase pressure on the United Nations to acknowledge responsibility for introducing cholera into the country. U.N. Secretary General Ban Ki-moon and his top advisers had invoked the panel’s ambivalent 2010 findings in arguing that the United Nations bore no legal responsibility for the epidemic, although they said the organization was committed to lead international efforts to respond to the health crisis and improve the Haiti’s sanitation infrastructure. The Boston-based Institute for Justice and Democracy in Haiti filed a compensation claim in November 2011 on behalf of the families of 5,000 victims, and it is preparing lawsuits against the United Nations in U.S. and Haitian courts on behalf of thousands more.

United Nations needs help fighting cholera in Haiti

The Aug. 12 editorial “Righting a deadly wrong in Haiti” rightly drew attention to the heavy and tragic toll of the cholera epidemic and the continued need for more resources and support. The United Nations shares The Post’s concern. Since the onset of the epidemic, we have been on the ground every day responding to alerts of new cases, supporting medical care for victims, rehabilitating cholera-treatment centers, disinfecting health facilities, treating sewage, training health workers and providing much-needed medicines and vaccinations. This work goes with our longer-term efforts on improving water and sanitation infrastructure. Last year, U.N. Secretary-General Ban Ki-moon launched a drive to support Haiti’s long-term plan to eliminate cholera and end the epidemic. So far, only half of the $444 million needed for the next two years has been mobilized, and less than a quarter of the $40 million earmarked for humanitarian needs has been received. The hurricane season is looming. Donors need to step up. With sufficient support, we can assist the people of Haiti in recovering from the double tragedy of earthquake and cholera, combat poverty and lay the foundations for stability and prosperity. This is what the people of Haiti need. Our job is to help them. ****Martin Nesirky** , New York** The writer is the spokesman for U.N. Secretary-General Ban Ki-moon.

U.N. hypocrisy in Haiti

_Charanya Krishnaswami is a student at Yale Law School and a member of the Transnational Development Clinic. Muneer I. Ahmad is a professor at Yale Law School, where he directs the Transnational Development Clinic._ PORT-AU-PRINCE, Haiti _T_ he mandate of the U.N. mission in Haiti includes ensuring “individual accountability for human rights abuses and redress for victims.” Yet instead of fulfilling its obligations to the roughly 600,000 Haitians affected by a cholera outbreak it caused, the United Nations is hiding, shamefully, behind a claim of immunity. By refusing to right its own wrong, the international body is violating the principles of international accountability and human rights that it purports to promote. For all its challenges, Haiti was free of cholera for about a century before a U.N. peacekeeping force arrived from Nepal in October 2010. Although there had been an outbreak of cholera in Nepal shortly before the troops left for Haiti, the U.N. mission failed to appropriately screen the peacekeepers for the disease. This error was compounded by the United Nations’ failure to provide the peacekeeping mission adequate sanitation facilities at their base in the town of Mirebalais. As a result, cholera-infected waste leaked into a tributary to Haiti’s largest river, the Artibonite.Because many Haitians depend on the river for water, the spread of cholera was as rapid as it was deadly, killing more than 8,000 people, as of last month, and sickening hundreds of thousands of others. Cholera continues to infect 1,500 people here every week. Community health advocates told us this week that patients lack access to care and simple life-saving supplies, thanks in part to continued U.N. inaction. Victims living steps away from the U.N. base — every one of whom has lost a relative, a friend or a neighbor in the outbreak — expressed their anger at the organization and their hopes to see it brought to justice. Although a 2011 U.N. report conceded that the strains of cholera “isolated in Nepal and Haiti” were “a perfect match,” the United Nations denies responsibility for the outbreak. In November 2011, 5,000 victims of the disease, represented by the Institute for Justice and Democracy in Haiti, a Boston-based human rights group, and the Haitian Bureau des Avocats Internationaux, filed claims for compensation under the procedures the United Nations promised to create as part of its agreement for sending peacekeepers to Haiti. After ignoring the claims for more than a year, the United Nations announced in late February that they were “not receivable” because the 1946 Convention on Privileges and Immunities gave it legal immunity. A U.N. spokesman said that the outbreak resulted from “a confluence of circumstances” and was “a painful reminder of Haiti’s vulnerability in the event of a national emergency” — the January 2010 earthquake. In other words, rather than providing its victims redress, the United Nations blames them. The U.N. failure to acknowledge the Haitians’ claims is both immoral and illegal. International law requires the organization to provide a way for parties to bring claims against peacekeeping forces. The same convention the United Nations cites as bestowing legal immunity says that the organization must “make provisions for appropriate modes of settlement” for claims that arise from its missions. Simply put, if the United Nations harms innocent bystanders, it must give those people a way to obtain justice and seek compensation for their injuries. The United Nations appeared to honor this obligation in 2004, when it entered into a status-of-forces agreement with Haiti that, among its provisions, required the U.N. mission to set up a commission to hear claims Haitians might have against U.N. peacekeeping forces. This is the claims process that victims of the epidemic tried to use in 2011. Yet in its statement last month, the United Nations made no mention of its obligation to establish a claims commission. This is not the first time the United Nations has ignored its duty to establish a claims commission. Although it has signed about 50 similar peacekeeping agreements since 1990, not once has the United Nations set up a commission, a World Justice Project analysis noted last August. This claims process is critical because the 1946 convention requires the United Nations to hold itself accountable when its peacekeepers do wrong. As then-Secretary General Kofi Annan explained in a series of reports to the U.N. General Assembly in the 1990s, the organization must be accountable when innocent parties are harmed by actions unnecessary to its mission. Leaking cholera-tainted human waste into a major waterway and consequently infecting hundreds of thousands of Haitians with a deadly disease not only undermined the U.N. mission in Haiti but also thwarted it. Two years after cholera claimed its first victims in Haiti, the outbreak continues to ravage the Western Hemisphere’s poorest nation. By flouting its international obligations and its own promises, the United Nations has destroyed its moral credibility among Haitians. How can it purport to hold human rights abusers in Haiti accountable when it refuses to hold itself to the same standard? **Read more about Haiti:** Amy Willentz: Helping Haiti by aiding one earthquake victim Cholera aside, Haitians stuck in camps suffer as well Haitian amputees struggle, but they are not dismissed as ‘good-for-nothings’ Photo gallery: Fighting disease in Haiti

The United Nations comes clean(ish) on cholera in Haiti

MORE THAN six years after a brigade of U.N. peacekeepers from Nepal introduced cholera in Haiti, triggering an epidemic that has killed at least 10,000 and sickened many more, U.N. Secretary General Ban Ki-moon has finally uttered the word “sorry.” Mr. Ban’s tortuously worded apology, delivered recently in a speech to the U.N. General Assembly, must be the beginning, not the end, of official contrition and accountability by the United Nations in Haiti. The glacial rate at which the United Nations grasped its moral responsibility for having wreaked a public-health disaster in the Western Hemisphere’s most impoverished nation has tarnished the institution. Cowed by its lawyers, jealously guarding its prestige, the United Nations averted its gaze from the victims, ignored incontrovertible scientific evidence and trembled at its potential legal liability. Only when it became clear that its credibility was in tatters, and its authority to insist that member states adhere to international norms was in jeopardy, did the United Nations finally come to terms publicly with its culpability in the cholera outbreak. “We simply didn’t do enough with regard to the cholera outbreak and its spread in Haiti,” Mr. Ban said. “We are profoundly sorry about our role.” His statement, coming just a month before his term as the United Nations’ eighth secretary general expires, painstakingly avoided an overt admission of what is already known: that the outbreak began when Nepalese peacekeepers, failing to use basic protocols of sanitation at their base when they arrived in 2010, contaminated a nearby river that provided drinking water for Haitians. Cholera was rampant in Nepal at the time; it had been unknown in Haiti for decades. What is critical now, as U.N. officials have acknowledged, is that the organization take concrete steps to make amends, namely by leading a public health blitzkrieg to eradicate the disease in Haiti and by making reparations, to victims’ families, their communities or both. Legal accountability is not the point; a federal appeals panel ruled this summer that the United Nations enjoys diplomatic immunity from the victims’ claims. But moral accountability demands a sustained effort to wipe out a disease that has caused so much suffering in that country. It won’t be easy. U.N. officials say they have nearly raised the $200 million they sought to overhaul water and sanitation infrastructure in Haiti, and to treat cholera’s steady flow of fresh patients there. That’s a first step toward what is likely to be a long struggle for eradication. Unfortunately, they have made little progress in raising from member states what they hope will be an identical amount of money to provide payouts, scholarships and other benefits to the relatives and communities of the dead. Under Mr. Ban’s successor, former Portuguese prime minister Antonio Guterres, who takes office Jan. 1, the United Nations has every incentive to press ahead both to heal Haiti to the extent possible and to restore its own moral standing. **Read more on this topic:** Joel Dreyfuss: Only Haitians can save Haiti The Post’s View: The Herculean task facing Haiti The Post’s View: The U.N. finally owns up to its role in Haiti’s cholera outbreak Charanya Krishnaswami and Muneer I. Ahmad: U.N. hypocrisy in Haiti The Post’s View: United Nations must admit its role in Haiti’s cholera outbreak

A painfully slow hurricane relief effort in Haiti gains speed

PORT-AU-PRINCE, Haiti — A week after Hurricane Matthew leveled swaths of western Haiti, the relief effort is finally gaining steam, with the flow of food and medicine increasing to cities that will serve as hubs for desperate outlying villages, aid workers and diplomats say. The storm that struck on Oct. 3 killed hundreds of people and forced thousands from their homes, setting off the worst humanitarian crisis in this impoverished country since the devastating earthquake six years ago. Winds tore buildings apart, and flooding has contaminated water supplies and helped spur a new outbreak of cholera along the coast, with at least 200 cases reported, according to the United Nations. “I’ve seen it from the air, and it looks catastrophic,” U.S. Ambassador Peter F. Mulrean said in an interview Tuesday. “I’ve seen it from the ground, and it is heartbreaking.” In some areas, residents have erected roadblocks with logs and brush to stop aid trucks so that they can ransack the supplies. Increasingly desperate survivors are pleading for food, water and shelter. “There have been worrying instances of looting of international aid and assistance on their way to most-affected communities,” said Ariane Quentier, spokeswoman for the U.N. Stabilization Mission in Haiti. “In more general terms, there are tensions mounting within communities awaiting help, which is also a worrying development.” Haiti’s national civil protection agency has increased the death toll nationwide from the hurricane to 473, but that seems likely to grow, and some estimates put it at more than 1,000. Some 175,000 people are living in shelters. The World Health Organization announced Tuesday that it was sending 1 million doses of cholera vaccine to Haiti. It said about one-quarter of the health- care facilities in southern Haiti had been destroyed or seriously damaged. Cholera can be deadly and is transmitted through contaminated water or food. American officials say the priority for relief remains saving lives: providing food and clean drinking water by truck, boat or helicopter to many communities that remain hard to reach. A U.S. disaster response team of more than 50 people has bivouacked in the atrium of the U.S. Embassy here, while the American military is working out of the airport, with about 425 affiliated personnel, moving relief supplies by helicopter. A cargo flight of U.S. government relief supplies, the fifth so far, was scheduled to arrive Tuesday and was to include hygiene items, cooking kits and tarpaulins for homes that lost their roofs. The U.S. government is working with charities and aid groups to hasten the distribution to remote villages. The Haitian government, operating with an interim president, has seemed largely absent from many shattered coastal towns. Aid workers and diplomats, however, say the government’s civil protection agency has been actively putting together the strategy for the hurricane response while relying on foreign donors to bring in the supplies and carry out the plan. Haiti is in the midst of a long-running political crisis. Last year’s first round of the presidential election was engulfed in accusations of fraud, and the second round was repeatedly delayed. An interim government, led by Jocelerme Privert, remains in charge, although his mandate expired in June. A presidential election scheduled for this past Sunday was postponed indefinitely because of the hurricane. Robert Perito, a Haiti expert and adjunct professor at George Mason University’s School of Policy and Government, said the fact that Haiti’s government was organizing an election was distracting officials from the immediate disaster relief. The “government is simply not present in many areas” and is “always slow to respond when it reacts at all,” he said. “Haitians are prickly about their sovereignty, but this is an interim government with little capacity, so incompetence is probably a factor.” Mulrean, the U.S. ambassador, said he has met or spoken with Privert almost every day and has toured the hurricane-damaged zones with him twice. Emergency operations centers in the capital and around the country, set up after the earthquake, are functioning well, and have embedded U.S. staff, he said. The government is “interim, but it’s in place, and they took their responsibility very seriously,” Mulrean said. “We’ve got a government that wants to be out front. That we want to be out front. Obviously they need a lot of support. And we and others are prepared to do that.” The provisional electoral council has met in recent days with the government and foreign ambassadors to discuss the timing for an election, but no date has been proposed. “Everyone agrees that the elections need to move forward and need to be completed and that having a newly elected president in place will allow the government to deal [better] with the longer-term issues than having a provisional government in place,” the ambassador said. He added that it was important to find “the balance between the political imperative to hold the elections as quickly as possible and what is technically feasible to run credible elections.” Among the main difficulties for the relief effort so far has been the inaccessibility of the villages battered by the storm. It struck the western edge of the Tiburon Peninsula, cutting off an already remote part of the country, a region where one paved road is often the only way to reach towns. Many of those roads were made impassable by fallen trees and washed-out bridges. U.S. officials said that communications had collapsed in the hurricane but were slowly coming back. Two cities, Jeremie and Les Cayes, have become hubs for shipments of food and other supplies that are to be distributed to smaller coastal villages. Beyond the immediate survival needs, Haiti faces a mass rebuilding effort, as thousands of homes and other buildings were damaged or destroyed. The peninsula is an important agricultural area, producing rice, fruit, cassava and other crops, and much farmland was damaged. “In some parts of Haiti you have 90 percent of homes destroyed, plus people losing all their crops,” said John Hasse, national director in Haiti for the aid group World Vision. “For them, it’s not just about getting immediate relief supplies; it’s more like: What happens next week? What happens next month?” Filipov reported from Washington.

Thousands died when the U.N. brought cholera to Haiti. Here’s why it’s getting off scot-free.

Who pays the costs when United Nations operations go wrong? This hypothetical question became very real in October 2010 when U.N. peacekeepers from Nepal brought cholera to Haiti, as we describe in a new article for the journal Perspectives on Politics. Although cholera is endemic in Nepal, the peacekeepers were not screened for the disease before their departure. Once in Haiti, they built a camp with substandard sanitation that allowed human waste to spill from open pits and cracked pipes into a nearby waterway. Soon after their arrival, the first cases of cholera appeared, leading to an epidemic that has cost over 9,000 lives and sickened more than 750,000 people.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The U.N. repeatedly denied any connection between its people and the epidemic, but the organization’s culpability was soon confirmed by a range of scientific studies, expert findings, and even a report commissioned by the secretary- general.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Though the U.N. is clearly responsible “in fact” for the epidemic, it has never been found responsible “in law.” The gap between the two is important, both for the U.N. and the people who suffered. The U.N. is protected from legal accountability for the harms it has caused by three legal and political factors: U.N. immunity, the absence of legal standing for individuals in international law, and Haiti’s position of dependence in the international system. The cholera victims and their lawyers have attempted to hold the U.N. accountable in two ways. First, they approached the U.N. with “petitions for relief”  that asked the organization to apologize, invest in clean water systems, and compensate the victims. But the U.N. refused to receive their petitions. How can the U.N. simply shut its door? While several treaties, including the Status of Forces Agreement between the U.N. and Haiti, establish that the U.N. is expected to consider such claims, none contains an explicit legal requirement that it must. Moreover, there is no process or institution through which the cholera victims can challenge the organization. Faced with the U.N.’s rejection, the victims attempted to sue the U.N. in U.S. federal courts. This approach has been stymied by the U.N.’s immunity from legal actions in domestic courts. There is some debate among international legal scholars over how far this immunity is supposed to extend, but in practice courts around the world have interpreted it as absolute protection against any lawsuit. This practice is endorsed by the U.S. State Department, and so it was no surprise when the U.S. courts dismissed the victims’ cases in early 2015. Though this decision is being appealed, it appears that the cholera victims have hit a dead end: They cannot hold the U.N. legally responsible for the harms it caused. **How did we get here?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico U.N. immunity was not originally intended to insulate the organization from all responsibility for its harms. Rather, its purpose was to protect the U.N. from national governments that might use lawsuits to harass or pressure it. It was understood originally as “functional immunity,” meaning that it covered the UN and its officials for actions taken in the performance of their official duties. For example, in the _Mothers of Srebrenica_ case, Dutch courts ruled that the mothers of men killed in the Srebrenica massacre could not sue U.N. peacekeepers for failing to prevent the massacre.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico On the other hand, the U.N. is legally responsible for harms not related to its official mandate — e.g., when U.N. peacekeepers kill someone in a car accident. Since 1945, the prevailing interpretation of U.N. immunity, advanced by courts, governments, and the U.N. itself, has expanded, with an ‘absolute’ position coming to dominate over the ‘functional.’ The second obstacle is that the international legal system gives few rights to individuals. As private citizens, the victims do not have standing —  i.e., legal status and ability — to address the U.N. or to advance claims against it in other international forums. Instead, international law presumes that governments will advance claims on behalf of their citizens. If the Haitian people want justice, then they have to rely on their government. The Haitian government has a number of legal options. It could use its position as a U.N. member to insist that the organization respond to its claims. It could use the Status of Force Agreement to establish a claims tribunal against the wishes of the U.N. Or it could encourage the U.N. to request an advisory opinion from the International Court of Justice, which, due to the particular circumstances of this case, would be binding on the U.N. However, for reasons unknown — but probably having to do with Haiti’s heavy dependence on the U.N. and the international community — the government has declined to take action. Legally, Haiti is able to hold the U.N. accountable, but practically, it cannot afford to bite the hand that feeds it. This is a world in which international institutions such as the U.N. have more power and responsibility over the fate of people than ever before but are essentially sheltered from legal accountability when things go wrong. People who are directly harmed by the actions of the U.N. have no way to seek redress. In some ways, this is beginning to change. Access to courts is now widely acknowledged as a human right. Some human rights tribunals are accessible to individuals; conversely, individuals can be prosecuted by the International Criminal Court. But as victims of U.N. negligence, the Haitians are still outside the legal system, looking in. **Where do we go from here?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Ideally, the U.N.’s functional operations and its accountability to individuals should not conflict, since U.N. operations should contribute to the welfare of local people. In practice, however, sometimes things inevitably go wrong. The issue in the Haiti case is: who is held responsible for those damages? The current system ensures that this is not the U.N. Restricting U.N. immunity would carry practical implications. Being responsible for damages makes it harder for the U.N. to do its job. The victims’ lawyers demanded that the U.N. pay $50,000 per illness and $100,000 per death. At this rate, U.N. liability amounts to roughly $38 billion—over four times the U.N.’s _total_ annual peacekeeping budget. A payout that size would dramatically undermine U.N. peacekeeping activities in Haiti (including cholera eradication) and elsewhere, potentially even shutting them down.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico If the U.N. cannot afford the bill, it would be passed on to member states. While it’s hard to imagine that national governments would be willing to pay,  it might make them think twice about authorizing future peacekeeping missions or contributing troops. In short, a large payout for the mess in Haiti could have consequences for all U.N. peacekeeping efforts. Functional immunity was designed to manage this tension by ensuring that local courts would not impede U.N. operations. But the Haiti case demonstrates that U.N. immunity has shifted too far toward the organization at the expense of the people it is meant to serve. Just outcomes are like pixilated images — they appear clear from a distance but are blurry and illusive up close. The law is a common frame for seeking justice, but it will never be perfectly able to deliver just outcomes. Sometime we need to think outside the legal box. Responsibility and accountability are not only legal concepts — they are also political and moral ones. There are a range of non-legal ways to promote accountability, including political pressure, public shaming, and media scrutiny. We see these at work when constituents call on misbehaving politicians to resign or consumers boycott companies. In Haiti, the U.N. is unable or unwilling to acknowledge the harm it has caused and the law doesn’t obligate it to. Civil society actors may ensure that law does not have the final word. _Mara Pillinger is a PhD candidate in political science at George Washington University. Follow her on Twitter @mplng._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico

United Nations must admit its role in Haiti’s cholera outbreak

ON THIS page Thursday, the spokesman for United Nations Secretary General Ban Ki-moon offered a response  — or something closer to a non-response — to The Post’s editorial Sunday about the United Nations’ responsibility for, and response to, Haiti’s deadly cholera epidemic . In a letter to the editor, Martin Nesirky, the spokesman, called attention to the United Nations’ wide-ranging and critically important work in providing aid and relief to victims of the cholera outbreak, to improving the country’s infrastructure so that it is less susceptible to such outbreaks in the future and to the pressing need for donors to open their wallets to help implement Haiti’s long-range campaign to eliminate the disease. However, Mr. Nesirky pointedly ignored the editorial’s central focus, which is that the United Nations’ responsibility derives not only from its mission as a major humanitarian relief organization, but also from the growing body of evidence that the cholera outbreak originated with U.N. peacekeepers deployed to Haiti in 2010 following a devastating earthquake. That is the conclusion of a range of experts, including a panel enlisted by the United Nations itself and, most recently, student researchers at Yale Law School and the Yale School of Public Health. It may be the case that lawyers for the United Nations have forbidden the organization’s officials from addressing the topic or even mentioning the battalion of blue-helmeted Nepalese peacekeepers who are widely thought to have introduced the cholera virus into the nation’s largest river and main water supply. Nonetheless, by refusing to acknowledge responsibility, the United Nations jeopardizes its standing and moral authority in Haiti and in other countries where its personnel are deployed. In effect, the United Nations faces two important tasks to address the outbreak, which has killed more than 8,000 people and sickened well over 600,000, and it has undertaken only one. To its credit, the United Nations does seem to be pressing hard to help Haiti eradicate cholera and lessen the effect of the epidemic. And it is useful to remind donors, as Mr. Nesirky did in his letter, that just half of the $444 million goal has been met to fund Haiti’s anti-cholera program. Yet without also speaking frankly about its own responsibility for introducing cholera to Haiti, the organization does a disservice to Haiti and Haitians, who deserve better. **Read more about this issue:** The Post’s View: The United Nations’ duty in Haiti’s cholera outbreak Charanya Krishnaswami and Muneer I. Ahmad: Hypocrisy in Haiti The Post’s View: ‘Really quite disastrous’ The Post’s View: Haiti’s terrible idea Paul Farmer: How we can save millions of lives

The Herculean task facing Haiti

JEREMIE. LES CAYES. PORT-SALUT. These Haitian towns, blasted and shattered by Hurricane Matthew, are unfamiliar to most Americans. Yet now that the storm has left them desperate for relief, it is to Americans they are turning for the most basic forms of lifesaving help: food, water, shelter, medical supplies. Americans have stepped up generously in the past to help Haiti, the hemisphere’s poorest country, notably after a cataclysmic earthquake in 2010 left at least 100,000 dead and hundreds of thousands more without homes. Matthew, which may have killed well over 1,000 people, is the most crippling natural disaster sustained by Haiti, or any other place in the Western Hemisphere, since then. It is hard to overstate the devastation wreaked by the hurricane, whose 145 mph winds tore across Haiti’s southwestern Tiburon peninsula. And it’s difficult to exaggerate the vulnerability of the affected area, a key agricultural region whose flimsy infrastructure — rickety bridges, villages accessible by a single narrow road, ramshackle homes — was ill-equipped to withstand a storm of Matthew’s might. Towns, villages and hamlets are pulverized and mud-caked, with tens of thousands of people in need of shelter, their homes badly or irreparably damaged. Fixing a casualty count has been a macabre, drawn-out process as some victims, swallowed in the mud, are unearthed only slowly. The hurricane left conditions ripe for a new spike in Haiti’s already deadly epidemic of cholera, which is spread by contaminated food and water. Flood waters washed through sewer systems and wells and sent ocean water surging ashore, leaving virtually no potable, readily available fresh water. That has contributed to what aid workers and journalists visiting the area describe as a growing sense of desperation, and given rise to reports that looters have targeted international humanitarian stockpiles and built roadblocks in order to ransack aid convoys. Hundreds of U.S. Marines and sailors are heading toward the affected region; they can help distribute water, food and essential relief equipment as well as help maintain order. That’s a critical function in a remote area where the Haitian government, never a model of efficiency, is barely visible. Americans should demonstrate generosity to ease Haiti’s plight, as they did after the earthquake. In addition to the Red Cross, many aid organizations are gearing up: the Salvation Army, World Vision, UNICEF, Mercy Corps, CARE, Save the Children, Catholic Relief Services and others. The scale of the project is vast. Some 1.4 million people, more than a tenth of Haiti’s population, need assistance. Cellphone towers are down and communications are a challenge. Farms producing coffee, beans, fruit and rice, among other staples, are badly damaged, raising the specter of food shortages. Roads, bridges, canals and water and sewer systems must be reconstructed quickly. Not least, the hurricane forced a postponement of an already long-delayed presidential election, leaving the Herculean task of relief and rebuilding in the hands of a caretaker government. To regain its footing, Haiti will need help, and quickly. **Read more here:** Joel Dreyfuss: Only Haitians can save Haiti The Post’s View: In Haiti’s upcoming election, the stakes are higher than ever

U.N. accepts role in deadly Haiti cholera outbreak for first time

Blue-helmeted U.N. “peacekeepers” sent to conflict zones have long suffered from a reputation for passivity. But the acknowledgment this week by U.N. officials that its troops bear responsibility for Haiti’s cholera epidemic comes at a time when the organization is already facing criticism for undermining countries it has been sent to stabilize. The United Nations’ admission that its forces played a role in triggering Haiti’s 2010 cholera outbreak is seen as a long-overdue official recognition of _something_ that has been widely known — but stubbornly denied by U.N. leaders — for years. It follows accusations this year that U.N. peacekeepers have committed rape and murder in the Central African Republic, and more recently that they failed to defend aid workers against brutal attacks in South Sudan. Critics say these scandals have laid bare the United Nations’ struggles to police its forces and investigate claims of wrongdoing and abuse, whether in cases of negligence — such as Haiti — or the allegations of more serious crimes in Africa. When the United Nations fails to accept its responsibility as well, said Akshaya Kumar, the deputy U.N. director at New York-based Human Rights Watch, the peacekeeping system breaks down. “I think one of biggest losses from cases like this is loss of trust between U.N. and communities they’re sent to serve; that is really hard to rebuild,” she said. __ That has been the case in Haiti, where thousands of heavily-armed troops with U.N. blue helmets have been deployed since the bloody 2004 ouster of then- President Jean-Bertrand Aristide. The U.N. Stabilization Mission in Haiti is resented by many Haitians who view the foreign troops as an occupying force. But their role in policing the volatile country is considered _critical_ by international donors and foreign governments. U.N. officials have refused for years to accept blame for bringing cholera to Haiti, but suspicions have long settled on a contingent of U.N. troops from Nepal who arrived after the January 2010 earthquake that devastated the capital of Port-au-Prince. A cholera epidemic in Nepal was underway at the time, and raw waste from the latrines at the U.N. troops’ camp in Haiti was allowed to seep into an adjacent river. In a statement sent to The Washington Post, Farhan Haq, a deputy spokesman for U.N. Secretary-General Ban Ki-moon, said that the organization has become convinced in the past year that it needs to do much more regarding its own involvement in the initial cholera outbreak in Haiti and the suffering of those affected by the disease, which has sickened hundreds of thousands and left about 10,000 dead. The U.N. acknowledgment, first reported by the New York Times, comes after top officials were provided a draft report by an adviser criticizing their handling of the cholera outbreak. Haiti’s 2010 earthquake left as many as 200,000 dead, and the damage has been compounded since then by periodic flare-ups of cholera. A recent report by Doctors Without Borders has raised the possibility the disease may have killed far more Haitians than previously estimated. Cholera spread virulently in the muddy, crowded tent camps where destitute Haitians took refuge after the quake. Nearly six years later, the disease continues to claim new victims, particularly in rural parts of the country without access to clean drinking water. A new spike in infections has been reported this year. Ban has pledged more than $2 billion to fight the disease in Haiti, but has struggled so far to raise the funds from member states. Haq said the Haiti report, written by Philip Alston, a New York University law professor and U.N. special rapporteur on extreme poverty and human rights, would probably be published late next month and presented by Ban at the U.N. General Assembly in October. Alston did not respond to requests for comment. The United Nations “wanted to take this opportunity to welcome this vital report,” Haq said. Without giving details, Haq said the draft report criticizing the U.N. handling of the outbreak, and its recommendations, “will be a valuable contribution to the U.N. as we work toward a significantly new set of U.N. actions." He said the United Nations has been working to fight cholera since the outbreak but would present a new set of measures after discussions with Haitian authorities and U.N. member states. A U.N. spokesman who was asked about the report Thursday said the organization’s legal position “had not changed” and that it was working to “figure out how to resolve” questions of its responsibility in the outbreak. The U.N. charter affords the organization broad diplomatic immunity from lawsuits and other legal action. Beatrice Lindstrom, an attorney for Haitian cholera victims who have filed a suit in U.S. federal courts seeking reparations from the U.N., said an acceptance of culpability could make it more likely that plaintiffs will finally receive financial compensation. “The U.N. has broad immunity from national courts, but that has always been conditioned on providing remedies out of court to victims who are harmed by U.N. operations,” Lindstrom said. “It has been in breach of the treaty granting it immunity in the first place, so if the U.N. follows through on remedies, that would make questions of immunity mute.” But Robert Fatton Jr., a Haitian-born political scientist at the University of Virginia, said Haq’s statement amounted to little more than “the idea that the U.N. might be more receptive to its own criticism.” “Will that entail more _than_ just empty promises to address the problem?” Fatton asked. “The question is whether the report will lead to some form of compensation for the victims of the epidemic and whether the moral outcry resulting from the U.N.’s irresponsibility will begin to erode the notion that the organization should continue to enjoy diplomatic immunity.”

Haiti is broken because of intervention

The Dec. 28 editorial “Haiti’s broken politics” concluded that, absent international intervention, Haiti will crumble into anarchy. In fact, Haiti’s crisis is, in large part, a consequence of U.S. and international intervention. This country has been occupied by U.N. soldiers for more than a decade. And it was U.S. pressure that led to the 2010 elections, months after the earthquake and weeks after the eruption of a virulent cholera outbreak, introduced by those U.N. troops. Fewer than 23 percent of registered voters cast a ballot. President Michel Martelly has never had a democratic mandate. It was only after a nine-member team from the Organization of American States, controlled by the United States and its allies, reversed the first-round results — in an unprecedented maneuver and without justification — that Mr. Martelly even made it to the second round. Since taking office, Mr. Martelly has failed to schedule elections, now more than three years delayed. He has appointed more than 130 mayors, sidestepping the democratic process. He stacked the electoral council with his supporters. The six “opposition” senators blamed in the editorial are a convenient scapegoat. These senators (and the thousands who have been protesting daily) are demanding legitimate, fair elections rather than a repeat of 2010. The international community indeed plays a role in shaping Haiti’s political future. But it is not one that it should be proud of. ****Greg Grandin** , New York** ****Keane Bhatt** , Washington**

Biggest story you missed-Haiti

“If it weren’t for politicians, this would be a pretty country.”  One candidate is called the “Banana Man.” Another is a lottery magnate. More than 50 people are trying to become Haiti’s next president, and nearly 2,000 are running for parliament. The outgoing president, Michel “Sweet Micky” Martelly, was a singer “famous for dropping his pants on stage, mooning audiences, and dressing in drag – or sometimes a diaper.” And if that’s not enough drama, consider that the results of the election, which took place this past Sunday, won’t be announced for several more days. Possibly weeks. Then, there will probably be a runoff election in December.   Political parties: 130 Presidential candidates: 54 Parliament candidates: 1,850 Registered voters: 5.8 million Total population: 10 million   Haiti is still struggling to recover from a 2010 earthquake that killed more than 200,000 people and devastated the capital. Tens of thousands still live in temporary structures. A cholera epidemic that began soon after is the worst in recent history. The parliamentary elections have been postponed for four years, and several people were killed before the vote. On Thursday, a leading presidential candidate alleged fraud, and his supporters burned tires in the streets. But Election Day was relatively peaceful, and that was a huge relief for Haitians, who hope their country can finally begin a new, more stable chapter. “Whether it’s earthquakes, hurricanes, cholera, or the everyday poverty in the poorest country in the hemisphere, Haiti is familiar with tragedy.”    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Joshua Partlow, a Washington Post correspondent who has reported from Haiti.

Cholera aside, Haitians stuck in camps suffer as well

The May 27 editorial “ ‘Really, quite disastrous’ ” correctly noted that “the world’s worst outbreak of cholera continues to ravage Haiti.” Not only have international donors “averted their gaze,” they have all but forgotten the survival needs of nearly a half-million Haitians who remain in deteriorating camps, awaiting relocation. Since the 2010 earthquake, more than 1 million people have been moved from emergency shelters to temporary or permanent accommodations, according to the International Organization for Migration (IOM). Those who remain in camps, however, are stuck in unimaginably bad conditions, with scant relocation prospects. With the job two-thirds finished, the international community has declared the emergency over and essentially moved on. There are several possible reasons for this: satisfaction with accomplishments to date, calls to move to next-stage development and other world crises. Humanitarian action in the camps is negligible. The U.N. office on humanitarian affairs says it has not received enough funds to meet the basic needs of those in the camps, and the IOM has reported deteriorating conditions in all aspects of camp life. As funding for camp management, health, water, sanitation and other services has declined, the vulnerability of women and children has become intolerable. Sexual and gender-based violence cases spiked in the last quarter of 2011, and they have continued to rise in 2012. True, cholera is rampant in Haiti. But that’s just one of many avoidable breakdowns. ****James N. Purcell Jr.,** Washington** The writer is president of the U.S. Association for International Migration. He served as director general of the International Organization for Migration from 1988 to 1998.

Only Haitians can save Haiti

_Joel Dreyfuss is a Washington Post Global Opinions contributing columnist._ Haiti won a rare victory on the international stage last week. After five years of evading accountability, the United Nations finally admitted that its peacekeepers were responsible for a deadly cholera epidemic that killed 10,000 men, women and children and sickened 700,000. Long after scientists traced the disease to the poor sanitation practices of Nepalese troops stationed in Haiti, the U.N. rejected the findings, claimed diplomatic immunity and enlisted Obama administration support to block efforts by Haitians to hold the agency accountable in U.S. courts. The U.N. backed down after a report by New York University law professor Philip Alston, an adviser on legal and human rights, became public. Alston called the U.N.’s stonewalling “morally unconscionable, legally indefensible and politically self-defeating.” The U.N.’s arrogant stance was just the latest example of how Haiti’s friends are so often its worst enemies. The U.N. military mission has been in Haiti since 2004, presumably to “stabilize” the country and nurture its fragile democracy. Yet that democracy is barely breathing, with a “provisional” president and a group of dubiously elected officials who can barely agree on a date for presidential elections. Consider the aftermath of the massive earthquake that killed 200,000 to 300,000 Haitians on Jan. 12, 2010. The international community did responded generously. Former presidents Bill Clinton and George W. Bush presided over a reconstruction commission that won $14 billion in international pledges and posed to help transform Haiti into a modern nation. However, what money was actually delivered was sucked into a morass of Beltway consultants, failed projects and nongovernmental organizations. “Valuable studies and assessments conducted by Haitians themselves were largely ignored,” the Organization for Economic Cooperation and Development reported in a postmortem study. Six years later, the rubble in downtown Port-au-Prince has been cleared, but little has been rebuilt. The nation’s center of commercial activity has moved to suburban Pétionville. Plans to revive the capital remain as vague as the early-morning fog that drifts across the majestic mountains that serve as a backdrop to Haiti’s tortured history. The Clintons have expressed a fondness for Haiti ever since they honeymooned there in 1975. Bill and Hillary have been up to their elbows in Haiti ever since 1994, when President Clinton used U.S. military power to restore Haiti’s first democratically elected president, Jean-Bertrand Aristide. Clinton, whose home state of Arkansas is the No. 1 rice producer in the United States, extracted an agreement from Aristide in 1995 to drop tariffs on imported rice. The resulting influx of cheap American rice destroyed Haitian’s near-self- sufficiency in food and sent thousands of poor farmers and their families into the overcrowded capital. Clinton has since apologized for his “devil’s bargain.” Fast-forward to today, and Haitians know that the United States’ presidential elections will have a profound effect on their future: A Hillary Clinton victory could mean more interference in Haiti’s affairs. The current political crisis was precipitated by the heavy-handed manipulation of Haitian politics by the “Core Group,” (the United States, Canada, France, Spain, Brazil, the European Union and the Organization of American States). In 2011, they excluded the most popular political party from presidential elections and discarded one of the top vote-getters, and Haitians ended up with former bandleader Michel Martelly as president. They tried the same tactics this year, putting heavy pressure on Haitians to complete a tainted second round of ballots. Fed up, thousands of Haitians took to the streets to reject that advice and force a new round of elections over strong American objections. Haitian identity at home and abroad is tightly linked to our native country’s status as the world’s first free black republic. Every August UNESCO commemorates the secret ceremony in Haiti’s Bois-Caiman in 1791 that triggered a successful slave uprising, which in turn fomented the revolution that led to its independence. I know I will offend many of my fellow Haitians by saying this out loud — but I wonder if Haiti will ever truly regain its independence. The reality is that Haiti, more than 200 years after it gained its freedom, has spent large chunks of its existence under the military, political or economic control of foreign powers. Haiti paid twice for its freedom, first with blood and then with money. Haitians handed Napoleon his first significant military defeat by repelling the 50,000 troops he sent to restore slavery. But fearing a new invasion, Haiti signed an agreement with France’s Charles X in 1825 to pay former owners of plantations and slaves tens of millions of francs (variously estimated by historians at between $3 billion to $25 billion in today’s dollars) as the price for recognition. The deal doomed Haiti to 80 years of distorted budgets focused on paying off foreign debt and starving its people of the infrastructure and educational facilities that might have set the young nation on a more prosperous path. The United States began its military occupation of Haiti in 1915 and remained there for 19 years. But even before American Marines landed in the country, Haiti’s many authoritarian and corrupt leaders plunged the country into debt and exacerbated the domination of the many by the few. Rosalvo Bobo, an early-20th-century Haitian politician, noted that Haitian leaders had replaced the liberating achievement of their ancestors for “slavery of blacks by blacks.” The ultimate challenge for Haiti — and many other small countries — is how to gain a measure of control over their own destinies, especially when they are in the “back yard” of powerful nations, dependent on foreign aid and are forced to deal with internal divisions. One way the U.N. could make restitution is to fulfill its pledge to rebuild Haiti’s sanitation system and begin planning a removal of the peacekeeping force. Those who want to help Haiti should begin consulting and involving Haitians at home and abroad in their grand plans. But the best incentive for change will come from Haiti itself. A new chapter for the embattled nation will come only when Haiti’s rapacious business and political elites and its masses of neglected poor learn the lessons from 200 years ago — that no one is coming to save them. **Read more on this topic:** The Post’s View: The U.N. finally owns up to its role in Haiti’s cholera outbreak The Post’s View: America’s nutty farm subsidies cause damage at home and abroad The Post’s View: Haiti on the brink The Post’s View: Haiti urgently needs international help overcoming its political crisis The Post’s View: Haiti’s dangerously sluggish electoral progress

Somalis are fleeing famine — only to find death in a place of refuge

IN BAIDOA, Somalia — Aftin Noor stepped back from the tiny graves he’d been digging and surveyed his work. Exhausted, he turned his palms skyward, squinting into the relentless midday sun, and asked God for an answer. “I dug three children’s graves this morning,” said Noor, his voice cracking, his undershirt soaked with sweat. “And I have dug 20 or more this month. Why?” The immediate answer is cholera. The waterborne bacterial disease is sweeping through this city’s sprawling refugee camps, which are filled with people driven from their villages by a vicious drought. Spotty, tantalizing rain showers have left fetid puddles, speeding the infection’s spread. Like a desperate predator, cholera often picks off the weakest targets: children. The drought and the looming specter of a famine have brought nearly 160,000 people to Baidoa from the baked countryside. They have come to save themselves from almost certain starvation. But an outbreak of cholera is spreading death through this place of refuge. The exodus to Baidoa began in November, when stores of food began to run out following two years of limited rains. More than 55,000 people arrived in April alone. Whole villages have relocated here. Somalia is no stranger to famine. Between late 2010 and early 2012, about 260,000 people perished, mostly around Baidoa, about 120 miles northwest of Mogadishu. Then, as now, the militant Islamist group al-Shabab, which controls almost all of rural southwestern Somalia and is hostile to aid agencies, made it nearly impossible for lifesaving food and water to be delivered anywhere but to the few cities under government control. Baidoa was al-Shabab territory then. People starved while walking from their homes near here to camps in the distant capital, Mogadishu, or in neighboring Kenya and Ethiopia. Now Baidoa is an island of government control. Aid agencies have established a presence here. Half of Somalia’s population, about 6 million people, is now dependent on humanitarian aid. The United Nations and a constellation of international and local aid agencies and donors think they are better prepared to address the crisis. Most think 2017 will not mirror 2011, even if the rains fail again. But the rapid coalescence of squalid camps has complicated the picture. More than 20,000 cases of cholera or related waterborne illnesses have been registered in the Baidoa region since January. Unlike the giant U.N. camps in, say, Jordan or South Sudan, Baidoa’s are new and not directly U.N.-administered, with the displaced people responsible for building their own shelters and buying their own food, mostly with cash they receive from international aid groups. The camps have sprung up on vacant land owned by locals. In that vacuum, sanitation facilities fell behind more immediate needs such as getting food, and now aid workers are trying to stay ahead of the cholera outbreak’s curve. “We are trying to negotiate with the landowners to allow us to build pit latrines, but some of them are being stubborn,” said Peter de Clercq, who oversees the U.N. humanitarian mission in Somalia. Cholera, which is endemic in Somalia, spreads quickly in places where people defecate in the open, and bacteria from the waste end up in food or drinking water. “There is still a significant advantage to being in the camps. People can access cholera treatment centers at hospitals. Cholera is easily treatable — it is a matter of catching it before it is too late,” de Clercq said. “From what we know, [you are] 4½ times more likely to die from cholera if you live in an al-Shabab-controlled area.” About 200 deaths from cholera and related diseases have been recorded in or near Baidoa, but aid workers caution that the toll in al-Shabab-controlled areas might be 10 or more times higher. Bashir Bille, 40, witnessed cholera’s terror in his village. In just a few hours, a body already weakened by hunger can lose all its water, effectively drying out from the inside. When Noor, Bille’s 4-year-old son, developed incessant diarrhea sometime after his family arrived in Baidoa two months ago, the father quickly sent the boy to the Bay Regional Hospital. Noor was a symbol of hope for Bille’s family. During the last famine, in 2011, they had fled alongside hundreds of thousands of others to Dadaab refugee camp in Kenya. They returned to their village near the town of Qansax Dheere only when they heard rains had fallen in 2013. They had survived, amid so much death. Bille’s wife, Oorow Madsheikh, gave birth to Noor. The child was admitted to the hospital in Baidoa during a time of growing alarm. The patient ledger at the cholera ward had started off with neat, single-spaced names, but after a bout of rain hit the camps, its pages became crowded, disorganized. Oral rehydration salts strengthened Noor enough for the hospital to release him after a few days. But a week later, on a Saturday morning in mid-May, he suddenly relapsed. He died in an hour. Two of his brothers are hospitalized with cholera symptoms. “I don’t know exactly how they got sick,” said their father, staring blankly ahead as Aftin Noor and his team of diggers took turns with a shovel and a pick ax, excavating Noor’s small grave. The diggers were from Bille’s village — everyone from there was here now. “Children run around. They touch things. They suck their fingers. We can’t watch them all the time.” UNICEF says that more than 275,000 children across Somalia are facing severe malnutrition, making them nine times more likely to die of diseases including cholera and measles. In Baidoa, 72 percent of households in the camps have a child younger than 5, according to the United Nations. The local hospital, which gets support from aid groups, has saved many lives, but some people are not comfortable sending their children there, believing instead in traditional medicine. When Faduma Abdirahman’s six grandchildren, entrusted to her by her daughter, fell ill in a camp in Baidoa, she decided to return to her starving village about six miles away rather than have them admitted. It had taken only a week in the camp for two of the children to develop uncontrollable diarrhea, and the four others to fall prey to a less widespread outbreak of measles. Abdirahman, 50, can barely speak now, her face frozen in an expression of sorrow. “I tried to save them by bringing them back to the village,” she whispered, her gaze on the scorched ground outside her home. “I didn’t know what else to do. They all died.” The only lasting relief from the drought will come in the form of rain. The wet season, which usually begins in April, is off to an uneven start. From a plane, one can see parched, sandy streambeds intersect with timeworn footpaths, giving the land the cracked look of dry skin. Noor’s body was brought to its resting place in that cracked land wrapped in a white shroud, which was in turn wrapped in a blue tarp. Aid agencies recommend double-wrapping for cholera victims. Noor was thus deprived of the traditional Islamic pre-burial cleansing, but a group of men still gathered to murmur his last rites. With a final “God is great,” the men lowered the boy into the earth, covering his body first in wet mud, then flat rocks, then dirt, but it was not enough to fill the grave. Only by skimming some soil off the top of another grave, dug that same morning, did they manage to fill it.

