Argument

Why Democracies Don't Get Cholera

It's about a lot more than just clean water.

Amartya Sen famously said that famines do not occur in well-run, democratic countries. The same is almost always true for cholera epidemics.

Not long after Haiti's earthquake in January, public health officials warned that poor sanitation and lack of potable water were creating conditions ripe for an outbreak of infectious disease. They were right. In the last week, a cholera outbreak has swept this impoverished country, with more than 3,100 confirmed cases and 250 deaths reported so far. So why -- if we knew that there was a danger of cholera -- couldn't it have been avoided? In short, because disease and democracy often work in opposite directions: vulnerable populations and inadequate government action create both the conditions for cholera epidemics to emerge and to become unmanageable.

Cholera epidemics stem from the same basic cause: poor people living in crowded and unsanitary conditions, with inefficient public health monitoring and limited health care. Cholera is a bacterial infection caused by the ingestion of fecally contaminated water or food. When an outbreak starts, it gains momentum fast.

But another cause is government denial and cover-up. Governments don't want to admit the failure of health-care or surveillance systems, and they are afraid of the trade and travel sanctions that may result from a large outbreak. But inaction leads to larger epidemics: Treating a few cases of cholera with oral rehydration salts or intravenous fluids is relatively straightforward, managing hundreds or thousands of cases is not. With prompt and proper treatment, less than 1 percent of those infected die. Without a fast response, death rates of five percent or more are not unheard of.

Unfortunately, there are more than enough examples of this worldwide. In 2008, in Zimbabwe, a cholera outbreak infected more than 100,000 people. In the past few months, nearly 50,000 people have been infected in four central African countries. Nigeria has been hardest hit, with about 40,000 cases and 2,000 deaths. Other outbreaks have occurred in the past few years in Kenya and Iraq. Two weeks ago, in flooded regions of Pakistan, 99 confirmed cholera cases were reported. In fact, cholera is on the increase across the globe. Each year, an estimated 3 million to 5 million people are infected with cholera; 100,000 to 120,000 of them die.

Haiti was vulnerable to this outbreak not only because of the January earthquake, but also because the country's rural population has long been marginalized, which has continued during reconstruction. Though rural villages and towns absorbed hundreds of thousands of individuals displaced after the earthquake, they have been largely excluded from the aid response. In rural communities, the already-stretched food and water infrastructure, has been pushed to the limits, while the humanitarian response has focused more on the earthquake-affected areas near Port-au-Prince.  

A second factor that predisposed Haiti to crisis was a weakened central government. Both prior to and particularly after the earthquake, the government was largely unable to deliver services. Instead, a precarious web of NGOs and relief organizations took on the job. This patchwork has supported water projects throughout rural Haiti, at various levels of functioning and disarray, meaning that communities often rely solely upon the charity of private groups. When projects fail, there is no accountability. 

Even if the infrastructure were perfect, however, clean water is not enough to prevent epidemics. You still need a government, and attention to housing and human rights. For several months, human rights organizations have been decrying the lack of a government plan for housing the 1.3 million people who still live in camps. To reduce the risk of cholera, the squalid living conditions in camps need to be addressed. This is not a task easily conducted by NGOs in piecemeal. Relief organizations and international donors must work to strengthen the capacity of the Haitian government, and to strengthen and empower local civil society.

The role of human rights in promoting accountability is frequently discounted in the immediate aftermath of a crisis. Similarly, the right to health is often misunderstood: It does not mean that everyone has a right to be healthy. Rather it means that governments, at a minimum, need to act to counter foreseeable health risks. Haiti has limited means to provide a broad guarantee to the right to health. But, with the support of private groups and international donors, the government can prevent the cholera epidemic from continuing to escalate and from affecting not just thousands, but hundreds of thousands, of people.

The bottom line is that cholera is avoidable and cholera deaths are preventable. When the immediate crisis is over, attention will turn back to rebuilding Haiti. By listening to the needs of rural residents, by ensuring that planning is participatory and inclusive, by building the capacity of the government to deliver services and fulfill the rights to health, water, and shelter, post-earthquake-rebuilding efforts can reduce vulnerability to cholera and ensure that the Haitian government can protect and fulfill the rights of its people. If it can do that, Haiti can provide an example for countries around the world.

THONY BELIZAIRE/AFP/Getty Images

Argument

Blood on Our Hands

Newly released war documents show how the U.S. military, in cable after grim cable, painstakingly chronicled Iraq's descent into bloody Shiite-on-Sunni violence. So why did top officials deny the obvious?

