. - Essay Platinum

To participate in the Discussion Board:

Each student must write a response to the prompt (minimum 250 words not counting reference list)

Select ONE of the following:

1) Analyze the vulnerability situation in Haiti before the earthquake using Week 2 Coppola's vulnerability types: physical, environmental, social and economic vulnerabilities. Link these pre existing vulnerabilities with the consequences of the earthquake. Note: Review Coppola reading on vulnerability (week 2): no need to define each type of vulnerability, it is common knowledge now so focus on this weeks case, Coppola does not count for the 2 minimum sources.

2) Discuss the cholera outbreak after the earthquake. What was the UN's role in the cholera outbreak and what are the lasting effects of this outbreak to this day.

Requirements: Prompt responses should answer the question and elaborate in a meaningful way using 2 of the weekly class readings (250 words of original content). Do not quote the readings, paraphrase and cite them using APA style in text citations. You can only use ONE multimedia source for your minimum 2 sources each week. The readings must be from the current week. The more sources you use, the more convincing your argument. Include a reference list in APA style at the end of your post, does not count towards minimum word content.

n engl j med 364;1 nejm.org january 6, 2011

P E R S P E C T I V E

nancially strapped and concerned about the cost of reform and its ability to meet their population’s needs.

Maine, Florida, Iowa, and other states have already indicated that they will seek waivers for some insurance rules that could desta- bilize local insurance markets. A recent proposal by Senators Ron Wyden (D-OR) and Scott Brown (R-MA) would grant states addi- tional f lexibility but falls short of giving them full authority to develop their own reform ap- proaches. Since reform cannot be implemented without them, states could choose to take a more in- dependent role even if Washing- ton is slow to give it to them.

Will the President’s health care reform look burdensome and un- workable 2 years from now? Re- form is no longer a 2000-page bill sitting on the desk of a sen- ator or representative. The exec- utive branch has been issuing guidance and regulations that are beginning to fill holes in the

legislation and will change the way the law works in practice. Much to the chagrin of the leg- islation’s most ardent support- ers, Secretary of Health and Hu- man Services Kathleen Sebelius has been granting waivers when the rules don’t work for every- one, albeit on a selective basis designed to avoid the worst po- litical heat.3 Although such de- cisions will soften the impact of reform, they neither alter the shift toward greater government control nor slow the growth of health care spending.

Despite the talk of repeal, Congress will not pass any major health legislation over the next 2 years, and the health sector and private employers will be hard at work preparing for 2014, when many ACA provisions take ef- fect. That does not make health care reform a fait accompli. Ab- sent a miracle, the country will still face crushing budget defi- cits when the next president takes office. A Republican president,

backed by a Republican Congress, would be wise to delay enroll- ment in the health insurance ex- changes, using the time and mon- ey to develop a more targeted plan that closes off open-ended sub- sidies for health insurance and gets the economic incentives right. A Democratic president would do the same thing out of neces- sity — but it would take longer.

Disclosure forms provided by the author are available with the full text of this arti- cle at NEJM.org.

From the American Enterprise Institute, Washington, DC.

This article (10.1056/NEJMp1012299) was published on December 8, 2010, at NEJM.org.

1. Streeter S. Continuing resolutions: FY2008 action and brief overview of recent practices. Washington, DC: Congressional Research Service, 2008. (CRS report RL30343.) (http:// www.rules.house.gov/archives/RL30343.pdf.) 2. Idem. The congressional appropriations process: an introduction. Washington, DC: Congressional Research Service, 2007. (CRS report 97-684.) (http://www.senate.gov/ reference/resources/pdf/97-684.pdf.) 3. Adamy J. Federal agency flexible on Mc- Donald’s plan. Wall Street Journal. October 1, 2010. Copyright © 2010 Massachusetts Medical Society.

Reforming Health Care Reform in the 112th Congress

Responding to Cholera in Post-Earthquake Haiti David A. Walton, M.D., M.P.H., and Louise C. Ivers, M.D., M.P.H.

Related article, p. 33

The 2010 Haitian cholera out-break has pressed local and international experts into rapid action against a disease that is new to many health care provid- ers in Haiti. The World Health Organization (WHO) has time- tested management protocols for emerging cholera outbreaks. These protocols have been used by the Haitian government to fight an epidemic that is merely one of several recent tragedies in Haiti. The use of these protocols has

allowed for a high standard of care in this complex and evolv- ing medical landscape. But where- as the current WHO cholera- treatment protocol (www.who.int/ mediacentre/factsheets/fs107/en/ index.html) recommends anti- biotics for only severe cases, the approach of the International Centre for Diarrhoeal Disease Re- search, Bangladesh (ICDDR,B), recommends antibiotics for both severe and moderate cases.

Several antibiotics are effec-

tive in the treatment of cholera, including doxycycline, ciprof lox- acin, and azithromycin, assuming that the cholera strain is sensi- tive. Currently, the epidemic strain in Haiti is susceptible to tetracy- cline (a proxy for doxycycline) and azithromycin but is resistant to nalidixic acid, sulfisoxazole, and trimethoprim–sulfamethoxazole. The WHO advocates giving anti- biotics to patients with cholera only when their illness is judged to be “severe.” This recommen-

The New England Journal of Medicine Downloaded from nejm.org on August 27, 2017. For personal use only. No other uses without permission.

After epidemic cholera emerged in Haiti in October 2010, the disease spread rapidly in a country devastated by an earthquake earlier that year, in a population with a high proportion of infant deaths, poor nutrition, and frequent infectious diseases such as HIV infection, tuberculosis, and malaria. Many nations, multinational agencies, and nongovernmental organizations rapidly mobilized to assist Haiti. The US government provided emergency response through the Offi ce of Foreign Disaster Assistance of the US Agency for International Development and the Centers for Disease Control and Prevention. This report summarizes the participation by the Centers and its partners. The efforts needed to reduce the spread of the epidemic and prevent deaths highlight the need for safe drinking water and basic medical care in such diffi cult circumstances and the need for rebuilding water, sanitation, and public health systems to prevent future epidemics.

Cholera is a severe intestinal infection caused by strains of the bacteria Vibrio cholerae serogroup O1 or O139, which produce cholera toxin. Symptoms and signs can range from asymptomatic carriage to severe diarrhea, vomiting, and profound shock. Untreated cholera is fatal in ≈25% of cases, but with aggressive volume and electrolyte replacement, the number of persons who die of cholera is limited to <1%. Since 1817, cholera has spread throughout the world in 7 major pandemic waves; the current and longest pandemic started in 1961 (1). This seventh pandemic, caused by the El Tor biotype of V. cholerae O1 and O139, began in Indonesia, spread through Asia, and reached Africa in 1971. In 1991, it appeared unexpectedly in Latin America,

causing 1 million reported cases and 9,170 deaths in the fi rst 3 years (2). The other biotype of V. cholerae O1, called the classical biotype, is now rarely seen.

Cholera is transmitted by water or food that has been contaminated with infective feces. The risk for transmission can be greatly reduced by disinfecting drinking water, separating human sewage from water supplies, and preventing food contamination. Industrialized countries have not experienced epidemic cholera since the late 1800s because of their water and sanitation systems (3). The risk for sustained epidemics may be associated with the infant mortality rate (IMR) because many diarrheal illnesses of infants spread through the same route. In Latin America, sustained cholera transmission was seen only in countries with a national IMR >40 per 1,000 live births (4). Although cholera persists in Africa and southern Asia, it recently disappeared from Latin America after sustained improvements in sanitation and water purifi cation (5,6). Although the country was at risk, until the recent outbreak, epidemic cholera had not been reported in Haiti since the 1800s, and Haiti, like other Caribbean nations, was unaffected during the Latin America epidemic (7,8).

Haiti: A History of Poverty and Poor Health Haiti has extremely poor health indices. The life

expectancy at birth is 61 years (9), and the estimated IMR is 64 per 1,000 live births, the highest in the Western Hemisphere. An estimated 87 of every 1,000 children born die by the age of 5 years (9), and >25% of surviving children experience chronic undernutrition or stunted growth (10). Maternal mortality rate is 630 per 100,000 live births (10).