Trump calls U.N. ‘just a club for people’ to ‘have a good time’

Three days after the United Nations adopted a resolution calling on Israel to halt Jewish settlement activity on Palestinian territory, President-elect Donald Trump tweeted that the international body “is just a club for people to get together, talk and have a good time.” The harsh criticism, which Trump made Monday while vacationing at his Mar-a-Lago resort in Florida, signaled he would likely challenge more than just the 71-year-old institution’s approach to the Middle East once he takes office. While Trump did not elaborate on why he considered the United Nations ineffectual, he made it clear both before and after the Security Council adopted the resolution condemning Israeli settlements in the West Bank and East Jerusalem that he believed the United States should have blocked the move. President Obama instructed U.N. Ambassador Samantha Power to abstain from voting, on the grounds that the Israeli government’s continued support for expanding Jewish settlements could undermine any prospect of eventually reaching a two-state solution to the simmering conflict. After the Security Council voted, Trump tweeted, “As to the U.N., things will be different after Jan. 20th,” which is the day he will assume the presidency. The United Nations has come under fire for years from critics on both the right and the left. Conservatives have attacked it for infringing on individual nations’ sovereignty as well as wasting resources, while many developing nations argue that most major decisions remain dominated by a handful of countries that were influential when the United Nations was established decades ago. In recent years, some of its peacekeeping troops have been repeatedly accused of raping civilians they were sent to protect, and this August the office of U.N. Secretary General Ban Ki-moon formally acknowledged that Nepali peacekeepers sent by the United Nations to Haiti six years ago inadvertently introduced an outbreak of cholera there, even as U.N. officials maintained they have legal immunity in connection to the epidemic. The disease killed thousands of Haitians in the wake of a devastating earthquake. But the United Nations continues to play a key role in helping deliver humanitarian assistance across the globe, brokering cease-fires during conflicts and serving as a forum for sprawling issues such as how best to address climate change. Obama has worked doggedly during his time in office to support multilateral institutions such as the United Nations. He has used his speech each year before the U.N. General Assembly as a way to lay out his vision for foreign affairs and has convened summits there to tackle questions that include the global refugee crisis and the fight against terrorism. Earlier this month, the president stopped by to personally thank Ban for his work when the secretary general, who is stepping down at the end of the month, was meeting with national security adviser Susan Rice at the White House. Americans see the U.N. more negatively than positively when it comes to effectively solving problems, though most see the organization in a positive light and its popularity has risen over the past decade. Democrats are far more favorably inclined toward the U.N. than Republicans, among whom ratings plummeted during the Iraq war and have not recovered.  Both Gallup and Pew show improved ratings for the U.N. since the late 2000s. The percentage saying the organization does a “good job” has risen from 26 percent in 2009 to 38 percent in 2016 in Gallup polls; Pew finds the share rating the group favorably rose from 48 percent in 2007 to 64 percent in 2016. The improved ratings in recent years have been concentrated among Democrats and independents. During a new conference last month, Obama emphasized that the United States must continue to play the leading role in maintaining “the basic framework of the world order” that was established after World War II. “And I’ve said before, that’s a burden that we should carry proudly,” Obama said. “And I would hope that not just the 45th president of the United States, but every president of the United States understands that that's not only a burden, but it’s also an extraordinary privilege. And if you have a chance to do that right, then you should seize it.”

The global complacency on Ebola must end

THE EBOLA epidemic now sweeping West Africa is a public health catastrophe, yet the world’s response has been to treat it like a faraway monsoon or volcano, perhaps frightening but not something that much can be done about. This complacency is wrong-headed and dangerous. The catastrophe is worsening by the day because of the actions and inactions of people, those on the ground and those far away. On Monday, the World Health Organization published a grim and shocking assessment of the outbreak in Liberia, the hardest-hit of the four countries where the virus has exploded. Liberia has more than 2,000 cases of infection and has suffered about 1,000 deaths. According to the WHO, Liberia “is experiencing a phenomenon never before seen in any previous Ebola outbreak.” As soon as a new treatment facility opens, it immediately fills to overflowing, “pointing to a large but previously invisible caseload.” The number of new cases is increasing “exponentially,” the WHO warned. “The number of new cases is moving far faster than the capacity to manage them in Ebola- specific treatment centers.” This is very bad news. With no vaccine or antiviral available, the means to control Ebola, known from past outbreaks, is to cordon off the infected and prevent transmission of bodily fluids by which the disease spreads. This is doable in small villages and isolated locations. But this outbreak has detonated in big cities, and because of inaction and fumbling by governments, as well as fear, suspicion and panic among residents, control efforts are a shambles. In Liberia alone, there will be thousands of new cases of infection in the next few weeks, rippling to tens of thousands. About half of them will die, judging by what’s happened so far. The WHO team in Monrovia estimated that the county around the capital urgently needs 1,000 treatment beds. It has some 240 available with another 200 on the way. President Obama has pledged support and asked Congress for more money; on Monday the Defense Department announced it would deploy a 25-bed field hospital to Liberia at a cost of $22 million. The U.S. military will deliver it, set it up and go home. The British are sending a 62-bed facility, which will be operational in eight weeks. Every little bit helps, but these responses are meager in face of the need. Hundreds of health-care workers are also required. The WHO reiterated what Doctors Without Borders and others at the front lines have been shouting from the rooftops: The current effort needs to be scaled up _three- or four-fold_. The states of West Africa cannot do it alone. Reports from the epicenter of the disaster are ominous. Taxis in Monrovia are filled with entire families, some of them infected, crisscrossing the city looking for treatment beds that don’t exist. No free beds exist anywhere in the country. The taxis are now becoming a hot source of potential Ebola transmission, too. When patients are turned away from full treatment centers, they go home to infect others. This is a dire emergency. The paltry response is unacceptable. **Read more on this topic:** The Post’s View: The lessons of the Ebola outbreak suggest a larger, faster response is needed Michael Gerson: The Ebola crisis demands that America act Jim Yong Kim and Paul Farmer: What’s missing in the Ebola fight in West Africa Michael T. Osterholm: What we need to fight Ebola

It’s been five years since Haiti’s earthquake. And the ‘redevelopment’ hasn’t been about helping Haitians.

Five years ago this month, a terrible earthquake struck my country. I was in the capital city, Port-au-Prince, when suddenly the earth shook and buildings around me and across the city collapsed—taking with them hundreds of thousands of lives and the hopes of my nation. The world stood with us that day and in the weeks and months that followed. Donations poured in; the United States and many other governments pledged to help us rebuild Haiti. But five years into the reconstruction, as a Haitian, I must ask: For whom are we rebuilding our country? Haitians are not benefiting as fully as they should from this global aid. Despite billions of dollars earmarked for Haiti, nearly 100,000 people still live under plastic tarps in displacement camps. Poverty has worsened all around the capital: more beggars on the streets, an increase in teen pregnancy, and more people turning to sex work. A cholera epidemic has wrought further devastation, killing thousands; the CDC and others have suggested the strong possibility that cholera was brought to Haiti by United Nations peacekeepers, the very force tasked with stabilizing the country. In truth, a great deal of the “redevelopment” has gone to help the rich and powerful, not the impoverished and displaced people who need it the most.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The Haitian government is using its scarce resources to invest furiously in tourism, the mining of gold and other natural resources, massive industrial construction projects and the exportation of our agricultural products. There are reasonable arguments for each of these strategies—after all, stimulating Haiti’s economy could increase the quality of life for people at all economic levels. But it takes little digging into recent investments to find stories of criminal abuses of power that have provoked outrage from Haitian citizens, whose land is being taken to make room for these projects without their consent. Haiti’s building boom often appears to serve the purposes of Haiti’s elite and of outsiders, who stand to benefit from the land, resources and untapped potential of our country. Take, for example, Île-à-Vache, a tiny, pristine island off Haiti’s southern coast that remains unknown to most of the world. The island holds Haiti’s sole remaining untouched forest, a green oasis in a country where all but 1.5 percent of the land has been stripped bare by logging. Île-à-Vache is home to tens of thousands of villagers who have lived there sustainably and peacefully for generations. All that changed in 2013, when the government declared the island a public utility and launched plans to build an international airport, 1,500 hotel rooms, a golf course and night clubs—a plan completely out of scale in a place formerly without cars, technology or government infrastructure.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico The government promotes the project as a shining example of land, community and development existing in harmony, with equitable distribution of benefits for all. But villagers tell a very different story. The government forged ahead without assessing how the project will affect the land and its people. The islanders have not been compensated for their land and will likely be forced to migrate to the cities in search of jobs. And contractors have brazenly razed a virgin old-growth forest, dredged the untouched Madame Bernard Bay and cut down fruit trees that families depended on for their livelihoods.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico When the community protested peacefully, requested information about the plans and asked to be included in decision-making about the project, the government sent heavily armed law enforcement teams to the island to suppress dissent. Local police officer and community leader Jean Mathelnus Lamy was arrested after organizing peaceful protests. Elsewhere in Haiti, citizens are concerned that officials will not be able to properly regulate the burgeoning mining industry, which has the potential to displace farmers from their land and negatively affect the environment; already, mining contracts have been awarded to foreign companies without public or parliamentary scrutiny. Meanwhile, the government is building industrial parks, including one for a South Korean clothing manufacturer on a tract of fertile farmland, instead of housing for earthquake survivors, even as the displacement camps that house them are closing. With no long-term plan to house them elsewhere, many of these displaced people may find themselves homeless again soon.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Fortunately, there are Haitian activists seeking to redress these wrongs. As a consultant to American Jewish World Service (AJWS), I work with 29 Haitian grassroots organizations that are using AJWS’s support to advocate for accountability in how relief funds are spent. These groups are working to rebuild Haiti for the benefit of all of its people, including those living in poverty and other groups that have been traditionally excluded, including rural communities, women and LGBT people. One such organization, Collective for Île-à-Vache (Konbit Peyizan Île-à-Vache, or KOPI), is behind the peaceful protest movement on the island. It is demanding that construction stop and that the government consult the community and conduct an environmental assessment (which is required by Haitian law) before the project resumes. If the government continues to threaten this community and the land, KOPI plans to bring the case to international courts. The world’s attitude toward Haiti and my own government’s attitude toward its people must radically shift. The U.S. government has taken steps in the right direction with last summer’s passage of the Assessing Progress in Haiti Act, which insists that the State Department be more transparent and accountable in the use of reconstruction funds. If Haiti fails to ensure that development benefits its people—something the government might be likelier to do with international oversight that the act promises to provide—then the earthquake will have meant not only a natural disaster, but also a radical redistribution of assets from the poor and vulnerable to the rich and powerful.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico

Aid slow to reach towns in Haiti that were slammed by hurricane

People throughout Haiti’s devastated southwest peninsula formed makeshift brigades Tuesday to clear debris and try to get back to their pre-hurricane lives as anger grew over the delay in aid for remote communities more than a week after the Category 4 storm hit. A community group that formed in the seaside community of Les Anglais began clearing tree limbs from streets and placing them into piles while others gathered scraps of wood to start rebuilding homes destroyed by Hurricane Matthew. Carpenter James Nassau donned a white construction helmet as he rebuilt a neighbor’s wall with recycled wood, hoping to earn a little money to take care of 10 children, including those left behind by his brother, who died in the storm, which hit October 4. “My brother left five kids, and now I’ve got to take care of them,” he said. “Nobody has come to help.” The scene repeated itself across small seaside and mountain villages dotting the peninsula, where people pointed out helicopters buzzing overhead and questioned why they haven’t received any help. Israel Banissa, a carpenter who lives near the small mountain town of Moron, said a Red Cross assessment team stopped outside his village to ask people questions but didn’t leave any supplies. “There’s no aid that’s come here,” he said as he sawed wood to help rebuild his home and dozens of others. “I don’t think they care about the people up here.” Health workers in the area are dealing with not only with injuries from the storm but also the threat of a spike in the number of cholera (pronounced COLL-er-uh) cases. “People will die soon if we don’t get some aid,” health worker Darline Derosier told the Associated Press on Monday. Derosier was the only one helping about 40 patients inside a police station that was turned into a medical clinic. Some of the patients had cholera, a deadly disease that infects people who drink contaminated water. Cholera has killed roughly 10,000 people in Haiti since 2010 and sickened more than 800,000. Dominique Legros, a top cholera official at the World Health Organization, said Tuesday that the agency had decided to send 1 million doses of cholera vaccine to Haiti “as soon as possible” and said safe drinking water and treatment of those affected by the disease are top priorities. The National Civil Protection headquarters in Haiti’s capital, Port-au-Prince, raised the official nationwide death toll to 473, which included at least 244 deaths in Grand-Anse. But local officials have said the toll in the region tops 500. In addition to disease, storm survivors faced a lack of food. Elancie Moise, director for the Department of Agriculture in southern Haiti, said between 80 to 100 percent of crops have been lost across the southern peninsula. “Crisis is not the word to describe it,” he said. “You need a stronger word. It is much worse. There is no food for people to eat.” The United Nations humanitarian agency in Geneva, Switzerland, has made an emergency appeal for nearly $120 million in aid, saying about 750,000 people in southwest Haiti alone will need “lifesaving assistance and protection” in the next three months. U.N. officials said earlier that 2.1 million Haitians have been affected by the hurricane.

Ethiopia’s candidate for the World Health Organization doesn’t like mentioning a certain disease

The WHO’s handling of the outbreak, which went on to kill more than 11,000 people, has been seen as a sign of the desperate need to reform this global organization, which is responsible for marshaling the global response to epidemics. On May 22, member state will choose among three candidates — all of whom have pledged deep changes to the organization — vying for the post of WHO director general. One of the candidates, however, has been accused of the same kind of emergency-related minimization of crises that marred the WHO’s response to the Ebola outbreak. Tedros Adhanom Ghebreyesus, 52, Ethiopia’s health minister from 2005 to 2012 and foreign minister until 2016, is a strong candidate for the post, backed by the African Union as well as countries in the Pacific and the Caribbean. He has an impressive track record in Ethiopia. The country also covered up cholera outbreaks under his watch. The candidate, who goes by his first name and campaigns as Dr. Tedros, presided over a dramatic expansion of Ethiopia’s health system and reductions in infant and maternal mortality as well as deaths from malaria. He also extended the reach of the health system deep into remote rural areas. In the past 10 years, Ethiopia is also the only country in the Horn of Africa that has not been touched by cholera — according to the government. Critics disagree.  The likely rationale for not calling the disease cholera is the same one that delayed the labeling of the Ebola outbreak an emergency in 2014 — it would make Ethiopia look bad, hurt tourism and could result in some countries banning food exports from Ethiopia. It is not clear whether Tedros had any input in the government’s decision to stop using the term “cholera,” but the change occurred during his tenure as health minister. Since then, there have been several AWD outbreaks, including in Addis Ababa in 2016 and in the drought-hit Somali region, where more than 16,000 have been diagnosed since January and 3,500 new cases are being declared every month. None have been identified as cholera. Yet under the rules of the WHO, countries are supposed to report outbreaks of such diseases.   But international aid organizations have privately expressed frustration at Ethiopia's refusal to call the disease cholera; such a move would trigger an international response. Human Rights Watch says local health workers are under pressure not to refer to the disease as cholera. “We have interviewed a number of health professionals who have been pressured by government officials not to refer to cholera outbreaks as such, instead referring to outbreaks as ‘diarrhea’ or AWD,” said Felix Horne, the organization's researcher for Ethiopia. “This is emblematic of the control that government exerts over some of its health professionals — there is little space to question health policies or to challenge the government’s success narratives.” So while neighboring Somalia, South Sudan and Kenya have cholera outbreaks, Ethiopia just has diarrhea outbreaks. The Ethiopian Medical Association has endorsed Tedros’s candidacy, saying Wednesday that he would bring a fresh perspective to the WHO. “One that is rooted in the reality of what it takes to design and implement change in a country that is resource-constrained with a high disease burden,” said the association's president, Gemechis Mamo. He would not comment on the cholera-denial accusations. “We have been informed that it was acute watery diarrhea,” he said.  The opposition, though, is increasingly mixed up in the bitter ethnic politics of Ethiopia. Tedros, like many influential people in government and business, is from the northern Tigray region, home of the rebel group that overthrew the socialist regime in 1991.  In interviews, Tedros says he has the practical and managerial experience to deal with global health challenges.  At the same time, it is an open question whether he would be able to heed the desires and demands of the WHO’s many members, some of which, like the Ethiopian government, might want to play down the effect or presence of some of these diseases.

U.S. envoy arrives in Central African Republic in bid to untangle humanitarian crisis

BANGUI, Central African Republic — Fear consumes them: Fear of the machete. Fear of the sudden, senseless attack. Fear for their lives. And so they come each day by the thousands, seeking safety in massive numbers. They cram into a squalid camp just outside the gates of the airport here in the capital of the Central African Republic, a nation shattered by months of violent religious and political conflict. A fetid open trench serves as a latrine for more than 20,000 people clustered in an expanding sea of makeshift tents fashioned from broken tree limbs and flimsy plastic sheets. Such was the grim scene that greeted Samantha Power, the U.S. ambassador to the United Nations, on Thursday as she landed here for a high-profile diplomatic mission aimed at untangling what has become an increasingly complex humanitarian crisis. Power, winner of a Pulitzer Prize for a book critical of the U.S. response to humanitarian crises, announced that U.S. military liaisons will soon be dispatched to help train the African Union soldiers who have joined French troops in a peacekeeping effort. She also said the United States will contribute $15 million in humanitarian aid, in addition to up to $100 million already pledged, to stem the crisis. The assistance is being offered even though the United States does not have significant financial or national security interests in the Central African Republic. Power’s trip served to raise international awareness of tit-for-tat atrocities committed against civilians by warring Muslim and Christian militias. In a series of high-level meetings and phone calls, she also sought to pressure the nation’s wobbly transitional government to take steps toward reconciliation, disarmament and scheduling elections no later than February 2015. Human-rights groups have estimated that at least 500 people have been killed in a spasm of retribution killings carried out by rival Muslim and Christian militias. During her visit Thursday, Power heard from a Muslim woman who said militiamen hacked her husband with machetes, doused him with gasoline and set him on fire in front of her. Power also heard from Christians victimized by Muslim militias. U.S. officials estimate that more than 400,000 people — nearly one-tenth of the country’s population — have been displaced. While Power met privately with transitional government officials at the airport, hundreds lined up to receive medical treatment nearby. Donaldo Bandasa, 42, a porter, showed doctors the machete wounds carved into his scalp and shin. For all his injuries, he was one of the lucky ones. Bandasa says he saw thugs from the predominantly Muslim militia known as Seleka slash the throats of his mother, father and son after wrongly accusing them of sympathizing with the previous non-Muslim government. “I can’t go home because my house has been burned and looted,” he said. Two U.S. military C-17 aircraft are transporting troops from Burundi into the Central African Republic to bolster an African Union force that is planned to grow to 6,000. Cheers went up from the encampment just beyond the runway as one of the giant planes disgorged a load of crisply dressed Burundian soldiers. “Somalia taught us what can happen in a failed state, and Rwanda showed us what could occur in a deeply divided one,” Power said. “The people of the Central African Republic are in profound danger and we all have a responsibility to help them move away from the abyss.” Power said that “urgent action is required to save lives.” The conflict stems from the March coup d’etat that ousted longtime Central African Republic leader Gen. François Bozizé, whose regime was plagued by allegations of corruption. The patchwork of mostly Muslim militias known as Seleka, or “alliance,” toppled the government of this predominantly Christian nation, spurred in part by claims that Bozizé’s government had not done enough for the northern Muslims. Seleka, which includes mercenaries from nearby nations such as Chad, installed Michel Djotodia as transitional president. In response to the attacks, Christian militias known as Anti-Balaka, meaning “anti-machete,” have formed and are targeting Muslim communities in retribution. Their name is a reference to Seleka’s weapon of choice: the machete. Power on Thursday met with humanitarian and religious leaders who said the conflict has been especially disconcerting because the Central African Republic had previously been known as a place of religious harmony. Djotodia’s actions have drawn disapproval from the United Nations and from U.S. officials. He has tried to oust three high-ranking ministers, a move that U.S. officials say is a violation of the transitional government charter. He has also stunned international observers by awarding military and police jobs to 5,000 Seleka militia members, some of whom may have been involved in atrocities. Djotodia claims to have control of the nation, but U.S. officials are dubious that his authority reaches beyond Bangui. Late Thursday, Power said that Djotodia, the nation’s prime minister and other top transitional government officials privately reaffirmed their commitments to step down after the 2015 elections. “We, the international community, are going to hold them to it,” Power said. She also urged officials here to employ national and international commissions of inquiry to hold accountable those responsible for atrocities. Outside the capital, tens of thousands of Christians and Muslims have fled to crowded shelters in the interior city of Bossangoa, Doctors Without Borders’ Ellen van der Velden said in a telephone interview from that city this week. A half-mile stretch of the city has been all but abandoned as nearly 40,000 Christians have sought shelter at a Roman Catholic church on one side of the city while thousands of Muslims have retreated to a neighborhood on the opposite side. Thousands more are believed to be hiding in the malaria-infested bush. Doctors Without Borders has issued a scathing open letter criticizing the U.N. response to the crisis, saying it has done little more than collect data and hold coordination meetings. “It’s clear that the international response falls short of the needs,” van der Velden said. “We had expected more than we have seen so far.” U.S. officials have rejected that criticism, saying a collaborative response is underway. In background briefings, U.S. officials have said the United States and the international community have a “moral interest” in intervening to stop the violence. The Central African Republic is a former French colony. The French government has taken the lead on the ground, dispatching more than 1,000 of its soldiers to the nation for peacekeeping operations. Two have been killed. “The potential for further mass violence is shockingly high,” said Peter Bouckaert of Human Rights Watch, which is calling on the United Nations to dispatch its own peacekeeping operation to the country. U.S. officials have defended the current approach using African Union and French troops, saying it is quicker and less expensive than mounting a full-scale U.N. peacekeeping operation. At the Doctors Without Borders field hospital near the airport in Bangui, the sounds of crying infants filled the air Thursday. The day before, two infants died at the camp. But eight were born, entering a world where the futures of their families and their country are far from certain.

Zika is the latest battle in a long war between humans and mosquitoes

Ever since a U.S. Army physician named Walter Reed helped prove more than a century ago that yellow fever was transmitted by mosquitoes, humans have waged a fitful war on the tiny disease carriers. They have drained swamps and cesspools from Argentina to Alabama, waged door-to-door campaigns to hunt down breeding sites across entire cities, dumped an ocean’s worth of pesticides on multiple continents. Without such efforts, the Panama Canal might never been finished in the early 1900s. Deadly outbreaks might have continued to ravage places as far north as Philadelphia. But always, through a mixture of resiliency and adaptability, the mosquito roared back. People grew complacent. Political willpower faltered. Eradication budgets shrank. Chemicals lost their killing potency as the enemy developed resistance. Now comes Zika, and yet another showdown. The mosquito-borne virus, which has raced through the Americas in recent months, is suspected of causing a range of serious, even devastating birth defects. Countries are once again calling for massive spraying efforts, renewed public education and collective vigilance from citizens. Some are considering new tactics such as genetically engineered mosquitoes that produce offspring that cannot survive to adulthood; the World Health Organization wants such unproven weapons evaluated with “particular urgency” and “extreme rigor.” Everyone would do well to remember the lessons of the past. For all the justifiable concern about Zika, the harm it is causing is nothing like the scourge people throughout the Americas once faced from yellow fever and malaria. Yellow fever decimated New Orleans in 1853 and parts of the Mississippi Valley in 1878. In the 1880s, thousands perished from both diseases during France’s failed attempt to dig the Panama Canal. A Cuban scientist, Carlos J. Finlay, was the first to theorize that the mosquito might be the vector for such outbreaks — not foul odors, stale beer, swamp gases or any of the other popular myths of the time. He published his findings in 1881, but it wasn’t until the American occupation of Cuba after the Spanish-American War that he was proved right. In June 1900, the U.S. Army sent Maj. Walter Reed to Havana to study Finlay’s findings about the spread of yellow fever. The selection was smart; the Virginian, a medical researcher as well as a physician, had previously investigated outbreaks of typhoid fever in military camps. On a patch of land outside Havana, Reed designed two wood-framed, 14-by-20-foot buildings in which to conduct his experiments. Volunteers were offered $100, according to Stan Cope, president of the American Mosquito Control Association. The buildings were known as the Fomite House and the Mosquito House. The first was fetid, filthy and unventilated. The men there slept with linens and blankets soiled with urine, black vomit and feces of recent yellow-fever victims — an environment that made some retch. But the house had no mosquitoes inside, and no one came down with yellow fever. By contrast, the Mosquito House was clean and well ventilated. Its linens and furnishings were sanitized. Inside, a partition divided the space into two sections. On one side, researchers released infected mosquitoes, which fed on the volunteers. Many soon became ill, while those who slept on the mosquito-free side were fine. “The experiments were incredibly simple, but they were absolutely bulletproof,” Cope said. The outcome proved Reed — and Finlay — correct. Poor sanitation was irrelevant; mosquitoes were the vector for the disease. As Reed later wrote his wife, the test helped lift “the impenetrable veil that has surrounded the causation of this most dreadful pest of humanity and to put it on a rational & scientific basis.” Soon, the Army was coating canals and waterways with a sheen of oil — a rudimentary larvicide — and attacking pools of stagnant water as part of public health and sanitation campaigns in countries where troops were stationed. In 1912, New Jersey Gov. Woodrow Wilson (D) set up the United States’ first mosquito-control district after opponents accused him of being “weak on mosquitoes,” according to Gordon Patterson, a historian at the Florida Institute of Technology who has authored two books on the origins of U.S. mosquito control. Fighting the bloodsuckers soon became a primary government responsibility. Mosquito control grew even more essential during the Great Depression, as the Tennessee Valley Authority and other agencies built dams, canals and reservoirs. Engineers learned to manipulate water levels to eliminate mosquito larvae, Patterson said. But by the late 1940s, manual mosquito-eradication methods were losing out to crop dusters and fumigation trucks loaded with the insecticide DDT. And by the time Rachel Carson’s groundbreaking 1962 environmental-science book “Silent Spring” alerted the public to the pesticide’s dangers to birds and other wildlife, many mosquitoes had developed a resistance. For the past half-century, public-health officials have emphasized “integrated pest management” that involves more sparing use of insecticides and focuses on other solutions, such as window screens, mosquito repellent and the elimination of breeding pools. Today, Patterson worries, increased travel, global commerce and possibly a warming planet all seem to be helping the mosquito to flourish again. Latin America has been hit especially hard by Zika, not to mention other viral pathogens such as dengue fever and chikungunya, in part because the _Aedes aegypti_ mosquito is almost uniquely adapted to human co-habitation. It breeds in minute amounts of water, hides in the shadows and dark corners of homes, and is a famously promiscuous biter, landing on as many people as possible for quick snacks. A much-heralded international effort in the 1940s and 1950s eliminated _Aedes aegypti_ from 18 countries in the region, until that success reversed because of fading political will and rapid urbanization, among other issues. The crowded, poverty-stricken sections of Central and South American cities, where uncollected trash, discarded containers and old tires are abundant, have proved a perfect setting for the disease’s spread. Many families without plumbing systems store water in tanks that are ideal spots for mosquitoes to lay their eggs. Homes also typically lack air conditioners and window screens — two factors that could limit the transmission of Zika in the United States. Yet the _Aedes aegypti_ mosquito has found ideal environments here, primarily along the Gulf Coast. Another mosquito, _Aedes albopictus_ , which is viewed as a separate possible vector for Zika, has a much wider range across the United States. Entomologist Janet McAllister of the Centers for Disease Control and Prevention is concerned by how much communities have let down their guard. “There is even [an environmental] movement here in the United States to start storing water again in rain barrels,” she said. “So we’re actually in some ways moving backwards in public health in terms of preventing mosquito breeding.” As warm weather returns, the primary vector for Zika’s spread will begin to breed again in the Southeast. States and localities, potentially facing the most troubling mosquito-borne disease outbreak in decades, are gearing up for the fight with a mix of old and new tools. President Obama is seeking $1.9 billion from Congress for the effort, including money for spraying, spreading larvicide and ramping up mosquito abatement. Relatively few Americans may realize how central such work once was to the nation’s identity. Because these insects carried disease, their extermination became an essential government service, another chapter in the long campaign to tame the wilderness. But the war wasn’t over and may never be, as the Zika virus is making clear. “We thought we had taken care of the _Aedes_ mosquito,” McAllister said. “Now, the problem has come back to haunt us.”

Don’t let disease spread

Ron Klain’s June 7 Sunday Opinion commentary, “Preventing the next pandemic,” correctly pointed to the urgent need for a better world response to outbreaks. The first line of defense should be strengthening the health-care systems in vulnerable countries so each has capacity to deal with infectious disease threats. There were only 117 doctors in Liberia in 2014, one for about every 33,000 people. The resilience gained from assets such as doctors and nurses trained in infection control, well-stocked clinics within walking distance of villagers and the ability to conduct disease surveillance would help countries contain potential epidemics themselves instead of collapsing under the strain. Guinea, Liberia and Sierra Leone released itemized recovery plans to revive and improve their health-care systems, but these plans need to be funded. Our next major opportunity to address the Ebola aftermath and show we’ve learned from the mayhem of the initial response lies with the International Ebola Recovery Conference on July 10. Let’s ensure we put our investments in the right places, with country health sectors at the top of the list. ****Marie Paule Kieny,** Geneva** The writer is assistant director general for health systems and innovation for the World Health Organization.

‘It is misery’: A video of Haiti’s camps after Sandy

Almost three years after an earthquake devastated Haiti, 370,000 people are still living in the tent camps that became their homes. Now, some have lost even that. Haitian officials say that 18,000 families living in tent camps have been rendered homeless by Hurricane Sandy, which has killed 52 there since making landfall last week. The number of casualties may continue rising, as aid workers have found 86 new cases of cholera just in the earthquake survivor camps of capital city Port-au-Prince. A cholera outbreak that began after the quake has killed an estimated 7,400 since October 2010. In the video above, desperate camp survivors describe life after Sandy. "No one has brought anything to help us," one man says. "It is though no one knows we exist." "We are hungry, things for me are bad, our tarp is torn," a woman tells the camera. "It's misery." A young woman says she no longer has a place to sleep as her bed has been soaked. Because no one appears to have built drainage into the camp, the tents are filled with standing water. "I couldn't sleep last night and I really wept," she says, describing a night of attempting to bail water out of her tent. "After Tropical Storm Isaac in August, these stocks have not been replenished," an aid worker warned Reuters when asked about diminishing food and water supplies. "What we're doing is scraping the bottom."

The damage America has done in Haiti

The Oct. 17 editorial “The Herculean task facing Haiti” asserted that “Americans have stepped up generously in the past to help Haiti.” While it is certainly true that the United States has provided invaluable aid to Haiti since the 2010 earthquake, one cannot understand Haiti’s present chaotic conditions without looking at its recent history. François “Papa Doc” Duvalier came to power in Haiti in 1957 and died in 1971, leaving his son to rule for 15 years. Their rule resulted in the murder of 30,000 to 60,000 Haitians, the exile of many more and a wrecked economy. The United States backed the Duvaliers for fear Haiti might become a communist country. The civil liberties — and the lives — of Haitians were traded for the United States’ need for hegemony in our hemisphere. Haitian presidential elections lacking a framework of justice and security may not be meaningful and, worse, may lead to further radicalization of the population, which is even poorer than it was after the earthquake. In addition to distributing water, food and essential relief equipment, the U.S. agenda should include active participation in reforming the judicial and law enforcement systems because we share responsibility for their destruction. ****J.P. Villedrouin** , Sterling** The writer, a native Haitian, is president of Heros-4Jal, a Haiti-focused nonprofit social justice group.

In Haiti, at least 470 dead and hundreds of thousands left with no relief in sight

LES CAYES, Haiti — A woman who gave birth two days before Hurricane Matthew, only to learn her husband was swept away in the flood, has spent the past week raising her newborn son on a wooden bench facing the chalkboard inside of an elementary school classroom. Down the hallway is a fourth-grader who attended this school but is now sleeping on its concrete floors crammed alongside more than 1,000 people whose homes were damaged or destroyed by Hurricane Matthew. During the day, the storm refugees pass a plastic cup to raise money for chlorine to keep cholera at bay. At night, bandits have descended on the school, where no police or local security stand guard, thrown rocks through the windows and ripped away the meager supplies of food. “They said they’re going to come back and rape the women,” said Bosman Cindy, a 10th-grader who has collected rainwater off the roof for survival and doesn’t know whether her father is alive. These newly homeless people living this precarious existence in the Liliane Mars Dumarsais Estime school are among the hundreds of thousands across Haiti’s southwestern peninsula now grappling with upended livelihoods and no relief in sight. The Haitian government’s response has been slow to arrive in Les Cayes, the biggest city on the southwestern coast, or in the devastated villages all around it. The mayor’s office has dispatched some food trucks, and candidates for the presidential election, scheduled for Sunday but postponed by the storm, have made personal donations. Western aid groups have given medical supplies to hospitals and clinics and have begun an assessment of needs in areas still marooned from the rest of the country by washed-out bridges and downed trees. While larger shipments of food and medicine by land and sea are on the way, aid workers estimate that a half-million people along the southern coast have still not been reached by outsiders. Dozens of places, many of them schools, are being used to house some 64,000 people in makeshift shelters, according to one person briefed by government and United Nations relief coordinators. Cholera cases have spiked, including in towns that are still cut off, said Sean Casey, an emergency response team leader for the International Medical Corps who is working out of Les Cayes. “A few people have walked out saying there are a lot of cases and people are dying,” he said. “We’re really concerned about cholera.” At least 470 people have died in one district of Haiti’s southwest region, a civil defense official told the Associated Press on Saturday. But an informal tally by Reuters from unidentified local officials put the death toll at more than 800 people, although reliable statistics are scarce because of poor communications and isolated terrain. Many people, including in the government, acknowledge that the needs far outstrip the available supplies. “The whole town is destroyed,” said Emmanuel Pierre, an aide to the mayor of Les Cayes. “Sixty to 70 percent of the roofs are gone. The population wasn’t prepared for this.” The people taking refuge at Dumarsais Estime are sleeping more than 100 per classroom, cooking over charcoal whatever food is donated or scavenged, hanging their clothes to dry on a fallen tree in the flooded courtyard. All of those interviewed said their homes were destroyed or severely damaged by hurricane winds and flooding. “It’s very critical now,” said Jean Alexi, 23, who has slept at the school since Monday night. “The kids are not being taken care of and could easily get diseases.” Those children, scampering around barefoot in the mud puddles, some naked, have been sleeping alongside the men, pregnant women, the elderly, crammed together for the past five nights, as many as 125 people per room. Residents of Les Cayes and surrounding areas came to the school the night of the storm, wading through floodwaters. Alexi formed a human chain with his neighbors to cross a bridge they feared would collapse in the driving winds. After a week at the school, he has become one of the classroom leaders — each of the 10 rooms now has a person in charge — a loose self-government for an ever more chaotic environment. Alexi is a high school graduate who hopes to attend university. Others living at the school work as farmers, drivers, street hustlers. Many of their homes were tin-roof shanties in a slum along the river. Few of their belongings, they said, survived the flood. Food is scarce at the school. Only one truckload of rice and oil had arrived so far, people said. On Friday afternoon, another food truck pulled into the school’s courtyard, followed by a crowd that had been chasing it down the street. People poured out of the classrooms, pleading for help. The truck doors opened and the only thing inside were bananas. Bananas that had traveled hundreds of miles across Haiti, courtesy of the “Banana Man,” Jovenel Moise, a banana magnate and a leading candidate, from the same party as the mayor, in the event that there is a presidential election. “My house fell to the ground, and a banana is not going to do anything for me,” said Jeannot Nilver, 25, who watched the crowd swarm the truck. “We need medicine. We need soap. We need beds. We need real food.” But the next day, Liciana Souverain, 39, kneeled barefoot behind a classroom, slicing the green bananas with a rusty blade that had no handle, preparing to cook them over a charcoal fire, because that was the only thing to eat. Ginette Jean-Claude, 30, gave birth on Saturday to a son, Yonelson. On Monday night, her neighbors carried them both out of her flooded house to the school. Her husband, Yonel Exama, did not survive the storm, she said. After nearly a week in a dirty classroom at the back of the school, the infant had developed a rash on his face. “And his stomach is aching, he cries a lot,” Jean-Claude said as she breast-fed her son. Her neighbors have given her baby powder and blankets to drape over the wooden bench where she has been sleeping. Jean-Claude herself hasn’t had much to eat, and her strength is flagging. “I have no place to go to,” she said. Outside of a municipal warehouse on Friday, dozens of people pleaded for food while staff loaded up trucks with bags of rice, spaghetti and cooking oil for delivery elsewhere. The municipality had enough food for 200 families; the next day, they hoped to feed 200 more. “We will have a lack of food in the near future,” said Moise, the presidential candidate, who landed at the Les Cayes airport on Friday afternoon after a tour of the southwestern coast. “Food, water, sheet metal, nails and wood,” he said, listing off what he considered the most urgent needs, in an interview with The Post. As he spoke, a crowd had massed at the airport’s chain-link fence. People clamored for the candidate’s attention, begging for food. “I’m here to send some food by helicopters,” he said, before walking into the crowd on the street. “But I’m obliged to give food to them because they’re hungry.”