In early March 2006, Donald Rumsfeld called a Pentagon news conference to declare Iraq peaceful -- and to say that U.S. reporters in Baghdad were liars for reporting otherwise.

Contrary to the jumble of "exaggerated" reporting from Baghdad, the then-secretary of defense said at the Washington press briefing, Iraq was experiencing no such thing as the explosion of sectarian violence that myself and many of my fellow journalists in Baghdad were covering in the aftermath of a fateful February 2006 bombing of a Shiite shrine in Samarra.

Certainly, some Iraqis were trying to incite civil war, Rumsfeld acknowledged. But Iraq's own security forces had "taken the lead in controlling the situation," he insisted, and quick action by the Shiite-led government had "a calming effect."

Rumsfeld also made clear at the time that U.S. officials were fighting another kind of war over Iraq -- the battle for U.S. opinion. The "misreporting" on the death toll was driving down U.S. support for the war, the defense secretary complained.

Four years on, however, WikiLeaks' release of contemporary troop logs raises serious questions about who, exactly, was doing the lying.

One of the few absolute revelations from the Wikileaks documents is the extent to which Rumsfeld, then-U.S. commander Gen. George Casey, and others had access to ample information from unimpeachable sources -- their own troops on the ground in Iraq -- regarding how badly events had turned in Iraq by 2006, but nonetheless denied a surge in killing to reporters and the U.S. public.

"The country is not awash in sectarian violence,'' Casey told one U.S. television network in the wake of the Samarra bombing. And talk of Iraq sliding into civil war? "I don't see it happening, certainly anytime in the near term,'' Casey said.

But in hundreds of terse log entries from the field -- now made public by WikiLeaks -- U.S. troops documented more comprehensively than we reporters could ever have hoped the explosion of retaliatory killings, kidnappings, tortures, mosque attacks, and open street fighting. The reports streamed in the hours and days after the bombing of the Shiite shrine in Samarra enraged Iraq's Shiite militias. What we reported then has now been confirmed: The bombing transformed Iraq's building sectarian violence into something even darker.

In one of scores of entries recording U.S. troops coming upon handcuffed, tortured bodies on Feb. 22, 2006, and in the days after, a U.S. officer recounted happening upon fighters as they threw bodies from a car. The commander was in time to note how fresh the corpses were: "BODIES WERE SHOT IN THE FACE AND BODIES WERE STILL WARM," he wrote.  

In fact, U.S. soldiers in Iraq saw and heard the eruption of civil war in Iraq from the first minutes. According to one of the tense, redacted log entries logging the moment of the mosque bombing, "AT ___ 0701C FEB ___, THERE WERE 2X AUDIBLE EXPLOSIONS THAT WERE REPORTED FROM A MOUNTED PATROL … THE ROOF OF THE GOLDEN MOSQUE HAD COLLAPSED."

By the afternoon of Feb. 22, 2006, U.S. soldiers in Baghdad, Basra, Diyala, and around central Iraq were recording dozens of retaliatory attacks with grenade launchers and small arms on mosques, and the outbreak of tense, angry demonstrations countrywide. (The log entries below are a sampling; pages of more such log entries for Feb. 22 and the days after can be found on www.wikileaks.org. An article I wrote for the Daily Beast gives a shorter version of the log entries.)

Not always comprehendingly, U.S. soldiers noted the massing protesters often were the armed and black-clad fighters of Shiite cleric Moqtada al-Sadr's feared Mahdi Army militia.

One report read:

"2006-02-23 08:25:00../././ AT 231425FEB2006, -/___ REPORTED AN ARMED DEMONSTRATION IN THE SAL AD DIN PROVINCE IN THE CITY OF ___ AT ___. THE MAJORITY OF THE DEMONSTRATORS ARE DRESSED IN BLACK AND ARE WEARING HOODS. THEY ARE PRIMARILY ___ AND ARE DEMONSTRATING THE RECENT ATTACK ON THE GOLDEN MOSQUE. THEY ARE ARMED WITH AK-___…"

In another incident elsewhere:

"___ INSURGENTS ARE PREPARING THEMSELVES FOR AN ENCOUNTER WITH ___ MILITIA IN //:___//. THE ___ INSURGENTS BELIEVE ___ MILITIA FROM BALAD //:___// AND BAGHDAD ARE HEADING TOWARDS ___ TO ENGAGE ___ IN RETALIATION FOR THE BOMBING OF THE GOLDEN MOSQUE //:___// IN ___. THE ___ INSURGENTS FROM AREAS NEAR ___ ARE EQUIPPING THEMSELVES AND HEADING TOWARDS THE ___ TO ENTER ___, NFI…"

The reports persisted, enough that the military seems to have given them a distinct heading, "Golden Mosque."

