1. Clear, Hold, Build:
Sustainable strategies to eradicate cholera
Team 6:
Christopher Lee, Raja Narayan, Samir Zaidi, Michael Zucker

2. Executive summary
• Cholera epidemic in Haiti has exacerbated a pre-existing state of poverty,
malnutrition and underdevelopment
• The program proposed both eradicates cholera and provides the public health
framework to deal with future crises
• The program updates the prior $2.3B MSPP cholera eradication plan,
incorporating new tech deployed more rapidly and at lower cost
• A claims process is essential to ensure justice for the Haitian people. This
proposal is based on strong precedent from prior mass torts

3. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

4. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

5. Haiti before the earthquake
Haiti still facing numerous challenges…
That remain unsolved despite int’l aid
94
$B 7.0
87
6.5
6.0
76
65
630
Int’l Assistance
Haiti GDP
5.0
58
4.2
4.0
3.0
34
22
1.2
Haiti
Americas
Access to
sanitation
(% of pop.)
Access to
clean water
(% of pop.)
7
% living below
poverty line
Maternal
mortality2
Child
mortality1
63
2.0
19
% of children
underweight3
19
3.4
1. Under 5 years, per 1,000 2. Per 100,000 births, 3. % of children under 5
Sources: http://ec.europa.eu/echo/files/aid/countries/Haiti_paper_01102010.pdf, OECD
1.0
0.3
0.6
0.0
2000
2005
2009
Pre-cholera aid supported:
• Government budget, special projects
• Technical assistance, capital equip. transfer
• Debt relief

6. Earthquake, cholera devastated Haiti
Underdevelopment provided fertile ground for epidemic
and deaths…
High level of infections…
Infections
(‘000)
had disastrous
consequences
Deaths
(‘000)
360
172,000
displaced
7.5
7.0
100
1.5
80
60
Without
intervention
With
intervention
40
20
0
1.0
Without
intervention
With
intervention
0.5
0.0
11 12 13 14e 15e 16e
Source: NEJM, WHO, team analysis
11 12 13 14e 15e 16e
3,000,000
food insecure

7. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

8. Approach guided by public health best practices
Strategic principle
Backward inductive approach
Taking an ecological view
Locally informed tactics
Harness positive deviance
Integrate intelligence
Application to program design
• 4 clearly articulated and measurable end-state goals
• Organization of funded projects into 4 well-defined pillars
• Program design considers politics, economics, law, medicine, and public
health in addressing the epidemic
• Clear hierarchy, decentralized mgmt. balances efficiency, control
• Investments in both infrastructure and human capital
• Haitian people included at all levels of mgmt., implementation
• $350M set aside for community-driven programs
• Surveillance pillar prioritized early
• Investment in “rapid response” concept to target epidemic reemergence

9. 4 end-state objectives by 2023
Emergency response teams in place by EOY 2014
Settlement of all claims by 2018
Remediate sanitation and water supply by 2018
Eradication of cholera by 2023

10. Effort will cost ~$2.8B over 10 years
Program spend by year and activity type ($M)
863
2,816
474
350
396
60
391
397
Claims: Ind
Claims: Comm
Reserve
Prevention
200
1,133
Infrastructure
438
332
332
50
2014
2015
2016
2017
2018
2019-2023
218
Total
Surveillance
Treatment
Administration

11. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

12. Holistic program to eradicate cholera by 2023
Four drivers of health system
reconstruction
Treatment
Surveillance
Implemented over three
phases
Phase 1:
Rapid response & relief
Phase 2:
Contain & control
Prevention
Infrastructure
Source: CDC, PAHO, WHO
Phase 3:
Eradicate & build
To yield sustainable results
• Death rate from infection
<0.5% by 2014, <0.01% by
2020
• Emergency response teams
in place EOY 2014
• 100% have access to
sanitation, clean drinking
water by 2018
• Cholera eradicated by 2023

13. Aggressive implementation of treatment pillar in phase 1
Treatment overview
Phase 1
Phase 2
Phase 3
218M
91
104
22
Health care
services
Essential
medicine
Micronutrients
• Standardize
management tools for
cholera
• Update information
databases
• Improve logistics,
support networks
• Supplement surveillance
in high-risk spots
• Purchase medicines and
supplies for emergency
response
• Establish communelevel medical depots
• Strengthen MSPP
supervisory
capabilities
• Purchase trucks
• Implement pharmacovigilance unit
• Introduce zinc, oral
rehydration solutions
• Micronutrient
distribution to all
communes
• Strengthen staff in the
nutrition unit as needed
Source: MSPP Cholera Eradication, team analysis