Let’s help the Philippines — but not like we helped Haiti

_Vijaya Ramachandran is a senior fellow at theCenter for Global Development. Owen Barder is a senior fellow and the director of the Center for Global Development in Europe. This essay is adapted from a post they wrote on the center’s blog._ The immediate aftermath of a natural disaster, such as the typhoon that devastated part of the Philippines on Nov. 8, can bring out the best in the global community. Already we are seeing the world’s governments and citizens responding generously to appeals for aid, reaffirming our shared humanity. The challenge is to ensure that this generosity reaches the people who desperately need it. Relief and reconstruction efforts in the Philippines have much to learn from previous mega-disasters, including, most recently, the massive earthquake in Haiti in 2010. We should help the Philippines — just not like we helped Haiti. We can, and must, help better. Lack of generosity is typically not the problem. Since Haiti’s quake, almost $6 billion in official aid has been disbursed in a country with a population of just under 10 million. Large nongovernmental organizations and private contractors, mostly in the United States or Europe, have been the initial recipients of most of these funds. But there are few publicly available records of what they have done with the money, and almost four years after the quake there is little to show on the ground: Even the Haitian capital still lacks decent roads, running water and reliable electricity, and an estimated 200,000 to 400,000 Haitians still live in tents. Pierre Erold Etienne, director general of the Haitian Finance Ministry, put it clearly: “We are required to be transparent. We publish the financial information relevant to the execution of our budget. All we ask is for the same transparency from our donor friends, which should help both us and them.” Problems arising from a lack of donor transparency are not unique to Haiti. About five years earlier, after a tsunami devastated coastal communities from Indonesia to India, well-meaning but disjointed aid efforts led to bottlenecks, gaps and duplication. The Red Cross reported that there were too many doctors but not enough midwives in Indonesia’s Banda Aceh province. Children became ill with the symptoms of measles after being vaccinated three times by three organizations, because the NGOs did not share records of which immunizations children had received. In India’s Tamil Nadu state, victims complained that they had all the cooking pots they could ever want, but needed shelter. The international community can and must do better in the Philippines, and there is reason to be hopeful. The first crowdsourced map of the path of Typhoon Haiyan, compiled by volunteers around the world using publicly available data, was online less than 72 hours  after the storm. In the days ahead, this open-source map can be used to track where people need help and what kind of help they need. But unless things change, some key data will be missing: official information from governments and private charities about their planned and actual responses. Coordinating response plans can be very time-consuming, so it is understandable that it often takes second place to the urgency of getting help to people who need it. Transparency, on the other hand, does not require centralized coordination and would enable everyone to make smarter decisions, informed by the knowledge of what others are doing. Yet organizations that find the time to issue news releases and organize photo-ops do not seem to be able to spare the resources to post information about what exactly they are doing and where. This could change fast, using platforms already in place. The Financial Tracking Service (FTS) of the U.N. Office for the Coordination of Humanitarian Affairs is specifically designed for this role. The European Union has a compatible system, the European Disaster Response Information System, through which donors can exchange information with the FTS and one another. Both systems will soon be able to share data with the global standard for aid transparency — the International Aid Transparency Initiative. For humanitarian aid, the U.N. and E.U. systems are fully operational; the challenge is persuading leaders of relief and aid agencies to commit to using them. The response to Typhoon Haiyan can and should be the first major relief effort in which all humanitarian organizations and aid agencies publish the details of their planned and actual spending and activities online, in real time, using a common format. This simple step would enable donors and the Philippine government to identify where activities overlap and where gaps remain, and would allow everyone who contributes to see where the money is going. The United States, which has announced $20 million in typhoon relief, with more likely to follow, should be a leader in this effort. The U.S. Agency for International Development is already required to report publicly on the activities of its primary contractors. But the actual work is usually done by subcontractors, and USAID does not collect or publish information about what they do. This is not hard to fix: USAID Administrator Raj Shah should announce that, starting with the Philippine relief and reconstruction effort, the agency will require all primary contractors to publicly disclose project-level data on their subcontractors’ activities in a timely fashion. This would not only help avoid overlaps and gaps in aid in the short term but would also make it possible to learn lessons about what worked — so we can do better in future disasters. American taxpayers should settle for nothing less. Of course, national and global aid agencies are not the only purveyors of assistance; the far-flung Philippine diaspora will undoubtedly help the victims of Haiyan. Research by Dean Yang at the University of Michigan has shown that in previous disasters in the Philippines, increased remittances from Filipinos working abroad helped to make up for as much as 60 percent of economic losses. This is very good insurance; other developing countries thinking about disaster preparedness may want to consider following the Philippines’ example and actively support citizens’ efforts to temporarily work abroad. One area where the Philippines has done less well is in the provision of secure identification, such as biometric IDs that are viable even if physical identification cards and supporting paperwork have been destroyed. Biometric ID, which uses new low-cost technology for iris scans, fingerprints and other unique traits, makes it possible to provide large numbers of poor people with proof of their identity. Research by our colleague Alan Gelb has shown that effective identification empowers the poor. It is crucial for the fair distribution of relief assistance, for government cash transfers and for the secure delivery of remittances. A good example of ID success comes from an unexpected place: Pakistan. In July 2010, floods covered a fifth of the country and millions of families lost their homes, with housing damage alone estimated at $1.5 billion. Many people sought refuge in temporary camps and urgently needed assistance to rebuild their homes and farms. Pakistan was able to take advantage of a national biometric-identification database to identify displaced people and provide them with cards that could be used at banks and other points of service to receive cash payments to help them rebuild. The first phase provided about $250 to each head of a flood-affected household, and a second phase brought the total to $1,250. The later phase is still being evaluated, but assessments of the first phase show that the payment mechanism succeeded; money reached the intended beneficiaries rather than being diverted. Recipients were easily able to withdraw their benefits, and most incurred only small travel costs to reach a location where they could get their cash. Despite some difficulties with the process — for example, not all people had kept their information up to date in the national database — most wished to receive further transfers through the cards, and some also wanted to turn their relief card accounts into permanent bank accounts. About 85 percent of the initial grant was used for food, medicine, health care, clothing, shoes, reconstruction, tools and other investment goods. Beyond the flood response, Pakistan’s ID is now being used more widely to underpin the provision of social grants, such as programs for poor women. The survivors of Haiyan have a lot to worry about in the days and months ahead, and the world is ready and willing to help. To make that aid effective, and to ensure that it reaches the people who need it, donors, starting with the United States, should commit to full and rapid transparency. Donors should also offer to support the Philippines in rolling out biometric ID, should the country want it. While it’s much better to put identification systems in place ahead of a disaster, India, which has implemented a massive program that has already identified half a billion people, has shown how quickly the technology can be rolled out. We must think ahead. Haiyan will not be the last typhoon to strike; nor is the Philippines the only vulnerable country. The international community must embrace the technology available to strengthen disaster preparedness, resilience and aid.

While Latin America struggles over Zika, Haiti faces epidemic with a shrug

MIREBALAIS, Haiti — When the Zika virus became a full-blown epidemic this year and global health officials began to anticipate its spread across the Americas, their worst fears settled on the place that looked most vulnerable: Haiti. The poorest nation in the region appeared to be primed for a Zika explosion, with woeful sanitation, urban overcrowding, a threadbare health system and plenty of mosquitoes. But nearly six months after the first Zika cases were confirmed in Haiti, the most dire predictions have not materialized. That is the good news. The bad news is that no one is really sure why. After the World Health Organization declared Zika a “global health emergency” in February, Haiti was tallying 300 infections a week. Now it’s down to about 30. “The peak seems to have reached Haiti already,” said Jean-Luc Poncelet, the top official for the Pan American Health Organization (PAHO) in Haiti. “But we don’t really know.” Haiti hasn’t registered a single case of Zika-related microcephaly, the congenital birth defect that results when the virus interferes with fetal brain development. The country has reported a dozen cases of Guillain-Barré syndrome, the sometimes fatal neurological disorder that Zika can trigger. Across the border in the Dominican Republic, a more prosperous country with a slightly larger population and a significantly better health-care system, authorities have reported 123 cases of Guillain-Barré — more than 10 times as many as in Haiti. While Zika is thought to be declining in South America, global health officials think the rate of new infection is increasing in the Caribbean. On Friday, the head of the U.S. Centers for Disease Control and Prevention, Tom Frieden, said the virus was spreading so fast in Puerto Rico that “dozens to hundreds of babies” could be born on the island with Zika-related birth defects in the coming year. Haiti’s comparatively low infection numbers do not indicate that it is becoming Zika-free, or even that the outbreak is declining here, experts warn. Rather, they say, Zika’s mysterious trajectory in Haiti may reflect some of the inherent challenges in identifying what happens when the virus fans out across countries with little ability to track it. Unlike infections such as Ebola, or cholera, or even other mosquito-borne viruses like chikungunya and dengue fever, Zika produces no symptoms in as many as 80 percent of the people who get it. Others typically experience a low-grade fever, skin rash and joint pain that go away after a few days. In a place like Haiti, that’s not enough for most people to seek medical attention. “Most Haitians who get a fever don’t go to the doctor. They drink tea,” said Joseph Donald Francois, the national coordinator for cholera and Zika at Haiti’s Public Health Ministry. “I had Zika,” he added, with a shrug. The virus was expected to take off in Haiti with the onset of summer, when afternoon thunderstorms make pools perfect for breeding mosquitoes in the uncollected garbage that fouls the capital and chokes its gutters. But aside from a few fliers posted in hospital waiting rooms warning of Zika, there are no signs of a major outbreak. Complicating matters, though, the decline in Haiti’s Zika numbers coincides with a three-month-old strike that has shuttered its public hospitals and left patients in more remote areas with practically no health-care services at all. “It’s hard to know if no information means the absence of disease, or if it means there’s just no information,” said Louise Ivers, an infectious disease specialist with the Boston-based nonprofit Partners in Health, which runs a teaching hospital, considered Haiti’s best, in this small city 30 miles north of Port-au-Prince. The hospital has had 10 pregnant women diagnosed with Zika so far, and all have given birth to normal babies. “Zika is here,” said Christophe Milien, an obstetrician-gynecologist in the maternity ward, which delivers about 300 babies a month. “We can’t say Zika isn’t a problem, because there are so many factors that stop women from coming to the hospital.” Expectant mothers who have other children to care for are not going to seek medical attention when they have a low-grade fever and a rash that will go away after a few days, he said. In more remote rural areas, the nearest highway can be several hours away on foot or donkey. No one has any idea what is happening with Zika in areas like that. Only about one-third of Haitian mothers deliver their babies in hospitals, according to government surveys. The rest deliver at home, and physicians here concede that babies born with birth defects such as microcephaly are sometimes abandoned in communities where deformities are viewed as the work of evil spirits. Abortion is illegal but not uncommon in Haiti, and doctors at the Mirebalais hospital say about 10 to 15 women seek medical attention each week after terminating a pregnancy, typically by taking drugs that induce labor and can lead to dangerous hemorrhaging. Because Zika poses the greatest risk to fetal brain development during the end of the first trimester and beginning of the second, it is possible that the country will begin seeing cases of microcephaly in the coming weeks. “The fact that we’re not seeing microcephaly suggests the Zika numbers are pretty low, but it just doesn’t make sense,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Texas. “I predicted Haiti would be hard-hit. So either Zika is being vastly underreported or it’s still in the process of emerging or it’s doing something very different compared to other patterns in the Americas.” Zika’s other telltale indicator is Guillain-Barré syndrome. The Partners in Health hospital has the only neurologist working in a country of 10 million people, Harvard professor Aaron Berkowitz, who right now splits his time between Boston and Mirebalais, where he is training a Haitian physician. Berkowitz said he and his Haitian colleagues first noticed something strange in January, when a man came in complaining of facial paralysis. Berkowitz diagnosed him with a rare form of Guillain-Barré syndrome. “A few days later, another man came in with the same symptoms,” said Berkowitz. The patient went to Boston for treatment, and his blood sample was sent to the CDC for testing, confirming he’d had Zika. In Brazil and Colombia, which together have reported more than 200,000 Zika infections so far, it’s possible to visit hospitals and find plenty of patients complaining of the virus’s symptoms. Not in Haiti. At one government hospital in Port-au-Prince that hasn’t been closed by the strike, doctors have not reported a single case of the virus, said medical director C. Henry Gateau. But it has had five cases of Guillain-Barré, one of which was fatal. “We did everything we could,” said Gateau. He added that he had never seen Guillain-Barré in his 15 years at the hospital. Without the sophisticated laboratory testing that can be done by the CDC, it is very difficult to confirm the presence of Zika, because the virus remains present in the blood for only about five days. But Poncelet, the PAHO director for Haiti, said it would be a mistake to invest in the kind of detailed epidemiological study that could give a more accurate sense of Zika’s spread in the country. “When you have such limited resources, you can do harm rather than solve problems if you only work on one disease, because it distorts the system,” said Poncelet. He noted that Haiti has 17,000 malaria infections a year and 34,000 cases of cholera.

The United States may be about to inflict a massive hardship on Haiti

POVERTY IN Haiti, by far the most destitute country in the Americas, is so extreme that it defies most Americans’ imaginations. Nearly 60 percent of Haitians live on less than $2.42 per day; a quarter of Haitians scratch out a living on half that amount. That the United States would intentionally inflict a sudden, massive and unsustainable hardship on such a country — one already reeling from a series of natural and man-made disasters — defies common sense, morality and American principles. Yet that is exactly what Homeland Security Secretary John F. Kelly is now considering. Incredibly, an agency under Mr. Kelly’s purview has recommended that some 50,000 Haitians now living legally in the United States be expelled en masse next January. If Mr. Kelly approves the expulsion, it would be a travesty. It would, at a stroke, compound the humanitarian suffering in a nation of 10.4 million already reeling from a huge earthquake in 2010, an ongoing cholera epidemic that is the world’s worst and a devastating hurricane that swept the island only last fall. The recommendation from U.S. Citizenship and Immigration Services, an agency within the Department of Homeland Security, involves Haitians who have lived in the United States since the 2010 earthquake and have been allowed to remain legally since then on humanitarian grounds, under a series of 18-month renewals. Now, the agency proposes to revoke the “temporary protected status,” or TPS, under which those Haitians live and work in the United States, a move that would trigger an exodus into a country ill-equipped to absorb them. It would also sever a major source of income on which several hundred thousand Haitians depend — namely, cash sent back to the island by their relatives working in the United States. In December, the same immigration agency now urging expulsion issued a report saying that the horrendous conditions that prompted the TPS designation in 2010 persist, including a housing shortage, the cholera epidemic, scanty medical care, food insecurity and economic wreckage. Haiti’s fundamental economic situation is unchanged since that report. The effects of Hurricane Matthew, a Category 4 storm when it hit Haiti last October, were particularly devastating, leading to catastrophic losses to agriculture, livestock, fishing and hospitals in rural areas, plus nearly 4,000 schools damaged or destroyed, according to the World Bank. The value of those losses is estimated at $1.9 billion, more than a fifth of Haiti’s gross domestic product; the storm left more than a million Haitians in need of humanitarian aid. In addition to Haitians, citizens of a dozen other war-torn, poverty-stricken and disaster-struck countries living in the United States have been granted temporary protective status, including El Salvador and Nicaragua, both of which are richer than Haiti. For the United States, the hemisphere’s richest country, to saddle Haiti, the poorest, with what would amount to a staggering new burden would be cruel and gratuitous. It may also be self-defeating. It’s hardly unthinkable that a sudden infusion of 50,000 jobless people could trigger instability in a nation with a long history of upheavals that often washed up on U.S. shores. Food for thought, Mr. Kelly. **Read more on this topic:** The Post’s View: A scandal of sexual abuse mars the U.N.’s exit from Haiti The Post’s View: The United Nations comes clean(ish) on cholera in Haiti Joel Dreyfuss: Only Haitians can save Haiti The Post’s View: The Herculean task facing Haiti

What worked in controlling the Ebola outbreak in West Africa

THE WORLD’S tardy response to the Ebola virus outbreak in West Africa, which has killed 8,810 people, demands that lessons be learned. Toward that end, a fresh batch of scientific reports has emerged in recent days to guide future responses. The World Health Organization, which stumbled in the initial period, seems to be recognizing its mistakes and looking for ways to correct them. Ebola spreads through bodily fluids, but transmission can be interrupted if those infected are identified and treated as soon as possible and contacts with others traced. In Conakry, the capital of Guinea, one of three West African nations affected, epidemiologists have reconstructed the chains of transmission of the virus. Their research, published in the Lancet Infectious Diseases journal, shows that after the first wave in the city, in the spring of 2014, the outbreak was somewhat well contained, but “an uncooperative family” still harbored the virus and unleashed a second epidemic wave. A third wave came from neighboring Sierra Leone. This demonstrates that it is vital to keep medical interventions in place for long periods — and a big mistake to declare victory too early. The research also shows that most transmission of Ebola occurred in families. Eighty-two percent of transmissions in the Lancet study happened in the community and 72 percent between family members. Neither hospitals nor funerals played a major role in transmission after countermeasures were taken in both. In fact, hospitals and treatment centers played a significant role in battling the disease. A study just published by the Centers for Disease Control and Prevention estimates that Ebola treatment centers and community care centers in Liberia saved thousands of lives. While there is no known effective cure for Ebola, the centers isolated patients from the healthy and thus prevented more infections. A lesson here is that, in parts of the world where health- care infrastructure is weak, it is of huge benefit to isolate the infected even in rudimentary facilities, and that an airlift of temporary centers can make a real difference. In the end, fighting an outbreak is not only battling a virus but also dealing effectively with people, modifying their behavior and taming their fears. Another new study from the CDC shows that, in Sierra Leone, an effective way to find and trace infected patients was demonstrated in a pilot project using village monitors who were given cellphones and trained to detect “trigger” events that the virus was afoot. The method helped locate the sick earlier; it also had a high degree of acceptance by key community leaders. The WHO’s response to the Ebola crisis was so lethargic that some experts have suggested establishing a new rapid-response organization. In a Jan. 25 meeting in Geneva, the WHO’s 34-member executive board agreed to create a special fund for use in emergencies and to undertake an overhaul to make it more responsive next time. The jury is still out on whether this will succeed, but the spirit was right. Next time, the world cannot be late to the scene of the fire. **Read more about this topic:** The Post’s View: Lessons from the Ebola outbreak in West Africa Ban Ki-moon: The Ebola fight is far from over Laurie Garrett: Five myths about Ebola Paul Farmer: The secret to curing West Africa from Ebola is no secret at all

What U.S. peanut donations mean to Haiti

Regarding the April 27 editorial “Nutty farm subsidies”: Haiti has among the highest rates of chronic poverty in the world. Almost one- third of all childhood deaths  are due to undernutrition, and Haiti is suffering from a crop-withering drought. For years, the United States has supported Haitians by helping to create jobs, boost incomes, reduce extreme poverty and ensure greater food security, especially for Haiti’s children. With the support of the Agriculture Department’s McGovern-Dole International Food for Education and Child Nutrition Program, the USDA has partnered with the U.N. World Food Program to provide daily hot meals to more than 175,000 children at 610 schools in Haiti’s most severely drought-stricken areas. The meals, which incorporate donated U.S. bulgur wheat, green peas and vegetable oil, will be supplemented by a morning snack of roasted peanuts thanks to the recent U.S. donation. I recently visited one of the schools and saw firsthand the daily struggle many Haitian families face. To ensure this aid complements ongoing development assistance, the USDA is funding research by the World Food Program into the use of locally procured peanuts in emergency rations and in school food programs in Haiti. The USDA is also funding a new vocational agricultural school to train a new generation of Haitian agricultural professionals. Haiti remains in crisis, and the nation’s children need our help now. Thanks to U.S. farmers and agricultural innovation, they have it. ****Alexis Taylor** , Washington** The writer is deputy undersecretary for farm and foreign agricultural services at the U.S. Agriculture Department.

A scandal of sexual abuse mars the U.N.’s exit from Haiti

THE U.N. PEACEKEEPING mission in Haiti, one of the world’s longest-running such deployments and the only one in the Americas, will end in a few months, but not before reckoning with a fresh scandal. A U.N. battalion of Nepalese peacekeepers in 2010 introduced a lethal strain of cholera  to Haiti, where it has since killed more than 9,000 people and infected hundreds of thousands. Now, the Associated Press reports that at least 134 U.N. peacekeepers from Sri Lanka took part in a sex ring in Haiti that victimized nine children, the youngest just 12, from 2004 to 2007. The report should serve notice that U.N. peacekeeping operations worldwide are badly in need of reform and oversight. The sex ring was part of what appears to have been a broader pattern of sexual exploitation and abuse, along with impunity, that has marked the U.N. mission in Haiti since it began in 2004 after an elected president was overthrown. The A.P. turned up hundreds of allegations of abuse in Haiti, many of them coldblooded and horrific, carried out by peacekeepers from Bangladesh, Brazil, Jordan, Nigeria, Pakistan, Uruguay and Sri Lanka. In very few cases did the troops face discipline. The U.N. announcement last week that the mission in Haiti would be wound down over the coming six months was unrelated to the A.P.’s nearly simultaneous revelations of sex abuse by peacekeepers. The troops’ withdrawal — they’ll be replaced by a much smaller contingent of police trainers — reflects both the country’s progress toward stabilization after successful elections and financial pressure to trim peacekeeping operations, owing partly to the Trump administration’s threat to cut U.S. contributions to the multinational organization by hundreds of millions of dollars. Even when the mission in Haiti is wrapped up, the United Nations will have more than a dozen peacekeeping missions worldwide; Haiti is by no means the only place peacekeepers have treated as a sexual playground. The United Nations must insist, as a precondition for accepting peacekeeping troops, that contributing countries will court-martial and punish soldiers who commit abuse. It should also sever payments to peacekeeping contingents implicated in sexual abuse if they fail to impose discipline. In the absence of such accountability, peacekeeping missions may do more harm than good. Haiti may have been especially vulnerable to exploitation by peacekeepers as the hemisphere’s poorest nation, leveled by a devastating earthquake in 2010 and a hurricane last year. Some children and teens reportedly were raped outright; others engaged in what victims called “survival sex,” coerced into trading their bodies for scraps of food or a few dollars. The United Nations insists it is making progress in holding peacekeeper-contributing countries to account; it said much the same thing a decade ago. **Read more on this issue:** The Post’s View: The United Nations comes clean(ish) on cholera in Haiti The Post’s View: The Herculean task facing Haiti Charanya Krishnaswami and Muneer I. Ahmad: U.N. hypocrisy in Haiti

‘It is misery': A video of Haiti’s camps after Sandy

WHO: Zika virus ‘spreading explosively,’ level of alarm ‘extremely high’

The World Health Organization announced Thursday that it will convene an emergency meeting to try to find ways to stop the transmission of the Zika virus — which officials said is "spreading explosively" across the Americas. "The level of alarm is extremely high, as is the level of uncertainty. Questions abound. We need to get some answers quickly, " Margaret Chan, director general of the WHO, said in Geneva during a briefing for member countries. The WHO said the pathogen, which was virtually unheard of in the region a year ago, is spreading so fast that it could infect as many as 3 million to 4 million people within 12 months. Chan said those numbers and the severity of the possible complications being reported -- from a brain abnormality called microcephaly in children to paralysis in adults -- make the situation dramatically different than what epidemiologists have seen with past outbreaks of the virus. Health officials said 24 countries and territories are affected by mosquitoes that are transmitting Zika locally. The Centers for Disease Control and Prevention said the United States has 31 confirmed cases in 11 states and the District of Columbia. All are travel-related, said Lyle Petersen, director of CDC’s vector-borne disease division, and "this number is increasing rapidly." At least one involves a pregnant woman, New York City officials said Thursday. There also are 20 additional cases because of local transmission in U.S. territories — 19 in Puerto Rico and one in the U.S. Virgin Islands. In a separate briefing with reporters Thursday, U.S. officials said all states are now required to report Zika cases. As a result, they expect to see a sharp increase in cases involving a traveler infected while abroad who becomes symptomatic after returning home. But local outbreaks are unlikely here, officials said. Global health authorities have already been criticized for not moving quickly enough to call an emergency meeting on Zika. Some public health experts accused the WHO of failing to learn lessons from the Ebola epidemic of 2014, when the organization delayed sounding the alarm for months. Lawrence O. Gostin, a global health law professor at Georgetown University, said Chan needs to "urgently mobilize international resources" to curb Zika's spread. "It is far better to be over-prepared than to wait until a Zika epidemic spins out of control," he said in a statement. "If the association between microcephaly and Zika virus is confirmed, there will be an ethical imperative to protect women of childbearing age from contracting the infection," Gostin added. At his daily briefing, White House press secretary Josh Earnest was asked if the U.S. and international response to the Zika virus was too slow. “What you have seen from this administration is a response consistent with the kind of threat that could be out there. At this point, here in the United States, the risks of disease spread by mosquitoes are quite low," he said. "The temperatures in North America right now are inhospitable to the mosquito population. Eventually that will change, and we have to be mindful of any possible risk here in the United States.” Earnest noted that President Obama on Tuesday convened a group of scientists and public health officials to discuss efforts to combat the disease and noted travel warnings issued by the CDC and a public information campaign by CDC and NIH. “We are in a stage right now where we want to educate the public about what the risks are," he said. "For most people, the risks of the Zika virus are minimal.” Brazil is the epicenter of Zika, and public health officials are investigating the suspected link between the virus and the rare condition that affects fetal brain development,  as well as a possible association between the pathogen and, in adults, a syndrome known as Guillain-Barré that can lead to paralysis. During a briefing to the WHO executive board on Thursday, Brazil’s health minister, Claudio Maierovitch, said the country is investigating 12 confirmed deaths of babies born with microcephaly for potential linkage with Zika virus infection. The country has more than 4,000 suspected cases of microcephaly, and while some have turned out to be other conditions, many have been confirmed through ultrasound, he said. He did not provide a figure. Pregnant women who tested positive for the Zika virus and later had babies with microcephaly had experienced a rash and fever during the “first and second parts of their pregnancy,” he said. Several countries in Latin America and the Caribbean have been so shaken by the reports that they have taken extreme measures by advising women of childbearing age to wait six months to two years before trying to become pregnant. Bruce Aylward, assistant director-general of the WHO, said its position is that women who are pregnant should engage in "an abundance of caution" to avoid being bitten by mosquitoes. Marcos Espinal, director of communicable diseases and health analysis for the Pan American Health Organization, said Zika is likely to spread to the same areas where dengue exists and predicted that “we can expect 3 to 4 million cases of Zika virus disease.” That reach includes parts of the southern United States, according to a map he presented at the briefing. The WHO said Zika appears to be spreading so rapidly for two reasons: One, because it is a new disease to the region and so the population does not have immunity, and two, because the Zika virus is primarily transmitted by a mosquito species known as A. aegypti, which lives in every country in North and South America except Canada and Chile. Previous outbreaks of Zika occurred primarily in areas with small populations -- a distinction from the situation in Brazil, where the virus is circulating in densely populated urban areas. CDC deputy director Anne Schuchat told reporters Thursday that living conditions in the United States, such as better air conditioning, more window screens and less crowding, are factors that make it much less likely for a widespread outbreak of Zika. But mosquito control is difficult even in this country, and she said state and local authorities need to be vigilant to "jump in" if there are locally transmitted cases. She said the Food and Drug Administration is also looking into whether any additional guidance is necessary regarding blood donations. Zika virus stays in the blood for only a few days, and "most people have cleared it by about a week," she said. The FDA is assessing whether travelers who have visited affected regions should defer donating their blood, a spokeswoman said. The agency is also working on recommendations to help maintain a safe blood supply in U.S. territories where the virus is present. "We cannot speculate on specific implementation timing at this point," said FDA spokeswoman Tara Goodin. WHO officials said that this type of mosquito also has been simultaneously carrying a host of other viruses — dengue, Chikungunya, yellow fever, West Nile — to those regions in recent years. Among the hypotheses scientists are looking into are whether the recent severe reactions may be related to co-infection with Zika and another virus, or previous exposure to one. Aylward said some of the women who gave birth to children with microcephaly had been tested, and some of them had other infections. "We don't have an answer as to what is actually going on," he said. There has been one reported case that the virus could have been transmitted through sex, and another case in the medical literature where the virus was found in semen two weeks after symptoms of infection, according to the CDC's Schuchat. "But the science is clear that Zika is primarily transmitted to people through the bite of an infected mosquito," she said. "That is really where we are putting our emphasis." Part of the challenge with Zika is that it is often "silent," with up to 75 percent of infected patients having no symptoms, said Sylvain Aldighieri, who works in epidemic alert and response for the WHO/PAHO. "We have big gaps in terms of confirmation of the real situation." Representatives from several countries raised concerns about whether we’re seeing a potentially more virulent mutated virus in the Americas, but WHO officials said tests so far show that it’s “very similar” to what was circulating in the Pacific region several years ago. WHO officials said that better diagnostic tests are in the works, as well as possible antiviral therapies and vaccines, but that any of these could take months to develop. Meanwhile, efforts are focused on controlling the spread of the virus by eliminating mosquito populations. In some countries, health officials have been going door to door to spray for mosquito breeding grounds and have launched public education campaigns to urge people to wear repellent clothing or use sprays. In a controversial experiment, a British company has announced it would release genetically modified mosquitoes whose larvae don't make it to adulthood to see if they can help stop the spread of the virus. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said Thursday that investigators may be able to start a clinical trial for a vaccine as early as this year. The WHO's Chan urged “every community, every family and individual” to do their part by, for example, taking care not to leave stagnant collections of water on their properties. She emphasized that every person in the world could be vulnerable to the virus. “The mosquito is ubiquitous,” she said. “You don’t need to travel to get the disease.” The WHO special session on Zika is scheduled to take place on Monday, and delegates will discuss whether to declare it a global public health emergency -- a designation that could help mobilize a more coordinated response. The WHO has only done this three times before: in 2009 during the H1N1 influenza epidemic, in August 2014 with Ebola and in May 2014 regarding the reemergence of polio. The declaration typically comes with a list of global recommendations to nations regarding everything from international travel and trade to scientific targets for diagnosis and treatment of a disease and has been considered critical to convincing wealthier countries to send more health workers and supplies to fight the outbreaks. _David Nakamura contributed to this report._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico _This post has been updated._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Read more:**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico FAQ: What is Zika, and what are the risks as it spreads?    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico CDC issues interim Zika guidelines for testing infants    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Why the United States is vulnerable to the alarming spread of Zika virus    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico With a little blue pill, could one city’s AIDS epidemic be ending?    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Scientists open ‘black box’ of schizophrenia with dramatic genetic discovery    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Principal to give former student ultimate gift: Her kidney    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico My nightmare didn’t end after I lost my child 8 hours after birth. The PTSD carried over to a new pregnancy.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico

Haiti needs food, jobs, doctors — and now a president

PORT-AU-PRINCE, Haiti — Last year’s presidential election fell apart amid cries of fraud. An interim government named in February was supposed to organize a new one. Now, no one is sure who is really in charge here. Political transitions always make for volatile times in Haiti. But the latest political crisis is whittling away whatever is left of the dream that Haiti could come back better and brighter from its devastating 2010 earthquake. The 120-day mandate of the interim president, Jocelerme Privert, expired at midnight Tuesday. Haiti’s parliament has not extended his tenure, nor appointed another caretaker figure. Privert’s opponents say his term has clearly ended; he and his supporters insist he remains Haiti’s de facto president unless lawmakers vote him out. The head of Haiti’s lower house has not been able to get lawmakers to decide on it. This sort of standoff is the last thing Haiti needs, producing an all- consuming distraction from its many other problems: economic stagnation, a tanking currency, drought, cholera, the Zika virus, food shortages and a three-month-old strike by public-health workers. Six years after the 7.0-magnitude earthquake that killed 200,000 and left more than a million homeless, the heady talk of rebuilding a stronger Haiti has given way to a sinking sense that the country’s political class is cracked beyond repair. Foreign governments that largely financed Haiti’s failed elections last year, to the tune of $100 million, are running out of patience but seem to be wary of destabilizing the country any further. They have reluctantly embraced the plan to redo the October presidential vote. “Haiti can’t afford to go without its democratically elected leaders, and those democratically elected leaders need to get to work,” U.S. Ambassador Peter Mulrean said in an interview. “For us as a government, it’s not the same thing dealing with a provisional president. We need a full-time partner in the government of Haiti, and that means both a president and a parliament who we can work with to deal with immediate crises and get development off the ground again.” Since the end of authoritarian rule more than 30 years ago, Haiti has struggled to stage orderly elections, a problem often explained with the observation that politics here is a business. That does not quite capture the nature of the problem. Politics in Haiti is more like an industry in a country that lacks other ways to make a living. With so few formal jobs, a struggling economy and a seasoned culture of corruption, getting into power and staying there is one of the few ways to secure regular employment and a decent salary. This makes electoral defeat something that is less likely to be publicly acknowledged than privately negotiated. Privert’s opponents, led by the Tèt Kale (“Bald Head”) party of former president Michel Martelly, who left office when his term ended Feb. 7, said they will mobilize street protests to force Privert out. The party — which appears to have enough backing in the Chamber of Deputies, Haiti’s lower house, to block an extension of Privert’s mandate — says Prime Minister Enex Jean-Charles should be recognized as Haiti’s interim leader. Ann Valérie Timothée, Martelly’s former chief of staff and now the leader of the Bald Head party, said in an interview that Haiti is not facing a “political crisis” but something far worse. “A crisis is something that has a beginning and end,” Timothée said. “We have a systemic problem.” Elections, she said, are always contested by the loser. Timothée said Privert’s attempt to stay in power without an electoral mandate will drag Haiti back into an era of undemocratic rule. “People have died for Haiti to have democracy,” Timothée said. The country is mostly calm for now. Campaign posters and political graffiti blanket the crowded streets of the capital, and recent pro- and anti-Privert demonstrations have been relatively small and peaceful by Port-au-Prince standards. But it is a city with a notoriously short fuse. On Tuesday, Privert’s supporters from the Fanmi Lavalas party, founded by deposed former leader Jean-Bertrand Aristide, marched through the streets calling for Privert to stay. Although Aristide returned to Haiti from exile in 2011, he has remained out of public view. Privert was a key cabinet member in Aristide’s government and spent two years in prison on charges that he was involved in the massacre of government opponents during a 2004 coup while serving as interior minister. Haiti is the poorest country in the Americas, with 80 percent of the population living in poverty. U.N. troops patrol the streets in blue helmets and body armor. Foreign doctors and aid groups keep the health system from collapse. Aside from a few apparel plants and agricultural exports, money sent home by Haitians working abroad is what mostly provides a lifeline. Much of the rubble from the 2010 earthquake has been cleared. But the latest crisis has reinforced the view that the country is stuck in a kind of externally managed poverty, in which foreign governments and aid organizations try to keep a lid on the place and ameliorate the worst suffering. “There’s no investment. Tourism is dead. The political parties have no plan whatsoever. They may talk about ideology, but the bottom line is power,” said Robert Fatton Jr., a political scientist at the University of Virginia who was born and raised in Haiti. Fatton said U.S. officials and other foreign donors have grown tired of Haiti’s political class and its seeming inability to work on behalf of Haitians trapped in misery. He said donors have increasingly become resigned to an approach in which two overarching goals are “political stability and no boat people.” Many Haitians, for their part, have come to see foreign governments and donors cynically, especially after international observers put a stamp of approval on last year’s disputed presidential election, calling it flawed but essentially fair. The losing candidates did not agree, and their allegations of fraud forced the cancellation of the runoff vote that would have given Haiti a president by now. Martelly was ineligible for reelection, and when he left office, Privert was appointed as a caretaker president by Haiti’s National Assembly. He formed a commission to investigate what happened during the first round of voting, and its lengthy report concluded that the election — featuring 54 presidential candidates — was so dirty that the results should be tossed out. The commission has recommended a new election for Oct. 9, with a runoff Jan. 8. Privert would be ineligible to run in that contest, but his opponents do not trust him to organize a fair election. Martelly’s Bald Head party has not accepted the new timeline. Its candidate, Jovenel Moïse, a farmer nicknamed “Banana Man,”won the highest number of votes in last year’s contest. But second-place finisher Jude Célestin refused to participate in a runoff, because he said the first round was so tainted, and his campaign has welcomed the plans for a do-over. The new elections for president and a portion of Haiti’s parliament will cost an estimated $60 million more.

World Digest: April 23, 2014

Syrian government forces have attacked rebel-held areas with chlorine gas in recent weeks and months, leaving men, women and children coughing, choking and gasping for breath, according to Associated Press interviews with more than a dozen activists, medics and residents on the opposition side. Syria flatly denied the allegations, and they have yet to be confirmed by any foreign country or international organization. But if true, they would highlight the limitations of the global effort to rid President Bashar al-Assad’s government of its chemical weapons. Witnesses near Damascus and in a central rebel-held village told the AP of dozens of cases of choking, fainting and other afflictions from inhaling fumes that some said were yellowish and smelled like chlorine. Some of those interviewed said they believed the gas was responsible for at least two deaths. They said the fumes came from grenades and helicopter-dropped “barrel bombs.” Activists have posted videos similar, though on a far smaller scale, to those from last August’s chemical attack near Damascus that killed hundreds of people and nearly triggered U.S. airstrikes against Syria. The new footage depicts pale-faced men, women and children coughing and gasping at field hospitals. **— Associated Press** Turkish Prime Minister Recep Tayyip Erdogan on Wednesday offered an unprecedented, conciliatory message to Armenians on the eve of the anniversary of the massacre of Armenians almost a century ago. Erdogan called the events of World War I “our shared pain” and acknowledged that the deportation of Armenians in 1915 had “inhumane consequences.” Erdogan released a statement in Turkish, Armenian and seven other languages expressing hope that those killed are at peace and offering Turkey’s condolences to their descendants. The message came a day before Armenians mark the 99th anniversary of the killings in 1915 by Ottoman Turks. The episode is considered by many historians as the first genocide of the 20th century. They estimate that about   1.5 million Armenians died. Turkey rejects the term “genocide,” saying that those figures are inflated and that there were deaths on both sides as the Ottoman Empire collapsed. Armenian President Serge Sarkisian accused Turkey of “utter denial” of what Armenia sees as the genocide of Armenians, but added that his country does not consider Turks its enemies. **— From news services** Dozens of Sherpa guides packed up their tents and left Mount Everest’s base camp Wednesday after the deaths of   16 of their colleagues in an avalanche exposed an undercurrent of resentment by Sherpas over their pay, treatment and benefits. With the entire climbing season increasingly thrown into doubt, Nepal’s government quickly announced that top tourism officials would fly to base camp Thursday to negotiate with the Sherpas and encourage them to return to work. But while the government has been heavily criticized for not doing enough for the Sherpas in the wake of last week’s disaster, the deadliest ever on the mountain, one top official blamed the walkout on “hooligans.” It was unclear just how many of the 400 or so Sherpas on the mountain had joined the walkout, but a number of expedition companies have already canceled their climbs, and the lucrative climbing season is in disarray. Most attempts to reach Everest’s summit are made in mid-May, when a brief window normally offers better weather. **— Associated Press** **— From news services**

Governments, groups striving to become as agile as the Ebola virus

The news out of West Africa in recent days — good and bad — has demonstrated a fundamental challenge in the fight against Ebola: The virus is more nimble than the human response to it. The landscape of infection and disease has changed dramatically in recent weeks, even as institutions have largely stuck to blueprints drafted months ago. The looming question now is whether governments and other organizations can find a way to become as agile as the virus, which has vanished suddenly in some hard-hit places while erupting just as quickly in new locations. The first Ebola treatment unit built in Liberia by the U.S. military is expected to open in the coming days, about two months after President Obama announced that he would send troops to supplement the civilian effort against the disease. But even before that first ETU has become operational, Liberia has seen a sharp drop in new infections and has empty beds in Ebola wards. The new ETUs, temporary structures that can’t easily be used for anything else, may not treat many patients. Up the coast of West Africa, Sierra Leone has made far less progress in the fight against Ebola. The country had three times as many new infections as Liberia in the most recent three-week monitoring period, according to the World Health Organization. The United States has sent troops to Liberia but not to Sierra Leone. Guinea, the third West African country hit hard by the virus, is another landscape entirely. It is bigger than Liberia and Sierra Leone combined. There was a drop in cases in the capital, Conakry, over the summer, but the virus recently surfaced again in some neighborhoods. In addition, hot spots continue to pop up in remote places, and health workers still encounter community resistance. As the epidemic enters this new phase, officials say the strategy must be more aggressive: looking for Ebola “brush fires” and recognizing that “sparks are igniting all over,” as Thomas Frieden, director of the Centers for Disease Control and Prevention, said in an interview last week. The contagion has to be tracked to the last patient and obliterated lest it flare anew. ****“We need the large U.N. aid agencies and bureaucracies to also work with a nimbleness, and adapt on the spot and on the fly and reroute resources,” Samantha Power, the U.S. ambassador to the United Nations, who recently toured the affected region, said in an interview Friday. “Nothing you achieve in Liberia is sustainable unless you contain and end the virus in Guinea and Sierra Leone.” In a speech in Brussels after her trip to West Africa, Power pointed out the inertial forces that often hamper big bureaucracies in situations like this: “We tend to plot out static, long-term plans to respond to the outbreak and then stick to them, rather than developing fluid structures that can move with the virus.” Officials involved in the response want to push ahead with the existing plan to build many ETUs in Liberia, for one obvious reason: Ebola has been known to subside for a while and then come roaring back, as it did in the spring. It’s a better-safe-than-sorry approach. “We don’t want to take the foot off the gas pedal until we’re absolutely sure,” said Jeremy Konyndyk, a top official with the U.S. Agency for International Development who joined Power on her tour. At the same time, U.S. officials are looking for ways to adapt that plan, for example by opening units in new locations and with only a small number of beds. This approach would mimic the brush-fire pattern of the epidemic at the moment. “As we’re dealing with this devious, adaptive virus as it is moving out in the real world, we have come to realize that 17 100-bed units are less needed,” Power said in the interview. Instead, what is needed is “a large number of 10-bed treatment units geographically dispersed to where the epidemic is now and where contact tracing suggests the virus might move.” U.S. officials also recognize that Guinea has not received enough support, so the United States is funding three ETUs there through the U.N. World Food Program, she said. Many major challenges remain, not least of which is staffing the health facilities. International aid groups continue to struggle to find the thousands of health-care workers needed for the effort. They are hard to come by, given the grueling work conditions, the unusually terrifying nature of Ebola and concerns that volunteers will be quarantined upon returning home. Adding to that is concern that the facilities won’t be in the places they’re needed most, said Sophie Delaunay, executive director of the U.S. arm of Doctors Without Borders. “At the moment, our main concern is less about staffing those facilities and more about the necessity to adapt the response based on the development of the outbreak,” she said. The United States has historic ties with Liberia, which was founded by African Americans in the first half of the 19th century. Reflecting colonial-era connections, Britain is focused on Sierra Leone, and France is concentrating on Guinea. “The crisis is accelerating,” said Sia Dean, a nurse who runs a company in Sierra Leone with her husband, Charles Dean II, and who spoke via Skype at an Ebola conference in Washington last week. She said that five doctors and dozens of nurses have died in Sierra Leone and that there are not enough ambulances to pick up the dead in Freetown, the capital. The British are taking too long to build the ETUs, she said, adding, “Time is against us.” The situation in Guinea also remains tenuous. The forested areas where the outbreak began late last year are still a challenge. They often are difficult to reach. And skepticism runs high, meaning health workers often must forge relationships with local leaders before they can earn the trust of residents. “The first people who show up can’t be wearing spacesuits,” said Michael Kinzer, the CDC’s team leader in the country. The Pentagon’s plan, announced in September, was largely crafted by the Army’s Africa Command, based in Germany. The ETU building process has taken longer than expected, in part because the rainy season and a lack of heavy-duty construction equipment and other infrastructure have slowed things down. The Army also has been hampered by the lack of a place to house soldiers. Some set up camp in hotel rooms pending the construction of living quarters at a Liberian military facility. The Army in recent days finished its first field hospital, designed solely for health-care workers who become sick treating Ebola patients. That achievement reflects the step-by-step requirements of mounting a major response to an epidemic: Volunteers have to know that they’ll be cared for if they contract the disease. The United States and Britain also have focused on creating medical-evacuation options for sick workers. Obama on Wednesday asked Congress for $6 billion to supplement about $1 billion already committed by the United States to fight Ebola in West Africa and domestically. The United States has had only one Ebola case in recent days, and New York’s Bellevue Hospital announced Monday that the patient, Craig Spencer, is free of the virus and will be released Tuesday. The president’s request will be the subject of hearings this week on Capitol Hill, starting Wednesday afternoon, when top administration officials will testify before the Senate Appropriations Committee. The funding would be used to send more U.S. civilian teams and supplies to fight the outbreak in Guinea and Sierra Leone. A chunk of money also would go toward upgrading more than 50 hospitals in the United States to ensure that they have good infection-control measures if Ebola is brought to this country again. Many of those hospitals are located near the five U.S. airports where passengers from West Africa are required to arrive. The CDC also will stockpile $2.7 million in personal protective equipment that it can deliver to U.S. hospitals caring for Ebola patients. That includes nearly 6,000 disposable gowns, more than 6,000 respirators and 55,000 pairs of gloves — enough gear for 250 days of treatment. What has worked well in West Africa, officials say, has been communication — broadcasting the message over and over that Ebola is not a hoax or a scam, and that its spread can be contained through adjustments in behavior, particularly in funeral practices that included repeated washing of the body. In Guinea, an Israeli cellphone company agreed to give free airtime to imams on Fridays so they could send text messages to congregants telling them about Ebola prevention. A new public-awareness campaign in Sierra Leone will feature one “big idea” per week, starting this week with “Safe Burials Save Lives.” Targeting local media outlets and opinion leaders, the campaign is full of common-sense advice, such as not touching the bodily fluids of sick people and assuming that anyone who is sick could have Ebola. Freetown has a new Ebola response call center, and residents are asked to call 117 when someone is suspected of having Ebola or when an infected person dies. On the wall of the call center is a map of Freetown. Red pins mark the spots where bodies have been reported. When teams bury a body, blue pins replace the red ones. When Power visited Oct. 28, the map showed one red pin surrounded by a sea of blue. A key effort is the enlistment of grass-roots women’s groups. In Grand Bassa County, Liberia, the Bassa County Women’s Development Association has been training women and religious leaders since August to spread the message. “We have been working here with them for a very long time, and they know what we tell them,” said Martha Karnga, the group’s executive director. The message is working, she said. “They understand because we see them practice hand-washing in the buckets.” Power has called the Ebola epidemic the greatest public health crisis of our time, and in Friday’s interview she said there is no time for traditional funding proposals or elaborately crafted plans. “We’re building the airplane as we fly it,” Power said. “We’re deciding how to allocate the spare parts depending on the signals on the control panel.” Related: Rate of new Ebola infections in Liberia is slowing Obama seeks $6 billion to fight Ebola in Africa, U.S. U.S. field hospital for health workers to open in Liberia