Haitians are at risk of spreading vaccine-preventable diseases, such as polio and measles, because childhood vaccination coverage is low (59%) for polio, measles-

Lessons Learned during Public Health Response to Cholera

Epidemic in Haiti and the Dominican Republic

Jordan W. Tappero and Robert V. Tauxe

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2087

Author affi liation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA

DOI: http://dx.doi.org/10.3201/eid1711.110827

SYNOPSIS CHOLERA IN HAITI

rubella, and diphtheria-tetanus-pertussis vaccines (9). Prevalence of adult HIV infection (1.9%) and tuberculosis (312 cases per 100,000 population) in the Western Hemisphere is also highest in Haiti (11,12), and Hispaniola, which Haiti shares with the Dominican Republic, is the only Caribbean island where malaria remains endemic (13).

Only half of the Haitian population has access to health care because of poverty and a shortage of health care professionals (1 physician and 1.8 nurses per 10,000 population), and only one fourth of seriously ill persons are taken to a health facility (14). Before the earthquake hit Haiti in January 2010, only 63% of Haiti’s population had access to an improved drinking water source (e.g., water from a well or pipe), and only 17% had access to a latrine (15).

Aftermath of Earthquake The earthquake of January 12, 2010, destroyed homes,

schools, government buildings, and roads around Port- au-Prince; it killed 230,000 persons and injured 300,000. Two million residents sought temporary shelter, many in internally displaced person (IDP) camps, while an estimated 600,000 persons moved to undamaged locations.

In response, the Haitian government developed strategies for health reform and earthquake response (16,17) and called on the international community for assistance. The Ministère de la Santé Publique et de la Population (MSPP) requested assistance from the Centers for Disease Control and Prevention (CDC) to strengthen reportable disease surveillance at 51 health facilities that were conducting monitoring and evaluation with support from the US President’s Emergency Plan for AIDS Relief (PEPFAR) (18) and at health clinics for IDPs (19). MSPP also asked CDC to help expand capacity at the Haiti Laboratoire National de Sante Publique to identify reportable pathogens, including V. cholerae (20,21), and help train Haiti’s future epidemiologic and laboratory workforce. These actions, supported through new emergency US government (USG) funds to assist Haiti after the earthquake, laid the groundwork for the rapid detection of cholera when it appeared.

Cholera Outbreak On October 19, 2010, MSPP was notifi ed of a

sudden increase in patients with acute watery diarrhea and dehydration in the Artibonite and Plateau Centrale Departments. The Laboratoire National de Sante Publique tested stool cultures collected that same day and confi rmed V. cholerae serogroup O1, biotype Ogawa, on October 21. The outbreak was publicly announced on October 22 (22).

A joint MSPP-CDC investigation team visited 5 hospitals and interviewed 27 patients who resided in communities along the Artibonite River or who worked

in nearby rice fi elds (23). Many patients said they drank untreated river water before they became ill, and few had defecated in a latrine. Health authorities quickly advised community members to boil or chlorinate their drinking water and to bury human waste. Because the outbreak was spreading rapidly and the initial case-fatality rate (CFR) was high, MSPP and the USG initially focused on 5 immediate priorities: 1) prevent deaths in health facilities by distributing treatment supplies and providing clinical training; 2) prevent deaths in communities by supplying oral rehydration solution (ORS) sachets to homes and urging ill persons to seek care quickly; 3) prevent disease spread by promoting point-of-use water treatment and safe storage in the home, handwashing, and proper sewage disposal; 4) conduct fi eld investigations to defi ne risk factors and guide prevention strategies; and 5) establish a national cholera surveillance system to monitor spread of disease.

National Surveillance of Rapidly Spreading Epidemic Health offi cials needed daily reports (which established

reportable disease surveillance systems were not able to provide) to monitor the epidemic spread and to position cholera prevention and treatment resources across the country. In the fi rst week of the outbreak, MSPP’s director general collected daily reports by telephone from health facilities and reported results to the press. On November 1, formal national cholera surveillance began, and MSPP began posting reports on its website (www.mspp.gouv.ht). On November 5–6, Hurricane Tomas further complicated surveillance and response efforts, and many persons fl ed fl ood-prone areas. By November 19, cholera was laboratory confi rmed in all 10 administrative departments and Port-au- Prince, as well as in the Dominican Republic and Florida (24,25) (Figure 1). Though recently affected departments in Haiti experienced high initial CFRs, by mid December, the CFR for hospitalized case-patients was decreasing in most departments, and fell to 1% in Artibonite Department (26). Reported cases decreased substantially in January, and the national CFR of hospitalized case-patients fell below 1% (Figure 2). As of July 31, 2011, a total of 419,511 cases, 222,359 hospitalized case-patients, and 5,968 deaths had been reported.

Field Investigations and Laboratory Studies To guide the public health response, offi cials

needed to know how cholera was being transmitted, which interventions were most effective, and how well the population was protecting itself. Therefore, CDC collaborated with MSPP and other partners to conduct rapid fi eld investigations and laboratory studies. Central early fi ndings included the following.

First, identifying untreated drinking water as the primary source for cholera reinforced the need to provide

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CHOLERA IN HAITI Cholera in Haiti and Dominican Republic

water purifi cation tablets and to teach the population how to use them. Although most of the population had heard messages about treating their drinking water, many lacked the means to do so.

In addition, in Artibonite Department, those with cholera-like illness died at home, after reaching hospitals, and after discharge home, which suggests that persons were unaware of how quickly cholera kills and that the overwhelmed health care system needed more capacity and training to deliver lifesaving care. Also, water and seafood from the harbors at St. Marc and Port-au-Prince were contaminated with V. cholerae, which affi rmed the need to cook food thoroughly and advise shipmasters to exchange ballast water at sea to avoid contaminating other harbors.

The epidemic strain was resistant to many antimicrobial agents but susceptible to azithromycin and doxycycline. Guidelines were rapidly disseminated to ensure effective antimicrobial drug treatment.

Cholera affected inmates at the national penitentiary in Port-au-Prince in early November, causing ≈100 cases and 12 deaths in the fi rst 4 days. The problem abated after the institution’s drinking water was disinfected and inmates were given prophylactic doxycycline.

Finally, investigators found that epidemic V. cholerae isolates all shared the same molecular markers, which suggests that a point introduction had occurred. The epidemic strain differed from Latin American epidemic strains and closely resembled a strain that fi rst emerged in Orissa, India, in 2007 and spread throughout southern Asia and parts of Africa (27). These hybrid Orissa strains have the biochemical features of an El Tor biotype but the toxin of a classical biotype; the later biotype causes more severe

illness and produces more durable immunity (28,29). A representative isolate was placed in the American Type Culture Collection, and 3 gene sequences were placed in GenBank (23).

Training Clinical Caregivers and Community Health Workers

CDC developed training materials (in French and Creole) on cholera treatment and on November 15–16 held a training-of-trainers workshop in Port-au-Prince for locally employed clinical training staff working at PEPFAR sites across all 10 departments. These materials were also posted on the CDC website (www.cdc.gov/haiticholera/ traning). The training-of-trainers graduates subsequently led training sessions in their respective departments; 521 persons were trained by early December.

During the initial response ≈10,000 community health workers (CHWs), supported through the Haitian government and other organizations, staffed local fi rst aid clinics, taught health education classes, and led prevention activities in their communities. Training materials for CHWs developed by CDC were distributed at departmental training sessions, shared with other nongovernmental organization (NGO) agencies, and used in a follow-up session for CHWs held on March 1–3, 2011 (see pages 2162–5). The CHW materials discussed treating drinking water by using several water disinfection products; how to triage persons coming to a primary clinic with diarrhea and

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2089

Figure 1. Administrative departments of Haiti affected by the earthquake of January 12, 2010; the path of Hurricane Tomas, November 5–6, 2010; and cumulative cholera incidence by department as of December 28, 2010.

Figure 2. Reported cases of cholera by day, and 14-day smoothed case-fatality rate (CFR) among hospitalized cases, by day, Haiti, October 22, 2010–July 25, 2011. UN, United Nations; CDC, Centers for Disease Control and Prevention; PAHO, Pan American Health Organization; MSPP, Ministère de la Santé Publique et de la Population.

SYNOPSIS CHOLERA IN HAITI

vomiting; making and using ORS; and disinfecting homes, clothing, and cadavers with chlorine bleach solutions. Materials were posted on the CDC website as well.