One of the WikiLeaks log entries, for 3:30 p.m. on the day of the mosque bombing, shows apparent Mahdi Army fighters posing as Iraqi Interior Ministry officials to take away Sunni prisoners from a police jail. "PRISONERS ARE NOW DEAD," the report noted:

AT 222335C FEB ___, IT WAS CONFIRMED BY PJOC THAT ___ PRISONERS HAD BEEN TAKEN FROM ___ POLICE STATION. AT ___, PJOC REPORTED THAT ___ ARRIVED AT ___ IN VEHICLES. THEY CLAIMED TO BE MEMBERS OF THE MINISTRY OF INTERIOR AND SECURED ___ PRISONERS RELEASE, BY THE USE OF FALSE MOI DOCUMENTS. ALL PRISONERS WERE HELD IN CELL ___. PJOC HAVE SENT THROUGH THE NAMES OF THE PRISONERS AND RECORDS THOSE WHO ARE PREVIOUSLY KNOWN TO MNF. PRISONERS ARE NOW DEAD AND ___ PRISONERS CRITICALLY INJURED. ___ DEAD AND ___ CASUALTIES FOUND BETWEEN GREEN ___ GREEN ___ AND ___ DEAD AND ___ CASUALTIES FOUND BETWEEN BLUE ___ AND RED ___. ALL PRISONERS ARE OF ___ RELIGION. IPS ARE CHECKING WHO IS DEAD AND WHO IS IN HOSPITAL. THE PERSONNEL THAT TOOK THE PRISONERS FROM ___ HAD MOI IDENTIFICATION. ‘'

In the streets of Iraq's capital, open fighting erupted between Shiite fighters -- known as the Mahdi Army, or Jaish al-Mahdi (JAM) --and Sunni men of the Sunni Iraqi Islamic Party:

"AT 221410CFEB06 THERE WAS A ___ BETWEEN JAM AND THE IIP (IRAQI ___ PARTY) AT BLUE ___. TSU HAVE BEEN TASKED TO THE SCENE. THE IIP BUILDING CAUGHT ON FIRE."

Soon, troops were reporting bodies in the streets of Baghdad. Without necessarily seeking them out, U.S. troops were coming across dozens of them. Half pages and full pages of such finds made their way into the logs, in numbing repetition:

# UNK 2006-02-24 18:00:00

MURDER, MND-BAGHDAD, 2 CASUALTIES

IP LOCATED 2X UNK MALE CORPSES IN THE ___ AREA OF BAGHDAD. VICTIMS WERE SHOT IN THE ___. REMAINS TAKEN TO FORENSIC MEDICINE DEPARTMENT.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-SE, 1 CASUALTIES

--

UNK # AIF OPERATING 2X ___ CAB PICKUPS KIDNAPPED ___ (SELF-EMPLOYED). HIS BODY WAS LATER FOUND SHOT (UNK LOCATION). REMAINS SENT TO LOCAL MORGUE.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-SE, 1 CASUALTIES

--

5X AIF WEARING BLACK UNIFORMS AND OPERATING A ___ CAB WHITE ___ KIDNAPPED ___ IN THE ___ AREA OF ___ BASRAH. . '___ BODY WAS FOUND SHOT IN THE ___ 0730C FEB ___. REMAINS TAKEN TO LOCAL MORGUE.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-SE, 1 CASUALTIES

1X MALE BODY ( , ___) FOUND IN THE ___ AREA OF BASRAH. VICTIM WAS SHOT IN THE ___ BY UNK MEN WEARING BLACK UNIFORMS AND OPERATING A ___ PICKUP. REMAINS SENT TO LOCAL MORGUE.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-C, 2 CASUALTIES

A CITIZENS REPORTS THAT THERE ARE MULTIPLE BODIES IN THE ___ VILLAGE NEAR THE ___.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-BAGHDAD, 2 CASUALTIES

2X UNIDENTIFIED MALE BODIES WERE FOUND SHOT. THEY WERE APPROXIMATELY -___ YEARS OLD.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-BAGHDAD, 1 CASUALTIES

