Fifteen-year-old cholera patient Jonas Florvil lies on a cot in a nearly empty ward at a Samaritan's Purse cholera treatment center in the Cite Soleil neighborhood of Port-au-Prince, January 8, 2011. 
Allison Shelley / Reuters

For centuries, war and disease have gone hand in hand. Smallpox served as vanguard for the Spanish forces in their conquest of the Americas, and yellow fever and typhus finally turned the tide—in Haiti and Russia, respectively—against the strategic genius of Napoleon. In fact, it wasn’t until World War I that a major conflict saw more soldiers perish on the battlefield than from disease—yet those soldiers’ comrades played a key role in spreading the 1918 flu pandemic, which claimed far more lives worldwide than the war.

Not long after the United Nations was formed in the aftermath of World War II, the world came to the novel conclusion that soldiers could be used not to wage war but to promote peace, resulting in the creation of United Nations Peacekeeping. Although peacekeeping has changed the role of the soldier, however, it has not severed the connection between soldiers and the spread of disease. The Haitian cholera epidemic, which has resulted in more than 730,000 infections and 8,900 deaths since 2010, originated with UN peacekeepers. This tragedy serves as a warning, as yet largely unheeded, about preventing those sent to help vulnerable populations from becoming a vector for disease. 

An earthquake survivor looks at the rain in the early morning in a provisional camp in downtown Port-au-Prince, November 5, 2010.
An earthquake survivor looks at the rain in the early morning in a provisional camp in downtown Port-au-Prince, November 5, 2010. 
Eduardo Munoz / Reuters
Until peacekeepers brought Vibrio cholerae to Haiti, the country had not recorded a case of cholera in at least a century. Conclusive scientific proof about the origins of the epidemic—Nepalese peacekeepers stationed at a base in Mirebalais, from which human waste was negligently allowed to enter the rivers that serve as the primary water source for tens of thousands of Haitians—has not spurred the United Nations to take effective action to end the epidemic, compensate the victims, or even simply admit responsibility. This is despite the fact that the risks of cholera transmission were well known, and that its introduction easily avoidable; effective screening of troops before deployment would have helped, as would have adhering to basic principles of sanitation on the base. 

Left with no other options, victims of the epidemic have turned to the courts to enforce their rights; the UN has responded to their claims by declaring itself immune from suit. This litigation thus raises important questions around the boundaries of UN immunity and about the organization’s legitimacy in promoting human rights and the rule of law. Determining the UN’s obligations to the victims of the cholera epidemic is important. So too, however, is examining how current UN practices leave other vulnerable populations at risk. Despite the scale of the Haitian tragedy, it has spurred surprisingly little action on the part of the UN to prevent such a tragedy from happening again.

UN peacekeeping constitutes a uniquely high-risk activity in this regard. Peacekeepers are dispatched to war-torn areas, where existing health and sanitation infrastructure has frequently been damaged. Once there, they regularly interact with displaced persons and other populations whose circumstances make them particularly vulnerable to disease.

Compounding the risk is the current model of UN peacekeeping, which increasingly relies on large troop contributions from countries which themselves face high burdens of infectious disease. A CDC briefing eight months before the Haitian epidemic highlighted the vulnerability of post-earthquake Haiti to waterborne disease, but noted that cholera importation was unlikely given that “most current travelers to Haiti are relief workers from countries without endemic cholera.” Peacekeepers were almost certainly the single biggest exception to this statement.

Wooden statues replicating UN military troops line a table on a roadside stand in Port-au-Prince, May 11, 2011. 
Swoan Parker / Reuters
Similarly, the Haitian tragedy highlights how peacekeeping can create unique population interactions that almost certainly would not have otherwise occurred; given that statistics from Nepal’s Ministry of Foreign Affairs show the combined value of trade between Nepal and Haiti in 2010 was roughly 813,000 rupees (currently worth about $8,000), without peacekeeping there would be no link connecting the epidemic’s Nepalese source and its rural Haitian epicenter. 