14. Scale-up of surveillance in phases 1-2 will enable flexible
responses
Surveillance overview
332M
1
Follow up
& evaluation
6
Epidemiologic
information
12
314
Research
capacity
Strengthen
DINEPA
Phase 1
Phase 2
Phase 3
• Build add’l surveillance
infra.
• Scale surveillance as
needed
• Repurpose unneeded
surveillance facilities
• Enable rapid
transmission, real-time
analysis of reports
• Train community
health agents to use
surveillance tools
• Disseminate regular
epidemiological bulletin
• Institutional support
• Construct regional
laboratories
• Integrate cholera
diagnostics in hospital
laboratories
• Organize sectoral
governance
• Implement standards,
performance metrics
• Build cooperative
mechanism for NGO
participation
• Monitor evolution of
water and sanitation
sector
Source: MSPP Cholera Eradication Plan, team analysis

15. Innovative water distribution solution saves >$500M over
original UN plan
Infrastructure overview
Phase 1
1,133M1
Phase 2
Phase 3
• Distribute Sunspring
system to Port-au-Prince,
medium-sized cities
• Complete Sunspring
rollout
• Commence chlorine
production
• Plan and begin building
permanent water supply
system
• Construction, repair of
sanitary facilities
• Develop sanitary
standards
• Review facilities
• Begin implementing
national plan
209
Water supply
515
Wastewater
& excreta
treatment
• Develop national
sanitation plan
• Develop & disseminate
education materials
• Build social awareness
407
Waste
collection
& treatment
• Triage and address
hotspots with temporary
improvements
• Plan to rationalize,
expand waste treatment
network
1. Includes 3M for institutional strengthening for solid waste
Source: MSPP Cholera Eradication Plan, team analysis

16. Ongoing prevention efforts required for eradication
Prevention overview
60M
8
39
Community
hygiene
Institutional
strenghtening:
health
promotion
Phase 1
Phase 2
Phase 3
• Mass communications
campaign
• Develop education &
entertainment materials
• Community & household
level programming
• Develop community
health agent training
facilities
• Recruit community
health agents
• Supervision and follow
up and agent network
• Develop public awareness • Re/train health
guide
inspectors
3
10
Food hygiene
Hospital
hygiene
• Construct 15 wastewater
treatment stations
Source: MSPP Cholera Eradication Plan, team analysis
• Develop
comprehensive
prevention plan
• Train food handlers
• Train communal staff on
hospital hygiene

17. Two categories for damages
Individual damages
• Damages for death:
• Based on economic loss
• Scaled up by “plus factors” (e.g.
marital status, children)
• Damages for illness = $100
• Most claims involve filling out a form,
attaching one add’l record
• Claims processed outside of Haiti
• Funds paid in 3 installments over 6 years
to minimize inflationary impact
Community-based damages
• “Highly impacted communities” can
petition for Community Bank funding
• In highly impacted communities:
• >10% of population infected
• Death rates >2% of infected
• Community Bank funds used for local
initiatives proposed by local gov’ts,
community leaders
• Projects should be high-impact and
scalable
• Projects overseen by UN-Haiti Project
Management Teams if >$1M

18. ~670M in awards expected over 5 years
Awards by injury type and year ($M)
783
117
Full implementation
of ind’l settlement
program mid-2015
666
68
87
124
177
504
406
Award type
224
193
24
2014
2015
2016
High Case
Assumptions:
• Total # ill up 10%
from 750K to 825K
• False reports 40%
instead of 20%
2017
2018
Note: Assumes only 75% of those with valid claim file, all claims filed between 2014-2018
Source: Team analysis
193
Total
High
Case
Illness
Death
Community Awards

19. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

20. Clear hierarchy ensures management efficiency
Settlement trust
Managed by a
court-appointed
Funds held in
separate acct to
ensure payment to
Haitian ppl.
Joint
Board of
Directors
UN-Haiti Project
Management Boards
Executing NGOs/Governmental
Agencies
Supporting
Agencies:
• Int’l agencies
(e.g. WHO,
World Bank)
• Donor nation
health
ministries
• NGOs,
independent
experts

21. Hierarchy balances local control, donor competency
Composition
Mission
Responsibilities
Provide project
leadership, monitor
progress and
funding
• Drive progress towards program
goals
• Coordinate with UN, donors
• Approve funded projects, monitor
program budget
UN-Haiti Project
Management
Boards
4 boards, each with
5 members
• UN: 1
• Ind. experts: 2
• Haiti: 2
Project management
and support for one
of four pillars
• Recommend projects for program
funding
• Oversee funded projects
• Liaise between funded programs
and UN leadership
Executing
Agencies
Varies, but must
include some local
leadership
Implement funded
programs
• Day to day project management
• Must engage with local leadership,
hire locally wherever possible
Joint Board of
Directors
15 members
• UN: 4
• Donors: 4
• Haiti gov’t: 4
• NGOs: 3