--

1X UNK MALE CORPSE (APPROX. /___) FOUND SHOT IN THE ___ NEAR A GAS STATION IN THE ___ AREA OF ___. BODY TAKEN TO ___ HOSPITAL. NO NAME REPORTED.…

--

# UNK 2006-02-24 18:00:00

MURDER, MND-BAGHDAD, 1 CASUALTIES

1X UNK MALE CORPSE FOUND IN ___. VICTIM WAS SHOT IN THE ___. REMAINS TAKEN TO THE LOCAL MORGUE. NO NAME REPORTED.…

--

# UNK 2006-02-24 18:00:00

MURDER, 0, 2 CASUALTIES

2X BODIES WERE FOUND IN DIYALA PROVINCE BY MNF. THEY WERE TAKEN TO THE LOCAL IPS IN THE AREA. BOTH WERE EMPLOYEES OF THE ELECTRIC DEPARTMENT OF ___. THEIR NAMES ARE ___ AND ___.…

On Feb. 23, the day after the mosque bombing, a log entry notes soldiers finding a mass grave with 47 bodies at Baghdad.

But many of those bodies wound up in the Baghdad morgue, which was administered by the Health Ministry. The Health Ministry was run by Sadr's own Shiite party, which had political, religious, and military (read: death squad) wings.

In the days after the Samarra bombing, my colleagues and I at the Washington Post made repeated trips to the morgue. I first stopped at the ministry's office at the morgue, where officials there told me the death toll was minimal.

We then went around to the part of the building where the bodies were kept. Families, mostly Sunni, thronged the morgue, desperately searching for brothers, fathers, and sons taken away by militias. The computer registrar told the families to be patient. The morgue had taken in more than 1,000 bodies since the mosque bombing, he said. It was behind on processing them.

A U.N. official also gave me the figure of more than 1,000 dead. An Iraqi government official gave the same figure to one of our Iraqi reporters. Based on that number, our trips to the morgue, our trips Feb. 22 to see the massing Shiite militias in Sadr City, interviews with Sunni families who had had relatives kidnapped, and other reporting, I wrote that sectarian violence had exploded in Baghdad, with more than 1,300 killed. Colleagues wrote similar stories, but citing the lower official death toll of 300-plus, given by the Shiite-led government and the Sadr-run Health Ministry.

In Baghdad, Casey immediately denied the reports -- particularly my death toll in the 1,300 range. A U.S. military release issued March 19, 2006 described Casey going out on a three-hour drive around Baghdad to investigate the reports of mayhem himself. The U.S. commander recounted "a lot of bustle, a lot of economic activity. Store fronts crowded, goods stacked up on the street.'' He didn't mention his troops finding handcuffed bodies.

In fact, the troop logs, in their stunning detail and volume, make it clear we were underreporting the extent of the killing in Baghdad. And all the killing, the logs show, took place amid hourly bomb attacks on Iraqi and U.S. forces, amid daily "escalation of force" and "defense" shootings in which U.S. troops were firing on Iraqis. Iraq appeared far, far messier in the troop logs than in the weekly briefings in the Green Zone.

Asked through an aide Monday about the documenting of the violence shown in the WikiLeaks reports, Casey, now the Army chief of staff, declined comment. Rumsfeld did not immediately respond to a request for comment. An aide acknowledged receiving it.

At the Pentagon, Defense Department spokesman Col. Dave Lapan said in an email that the military would have used tactical reports such as the ones shown in the WikiLeaks logs to brief Casey and other higher-ups. "The reports themselves generally wouldn't get to GEN Casey (or above)," Lapan wrote.

"I would caution against drawing Iraq-wide or even regional conclusions from the snapshots in these reports," Lapan wrote.

As the Sunni-Shiite war raged on in the months after the mosque bombing, Casey, Rumsfeld, and other officials eventually found fewer buyers for their claims that Iraq was going well. Abruptly, the public mood turned.

The higher death tolls during the aftermath of the Samarra bombing seem now to have won official acceptance. Last fall, a former Bush administration official said matter-of-factly in a seminar I attended that violence in the aftermath of the Samarra bombing had killed more than 1,000 people in a single day.

On Monday, Lapan, the Pentagon spokesman, sent along a military report with a graph showing civilian deaths from violence in Iraq topping 2,500 in February 2006, sourced to "coalition and Iraqi forces." Furiously denied at the time, Iraq's bloody sectarian civil war was already making its way into the history books.

Mark Wilson/GETTY IMAGES