We made our way down the steep bank to the meandering river, Haiti's largest: the Artibonite. My friends warned me about the strong currents, and also about the dangerous spirits that lurk beneath the surface in deep parts, waiting to drag any wayward swimmer into their murky depths. We stayed close to the shore, sitting on rocks or treading water as we bathed, played and did the laundry. Amid our laughter, I was reminded that the river holds other deadly presences.
Along its many miles, people are washing dirty clothes and sheets, washing themselves, washing vehicles, bringing animals to drink and dumping sewage. The latter sparked what would quickly become the world's largest cholera epidemic in recent history. Since October 2010, when cholera was introduced into Haiti after sewage from a UN peacekeeping base was dumped into the river, close to 800,000 cases have been reported and more than 9,000 people have been killed. The UN continues to refuse to acknowledge or take responsibility for its proven involvement.
In both Haiti and Flint, toxic drinking water is linked to unjust - if not criminal - circumstances.
For two months in 2015, I lived and conducted ethnographic research in a rural region of Haiti near the mouth of the Artibonite River. I returned for a brief visit - and to celebrate the 212th anniversary of Haiti's independence - in January 2016. In 1804, the nation of Haiti liberated itself from French colonial rule, becoming the world's first independent Black republic. What followed has been a complex history made tumultuous by foreign intervention, natural disasters, political instability, epidemic disease, institutionalized elitism and legacies of colonialism, structural adjustment and trade "liberalization" that have wreaked havoc on Haiti's economy and capacity for self-sufficiency. For many, even myself, Haiti occupies a particular place in the collective imaginary, often relegated to such superlative categories as "poorest," "developing" and "third world."
Upon returning to the United States, where I'm an M.D./Ph.D. student at the University of Michigan in my second year of medical school, I was reminded of the reality that we live within one world, not subdivided into three (first, second, third) or even two (developed or developing). We each exist within communities tethered in a massive, interconnected web of globalized exchange, movement, communication and influence. Thanks to infrastructural inadequacies, poverty, governmental neglect, institutionalized racism and other forms of oppression, some communities have been made more vulnerable to acute shocks or indolent disasters lurking beneath the surface.
From Haiti to Michigan and across the world, millions - especially poor and marginalized populations - are being denied the human right to clean water and sanitation. On January 5, 2016, Michigan Gov. Rick Snyder declared a "state of emergency" in Flint, not because of earthquakes, droughts or floods like the ones that have gripped Haiti, but because thousands of people in the city have been exposed to toxic levels of lead, bacteria and other particulates in the tap water. In both Haiti and Flint, toxic drinking water is linked to unjust - if not criminal - circumstances.
These water crises, though distinct in important ways, can both be traced back to longstanding human-made systems that have simultaneously neglected and exploited low-income communities of color. As much as they are related to health, these human-made catastrophes are issues of social justice. Health equity must be at the core of efforts to eliminate cholera transmission in Haiti and to remedy lead exposure in Flint. In the years to come, the success and sustainability of relief and reconstruction efforts will depend as much on adequate funding as they will on community-based partnerships that tackle the accompanying etiologies and manifestations of poverty and injustice.
In April 2014, when Flint was under the direction of an emergency manager appointed by the state, the city began drawing its water from the Flint River, rather than from Detroit's system, which was deemed too costly for the insolvent city. But the river's caustic water began corroding Flint's aging pipes, leaching lead into the water supply. For months, state officials ignored irrefutable evidence that the water pumped from the Flint River exposed residents to extreme toxicity. In the city of Flint, whose population is 57 percent Black, lead has been accumulating in the bodies of children, with the potential to cause long-term neuropsychological effects like lowered IQ and behavioral disorders such as ADHD. Residents have been experiencing diarrhea as well as rashes on their skin from using and bathing in polluted water, similar to the rashes I witnessed on people's bodies while shadowing at a rural health center in Haiti. E. coli - the presence and abundance of which is used to infer the degree of fecal contamination in surface water - was detected at unacceptably high levels in the Flint River in 2014, and as far back as 2008. Levels in the Artibonite River are more than 2,400 times the maximum standard. Less than half of households in rural Haiti have access to "improved drinking water," which really just means a source that is not contaminated with fecal matter. No one should be forced - whether by poverty or poor governance - to rely on toxic water for drinking, cooking or bathing.