Working with Partners to Increase Capacity for Cholera Treatment

Supply logistics were daunting as cholera spread rapidly across Haiti. Sudden, unexpected surges in cases could easily deplete local stocks of intravenous rehydration fl uids and ORS sachets, and resupplying them could be slow. The national supply chain, called Program on Essential Medicine and Supplies, was managed by MSPP, with technical assistance from the Pan American Health Organization, and received shipments of donated materials and distributed them to clinics.

Early in November the USG provided essential cholera treatment supplies through the US Agency for International Development’s Offi ce of Foreign Disaster Assistance (OFDA) to the national warehouse and IDP camps. CDC staff also distributed limited supplies to places with acute needs. To complement efforts by MSPP and aid organizations to establish preventive and treatment services, OFDA provided emergency funding to NGO partners with clinical capacity.

When surveillance and modeling suggested that the spread of cholera across Haiti could outpace the public health response, the USG reached out to additional partners to expand cholera preventive services and treatment capacity. PEPFAR clinicians were authorized to assist with clinical management of cholera patients and participated in clinical training across the country. In December, CDC received additional USG emergency funds and awarded MSPP and 6 additional PEPFAR partners $14 million to further expand cholera treatment and prevention efforts through 4,000 CHWs and workers at 500 community oral rehydration points. Funds were also used to expand cholera treatment sites at 55 health facilities. In addition, CDC established the distribution of essential cholera supplies to PEPFAR partners through an existing HIV commodities supply chain management system.

Improvements in Water, Sanitation, and Hygiene To increase access to treated water and raise awareness

of ways to prevent cholera, a consortium of involved NGOs and agencies, called the water, sanitation, and hygiene cluster, met weekly. Led by Haiti’s National Department of Drinking Water and Sanitation and the United Nation’s Children’s Fund, the members of this cluster targeted all piped water supplies for chlorination and began distributing water purifying tablets for use in homes throughout Haiti. CDC helped the National Department of Drinking Water and Sanitation monitor these early efforts with qualitative and quantitative assessments of knowledge, attitudes,

and practices. Emergency measures, especially enhanced chlorination of central water supplies, were expanded in the IDP camps because of the perceived high risk. OFDA and CDC provided water storage vessels, soap, and large quantities of emergency water treatment supplies for households and piped water systems. Distributing water purifying tablet supplies to diffi cult-to-reach locations remained a challenge.

Educating the Public Beginning October 22, MSPP broadcast mass media

messages, displayed banners, and sent text messages encouraging the population to boil drinking water and seek care quickly if they became ill. Early investigations affi rmed the public’s need for 5 basic messages:1) drink only treated water; 2) cook food thoroughly (especially seafood); 3) wash hands; 4) seek care immediately for diarrheal illness; 4) and give ORS to anyone with diarrhea. In mid November, focus group studies in Artibonite indicated that residents were confused about how cholera was spreading

2090 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011

Figure 3. Educational poster (in Haitian Creole) used by the Haitian Ministère de la Santé Publique et de la Population (MSPP) to graphically present the ways of preventing cholera. DINEPA, Direction Nationale de l’Eau Potable et d’ Assainessement; UNICEF, United Nations Children’s Fund; ACF, Action Contre la Faim.

CHOLERA IN HAITI Cholera in Haiti and Dominican Republic

and how to best prevent it, but they understood the need to treat diarrheal illness with ORS, how to prepare ORS, and how to disinfect water with water purifi cation tablets (30). Posters provided graphic messages for those who could not read (Figure 3). On November 14, Haitian President René Préval led a 4-hour televised public conference to promote prevention, stressing home water treatment and handwashing, and comedian Tonton Bichat showed how to mix ORS.

Cholera Epidemic in Dominican Republic Compared with Haiti’s experience, the epidemic

has been less severe in Dominican Republic. Though the countries share the island, conditions in Dominican Republic are better than in Haiti: the IMR is one third that of Haiti, gross domestic product per capita is 5× greater, and 86% of the population has access to improved sanitation. Within 48 hours of the report of cholera in Haiti, the Ministry of Health in the Dominican Republic and CDC established the capacity for diagnosing cholera at the national laboratory; the fi rst cholera case was confi rmed on October 31. Dominican offi cials quickly planned for cholera treatment centers in at least 70 hospitals, trained staff in primary care clinics and prison dispensaries, and stocked medical supplies suffi cient to treat 20,000 cases. By December, 75% of doctors had received training in the management of cholera. Chlorination levels and water quality were monitored in municipal water systems across the country. The border with Haiti was not closed, and no major trade disruptions occurred. Sanitation improvements were instituted in border markets, schools, institutions, and mass gatherings. Public education in the fi rst 3 months included dissemination of 4,300 mass media messages, nearly 3 million fl yers, 50,000 classroom booklets for teachers, and a volunteer effort to visit 1 million homes. A survey of the knowledge, attitudes, and practices of residents of Santo Domingo showed that 89% had received cholera prevention messages. Transmission was limited, but sustained, in mid December and continued at low levels through the spring. One large outbreak affected guests at a wedding in January 2011, including some visitors from Venezuela and the United States (see pages 2172–4). From October 21, 2010, through July 30, 2011, a total of 14,598 suspected cases of cholera were reported; 256 persons died (of these, cases in 92 patients were laboratory confi rmed) (31).

Uncertainties and Challenges of Cholera in the Caribbean

Cholera may increase seasonally in Haiti each year (during the rainy season) as it did in 2011. The lack of a history of cholera in the Caribbean makes prediction a challenge because cholera seasonality varies from place to

place. Other unknown factors are what proportion of the population has now been immunized by natural infection and how long this immunity might last. In a setting in which the population has poor access to clean water and sanitation, endemic transmission could persist for years if the epidemic strain fi nds long-term reservoirs in brackish coastal waters. Antimicrobial drug resistance may emerge in toxigenic V. cholerae O1, making continued monitoring of antimicrobial drug susceptibility essential.

Whether the epidemic will spread beyond Hispaniola is also uncertain. With the highest IMR in the Western Hemisphere (refl ecting major gaps in sanitation and health care), Haiti is uniquely susceptible. Other countries in the Caribbean region have an IMR less than half that of Haiti (Guatemala is next with an IMR of 33), which suggests less risk for sustained transmission. If shipmasters leaving Haitian ports would exchange their ships’ ballast water at sea, they could help prevent the transfer of epidemic cholera from harbor to harbor.

The origin of cholera in Haiti also raises questions. United Nations peacekeeping troops from Nepal may possibly have introduced cholera into Haiti (32). Genetic comparison of the Haitian epidemic strain with other strains from around the world suggests that it resembles strains seen in southern Asia and in Nepal (33). Although knowing how cholera was introduced into Haiti would not help dampen its spread throughout Hispaniola, the knowledge might help foster disease monitoring and sanitation policies that would prevent such introductions elsewhere (34).

A continuing challenge facing Haiti is how to manage cholera treatment with limited resources. Cholera training for doctors and nurses should be added to clinical curricula. By increasing use of ORS and expanding the antimicrobial drug treatment of hospitalized patients, intravenous fl uid needs might be decreased, without posing an undue risk for antimicrobial drug resistance. Focusing on supply chain logistics is critical to ensuring the maintenence of tenuous buffer stocks of supplies.

Residents of IDP camps have been largely spared from the outbreak because of safer water supplies and improved sanitation in the camps, but preserving that protection as persons move on to homes without piped water or sewage systems will be a challenge. Encouraging and empowering residents to disinfect drinking water in their homes, schools, and clinics by using chlorine products has been effective in many African and Latin American countries and is a practical interim solution for Haiti (35).

The role of oral cholera vaccine in the immediate postepidemic period continues to be evaluated (36,37). Both the global cholera vaccine supply and Haitian vaccine cold chain are currently insuffi cient to mount national vaccination campaigns on Hispaniola. A limited vaccination pilot study could increase our global understanding of the

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SYNOPSIS CHOLERA IN HAITI

costs, benefi ts, and practical applicability of using oral cholera vaccine in such circumstances.