Social networks can help predict gun violence

_Andrew V. Papachristos is an associate professor of sociology at Yale University._ Is it possible to predict who is most likely to die at the hands of a gun? Not shootings like those at  Sandy Hook Elementary School in Connecticut , the movie theater in Aurora, Colo. , or the  Washington Navy Yard , but the all- too-common shootings that occur in neighborhoods across the country. The idea is not far-fetched if one drills down into the nature of gun violence, which, in the way it is transmitted, bears striking similarities to public health epidemics such as cholera in Haiti or HIV/AIDS in the United States. Epidemics of any kind are not random. HIV is a blood-borne pathogen transmitted primarily through sex or intravenous drug use. Once its patterns of transmission and the communities most affected were identified in the United States, extensive public health campaigns helped transform AIDS from an always-fatal disease into one that is chronic and manageable for many of those infected. Along the same lines, a cholera epidemic exploded in Haiti in 2010 when sewage from a base housing United Nations peacekeepers leaked into a nearby river that supplied drinking water. The transmission, far from random, ultimately killed more than 8,000 Haitians. So it is with gun violence. There are patterns of transmission in the United States that go beyond aggregate factors such as race, age, gender and income. On an individual level, social networks — the people one hangs out with — can predict a given person’s likelihood of being shot and killed. In a study published last month in the American Journal of Public Health, my colleague Christopher Wildeman and I applied the science of social networks to patterns of gun homicide in Chicago. The idea is straightforward: Treat gun homicide like a blood-borne pathogen, something transmitted from person to person through specific risky behaviors. Put another way, gun violence is not an airborne pathogen: You don’t catch a bullet like you catch a cold. More than 40 percent of all gun homicides in the study occurred within a network of 3,100 people, roughly 4 percent of the community’s population. Simply being among the 4 percent increased a person’s odds of being killed by a gun by 900 percent. These numbers tell us that gun violence spreads like HIV infection: You’re more likely to “catch” the disease if you engage in risky behaviors with someone who might be infected. And it’s not just people’s friends who affect their likelihood of getting shot, but also their friends’ friends. This is similar to the transmission of HIV: Your current partner’s past sexual partners affect your exposure, even if you don’t know them. In the case of gun homicide, seemingly random victims end up “in the wrong place at the wrong time” by indirect exposure, such as getting a ride from a friend’s cousin or by going to the party of a friend’s friend. In these cases, victimization is tragic but not random. Understanding the networked nature of gun violence has important implications for how it can be addressed. Prevention efforts can be directed toward those individuals and communities most susceptible to the infection. The solution is not broad, sweeping policies, such as New York’s “stop and frisk” or mass arrests, but the opposite: highly targeted efforts to reach specific people in specific places, akin to providing clean needles to drug users to prevent the spread of HIV. By studying  gun violence like we study  disease, we, as a society, can improve our chances of discovering who has a greater chance of being shot and focus resources to police better, smarter and more fairly. **Read more about this topic:** The Post’s View: Counting the young victims of firearm violence Eugene Robinson: The NRA’s tone-deaf rhetoric Aaron Kupchik: The flaws in the NRA’s school-security proposal Philip Caputo: Guns do kill people

World Digest: July 6, 2013

Tuareg separatists who drove the Malian military out of Kidal 16 months ago protested Saturday against the army’s return to the northern town, gathering outside the camp where soldiers are staying. The West African country’s army is overwhelmingly made up of soldiers of southern Malian ethnicities, who are accused of carrying out reprisal killings against Arab and Tuareg civilians in the other northern towns they retook this year. The military’s presence in Kidal removes a major obstacle to the presidential election, scheduled to take place in three weeks. Many had wondered how a national election could be held with an important provincial capital in the hands of rebels. In preparation for the campaigning, Mali’s government on Saturday also lifted the state of emergency that had been reimposed in January after al-Qaeda-linked militants began attacking towns farther south in the country. But many fear that the Tuareg separatists will not accept the army’s presence, a concern underscored by Saturday’s demonstration. **— Associated Press** The United Nations sent Nepalese peacekeeping troops to bring relief to Haiti after it was devastated by a 7.0-magnitude earthquake in 2010. A study published last week in mBio, the journal of the American Society for Microbiology, concludes that the peacekeepers also brought cholera, triggering an epidemic that has sickened hundreds of thousands of Haitians and killed more than 8,000. After sequencing the DNA of 23 samples of the cholera-causing bacterium from Haiti and comparing them to the DNA of strains found elsewhere, researchers said the outbreak could be traced to Nepal, where the disease is endemic. They also concluded that the outbreak in Haiti came from a single source, undermining the hypothesis that the disease was repeatedly introduced to the country over the past three years. **— Los Angeles Times** ******Italian crime boss arrested in Colombia:** A fugitive Italian organized crime boss, who prosecutors allege arranged monthly shipments of tons of South American cocaine to Europe and was one of the world’s most powerful drug brokers, has been captured in a shopping mall in Bogota, Colombia, Italian and Colombian authorities said. Roberto Pannunzi, who fled while under arrest in a private Rome clinic in 2010, was reportedly captured Thursday and was to be returned to Italy on Saturday night. **Protesters dispersed near Istanbul square:** Turkish police fired volleys of tear gas at protesters who tried to enter a cordoned-off park near Istanbul’s landmark Taksim Square, hours after the city’s governor warned that the demonstration was illegal and participants would be dispersed. A few thousand people converged on the square, with the aim of entering Gezi Park, whose redevelopment plans sparked anger and morphed into nationwide anti- government protests in June. **Tibetans mark Dalai Lama’s 78th birthday:** Thousands of Tibetans waved banners and danced, and schoolchildren sang prayers at a Tibetan university in Bylakuppe, southern India, to celebrate the Dalai Lama’s 78th birthday. Speaking after an interfaith meeting, the Tibetans’ spiritual leader, who has lived in exile in India since 1959, called for love and compassion and said the real meaning of jihad was “to combat our negative emotions,” not engage in “beating or killing.” **Bombing in eastern Pakistan kills 4:** A bomb exploded in a busy market street in the eastern Pakistani city of Lahore, killing at least four people and wounding 40, police said. Lahore, the capital of Punjab province, is also the home city of Pakistani Prime Minister Nawaz Sharif. There was no claim of responsibility for the attack. **** **— From news services**

This is how the U.S. must lead the fight against Zika

_Michael Gerson and Raj Shah are senior fellows withResults for America. Gerson, a Post columnist, served as assistant to President George W. Bush for policy and planning and is a senior adviser at the anti-poverty group One. Shah served as administrator of the U.S. Agency for International Development under President Obama._ In the aftermath of the 2014 Ebola crisis, public-health officials, disease experts and politicians said that 11,000 painful, frightening deaths had not been in vain. Images of children dying in their mothers’ arms in Africa and the fear of Ebola transmission here at home should have been a wake-up call to the world. At least four systematic reviews of the Ebola crisis were conducted (including one by a high-level U.N. panel on which one of us, Raj, served). All these studies called for greater global rapid-response capabilities; clearer lines of authority ending in a single, accountable leader; flexible resources, including a trained workforce that can be called quickly into aggressive action and deployed to whichever countries needed help; and a rapid-response organization capable of reacting to circumstances on the ground. Now, the response to Zika is revealing many of the same weaknesses, allowing the virus to gain a dangerous momentum that could bring unnecessary tragedy to thousands of families and justified fear to America’s shores. The world is not mounting a sufficient operational response to Zika in the South and Central American countries that are at risk. Brazil, Colombia and other nations are not applying the scale of resources required to rapidly reduce transmission. Within a year, Puerto Rico could have hundreds of cases of microcephaly, leading to disastrous consequences for its already troubled and tourist-driven economy. Nearly every Ebola study called for the World Health Organization to create an operational entity prepared to step in and support countries that need help fighting pandemics. Given that this has not yet happened, we need a single authority tasked with the responsibility of coordinating the operational response in foreign countries — such as retired Rear Adm. Tim Ziemer. As U.S. global malaria coordinator under both President George W. Bush and President Obama, Ziemer has helped save millions of lives through mosquito control and could be tasked with one more mission. We also need clear, evidence-based and comprehensive strategies capable of rapidly interrupting disease transmission in Central and South America. These should include data-driven insecticide spraying campaigns; widespread use of mosquitoes that mate with Zika-spreading mosquitoes and block reproduction; and immediate communications campaigns that promote using protective clothing, bug spray and condoms (because the virus can be transmitted sexually as well). Critical research into better pesticides, more accurate rapid testing and a Zika vaccine have already been prioritized and will improve the effectiveness of at-scale response to end transmission. To succeed, we need resources — both financial resources and trained people willing to put themselves at risk. But the U.S. budgetary and political process has been irresponsibly slow. The WHO declared a global health emergency early in February. Later that month, the Centers for Disease Control and Prevention sent a detailed request to the White House. The Senate approved a lower amount than the Obama administration proposed. The House came in with a smaller number still and proposed to divert money — with absurd pound- foolishness — from the continuing Ebola response. And now Congress has gone on vacation without passing a funding bill. This partisan delay is tremendously dangerous. It is precisely at this stage of a pandemic that the eventual shape of an epidemic curve is determined. The effects of even small delays become magnified. And the delays on Zika response are accumulating. As CDC Director Tom Frieden has said, “Anything we don’t do now we will regret later.” That regret will come in the form of personal suffering for families that should not have to hold a young child suffering from severe birth defects. The fight against Zika requires global leadership to coordinate a coherent, multi-country strategy committed to measurable outcomes, relentless innovation and making good use of data. Only the U.S. government has shown the ability to lead that effort. Bush fought the HIV/AIDS pandemic in Africa with a successful, evidence-based strategy. Obama demonstrated leadership by successfully investing U.S. resources to fight Ebola and creating a global health security partnership with countries around the world. On health issues such as HIV/AIDS and Ebola, U.S. leadership — our science, technical skill, compassion and political will — has been essential to changing the course of history. On Zika, important preparations, including with federal and state authorities, are ongoing. But a heightened global focus is required to make all our efforts effective. This requires Congress to return from its recess and pass a meaningful funding bill. Each of these pandemics demonstrates how our interests as Americans and our values as the world’s truly exceptional nation lead us in the same direction: to fight with urgency and ambition for the health of the world. **Read more about this topic:** The Post’s View: Zika arrives, Congress shrugs The Post’s View: It’s us against Zika — whose side is Congress on? Ronald A. Klain: Zika is coming, but we’re far from ready

A global attention on disease gives Bill Gates his moment

“Ebola has reminded people that it is not just poor people who can die of infectious disease,” Bill Gates tells me, in a characteristically matter-of-fact tone. In a tragic, unsought sense, this is Gates’s moment. The focus of his life — preventable disease — is suddenly the obsession of the world. Gates, who has donated $50 million to the Ebola fight (through his foundation), will give a major address Sunday at the American Society of Tropical Medicine and Hygiene. According to a preview copy of the speech, he will cover the waterfront of vicious infections, from sleeping sickness to dengue to chikungunya (a decidedly unpleasant virus, which is spreading by mosquito in the Western Hemisphere, and which my brother recently contracted on a trip to Haiti). Gates’s remarks on Ebola are the most likely to reach the media bloodstream. He will draw some lessons from the epidemic: on the interconnectedness of global health challenges; on the need to strengthen health-care systems in the developing world so they can identify and confront outbreaks earlier; and on the urgency of staying “fully invested in the R&D pipeline for new drugs, new vaccines, new diagnostics.” Typically, Gates will set out a large goal. Instead of preventing the next Ebola epidemic, he will talk of making this “the last Ebola epidemic.” During our conversation, he said that, by the end of the current outbreak, we should have “vaccines and some drugs that, if stockpiled, should stop a major Ebola outbreak in the future.” Someone — perhaps Gavi, the Vaccine Alliance — will need to gather that stockpile. But it should be possible (as new technologies come online) to prevent Ebola from becoming a recurring epidemic. The need for an unclogged research pipeline is a refrain from Gates, the humanitarian technologist. It is the task of innovation to stay ahead of evolutionary biology — the mutations that make diseases more deadly, easier to transmit, or more resistant to treatment. Gates acknowledged that the Ebola outbreak — given the virus’s history — would have been difficult to anticipate. But “for the big killers, society still underinvests on research.” “Look at very fast-spreading epidemics we are not currently prepared for,” he said. “We see forms of flu that could kill large numbers of people. And forms that transmit easily between humans. Since 1918, we have not seen one that combines both features.” That prospective combination should frighten us into preparation. The focus of Gates’s speech, however, is not flu or Ebola; it is malaria. This is an intentional revolt against the news cycle. It also illustrates Gates’s ambition. In 2007 — as malaria remained uncontrolled in many regions and was taking the lives of more than 1 million people each year — Gates declared the goal of malaria eradication. Some in the field regarded this as fanciful and naive. But programs such as the President’s Malaria Initiative and the Global Fund began making serious progress with existing technologies (bed nets, indoor spraying, artemisinin-based treatment). The Gates Foundation, meanwhile, has made serious investments in the development of products — drug treatments, insecticides and promising vaccines — to stay ahead of the evolution of the parasite that causes the disease. During his upcoming speech, Gates will announce a significant increase in his foundation’s malaria commitment. In our discussion, Gates made clear that ambitious public health goals are not always wise — when premature, they can drive resources in unproductive directions. But the goal of eradicating smallpox, he said, “was a good choice. Polio is a hard but reasonable choice. Malaria is a very reasonable choice.” Gates projects that malaria can be eliminated over the next few years in 30 to 40 countries. And he says — at the age of 59 — that he will be “very disappointed” if malaria is not eradicated in his lifetime. The Plasmodium parasite has reason to be concerned. Yet the Ebola outbreak, in addition to producing corpses and panic, is seriously complicating the work of malaria control and elimination. In affected countries, the breakdown of health systems has set back malaria control efforts by perhaps a decade. And in developed countries, there is a possibility that funds to fight Ebola may be reprogrammed from other diseases such as malaria — which Gates characterized to me as “a huge mistake.” Following the Ebola crisis, infectious disease should remain a focus for good reasons: because dramatic gains are possible. And because losses can be sudden and deadly, affecting rich and poor alike. _Read more fromMichael Gerson’s archive, follow him on Twitter or subscribe to his updates on Facebook _. **Read more on this topic:** Erik Wemple: President Obama links ‘headlines’ to Ebola fear The Post’s View: Ebola fears should not lead to overreaction Ellen Johnson Sirleaf: The long-term cure for Ebola: An investment in health systems John T. Fox: Beating Ebola through a national plan Paul Farmer: How we can save millions of lives

In Haiti, a Marriott’s opening is the latest milestone in quake recovery

A quarter of the country’s people live on less than $1.25 per day. About three-quarters are unemployed or subsist on their own. More than 50,000 people are still living in displacement camps, five years after their homes were destroyed. When one of the world’s strongest earthquakes in recent years ravaged one of the globe’s poorest countries, Haiti, in January 2010, the images of suffering and the staggering fatalities prompted $10 billion in aid commitments from around the world. There are signs of rebirth, and one of the most prominent was highlighted Tuesday when Haitian leaders, former president Bill Clinton and actor Sean Penn joined executives from Marriott International and a Caribbean telecom provider in opening a $45 million, 175-room hotel outside the capital of Port-au-Prince. Tourism, along with agriculture and light manufacturing, is among the industries the Haitian government and international supporters are betting on to drag the country’s economy into a sense of stability so water access, sanitation, electricity and other services can be expanded to rural parts of the country. Clinton said aid would continue from the Haiti Action Network, put together by the Clinton Global Initiative. “If the members of that network keep the commitments they have already made over the next three years, collectively they will invest more than $500 million in Haiti to help put people to work, keep children healthy, educate children and create jobs,” Clinton told a gathering of media at a ceremony welcoming the new Marriott. The international efforts have made some critical improvements in living conditions in Haiti since the earthquake in which 220,000 people died, 1.5 million were displaced and the country’s central government buildings, hospital and port were destroyed or damaged. Only 4 percent of those forced into settlement camps remain there, according to the World Bank. School participation among children is up to 90 percent, from 78 percent before the earthquake. About 24 percent of the country’s 10 million people now live in extreme poverty — meaning on less than $1.25 per day — down from 31 percent in 2000. “Haiti has made a lot of important gains, but it’s fair to say it’s still battling with poverty and inequality, particularly in rural areas,” said Mary Barton-Dock of the World Bank. She cautioned that the economy needed to stabilize as international donations wane: “As aid starts to decline or reduce slowly after the response to the earthquake, these indicators could also reverse.” The Marriott isn’t the first American hotel brand to open in Haiti since the earthquake (a Best Western opened two years ago), but its investors said it would advance the country’s reputation as a place where Western companies can do business. Haiti’s minister of tourism, Stéphanie Villedrouin, called it “a huge vote of confidence in the future economic viability of Haiti” in a statement. Built and owned by the Caribbean cellphone firm Digicel Group and its founder, Denis O’Brien, the hotel is to employ 200 people and make use of Haitian-made coffee, soap and produce. Haitian metalwork and papier-mâché artwork will be on display. The hotel’s general manager relocated from the same job at the Paris Marriott Champs Elysees. Arne M. Sorenson, chief executive of Bethesda-based Marriott, said he agreed to open and operate the hotel after discussions with Clinton and O’Brien. He said he hoped the hotel would serve as an “open-for-business sign” for Haiti but also predicted it would be a financial success by catering to business travelers. “There is enough volume that I think the hotel will be successful,” Sorenson said. “The longer term question for Haiti is can a tourism market develop of any sort of size. There are obviously some beautiful locations in Haiti and some small hotels, but it is still very much on the adventurous edge to take a vacation in Haiti.”

These heart-wrenching photos show what life after Hurricane Matthew is like in Haiti

One early morning in late October, Bellande Lubin washed her shoes in a river near her home town of Les Cayes, Haiti. She was wearing her favorite pastel pink dress, given to her by her mother. The river, used by the community for bathing, washing clothes and as a latrine, was flooded a month earlier by Hurricane Matthew. Lubin’s in fifth grade but can’t return to school because it’s being used as a shelter by some of the tens of thousands who lost their homes to the storm. Matthew has left 800,000 Haitians in desperate need of food. Along the roads, starving children beg for something to eat. Homeless families sleep under trees. Emergency help is arriving, but there is not enough of it. The United Nations has raised just a third of the $120 million needed to cope with the emergency. Storm-hit areas have reported around 3,500 suspected cholera cases. The death toll stands at 546, but local officials have reported twice that many killed. Washington Post photographer Sarah Voisin visited the county in late October. Here’s a look at what life is like a month after the devastation of Matthew.

In South Sudan, a wave of tribal killings

LIKUANGOLE, South Sudan  — Nothing is intact in this town, save the memories. Every hut was burned to the ground. The only health clinic and the only school were torched. Hundreds were killed or injured. Thousands more fled. The United Nations and South Sudan’s government had combat forces in this town at the time of the assault late last year. But witnesses say they did nothing to stop the killings. When the attackers reached a village nearby, they shot Nyandit Allan, 28, twice in her left leg and again in the face, then slit the throats of her two stepsons. “They were singing as they left,” said Allan, who is now recuperating in a clinic. Six months after celebrating independence, the world’s newest nation is grappling with a virus of tribal violence. In many ways, the inevitable has happened, as ethnic and political tensions exploded after being suppressed by the promise of separation from the north, after a decades-long war against rulers in Khartoum. The United States and its allies have spent billions to help South Sudan become a stable, pro-Western pillar in a region plagued by terrorism and militant Islam. But now the intensifying attacks have ignited tribal violence and threaten to undermine a government already facing a long list of daunting challenges. Stopping the violence “would demand a very, very significant military operation, and the government also would have to move significant forces to make that happen,” said Hilde Johnson, the head of the U.N. mission in South Sudan. The state of Jonglei has long been gripped by poverty, ethnic and political tensions, a massive influx of weapons and a history of cattle raiding between the Nuer and Murle tribes. Last year, the United Nations documented 208 attacks that displaced more than 90,000 people. But the current bloodletting appears far more vicious and widespread. Once, only cattle camps were raided. Now, entire villages and towns are being razed, infrastructure destroyed. “Our clinic is full of women and children,” said Karel Janssens, field coordinator for the aid agency Doctors Without Borders in the town of Pibor, where many of the wounded have sought refuge. Since the attacks by the Lou Nuer, a subgroup, on this area in late December and early January, the Murle have risen up. They have marauded Nuer areas across Jonglei. Two weeks ago, 47 people were killed in the village of Duk Padiet. Aid agencies have launched a massive humanitarian effort to help those harmed by the raids, which the United Nations now numbers 120,000 people. On Dec. 17, a Nuer militia known as the White Army announced that it would protect the Nuer population and their cattle from the Murle because the government was not doing enough. The militia, which has a fundraising and media arm in the United States, said it was also seeking revenge for the massacre of 700 Nuer by Murle warriors in August, a month after South Sudan declared independence. In a telephone interview, Gai Bol Thong, a Nuer spokesman who lives in Seattle, said his group had raised $45,000 from supporters in the United States and Canada for food and other “humanitarian” needs of the fighters. On Dec. 25, the White Army e-mailed a statement vowing to “wipe out the entire Murle tribe on the face of the earth.” The next day, 6,000 Lou Nuer fighters attacked Likuangole. They stole thousands of heads of cattle. They destroyed all the boreholes, eliminating the main source of water here. Groups of warriors targeted Murle men, while others tracked down women and children who had fled into the thick bush. Kayoi Maze, 42, was separated from her two daughters, ages 18 and 16. Her neighbors later told her that the fighters had abducted them. “I don’t expect to ever see them again,” said Maze, who like hundreds of villagers returned to Likuangole to receive aid from the U.N. World Food Program. “At least I have two daughters left.” Local officials estimate that 850 people were killed in Likuangole and nearby villages, including 660 women and children. An estimated 150 women and children were abducted. An additional 2,250 people were killed in surrounding areas. But neither the United Nations nor the government have confirmed those figures. In Likuangole, two human skulls lie on a patch of charred ground near the U.N. base. The smell of rotting flesh still wafts through the air. In graffiti covering the walls of the school, the Lou Nuer fighters have declared the town part of their territory. “We have done this to you,” reads one message, “because you have done it to us.” When the gunmen attacked, Achiro Manibon remembered running in one direction as his three wives and four children ran the other way. They were all shot dead. Manibon, 35, had expected the United Nations combat force and South Sudanese troops stationed in the town to fend off the attackers. But they didn’t fire a weapon, he said. Across this area, people feel betrayed by their military and the U.N. peacekeepers, which has a mandate to use force, if needed, to protect civilians. For weeks, the peacekeepers had tracked columns of Lou Nuer fighters making their way toward Likuangole and Pibor. Yet they dispatched only 400 of their 3,000-member force. Simon Ali, a local administrator, said he brought five disabled people to the U.N. base for protection. The peacekeepers told him to put them in a hut about five yards from the base, he said. When the Lou Nuer arrived, they fired into the hut. Then, they torched it with the people inside, Ali said. “The U.N. failed us,” he said. “We asked for their help and they did nothing.” Johnson, the head of the U.N. mission in South Sudan, said U.N. forces in Likuangole had evacuated 41 people, mostly disabled and elderly, before the attack, “but we cannot rule out there might have been some civilians left.” She added that she was not aware of any incidents in which U.N. forces did not provide assistance to civilians seeking refuge. In Likuangole, there’s also deep mistrust of the government. Many senior officials, including Vice President Reik Machar, are Nuer, and Lou Nuer soldiers number in the thousands in the military and are unlikely to intervene, residents said. Col. Philip Aguer, a South Sudanese military spokesman, said that only 500 soldiers were in Likuangole at the time of the attack, and that it would have been like “sentencing your soldiers to death” if they had tried to fight the 6,000 Lou Nuer warriors. “The real reason why they did nothing is because the force was not capable of confronting the attackers,” Aguer said. “Not because many are Nuer.” Today, roughly 1,500 U.N. peacekeepers — half the force — are patrolling Jonglei state. But it has become even more difficult to stop attacks. The Murle fighters are moving in small groups, staging swift stealth attacks, making the violence harder to monitor and predict. “You could see a pattern of where they are moving, but we, with all our helicopters, are not able to detect that they are going to that village or not that,” Johnson said. Back in the United States, Gai Bol Thong is continuing to raise funds for the White Army. If the government cannot protect the Nuer community, “we will do some revenge against the Murle,” he warned. **More world news coverage:** \- European leaders adopt treaty to combat debt \- Clinton to attend U.N. meeting on Syria \- Pakistan allows former envoy to leave \- Read more headlines from around the world ****

Trump calls U.N. ‘just a club for people’ to ‘have a good time’

Three days after the United Nations adopted a resolution calling on Israel to halt Jewish settlement activity on Palestinian territory, President-elect Donald Trump tweeted that the international body “is just a club for people to get together, talk and have a good time.” The harsh criticism, which Trump made Monday while vacationing at his Mar-a-Lago resort in Florida, signaled he would likely challenge more than just the 71-year-old institution’s approach to the Middle East once he takes office. While Trump did not elaborate on why he considered the United Nations ineffectual, he made it clear both before and after the Security Council adopted the resolution condemning Israeli settlements in the West Bank and East Jerusalem that he believed the United States should have blocked the move. President Obama instructed U.N. Ambassador Samantha Power to abstain from voting, on the grounds that the Israeli government’s continued support for expanding Jewish settlements could undermine any prospect of eventually reaching a two-state solution to the simmering conflict. After the Security Council voted, Trump tweeted, “As to the U.N., things will be different after Jan. 20th,” which is the day he will assume the presidency. Trump moved relatively quickly to select a U.N. ambassador nominee after being elected. But his choice, South Carolina Gov. Nikki Haley (R), has little international affairs experience beyond leading trade missions to about half a dozen countries while serving as governor. The United Nations has come under fire for years from critics on both the right and the left. Conservatives have attacked it for infringing on individual nations’ sovereignty as well as wasting resources, while many developing nations argue that most major decisions remain dominated by a handful of countries that were influential when the United Nations was established decades ago. In recent years, some of its peacekeeping troops have been repeatedly accused of raping civilians they were sent to protect, and this August the office of U.N. Secretary General Ban Ki-moon formally acknowledged that Nepali peacekeepers sent by the United Nations to Haiti six years ago inadvertently introduced an outbreak of cholera there, even as U.N. officials maintained they have legal immunity in connection to the epidemic. The disease killed thousands of Haitians in the wake of a devastating earthquake. But the United Nations continues to play a key role in helping deliver humanitarian assistance across the globe, brokering cease-fires during conflicts and serving as a forum for sprawling issues such as how best to address climate change. Obama has worked doggedly during his time in office to support multilateral institutions such as the United Nations. He has used his speech each year before the U.N. General Assembly as a way to lay out his vision for foreign affairs and has convened summits there to tackle questions that include the global refugee crisis and the fight against terrorism. Earlier this month, the president stopped by to personally thank Ban for his work when the secretary general, who is stepping down at the end of the month, was meeting with national security adviser Susan Rice at the White House. Americans see the U.N. more negatively than positively when it comes to effectively solving problems, though most see the organization in a positive light and its popularity has risen over the past decade. Democrats are far more favorably inclined toward the U.N. than Republicans, among whom ratings plummeted during the Iraq war and have not recovered.  Both Gallup and Pew show improved ratings for the U.N. since the late 2000s. The percentage saying the organization does a “good job” has risen from 26 percent in 2009 to 38 percent in 2016 in Gallup polls; Pew finds the share rating the group favorably rose from 48 percent in 2007 to 64 percent in 2016. The improved ratings in recent years have been concentrated among Democrats and independents. During a new conference last month, Obama emphasized that the United States must continue to play the leading role in maintaining “the basic framework of the world order” that was established after World War II. “And I’ve said before, that’s a burden that we should carry proudly,” Obama said. “And I would hope that not just the 45th president of the United States, but every president of the United States understands that that's not only a burden, but it’s also an extraordinary privilege. And if you have a chance to do that right, then you should seize it.”

In Yemen’s grinding war, if the bombs don’t get you, the water shortages will

SANAA, Yemen — For months, citizens of this war-torn country have been terrorized by bomb explosions and mortar attacks. Now another threat is growing, which could be just as deadly. Yemenis are running out of water. This poor Arabian Peninsula country has faced a severe scarcity of water for decades. But four months of fighting have dramatically worsened the situation, with attacks destroying water pipes, storage tanks and pumping facilities. The number of Yemenis who lack access to drinking water has almost doubled since the war began, according to the United Nations and aid agencies. Now, they say, more than 20 million people — about 80 percent of Yemen’s population — struggle to find enough water to quench their thirst and bathe. Diseases such as malaria are spreading, killing hundreds of people, because so many residents are forced to use improperly stored and unsanitary water, health experts say. The crisis is compounding a humanitarian emergency that already has prompted U.N. officials and aid workers to warn of famine. If the shortages aren’t alleviated soon, there could be large-scale epidemics and many more deaths, said Ahmed Shadoul, the World Health Organization’s head of mission in Yemen. “We expect a lot of people to die if the water situation remains unchanged,” Shadoul said. Many Yemenis are so desperate for water that they bathe with a damp cloth. During storms, people crowd the streets to catch rain in buckets. Being bald has become more popular, but not as a fashion statement. “People are shaving their heads because they don’t have enough water to wash their hair,” said Mubarak Salmeen, 58, who lives in Aden with his wife and five children. This country has long experienced water shortages because of rapid population growth, a dry climate and government mismanagement of the water system. Not helping the problem is a national obsession with a drug called khat. Huge amounts of precious groundwater have been diverted to cultivate the plant, the leaves of which are chewed by millions of Yemenis for its stimulant effect. In recent months, an escalation in fighting has led to unprecedented disruptions in accessing water. Air raids, shelling and ground assaults have destroyed water infrastructure. In the southern port city of Aden, home to roughly a million people, most taps have run dry. “The water situation is a disaster,” said Najib Mohammed Ahmed, director of Aden’s water and sanitation authority. The war pits Shiite rebels known as Houthis against supporters of President Abed Rabbo Mansour Hadi, whose government was toppled in February. A Saudi-led coalition launched a bombing campaign against the insurgents the following month. Saudi Arabia maintains that the rebels are a threat because they receive support from Iran, its regional foe. The water problems go beyond the destruction of infrastructure. Power plants and electricity lines have been damaged in the fighting, hampering municipal authorities’ ability to pump water to residents. Diesel fuel for backup generators, which could be used to power the pumps, has become scarce because of the difficulties of transporting it through war zones. In addition, U.N. officials and aid workers say an air and naval blockade established by the Saudi-led coalition is severely restricting imports. Saudi officials deny they have choked off supplies of energy, saying that ships and aircraft are allowed to bring food and fuel into Yemen after undergoing inspections for illicit arms. The lack of water has transformed many Yemenis’ lives. “It used to be that we would run for shelter when it rained. Now, if there’s rain, we all run outside with buckets,” said Hussein bin Mohammed, 38, a pharmaceutical salesman from the southern city of Taiz. The worsening shortages have sharply driven up the price of water in a country where the average resident earns $122 a month. Fuad Abdulrahman Ali, 53, an antiques salesman from Sanaa, said that prices have more than quadrupled for water trucked in from wells in surrounding villages. “I never thought we’d be at the point of thinking about whether we can afford water,” said Ali, a father of three. The shortages are so intense that wildcat drillers are boring wells and extracting untreated groundwater that they sell to consumers, health experts say. Meanwhile, residents are storing water for drinking and cooking in uncovered containers that become breeding grounds for mosquitoes that transmit malaria and dengue fever, according to the United Nations and aid agencies. In recent weeks, those organizations have identified at least 8,000 suspected cases of those diseases, far more than the usual number. “These containers at people’s homes have become a primary reason for the proliferation of mosquitoes that is causing large outbreaks of these diseases,” said Alkhader Laswar, the Aden director for Yemen’s Health Ministry. In his city, he said, malaria and dengue fever have killed several hundred people. Cholera and other waterborne diseases are also likely to spread as people use contaminated water. The United Nations says that 120,000 children could die if the lack of access to clean water, sufficient food and adequate health care persists. The fighting has forced many hospitals and medical clinics to close. So far, about 3,500 people have been killed in the attacks. “Children are dying of the current health conditions in the country much more so than before,” said Julien Harneis, the Yemen representative for UNICEF. More than a million Yemenis have been displaced by the fighting. Many have sought refuge in rural areas with few wells and springs. The intensifying competition for water could create more conflicts. “Now you have wells in these rural communities that are supplying water to 1,700 people instead of just 700,” said Mohammed Shamsan, an adviser to the Ministry of Water and Environment. “This is frightening.” Ahmed al-Sanna has certainly seen a rise in demand for the water in his village, located in a sparsely populated area south of Taiz. Before the war, a trip to a local well would take less than half an hour. Now, the 46-year-old farmer said, the lines for water are so long that he has to wait seven hours to fill the containers that are hauled back home by the family’s donkey. “The lines are becoming too long,” Sanna said. “We don’t know what we’re going to do.” Naylor reported from Beirut. **Read more:** Fighting in Yemen is creating a humanitarian crisis Yemeni militiamen appear to be driving Houthi rebels out of Aden Quietly, al-Qaeda offshoots expand in Yemen and Syria

Acid attacks rising in Colombia

BOGOTA, Colombia – Every glance at a mirror transports Consuelo Cordoba to the moment when her boyfriend doused her with a skin-searing acid that obliterated her face, leaving her with gruesome wounds that will never heal. The chemical burned off an ear, melted an eye, ate through her lower face and ruined her teeth. She now wears a skin-tight elastic mask, breathes through a straw-like tube that protrudes from her nose and walks the streets looking “like a monster,” as she put it. “I would like to go to sleep today and not wake up tomorrow,” she said. “The truth is life is too hard and I am alone.” ****A cheap and quick way of destroying a woman’s life, acid attacks in India, Afghanistan and Bangladesh have received widespread attention in recent years, witha documentary about victims in Pakistan winning an Oscar this year. While the gruesome assaults have been rare in the West, a rising number of attacks in Colombia has alarmed prosecutors and public health officials and terrified women. Dozens of such attacks, in which assailants soak their victims with sulfuric or nitric acids, are believed to take place here each year. The precise reason for the spike here — and not in, say, neighboring Peru — is not known. But women’s rights advocates in Colombia talk about an epidemic of violence against women, from spouse-battering cases so extreme that they make the nightly news to reports of illegal armed groups using rape as a weapon in a murky rural conflict. “Sometimes in the West we make fast judgments and say, ‘Look how terrible they treat women in the East,’ and we don’t look first at ourselves,” said Monica Roa, the Bogota-based international programs director of Women’s Link Worldwide, a rights group. “The violence here may be different, but it emanates from the same place. This is a culture where machismo reigns, where men do what they want to do.” If a woman is attacked over a dowry in India or because she ventured outside without a veil in Pakistan, in Colombia a woman might be attacked because of sheer rage over her independence or even by a disturbed man she doesn’t know. That’s what happened in 2004 to Maria Cuervo when a complete stranger shouted, “This is so you don’t think you’re so pretty” and drenched her face with acid. Mostly, though, a jilted boyfriend or a husband intoxicated with jealousy is behind the attack. “He had hit me because of jealousy, so I ended it,” Erica Vanessa Vargas, a slight, soft-spoken woman of 20, said of the day she ended her relationship with a boyfriend four years ago. “He then said, ‘If you’re not mine, than no one will have you.’ ” Her former boyfriend paid a small boy $1.75 to throw acid at her — changing the course of a young life. “I stopped going to school, I can’t work, I can’t depend on my own self,” said Vargas, wearing a scarf to shield her scarred neck and chin. The statistics on acid attacks are hazy in Colombia, as in other countries where they take place. Bogota city councilwoman Olga Rubio, a victims’ advocate, said about 100 of the assaults have taken place so far this year across Colombia. It is a pace that would easily surpass last year’s total of 150. The state’s forensic science institute registers more than eight cases a month, though most involve male victims, many of whom were assaulted by muggers using acid as a weapon. The attorney general’s office, meanwhile, said it is investigating 56 cases, 36 of them involving women. But Attorney General Eduardo Montealegre said he believes “a considerable volume of crimes and aggressions are not reported.” “Experience shows that what’s reported does not correspond to reality,” he said, explaining that victims are sometimes attacked by relatives and fear coming forward. Noting an increase in acid attacks, Montealegre said he is creating a new team of prosecutors and crime-scene experts to investigate the crimes. The team would also determine whether authorities have inadvertently downgraded the gravity of reported acid attacks, instead of cataloguing some of them as attempted homicides. The perpetrators often receive no jail time because the attacks are treated as minor assaults, said Sen. Carlos Baena. “The punishment is very light and doesn’t take into account the very dramatic pain that the victim has to go through,” said Baena, who is sponsoring a bill to impose at least a 20-year prison term on convicted attackers. He and the city councilwoman, Rubio, are also proposing regulations to require buyers of acids to register their purchase. Such reforms might have an impact. The number of attacks in Bangladesh fell from about 500 a year a decade ago to about 100 a year after that country imposed tougher sentencing guidelines and began to register acid sales, said Jaf Shah, the executive director of London-based Acid Survivors Trust International. Health care providers describe a heinous crime that can literally wipe away a victim’s face. Linda Guerrero, director of the Foundation for the Burned, which provides plastic surgery, physical therapy and psychological assistance to victims, said the chemicals in the acids corrode the proteins in facial skin and sear through delicate tissue. “It’s the worst thing that can happen to your skin,” she said. And then there is the psychological damage to the victim, of having to live with a gruesomely disfigured face she does not recognize, a face that can repel even family members. The shock seems to be magnified in a society like Colombia that so venerates beauty. “Our society is not prepared for people with deformities and less so people with facial deformities,” said Alan Gonzales, a plastic surgeon has operated on several acid attack victims. “They are discriminated by society, perhaps not in a premeditated way, but spontaneously because we do not have a culture that is equipped to deal with tragedies like these.” The acid thrown at Viviana Hernandez, 29, not only burned her face and chest but also damaged a cornea and ate through her eyelids. “It’s devastating economically and psychologically,” she said of the 2007 attack by her former partner. “But I think more psychologically than physically. This is something you never, ever leave behind.” Hernandez said she made it with the help of her three children, her siblings and mother. She now works as an accountant. Consuelo Cordoba, though, says she can only dream of a job and family. She has neither, she said, and instead begs in Bogota’s sprawling wholesale food market. An evangelical church gives her the $120 she needs for her monthly rent. People who have read about her in local newspapers provide her with meals. Though she has had about 40 operations since being attacked a decade ago, she must still wear a mask. She even has trouble eating, because of the damage done to her teeth. “There are some who just stare at me, shocked, and others who make fun,” she said. “I don’t pay attention to them. Sometimes it hurts, but you have to continue living.” She had once been a vivacious woman, decked out in jewelry and wearing colorful, velvety dresses, as evidenced by the old pictures she still has. “I was pretty, I had beautiful hair, I had a nice smile and perfect teeth,” she said. “And then this happened to me and it was all taken away.” **More world news coverage:** \- Egypt demands release of Guantanamo detainee \- China hits back at Clinton on Africa \- With Americans gone, Afghan base in disrepair \- Read more headlines from around the world

If news media had covered Ebola sooner, could latest outbreak have been contained?