22. Agenda
• Current situation in Haiti
• Solution overview
• Program deep-dives:
• Remediation
• Claims
• Organization
• UN/DPKO moving forward

23. DPKO action must be taken to prevent repetition
New guidelines for future DPKO operations…
• Screening of all relief workers to limit such
future public health crisis
• More detailed pre-departure health
examination
• Expand screening to cover all UN
forces, workers, and contractors
• Expand medical monitoring of DPKO forces
once deployed
• Educate foreign workers on sound public
health practices
• Continued research into cholera incidence
and treatment methods to improve future
responses
and a new screening form
Need to tailor U.N. foreign health screening form
for infectious diseases endemic to DPKOcontributing nations

24. High visibility UN actions will help build trust
UN apologies
Convert MINUSTAH
camp in Méyè to medical
center
•
•
•
•
•
Public apology by UN Office of the Secretary General
News conference in Port-au-Prince to government and people of Haiti
Admit responsibility for introducing South Asian Vibrio cholerae strain
Will help strengthen relationship between UN and local population
Trust critical for program success
• MINUSTAH camp in Méyè was origin site for epidemic
• Camp serves as a contentious reminder to the world and local population of
U.N. culpability in cholera epidemic
• Convert and re-design camp as a medical center, focused on the active
treatment and prevention of transmittable diseases
• Serves as a symbolic mea culpa

25. Questions?

26. Appendix 1: Team analysis

27. Two methods for determining damages
Fill out the form
• Formula-based determination of damages
• Requires a simple form and one (injury)
to two (death) affidavits
• Forms will be distributed to local clinics,
government offices, …
• Payment will be paid out of the
settlement trust through check, wire, or
mobile transfer
• Expect the vast majority of damages to be
paid out this way
Administrative determination
• Used for special cases, or where
claimants dispute calculation
• Requires claimants to present evidence
before an administrative panel
• Panel uses the settlement factors as a
guide to determining damages
• Decisions of the administrator are final
and binding

28. Fill out the form: calculation of damages
Economic damages
• Calculation of lost earnings
• Based on higher of last 3 yrs of income, or
$4561
• Assumptions:
• Income growth = discount rate
• Life expectancy = 63 years
• For victim at age 30:
• Minimum award = ~$15,000
• Average award = ~$24,000
Plus factors
X
• The settlement committee should develop
formulas for various plus factors, including:
• Marital status
• Number of children
• Special adjustments to income for
students
• Pain & suffering
• Plus factors will serve as a multiplier to the
award, and shall not exceed 3x of the award
value
• For those who fall ill and recover, fixed
damages of $100 + health expenses
Payments for deaths will be made in 3 installments over 6 years to minimize inflation
1. World Bank poverty line, at $1.25/day
Source: World Bank, Team analysis

29. Misappropriation of funds will be a significant challenge to
program implementation
WEF Global Competitiveness Index Ratings (selected items, 1-7 scale, 1 is worst)
5.0
4.6
4.1
4.1
3.5
3.2
3.0
2.5
2.3
3.2
3.2
2.4
Haiti
Global Average
Diversion of
public funds
Rank/148
Source: WEF
Irregular
payments,
bribes
Favoritism by
gov’t officials
Wastefulness in
gov’t spending
Organized
crime
Strength of
auditing,
reporting
126
122
118
119
114
138

30. ~10-20% of increased costs due to local challenges assumed
for program
Estimates of local misappropriation of funds (% of total spend misappropriated, selected examples)
87
79
24
8
13
18
14
8
2
Uganda:
bribes,
all firms
Indonesia: Mozambique: Uganda:
trucking shipping bribes education
bribes
graft
Source: Olken & Pande, “Corruption in Developing Countries”
Indonesia:
infra. graft
Indonesia:
graft in
subsidies
Iraq: Oilfor-Food
2
India:
subsidy
graft
Brazil:
municipal
gov’t audits
India:
municipal
gov’t

31. Cost reduction of ~$450M over MSPP plan achieved by
utilizing Sunspring system
Sunspring overview
Calculation
• Flexible, rapidly deployable water treatment
& purification system
• Each unit serves 2,500-10,000 people
• Only decentralized solar powered system
WQA Gold Seal certified
• Sunspring systems serving 200,000+ already
in place in Haiti
• MSPP plan $ for water supply = $650M
• Sunspring cost:
• 1 unit per 2500 people
• 4000 units x $25,000/unit = $100M
• 4000 units x maintenance @ $24/unit/year
* 10 years = ~$10M
• 4000 units * failure rate @ 0.5%/year *
$25,000/replace = $10M
• Train local personnel to maintain replace
systems = $10M
• Total = $190M * 10% corruption scale-up
= $209M

32. Appendix 2: Prior MSPP plan budget