Lessons Learned The existing PEPFAR program that provided support

for clinical care delivery and public health infrastructure was a powerful framework that sustained the national cholera response in Haiti. Through additional USG funding for PEPFAR partners, an expanded cadre of Haitian clinicians and CHWs received cholera training, resulting in expanded access to cholera treatment throughout Haiti. In addition, the postearthquake enhancement of diagnostic laboratory testing capacity for reportable diseases enabled health offi cials to quickly confi rm the cholera outbreak and monitor antimicrobial drug susceptibility of the bacterial strains.

The Haitian epidemic shows that as long as cholera exists anywhere in the world, many who drink untreated water and live in areas of poor sanitation are at risk. The epidemic also shows how cholera can emerge where it is least expected. Despite heightened efforts to detect acute watery diarrhea among persons in urban IDP camps, cholera appeared fi rst in rural Haiti, just as in Mexico in the 1990s, where it fi rst emerged unexpectedly in a remote mountainous region (8). Therefore, the ability to detect and confi rm cholera needs to be broadly available.

The Haitian experience also shows the continued success of the rehydration treatment strategies fi rst developed in Bangladesh and refi ned over the past 40 years. With training and adequate supplies and treatment facilities, hospitalized case-fatality ratios of <1% were achieved. If the improvements in ORS use in treatment of diarrheal illness are sustained, these actions could reduce childhood deaths permanently.

The more moderate course of the epidemic in the Dominican Republic and the relative sparing of the IDP camps in Haiti illustrate how safer water and better sanitation can prevent transmission. Without these basic public health bulwarks, the risk for recurrent cholera and other major waterborne diseases remains high. In the interim, safe water and handwashing practices should be integrated into household and community settings (35).

Investing in Safe Water and Sanitation Global experience with cholera suggests that the

epidemic in Haiti could last for years. Although case counts decreased in early 2011, cases again increased with the onset of the rainy season, and conditions that permit waterborne transmission persist. Improving Haiti’s water and sanitation infrastructure is critical to achieving the same profound health gains brought by improved water and sanitation infrastructure elsewhere (3,6,38).

The World Health Organization estimates that meeting the global Millennium Development Goal for improving

access to safe water and improved sanitation would have a huge return on investment worldwide (39). For each $1 invested, the economic rate of return in regained time at work and school, time saved at home by not hauling water, increased productivity, and reduced health costs would be as much as $8, in addition to the direct health benefi ts. For Haiti to meet this goal, an estimated 250,000 households would need access to an improved water source, and ≈1 million families would need access to improved sanitation. The Inter-American Development Bank estimated in 2008 that Haiti would require $750 million to achieve this goal (40). After the earthquake, the international community pledged >$6 billion to Haiti for relief. A long-term plan to build safe drinking water and sewerage systems is well within the range of the resources pledged.

Acknowledgments We salute the dedicated efforts of the many Haitians and non-

Haitian NGO staff, who have struggled to control the epidemic and its human toll. We are grateful for the thoughtful feedback and contributions made by Roodly Archer, Stephen Grube, Thomas Handzel, Barbara Marston, Eric Mintz, Daphne Moffett, Oliver Morgan, Jessica Patrick, Nathalie Roberts, Valerie Johnson, John O’Connor, and Michael Wellman.

Dr Tappero is director, Health Systems Reconstruction Offi ce, Center for Global Health, CDC. His research interests include the epidemiology of emerging infections, hemorrhagic fevers, HIV, tuberculosis, malaria, meningococcal disease, and leptospirosis, as well as developing, strengthening, and reconstructing public health systems in countries in need.

Dr Tauxe is deputy director, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Diseases, CDC. His research interests include the epidemiology and ecology of enteric bacterial infections; the evolution of antimicrobial drug resistance; and improving public health systems to detect, investigate, and control outbreaks of enteric illnesses.

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30. Gaines J, Gieselman A, Jacobson L, Demas D, Person B, Roels T, et al. Life inside an outbreak: a quantitative assessment of cholera response efforts, Artibonite Department, Haiti, 2010. Poster 20. In: 60th Annual Epidemic Intelligence Service Conference, April 11–15, 2011, Atlanta, Georgia, USA. Atlanta: Centers for Disease Control and Prevention; 2011.

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32. Piarroux R, Barrais R, Faucher B, Haus R, Piarroux M, Gaudart J, et al. Understanding the cholera epidemic, Haiti. Emerg Infect Dis. 2011;17:1161–8. doi:10.3201/eid1707.110059

33. Hendriksen RS, Price LB, Schupp JM, Gillece JD, Kaas RS, Engle- thaler DM, et al. Population genetics of Vibrio cholerae from Ne- pal in 2010: evidence on the origin of the Haitian outbreak. MBio. 2011;2.

34. Cravioto A, Lanata CF, Lantagne DS, Nair B. Final report of the independent panel of experts on the cholera outbreak in Haiti. May 4, 2011 [cited 2011 May 17]. http://www.un.org/News/dh/infocus/ haiti/UN-cholera-report-fi nal.pdf

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35. Tauxe R, Quick R, Mintz E. Safer water, cleaner hands and safer foods: disease prevention strategies that start with clean water at the point of use. In: Choffnes MA, editor. Global issues in water, sanita- tion, and health: workshop summary. Forum on microbial threats; Institute of Medicine. Washington: National Academies Press; 2009. p. 73–94.

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Address for correspondence: Robert V. Tauxe, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop C09, Atlanta, GA 30333, USA; email: [email protected]

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2093

Overview of the 2010 Haiti Earthquake

Reginald DesRoches,a) M.EERI, Mary Comerio,b) M.EERI, Marc Eberhard,c) M.EERI, Walter Mooney,d) M.EERI, and Glenn J. Rix,a) M.EERI

The 12 January 2010 Mw 7.0 earthquake in the Republic of Haiti caused an estimated 300,000 deaths, displaced more than a million people, and damaged nearly half of all structures in the epicentral area. We provide an overview of the historical, seismological, geotechnical, structural, lifeline-related, and socioeco- nomic factors that contributed to the catastrophe. We also describe some of the many challenges that must be overcome to enable Haiti to recover from this event. Detailed analyses of these issues are presented in other papers in this volume. [DOI: 10.1193/1.3630129]

INTRODUCTION

On 12 January 2010, at 4:53 p.m. local time, a magnitude 7.0 earthquake struck the Republic of Haiti, with an epicenter located approximately 25 km south and west of the cap- ital city of Port-au-Prince. Near the epicenter of the earthquake, in the city of Léogâne, it is estimated that 80%–90% of the buildings were critically damaged or destroyed. The metro- politan Port-au-Prince region, which includes the cities of Carrefour, Pétion-Ville, Delmas, Tabarre, Cite Soleil, and Kenscoff, was also severely affected. According to the Govern- ment of Haiti, the earthquake left more than 316,000 dead or missing, 300,0001 injured, and over 1.3 million homeless (GOH 2010). According to the Inter-American Development Bank (IDB) the earthquake was the most destructive event any country has experienced in modern times when measured in terms of the number of people killed as a percentage of the country’s population (Cavallo et al. 2010).

The Republic of Haiti occupies the western third (27,750 km2) of the island of Hispa- niola, located in the northeast Caribbean between Puerto Rico to the east and Jamaica and Cuba to the west (Figure 1), and had a population of approximately 9.6 million prior to the earthquake. The metropolitan area surrounding its largest city, Port-au-Prince, has an esti- mated population of 3 million. Haiti has been impacted by other natural disasters in recent years. In 2008, more than 800 people were killed by a series of four hurricanes and tropical storms that struck Haiti during a two-month period.

a) Georgia Institute of Technology, School of Civil and Environmental Engineering, 790 Atlantic Dr., Atlanta GA 30332-0355

b) University of California Berkeley, Department of Architecture, 232 Wurster Hall, Berkeley, CA 74720-1800 c) University of Washington, Department of Civil and Environmental Engineering, 233 More Hall, Seattle, WA 98195-2700

d) Earthquake Science Center, US Geological Survey, MS977, 345 Middlefield Rd., Menlo Park, CA 94025 1The number of casualties is a highly debated issue, with estimates ranging from 70,000 to 316,000. At the time of this publication, the official number from the Government of Haiti is 316,000.