On June 3, the international humanitarian organization Doctors Without Borders issued a news release with a stark headline: “Resurgence of Epidemic Ebola in West Africa.” A day later, the World Health Organization declared the outbreak one of the deadliest ever, with 223 victims in three countries. Neither announcement caused much of a stir in newsrooms across the United States. The Associated Press moved a 315-word dispatch about the developments. The New York Times carried a brief editorial a few days later (“the outbreaks will require a large educational effort to alert people to the dangers” of the virus, it decorously advised). No U.S. television network said a word about it, according to the Nexis database. Three weeks later, Doctors Without Borders issued another, more urgent communique. “Ebola in West Africa: Epidemic requires massive deployment of resources,” read the headline. “The epidemic is out of control,” declared the organization’s director of operations, Bart Janssens. The WHO weighed in at month’s end. It tallied 467 victims — twice the count at the start of the month — in Sierra Leone, Guinea and Liberia, making the outbreak by far the largest on record. The organization urged  “drastic action” to contain it. The news media’s reaction this time was bigger, but hardly big. CNN did a brief segment on the emerging scourge on June 25, as did CBS, ABC and PBS’s “NewsHour.” NPR’s “Morning Edition” devoted four minutes to the developments. The Washington Post blogged about it and wrote an editorial. Among the handful of American newspapers that mentioned the disease over the following 10 days, only the Pittsburgh Post-Gazette and the Herald-Sun in Durham, N.C., accorded front-page play to the topic. And then, for the next few weeks, the story largely faded from view again. As the death toll climbed past 1,000 and new infections emerged each day, little was heard about Ebola in the American news media. Outside of the wire services, no domestic news organization sent a reporter to the affected region until after July 4. By the end of the month, only NPR and the New York Times had correspondents in the field. News about the Ebola crisis has been inescapable in the U.S. media for the past two months or so. But the outbreak incubated and grew into a crisis without much attention. Most major news organizations, including The Post and the Times, reported on it sporadically; none gave much prominence to the stories. A few major outlets — NBC, Fox News, Time, the Los Angeles Times — reported nothing for months as the disease jumped borders and international aid organizations issued ever more alarmed calls for help. The coverage languished even as the disease reached milestone after grim milestone: the first outbreak in an urban area; the first to cross international borders; the greatest number of infections and deaths since Ebola was identified in 1976. “I was screaming and yelling about it back in May, and I was stunned by how little interest there was,” said Laurie Garrett, a global health expert at the Council on Foreign Relations and a former reporter who won a Pulitzer Prize in 1996 for her coverage of an Ebola outbreak in what was then the Republic of Zaire. “I was frustrated. . . . There were so few people on the story. There weren’t enough people keeping their eyes on the prize.” The question — purely hindsight now — is whether it would have mattered if there had been. Would sustained and earlier news coverage by the American media have made any difference in the fight against Ebola? Could the news media have mobilized public opinion earlier to compel the response, including U.S. military intervention, that the Obama administration is only now marshalling? Some of those involved in fighting the disease suggest it could have. “We felt like in May, June or early July that we had an opportunity to stop this disease. But we couldn’t get the attention we needed,” said Ken Isaacs, vice president of programs and government relations at Samaritan’s Purse, a North Carolina-based relief organization that is involved in Ebola-treatment efforts. “The media can create public interest by what it decides to cover, and the gravity of this disease was not represented by the media coverage” in the spring and early summer. The media’s inattention to the Ebola story appears to have been a result of multiple factors. Most significant was that the outbreak came at an inconvenient time, at least for news organizations: The disease began to spread as other big international stories were capturing the attention — and limited resources — of media outlets. Among others, there was the Russia-Ukraine conflict; the rise of the Islamic State in Syria and Iraq; the Israel-Palestinian clash in Gaza; and the World Cup in Brazil. Journalists acknowledge that other stories took a higher priority than the developing catastrophe in West Africa. “My argument is that, as great as our resources are, we still can’t do everything,” said Dean Baquet, the executive editor of the New York Times. “We can’t do 100 stories on Ebola when there are 50 other important topics to cover. There’s a limited number of stories we can cover that way, and that’s just reality. It’s not just about the expense. It’s the attention of the editors, too.” Added Baquet, “Of course, if we had all known how the story was going to evolve, we would have covered it sooner. But I don’t think anyone quite saw how big it would be. If we had, we would have jumped on it sooner. As it was, I would argue that the press moved more quickly than the government. I think you could make the case that we _did_ influence the government.” Kevin Merida, The Post’s managing editor for news, said, “There was never a lack of interest in the Ebola story. We recognized that this was a major medical crisis growing in significance. We struggled initially to get someone on the ground, as our Africa correspondent was deployed on an ambitious project and other logical candidates were [covering] other important stories. . . . So for a while we did the best we could to report on Ebola with our resources in Washington.” Merida points to “the breadth, ambition and momentum of our work since August.” The remote location of the outbreak — primarily rural areas of underdeveloped nations — presented a perception issue, too; earlier outbreaks had flared in such locations and quickly burned out. “As long as it appeared to be something afflicting isolated, remote rural areas in Africa, as in the past, it was not a huge story,” said Adam Nossiter, the Times’ bureau chief in West and Central Africa. But Nossiter noticed something different about this outbreak at the end of June: resistance by villagers in Guinea to outside intervention, complicating efforts to contain the virus. In early July, he traveled to Conakry, Guinea’s capital, and then to the forest region near Gueckedou, to investigate. He filed his first story from the region on July 12; it was published on July 28 on the Times’ front page, marking the first time the outbreak received such prominent treatment by the newspaper. Some of the American media’s indifference to the story may have reflected entrenched attitudes toward Africa, said A. Trevor Thrall, the director of George Mason’s biodefense graduate program. “Thanks to low public interest in Africa and the fact that very few U.S. news organizations have any footprint in Africa, Africa is more or less invisible in the U.S. media most of the time,” he said. “With a few exceptions, Africa shows up only when something happens that directly affects Americans or when the U.S. government takes some kind of action.” As it happens, the story’s trajectory changed dramatically on July 27, when news services reported that two American missionaries in Liberia, Texas doctor Kent Brantly and medical worker Nancy Writebol of North Carolina, had been diagnosed with the virus. Suddenly, outlets that had shown little interest in Ebola before — from “Good Morning America” to local TV stations — were reporting about Brantly and Writebol and the scourge sweeping West Africa. Their evacuation to a specially equipped hospital at Emory University was widely covered for days. The news of the first patient being brought to the hospital received car chase-like treatment on CNN, which broadcast live aerial images of an ambulance driving to the hospital. For some television journalists, an early barrier to covering the story was finding a way to make it visually compelling and “relevant” to viewers, said Richard Besser, ABC’s chief health and medical editor. Two years ago, Besser, a physician, covered an Ebola outbreak in Uganda by embedding with epidemiologists from the Centers for Disease Control and Prevention who were hunting for new cases. But when Besser, himself an epidemiologist, reached out to the CDC in the spring, he was told that the agency intended to send only data specialists to West Africa to set up a case-monitoring system. “From my side, that’s not very interesting TV,” Besser said. “The visuals of someone sitting at a laptop don’t really work for a minute and a half or two minutes of network TV.” But once the two Americans became sick in late July and returned to the United States, “it definitely became a major story. It made it easier to relate to the story and made it more relevant to people’s lives.” A week later, Isaacs of Samaritan’s Purse, which employed Brantly, told a House subcommittee hearing that “it took two Americans getting the disease in order for the international community and the United States to take serious notice” of the epidemic. Overall, however, Thrall says the news media were somewhat ahead of the government in paying attention to the disease. But once the government got involved, media interest took off, he said. On Aug. 8, the WHO called the outbreak a “public health emergency,” providing a fresh boost to news coverage. The story spiked again in early September when President Obama pledged U.S. military support to fight the disease. And it spiked again Sept. 23 when the CDC projected as many as 1.4 million infections in West Africa by January. Thrall says each spike was predictable. “The U.S. news media tend to take their lead from the U.S. government,” he said, “especially on scientific or medical issues that journalists need expert help to understand. . . . Without decisive U.S. government action or concern, it can be difficult for news organizations to keep stories alive.” Which is why Thrall thinks it’s unrealistic to have expected the news media to have devoted more attention to the virus earlier: Because government officials were not seriously alarmed or engaged until August, the media could not have known just how devastating the Ebola outbreak would be. It was the government, not the media, he said, that misjudged the severity of the outbreak. “The early press coverage was perfectly responsible,” Thrall said. “It only looks problematic looking back because public-health experts predicted that the outbreak would be limited like all previous Ebola outbreaks. Journalists all heard the same thing early on — Ebola is incredibly fatal but relatively straightforward to contain. . . . Even if a journalist had somehow suspected it would be worse, there is no way to track these diseases except on the ground through the public-health system, so there is no way journalists could have known any sooner than public-health officials what was happening.”

Notable deaths

Julius Rudel, who was the general director and principal conductor of the New York City Opera for 22 years until 1979 and led other operas around the world, died June 26 at his home in New York. He was 93. A family representative confirmed the death but did not disclose the cause. Mr. Rudel was born in Austria and moved to the United States as a teenager. He led more than 150 operas in the world’s major opera houses, including the Vienna Staatsoper, the Paris Opera, the Metropolitan Opera and the Los Angeles Opera. He was the first music director of the John F. Kennedy Center for the Performing Arts in the District, serving from 1971 to 1975. He joined the New York City Opera in 1944. The City Opera filed for bankruptcy and shut down late last year. He wrote a memoir, “First and Lasting Impressions.” Leslie Manigat, a prominent figure in the Haitian political establishment whose term as president was cut short by a military coup in 1988, died June 27 at his home in Port-au-Prince, Haiti. He was 83. Evans Baubrun, deputy secretary of Mr. Manigat’s political party, confirmed the death but did not disclose the cause. Baubrun said Mr. Manigat’s condition may have been complicated by a recent bout of chikungunya, a debilitating mosquito-borne virus that has been rapidly spreading in Haiti since the first locally transmitted cases emerged earlier this year. Mr. Manigat, a former professor of history and political science, won the presidency in January 1988 amid the tumult that followed the fall of former dictator Jean-Claude Duvalier two years earlier. The election, which was boycotted by the main opposition parties, was widely seen as illegitimate. A round of balloting three months earlier was called off after gunmen shot into lines of voters at polling stations and other assailants hacked people to death. Witnesses said soldiers took part in the shooting, and the opposition said the military organized the bloodshed to ruin the first free election in three decades. Within six months, Mr. Manigat was ousted in a coup led by Lt. Gen. Henri Namphy. Upon fleeing to the neighboring Dominican Republic, he appeared finished with politics. “I’m not going to fall into the classic trap of deposed political men who see the return to power from one moment to the other and pass all their time waiting for that imminent return,” he told reporters at the time. “I’m not only a politician, but a political scientist. I can avoid that vision, that force of mistaken politics and personal frustration.” He did eventually return to Haiti and politics. He ran for president in 2006 but came in second to René Préval. In 2010, his wife, Mirlande Manigat, ran and was defeated by Michel Martelly, the current president. Ramón José Velásquez, a former Venezuelan president known for his role in opposing dictatorship in the South American country, died June 24, it was reported from Caracas, Venezuela. He was 97. Opposition politician Henry Ramos Allup announced the death but did not disclose the cause. Mr. Velásquez assumed the presidency for eight months spanning 1993 and 1994 after his predecessor, Carlos Andrés Pérez, was impeached for embezzlement. Before becoming president, Mr. Velásquez worked as a lawyer, journalist and historian. He was jailed repeatedly in the 1950s under the dictatorship of Marcos Pérez Jiménez. One of his arrests was for his contributions to a book detailing the administration’s misdeeds. Mr. Velásquez served as the director of the newspaper El Nacional, one of the country’s largest and most prestigious dailies. He became a politician after the country transitioned to democracy. He spent time in Congress and served in various presidential administrations before he was appointed president. Pamela Sanders Brement, a Time magazine correspondent who worked in Vietnam, New York and Washington and later wrote books and plays, died June 26 at her home in Tucson. She was 79. The cause was liver cancer, said Dr. Orest Zaklynsky, a family friend. Mrs. Brement was born in Manila to Anglo American parents and was interned during the Japanese invasion of the Philippines in World War II. She wrote a column for the Manila Times before she began working for Time in 1960 as a freelance reporter in Laos and Vietnam. She left Vietnam in 1963 but returned 11 years later with her husband, Marshall Brement, a Foreign Service officer. Marshall Brement served as U.S. ambassador to Iceland in the early 1980s. Mrs. Brement’s books included “Iceland 66 Degrees North” (1985), with the photographer Roloff Beny, and “Iceland, Isle of Light,” written with her husband. She also wrote a novel, “Miranda” (1978), and a comic play about old age, “I’ll Be Seeing You.” **— From staff reports and news services**

Syrian activists accuse government of deadly chemical attack near Damascus

BEIRUT — The Syrian opposition on Wednesday accused the government of launching a chemical weapons attack in the Damascus suburbs that killed large numbers of civilians as they slept and packed makeshift hospitals with hundreds of victims convulsing and gasping for breath. Photographs and videos posted online showed the bodies of men, women and children, many appearing to be dead, without visible wounds. Varying opposition claims put the death toll in the hundreds, with some saying it was more than a thousand. While the exact cause of the deaths remained unclear, there was widespread agreement, as one European expert noted, that “something terrible has happened.’’ If confirmed, the use of toxic agents would be the most serious in decades, presenting a renewed challenge to President Obama, who said last year that the use of chemical weapons in Syria would constitute a “red line” requiring a U.S. response. The Syrian government strongly denied responsibility. But a White House statement put the blame squarely on Syrian President Bashar al-Assad, referring to “reports that hundreds of Syrian civilians have been killed in an attack by Syrian government forces, including by the use of chemical weapons.” French Foreign Minister Laurent Fabius said the international community should respond “with force” if the allegations are proven true, news services reported. The deaths touched off a vigorous debate among independent experts about whether available information pointed to the use of a well-known chemical weapon such as the nerve agent sarin or to some other toxic agent. U.S. intelligence agencies offered no early verdict. The attack came as U.N. investigators were already on the ground in Syria to investigate previous incidents in which the United States and its allies have said small quantities of chemical weapons were used. But the U.N. Security Council was unable to agree Wednesday on whether those experts should immediately investigate the new incident. The Russian government, Assad’s strongest supporter, suggested that the opposition itself had staged the attack in a “pre-planned provocation.’’ Witnesses said the attack began when Russian-made Grad rockets began falling at around 2 a.m. in neighborhoods east of the capital where rebels have had some recent success in repelling government forces. Sama Masoud, an opposition activist who lives in one of the targeted neighborhoods, described scenes of chaos on the streets as panicked residents did not know whether to stay in their homes or flee. “The fiance of my sister has died,” she said. “My friend, her husband and her husband’s uncle — all dead while asleep.” More than 130 videos were posted online showing the victims. In some, children lay on tiled floors, vomiting, convulsing and struggling to breathe as they were treated with hand-held respirators or as medics desperately administered chest compressions. In others, men sprawled on the floor of a makeshift hospital were hosed down with water in what appeared to be a desperate attempt to wash off the remnants of the poisonous gases. Majed Abu Ali, a medic in nearby Douma, said his team had treated 600 patients with symptoms that included reddened eyes with constricted pupils, vomiting, skin rashes, loose bowels and extreme difficulty in breathing. He said 65 people had died and that the “overwhelmed” medical staff had little to protect themselves from toxins. Some experts questioned the video evidence. “It strikes me as odd that the people who are treating the infected victims are not undressing them,” said Raymond Zilinskas, a biologist and former U.N. weapons inspector in Iraq. “When you’re dealing with a chemical event, there is always a ‘red zone’ and a ‘green zone’ — always,” to protect medical providers. But others said the symptoms exhibited by victims were far more convincing than in any of the previous alleged chemical incidents. Amy Smithson, a senior fellow at the James C. Martin Center for Nonproliferation Studies, said the photographic evidence “clearly indicates exposure to a toxic chemical,” citing a combination of telltale symptoms such as respiratory problems and twitching, and the near-absence of wounds that would be associated with conventional explosives. But she acknowledged that it was impossible to tell whether the apparent poisoning was caused by sarin or one of the other known toxins in Syria’s arsenal. “Regardless of whether this was a classic warfare agent like sarin, the Chemical Weapons Convention outlaws use of any toxic chemical for military purposes,” Smithson said. Jean Pascal Zanders, an expert on chemical and biological weapons at the European Union Institute for Security Studies in Paris, said in a blog posting that the photographs appeared to confirm “exposure to toxin,” but not necessarily nerve gas. He added, “It is clear that something terrible has happened. These scenes could not have been stage-managed.” Even the more-conservative opposition casualty estimates of Wednesday’s attack would make it the most extensive use of chemical weapons since 1988, when thousands of Iraqi civilians were killed in the Kurdish village of Halabja in an attack launched by President Saddam Hussein. At a news conference in Istanbul, George Sabra, deputy head of the Syrian Opposition Coalition, said the death toll had reached 1,300. The Britain-based Syrian Observatory for Human Rights put the number at 136. Denouncing the lack of international action on Syria, Sabra reiterated calls for a no-fly zone, saying that not only is the Assad regime killing the Syrian people but “the weakness of the U.N. is killing us. The U.S. hesitation is killing us.” Obama has steadily escalated U.S. aid to the opposition, although rebel fighters said that light arms and ammunition shipments that administration officials said were recently cleared for delivery have not arrived. But the administration has remained divided over the wisdom of the more direct military support that the rebels and some U.S. lawmakers have demanded. In an Aug. 19 letter to Rep. Eliot L. Engel (D-N.Y.) released Wednesday, Gen. Martin E. Dempsey, chairman of the Joint Chiefs of Staff, said that more robust military assistance, including U.S. air assaults against Assad’s air force, could not ensure that U.S.-favored moderates in the fractured opposition would prevail. In a surprisingly direct statement of his own policy recommendation, Dempsey wrote that “the best framework for an effective U.S. strategy . . . going forward” is more humanitarian aid and support for opposition moderates. DeYoung reported from Washington. Ahmed Ramadan in Beirut, Joby Warrick in Washington and Colum Lynch in New York contributed to this report.

Haiti dreams of tourism revival

A couple of rumpled aid workers were sucking down Sunday morning beers at the Hotel Florita here when the minister of tourism rolled up to the curb, followed by the interior minister with body guards toting AR-15s and then the star of the show, New York fashion designer Donna Karan of DKNY. The notables were in Jacmel, the funky art and carnival capital of Haiti, to plot the transformation of the earthquake-rattled port from a faded flower of the Caribbean to a resort destination for jet-setters. “We’re trying to rebrand Haiti,” Tourism Minister Stephanie Balmir Villedrouin said in an interview, her toddler in her arms. “We’re trying to raise the bar a little bit, and so we’re bringing Donna here to help us with our vision.” Said Karan, as she swept through the abandoned Hotel Jacmelienne — its seaside swimming pool green with algae, its overgrown gardens littered with broken glass, coconut husks and discarded condoms — “Oh, we can definitely work with this!” As hard as it may be for young Haitians to believe, their country was once a tourist destination. Even during the bad old days of the Duvalier dictatorships and their creepy bogeymen, the Tontons Macoutes, the tourists came. Or at least a few: See Graham Greene’s 1966 novel “The Comedians,” set incidentally at a hotel and based on a real-life gingerbread mansion, the Hotel Oloffson in the capital; the hotel is still in operation but is now run by Richard Morse, front man for the voodoo rock band RAM and the new government’s special political envoy to the Americas. Today, nobody visits Haiti for fun, except Haitians returning from the diaspora. The arrivals lounge at the Port-au-Prince airport is filled with Baptist missionaries, U.N. bureaucrats and American nurses — not a bona fide tourist in sight. Yet across the Caribbean, revenue from tourism represents about 16 percent of gross domestic product, and many island nations, such as the Bahamas, Barbados and Antigua, generate at least a third of their GDP from visitors. For most of the Caribbean, tourists’ dollars, euros and pesos are the No. 1 source of foreign investment. Haiti let its tourism infrastructure degrade over three decades of political instability, violent coups, a U.S. invasion, hurricanes, earthquakes and cholera. But the poorest country in the Western hemisphere has a lot to offer the adventuresome visitor, according to international planners and Haitian officials. The Creole French cuisine here is some of the best in the Caribbean; its artisans are of world renown, its blend of African and Spanish music unique. All this, and voodoo, too. The still-evolving plans for Haiti 2.0 envision Jacmel as a stand-alone destination, meaning tourists would not land in the chaotic, intimidating, impoverished capital, Port-au-Prince, but arrive directly here via air or boat. With development aid from banks and donor nations, the government of former carnival singer and current president Michel Martelly is planning to extend the airport runway at Jacmel so it can accommodate small jets that would shuttle from Miami and Fort Lauderdale, Fla.; Puerto Rico; and Guadaloupe. The forlorn port is also scheduled for restoration to allow big cruise ships to dock. In the late 1800s, Jacmel was an important Caribbean crossroads in Haiti — then called the “Pearl of the Antilles” — and its downtown still harbors the Creole architecture of wrought-iron balconies and shuttered warehouses for coffee, saffron and orange peel. The town reminds many visitors of the French Quarter in New Orleans, and it hosts one of the best carnivals in the Caribbean, as well as a music festival and a film festival, now struggling to gain traction again after the 2010 earthquake. Donna Karan knows Jacmel well; she shot her fall catalog at the Hotel Florita. The New Yorker gamely jumped into the bed of a pickup truck for a tour of town. It stopped at the Manoir Alexandre, once the most prominent building in the city and now a ruin that is slowly being restored by Leon Paul, a Haitian American orthopedic surgeon from New York. “We want to restore the manoir to its former glory, but as you can see, that is a big job,” Paul said as he walked Karan through the property, with its peeling wallpaper, holes in the roof, missing stairs and tilting balcony. He said Jacmel, his home town, will rise from the rubble, and he promised that someday soon, Haitians and visitors will be sitting in his restored mansion, listening to a band, drinking rum and celebrating. As Karan crawled through the ruins, she saw not despair, but hope: “Wow. Look at this. These are my colors. The rust, yellow and blue. Take a picture. This is perfect!”

West Africa can’t manage the Ebola outbreak

An alarming report released last week by Doctors Without Borders said that West Africa’s current Ebola outbreak is “out of control.” That should shock the governments of Guinea, Sierra Leone and Liberia into action. It marks a frightening moment for a disease that has been contained numerous times before. The outbreak, already the deadliest in history, had killed almost 400 people as of Thursday. It began in March but then slowed, causing the Guinean president to declare to the World Health Organization (WHO) in April that “the situation is well in hand.” But all was not well, and complacency led to relaxed measures and a second surge. More than 600 cases have now been reported, with the patients experiencing headache, fever and internal and external bleeding. The virus kills up to 90 percent of the people it infects, but it leaps from person to person only through contact with bodily fluids. Unlike some viruses — including the one causing Middle East respiratory syndrome — Ebola is not new. It was discovered in 1976, and small outbreaks have been recorded occasionally since then. No cure exists, but medical teams have always effectively segregated infected areas and stopped the virus’s spread. The method is understood: treat the patients, trace their contacts and isolate those people. But West Africa had not seen a major Ebola outbreak and was unprepared. Its public-health infrastructure is weak. There was no quick incident response system with a command-and-control structure, and no comprehensive public health plan for a mobile population. In the early stages of the crisis, Guinea buckled under economic and political pressure. To this day, the health ministries of the three countries lack effective ways to build public awareness. Among the biggest challenges is the public’s reluctance to cooperate. A stigma attaches to those who are infected, and so families hide the sick, making it more difficult to trace contacts. Some run away and in so doing spread the disease. A death can lead to a dozen more infections among those who clean and prepare the body for the funeral. International groups sometimes have difficulty discouraging these behaviors. In April, an angry crowd attacked a Doctors Without Borders clinic in a town in Guinea. The locals charged that the health workers were bringing Ebola to the villages. Mobs not infrequently have thrown rocks at medical workers. The WHO is convening an 11-country meeting this week to coordinate a regional response. It plans to recruit more village heads and local chiefs to participate in the public awareness campaign. This meeting is promising. But there is a real risk that Ebola will spread. Other West African countries must heed the lesson of Guinea, Sierra Leone and Liberia. Deaths can be prevented if their leaders face the danger and implement complete, proven methods of control. **Read more from Opinions:** The Post’s View: Killer virus demands open accounting Holly Burkhalter: Curbing the child migration crisis begins with combating sexual abuse The Post’s View: As measles cases increase, a sharp call for vaccinations Stephen Lerner and Nelini Stamp: When heroin use hit the suburbs, everything changed

In one of Haitian capital’s roughest neighborhoods, a pretty good second chance

In helping give birth to modern cities, disaster has been a useful, if cruel, midwife. In the months following Haiti’s massive earthquake in 2010, people hoped it might be true here, too. There was plenty of precedent. ****The Chicago fire of 1871 left one-third of the city’s population homeless. The city’s economy, however,grew faster in the year after the fire than in the year before it. The earthquake and fires that struck San Francisco in 1906 destroyed 28,000 buildings. Almost overnight, it cleared vast areas on which a healthier and more handsome city was built. By now, though, it seems unlikely that Haiti’s capital will be similarly transformed by the earthquake that damaged or destroyed about 180,000 buildings in the metropolitan area. The best intentions and money pledged will not come close to what is needed to turn Port-au-Prince into a modern city with wider streets, bigger houses, more public space, and water and sanitation for all. But one neighborhood, Ravine Pintade, gives a hint of what is possible on a small scale. It has been transformed. A giant pile of rubble — bigger in volume than the Washington Monument — has been carted away. The ravine’s slopes have been stabilized with 7,900 feet of retaining walls. Nearly 8,000 feet of buried pipe carries rainwater that used to sluice through the streets. The footpaths that residents used to joke were “too narrow for a rat to get down” are now four feet wide. More than half the community’s 900 families have a new house or had repairs done to the one they were in. Almost every new dwelling has a system for capturing rainwater for washing and bathing. People can buy potable water for a small price from five community-run kiosks. Groups of houses share 23 septic tanks and 100 bucket-flush toilets, which can be locked for privacy. Twenty solar-powered lights illuminate streets. No one would call the rebuilt Ravine Pintade a model neighborhood. But it is far better than it was. More important, it is a product of Haitian planning and labor — and is what the residents wanted in almost every detail, including the not-very-good ones. “There are a lot of people spending a great deal of time planning unrealizable actions,” the project manager, Aram Khachadurian, said of the past two years of Haiti rebuilding. “The balance of planning and doing should be shifted more in the direction of doing, even now.” Khachadurian, 55, works for CHF International, a charity based in Silver Spring that was originally called the Cooperative Housing Foundation. He was previously a banker, a real estate developer and a regional planner for New York City. Named “Katye” — the Creole word for “neighborhood” — the project was paid for with $8.5 million from the U.S. Agency for International Development. CHF and another nonprofit, San Diego-based PCI (formerly Project Concern International), were the “implementing partners.” The project employed about 55 people — only four were non-Haitians — and provided $1.4 million in direct economic stimulus to the community. The most visible change is 260 new one-story dwellings and 75 two-story ones. Steel-framed, with wood and composite walls, they are expected to last at least 25 years. Less apparent but equally important, Khachadurian said, is the “local ownership” — something many projects pay lip service to but few achieve. “We had quite a different approach,” he said. “Everybody was involved in everything.” Roughly $12.4 billion has been pledged in private and international post-earthquake aid to Haiti through this year. At least a third of that total went toward emergency relief for earthquake victims: food, water, shelter, medical care and cash. Whether the rest of the aid would have been enough to turn Port-au-Prince into a modern city is uncertain. The reconstruction of Chicago, San Francisco and many other disaster-damaged cities was financed by economic growth, not charity. Haiti’s stagnant economy assured that was not going to happen here. But there were other reasons, as well. Less than a quarter of recovery aid (which could pay for long-term rebuilding) went to Haiti’s government, according to an analysis by the Center for Global Development, a Washington think tank. Charities, non-governmental organizations and contractors continued to be the main conduits for help and money. That has been true for decades, thanks to the country’s legendary instability and reputation for corruption. (Since 1806, 56 presidents have served, with fewer than a dozen completing their terms.) Governance has continued to be difficult. The current president, Michel Martelly, has had two prime ministers since taking office in May 2011. Most experts say that a well-funded, strong national government — or its equivalent, such as an occupying army — is necessary to execute projects such as repaving streets, laying water and sewer lines, and forcing changes to lot sizes. “Because the money went to NGOs, I don’t think it was ever realistically an option” to modernize Port-au-Prince, said Vijaya Ramachandran, an economist at the Center for Global Development and co-author of the report. “NGOs don’t work at the level of rebuilding cities.” Her fellow author, Julie Walz, added, “You can’t rebuild an entire city through one project here, one project there.” But you can rebuild a neighborhood. Ravine Pintade is a 40-acre, V-shaped gash in the hills above downtown Port-au-Prince. It was poor and dangerous before the earthquake. The disaster did not make it more prosperous or safe. Rebuilding the area was a high priority for Haiti’s government because it was heavily damaged and many of the residents were living in a displaced-persons camp in a downtown park. However, there was only enough money to rebuild one side of the ravine. The north side was chosen because CHF and PCI had “strong existing community relationships” there, Khachadurian said. As it turned out, that asymmetry was the source of recurrent trouble during the 17 months of reconstruction. Participation was voluntary. People were not forced to get new dwellings if their own house was salvageable and they wanted to fix it up. Residents were consulted about design and were expected to find solutions to showstopping problems. When the project was finished in May, maintenance of common spaces and infrastructure became the residents’ responsibility. The project engineers started with a test plot in which 30 house lots were cleared and new dwellings were built while the residents lived on-site in tents. It quickly became clear, however, that that strategy was not practical for the whole project. Hundreds of families would need to find temporary housing. “We met with the community and said: ‘We need to start work on this date. What do we do?’ ” Khachadurian recalled. It turned out that most people had friends or relatives with whom they could stay. For the few who did not, tent sites would be found. Another big problem was that wider paths and outdoor places to sit were neighborhood priorities but there was not any unoccupied land for them. As the project evolved, 201 households agreed to reduce the size of their plots, 171 agreed to reshape them, and 51 agreed to share their plots with another family by living in two-story houses. “New” land was also created by building vertical retaining walls where dirt slopes had taken up space. “We were able to create huge changes in the public spaces, but it was adding up centimeters at a time,” Khachadurian said. There were limits, however, to the project managers’ deference to local wishes. The plan called for six water kiosks, where the public could buy chlorinated drinking water. Space was found for five. The only place the community could agree on for the sixth was was in the middle of a widened and rehabilitated road. The engineers said no. There are only five water kiosks now. Crime temporarily halted the project several times. South-side thugs forced a contractor at gunpoint to deliver sacks of cement to their side of the ravine, which was not part of the project. Someone robbed a contractor, again at gunpoint, as he distributed payroll. A south-sider stoned the construction headquarters, shouting that his neighborhood was being left out, and in return was severely beaten. **** There were ongoing annoyances. Ralph Chery, the 39-year-old Haitian in charge of erecting the dwellings, said that in some parts of the neighborhood his crew had to work extra-long days and lug out uninstalled steel, cables and plywood each night. “Not everyone in the neighborhood is a beneficiary,” he said, noting that thieves lived on both sides of the ravine. Khachadurian, who speaks French and Creole, visited the south side several times and did some rubble removal there as a gesture of goodwill. He told the residents he understood their resentment. He said he would try to get a project for their half of the ravine, too. In December, one of the Haitian engineers was kidnapped. Work was halted again. For three days and nights people from both neighborhoods looked for the man. The searchers included the stone thrower and a man who had once come into the project office courtyard wielding a machete. On the fourth day, after his family paid ransom, the engineer was put out of a car on a nearby street, shaken but unhurt. That night, people from both sides of the ravine gathered in the courtyard to welcome him back. (The current belief is the kidnappers, never identified, were not from either neighborhood.) It was a “West Side Story” moment, only with a happy ending. “There was a triumphant look in their eyes,” Khachadurian said, choked with emotion at the memory. “I just felt the message coming from these people — ‘We’re going to have our conflicts, we’re not going to be totally honest sometimes, but in the end this is our project. You can count on us.’ And it really was true.” CHF has a proposal pending with the World Bank for $10 million to do a Katye-like project on the south side of Ravine Pintade. It just got an invitation to come in and talk.

Charles Lane: Cuba’s hard truths exposed

Cholera is a potentially fatal, water-borne, gastrointestinal disease usually associated with poverty and inadequate sanitation. Some600,000 people contracted the disease in Haiti after the 2010 earthquake, 8,000 of whom died. It is not the sort of illness that you would expect to find in Cuba, where Fidel Castro’s 1959 revolution ushered in an era of free high-quality health care and excellent public health — or so we are often told. The truth about Cuba, however, is that the revolution’s achievements were never as great as its propagandists claimed and that economic and social conditions on the island trail those of many Latin American countries Cuba once surpassed. Cholera has returned to Cuba for the first time in more than a century. In three reported outbreaks since the summer of 2012, more than 600 people have been sickened and at least three have died, according to official Cuban data. Of course, no one can say for sure whether these figures tell the whole story; they have been grudgingly admitted by a regime that is both totalitarian and eager to reassure the tourists upon whom it depends for hard currency. Cuban authorities did their best to play down the bad news about cholera until visitors from Europe and Latin America — as well as a Cuban American from New York — contracted the disease this year and their cases made the press abroad. Meanwhile, another kind of devastating truth about Cuba is influencing international public opinion in the form of “Una Noche” (“One Night”), a brilliant new indie film by first-time director Lucy Mulloy. After premiering at the Berlin and Tribeca film festivals in 2012, it is in limited release in theatres and available for download on iTunes. Whereas the cholera epidemic bespeaks the decline of physical conditions on the island, “Una Noche” dramatizes the heartbreaking moral and psychological decay of the revolution’s subjects, especially Cuban youth. Denied free expression, forced to hustle incessantly for life’s necessities, bombarded by propaganda and hounded by brutal police, young Cubans live in what Mulloy aptly calls a state of “nervous desperation.” As one of her Cuban characters mutters, there only two things to do in Cuba: “sweat and f---.” Prostitution, sexual and otherwise, is the dominant mode of human interaction, but every transaction is ultimately rigged in favor of the authorities and the tourists whose dollars help fuel the regime. The brothers in charge of this corrupt madhouse, Fidel and Raúl Castro, never appear in the film; they are not mentioned by name, much less criticized. One wonders if this was the price Mulloy paid for her apparently extensive access in Cuba. It hardly matters, since the audience knows who has been in power for the past 55 years and who is accountable for what Cuba has become. The film’s turning point comes when Raul, a teenager eager to escape this crazy-making milieu, assaults a tourist he has caught having sex, for cash, with his mother. She needed the money for AIDS medicine. With the police hunting him in every alleyway, Raul decides to flee to the United States. He and two companions take to the sea on a precarious raft fashioned from stolen styrofoam and bartered inner tubes. It is the same desperate course taken by tens of thousands of Cubans, many of whom have died in the attempt. I won’t spoil the ending except to say that the movie culminates on a realistic note — which, since it’s about Cuba, cannot be a totally happy one. Mulloy’s camera takes in Havana with the precision of a documentarian and the rhythm of a rapper. The result is a pulsation of conflicting images — fetid hotel kitchens, speeding police cars, street fights, parading hookers, jet-skiing foreigners — as hectic as the city itself. She slows only occasionally, to linger on collapsed walls, patched-up roofs and crumbling sidewalks. It’s as if Havana had been hit by some massive artillery barrage — but we know this is the urban legacy of a half-century of communism. “Una Noche” may do for nervous, desperate Havana what “Slumdog Millionaire” did for the shantytowns of Mumbai: portray it in a visual idiom that resonates with the new generation of pop-culture consumers and touches their hearts. At least, I hope “Una Noche” has that kind of impact. Because another truth about Cuba is that Americans have grown too complacent about the Castro dictatorship. Enough already with the benign neglect. Enough already with the excuses — the U.S. embargo chief among them — and the phony promises of “reform.” Enough already with a system, just 90 miles from our shores, that offers its people no sane alternative but escape. _Read more fromCharles Lane’s archive, follow him on Twitter or subscribe to his updates on Facebook._ **Read more in Opinions:** The Post’s View: For Cuba, a torch of freedom The Post’s View: Raúl Castro’s empty talk on civility in Cuba Katrina vanden Heuvel: U.S. should end the Cuban embargo Harold Meyerson: Afro-Cubans fight for equality under Castro regime

For Haiti’s elephantiasis patients, specter of voodoo lingers, hampering care

LEOGANE, Haiti — The clinic at St. Croix Hospital is clean and tiled and brightly lit, but the spirits of voodoo have not entirely loosed their hold on the elephantiasis patients who go there for treatment. Many of them still believe that magical powder sprinkled in their path caused the disfiguring disease that made their legs permanently swollen. Most sought treatment first from voodoo priests and traditional healers — and too late from physicians. As Haiti carries out a decade-long effort to eliminate lymphatic filariasis, the mosquito-borne infection that causes elephantiasis, the old view is finally losing some of its power. Patients are now willing to consider a medical cause alongside a magical one. “It is not easy to differentiate the natural causes from the fetish causes,” said a man attending a support group at the hospital. “But it is possible. You need to consult both medical doctors and witch doctors.” Luccene Desir, a 35-year-old Haitian physician who has treated elephantiasis here for more than a decade, has seen a change in people’s thinking. “If they see someone in the market with a large leg, people may say, ‘You need to go to the hospital,’ ” Desir said. Some voodoo priests, he added, sometimes give that advice as well. Leogane is a commune — roughly a county — of 150,000 people west of Haiti’s capital, Port-au-Prince. Sugar cane is grown here, as, in the past, was rice. Both are associated with a high prevalence of lymphatic filariasis. By one measure of infection, about half of Leogane’s people were carrying the parasite in the late 1990s. If the country succeeds in eliminating the disease through mass drug distribution, the achievement will come too late for the St. Croix patients. They enter the hospital through a side door that is labeled “big foot,” the condition’s local name. Just inside is a tiled area with benches and four spigots where patients can scrub their legs. The organism that causes the disease, Wuchereria bancrofti, can block veinlike vessels called lymphatics. Lymphatic fluid that is usually delivered back to the bloodstream leaks into tissue. Binding the limb can squeeze some of it out, but only temporarily. Treated in its early stages, the swelling of elephantiasis can often be reversed. Once it has become extreme, it can’t be. Further enlargement — and painful, feverish exacerbations — can be prevented by keeping the leg clean and elevated. Desir and a staff of 15 people do clinical care and research on lymphatic filariasis. Their salaries are paid by a charitable foundation affiliated with the drug company Abbott Laboratories. One of their activities is a monthly support group called “Hope Club” where patients talk, sing and pray. Desir invited some of its members in to talk to visitors. Nearly all were women; they ranged in age from 30 to 88. The younger ones were in pants, the older ones in dresses. Some sat with a leg up on small stools the clinic has in abundance. Mimose Louissaint, a 56-year-old woman with pigtails, said she believes her case came from two abscesses she got escaping a burning factory where she worked as a teenager. But she is not willing to rule out a voodoo cause for some of the other patients’ afflictions. “You could simply be in trouble with someone, and they might have an evil powder,” she said. Eline Antoine, 30, pulled up the left cuff of her jeans. Her leg was the worst in the group. It was covered with thickened skin, dry and deeply fissured. “The reason it has gotten that bad is because I believed it was a fetish,” she said, meaning sorcery. She now wishes she had not put so much confidence in herbal healers. Marie Muracile Joseph, a thin 36-year-old with a mild case, said that in cases of sorcery the condition proceeds quickly and that “it may produce multiple toes.” She was referring to wartlike excrescences that can form on the front of the foot in severe cases. With Haitians now willing to consider infectious causes of the disease, the stigma associated with elephantiasis has lessened a bit. Elizabeth Ajax, 45, was fired from her teaching position more than 20 years ago. “Back then I was put out of society,” she said. “It is less humiliating now.” Poline Guerrier, also 45 and wearing a large straw hat, said she was still embarrassed to walk on the street. “Everybody’s eyes are on you,” she said. “They call you ‘yam leg.’ ” Desir explains to his patients that their disease is caused by a parasite with a complex life cycle and an insect vector. He does not belabor this. However, he is not beyond making a point. A few years ago a voodoo priest came in for treatment. Desir said he asked him why he did not just treat himself: “He said, ‘No, I cannot. I have to see a doctor.’ So I asked, ‘Why do you receive those that come to you?’ ” The doctor laughed ruefully as he recalled the priest’s response: “He said, ‘I have to make money!’ ” \- READ: Haiti takes on a dreaded, disfiguring disease one mouth at a time \- READ: The facts about lymphatic filariasis

Venezuela should join the fight against the Zika virus

Regarding the Feb. 16 front-page article “Venezuela lacks tools to battle Zika virus”: After being declared an international public health emergency, the Zika virus is not receiving essential attention from Venezuela’s government. Instead of joining and supporting multinational efforts to prevent spreading the virus, the government seems to be denying that the problem exists and even worse, facilitating the virus’ expansion. The World Health Organization recommends people in Zika-affected areas protect themselves from mosquitoes and practice safe sex, but if the population has no access to birth control, including condoms; abortion is illegal; and essential supplies such as pain relievers, gauze and lab tubes are limited, then a crime against humanity is in progress. Furthermore, as scientific research groups , journals and funding institutions pledged to share information to help fight the Zika virus, Venezuela’s refusal to report all cases and its denial of information about the virus to its citizens should prompt world organizations to intervene. It is alarming that the Zika virus is quickly spreading throughout the Americas, affecting so many countries. Global commitments are fundamental in order to win this battle. ****Tina Nunez** , Charlottesville**

‘There is nothing left to live on’: Haiti’s hurricane survivors cope with loss, despair

CHANTAL, Haiti — As the creek behind Hermosante Fedna’s home overflowed its banks and lapped at her walls, she waited, afraid the hurricane winds outside posed the greater danger. She and her husband, Tiophal Sintable, had built their home and raised seven children there. He grew rice and cassava in the green coastal fields behind it. She sold them in the market. But the sounds Monday night were tremendous, like roaring engines. The winds uprooted towering palm trees and hurled them into the cinder-block shacks all around her. Coconuts landed like cannonballs. When the wind shook her walls and the floodwaters reached her knees, her son carried the 85-year-old Fedna to church to wait out the storm. Haitians all along the southern coast are now reckoning with the extraordinary toll of that night, destruction on a scale none there had ever seen. Along the southern peninsula that was largely spared from the devastating 2010 earthquake, Hurricane Matthew landed a ferocious blow, damaging or smashing thousands of homes, schools and churches, razing trees and crops, and sweeping away farm animals. Fedna’s house was flattened. Her husband, who fled to a different building, died when the ceiling crashed down, pinning him under the wreckage with a flashlight in his hand. “This is the worst thing to ever happen to our town,” Fedna said Friday, tears glistening on her cheeks. Hurricane Matthew has killed at least 300 people in Haiti, according to the national government, but the figure was sure to rise as aid teams reached areas cut off by washed-out bridges or fallen trees. A Reuters tally from local and national officials put the death count at more than 800. The town of Chantal and its surroundings are among the worst hit, with 106 confirmed dead. U.N. officials have called the hurricane the country’s worst humanitarian crisis since the 2010 earthquake, which killed about 200,000 people. Residents said people died after being struck by falling trees or collapsing roofs. Others disappeared in the floodwaters. “This is killing us,” said Fedna, weeping quietly. “There is nothing left to live on. Our trees and our crops are gone.” The United Nations reported that more than 350,000 of the 1.5 million people living in the area affected by the storm need assistance. Aid agencies fear that cholera — a deadly disease spread by contaminated water — could also decimate vulnerable populations. Already, new cases are being reported at local clinics. Four days after the hurricane slammed into the Western Hemisphere’s poorest nation with winds reaching 145 mph, thousands of Haitians remained without power, communications or clean water. The powerful storm continued its destructive march through the Caribbean and hammered Florida on Friday. In Jeremie, the hard-hit capital of the Grand’Anse department at the western end of Haiti’s southern peninsula, 80 percent of the buildings have been damaged or destroyed, said Holly Frew, a spokeswoman for the aid group CARE. The western area “is pretty much still cut off,” and many communities are accessible only by motorbike, she said. “As information begins to come in from the west, we’ll continue to see the death toll rise,” Frew said from Jacmel on the southern coast. “Over in the southwest, it’s utter despair.” Conor Shapiro, 35, who runs the St. Boniface Hospital in Fond-des-Blancs, said few patients have been able to get to his hospital, the largest on the southern peninsula, because roads are blocked and a key bridge washed out. He said he hoped to see more of an international rescue effort soon. “Maybe the surge will come,” he said. “But this feels like a forgotten disaster.” Chantal is on the far side of a damaged bridge over the L’Acul du Sud River — still cut off from main roads in this part of Haiti — and residents now fear for their access to food. Before his house collapsed, Pierre Listene, 37, grabbed small plastic sacks of coffee beans and black beans, which he spread on the ground Friday at a chaotic makeshift market along the riverbank. His livestock — five cows, five pigs and 25 chickens — had been swept away. “This is all we were able to save,” he said. “There is going to be hunger.” The scope of the storm damage was difficult to discern in the first couple of days because this peninsula was unreachable by road, and aid groups have only recently begun to explore coastal villages to assess the problems. Some towns are still isolated, and only rumors of destruction have trickled out. Power was still out along the coast, and phone service was sporadic. Health-care workers expressed worry that hospitals had insufficient supplies to deal with the injuries or disease that could follow the storm. Along this part of the coast, most houses appear to have suffered some damage from wind, flooding or falling trees. Gisette Maurice, 62, began building a two-bedroom home outside the nearby city of Les Cayes after her husband died nine years ago. She farmed rice to scrape a meager living and to buy the concrete blocks and metal sheeting for the roof. Maurice finally moved in this past December. She shares the humble home with 19 other relatives. The hurricane ripped off her roof, submerged the television and refrigerator, washed away her children’s and grandchildren’s birth certificates, and made her eight-year achievement uninhabitable. “I’ve lost my appetite; I can’t eat,” she said. “I just keep thinking about what I have to do to rebuild this.” “The kids are still in school,” she went on. Then she started to cry. Maurice and her family are now sleeping with neighbors. The government estimates that about 35,000 Haitians are in shelters across the south. Residents are struggling to dry out from the deluge. Up and down the roads Friday, people were hanging their clothes to dry on fallen tree branches, on downed power lines, on gravestones and on the ground. Women dragged soaked furniture and mattresses out into the sun. Men fired up chain saws to cut through downed trees that blocked the roads. Denise Louis, 40, did not need to move anything outside to dry; the sun now poured right into her home. Only one wall still stood after the storm, exposing all her belongings to the passing cars. “I’ve seen flooding, but never something like this,” she said. Louis, who sells cosmetics in the local market, fled with her two sons when her walls rattled violently, running to a neighbor’s house on higher ground. She returned to no home at all. Muddy clothes, shoes, scraps of homework assignments and a soggy mattress were all jumbled on the floor and strewn in the yard. The front door was propped sideways on the ground. With a $400 debt outstanding at the bank, and her cosmetics lost in the flood, Louis had no idea what would come next. “I’ve lost everything,” she said. Brian Murphy and William Branigin in Washington and Paul Schemm in Addis Ababa, Ethiopia, contributed to this report.