In this way, Flint's water crisis is not unlike Haiti's. It never comes down to one bad decision made about pumping water from the Flint River or dumping sewage into the Artibonite River. It is neglected - or absent - infrastructure that's deadly. And neglected infrastructure stems not only from impoverished governance, but also from impoverished communities, deprived of their capacity for self-reliance by a lack of access to quality education, health care, social services and income. With average household water and sewer charges of $140 per month (in 2014), Flint's rates are among the highest in the country. Residents, 40 percent of whom live below the poverty line, spend an average of 7.2 percent of their annual income on water and sewer bills alone. It's not uncommon to find bills as high as 10.3 percent, and outrageous rates are still being billed in spite of the water crisis. In Haiti, one study revealed families spending 12 percent of their annual income on water. Poverty, eroding infrastructure and unaffordable water aren't unique to Haiti. They also devastate communities as seemingly far as Flint, Michigan.
Eleven days after Governor Snyder's announcement, President Obama declared a federal emergency in Flint on January 16, but denied requests for a disaster declaration that would make more federal funding available for response efforts. Federal law stipulates, however, that only natural disasters are eligible for disaster funds. Like the cholera epidemic in Haiti, the water crisis in Flint is very much a human-made catastrophe - one with very real long-term implications that will leave a toxic legacy far beyond an immediate disaster.
In Haiti, people in high-risk areas continue to fall ill and die from cholera, a disease spread by water contaminated with Vibrio cholerae bacteria that, when ingested, can cause extreme and potentially fatal dehydration from diarrhea and vomiting. Over the past five years, the epidemic has taken a toll not only on the health of Haitians, but also on their productivity. Among the most vulnerable to diarrheal diseases like cholera, as well as their lasting effects, are children: One out of five children under the age of 5 suffers from diarrhea, which in turn impacts their nutrition, education, safety and long-term health outcomes.
Children in Flint are also among the most vulnerable to the consequences of the water crisis, particularly the irreversible effects that lead toxicity has on the brain. Evidence shows that people who've been exposed to unsafe levels of lead at young ages can develop serious difficulties retaining information, learning in school, controlling impulses or holding a steady job. Lead toxicity has a biological burden as well as a social and economic one. The vast majority of US communities suffering from the devastating effects of lead exposure - the consequences of which can persist for several generations - are low-income communities of color. Resolving the crisis in Flint will not only require replacing eroded water infrastructure, but also addressing its lasting implications for physical and mental health, education, employment, social services and community safety.
Health and Social Justice
The question now facing Flint, as it did Haiti five years ago and Detroit in 1834 (when the city's last cholera epidemic happened), is: "What's next?" In 2013, Haiti and its partners released a 10-year plan to eliminate cholera that involves both rapid response efforts as well as long-term epidemiological, structural and management improvements in water supply, sanitation and health. As of 2015, however, only 18 percent of the plan's $2.2 billion budget had been financed. Beyond a dearth in funding, the elimination plan lacks built-in measures to tackle underlying factors that have sustained cholera in Haiti unless addressed. Cholera will not be eliminated by handing out bottled water and water filters, just as the water crisis in Flint will not be solved by addressing water infrastructure alone. Systemic poverty generates a vicious cycle of increased burdens of disease and suffering, mediated by such elements as unemployment, unsafe housing, water insecurity, sanitation insecurity, food insecurity, poor governance and lack of access to effective health care.
How different, how less vicious, devastating and complex, than a cholera epidemic is an epidemic of lead exposure? Whether in Haiti or Flint, all humans deserve the right to clean water and sanitation. From Haiti to Flint, communities are calling for accountability. They're calling for an end to 11 years of UN occupation; they're calling for an end to so-called "emergency management"; they're calling for the immediate improvement or replacement of water infrastructure. Their human rights have not simply been denied; they've been violated outright. It's a question of health equity. It's recognizing that Black lives - and Black health - matter. We live within one world, and within this world health is intimately linked to poverty and injustice. Eliminating cholera or lead from drinking water rests on a comprehensive, multisectoral approach to eliminating the cycles of poverty that keep marginalized communities poor, and keep the poor sick.