Earthquake Spectra, Volume 27, No. S1, pages S1–S21, October 2011; VC 2011, Earthquake Engineering Research Institute

The damage to the infrastructure from the earthquake in Haiti was staggering. More than 300,000 homes collapsed or were critically damaged. It is estimated that 60% of the nation’s administrative and economic infrastructure was lost, and 80% of the schools and more than 50% of the hospitals were destroyed or damaged (GOH 2010). More than 180 government buildings and 13 out of 15 key government offices collapsed, including the presidential palace and parliament. The partial destruction of the main port of Port-au-Prince and blockage of roads from debris hampered the response and recovery for many months af- ter the earthquake. Even nine months after the earthquake, the destruction continued to dis- rupt the lives of many Haitians. The Interim Haitian Reconstruction Commission estimated that as of 12 October, 1.3 million people were still displaced—either in one of the more than 1,300 camps and other settlements registered by the International Organization for Migration (IOM) or in temporary housing situations in both the quake-affected zone and in non-affected regions (IHRC 2010).

Overall losses and damages from the earthquake are estimated to be between US$7 bil- lion and US$14 billion (approximately 100%–200% of Haiti’s gross domestic product), making this the most costly earthquake event in terms of the percentage of a country’s gross domestic product (Cavallo et al. 2010).

PRE-EARTHQUAKE HAITI: SETTING THE CONTEXT

It is difficult to quantify the impact of pre-earthquake conditions on the devastation resulting from the earthquake in Haiti. However, there is no doubt that the dire socioeco- nomic conditions that existed prior to the earthquake were a major contributor to the

Figure 1. Geographic and tectonic setting of the island of Hispaniola, of which Haiti occupies the western third. The 2010 earthquake occurred on or near the Enriquillo-Plantain Garden fault zone and was preceded by earthquakes in southern Haiti in 1751 (two events, in October and November), 1770, and 1860. The location of the main shock of 12 January 2010 and aftershocks are shown in Figure 2.

DESROCHES ET AL.S2

resulting damage. Following a slave rebellion in 1804, Haiti became the first free black nation in the world. It was subsequently forced to pay France a massive indemnity for prop- erties lost in that rebellion, and was ostracized socially and economically by countries all around the world. Haiti subsequently became entrapped in a cycle of poverty and misgov- ernment from which it has never emerged (Heinl 1996).

Haiti is the poorest country in the Western Hemisphere, ranking 145 out of 169 on the UN Human Development Index (UNDP 2010). Less than 10% of the population has access to potable tap water and less than one-third has access to electricity, even intermittently (UNSD 2010), which are the lowest respective percentages in the Western Hemisphere. More than half of Haiti’s population lives on less than US$1 per day, and more than three- quarters live on less than US$2 per day. Haiti has the highest rate of mortality among infants, children under 5, and during maternity of any country in the Western Hemisphere (UNSD 2010). Haiti’s exports are small: 10% of the gross domestic product. Haiti’s poor economic performance is, in part, the result of the decline of its agricultural sector, which in turn is due in large part to the degradation of the environment. Haiti ranks 155 out of 163 countries when it comes to general environmental degradation. For years, Haitians have cut down trees to use as cooking fuel, resulting in less than 3% of Haiti being covered by forest, a stark contrast to the lush forests of its neighbor, the Dominican Republic. The environ- mental degradation only increases Haiti’s vulnerability to natural hazards.

In addition to its poor socioeconomic standing, Haiti’s limited recent history of large earthquakes (Figure 1) left it unprepared for the 12 January 2010, earthquake. Haiti had few seismologists and no seismic network in the country. It only had one seismic hazard map, which was outdated and lacked sufficient detail to be useful. The best geological map dated to 1987 (Lambert et al. 1987). The building code was outdated, rarely used, and not enforced (CUBiC 1985). There was no earthquake preparedness program and no contin- gency plan for earthquakes. The typical university curriculum did not include seismic design, seismology, or the geosciences.

SEISMOLOGICAL ASPECTS

GEOLOGY AND TECTONICS

The geologic evolution of Hispaniola can be traced to the Mesozoic breakup of Pangea and the creation of the Atlantic Ocean. This process resulted in the formation of the Carib- bean microplate, with subduction zones forming around the margins (Garcia-Casco et al. 2008). The geology of Hispaniola, including Haiti, consists of igneous rocks formed within a volcanic island arc, as well as abundant marine sedimentary rocks that have accreted at the oceanic subduction margin (Woodring et al. 1924, Maurrasse 1982).

The 12 January 2010 earthquake occurred on or near the Enriquillo-Plantain Garden Fault, a prominent strike-slip fault that is clearly evident in high-resolution relief maps of the Southern Peninsula of Haiti. Field studies confirmed that the mapped Enriquillo-Plantain Garden Fault in the epicentral region separates basaltic rocks south of the fault from marine sedimentary rocks (chalk, sandstone, and limestone) to the north. Thus, the fault can be eas- ily discerned by its morphology and geology. However, detailed field and geophysical stud- ies indicate that the fault rupture was a complex event that involved slip on more than just

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S3

the Enriquillo-Plantain Garden Fault (Nettles and Hjörleifsdóttir 2010, Prentice et al. 2010, Calais et al. 2010, Hayes et al. 2010).

SEISMICITY

For several decades prior to the 12 January 2010 earthquake, seismic activity within the island of Hispaniola had been heavily concentrated in the eastern two-thirds of the island in the Dominican Republic, and Haiti had been relatively seismically quiescent. Indeed, since the establishment of a modern global seismic network in 1964, the Port-au-Prince region of southern Haiti has experienced only one earthquake of magnitude greater than 4.0, with sev- eral additional events occurring 100 km to the west. However, studies of historical seismic- ity have established that large (magnitude 7.0 or greater) earthquakes have struck the Port- au-Prince region in the historic past. These earthquakes are all attributed to movement on the east–west oriented Enriquillo Fault (Figure 2). The largest earthquakes occurred in 1751 (two events), 1770, and 1860 (O’Loughlin and Lander 2003). One of the two earthquakes of 1751 occurred near the longitude of Port-au-Prince and destroyed buildings throughout the city (modified Mercalli intensity [MMI] of X). The 1770 earthquake occurred an

Figure 2. Topographic map of the Southern Peninsula of Haiti: (a) Port-au-Prince, (b) Léogâne, and (c) Port Royal. The east–west oriented Enriquillo Fault (red line) passes the main shock epi- center (single larger focal mechanism SE of Léogâne). The Enriquillo Fault is a left-lateral fault that accommodates 7þ=�2 mm=yr of strain (Manaker et al. 2008). Aftershocks (yellow circles) are concentrated to the west of the main shock, and their focal mechanisms (orange) indicate reverse faulting. Panels centered on Léogâne indicate the extent and magnitude of fault slip on three rupture planes (Figure 3).

DESROCHES ET AL.S4

estimated 30–50 km further to the west on the Enriquillo Fault, and once again resulted in the widespread destruction of buildings in Port-au-Prince and Léogâne (O’Loughlin and Lander 2003). The 1860 earthquake was located still further to the west of Port-au-Prince and was observed to cause uplift of the sea floor. This uplift is significant because it indi- cates that crustal strain accommodation and release is partitioned between pure strike-slip and reverse-faulting structures (Nettles and Hjörleifsdóttir 2010, Hayes et al. 2010, Calais et al. 2010).

THE MAIN SHOCK AND AFTERSHOCKS

The 12 January 2010 event occurred at 04:53:10 p.m. local time. The U.S. Geological Survey (USGS) located the epicenter at 18.44� N, 72.57� W, which placed the event 25 km WSW of Port-au-Prince, on or near the Enriquillo Fault. The estimated depth was 13 km, but the lack of local seismic data made the precise depth uncertain. The USGS assigned a horizontal uncertainty of þ=� 3.4 km. The first-motion focal mechanism (ref) for the main shock indicated left-lateral oblique-slip on an east–west oriented fault. However, there was clear evidence of coastal uplift north of the Enriquillo Fault (Hayes et al. 2010) as well as vertical ground deformation imaged by interferometric synthetic aperture radar (InSAR) data. These observations require significant slip on a nearby reverse fault (Figure 2). The fi- nite fault model by Hayes et al. (2010) showed slip on three fault planes and satisfies seis- mologic, geodetic, and geological observations. This model showed a maximum slip of 3.5 m on the reverse fault (Figure 3). The earthquake source zone (i.e., the surface area of the fault that slipped) was quite compact, with a down-dip dimension of approximately 15 km and an along-strike dimension of close to 40 km. This source dimension is about two-thirds the size of a typical Mw 7.0 earthquake. The earthquake rupture was very abrupt and sharp; maximum moment release occurred in the first 4–8 seconds of the fault slip, and 80% of the moment release occurred in 12–14 seconds (Hayes et al. 2010).