Ebola demands an urgent response from the United States and its allies

In an Aug. 3 Outlook commentary, “What we need to contain Ebola,” Michael T. Osterholm stated clearly that a quick and major response was needed to the outbreak in West Africa. Now, a month later, The Post is still calling for this large response because none has been forthcoming [“A fire not yet extinguished,” editorial, Sept. 2]. Meanwhile, the number of infections and deaths grow and the main countries hit by the outbreak are breaking under the strain of attempting to contain the disease with very limited facilities and staff. The United States needs to provide support now and get our allies around the globe to ante up immediately, too. We’ve already lost a month. ****Tena Turner** , Silver Spring**

‘It’s despair on all fronts,’ says Ebola aid worker

For Lance Plyler and the other health workers treating Ebola patients at the small missionary hospital in Liberia, exhaustion came in many forms. The physical demands of working under layer upon layer of protective gear, sweating profusely in the sweltering African heat. The mental challenge of staying alert to the risk of infection while caring for patients suffering bouts of vomiting, diarrhea and fever. The realization that no matter how hard the health workers tried, most patients would die. “It’s despair on all fronts,” said Plyler, an American doctor who led the Liberian disaster response efforts for the international relief organization Samaritan’s Purse. “It wears on you after a while. . . . It breaks some people.” President Obama plans to announce Tuesday that the United States will significantly ramp up its aid to Ebola-ravaged countries in West Africa, from sending supplies and setting up field hospitals to providing health-care personnel and training local medical staff. The commitment comes days after the World Health Organization issued a plea for more volunteers, saying at least 500 doctors and 1,000 more health-care workers are needed. But while the additional U.S. aid will come as good news for West African officials and aid organizations, it remains unclear how quickly it will make an impact on the ground. International relief groups that have shouldered the burden for months say their staffers are fatigued and fragile. Finding volunteers to relieve workers battling the epidemic has been a struggle. “We are so much at the breaking point,” said Joanne Liu, international director for the humanitarian group Doctors Without Borders. “My people are telling me, ‘We don’t know how much longer we’re going to last.’ ” More than 240 medical staffers have gotten sick while fighting the outbreak, and about half of those have died. And the epidemic has spread rapidly in recent weeks. More than 2,400 people have been killed. Despite pledges of support in recent days, including $50 million from the Bill and Melinda Gates Foundation and Cuba’s commitment to send 165 health workers, the response remains disturbingly inadequate, humanitarian groups say. A serious need exists for more workers who can provide logistical and operational help, such as running isolation units, distributing medical supplies and conducting safety training, Liu and others said. In the meantime, relief workers care for swelling numbers of patients at overburdened treatment centers. Cleaning crews must disinfect corpses and sanitize isolation wards covered in blood, vomit and feces. Burial teams put themselves at risk while safely disposing of the bodies of victims. One of the most stressful jobs at a Doctors Without Borders Ebola-treatment camp in Monrovia, the Liberian capital, is working the front gate, which often involves telling very sick people there is no room in the facility. Some African nationals working alongside international staffers face the additional burden of the skepticism that surrounds the disease, making them stigmatized in their own communities. At the Monrovia treatment center, Western medical staffers have been working eight-to-12-hour days in the humid Liberian weather, with perhaps an afternoon off each week. Locals generally work three shifts before taking their fourth day off. “They’re working too hard,” Sylvia Wamser, an Austrian clinical psychologist who spent three weeks in Sierra Leone working for Doctors Without Borders, said of the clinic staffs. There are “feelings of helplessness and guilt. It’s a bit like Sisyphus; you try to do your best, but you know there’s so much work out there to do.” Wamser said she counseled weary workers in stress-management techniques. She taught them to mentally revisit better days, such as a visit to the beach. She encouraged them to listen to music, watch movies or go jogging. Most aid groups limit the number of days and hours that staffers can work without a break. They also try to rotate in new workers before employees are burned out. But that has proved more difficult during the Ebola outbreak than in past disasters. “Where are the volunteers?” said Ken Isaacs, a vice president at Samaritan’s Purse and a former director of foreign disaster assistance at the U.S. Agency   for International Development. “There aren’t so many people willing to go there, because it’s so deadly.” Joe DiCarlo, vice president of programs at Medical Teams International, a Christian health organization that has operated in Liberia since 2004, said his group has a roster of more than 300 trained medical professionals that it calls on when disasters happen around the world. But when the group sought people to head to West Africa, some said no or simply did not respond. “There is hesitation from volunteers. ,” DiCarlo said, adding: “But there are people who are willing to go.” Dan Kelly is one of them. When the infectious-disease expert decided to join the Ebola fight in Sierra Leone this summer, colleagues at the University of California at San Francisco seemed to think he was crazy. Alarming numbers of health-care workers in West Africa were getting sick and dying. Still, Kelly thought he would be followed by many like-minded doctors and scientists. He was wrong. “I’m still fighting an uphill battle to get anyone interested in going,” Kelly said, having returned from a three-week visit to Sierra Leone, where he taught modern infection control practices and checked in on a health-care nonprofit group, Wellbody Alliance, that he started in 2006. In addition to the new U.S. aid, more help on the way — eventually. Cuba’s health professionals are to arrive early next month. The World Health Organization is training hundreds of workers in the protocols needed to prevent Ebola transmission, and the U.S. Centers for Disease Control and Prevention has scheduled its own training next month. USAID has put out a call for volunteers; so has UNICEF, the global children’s rights and emergency relief organization. Samaritan’s Purse and other aid groups that were forced to pull some workers out are planning their return, despite the risks. “It really is analogous to going to war,” said Plyler, the Samaritan’s Purse doctor. “This is literally a deployment where your life is on the line.” Meanwhile, health-care workers in the affected countries — particularly Liberia, Sierra Leone and Guinea — wait for relief. “You need more people so it’s not such an incredible burden on the people doing the work,” said Dan Lucey, an expert on global virus outbreaks at Georgetown University Medical Center who recently returned from three weeks in Sierra Leone. “There are far too few people to provide basic care.” Lucey, who plans to begin a six-week stint in Liberia this month, spent part of his time in Sierra Leone inside an isolation unit at Connaught Hospital, caring for patients waiting to learn whether they had Ebola. He remembers the feeling when he showed up to discover only two other doctors caring for dozens of patients: “You get there, and you look around, and you say, ‘Where is everybody?’ ” Related: U.S. to announce major increase in Ebola aid

Saving themselves: Haiti’s unsung grassroots heroes do the work of rebuilding communities

Today marks the five-year anniversary of the deadly earthquake that devastated Haiti, killing over 300,000 people and nearly leveling an entire country’s infrastructure. The country continues to grapple with rebuilding itself even after over $12 billion in aid was pledged by over 50 countries, 80 percent of which has been distributed, according to the United Nations. In 2014, photographer Felipe Jacome began taking portraits of Haiti’s change makers, taking a closer look at local leaders and grassroots organizations trying to bring change to their communities, often with very little resources in the face of tremendous hardships.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico “Over past the four years working as a documentary photographer in Haiti, I have encountered a remarkable amount of stories of individuals and grassroots organizations creating positive change,” Jacome tells In Sight.  “The types of initiatives range widely as they tackle the long list of Haiti’s illnesses. There is the story of KOFAVIV, a support group of rape survivors helping the thousands of women and children raped in the aftermath of the disaster. There is the tireless campaign of Haiti’s amputee soccer players to demand respect for the marginalized handicapped population.” Jacome’s portrait piece seeks to highlight the stories of Haitians changing Haiti, a story sometimes overlooked by the international aid apparatus and muffled by the country’s political instability.

Death toll from Hurricane Matthew surpasses 300 as Haiti tallies devastation

LES CAYES, Haiti — The death toll from Hurricane Matthew neared 300 Thursday as the scope of the devastation in Haiti became clearer, officials said. Aid workers found vast numbers of damaged homes, as well as uprooted palm trees, toppled cellphone towers and downed power lines. Two days after the hurricane slammed into the Western Hemisphere’s poorest nation with winds reaching 145 miles per hour, thousands of Haitians remained without power, communications or clean water. Aid groups warned that cholera could spread quickly, adding to the humanitarian crisis. According to a Ministry of Interior spreadsheet available at a hurricane response coordinating meeting at the United Nations compound in Les Cayes, there have been at least 299 deaths just in parts of southern Haiti. Haiti’s interior minister, François Anick Joseph, had earlier said that at least 108 deaths were caused by the storm. At least four more deaths were reported in the neighboring Dominican Republic. The town with the highest death toll on the document was Chantal, with 106 deaths, followed by Les Anglais, with 85. More than 35,000 people had taken refuge in shelters in the south, according to the document. Other towns that were reportedly hard hit but which have been hard to reach, such as Jeremie, on the north side of the southern penninsula, had yet to be counted. “That’s just the south, and that’s just what they know about,” said Conor Shapiro,35, who runs the St.Boniface Hospital in Fond des Blancs, the largest hospital on the southern peninsula. Shapiro said that very few patients had been able to get to his hospital since the storm because roads are blocked and a key bridge washed out. He hoped to see more of an international rescue effort soon. “Maybe the surge will come,” he said. “But this feels like a forgotten disaster.” The hurricane, the most powerful Caribbean storm in nearly a decade, took aim at Florida on Thursday after carving a punishing path through the region, also striking Cuba and the Bahamas. A helicopter tour Thursday of Les Cayes, a port city on Haiti’s southwestern coast, showed extensive damage, with cinder-block buildings knocked to the ground and metal roofs peeled back like tin can lids. Everywhere, trees were flattened, and the main river that runs through town was swollen to the top of its banks and running the color of milk chocolate. Aid workers rushing to the scene to assess the damage feared that some towns were still cut off from the outside world, since bridges have been swept away and trees have fallen across rural roads. Thousands of people have been displaced. “Flying over, we were able to see quite a lot of destruction. Storm surges, downed trees, crop damage, farm damage,” said Margaret Traub, head of global initiatives for International Medical Corps, who landed in Les Cayes with two colleagues and a journalist Thursday afternoon. “If I had to estimate, I would say at least 80 percent of buildings saw damage. Many of them were destroyed.” Meanwhile, other alarming signs were emerging. At least three cases of cholera were reported in Jeremie, on the tip of Haiti’s southwestern peninsula, said Holly Frew, a spokeswoman for the aid group CARE in the Haitian capital, Port-au-Prince. At a central hospital in Les Cayes, two people with cholera had shown up Thursday, but the hospital staff didn’t have the intravenous fluids or antibiotics to treat the disease. Cholera, a potentially deadly disease spread by contaminated water, is a main concern for relief agencies struggling with how to bring clean water and emergency sanitation systems to areas now accessible only by air. “This is a very great danger for the city,” said Tony Guillaume, an orthopedic surgeon in the hospital in Les Cayes. “They can contaminate others.” Only one nurse was available to treat the crowd that showed up in one of the muddy hospital waiting rooms. Some sat waiting with broken limbs. A young man vomited on the floor. Some residents had cuts from metal roofing that blew off in the storm and sliced into people. Doctors said they hoped to soon reopen the cholera ward, which had closed before the storm swept in, dumping waist-high water around the hospital. Aerial images provided by the U.S. Coast Guard showed scenes of near-total damage in some areas: wooden homes now just scattered timbers, roofs sheared off and palm groves leveled by the Category 4 storm. In some areas of Haiti, people have been living in makeshift structures since a major earthquake six years ago that killed 200,000 people. Haitian officials said 38 of the hurricane deaths occurred in the department of Grand Anse in the southwest of the country, which was especially hard hit. About 80 percent of the buildings were destroyed in Jeremie, said Frew, the CARE spokeswoman. The U.N. deputy special representative for Haiti, Mourad Wahba, has described the hurricane as the country’s worst humanitarian crisis since the earthquake in 2010. Matthew slammed eastern Cuba before churning Thursday over the Bahamas, where residents were urged to move to high ground and the capital, Nassau, was battened down for the strongest hurricane in the Caribbean since Felix struck in 2007. In Les Cayes, white United Nations trucks drove through the streets Thursday afternoon carrying heavy machinery, such as bulldozers and earthmovers, to serve the rescue and rebuilding efforts. Residents were out clearing away debris and beginning their repairs. Many roads were flooded, but some main thoroughfares were passable. Across the hurricane-hit region, many Haitians sought shelter in schools where votes were meant to be cast on Sunday. Haiti’s electoral council on Wednesday postponed a presidential election that has already been delayed several times. Authorities said the situation would be evaluated over the next week before a new date was announced. The U.S. Navy has sent three ships to Haiti, including an aircraft carrier and a hospital ship. About 300 Marines were aboard the USS Mesa Verde, an amphibious transport vessel. The Haitian Embassy in Washington described the next few days as “critical to the recovery process” and urged governments, organizations and private individuals to coordinate their aid efforts to avoid overlap and waste. “It is expected that many will want to engage and take initiatives toward recovery and relief efforts,” the statement said. “The state of Haiti strongly encourages all individuals who are in the process of organizing specific responses and action plans, to work with the local organizations and institutions in Haiti.” Murphy reported from Washington. Paul Schemm in Addis Ababa, Ethiopia, contributed to this report.

The lessons of the Ebola outbreak suggest a larger, faster response is needed

THE WORLD is fast learning lessons about how to combat the Ebola virus ravaging West Africa and yet not learning them fast enough. The virus, for which there is no known vaccine or antiviral, has now infected 3,069 people and killed 1,552 in Guinea, Liberia, Nigeria and Sierra Leone. Senegal has just reported its first case. Overall, the pace is accelerating; nearly 40 percent of the cases have been in the last three weeks. The World Health Organization (WHO) predicted on Aug. 28 that eventually 20,000 may become infected. Research to chart the genome of the virus has pinpointed its origin from a lone animal somewhere in West Africa in late December. From that moment on, the virus leapt from human to human by close contact with bodily fluids. The research underscores a basic fact about control: The best way is stopping contact with infected people. It has been a proven method for decades in smaller outbreaks. However, this outbreak has been larger than all previous ones combined, and that is where the new lessons are emerging. West African nations, with fragile health-care systems and weak governments, had no experience in fighting the disease. Panic, suspicion and fear have overrun public health concerns. The lesson is that health authorities and governments need to pay attention to the attitudes of everyone, not just the infected. To calm the affected regions in the months ahead will require delivery of massive humanitarian aid to the living above and beyond the medical supplies required to treat the sick. A related lesson is that, while isolation of the sick is critical, it can’t be imposed at the point of a gun. This has been on stark display in the West Point area of Monrovia, where the government decided to establish a quarantine enforced by the army and police. People desperate for work and food sought to evade it, and the quarantine began to leak — inevitably leading to spread of the virus. The cordon was taken down. Any effort at control can only work with the cooperation of those affected. It is far better to move the sick away from a city than to close off a whole section of it. Finally, Ebola demands a massive, rapid reaction. The scale is important. The initial response was too hesitant despite warnings from Doctors Without Borders, which has been at the forefront of the struggle, and reports that the response is still lagging. The just-approved WHO “road map” for the coming months points out that “a massively scaled and coordinated international response is needed” to fight such an outbreak, particularly at ports and in large cities. Such rapid-response surges may still be required in the months ahead. Serious shortages of health-care workers, disrupted aviation links and lack of leadership, among other things, hinder the effort. The WHO has published a plan to get Ebola under control in six to nine months at a cost of $490 million. But plans on paper are not enough. A concerted global effort to implement the road map is the only way to put out this fire. **Read more on this topic:** The Post’s View: The real Ebola risk is to Africa, not the United States Michael Gerson: Ebola fever Jim Yong Kim and Paul Farmer: What’s missing in the Ebola fight in West Africa Michael T. Osterholm: What we need to fight Ebola

Colonialism in Africa helped launch the HIV epidemic a century ago

We are unlikely to ever know all the details of the birth of the AIDS epidemic. But a series of recent genetic discoveries have shed new light on it, starting with the moment when a connection from chimp to human changed the course of history. We now know where the epidemic began: a small patch of dense forest in southeastern Cameroon. We know when: within a couple of decades on either side of 1900. We have a good idea of how: A hunter caught an infected chimpanzee for food, allowing the virus to pass from the chimp’s blood into the hunter’s body, probably through a cut during butchering. As to the why, here is where the story gets even more fascinating, and terrible. We typically think of diseases in terms of how they threaten us personally. But they have their own stories. Diseases are born. They grow. They falter, and sometimes they die. In every case these changes happen for reasons. For decades nobody knew the reasons behind the birth of the AIDS epidemic. But it is now clear that the epidemic’s birth and crucial early growth happened during Africa’s colonial era, amid massive intrusion of new people and technology into a land where ancient ways still prevailed. European powers engaged in a feverish race for wealth and glory blazed routes up muddy rivers and into dense forests that had been traveled only sporadically by humans before. The most disruptive of these intruders were thousands of African porters. Forced into service by European colonial powers, they cut paths through the exact area that researchers have now identified as the birthplace of the AIDS epidemic. It was here, in a single moment of transmission from chimp to human, that a strain of virus called HIV-1 group M first appeared. In the century since, it has been responsible for 99 percent of all of the world’s deaths from AIDS — not just in Africa but in Moscow, Bangkok, Rio de Janeiro, San Francisco, New York, Washington. All that began when the West forced its will on an unfamiliar land, causing the essential ingredients of the AIDS epidemic to combine. It was here, by accident but with motives by no means pure, that the world built a tinderbox and tossed in a spark. Many simians, such as gorillas and monkeys, can carry a virus that resembles HIV. But scientists now know that HIV-1 group M was born from a virus circulating among a community of chimpanzees concentrated in Cameroon, a sprawling country with bustling Atlantic Ocean ports, populous highlands, and a lightly developed southern region where relatively few people live even today. This was home to the chimps. Finding a more exact location took a remarkable degree of scientific ingenuity. An international research team led by Beatrice Hahn of the University of Alabama at Birmingham and Paul Sharp of the University of Edinburgh developed an elaborate project that involved searching for the simian virus in chimp feces collected across a vast swath of southern Cameroon. To find a strain of the simian virus that was, on a genetic level, essentially indistinguishable from the most lethal form of HIV, the research team set up 10 stations across the region. Two of the stations were in the particularly remote southeastern corner of the nation, as far as possible from major population centers. It was in these two stations where Hahn and Sharp’s team discovered samples of the simian virus that was almost a perfect match for the HIV-1 group M that eventually killed tens of millions of humans. This discovery, published in the journal Science in 2006, intensified the quest for a birth date for the virus. Again, genetic research offered the key clues. Scientists had long known that a blood sample, preserved from 1959, showed that HIV had been circulating in Kinshasa, the capital of Congo, for several decades before the virus first drew international attention in the 1980s. In 2008, evolutionary biologist Michael Worobey sharpened that picture when he reported in the journal Nature the discovery of a second sample of the virus, trapped in a wax-encased lymph node biopsy from 1960. By comparing these two historic pieces of virus and mapping out the differences in their genetic structures in his lab at the University of Arizona, Worobey determined that HIV-1 group M was much older than anyone had thought. Both samples of the virus appeared to have descended from a single ancestor at some time between 1884 and 1924. The most likely date was 1908. Taken together, these two discoveries offered the clearest clues to the birth and early life of the epidemic. Not far from where HIV-1 group M was born was a major river, the Sangha, flowing toward the heart of Central Africa. This section of the Sangha was not ideal for navigation because of its ribbons of sandbars and the dense vegetation along its banks. In the especially treacherous middle section, near where Hahn and Sharp’s team found the viral ancestor of HIV, few major human settlements ever developed. But there were numerous communities on the Sangha’s more accessible stretches. And due south, past riverside trading towns, was the mighty Congo River itself, the superhighway of Central Africa. Once the virus made the jump from chimp to human, a single infected person could have carried HIV down the Sangha, onto the Congo River and into Kinshasa. The Belgians had founded the city in 1881, during what historians call “The Scramble for Africa,” when colonial powers carved up the continent into areas of influence. By the early 20th century Kinshasa, then called Leopoldville, was the biggest city in Central Africa, fueled by the dizzying growth of trade with the outside world. A final, powerful bit of evidence supported the theory that Kinshasa lay at the heart of the epidemic’s early movements. Scientists studying HIV-1 group M already had found many related varieties, what scientists call subtypes, each with slightly different genetic structures and paths through the world. One, scientists discovered, had traveled east from Kinshasa toward Lake Victoria. One went south to Zambia, Botswana and South Africa. One hopped all the way across the ocean to Haiti, then to the United States and Europe. Many others traveled not very far at all, staying in the Congo Basin. But as scientists plotted out the genetic histories of these varieties and built an extensive family tree for HIV, they all appeared to have spread from a single explosion, a big bang of the AIDS epidemic: Ground Zero was Kinshasa. Powering the big bang was the burgeoning trade of colonial Africa. Ivory may seem a touch quaint today, but in its heyday it was seen as beautiful, versatile and essential to many everyday products. It was used to make billiard balls, jewelry and cutlery. Furniture makers incorporated it into their cabinets, artists into their statues. Bagpipe makers used ivory for mounts, ferrules, buttons and mouthpieces. When supplies of ivory gradually grew short, as colonial agents killed the once plentiful elephants by the thousands, rubber took its place as the economic lifeblood of colonialism in the Congo Basin. The first inflatable rubber tires for bicycles became popular in the 1890s. Mass production of cars soon spiked demand for rubber tires again. The only obstacle to European companies’ reaping huge profits was that collecting ivory and rubber required massive amounts of labor. Getting ivory from an elephant meant stalking the animal, killing it and cutting off its tusks. Getting rubber from vines required slashing them, collecting the oozing white sap and drying it — sometimes on the collector’s own skin. The solution to the manpower demands soon became obvious. Colonial powers created what was essentially slavery: cheap muscle at the point of a gun. This approach was not confined to collecting ivory and rubber. These industries created tremendous new needs for infrastructure to get goods to oceangoing ships along the Atlantic coast. That meant African porters had to carry goods and supplies anyplace the steamboats couldn’t reach. Workers were needed to build railroads, trading stations, dormitories. And somebody needed to operate the steamboats, load the railroad cars, carry the tusks or gobs of rubber in from the jungle. When workers became unruly, the colonial companies deployed heavily armed soldiers to keep the cogs of these vast enterprises moving. All these roles were filled by Africans, many imported from villages hundreds or even thousands of miles away. African life here was beyond cheap. It was disposable. Contemporary accounts by journalists and missionaries tell of colonial officials across the Congo Basin ordering mass slaughters and the torching of restive villages while creating forced settlements that resembled nothing so much as concentration camps. In December 1895 German colonial authorities heard reports that Cameroon’s southeastern corner contained fabulously rich ivory and rubber stocks awaiting exploitation. The Germans soon after gave authority to a colonial company to take control of the region by force. Over the next four years they extended their power all the way through southeastern Cameroon and established a trading station on the Ngoko River about 75 miles upstream from where its waters merged with the Sangha. In the wedge of land defined by these two rivers, HIV either had just been born or soon would be. The trading station was called Moloundou, and a busy town remains there today. But at the time it was almost unimaginably remote. Few human settlements had developed among these forbidding forests. And there were only two practical ways out: by steamship down the Ngoko to the Sangha and on to the Congo River; or overland by foot to the Atlantic. The river route was the easier of the two, and steamships transported the bulk of the ivory and rubber collected in southeastern Cameroon. But overland routes were necessary to connect Moloundou with other trading stations and inland areas rich with rubber and ivory. For these journeys the bounty was borne by Africans who carried loads averaging 55 pounds each. At the peak of the foot traffic that would develop between inland areas and the coast, the busy way station recorded more than a thousand porters passing by on a typical day. Ominously, something else followed the rubber trade through Cameroon: disease. Sleeping sickness, smallpox and skin infections were the most obvious. Colonial authorities attempted mass inoculation campaigns for smallpox and set up quarantine zones that restricted where the porters were allowed to travel. But even so, the diseases spread. Among them was syphilis, which arrived with the Europeans. In just a few years it reached epidemic proportions along porter routes and riverside trading posts in Cameroon and throughout the Congo Basin. It’s impossible now to determine how much of this spread resulted from rapes as opposed to other kinds of encounters, but it’s clear that colonial commerce created massive new networks of sexual interactions — and massive new transmissions of infections. (In later decades, transmission through the reuse of hypodermic needles in medical care probably had some role in HIV’s spread as well.) So HIV’s first journey looked something like this: A hunter killed an infected chimp in the southeastern Cameroonian forest, and a simian virus entered his body through a cut during the butchering, mutating into HIV. This probably had happened many times before, during the centuries when the region had little contact with the outside world. But now thousands of porters — both men and women — were crossing through the area regularly, creating more opportunities for the virus to travel onward to a riverside trading station such as Moloundou. One of the first victims — whether a hunter, a porter or an ivory collector — gave HIV to a sexual partner. There may have been a small outbreak around the trading station before the virus found its way aboard a steamship headed down the Sangha River. For this fateful journey south, HIV could have ridden in the body of these first victims, or it could have been somebody infected later: a soldier or a laborer. Or it could have been carried by a woman: a concubine, a trader. It’s also possible that the virus moved down the river in a series of steps, maybe from Moloundou to Ouesso, then onward to Bolobo on the Congo River itself. There might even have been a series of infections at trading towns along the entire route downriver. Yet even within these riverside trading posts HIV would have struggled to create anything more than a short-lived, localized outbreak. Most of this colonial world didn’t have enough potential victims for such a fragile virus to start a major epidemic. HIV is harder to transmit than many other infections. People can have sex hundreds of times without passing the virus on. To spread widely, HIV requires a population large enough to sustain an outbreak and a sexual culture in which people often have more than one partner, creating networks of interaction that propel the virus onward. To fulfill its grim destiny, HIV needed a kind of place never before seen in Central Africa but one that now was rising in the heart of the region: a big, thriving, hectic place jammed with people and energy, where old rules were cast aside amid the tumult of new commerce. It needed Kinshasa. It was here, hundreds of miles downriver from Cameroon, that HIV began to grow beyond a mere outbreak. It was here that AIDS grew into an epidemic. Laying the scientific story alongside the historical one offers one final revelation. In the 1920s, as railroads became widely available, the Sangha River’s value as a steamship route dwindled sharply. Global rubber prices also collapsed. The pace of human movement through the region eased. So the improbable journey of the killer strain of HIV was feasible for only a few hectic decades, from the 1880s to the 1920s. Without “The Scramble for Africa,” it’s hard to see how HIV could have made it out of southeastern Cameroon to eventually kill tens of millions of people. Even a delay might have caused the killer strain of HIV to die a lonely death deep in the forest. From “Tinderbox” by Craig Timberg and Daniel Halperin. Reprinted by arrangement with The Penguin Press, a member of Penguin Group (USA) inc. Copyright © Craig Timberg and Daniel Halperin, 2012. Timberg, a former foreign correspondent in Africa, is acting national security editor of The Washington Post. Halperin was a senior HIV prevention adviser in the U.S. government’s global AIDS program and is now an epidemiologist at the University of North Carolina.

Looking for leadership in the Ebola epidemic

As the Ebola epidemic spreads in West Africa, the international president of Médecins Sans Frontières (MSF) — or Doctors Without Borders — is calling for greater resources on the ground and better leadership in response to the outbreak. Cases are now confirmed in Nigeria, the fourth country in the region.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Dr. Joanne Liu, a physician who leads the organization’s International Board and International General Assembly, has worked on MSF’s responses to the tsunami in Indonesia, the earthquake and cholera epidemic in Haiti, and Somali refugees in Kenya. She has called the Ebola outbreak “unprecedented” and says it needs an equally extraordinary response.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico We spoke with her by telephone on Thursday from Geneva, a week after she returned from 10 days in West Africa, about MSF’s response to the epidemic and the leadership in the region. The below excerpts from our conversation have been lightly edited for space and clarity. **Q. You have said there is a “vacuum” of leadership in the outbreak response. Can you describe what you mean?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** The magnitude of the Ebola epidemic is unprecedented. We’ve never had an Ebola outbreak with this many people contaminated in so many different sites, in such high numbers. The other particular thing about this epidemic is it has reached urban areas, whereas in the past it’s always been in isolated, remote, rural areas. This is what makes it different, and this is what makes it much more concerning as well.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico What has been lacking since the beginning is an entity or body that will somehow portray themselves as seeking the leadership and the coordination of the response to the Ebola epidemic. The current governments are trying to do their best, but the reality is they don’t have the capacity. They don’t have the experience. **Q. In a global health crisis like this, what does good leadership look like? What kinds of structures, processes and coordination need to be put in place that haven’t?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** The thing is, you need people who are operational in the field. You don't just need people sitting in meetings discussing things. You need to come out with a plan with clear priorities and capacity to implement it. This is not happening yet.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico We have some hope [with the visit of two U.N. officials who were in the region at the time of our interview, Dr. David Nabarro and Dr. Keiji Fukuda] that we are going to have a plan of action afterwards. But saying all that, we're five months into the epidemic. Governments in place need to take more leadership. They need to reassure the population. They need to explain what is going on. But those governments need some support, and the best body to do that is the WHO — the United Nations' World Health Organization. They need to step up to the plate now. _Note: Later in our conversation, Dr. Liu reiterated her hope that the visit serve as a "turnaround point" for the WHO to take a "more assertive leadership role." Then on Friday, the day after we spoke with Liu, Nabarroannounced that more health workers would be brought in and said “the United Nations is looking at ways to radically scale up support to fight Ebola." And on Tuesday, Bloomberg reported that the WHO is developing a plan outlining the funds that will be required and its goal for reversing the trend of new Ebola cases. E-mail and phone messages to WHO representatives asking for a response to Dr. Liu’s comments were not immediately returned. _    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Q. Should there be more of a response frominternational leaders?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** Absolutely. I think that today it’s part of the solution. I know that the U.S. is quite involved. They really are trying to scale up. But other countries like the U.K., France, Germany and Canada need to provide more help as well.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Everybody is scared of Ebola. People are scared in Liberia and Sierra Leone and Guinea, but people are also scared in Canada and the U.S. The reality is the only way to contain the epidemic is if we increase the response capacity in the countries where we have patients infected. It’s not by barricading ourselves in our home country, or by stopping flights or just giving money. We need to have people sent to the ground to do the legwork. We need more people to do health promotion. We need more people to do the data collection, the contact tracing, the safe burials. We need more people to care for patients who are infected. **Q. You’ve spoken before about what you’ve called an “Ebola psychosis.” What do you mean by that?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** People are absolutely scared of it. It’s understandable, but in the Western world I think maybe it’s a bit out of proportion. The chance that you are going to be exposed in the Western world to Ebola is very, very unlikely. But when people don’t completely understand the disease and the chain of transmission, and they know it has a deadly outcome, it’s scary. That’s normal. It was the same thing when we started to have HIV patients in the past. We were scared. It’s normal.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Q. A doctor on the ground in West Africatold The Guardian newspaper “it's not rocket science” to trace people who’ve been in contact with the disease, “but it needs an organizational structure and good leadership.” I’d imagine the need to manage the multiple organizations involved is one of the biggest leadership challenges.**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** Just to be clear and give a reality check, the number of organizations that are acting in the field right now can be counted on the fingers of my hands. So there’s not that many. It’s not like Haiti after the earthquake, where you had 12,000 NGOs trying to bustle around and find a way to justify their presence. The reality is there are very few organizations that are deploying right now.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico We want to change the narrative to some extent. A lot of people think the only way to make a difference in terms of responding to the Ebola crisis today is by coming with a space suit and treating people in an isolated care facility. There are other ways. Like the doctor said, the contact tracing is not rocket science. You just need to get the name of a patient, then find out where they are and follow them up. This type of organization needs to happen. **Q. If there aren’t that many organizations on the ground there, why is it still so important to have an entity in charge?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** You always need a coordinating body. You need someone who’s going to centralize the information, and centralize what is going on. That’s always necessary, even if you have five or 10 people, and not 400 or 12,000 like we saw in Haiti. That’s part of the basic management.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Q. This fear you’ve spoken about, how does your own organization prepare its health workers to deal with that and live with that?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** We have a special training for it. We have experienced people who have been in other Ebola epidemics before and they’re matched with the new people. When you start to work — and I’m going to take the example of working in an isolation center — you’re not on your own. You’re paired for at least 10 days just to make sure you really are integrating the whole routine about personal protection.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico This is not something that we take lightly. We are absolutely rigid about our protection for our staff. This is one of the reasons why we haven’t been able to scale up in terms of capacity. When you think of other types of emergencies, like cholera, it was easy to scale up because the contamination was not as difficult to control. But for Ebola it’s another set of rules, another game. Inside the Ebola protective clothes, it's more than [104 degrees Fahrenheit]. It's like being in a sauna. So you can’t last more than an hour at a time inside the center. You have to do turnover between people who are going to go inside. It’s not the same thing. We’re not talking about the same kind of care. **Q. How much worse have things become since MSF first started engaging in the outbreak?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** When it started in Guinea, our Ebola center was the size of 30 beds. Back then — and I’m just talking in March, only five months ago — we were like, ‘Oh my God, this is such a huge center. This is really something new.’ We were all wide-eyed, concerned.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico Today, we are in Monrovia [the capital of Liberia] with a center of 100 beds and we’re contemplating the idea of doubling the size of it because of the demand. It’s not enough places to care for patients who are infected. Every day we are breaking new ground in terms of the case management. _Note: MSFcalled the Ebola outbreak in West Africa “unprecedented” as early as March of this year, noting that Guinean health officials had recorded 122 suspected patients and 78 deaths. Today, MSF has six centers and more than 1,000 staff on the ground._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico _Anupdate from the WHO on Friday said the epidemic had spread to four countries and claimed at least 1,427 lives. In a news release, the organization also said the number of Ebola cases has been underestimated._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico _I later wrote Dr. Liu to ask her a few follow-up questions. One of them — asking about her greatest challenge in leading MSF’s response to the Ebola outbreak — did not elicit a response. But she did answer the following question in an email._    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Q. What has been the biggest thing you've learned about leadership in the process of leading MSF's response to Ebola?**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **A.** I don't have much to say on this except that in extraordinary circumstances, one needs to take extraordinary measures. MSF, as an organization, has tried to adapt and went beyond its comfort zone. The epidemic is unprecedented.    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **Read also:**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico From loss to strength in Tanzania    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico **LikeOn Leadership? Follow us on Facebook and Twitter.**    *[WSU]: Wayne State University   *[Tue]: Tuesday   *[Wed]: Wednesday   *[UNM]: University of New Mexico

Global response to Ebola marked by lack of coordination and leadership, experts say