Given this potent mix of risk factors, the cholera epidemic in Haiti is not even the worst-case scenario. That distinction would likely go to the spread of drug-resistant malaria. Most current UN peacekeeping missions take place in sub-Saharan Africa, the region that accounts for the vast majority of global malaria morbidity and mortality. The region’s malaria burden has been rolled back in recent years, in large part due to the availability of effective artemisinin-based drugs. Given their importance, it is extremely worrying that artemisinin resistance has emerged in Southeast Asia. 

For a preview of the consequences of losing an effective and affordable drug, look to the spread of chloroquine-resistant malaria, which emerged in the same region in the 1950s and 1960s before spreading to Africa beginning in the late 1970s, where it caused a two- to three-fold increase in mortality. Soldiers from multiple countries where artemisinin resistance has been detected—Cambodia, Thailand, and Vietnam—have participated in current African missions. Nevertheless, the UN has failed to implement an effective process to prevent the introduction of artemisinin-resistant malaria. 

Inaction in the face of grave public health risks is unfortunate given that peacekeeping is not only a particularly high-risk activity but one especially well suited to mitigating those risks
In contrast to cholera, whose spread could have been halted by proper sanitation even after infected personnel had entered Haiti, once drug-resistant malaria is recorded it may already be too late. UN forces, no matter their country of origin, regularly contract malaria while on mission; in some troop-contributing countries, such as Jordan, returning peacekeepers account for the bulk of all imported cases. Once bitten, a soldier already infected with a drug-resistant parasite could in turn introduce that parasite into the local mosquito population, and from there into local humans. The historical failure of malaria eradication efforts in the very African countries currently hosting peacekeepers underscores the virtual impossibility of reversing the damage of drug resistance once it has been introduced. The only solution is preventing it from arriving in the first place. Effort needs to be put into determining the most effective methods of doing so, such as appropriate pre-deployment testing and treatment.

This has not been the United Nations’ approach thus far. Existing guidelines on peacekeeping and disease focus on protecting peacekeepers from local diseases, overlooking the risks to locals from imported ones. Although the UN accepted a number of the recommendations put forward by the independent panel of experts it charged with investigating the Haitian cholera epidemic, such as taking steps to improve sanitation on bases, it remains to be seen how effectively they will be implemented. At the same time, victims of the epidemic are still without a remedy and the UN-endorsed plan to eradicate cholera from Haiti remains grossly underfunded, even as the ongoing peacekeeping mission in the country costs over half a billion dollars per year. And while some countries, such as Cambodia, have recognized concerns around peacekeepers and artemisinin resistance, the UN itself remains silent on the issue.

Inaction in the face of grave public health risks is unfortunate given that peacekeeping is not only a particularly high-risk activity but one especially well suited to mitigating those risks. Peacekeeping missions, and who participates in them, are defined in detail. They are subject to oversight by a single centralized organization with both the expertise and capacity to craft effective policies to address risks as they arise. And once those decisions have been made, the military structure of UN peacekeeping makes it easier to directly implement and enforce new policies. 

In this case, although participation by a broad spectrum of countries in UN peacekeeping missions is something to be welcomed, the UN must take steps to address the attendant risks. Doing so would require relatively little change in how peacekeeping is managed. The current method of financing peacekeepers ensures that peacekeepers from lower-income countries are in effect subsidized by the UN; the relative cost of appropriate screening and prevention measures could readily be incorporated into this subsidy. In turn, such an investment could also help build domestic capacity—particularly in areas like laboratory diagnostics—that would have positive spillover for public health programs within troop-contributing countries. 

Political inertia can be overcome; for instance, as Ebola hit the headlines, the UN agreed to suspend rotations of African soldiers to Haiti over concerns about the virus, even though the practical risk of introducing the disease was far lower than it ever was for cholera. The UN has access to the expertise necessary to develop effective policy, and a structure that is well suited to its implementation. It also has a duty to ensure that peacekeepers protect the most vulnerable not only from war but from pestilence as well. 

  • ADAM HOUSTON is CIHR Fellow in Health Law, Ethics & Policy 2015-2016. He works with the Institute for Justice & Democracy in Haiti (IJDH).
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