The main shock was followed within 20 minutes by two large aftershocks with moment magnitudes of 6.0 and 5.7, respectively. Eight days after the main shock, on 20 January 2010, a Mw 5.9 aftershock occurred. Overall, the early aftershock sequence from this earth- quake was three times more productive than a typical aftershock sequence in California.

SEISMOLOGICAL AND GEODETIC FIELD ACTIVITIES DURING 2010

The first accelerometer to measure aftershocks was installed on the grounds of the U.S. Embassy in Port-au-Prince on the evening of 27 January 2010 (Eberhard et al. 2010). In March 2010, additional temporary seismographs were deployed by the USGS and French and Canadian research groups and these data were being interpreted at the time of this writ- ing. GPS and InSar data have been collected (Calais et al. 2010, and references therein), and Coulomb stress changes imparted by the 12 January 2010 event have been calculated (Lin et al. 2010). These data and additional analytical models will be used to guide the next generation of seismic hazard maps (Frankel et al. 2010).

GEOTECHNICAL

The earthquake-affected region is a physiographically diverse area with a complex geo- logic history. The topography within the study area is relatively rugged, with steep mountain

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S5

ranges and hillfronts, deeply incised streams and narrow intermountain stream valleys, and broad coastal delta fans and valleys. Quaternary deposits in the epicentral zone include Holo- cene to late Pleistocene fluvial alluvium (channel, terrace, floodplain overbank deposits) de- posited in the Port-au-Prince valley and interior incised river valleys, alluvial fan and collu- vial wedge deposits along the margins of larger valleys, coastal delta fan complexes where larger streams discharge into the sea along the coast, localized organic sediments within marshes and swamps, and beach sands along protected portions of the coast. Port-au-Prince spans a broad region from the relatively level floor of a large alluvial valley underlain by Holocene to Pleistocene deposits, southward to low hills underlain by Mio-Pliocene deposits. Léogâne and Carrefour are located on large delta fans and are underlain by Holocene to Pleistocene alluvium. Coastal areas adjacent to Port-au-Prince are mostly composed of artifi- cial fill placed during westward expansions of the city during the past 200 years. Post-earth- quake reconnaissance visits to Haiti have provided opportunities to acquire detailed informa- tion on geologic and geotechnical conditions throughout the affected area (Cox et al. 2011, Green et al. 2011, Rathje et al. 2011, Hough et al. 2011, Lekkas and Carydis 2011).

Figure 3. Geometry of fault ruptures for the January 2010 Haiti earthquake. Fault plane A (red outline) contains the earthquake hypocenter (locus of slip initiation; red star) and is a steeply- dipping (70�) left-lateral strike-slip fault. Fault plane B (blue outline, top) is a blind thrust fault (55� dip), shows the largest slip displacement (up to ca. 350 cm) and is responsible for approx. 80% of the seismic moment released during the earthquake. Fault plane C (black outline, bot- tom) is a reverse fault with a modest amount (ca. 100–200 cm) of slip (from Hayes et al. 2010).

DESROCHES ET AL.S6

The observed structural damage from the earthquake correlates well with these geologic conditions. Ground-motion amplification was a primary factor in alluvial soils in the north- central and coastal region of Port-au-Prince, Carrefour, and Léogâne. Hough et al. (2010) used weak-motion data from aftershock recordings at seismograph stations deployed fol- lowing the earthquake to determine that the mean amplification ratio of peak ground accel- eration (PGA) for stations on alluvium was 1.78 þ=� 0.58 compared to a reference station on hard rock. Rathje et al. (2011) documented that the largest concentrations of damage occurred in areas underlain by Holocene alluvium with average shear wave velocities in the upper 30 m (VS30) of approximately 350 m=s, which corresponds to National Earthquake Hazards Reduction Program (NEHRP) Site Class D.

Large concentrated zones of damage also occurred in the southern portion of Port-au- Prince that extends into the hills underlain by Mio-Pliocene, weakly cemented deposits. In these areas, both topographic amplification and site effects contributed to higher levels of shaking. Hough et al. (2010) compared weak-motion recordings at sites located in the foot- hills of Port-au-Prince with a hard-rock reference station and found that the PGA was ampli- fied by a factor of 2.94 þ=� 1.06; amplification ratios as high as 5 were calculated for fre- quencies of several Hertz. Rathje et al. (2011) and Hough et al. (2011) have used digital elevation models to correlate observed damage patters with topographic features in the area.

Artificial fill in the port areas of Port-au-Prince and Carrefour experienced extensive liquefaction, lateral spreading, and settlement damage. At the Port de Port-au-Prince, lique- faction-induced lateral spreading (Figure 4) resulted in the collapse of the pile-supported North Wharf, damage to two steel-frame warehouses, and other port facilities (Green et al. 2011, Werner et al. 2011). Geotechnical site investigations performed after the earthquake includes soil borings with standard penetration tests (SPT), dynamic cone penetration tests (DCPT), and surface wave (MASW and SASW) tests (Green et al. 2011). Grain size analy- ses indicated that the coarse-grained soils were well-graded mixtures of sands and gravels

Figure 4. Liquefaction-induced lateral spreading leading to the collapse of the North Wharf at the Port de Port-au-Prince.

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S7

with median grain sizes ranging from 0.2 mm to 10 mm. The calcium carbonate (CaCO3) content of the materials was 80%–90% and is attributed to the marine origin of the fill mate- rials. Level-ground liquefaction analyses performed using the SPT and DCPT data indicated that the liquefaction potential of the soils is very high, which is consistent with the extent and severity of liquefaction-induced ground failures at the port. Green et al. (2011) also compare observed values of permanent deformation with estimates obtained from various empirical methods and found that the observed values generally exceed the estimated val- ues. Ground-motion amplification in the soft fill soils was likely a contributing factor to the partial collapse of and extensive damage to the remaining portion of the South Pier at the Port de Port-au-Prince (Werner et al. 2011).

Many of the road failures observed along the coast west of Carrefour occurred where the road crosses marshy ground and the distal ends of small alluvial valleys. Settlement and localized creep=slumping of sediments underlying the roadbed appear to be responsible for many of the road failures, rather than lateral spread failure, because cracking typically was confined to the roadbeds and fill and did not extend through natural soils shoreward of the roadways. Localized liquefaction of loose, saturated sediments in these areas may have con- tributed to the road failures, but was not the major factor.

Numerous landslides and rockfalls occurred within the Mio-Pliocene and older lime- stone bedrock in steep slopes and roadcuts within the epicentral zone. In some cases these failures appear to have been restricted to colluvial soil and fractured=dilated rock within a weathered zone that extends about 1–3 m deep into the slopes. However, some deeper- seated slumps and debris avalanche/slide failures occurred in less-weathered, deeper bed- rock in steep mountainous slopes. These failures appear in part to be influenced or con- trolled by bedrock joints or weak zones. In places, developments on steep slopes appear to have been impacted by slope raveling or foundation sliding=slumping. Additional analyses of landslides in the epicentral zone are described in Liu et al. (2011).

PERFORMANCE OF BUILDINGS

The earthquake caused extensive damage to buildings throughout the Port-au-Prince metropolitan area, and in the rural areas and towns to the west and south of the city. Nearly all of the severe damage and collapses appeared to occur in buildings that were constructed without considering the effects of earthquakes. The majority of buildings that were designed for earthquakes and that were well constructed did not collapse in the earthquake.

BUILDING INVENTORY

A nationwide census conducted in 2003 documented many characteristics of Haitian so- ciety, including the frequency of common building types, as well as the materials used to construct the walls, roofs, and floors. The percentage of each type of building is reported for urban and rural areas in Table 1, which was compiled with data from the Haitian Ministry of Statistics and Informatics (IHSI). Within urban areas, 78% of the buildings were classi- fied as one-story houses and another 14% were classified as multistory houses or apartments (IHSI 2010). The remaining 8% of the buildings consisted of slum housing or traditional forms of construction (two common types are kay atè, buildings with a combined roof and walls, and ajoupas, rural homes with thatch, straw, or palm leaf roofs). Within rural areas,

DESROCHES ET AL.S8

ordinary one-story houses were again most common (69%), multistory structures were rare (<1 percent), and ajoupas made up 25% of the building inventory.