More than six months into the worst Ebola outbreak in history, there is no clear sense of who is leading the international response, how funds are being collected and disbursed, which organizations are providing equipment and personnel, and when any of these efforts will make a significant difference in slowing the epidemic in West Africa. The confusion and lack of coordination have delayed shipments of desperately needed supplies; some of those being pledged now won’t arrive for months. For example, a 62-bed facility that the British government on Monday promised to deliver will take eight weeks to be operational; the 25-bed field hospital the Pentagon has offered will take at least a month before it is up and running. The lagging response means that the relief effort is three to four months behind where it should be, given the seriousness of the epidemic, health experts say. “There is no one who is really in charge with the capacity and the ability to completely lead the international response,” said Josh Michaud, associate director of U.S. global health policy at the Kaiser Family Foundation. With the exception of the international aid group Doctors Without Borders, global health officials were caught off guard by the severity of the outbreak. The World Health Organization underestimated its complexity and magnitude, and now a rapidly rising caseload is far outstripping the ability of aid groups, regional governments and international health officials to bring it under control. “Where we are today is probably where we should have been in May,” said Ken Isaacs, a former director of foreign disaster assistance at the U.S. Agency for International Development, and a vice president at Samaritan’s Purse, a Christian aid organization that has been active in the region. The responses were far different for other international disasters in recent years. When a tsunami hit Indonesia in 2004, and an earthquake struck Haiti in 2010, governments and international health authorities rushed to offer money, manpower and other forms of aid. Those disasters killed hundreds of thousands of people — many more than the nearly 2,300 for the current Ebola outbreak. And even though the actual Ebola fatalities are probably much higher, the epidemic has not been “a big, acute event that everyone can rally around,” Michaud said. “This has been on a slow burn for a while” in five nations in West Africa. The slow burn, however, is now “spreading like wildfire, devouring everything in its path,” Liberia’s defense minister, Brownie Samukai, told the U.N. Security Council this week. He said that Liberia, which was torn by two civil wars that left more than 250,000 dead, is “facing a serious threat to its national existence.” The Ebola epidemic, experts say, has highlighted dangerous gaps in the world’s ability to respond to deadly pathogens. The three countries hit hardest by the epidemic are among the poorest in the world, with health systems and other infrastructure so decimated by civil war and conflict that they are barely able to provide basic care. At the same time, the WHO has been so ravaged by budget cuts and the loss of staff in recent years that it is “a shadow of its former self, racing to regain its own credibility in this crisis,” said Laurie Garrett, senior fellow for global health at the Council on Foreign Relations and author of one book about the 1976 Ebola epidemic and another about the global health system. Garrett said that she spoke to public health workers in the region Thursday and that they estimate the number of people in West Africa stricken with Ebola, including those who have died, will be 250,000 by November. Meanwhile, top officials at the United Nations and within the U.S. government and its allies are scrambling to improve their response. In Washington, Gen. Martin Dempsey, chairman of the Joint Chiefs of Staff, convened a meeting Wednesday on the situation, according to Garrett, who attended the session and warned the other participants of widespread regional instability if the outbreak is not halted. Administration officials have said U.S. military involvement will reflect President Obama’s decision to treat the epidemic as a national security concern but have not provided details. But Garrett noted that the U.S. military is stretched thin and faces more demands in the Middle East and elsewhere. “The cavalry is not going to ride to the rescue,” she said Thursday, addressing a global health conference. “At least not in the numbers people are dreaming of.” At the United Nations, meanwhile, David Nabarro, who was put in charge of coordinating the international response last month, said the challenges are numerous. “We are trying to knit together one of the most complicated coalitions of support that we have ever been involved in,” he said in an interview last week from Geneva, adding that Ebola was “the number one global crisis” for the United Nations. Nabarro predicted that there would be a “massive” improvement in the situation in Liberia and Sierra Leone within four weeks, adding that officials are focusing on helping national governments manage the crisis rather than bringing in outsiders to take over the relief effort. But some aid experts say that approach is wrong. More outside direction is needed, especially from the U.S. military because of its enormous logistical capacity, extensive air operations and highly trained medical corps. “Why would the world allow what is potentially a global epidemic to be managed by three of the poorest countries in the world?” said Isaacs of Samaritan’s Purse. “There’s not a high level of confidence in the ministries of health in these countries to equitably distribute goods to where they are needed,” he said. “They don’t even have ambulances to move people to the clinics, not to mention all the corruption.” ****Nabarro has estimated that it will cost at least $600 million to fight the epidemic and deal with the broader economic and social devastation suffered by the hardest-hit countries — Liberia, Sierra Leone and Guinea. The U.S. government has spent more than $100 million in the region, and additional requests for aid, if approved by Congress, would bring the total commitment to more than $250 million. The United States is providing logistical and operational support, including personal protective equipment, mobile labs and other basic supplies and food. The biggest need is for skilled personnel to relieve exhausted health-care workers. But a top U.S. official said this week that the only workforce with experience in treating Ebola is Doctors Without Borders. The WHO is training 500 workers in the special protocols needed to prevent transmission. The World Bank is working with the United Nations to set up a system to track donations and distribution of funds, a senior bank official said. The bank has also pledged a $230 million aid package, including $117 million in emergency response, most of it in grants. World Bank President Jim Yong Kim, an infectious disease expert, also organized a task force last week to develop a standard protocol for all health-care workers to follow at treatment centers in the region. Countries and organizations have also increased pledges and donations. But so far, there is no central account to receive corporate private donations. And aid groups say there isn’t even a master list of the most urgent items and tasks. “Everybody would like to get a matrix of what are the needs for burial, for treatment centers, for [disease] surveillance,” said Joanne Liu, international president of Doctors Without Borders. Because the group has been the most active aid group from early in the epidemic and has 2,000 staff members working in the three countries, it was asked by the international community to provide such a list. But Liu said the group is overwhelmed. “We are burying people and treating patients,” she said. “We are doing everything, and no one is coming out to relieve us from any of those activities.” Brady Dennis contributed to this report. Read more: U.S. Ebola response hampered by lack of expertise in virus This is how West Africans are being warned about the epidemic Ebola is ‘devouring everything in its path.’ Will Liberia collapse? Ebola survivor Kent Brantly donates blood to infected American in Nebraska

Two years after quake, signs of progress in Haiti

Hope here is measured in bags of cement. Progress is a city park without a tent. The future is a bus that takes children to school without charge. Its destination, etched above the driver’s window, reads: “Dignity.” In Haiti, two years after the worst natural disaster in a generation — made worse by a paralyzing political crisis and an imported cholera epidemic — advances are everywhere, even if they are sometimes hard to see: The neighborhood lit by yellow candles a year ago is now strung with electric lights; the road once blocked by earthquake rubble is now snarled with morning traffic. Work crews are planting brave little palm trees on the road to the airport. The cellphone carrier is building a Marriott hotel. The South Koreans, lured by generous subsidies and tax breaks, are coming to open a garment factory and employ 20,000 people, the single-largest jobs program in Haiti in 30 years. “Recovery is here. It is painfully slow, it is agonizing to watch, but it is recovery,” said Paul Farmer, a Harvard physician who has spent three decades in Haiti and whose group, Partners in Health, is opening a modern, 320-bed public teaching hospital an hour north of the Haitian capital. Progress may be coming to the poorest country in the hemisphere, but it is not coming easily. A year ago, to get anything done in Haiti, supplicants sat in frustrating meetings with foreign aid bureaucrats at the United Nations’ logistics base. Now they sit in frustrating meetings with the three-month-old Haitian government — led by the irrepressible President Michel Martelly, a political neophyte and former carnival singer once known as “Sweet Micky,” who is learning on the job. The government is functional after a lost year that included a presidential election plagued by fraud, a chaotic runoff and a months-long brawl with opposition parties in parliament over the approval of a new prime minister. “The best thing that has happened to Haiti is me being president,” said Martelly, who went on to explain that his government is making good on its promises, providing free schooling, building hundreds of miles of road, moving displaced people out of camps and providing loans to the poor to rebuild homes. “We have been able to keep hope high and show people that things are changing,” Martelly said in an interview. “You can see where there were camps everywhere, now you can see kids playing in those parks. Life is coming back to normal.” Almost a million people have moved out of the increasingly dangerous tent cities. Some were pushed. But most were pulled away by programs that offered rent subsidies or home-repair assistance. But 500,000 people remain under tarps. About 20,000 still live in a squalid camp in downtown Port-au-Prince, their once-crisp tents, stamped USAID, now soiled gray and sagging in the heat in front of the collapsed National Palace. Some of their kids are at least going to school. Haiti is providing free education for 900,000 children, many of whom have never been in a classroom before. The program is immensely popular, as are the free school buses. But the government hasn’t figured out how to pay for it. “Sweet Micky is giving them free school? I am the one who is paying for this school,” said Jean Moreno, owner and principal of the Andre Malraux primary school, who said he accepted 200 students in October and has yet to be paid, despite government promises. The open-air school was rebuilt on rubble after the earlier structure was destroyed in the quake. There is a tin roof, an ancient blackboard, broken chairs and a latrine donated by a nongovernmental organization. “No, no books,” Moreno said. “But we are open.” The government plans to pay for Moreno’s school and others by taxing money transfers and international calls. But the school fund’s balance remains a mystery, and the owner of Haiti’s No. 1 cellphone provider, Digicel, says he wants an audit. A terrifying epidemic of cholera exploded on the island in late 2010, but it is now under control. The disease was introduced into Haiti by Nepalese troops serving as U.N. peacekeepers, whose sewage ran into a nearby river in the Artibonite Valley. Hundreds of thousands of Haitians were sickened, and 7,000 died. But after a slow-motion response, crippled by poor coordination among aid groups, the death toll is down to about 1 percent of those infected, which is in line with international standards. Attorneys for the relatives of the dead and those sickened by the disease are seeking millions of dollars in reparations from the United Nations. In the first year after the earthquake, Haiti was filled with urban planners who imagined broad avenues and seaside promenades rising from the slums. But those dreams of new office towers here are still just drawings on tables at architecture firms in Miami, which played an outsize role in the planning. The rebuilding of downtown has barely begun. But workers are busy renovating the crumbling international airport. The departure lounge is repaired, but the arrival wing remains a mess. The 7.0-magnitude earthquake that destroyed wide swaths of the city on Jan. 12, 2010, left behind 10 million cubic meters of rubble, enough to fill a line of dump trucks stretching from Key West, Fla., to Bangor, Maine. Half the rubble remains where it fell, much of it in dense urban neighborhoods where it is difficult to maneuver even a wheelbarrow, let alone an earthmover. “Debris is, unfortunately, not a very sexy intervention for the donor community,” Prime Minister Garry Conille said in an interview. “Our friends in the international community would prefer to build a hospital or a school.” The international aid group Oxfam has witnessed some progress in Haiti but declared this week that reconstruction has proceeded “at a snail’s pace.” There is plenty of blame to spread around. The previous administration was notoriously ineffective, and donors were slow to give money to the government during a year of political chaos. The mandate of the Interim Haiti Recovery Commission, led by former U.S. president Bill Clinton, has expired, and the effort left a mixed legacy. Diplomats and donors praise the commission for bringing transparency and order to the vetting process for new projects. But most Haitians — including those in power — complain that Clinton and the commission overpromised and underperformed. Martelly’s government would like to revive the commission, but the parliament has delayed its decision because lawmakers say Haitians had little say in the commission’s decision making. “The NGOs and international community have ruled Haiti in the past,” Martelly said. “But I will tell you today we have the right government, we want to take control, we want to identify our priorities, ourselves. We want friends and partners, but we want them to act where we want them to act.” According to the U.N. special envoy to Haiti, donor nations have dispersed only about 53 percent of the pledged reconstruction funds in 2010 and 2011. Of the $4.5 billion promised, $2.3 billion has been delivered. The United States is among those slow to cut checks. About $2.2 billion of the $3.1 billion committed by Washington has been dispersed. But U.S. diplomats say they will catch up in 2012. “I’m pretty optimistic. Haiti is in a pretty good place right now, not unlike where we were before the earthquake,” when Haiti was beginning to attract the attention of investors, U.S Ambassador Kenneth Merten said in an interview. At the moment, Haitians are so desperate for work that thousands have traveled to Brazil’s Amazon basin. Moved by their plight, Brazil said it would give them temporary work visas instead of kicking them out. But Haiti boosters hope that the Caracol industrial park in northern Haiti, scheduled to open in March and house the South Korean textile factory, will help change the story line. “You need job creation. You need to put money in people’s pockets and the government coffers,” Merten said. “Unless you get investment, no matter how much aid you give, it won’t be that effective over the long term.” **More world news coverage:** \- Iranian nuclear scientist killed in Tehran bomb attack \- China denounces ‘Hong Konger’ trend \- Fear that austerity is killing Greece’s economy \- Read more headlines from around the world

Haiti takes on dreaded disease elephantiasis one mouth at a time

In a sunny courtyard of the Evelina Levy School for Girls, hundreds of girls in blue uniforms did their part to rid Haiti of an ancient and reviled disease. They lined up in pairs to get three pills dropped into their mouths. They swallowed them down with a quarter-cup of water. They got a second medicine, a flavored tablet, to chew as they walked back to class. Two middle-aged women treated 12 girls every 21 / 2 minutes, one pouring the water and the other shaking out the pills. Another woman ticked the columns for age, sex and drug on a white form with a green pen. “Mass drug administration” is easy if your target is elementary school students. It’s harder when you want to reach nearly everyone else in a country of 10 million people. That is the goal Haiti set this year in its campaign against a parasitic infection called lymphatic filariasis that is present in 80 percent of the country. Spread by mosquitoes, in severe cases it leads to permanent swelling of an arm or leg. That condition, called “elephantiasis,” can be grotesque and life-changing. In men, the worms can cause a swelling of the scrotum that is even more stigmatizing. Lymphatic filariasis is a “neglected tropical disease,” the name for a group of maladies that have disappeared from industrialized countries or never existed there. Others include onchocerciasis (“river blindness”), schistosomiasis (“snail fever”), soil-based intestinal worms, and the eye infection trachoma. For 1.9 billion people, most of them poor, they are still threats. Eliminating the diseases has been an object of intense effort and research over the past decade. The work is largely unknown outside the global health community, overshadowed by higher-profile campaigns against AIDS, malaria and tuberculosis. In 2010, 484 million people worldwide took drugs against filariasis — more than for any other neglected tropical disease but still only one-third of the people at risk for it. “You could argue it’s the world’s largest public health program,” said Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. Most of the neglected diseases can be cured in their early stages with drugs taken once or twice a year. Pharmaceutical companies are donating drugs for mass administration. A bonus is that some treat more than one infection. Ivermectin, donated by Merck, cures river blindness and filariasis. Albendazole, donated by GlaxoSmithKline, gets filariasis and intestinal worms. Some subsidiary effects are only now being discovered. When ivermectin was distributed for river blindness in Senegal, it reduced malaria transmission. When azithromycin (provided by Pfizer) was distributed twice a year to Ethiopian villagers for trachoma, childhood mortality fell 50 percent. “What’s that all about? That’s the $64,000 question,” Hotez said. Congress began earmarking money for mass drug administrations in 2006, and in 2008 President George W. Bush announced a five-year program to fight neglected tropical diseases. This year, the United States will spend $89 million on them — roughly 10 percent of the Obama administration’s global health budget. After years of mass drug administrations, nine countries — Burundi, Cape Verde, Costa Rica, Mauritius, Rwanda, Seychelles, the Solomon Islands, Suriname, and Trinidad and Tobago — were declared free of lymphatic filariasis in 2011 by the World Health Organization. Haiti hopes to join them. Until the earthquake of Jan. 12, 2010, Haiti and its foreign donors fought the disease only where it was most prevalent. Over time, more and more parts of the country were included in the campaign. However, Port-au-Prince, a place where the disease was uncommon, was always judged out of reach. The capital was simply too crowded and chaotic for mass drug administration. Ironically, the earthquake changed people’s minds about what was possible — and necessary. One-third of Haiti’s population was affected by the quake. More than 2 million people became homeless or chose to move. Internal migration threatened to redistribute the disease, interrupt the every-year treatment for many people, and generally undo all the gains of the previous decade. At the same time, the earthquake brought a flood of money and human energy to Haiti. Suddenly, nationwide drug administration — including in Port-au-Prince — became just one more ambitious task that had to be done. “There was this feeling that we just couldn’t quit. Things had come too far to walk away,” said Patrick J. Lammie, a scientist at the U.S. Centers for Disease Control and Prevention who has worked on filariasis in Haiti for more than two decades. As a consequence, for four weeks this past winter, two medicines — albendazole and diethylcarbamazine (DEC) — were handed out in Port-au-Prince’s schools, markets, churches, factories and public places. They were also delivered to the squatter camps where more than a half-million earthquake-displaced people still lived. In all, about 70 percent of the capital’s population took them, according to a CDC survey in the spring. Today, more than two years after the earthquake, “everyone in Haiti has gotten the drugs,” Lammie said. (The actual estimate is 8.7 million.) “That’s the success story of Haiti. Now we have to do it on an annual basis.” The rationale for such an ambitious effort is this: Albendazole and DEC kill off the larval form of the filariasis parasite, which if not treated matures into an unkillable worm in about a year. If an entire population takes the drugs regularly — adults once a year, children twice — the amount of parasite larvae circulating in people and mosquitoes falls so low that no new transmissions occur. Biologists think that 70 percent coverage for eight years is enough to stop new cases, assuming the same people are not missed year after year. If they are, those people can become a permanent reservoir from whom mosquitoes can pick up the parasite and pass it on to new victims through bites. Haiti will know by the end of the decade whether it has pulled the trick off. In Haiti, the government’s health ministry is doing most of the work. Two charities, IMA World Health and RTI International, provide advice, along with the University of Notre Dame. A foundation associated with the drugmaker Abbott Laboratories is helping with salaries. The target in a mass drug administration may be the whole population, but that does not mean you can take your eye off the individual. Abdel Direny, the 39-year-old Haitian physician in charge of the campaign in Jacmel, knows that. After assuring himself that the drug distribution at Evelina Levy School was going well, he drove to another school. What he found was a platoon of volunteers in campaign T-shirts helping teachers pass out pills. The students, high school girls, were being told to take the medicine when they got home. The city water supply to the school was not working that day, and nobody had brought bottled water as backup. “They’re not supposed to do that,” Direny said to Edgar Isidor, a community leader in a porkpie hat who came along to enhance the doctor’s authority. “The pills are supposed to be poured into their mouths.” To much consternation, Direny stopped the drug distribution and ordered it rescheduled for the next day. Just as the principal was finally persuaded, somebody rolled a wheelbarrow full of blue five-gallon water jugs into the school’s courtyard. But it was too late. How much difference can some missed mouths make? In 2000, about 15 percent of the 150,000 people in the commune of Leogane, west of Port-au-Prince, had microscopically visible parasites in their blood. (Communes are like counties; Haiti has 140 of them.) After six years of mass drug distribution, that was down to less than 1 percent — a level that if maintained for a decade would have stopped the disease altogether. Civil unrest, however, prevented drugs from being handed out in the seventh year. Filariasis roared back. By 2008, the prevalence of infection was up to 4.6 percent. More troubling, a survey found that 24 percent of people said they had never taken a pill against the disease — and thus were probably a hidden reservoir for it. The lesson: Every mouth counts. Mass drug administration is the main tool against lymphatic filariasis. But it is not the only tool. In an industrial park in Port-au-Prince, a theoretically easier way to rid the country of the parasite is underway. The Rev. Jean Michelet Dorescar, a Catholic priest, runs a factory that fortifies salt with DEC, one of the two drugs used in the mass campaigns. Eating that food additive year after year will kill off filarial larvae in an entire population. China used the strategy (which was invented by English biologist Frank Hawking, father of cosmologist Stephen Hawking) to eliminate filariasis in the 1980s. The Haitian government has not mandated the use of medicated salt. The factory’s product, subsidized by charities, must compete with plain salt evaporated from seawater and sold by the handful in Haiti’s markets. Fortified salt, promoted heavily in Guyana a decade ago, never really took hold. Dorescar knows his salt must look good and taste good, first and foremost. He has a hard time finding high-quality salt from Haiti. He recently bought a load from Jamaica and was disappointed by it, too. “When I opened the bag I was very surprised to see the stones,” he said. He stood next to a table covered with bright white salt. Four men were picking out pieces of gray gravel by hand. The factory is owned by Haiti’s government but operated by the University of Notre Dame, which along with other donors subsidizes the product. Last year, it sold 71,000 pounds of treated salt to markets in the three communes with the most filariasis. A survey is underway to see whether the rate of filariasis infection has changed in the places where people stir it into their rice and beans. \- READ: The facts about lymphatic filariasis \- READ: Specter of voodoo lingers for Haiti’s ill

Lessons from the Ebola outbreak in West Africa

THE OUTBREAK of the Ebola virus in West Africa this year came as a surprise. Perhaps no one could have predicted that such a terrible scenario would unfold. But over the past decade, there have been four major outbreaks of infectious disease caused by a virus: severe acute respiratory syndrome, or SARS; swine flu; Middle East respiratory syndrome; and now Ebola. Each has taken populations by surprise. Next time, the world should not be gobsmacked. It is possible to be better prepared, be more aware of the potential threats and not start from zero every time the alarm goes off. Speed is of the essence. The global response to Ebola was tardy, in part because 24 previous outbreaks of the virus since 1976, mostly in remote locations, were contained, so it was assumed that this one would also be extinguished quickly. But when Doctors Without Borders began to warn in April that something different was unfolding — that Ebola was getting out of control in West Africa, where it had not previously struck — the call was not heeded. The World Health Organization response lagged. The U.N. agency has suffered budget cuts and is poorly structured, with regional offices not easily accountable to its headquarters in Geneva. In this case, the Africa office of the WHO was slow to react, and that put the whole organization behind the curve. Margaret Chan, the WHO director general, first learned of the urgency of the situation in June, according to a WHO timeline disclosed by the Associated Press. No doubt the slow response was also a product of public health agencies that were ill-prepared and overwhelmed in the three hardest- hit countries: Guinea, Sierra Leone and Liberia. It would be smart to begin thinking of a more agile and effective organization or system for responding to such dire threats, one that could bring together a capability for surveillance, early warning and rapid response; and that would be wired into the pharmaceutical industry. Another important lesson is that fighting a disease outbreak is not only a medical challenge but also must take into account economics, politics, culture and traditions. The Ebola response was hampered by deep suspicion among those affected, a failure of responders to build confidence in communities and methods that backfired, such as the containment of a whole section of Monrovia, Liberia, which led to panic and frequent violations of the cordon. The traditional burial methods of touching the deceased and washing the body also spread the disease. Many of these errors were later rectified in an admirable way — special burial teams have been notably effective — but these are lessons that should not have to be learned on the fly. The knock-on effects of the epidemic are still being felt. Half a million people have been classified as “severely food insecure” in the three countries, because of border closures, quarantines, and disruption in food markets and processing chains, according to the United Nations’ Food and Agriculture Organization . Another lesson is the importance of getting the low-tech, simple things right, such as adequate personal protective equipment for first responders, who have suffered a terrible toll. Ebola has demonstrated that disease threats do not stop at passport control and that health security is national security. Stopping the virus in West Africa is an investment in keeping it from U.S. soil. The Obama administration has championed a global health security agenda with this in mind, but it was initially slow in rallying to the challenge of Ebola. The president’s decision to deploy the military in September put the United States in position to lead, but that should have happened sooner. Perhaps the most difficult challenge is to develop biomedical treatments — vaccines and antivirals — for an emergency on the scale of Ebola. It wasn’t a serious threat before, so the pharmaceutical industry did not have the incentives to develop treatments. Someday, it may be possible to dial up a rapid response to a novel disease threat, but science hasn’t found the way yet. More ought to be done jointly by governments and the private sector to improve the ability to swing into action. **Read more about this topic:** Ban Ki-moon: The Ebola fight is far from over Joanne Liu: A concrete response to the Ebola outbreak cannot wait Laurie Garrett: Five myths about Ebola Marc Thiessen: Ebola and Obama’s crisis of competence Dana Milbank: The nasty politicization of Ebola

Don’t oversimplify Haiti’s problems

Regarding the Feb. 4 editorial “Haiti needs new leadership — fast”: No one will deny that Haiti is facing severe problems, not the least of which is a political crisis that only threatens to make things worse. However, it is shortsighted and irresponsible to propose that the solution to Haiti’s problems lies in international intervention, particularly when international intervention was instrumental in creating this crisis. The international community, specifically the United States, pressured Haiti to continue with an election marred by violence, fraud and irregularities. Yet further investigation has yet to occur because the foreign governments helping to fund the election process just wanted to get it over with. The international community wants a stable government in place but doesn’t understand that if you chase stability over democracy, you end up with neither. Fortunately, Haitians do understand that and, through largely nonviolent protests, blocked the Provisional Electoral Council from proceeding with the sham election. It remains to be seen whether the international community has learned its lesson and will allow the democratic process to function properly. When the media portray Haiti as besieged by crises without contextualizing those problems in five centuries of continuous foreign exploitation and intervention, they perpetuate racist and xenophobic ideas about the country. Those who wish to see progress in Haiti must start by telling the whole story. ****Erica Lloyd** , Port-au-Prince, Haiti**

U.N. health agency: Africa’s Ebola outbreak over but ‘vigilance’ needed

NAIROBI — The Ebola outbreak in West Africa, which killed more than 11,300 people over the past two years, officially ended Thursday, according to the World Health Organization. The U.N. agency made its declaration 42 days after Liberia’s last Ebola patient tested negative for the disease twice — the traditional marker of an epidemic’s conclusion. The two other worst-affected countries, Sierra Leone and Guinea, were declared Ebola-free last year. Still, the organization warned in a statement that “more flare-ups are expected and that strong surveillance and response systems will be critical in the months to come.” In recent months, Liberia had been declared free of Ebola, but new cases were later discovered. The Ebola epidemic began in West Africa in late 2013 and swept through some of the world’s poorest countries over the next year. By the time global health agencies mobilized resources, villages and cities across a huge swath of West Africa were overwhelmed with cases. Without treatment, many died in the streets or in their homes, widening the circle of infection. As fears spread that Ebola might travel across borders and oceans, potentially wreaking havoc far from West Africa,   the U.S. government allocated $5.4 billion in emergency funding. On Tuesday, in his State of the Union address, President Obama commended American physicians and development workers who helped stop the spread of the virus. “They set up the platform that then allowed other countries to join in behind us and stamp out that epidemic. Hundreds of thousands, maybe a couple million lives, were saved,” Obama said. But critics say the United States, like much of the international community, was late in delivering a robust response in West Africa. By the time it had constructed more than a dozen Ebola treatment centers in Liberia, for example, the disease was already fading away, and some of those centers sat empty. With Thursday’s official announcement that Ebola’s transmission has ended, global health officials acknowledged both the achievement and the unprecedented challenge posed by the disease. “Detecting and breaking every chain of transmission has been a monumental achievement,” said Margaret Chan, director general of the WHO. “So much was needed and so much was accomplished by national authorities, heroic health workers, civil society, local and international organizations and generous partners.” However, she added, “our work is not done, and vigilance is necessary to prevent new outbreaks.” Officials also cautioned that the days and weeks ahead are crucial, with the risk of a flare-up still high. “We are now at a critical period in the Ebola epidemic as we move from managing cases and patients to managing the residual risk of new infections,” said Bruce Aylward, the WHO’s special representative for the Ebola response. Aside from the ravages of the disease, Liberia, Sierra Leone and Guinea are facing massive economic challenges because of their virtual paralysis during the peak of the epidemic. A U.N. report last year said West Africa could lose up to $15 billion from 2015 to 2017 because of the fallout from the Ebola crisis — including effects on trade and tourism. Meanwhile, those countries still need to find a way to care for thousands of children dubbed “Ebola orphans.” And West Africans who helped burn the bodies of the dead or transport the sick still face significant social stigma. In some cases, they have been cast out by their families. **Read more:** Photos: A reporter’s journey through an Ebola-stricken Liberia Could a pregnant woman change the way we think about Ebola? In Sierra Leone, the ghosts of war haunt an Ebola graveyard

Putting out the fire, next time

**Read more on this topic:** The Post’s View: The world should learn from the Ebola crisis to combat MERS in Saudi Arabia The Post’s View: Rebuilding after Ebola will require the world’s help The Post’s View: What worked in controlling the Ebola outbreak in West Africa The Post’s View: Lessons from the Ebola outbreak in West Africa THE EBOLA virus has not been eliminated from West Africa, but the public health crisis has eased. The virus, for which there is no ready cure, infected more than 27,000 people and caused more than 11,000 deaths since the outbreak began in early 2014. The pain and suffering have been immense. Now it is time to confront another hard problem: addressing the weaknesses in global response that allowed the virus to spread so rapidly. Without the urgency of another outbreak, national governments and the World Health Organization will be disinclined to change the way they do business. But change they must, or there will be another wave of disease, panic and unnecessary death. The WHO’s lethargic response to Ebola in West Africa has brought calls for creation of a new organization that would have responsibility for emergency response. The belief in the need for rapid response to infectious disease has been gathering steam with a succession of outbreaks that spanned national borders: severe acute respiratory syndrome, or SARS; bird flu; swine flu; Middle East respiratory syndrome, or MERS; and Ebola virus disease. Although different in transmission, virulence and danger to people, all of these tested the ability of humankind to respond. Now, a panel appointed by WHO Director General Margaret Chan has examined all aspects of the organization’s response to the Ebola outbreak and concluded that a new organization is not the right answer. The panel declared in a report that such an agency would take too much time to set up and be unnecessarily duplicative. Instead, the panel said, the WHO “must re-establish its pre-eminence as the guardian of global public health.” This is a tall order, and the panel’s report explains why. A sea change in thinking and organization will be needed. The WHO “does not currently possess the capacity or organizational culture to deliver a full emergency public health response,” the panel stated. “There are no core funds for emergency response.” The WHO’s overall weakness in this field was underscored by the stark fact that it was not the WHO but rather Doctors Without Borders, a charity, that took the early lead in warning about Ebola and in battling the virus in West Africa. The panel offered a host of valuable ideas for improvement, including creation of a WHO center for emergency response and a contingency fund to support it. The WHO says it is already working on the fund. The panel also pointed out that the WHO was slow in declaring a “public health emergency of international concern” because messages from the field about Ebola either “did not reach senior leaders or senior leaders did not recognize their significance.” A more sensitive early warning system is needed. The WHO is made up of member states, but they, too, performed poorly. Many have failed to implement stronger standards for public health adopted a decade ago with the goal of spotting and reporting local outbreaks that could become a global emergency. This neglect is irresponsible and could be repaid in deadly epidemics to come.

Aid teams in Haiti struggle to reach regions slammed by Hurricane Matthew

Emergency teams in Haiti struggled Wednesday to reach hurricane-ravaged areas cut off by washed-out bridges and mudslides after Hurricane Matthew roared over the nation’s western tip and began a devastating island-hopping path that arcs toward the U.S. coast. The full extent of Matthew’s blow to Haiti remained unclear, with communications severed to some regions in the Western Hemisphere’s poorest nation — where tens of thousands of people still live in tents after an earthquake six years ago killed 200,000 people. At least 16 deaths — including at least 10 deaths in Haiti and four in the neighboring Dominican Republic — have been blamed on the hurricane, according to Reuters. It packed winds of up to 145 mph when it swept over Haiti on Tuesday and then hit Cuba and the Bahamas. A slightly weakened Matthew was expected to make landfall in Florida on Thursday. “What we know is that many, many houses have been damaged,” Haitian Interior Minister François Anick Joseph said. “Some lost rooftops and they’ll have to be replaced, while others were totally destroyed.” John Hasse, national director of the aid group World Vision in Haiti, estimated “thousands of houses destroyed or damaged” in the areas hardest hit. The Haitian government said at least 350,000 people were in need of immediate help around the country, the United Nations said. At the same time, fears rose of possible outbreaks of cholera or other diseases. Samuel Darguin, a worker with the aid group Haitian American Caucus-Haiti, said relief convoys were prevented from reaching many areas because bridges had been swept away by floodwaters. Local teams in the isolated regions were in “search-and-rescue mode,” he said, with reports of people missing. That suggested the death toll could rise. Faced with the devastation, Haiti’s electoral council on Wednesday postponed a long-delayed presidential election that was scheduled for Sunday. There was no immediate word on when it would be held. Many schools and churches designated as polling places were being used as shelters. International aid was underway, meanwhile, with a focus on shelter and clean water. The U.S. Navy has sent three ships to Haiti, including an aircraft carrier and a hospital ship. About 300 Marines were aboard the USS Mesa Verde, an amphibious transport vessel. The United States announced $1.5 million in aid available to the Caribbean countries in Matthew’s wake. Disaster response teams were pre-positioned with some supplies and were assessing the damage and urgent relief needs, said Kenneth Merten, deputy assistant secretary of state for the Western Hemisphere and a special coordinator on Haiti. Beyond food, the aid includes shelter, blankets, and kits for hygiene and water purification to help prevent the spread of cholera, said David Harden, an official with the U.S. Agency for International Development. Venezuela, battered by a major economic crisis, mobilized an airlift of humanitarian supplies, and the British-based group Oxfam concentrated on sanitation and clean water efforts. Many people live in rudimentary shacks crowding the hillsides that are especially vulnerable to the high winds and lashing rains of a hurricane — as well as the landslides that often occur afterward in rain-loosened soil. In Port-au-Prince, the capital, water remained knee-deep in some low-lying districts. Boats and other flotsam were wedged amid stores and homes. Mourad Wahba, the U.N. deputy special representative for Haiti, called Matthew “the largest humanitarian event” in the nation since the earthquake and said that “much of the population” has already been displaced. Jean-Michel Vigreux, director in Haiti for the aid group CARE, said estimates on damage have reached as high as $1 billion even before the full extent of the devastation is tallied. “It is very scary,” he said in a statement. By Wednesday evening, Matthew was lashing the southern Bahamas with maximum sustained winds of 120 mph and heavy rain. The storm — now downgraded to a Category 3 hurricane — was heading northwest at 12 mph on a path that would take it close to the east coast of Florida by Thursday evening, the National Hurricane Center reported. In Cuba, the hurricane destroyed dozens of homes and damaged hundreds of others in Baracoa, a city on the country’s eastern tip. Authorities prepared for the storm by moving people out of threatened coastal areas. At the Guantanamo Bay Naval Base, about 700 family members of U.S. personnel and others were evacuated from the area before Matthew hit. The storm knocked down trees there and flooded roads but caused no injuries or major damage, a base spokeswoman said. Officials in the Bahamas urged residents to move to higher ground amid the dozens of low-lying islands in the archipelago, and residents of the capital, Nassau, braced for Matthew’s wrath as forecasters predicted a storm path close to the city. Citing a combination of dangerous storm surges and large, destructive waves, the National Hurricane Center warned of “a danger of life-threatening inundation” on Thursday and Friday along parts of Florida’s east coast from North Palm Beach to Fernandina Beach. The governors of Florida, Georgia, South Carolina and North Carolina declared states of emergency, and at least 500,000 people in Florida and South Carolina were asked Wednesday to evacuate low-lying coastal areas.

‘Peacekeeping’ review: Haiti endures despite outsiders’ good (and bad) intentions

In our collective memory there’s a consensus that the United States invaded Haiti in 1994 to restore democracy and inject the island with an 18-month dose of revitalizing American can-do, but that memory would be an illusion. Learning the wrong lesson from Vietnam, Bill Clinton destroyed the island to save it, handing the whole mess off to the United Nations and a Babylon of international agencies. And yet, 10 years later, Haiti was still languishing in democracy’s neonatal intensive care ward. Out went the elected president in a coup d’etat, in came another iteration of the United Nations peacekeeping mission, a 10,000-strong force of soldiers, police and bureaucrats, including, in 2007, a U.N. official whose husband was a freelance journalist and novelist named Mischa Berlinski. Berlinski remained with his wife in Haiti until 2011, occasionally firing off reports about the country for the New York Review of Books, which earned him the scorn of the writer Amy Wilentz , the apparent gatekeeper of all things Haiti, who accused Berlinski of ignorance and racism. Berlinski, Wilentz argued, thinks, like many U.S. foreign policy types, that interventions are good, saving places like Haiti from outright barbarism. Readers of Berlinski’s marvelous new novel, “Peacekeeping,” however, might find themselves puzzled by Wilentz’s snarky accusations. Berlinski’s first novel, “Fieldwork” (2007), was set in northern Thailand, another of his wife’s postings. It garnered splashy reviews by Stephen King and Hilary Mantel, a National Book Award nomination and a $50,000 Whiting Award. Anyone who has read “Fieldwork” will immediately recognize in Berlinski’s second novel what can now be understood as the author’s MO. Not only does he choose to immerse himself in exotic locales, he also insists on anchoring himself, Mischa Berlinski, journalist and novelist, as the narrator, intermediary and witness. The result is not fictionalized autobiography but something a bit more playful or maybe even spellbound, as if Berlinski had gone native into his own books, unable to pry himself out of the dynamics of the story’s spectacle. In an author’s note at the end of “Peacekeeping,” Berlinski explains, “I am not I, you are not you,” which seems perfunctory as far as assurances go. If one good meta-wink deserves another, then I’m not me, either, Bob Shacochis reviewing this book. Rather, in an alternative universe, I’m the fellow who met Berlinski in a bar in Port-au-Prince, where the two of us made a pact to write novels about Americans who want to make the world a better place. And then we died laughing, real tears rolling down our cheeks. Seriously, despite the fact of Haiti’s geopolitical purgatory, a nation occupied and molested by external (and internal) forces for centuries, when you’re not suppressing the urge to weep for the suffering of Haitians, there’s much to laugh at in “Peacekeeping.” For starters, the protagonist is Terry White, a.k.a. Terry the White, a U.N. policeman stationed in the far-flung city of Jérémie on Haiti’s coastline. After 20 years as a deputy sheriff in a Florida Panhandle county, White, “the stereotype of the southern lawman,” lost his career, his home and his inner compass when he played in the Big Boy sport of Florida politics. “He was a know-it-all,” writes Berlinski. “Even Terry White’s kindnesses had about them some trace of superiority.” The U.N. mission in Haiti offers him a chance to reboot himself. White is passionately committed to protecting good people from bad people. Haiti, of course, feeds and frustrates the noble desire of such personalities, never more so than when White enters into the orbit of Johel Célestin, a light-skinned, Kennedyesque district judge who speaks with “the clipped inflections of educated American speech.” Célestin, who went to New York as a child fleeing the brutality of the Duvaliers, returned to Haiti six years ago, long enough to have developed a tactile sense of intolerance for the injustice crushing the lives of everyday Haitians. He has reluctantly decided, with White’s prodding, to become a candidate for the Haitian Senate. His entrenched opponent, Sen. Maxim Bayard, also light-skinned and a former exile, seems to be an easy target, appearing to represent the moral bankruptcy infecting the core of Haitian politics. But in the hands of an accomplished novelist such as Berlinski, no character’s assigned roles are what they seem to be. Célestin’s lover and future wife, the blue-eyed, ebony-skinned Nadia, is presented as a foil to these three men and their various shades of pale. She hovers and swoops as the story’s avatar of blackness, the vessel through which flows the terrible history of Africans in the New World. “Peacekeeping” gallops ahead toward the horizon of tragedy, yet the novel is brightened by the author’s sense of the absurdities that saturate an enterprise like a U.N. mission and the weird, byzantine intimacies at the ground level of globalization. Berlinski is also delightfully deft with dialect and bawdy humor — to do otherwise would be a disservice to Haitians and the brilliant spectrum of their culture. In this respect, the novel belongs next to Herman Wouk’s “Don’t Stop The Carnival,” a comedy about a white American’s middle-age crisis in the Caribbean, until Berlinski’s narrative suddenly reaches a disaster. Then it resembles Thornton Wilder’s masterpiece “The Bridge of San Luis Rey.” But too often Haiti has been a stage for the kabuki performance of our good intentions, as well as a mirror reflecting the vanity of our exceptionalism, and it’s never a bad idea to look toward Haiti for a reality check on who we are in the world. “Peacekeeping,” in that sense, is a welcome bearer of enlightenment and a raw reminder of the limits of empathy. ******Bob Shacochis** ’s most recent novel is “The Woman Who Lost Her Soul.” _Read more_ : The Post’s View: Haiti on the brink By Mischa Berlinski Sarah Crichton. 372 pp. $27

Rebuilding after Ebola will require the world’s help

THE RAVAGING of populations in Liberia, Sierra Leone and Guinea by the Ebola virus over the past year has been devastating. The virus killed 10,702 people and left behind vast economic and emotional tolls. The rest of the world responded slowly to the outbreak but eventually rallied. Now it is time to do the same with the aftermath and extend a hand for rebuilding. The economic impact is “as much a tragedy and disaster as the disease,” President Ellen Johnson Sirleaf of Liberia told us Thursday. In those early frightening months after the outbreak began, airlines abandoned her country, markets closed, growth stalled and tourism and foreign investment vanished. The story was much the same in the other two nations. Liberia’s economy is slowly recovering, Guinea is stagnating and Sierra Leone is suffering severe recession, according to a World Bank update released April 15. All three face serious vulnerabilities, including decimated government budgets and the need to rebuild employment, education, infrastructure and routine health care. During visits to Washington this week, Ms. Johnson Sirleaf, Guinean President Alpha Condé and Sierra Leonean President Ernest Bai Koroma appealed to the international community not to forsake them. They asked for debt relief of $3.2 billion and an $8 billion commitment from different sources over several years for a kind of post-Ebola Marshall Plan. The details will have to be hammered out — a donors conference is set for July — but in general we think their appeal makes sense. The World Bank announced Friday it would provide about $650 million in aid over the next 12 to 18 months. The outbreak has receded, but weak local health-care systems proved inadequate when the virus began to spread last year, and improvements are vital in all three countries, especially a much-strengthened system of surveillance to spot any resurgence. Trained health-care workers are in short supply. A small but important step was taken recently in the announcement that the Centers for Disease Control and Prevention will help set up an African CDC that could keep the continent one step ahead of another scourge. But the rest of the world also has a stake in making sure that the region builds a better firewall against infectious disease. All three nations need to recover from the social toll. Ms. Johnson Sirleaf described her efforts to empower communities to fight the disease, a far more effective approach than commands from above. One of the most profound lessons of the Ebola disaster is that, in addition to the need for treatment centers and provisions, an outbreak is a crisis of human behavior. Fear can unleash irrational and dangerous actions that only spread the illness. It is essential to build trust with people affected. Ms. Johnson Sirleaf acknowledged that “we made some false starts” by trying to restrict neighborhoods rather than enlist their help. But she also noted that Liberia took hard steps, such as carrying out cremations instead of burials, an unheard-of departure from tradition that was necessary to stop the virus from spreading. All these lessons must be learned and learned well, because there will be a next time. **Read more about this topic:** The Post’s View: What worked in controlling the Ebola outbreak in West Africa The Post’s View: Lessons from the Ebola outbreak in West Africa Paul Farmer: The secret to curing West Africa from Ebola is no secret at all

Why Zika is ‘much more insidious, cunning and evil’ than Ebola

Global health authorities and government officials are mobilizing to battle the fast-spreading Zika virus, sending rapid-response teams to affected regions, issuing travel warnings for pregnant women, accelerating vaccine trials and even deploying mosquito-fighting troops to hard-hit areas in Brazil. Stung by criticism that the world’s response to the Ebola epidemic was halting and disjointed, officials in Latin America, the United States and Europe say they are determined to do better against a new foe that, in some ways, is more daunting than the hemorrhagic virus that killed 11,000 people in West Africa. But their efforts are being hobbled by a fundamental lack of understanding of a disease that has spread to nearly three dozen countries and is moving so quickly that some experts estimate it could infect as many as 3 million to 4 million people within 12 months. Unlike the highly lethal Ebola, which had been studied extensively by the time it emerged in Guinea in late 2013, Zika wasn’t considered a menace. Most infected people didn’t even show symptoms. For decades, Zika got little scrutiny before showing up in Brazil in May. Now, for the first time, Zika is suspected of being the culprit behind a constellation of devastating birth defects, most notably microcephaly, a rare condition in which babies are born with head and brain abnormalities. In adults, the virus has been associated with another rare condition, called Guillain-Barré syndrome, that can result in paralysis and even death. But, even at this point, scientists are not able to say definitively that Zika is the cause of the problems. The mystery surrounding the virus — officials aren’t sure what will turn up next — makes it “much more insidious, cunning and evil” than Ebola, said Bruce Aylward, a World Health Organization official who helped coordinate the organization’s Ebola response and is now leading the Zika effort. The urgency to understand the virus, along with pressure not to repeat its slow-footed reaction to the devastating Ebola crisis, prompted the WHO to move faster this time to declare a global public health emergency. “This emergency is because of what’s unknown,” said David Heymann, an infectious-disease professor at the London School of Hygiene and Tropical Medicine and chairman of the expert committee that urged WHO to call a global health emergency. “The Ebola emergency was because of what was known.” But declaring an emergency is just the beginning, and many public health experts are pressing for quick and aggressive steps. There has been no public announcement yet of a strategic plan with a timetable and cost estimate to make it work, said Lawrence Gostin, a global health law professor at Georgetown University. “Calling an emergency only scratches the surface,” he said. “There has to be action that follows it.” On Saturday, the WHO said it plans to soon release an “overview of needs and requirements” to fight the epidemic. As the WHO works to detail the threat to affected countries, some government officials and others are planning for worst-case scenarios. Scientists around the world are scrambling to learn why so many people are getting sick and how those illnesses are related to the virus, particularly for pregnant women and others at greatest risk. So far, only Brazil has reported a surge in cases of microcephaly. French Polynesia, Brazil, El Salvador, the French territory of Martinique, Colombia, Suriname, Venezuela and Honduras have all reported increases in people with Guillain-Barré syndrome, according to the WHO. Some involved in the Zika response say the international coordination is already much better than it was during the Ebola crisis. Part of that has less to do with the institutions involved than with the people who work for them, many of whom formed tight bonds during the last epidemic. “Groups are just linked up in a way that wasn’t true in the first nine or 10 months of Ebola,” said Jeremy Farrar, director of the Wellcome Trust, a London-based biomedical research charity that worked in West Africa. “There’s much more free flowing of information about what each other is doing. I’m not saying it’s perfect, but it is completely different.” Farrar said the WHO and others need to take advantage of the momentum and move decisively. “The worst situation is we under-react for a year and an epidemic gets out of control and causes death on the scale that Ebola did,” he said. “If we’ve taken a lesson from Ebola, it is the need to be bolder and more courageous. To say, ‘We need to act now.’ ” But it is not always clear what that decisive action should be, or how to marshal the political and financial resources needed to make it happen. One challenge involves the way people are infected. Ebola requires close human contact for person-to-person transmission, so health officials knew essentially what needed to be done, even if help was slow in coming: warn people not to touch the dead bodies of loved ones, build centers to treat and isolate patients, and shore up fragile health systems. But because Zika is spread primarily by the _Aedes aegypti_ mosquito, curbing the epidemic is more complicated. Much depends on individual governments — and citizens — mounting aggressive efforts to kill mosquitoes and deprive them of breeding grounds. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, said it’s worth considering a “military-style campaign,” such as the effort in the middle of the past century in which authorities eradicated _Aedes aegypti_ in much of South America and parts of the Caribbean in a bid to stop dengue fever. But he knows that won’t be fast or easy. “It’s labor intensive,” Hotez said. “There would have to be a lot of political will.” The Centers for Disease Control and Prevention, one of the lead agencies in the fight against Ebola, is sending teams to affected regions to research Zika and help with mosquito control. In its Atlanta-based emergency operations center, which is on the highest level of activation, hangs an enormous photo of the _Aedes aegypti_. This mosquito, considered one of the most effective disease-spreading vectors in the world, bites only humans and attacks aggressively during the daytime, often biting four to five people at one blood meal. Its bite is relatively painless, so people don’t swat and kill it. It thrives in dense, urban environments, breeding in the tiniest of places, such as a drop of water in a bottle cap. Its larvae don’t necessarily need water to survive, laying dormant during a drought and hatching during the rainy season. All of that makes it a formidable foe. “It takes near-perfection to stop Ebola, but if you do the right things, you can halt it,” said Thomas Frieden, director of the CDC. “Mosquito control requires meticulous attention to detail, trained staff and, like other parts of public health, it has to be done day in and day out.” Throughout the affected region, countries are coming up with different strategies to try to contain the epidemic. While Brazil has mobilized a national effort, deploying soldiers to join health workers, El Salvador is urging women to wait until 2018 to become pregnant. Colombia is concentrating its resources and attention in a few key states. “This is classic ‘building your boat as you sail it,’ ” said Aylward, the WHO’s man in charge of fighting epidemics. “People said that about Ebola, and that was trying to get a bigger sail on the boat. Here we’re still stitching the sail, and we’re not quite sure what kind of sails you really need.” An overarching goal is protecting pregnant women. After a Dallas resident was infected by having sex with a person who had contracted the disease in Venezuela, the CDC within days issued new guidelines detailing measures for pregnant women to protect against sexual transmission of Zika. It was only the second reported case of sexual transmission. Diagnosing Zika in pregnant women also is challenging. The virus stays in the blood only for about a week. After that, it’s difficult to know if a woman was infected because the tests used aren’t sensitive enough to differentiate between Zika and two related viruses on a routine basis. Those other viruses, dengue and chikungunya, are transmitted by the same type of mosquito, and many of the Zika-affected countries continue to battle outbreaks of those viruses. The CDC has sent out material to state labs and health departments to perform 30,000 tests for Zika. It’s getting ready to send out material for tens of thousands more tests. But that’s not going to be enough to promptly test all the pregnant women who will be returning from Zika-affected countries, Frieden said during recent congressional testimony. In any given year, 30 million to 40 million people travel back and forth between the United States and South America and the Caribbean, including half a million pregnant women. Meanwhile, affected countries are struggling to put in place systems to detect signs of microcephaly and Guillain-Barré syndrome, and to brace for the far-reaching effect on families trying to care for infants who might have disabilities. In poor countries, that will be especially difficult. “These women will need care that may be beyond what we can provide in a place like Haiti,” said Joia Mukherjee, chief medical officer for Partners in Health, a Boston-based nonprofit that provides health care in Haiti. There aren’t enough ultrasound machines to screen pregnant women, or specialists to provide long-term support for disabled children. “This is going to be a huge burden to a poor family,” she said. As health experts grapple with the latest epidemic, some say that the biggest lesson from Ebola — the importance of building robust health systems so countries are prepared for newly emerging diseases — has not yet been learned. “We can’t keep being caught off guard and unprepared,” said Georgetown’s Gostin. “There are going to be global health emergencies, and we need to have funding already mobilized, planning already done. . . . None of that is happening.” **Dec. 26, 2013** | Ebola’s first signs A young boy dies of a fever in Guinea. He is later determined to be the first case in the latest Ebola outbreak. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ** 86 days pass until . . .** **March 22, 2014** | Link reported Guinea reports the boy’s fever is confirmed as Ebola. Dozens of others have already died. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ** 140 days pass until . . .** **Aug. 8, 2014** | Emergency declared The World Health Organization declares Ebola an international public health emergency. **May 7, 2015** | Zika’s first signs The Pan American Health Organization issues an Epidemiological Alert for Zika in northeast Brazil. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ** 194 days pass until . . .** **Nov. 17, 2015** | Link reported Brazil’s Ministry of Health reports possible association of microcephaly with Zika virus infection during pregnancy. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ** 77 days pass until . . .** **Feb. 1, 2016** | Emergency declared The World Health Organization declared the Zika virus to be an international public health emergency. Sources: News reports, health organizations

World Digest: March 18, 2014

A suicide bomber killed 15 people in an attack on a busy marketplace in northern Afghanistan on Tuesday, officials said. The Taliban has threatened to kill anyone who takes part in next month’s presidential election, and eight people involved in political campaigning have been killed since electioneering started last month. A group of election officials has also been kidnapped. It was not clear whether the bombing was related to the election. At least 47 people were wounded when the suicide bomber, driving a three-wheel rickshaw, blew himself up in Meymaneh, the capital of Faryab province, the Health Ministry said in a statement. “It was a bazaar day and everybody was busy buying or selling when the bomber detonated his explosives,” said Mohammadullah Batash, Faryab’s governor. Two children were among the dead, the United Nations said. The United Nations said improvised explosive devices have killed 190 civilians in Afghanistan so far this year, a 14 percent increase from the same period last year. **— Reuters** Doku Umarov, a Chechen Islamist warlord who threatened to attack the Winter Olympic Games in Sochi to punish Russia, is dead, the insurgent Web site Kavkaz Center announced   Tuesday. The notice gave no details about the circumstances of his death. Umarov, known among Islamists in the Caucasus as Doku Abu Usman, had warned in July, as Russia was scrambling to complete facilities for the Sochi Olympics, that his fighters would target the international event. Umarov, one of Russia’s most-wanted militants, claimed to have ordered terrorist attacks on Russian targets in the past, including suicide bombings of the Moscow Metro in March 2010 that killed 40 people and an assault on Moscow’s Domodedovo Airport 10 months later in which three dozen people were killed. **— McClatchy-Tribune** A Haitian official said Tuesday that drought is causing an “extreme emergency” in the country’s northeast. Pierre Gary Mathieu of the government’s National Coordination of Food Security agency said the eight-month-long drought has destroyed bean, plantain and corn crops, as well as livestock. He said it will take six months for the area to recover. The usually arid area has seen some rain lately but not enough to replenish crops. A U.S.-government financed food program says that a second rainy season began later than usual last year. Northeastern Haiti received very little of that rainfall. **— Associated Press** **— From news services**

‘Piles’ of bodies left after attack on civilians by gunmen in South Sudan

NAIROBI, Kenya — Gunmen in South Sudan who targeted civilians, including children and the elderly, left “piles and piles” of bodies, many of them in a mosque and a hospital, the United Nations’s top humanitarian official in the country said Tuesday. Toby Lanzer told the Associated Press in a phone interview Tuesday that the ethnically targeted killings in a provincial capital are “quite possibly a game-changer” for a conflict that has been raging since mid-December and has exposed long-standing ethnic hostilities. There was also a disturbing echo of Rwanda, which is marking the 20th anniversary this month of its genocide, in which an estimated 1 million people were killed. In the Rwandan genocide, orders to kill were broadcast by radio — and it happened in South Sudan, too, Lanzer said. “It’s the first time we’re aware of that a local radio station was broadcasting hate messages encouraging people to engage in atrocities,” said Lanzer, who was in Bentiu on Sunday and Monday. “And that really accelerates South Sudan’s descent into an even more difficult situation from which it needs to extract itself.” U.N. human rights investigators said late Monday that hundreds of civilians were killed last week because of their ethnicity after rebel forces seized Bentiu, the capital of oil-producing Unity state. Those rebel forces are Nuer, the same ethnic group to which former vice president Riek Machar, who is now a rebel leader, belongs. Lanzer said thousands of civilians from several ethnic groups are streaming to the U.N. peacekeeping base in Bentiu because many think more violence is coming. The base now holds 25,000 people but has only one liter of water per person per day and only one latrine per 350 people. “The risk of a public health crisis inside our base is enormous,” he said. Raphael Gorgeu, head of Doctors Without Borders in South Sudan, said people will die inside the U.N. base in coming days because of the water and sanitation situation. As rebel forces entered Bentiu last week, residents were led to believe that by entering the mosque they would be safe, Lanzer said, citing accounts from survivors. But once inside, they were robbed of money and cellphones, and a short while later, gunmen began killing, inside both the mosque and the city hospital. Those who were not Nuer could not be saved, Lanzer said. The gunmen killed wantonly, including children and the elderly, he said. Gorgeu said his team members in Bentiu — including 12 international staff members — have treated more than 200 people wounded in the violence, many gunshot victims among them. British Ambassador Ian Hughes said Tuesday that the April 15-16 killings are a clear violation of international law. He said those behind the atrocities and those inciting the killings will be held to account. The violence is only one part of a dual crisis that South Sudan faces. Because of the fighting, more than 1 million people have fled their homes, and very few residents are tending to their crops. Lanzer said there is a severe risk of famine in coming months because April and May is the period when residents should be planting and cultivating.

Leading from behind the curve on Ebola

The nation of Liberia — founded by liberated American slaves with support from Henry Clay, Daniel Webster and James Monroe — is not unacquainted with suffering. Two civil wars in the period from 1989 to 2003 and decades of economic mismanagement caused an 80 percent decline in per capita GDP — perhaps worse than any country since World War II. Warlords reduced Liberia’s infrastructure to rubble. In the 15 years following 1991, there was no electricity in the country except for private generators. When I last visited in 2012, President Ellen Johnson Sirleaf (Africa’s first female president) was leading a tentative recovery. She talked of action plans on reconstruction, development and health infrastructure. All are now in ruins. Sirleaf recently sent a letter to President Obama saying that Ebola threatens to “overwhelm us.” Her defense minister warns that Liberia’s “national existence” is at stake. Sirleaf just sacked 10 senior government officials who have fled the country and refused to return — hardly a reassuring development in a frightened nation. What difference does one more misfortune make in a distant, unfortunate place? A big difference, it turns out. The welcome globalization of markets, culture and travel also involves the unavoidable globalization of threats, including terrorism and pandemic diseases. A virus infecting a single patient — perhaps, in this case, a 2-year-old boy from a Guinea border town who died just before Christmas in 2013 — can reduce three countries (Liberia, Guinea and Sierra Leone) to desperation and civil disorder, result in the August declaration of an international health emergency by the World Health Organization (WHO) and raise the prospect of further spread and (more remotely) of disastrous genetic mutation. There is no escape, no isolation, no sanctuary. Any doctrine of “non-intervention” in such a world is not only a dream but a danger. This is the context in which President Obama has properly decided to step up the U.S. response to the Ebola outbreak — a plan involving additional hospital beds, an expanding role for the Defense Department and broader efforts to prevent the rapid spread of the disease in places such as Nigeria (which would be a regional and global nightmare). Whatever the intentions of the president’s plan, its success will be measured by a few things. Speed is essential — even days of delay would have large consequences given the upward curve of cases. Coordination is key — other governments, international institutions and nongovernmental organizations need someone to be unequivocally in charge on the ground. And a massive education effort will be essential — the next stage of preventing transmission may require people who fear they are infected to stay in place, wait to see if they get sick and then be nursed by relatives with home-care kits (if an Ebola treatment facility is not readily available). The Ebola outbreak is a continuing crisis that will doubtlessly demand further resources and effort. But it is also a stress test for future emergencies. The virus, at this point, spreads through contact with bodily fluids. Future threats may only require a touch or a cough. This is not alarmism but a repeated pattern of struggle between humans and microbes, in which humans have often suffered massive casualties (the 1918 flu pandemic killed 3 percent to 5 percent of the world’s population). This test has revealed several weaknesses: First, we have seen how diseases take root and grow in parts of the world with fragile or nonexistent health systems, where the normal responses to disease outbreaks (case investigation, contact tracing) quickly break down. There is no better argument than Ebola for addressing massive global disparities in health infrastructure. Second, we have seen the essential hollowness of the response of international institutions. The United Nations and WHO issue warnings and assemble road maps and blueprints, but they do not constitute an effective emergency response mechanism. The world needs one. Third, we have seen that the U.S. government’s response to an outbreak can be fragmented and slow off the mark. The administration offered an incrementally growing response to an exponentially growing problem. In this case, expertise and a sense of urgency were scattered unevenly across bureaucracies including the Centers for Disease Control and Prevention, the National Institutes of Health, the Department of Health and Human Services, the State Department, the U.S. Agency for International Development and the Defense Department. All these varied capabilities — so essential during a global health emergency — become more difficult to summon from behind the curve. _Read more fromMichael Gerson’s archive, follow him on Twitter or subscribe to his updates on Facebook _. **Read more about this topic:** Richard E. Besser: The world yawns as Ebola takes hold in West Africa The Post’s View: The global complacency on Ebola must end Joanne Liu: A concrete response to the Ebola outbreak cannot wait Michael Gerson: The Ebola crisis demands that America act The Post’s View: Time to cut the hype and focus on the real dangers of Ebola

Haiti’s dangerously sluggish electoral progress

HAITI’S CARETAKER president, Jocelerme Privert, took power on Valentine’s Day thanks to a deal among politicians who granted him a 120-day term and a limited mandate: to prepare the way for balloting that would produce a new, popularly elected leader. Now, 120 days have come and gone, there is no new president, and presidential elections seem months away at best. Democracy has never had a firm foothold in Haiti; little wonder so many Haitians tend to shrug at the latest lapsed electoral deadline. But neither Haitians nor the international community should be complacent. Without free and fair elections, the hemisphere’s poorest country, still rebuilding from a devastating earthquake in 2010, has little chance of restoring political stability and reviving its listless economy. Mr. Privert, who led the Haitian Senate before he was elevated to lead a transitional government, had to navigate Haiti’s rocky political terrain to appoint a special electoral council charged with reviewing last year’s first round of presidential elections, which were marred by allegations of fraud. The rationale for reviewing the results is that confidence in the electoral process must be restored before proceeding with a new vote — whether a rerun of the first round or a runoff between the putative two top finishers. It remains to be seen whether the council has the credibility to make that call and make it stick with disillusioned Haitians. The council is due to render its judgment by the end of May. The risk is that its verdict will trigger a new round of recriminations and instability. If the council gives its blessing to the first-round results, that will infuriate the second-place finisher, Jude Celestin, and his backers, who allege that fraud was rampant. If instead it recommends that the results be scrapped and the election rerun from scratch, there is likely to be an uproar from the camp of the first-place finisher, Jovenel Moise, the heretofore obscure hand-picked successor of Michel Martelly, the dictatorial president who stepped down in February. U.S. officials, impatient for a runoff, have urged that Haiti get on with it; Secretary of State John F. Kerry last month grumbled about “this process of delay.” Like much of what comes from Washington, however, that stance is viewed with misgivings in Haiti, which was occupied by U.S. Marines a century ago. Supporters of Mr. Celestin, who was excluded from the runoff election five years ago at Washington’s behest, suspect the fix is in again. Yet it is in Haiti’s interest, far more than Washington’s, to hold new elections sooner rather than later. In a nation beset by crony capitalism and threatened by inflation, little progress is likely in the absence of a legitimate, fully formed government. The longer that is delayed, the greater the danger that political instability, rarely much below the surface, will erupt into full-fledged violence. Haitians deserve clean elections and Haitians themselves will benefit from them. So why delay? **Read more on this topic:** The Post’s View: Haiti urgently needs international help overcoming its political crisis The Post’s View: Haiti on the brink The Post’s View: After canceling its presidential election, Haiti heads toward chaos

Trump calls U.N. ‘just a club for people’ to ‘have a good time’

Three days after the United Nations adopted a resolution calling on Israel to halt Jewish settlement activity on Palestinian territory, President-elect Donald Trump tweeted that the international body “is just a club for people to get together, talk and have a good time.” The harsh criticism, which Trump made Monday while vacationing at his Mar-a-Lago resort in Florida, signaled he would likely challenge more than just the 71-year-old institution’s approach to the Middle East once he takes office. While Trump did not elaborate on why he considered the United Nations ineffectual, he made it clear both before and after the Security Council adopted the resolution condemning Israeli settlements in the West Bank and East Jerusalem that he believed the United States should have blocked the move. President Obama instructed U.N. Ambassador Samantha Power to abstain from voting, on the grounds that the Israeli government’s continued support for expanding Jewish settlements could undermine any prospect of eventually reaching a two-state solution to the simmering conflict. After the Security Council voted Trump tweeted, “As to the U.N., things will be different after Jan. 20th,” which is the day he will assume the presidency. The United Nations has come under fire for years from critics on both the right and the left. Conservatives have attacked it for infringing on individual nations’ sovereignty as well as wasting resources, while many developing nations argue that most major decisions remain dominated by a handful of countries that were influential when the United Nations was established decades ago. In recent years, some of its peacekeeping troops have been repeatedly accused of raping civilians they were sent to protect, and this August the office of U.N. Secretary General Ban Ki-moon formally acknowledged that Nepalese peacekeepers sent by the United Nations to Haiti six years ago contributed to a cholera outbreak there even as U.N. officials maintained they have legal immunity in connection to the epidemic. But the United Nations continues to play a key role in helping deliver humanitarian assistance across the globe, brokering cease-fires during conflicts and serving as a forum for sprawling issues such as how best to address climate change. Obama has worked doggedly during his time in office to support multilateral institutions such as the United Nations. He has used his speech each year before the U.N. General Assembly as a way to lay out his vision for foreign affairs and has convened summits there to tackle questions that include the global refugee crisis and the fight against terrorism. Earlier this month, the president stopped by to personally thank Ban for his work when the secretary general, who is stepping down at the end of the month, was meeting with national security adviser Susan Rice at the White House. During a new conference last month, Obama emphasized that the United States must continue to play the leading role in maintaining “the basic framework of the world order” that was established after World War II. “And I’ve said before, that’s a burden that we should carry proudly,” Obama said. “And I would hope that not just the 45th president of the United States, but every president of the United States understands that that's not only a burden, but it’s also an extraordinary privilege. And if you have a chance to do that right, then you should seize it.”

To South Sudan’s woes, add famine — 50,000 kids at risk of death

MALAKAL, South Sudan — Nyarony Choing is as old as South Sudan. And like the world’s newest nation, she has been to hell and back before her fourth birthday. When civil war broke out eight months ago in Juba, the capital, Nyarony’s mother fled with her three children, winding up in a refugee camp inside a base run by the United Nations in the northern city of Malakal. Every time it rains, which is often, the floor of their tent disappears underwater, the thick, cloying mud of the Nile basin mixing with the human excrement that flows freely in the camp. “The only thing worse than the conditions we are living in,” said Nyabac Chan Yor, Nyarony’s 26-year-old mother, “is the condition of my daughter.” Less than four years after South Sudan declared independence from Sudan, a milestone that successive U.S. administrations worked to bring about, aid workers are racing to head off a large-scale humanitarian disaster. According to UNICEF and the World Food Program, close to a third of South Sudan’s population faces “acute” or “emergency” levels of hunger and malnutrition. By the time Nyarony’s family made it to the U.N. base, the 3-year-old was emaciated and suffering from acute malnutrition. Her feet had swollen to nearly twice their normal size — the result of water flooding into excess vascular space as her digestive system shut down — and her muscles had all but wasted away. Nyarony is now gradually recovering after receiving medical treatment on the U.N. base, but thousands of children remain stranded in remote parts of the country, where they are at risk of starvation. Aid agencies estimate that 235,000 children could become dangerously malnourished by the end of the year, and 50,000 of them could die unless they get treatment. South Sudan’s food crisis is almost entirely man-made. After eight months of civil war, about 1.1 million of its roughly 11 million people are internally displaced. Farmers missed this year’s planting season because of the violence. Livestock, which accounts for as much as 70 percent of the calories consumed by some communities, has been looted, killed and scattered in the mayhem. River trade, which forms a lifeline for many towns and cities cut off from the capital by road during the rainy season, has ground to a virtual standstill. The humanitarian situation is “getting [more] desperate by the day,” said Cosmos Chanda, the representative for the U.N. High Commissioner for Refugees, in an interview from Juba. The fighting, he said, “has totally suffocated our ability to reach a lot of these locations” where people are at risk of starvation. Experts have held off on making a formal famine declaration — there are specific criteria, including a death rate of 2 out of 10,000 people per day, which must be met before such a declaration can be made — but aid workers caution against waiting for that before taking action. “The declaration of famine is a technical term. It’s a scientific thing that takes time,” said Jonathan Veitch, UNICEF’s representative in South Sudan. “It will be too late if we wait. We have to all act now.” Children are already dying, he said. By the time the United Nations declared a famine in Somalia in 2011, roughly half its 260,000 victims had perished, according to a study commissioned by the U.N. Food and Agriculture Organization. South Sudan also is facing a deadly cholera epidemic. Transmitted mainly through contaminated food or drinking water, cholera causes severe dehydration and can lead to death in a matter of hours. “People are living in horrid conditions,” said Patrick Robitaille, the field coordinator in Malakal for the aid group Doctors Without Borders, “so disease is spreading very rapidly.” A total of 4,765 cholera cases were reported in South Sudan between April and the end of July, 109 of them fatal, according to the doctors’ group, known by the French acronym MSF. But the outbreak could have been much more devastating; one of the small victories amid the conflict was an emergency cholera vaccination drive that has kept the disease from ravaging refugee camps. Nonetheless, efforts to contain the outbreak — and to head off a potential famine — have been hampered by persistent insecurity in the country’s northeast, where most of the fighting has occurred. Despite an internationally mediated cease-fire, sporadic clashes between government and rebel troops have continued, and there have been reports of both sides obstructing aid to civilians. This month, six aid workers were targeted in what were apparently ethnically motivated killings. The fighting began as a power struggle between President Salva Kiir and his former vice president, Riek Machar, but quickly took on an ethnic tinge. Kiir comes from South Sudan’s largest ethnic group, the Dinka, while Machar comes from its second-largest group, the Nuer. More than 500 miles away in the Ethiopian capital of Addis Ababa, peace talks have continued intermittently for months without making much headway. On Aug. 10, negotiators missed a key deadline to form a transitional government, fueling the perception that leaders on both sides are content to squabble over the country’s oil riches while ordinary people suffer. “Neither of the parties exhibit much urgency around the humanitarian issue,” said John Prendergast, a former Clinton administration official with years of human rights activism on Africa issues. He described the hunger crisis in South Sudan as a “ticking time bomb.” If hostilities continue into the dry season, aid workers fear that conditions could deteriorate substantially. As bad as the situation is now, at least there are water and plants on which displaced populations can survive. Once the dry season hits, those last lifelines will disappear. MSF predicts that South Sudan will hit “peak malnutrition” in February or March. Aid agencies say that is when a famine is most likely to be declared. In Malakal, which has changed hands six times since the war began and where some of the worst atrocities have been committed, most of the refugees are living day to day. “I just put one foot in front of the other,” said Nyabac, Nyarony’s mother, peering out of her tent at the rain slowly filling up the grimy tarpaulin world around her. “What else can I do?” This reporting was made possible in part by the Pulitzer Center on Crisis Reporting.

Book review: ‘Spillover: Animal Infections and the Next Human Pandemic’ by David Quammen

We kept a bottle of mosquito repellent right next to the back door this summer and made sure the balky screen door was pulled tight each time we came in from the garden. Firing up the grill in the evening called for long sleeves, long pants and proper shoes, not flip-flops. The mosquitoes in our corner of Washington have always been thick and aggressive. But this year, with the surge in West Nile virus infections, those critters were downright menacing. The precautions we took were familiar: They were the same ones I followed when traveling to far-off tropical locales where malaria-carrying mosquitoes were a danger. But here, literally in my back yard? This should be no surprise, according to the tale David Quammen tells in “Spillover,” his highly engaging exploration of animal infections and the perils they pose for people. This year’s West Nile outbreak, the deadliest in the United States since the virus was first spotted in New York in 1999, represents the local front in a perpetual global struggle with what are called zoonotic diseases. These are diseases that cross from animals to humans, and they are the subject of Quammen’s inquiry and his many adventures. An intrepid author, he tracks the killers — some with storied names such as ebola, SARS and HIV, others lesser known such as Hendra and Q fever — across jungles and farms to identify the animals on which the germs hide and to chronicle how they make the leap to people. These diseases merit our urgent concern. For one, they constitute the majority of all illnesses that strike humans. More than 1,400 human pathogens have been catalogued, and about 60 percent of them cross from nonhuman species to humans. An even higher proportion of human diseases that have emerged in recent decades, such as SARS and Lyme disease, have their origins in animals. And since the 1970s, the emergence of new zoonotic diseases has been accelerating. If we’re watching for the source of the next big epidemic, look to the animals. As Quammen writes, such zoonotic diseases are particularly confounding because they are so hard to eradicate. Over the generations, mankind has notched only a few victories over microbes. The elimination of smallpox was one. For years, armed with a range of vaccines, global public health officials have been closing in on polio as well, with the virus continuing to circulate only in a few Asian and African countries. Neither virus infects animals. So when global vaccination campaigns finally eliminate polio in humans, it’s finished. But diseases such as influenza and HIV live on in animals — in water birds in the former case, chimpanzees in the latter — and as long as they do, the bug can again cross to humans and ignite a new epidemic. Identifying the species that act as reservoirs, silently sheltering the pathogens with few outward signs or symptoms, can be a challenge. Quammen accompanies researchers on their hunts time and again. In pursuit of the Nipah virus, which frequently causes fatal inflammation of the brain, he journeys to the Ganges Delta of southern Bangladesh and recounts the efforts on a moonless night to catch flying fox bats in vast mist nets for testing. In northern Bangladesh, he joins a team of researchers at a Hindu shrine atop a hillock overrun by macaques possibly infected with the herpes B virus, which can devastate the human neurological system. The team courageously corners several of the frenzied monkeys in a makeshift trap and injects them with a tranquilizer before stuffing them into a duffel bag. In pursuit of ebola, a highly lethal disease that causes intense fevers and massive internal bleeding, Quammen roars into the forests of Central Africa in a Bell helicopter. There, he links up with a team of medical researchers trekking across Gabon, in part to study the effects on gorillas. While probing the emergence of HIV/AIDS in humans generations ago, Quammen ventures to the frontier between Congo and Cameroon and in the warrens of local markets searches for poached ape meat to reconstruct how the virus could have crossed from chimp to human hunter. His accounts make for colorful reading. Though they can meander at times, at their best they are arresting and unnerving. And Quammen intersperses judicious helpings of science and epidemiology, enough to leaven the narrative without bogging it down. As the book nears its close, Quammen writes that the outbreak of these diseases, whether new or recurring, is the result of human action: “We should recognize that they reflect things that we’re doing, not just things that are happening to us.” Often, they are products of human development. As farms and pastures encroach ever deeper into the wilderness, ecosystems are disrupted and people come into closer contact with disease carrying animals. As jungles and rain forests are razed, as factory farms proliferate to produce chicken and other meat for a global middle class, as jetliners knit the skies with multiplying flights and routes, microbes have more opportunities to jump from animal to person and speed around the globe. Public health experts suspect that West Nile virus, first identified in Uganda 80 years ago, made landfall in the United States when a mosquito carrying it stowed away on a transcontinental flight. The mosquito infected a blue jay or a crow, and birds became the reservoir for the virus. This year, a mild winter and an unusually hot summer — which look suspiciously like results of man-made climate change — yielded a bumper crop of virus- carrying mosquitoes. The result is an unprecedented outbreak that has sickened people in almost every state. According to top West Nile experts from the Centers for Disease Control and Prevention, the disease is still in its “adolescence” and could be with us for decades. In “Spillover,” Quammen advances an argument about the costs of human progress. The book would have benefited if he had made this case more thoroughly, using the theme of unintended consequences to stitch together chapters that at times read like a collection of dispatches from the microbial battlefront. But he does muster the argument in compelling fashion in the book’s final pages, warning that we disrupt the environment at our own peril. “We shake the trees, figuratively and literally,” he writes, “and things fall out.” **Alan Sipress** is The Washington Post’s deputy business editor and author of “The Fatal Strain: On the Trail of Avian Flu and the Coming Pandemic.” **SPILLOVER** **Animal Infections and   the Next Human Pandemic** By David Quammen Norton. 587 pp. $28.95

Death by siege in Syria’s civil war: Hundreds of thousands at risk

BEIRUT — Hundreds of thousands of people across Syria in areas besieged by government forces and opposition fighters are at risk of starvation and worsening malnutrition, U.N. officials, aid workers and activists warn. The warring parties are cutting off food and medicine to more than a dozen areas, causing civilians to die and complicating renewed peace efforts to end the country’s civil war. Disturbing images on social media purporting to show emaciated men, women and children in the town of Madaya, which has been blockaded by government forces, have in recent weeks added urgency to the issue. “As the conflict goes on and on, the situation on the ground is collapsing, especially in areas that are under siege,” said Pawel Krzysiek, a spokesman for the International Committee of the Red Cross who is based in the Syrian capital, Damascus. Even before Madaya, sieges were common in the Syrian war, which has led to more than 250,000 deaths, displaced millions and generated a humanitarian catastrophe. But the tactic appears to be increasingly applied as President Bashar al-Assad’s forces, backed by Russian airstrikes, wage a new offensive against rebel groups. The grim consequences are manifested in the vitamin-deficient mothers in blockaded areas who increasingly struggle to breast-feed, U.N. officials and aid workers warn. They say a growing number of the sick, elderly and young appear to be succumbing to otherwise preventable illnesses. In some places, such as Madaya, people have starved to death, aid agencies say. “We’re starving to death, women and children. We have no food,” said Dani Qappani, an activist in Moadamiyeh, an opposition-held town just a few miles southwest of Damascus that is under siege by government forces. In recent weeks, as many as seven people in the community of 44,000 have died because food and medicine have been cut off, said Qappani, a nom de guerre. The tempo of the war has increased since Russia intervened with airstrikes against rebel forces in Syria late last year. Moscow’s air raids have exacerbated already dire humanitarian conditions in the country, with pro-government forces on the ground in turn tightening sieges on opposition strongholds, analysts and activists say. Russia, a key ally of Assad, says its intervention is aimed at the Islamic State militant group, but Syrian opposition groups say the air raids have mostly targeted other rebel groups. The sieges appear to be threatening U.N.-backed peace talks that are supposed to start in Geneva next week. Several rebel groups recently announced they would not participate in the negotiations unless the government allows humanitarian aid into areas that its forces are blockading. Emile Hokayem, a Middle East analyst at the London-based International Institute for Strategic Studies, said Assad’s forces are pressing sieges on rebel-held areas as part of an attempt to seize as much key territory as possible ahead of the Geneva talks. Sieges are part of the government’s long-running strategy to “break and expel populations that are not loyal,” he said. In general, U.N. officials and aid workers have increasingly expressed alarm about residents who are cut off from food and medicine by belligerents on both sides of the conflict, an age-old war tactic that is a violation of international law. According to the United Nations, about 400,000 people are besieged in 15 locations in Syria. The world body defines an area as under siege if it is “surrounded by armed actors with the sustained effect that humanitarian assistance cannot regularly enter and civilians, the sick and wounded, cannot regularly exit the area.” Opposition activists in Syria accuse the United Nations of playing down the number of people living under siege, excluding in its figures some areas that are cut off by government forces. Senior U.N. officials have denied the accusation. Hassan Hassan, a Syria analyst based in Washington, said government sieges tend to be harsher and affect a far larger number of people than rebel-imposed ones. Furthermore, he said, Assad’s forces have aircraft, which rebels lack, to bomb areas it is besieging and airlift aid to loyal populations that are surrounded by opposition fighters. Madaya, a town of more than 20,000 people, has been blockaded by government forces and allied fighters from Lebanon’s Hezbollah militia since the summer, causing more than two dozen people to die of starvation, aid workers say. A U.N.-backed agreement recently allowed humanitarian aid into the town. In Moadamiyeh, which is not classified by the United Nations as besieged, residents and activists say government forces have completely halted the flow of food, medicine and people for the past month. A shaky truce with local rebels broke down as government forces increased attacks to capture nearby opposition-held areas. Activists say five children, a woman and an elderly man have died of starvation-related causes since the siege was tightened in December. Like in Madaya, the activists said, Moadamiyeh residents face soaring food prices — two pounds of rice now costs about $20 or more. “My family is living on making soup with some grass and pepper to survive,” said Majed, 22, an activist in Moadamiyeh who gave only his first name because of concerns for his safety. Elizabeth Hoff, a World Health Organization (WHO) representative in Syria, said doctors in Moadamiyeh are warning that women are increasingly struggling to breastfeed because of a lack of nutrients. “This is a sign that you might find severe malnutrition cases, like in Madaya,” Hoff said. WHO has been unable to verify claims of starvation deaths because the government has denied the organization’s requests since June to enter Moadamiyeh, she said. Conditions are also difficult in areas besieged by opposition forces, such as the areas of Deir al-Zour that are surrounded by the Islamic State, which controls vast territory in Syria and Iraq. But activists from the city also accuse the Assad government of exploiting the misery of residents who face brutal attacks by the militant group, highlighting perhaps the unexpected difficulties of those who live under blockade. Government air drops of food aid are insufficient and confiscated by officials, who then sell the food to desperate residents for exorbitant prices, said Jalal al-Hamad, director of Justice for Life in Deir al-Zour, a monitoring group that has activists in the city. To flee the area, government officials charge hefty fees that most residents are unable to pay, he said. “People in government neighborhoods are in reality under siege by two groups: ISIS and the Assad regime,” said Hamad, a native of the city who spoke by Skype from Turkey. “It’s a disaster.” Suzan Haidamous contributed to this report. **Read more:** Today's coverage from Post correspondents around the world

In Central African Republic, South Sudan and Syria, staying ahead of famine is imperative

Ban Ki-moon’s April 14 op-ed commentary, “A ticket out of misery,” must stir us all to action. The Central African Republic stands on the brink of famine. We need to support the World Food Program, UNICEF and other agencies before it’s too late. Since funding has been so low, food rations have already been reduced for war victims. These relief agencies depend on voluntary donations from governments and the public. With the country’s food-supply system destroyed by the conflict, a pipeline of aid needs to be filled. Every day we wait gives malnutrition a stronger hold on the population. The damaging effects of this malnutrition are often irreversible. We don’t want to say later that we should have acted sooner. We need to stay ahead of the famine in the Central African Republic — and in South Sudan and Syria. ****William Lambers** , Cincinnati**

The moral depravity of our Syria policy

Samantha Power, U.S. ambassador to the United Nations, appeared on ABC’s “This Week” to talk primarily about Ukraine. At the end of the interview, host George Stephanopoulos got a chance to ask her about Syria. This was the exchange:    *[WSU]: Wayne State University STEPHANOPOULOS: Finally, some disturbing video coming out of Syria this week — and I think we’re going to show it — right now reports of another poison gas attack, the first since August.  The rebels have put out the video. Syrian state television has claimed that actually the rebels are behind the gas attack, not the government. Do we know who is behind this? *[WSU]: Wayne State University POWER: We are trying to run this down. So far, it’s unsubstantiated. But we’ve shown, I think in the past, that we will do everything in our power to establish what has happened and then consider possible steps in response. STEPHANOPOULOS: And if the government did this after the president draws the red line, after they promised to turn over chemical weapons, will we have any option but to strike militarily? POWER: Well, I’m not going to get ahead of the president, but the president has made very clear how alarming he finds chemical weapons use, how outrageous he found it, that’s why he put the credible threat of military force on the table, that’s why we’ve been able to destroy and remove more than half of Syria’s chemical weapons up to this point. But certainly the point of what we’ve done so far is to prevent further use.  We weren’t just removing for removing sake, it was to avoid use. So we will have to look at our policy on this. Her disingenuousness is remarkable, even in this administration. Let’s begin by recalling that Power wrote a Pulitzer Prize-winning book on humanitarian intervention, a bold call for action when mass slaughter of innocents is going on. Repulsed by our failure to intervene in genocidal episodes like Rwanda, she received plaudits from liberals and conservatives for her indictment of a policy that, ironically enough, took form under the watchful eye of Susan Rice, who is now national security adviser. President Obama has not moved — militarily or to aid rebels sufficiently — to prevent a death toll approaching 200,000 in Syria. Someone should ask Power in a future interview what she thinks about that, whether mass murder by conventional means is any less horrible and what she thinks history will say about the administration’s actions. Frankly, many of us would like to know how she sleeps at night, knowing her boss is repeating the grotesque experience of the Clinton administration, which attracted her ire. She notes “we will do everything in our power to establish what has happened,” but then only “consider possible steps in response.” They _consider_ , and tens of thousands die. They work very hard (but not quickly), we learned last year, in figuring out what occurred. That, however, does not translate into meaningful action.    *[WSU]: Wayne State University And it’s good to know that the president finds the use of chemical weapons “alarming” and “outrageous,” because they were used many times, we now know, before he promised to act, then didn’t and finally shoved the whole mess in Russia’s direction. What message does it send when simply giving back _part_ of your chemical weapons haul is the only price to be paid after they are used, and used repeatedly?    *[WSU]: Wayne State University Continuing on, Power really must be pulling our leg when she said that the president put out the “credible threat of military force.” Yes, he did. And then looked to Congress to bail him out. And then did not use the threat of force. If this is “credible,” then the word has no meaning. And finally, she lets on that Syrian President Bashar al-Assad has about half his stash of chemical weapons as we come up on the one-year mark of their first suspected use. Obama never disarmed Assad or employed force to deter future use, so it should not be surprising that Assad still has a whole lot of chemical weapons and is very possibly still using them.    *[WSU]: Wayne State University Her interview reminds me of a question: _Doesn’t anyone resign on principle anymore_? I know people get fired. And some people get other, more lucrative jobs. Some people get worn out. But what ever happened to a strongly worded letter explaining why one’s conscience does not allow further service in an administration? I suspect people these days delude themselves into thinking they are making a difference. Or maybe careerism trumps everything.    *[WSU]: Wayne State University Power is no worse than others, I guess, but her previous writings and speeches led many (falsely, I guess) to think that she had some moral spine about these issues. I wonder who will write the book about the mass murder that the Obama-Power-Hillary Clinton-John Kerry team couldn’t bestir themselves to end.