The wall materials for each building type in urban areas are summarized in Table 2, which was also developed from the IHSI data. In urban areas, concrete block walls predo- minated (79%), particularly in multistory houses and apartments (97%). In rural areas, the most common wall material was earth (33%), followed by concrete block (22%), and clis- sage (19%), consisting of intertwined sticks, twigs, and branches. Considering all building types and regions, approximately two-thirds (69%) of the structures had metal roofs, but for multistory houses and apartments, 89% had roofs made of concrete (IHSI 2010).

Typical reinforced concrete frame buildings with concrete block infill had numerous vulnerabilities known to cause seismic damage. Figure 5 shows a typical low-rise reinforced concrete frame building with infill concrete block walls that was under construction at the time of the earthquake. Columns were slender with depths in the range of 200 mm to 250 mm. Such columns were often reinforced with 4 #4 bars, sometimes deformed and some- times smooth. Column and joint transverse reinforcement was minimal (e.g., #2 smooth ties) and spaced at a distance roughly equal to the column depth. Concrete and mortar

Table 1. Distribution of building types in urban and rural areas (IHSI 2010)

Location

Type of Building Urban Areas (%) Rural Areas (%) Combined (%)

Kay atè (combined roof and walls) 0.5 1.9 1.4

Taudis (slum housing) 3.2 2.5 2.8

Ajoupas (rural home with roof made of thatch, straw, or palm leaves)

3.7 25.3 17.6

One-Story House 78.3 69.2 72.5

Multistory House=Apartment 13.7 0.8 5.4

Others 0.6 0.3 0.4

Table 2. Distribution of wall materials for each building type in urban areas (IHSI 2010)

Wall Material

Type of Building Concrete

Block (%) Earth (%)

Wood/ Planks (%)

Clissage (%)

Other (%)

Kay atè (combined roof and walls) 0.0 91.3 0.0 7.6 1.1

Taudis (slum housing) 11.3 8.3 15.3 8.5 56.6

Ajoupas (rural home with roof made of thatch, straw, or palm leaves)

0.0 54.6 9.6 28.2 7.6

One-Story House 82.4 3.8 2.9 3.0 8.0

Multistory House=Apartment 97.4 0.0 0.6 0.0 1.9

Others 67.0 0.4 6.2 0.7 25.7

All 78.7 5.7 3.2 3.7 8.8

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S9

quality appeared to vary significantly. In the building shown Figure 5, concrete blocks were placed outside the frame lines. More typically, the concrete block walls were used as infill. In some structures, column steel splices were placed directly above the elevation of the floors.

BUILDING PERFORMANCE

Damage to residences and commercial buildings was widespread. According to Figure 11 (USAID 2010), approximately 40%–50% of buildings were “destroyed” in Carrefour and Gressier, communes near Port-au-Prince. In downtown Port-au-Prince, Eberhard et al. (2010) found that 28% of the 107 buildings surveyed had collapsed partially or totally, and an additional 33% were damaged enough to require repairs. The damage was even higher in Léogâne, the city nearest the epicenter. According to Figure 11, 80%–90% of buildings there were destroyed.

Two adjacent structures in downtown Port-au-Prince illustrate the consequences of poor seismic proportioning and detailing. Figure 6 shows the collapse of the multistory Turgeau Hospital, constructed in 2008. The building’s lateral-force resistance was provided by a re- inforced concrete frame with masonry infill. As with the residence shown in Figure 5, the columns were slender, and the columns and joints had little transverse reinforcement. In contrast, the Digicel building (Figure 7) across the street had only minor structural damage, consisting mainly of concrete spalling at the base of the columns. The building had been designed to resist earthquakes; it had much larger columns with closely spaced ties and included shear walls.

It appears that some buildings performed better than their neighbors because of their low mass. For example, the wood-frame building shown in Figure 8a was adjacent to a col- lapsed reinforced concrete structure. Similarly, the one-story church shown in Figure 8b had a light-metal roof supported by masonry walls. Although it appeared to be constructed with materials of poorer quality than those used in a neighboring concrete bearing-wall house, the masonry church structure suffered less damage.

Figure 5. Residential concrete block slab construction.

DESROCHES ET AL.S10

PERFORMANCE OF LIFELINES

BRIDGES

There are very few bridges in Haiti, and most are short, single-span bridges or culverts. We did not learn of any bridge collapses attributable to the earthquake. Within Port-au- Prince, most of the crossings over streams were accommodated by box culverts, which did not appear to be damaged. Along the Route Nationale No. 2, small streams were also spanned by culverts. The culverts themselves were not damaged, but in at least one case, the approaches to the culvert settled relative to the culvert itself.

The main river crossings on Nationale No. 2 were spanned by bridges with precast gird- ers resting on cast-in-place reinforced concrete bents and supporting a cast-in-place deck. We observed damage to two such bridges. The bridge over the Momance River had minor pounding damage at one of the intermediate supports. In the Carrefour section of Port-au- Prince the external shear keys (Figure 9) of a similar bridge were damaged at both interme- diate supports. This failure was apparently caused by the lack of hook anchorage at the end of the top beam reinforcement.

WATER AND WASTEWATER

The main public water system in Port-au-Prince is supplied by a series of springs located in the nearby mountains. The water is chlorinated in the spring boxes and sent to the distribution system, which serves 1,000,000 people (Edwards 2010). Prior to the earth- quake, this supply was unreliable, and the water was not drinkable without further treat- ment. There were relatively few water main breaks, which is unusual for a system this large. Most of the breaks were repaired within one to two weeks of the earthquake.

There were no working wastewater treatment plants in Haiti. In the metropolitan areas, wastewater was discharged in open drainage channels and directed to Port-au-Prince Bay. Many of the drainage channels were blocked by debris and trash.

Figure 6. Turgeau hospital in downtown Port-au-Prince: (a) Before the earthquake (Simon Young CaribRM), and (b) collapsed structure after the earthquake.

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S11

Figure 7. Damage to two structures across the street from one another in Port-au-Prince: (a) Reinforced concrete frame with masonry infill, and (b) new Digicel building under construction appears to be nearly undamaged.

DESROCHES ET AL.S12

Figure 8. Light buildings that were damaged but did not collapse: (a) Wood-frame building, and (b) church with masonry walls and light-metal roof.

Figure 9. Damage to shear key at intermediate support.

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S13

TELECOMMUNICATION SYSTEMS

The telecommunication system in Haiti is comprised of a single wireline carrier (Tel- eco), and three wireless mobile vendors (Edwards 2010). Teleco is a wireless-based utility providing service through a network similar to those operators throughout the United States. The earthquake caused the collapse of the Teleco building in Port-au-Prince. At several locations throughout the Port-au-Prince metropolitan region, the placement of COWS (Cells on Wheels or Mobile Cellular System and Telescoping Antenna Array) outside of several telephone central offices was a temporary solution to enable inter-exchange traffic.

Digicel, one of Haiti’s largest wireless cellular providers, had significant damage due to the collapse of buildings onto antennas. According to Digicel officials, it was estimated that 20% of the company’s network was damaged beyond repair and unable to return to service. By 27 January 2010, the company had restored 92% of radio frequency capability with the regulator’s grant of additional spectrum for a period of 12 months.

SOCIOECONOMIC IMPACT

Researchers distinguish between emergencies, disasters, and catastrophes (Comerio 1998, Teirney 2008), and by all measures, the earthquake in Haiti can certainly be classified as a major catastrophe—perhaps the worst in modern history. Not only were the physical and social impacts extremely large relative to the population of the affected areas, but also relative to the country as a whole. Given the extent of the damage, the government was paralyzed and an international response faced massive challenges—with limited access to the damaged port and airport, and uncertainty over who could or should take charge. The United Nations (UN), which had a peacekeeping mission in Haiti prior to the earthquake, lost a significant number of their own staff, as did the numerous International Non-Government Organizations (INGOs) that provided a wide variety of health care, housing assistance, training, and other social services. With every segment of civil society impacted—the government, schools, uni- versities, businesses, health clinics, orphanages, INGOs, and churches—it was often difficult to understand who could provide relief and assistance to the earthquake victims.

The U.S. Armed Forces initially took over airport operations. UN and World Bank rep- resentatives, in partnership with Haitian officials, became key leaders in managing relief services, damage data collection, and shelter planning. Meetings of various groups were coordinated daily at the Hotel Caribe (where the lobby and meeting rooms were undam- aged) and at the UN peacekeeping base near the airport. The initial weeks were driven by the dual purposes of providing food and shelter to victims on one hand, and collecting sound data for recovery planning on the other. At that time, it was already clear that the government of Haiti would not fully be in charge of the recovery, in part because the inter- national organizations would control the funding and in part because the already weak Hai- tian government was weakened further by the disaster, leaving a leadership vacuum. Of the US$1.8 billion in earthquake relief that has been sent to Haiti (as of July 2010), less than 2.9% has gone directly to the Haitian government (Farmer 2010).

Tents and tarps were provided by a variety of international groups, but many Haitians formed informal tent camps with materials salvaged from the rubble, as shown in Figure 10. Of the 1.3 million homeless, UN Habitat and USAID estimated that over 500,000 left Port-

DESROCHES ET AL.S14

au-Prince for outlying provinces: 163,000 to Artibonite, 91,000 to Centre, 120,000 to Grand Anse, and the remainder to the other six provinces (USAID 2010, see Figure 11). Haitian architect and planner Leslie Voltaire was involved in planning operations that argued for aid supply to the outlying provinces so that the displaced could stay in and be supported by those regions, thus limiting the need within Port-au-Prince.

An early return and resettlement plan by UN Habitat assumed that approximately 240,000 households needed resettlement and that ideally, it was best if people could return to a safe house in their community of origin, and only be settled elsewhere if that return was not possible. Transitional camps with temporary shelters were used for those with no other options (see Table 3) (UN Habitat 2010).

Almost one year after the disaster, this plan has been difficult to implement for a variety of complicated reasons. People remain fearful of returning to existing buildings and prefer to sleep in the tents. Although it has been documented that families do return to their homes in the daytime, they generally do not stay there overnight. The camps continue to be a source of free food, clean water, and sanitation facilities. In a testimony to the U.S. Con- gressional Black Caucus on 27 July 2010, Dr. Paul Farmer noted that diarrheal diseases dropped 12% after the earthquake because disaster aid agencies provided clean bottled water to the displaced population. He went on to acknowledge that while a burst of attention can make some improvements, the overall lack of food security, sanitation, clean water sources, jobs, education, health care, and other basic services are all critical issues which highlight the need for a functioning government public sector, not simply short-term aid from INGOs (Farmer 2010).

Nearly one year after the earthquake, there are hopeful signs that coordination is taking place between the Haitian government, INGOs, and religious organizations, and progress is being made on a number of fronts. The UN has been testing the concept of a humanitarian coordination hub. The leaders from all of the UN cluster groups convene to coordinate their own activities as well as those of the more than 10,000 NGOs that are working in Haiti. USAID has contributed one of its officers to assist with information sharing, which means that most of the major funders are well-represented in the coordination efforts.

Figure 10. (a) Salvaging materials from damaged buildings, and (b) tent camps created by earthquake victims.

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S15

Figure 11. Earthquake-affected areas and population movement in Haiti following 12 January 2010 earthquake.

DESROCHES ET AL.S16

Some 220,000 temporary shelters are expected to be completed by August 2011, up from the original estimate of 125,000. This increase may be partially due to the ever- increasing number of people returning from the countryside. It is estimated that 40% of those who left Port-au-Prince after the earthquake have returned (as of October 2010). Two critical issues affect all the shelter efforts: rubble removal and land tenure. A year after the earthquake, piles of rubble still block Port-au-Prince’s traffic-choked streets. Clearing the debris is crucial for rebuilding, but rubble removal is not a priority for donors, so funds are not readily available for this primary task. Less than 5% of the rubble has been removed, and the disposal of the estimated 20 million cubic meters of rubble lacks a dumpsite and the equipment to move it. It seems that the UN could “tax” donors on new construction projects in order to allow this critical task to be completed.

The longstanding problem of ill-defined property ownership and the population influx to Port-au-Prince in recent years created squatter settlements in slum areas before the earth- quake. It is estimated that 60%–70% of the earthquake-displaced people were squatters and most have no funds for rent and thus will live in the camp settlements indefinitely. Less than 5% of Haiti’s land is officially registered in public land records; and there is no proper land registry system. A recent UN Habitat report noted that because of an informal land ten- ure system (with many titles being passed through oral tradition), large numbers of now- deceased landowners, contradictory laws, and weak institutions for enforcement, there is a profound lack of land tenure security, which will significantly impede rebuilding. The state of insecure property and land rights is also stifling local enterprise. Many Haitian business leaders are struggling to obtain bank loans because they are unable to prove that they own land. It is also causing potential foreign investors to be wary (D’Amico 2010).

CONCLUSIONS

The Mw 7.0 earthquake that struck the Republic of Haiti on 12 January 2010 was among the most devastating events in recent history. The death toll is estimated at 300,000; 1.3 mil- lion people remain homeless 10 months following the earthquake; and the estimated losses of US$7 to US$14 billion exceed the gross domestic product of the country. Many factors contributed to the scale of the catastrophe. Pre-earthquake socioeconomic conditions—Haiti lacks effective government and institutions and is the poorest country in the Western Hemi- sphere—increased vulnerability. The absence of significant seismic activity in Haiti since the 18th and 19th centuries contributed to a lack of earthquake awareness and preparedness. The proximity of the epicenter to the capital city of Port-au-Prince exposed a dense urban area to intense ground shaking. Geological and geotechnical conditions in the epicentral

Table 3. UN Habitat estimates of sheltering options

Shelter Options Percent No. Households

Return to Safe House 40% 96,000

Return to Safe PlotþTemp Shelter 20% 48,000 Resettlement in proximity: LotþT. Shelter 20% 48,000 Resettlement in new neighborhoodsþT. Shelter 10% 24,000 Host Family support 10% 24,000

OVERVIEW OF THE 2010 HAITI EARTHQUAKE S17

area include artificial fills, soft alluvial soils, and topographic features that caused ground- motion amplification and liquefaction-induced ground failures. The lack of an effective building code, inadequate seismic proportioning and detailing, inferior construction materi- als, and the lack of quality control all contributed to the poor performance of structures in the earthquake-affected area. Typical reinforced concrete frame buildings with concrete block infill had numerous vulnerabilities known to cause seismic damage, including slender columns and inadequate transverse reinforcement.

The earthquake demonstrated not only the weakness of Haiti’s physical infrastructure and environmental degradation, but also the more fundamental weakness of its institutions and government. This disaster, perhaps more than any other in recent history, illustrates the role of socio-vulnerability in a natural disaster. With every segment of civil society impacted—government, schools, universities, businesses, health clinics, orphanages, non- governmental organizations (NGOs), and churches—it was often difficult to understand who could provide relief and assistance to the earthquake victims. One year after the earth- quake, however, there are hopeful signs of coordination between the Haitian government, NGOs, and religious organizations and progress is being made. Haiti’s long-term recovery depends on providing food security, sanitation, clean water, jobs, education, property and land rights, health care, and other basic services that require a functioning government pub- lic sector, not simply short-term aid from NGOs. Building capacity at all levels—technical, institutional, and governmental—will be required to put Haiti on a new path of economic growth and social justice.

ACKNOWLEDGMENTS

This material is based on work supported by the National Science Foundation Rapid Grant, Nos. CMMI-1034793, and funding by the USGS, the Earthquake Engineering Research Institute (EERI), the Network for Earthquake Engineering Simulation (NEES), the Geo-Engineering Extreme Events Reconnaissance (GEER) Association, and the Applied Technology Council (ATC). The EERI contribution was funded by the EERI Learning from Earthquakes project under Award No. CMMI-0758529 from the US National Science Foundation. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.

The reconnaissance effort was made possible by the logistical support of the US South- ern Command and the officers, soldiers, marines, airmen, and civilians of Joint Task Force Haiti. The institutional support of the US Embassy and US Agency for International Devel- opment was also crucial. The authors also thank the various members of the Haitian com- munity that were helpful in supporting the reconnaissance effort.

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