When it comes to granting interviews about the world’s worst ongoing cholera epidemic, the UN is in a tough spot. On one hand, desperate for funds, the organization needs all the publicity it can get. Fourteen months after it announced a $2.27 billion project to eradicate the waterborne disease in Haiti and the neighboring Dominican Republic with high-level fanfare, just $180 million has been disbursed. Badly needed water and sanitation infrastructure remain a pipe dream in Haiti, while doctors and other cholera responders are leaving the Caribbean country in droves.

But the UN is equally desperate to avoid questions when it comes to one sticky detail: the overwhelming evidence that the UN caused the epidemic in the first place. The organization’s main tactic has been to cover up its role; recent attempts to get comment on the record have yielded absurdities, obfuscation, and reporters chasing UN Secretary-General Ban Ki-moon down the hall. Now, having declined to internally review the claims, the UN is facing a U.S. federal lawsuit that could compel it to pay billions in restitution—another good reason not to talk.

The man caught in the middle is Pedro Medrano, the assistant UN secretary-general tapped last fall to coordinate the UN’s cholera response in Haiti. A Chilean-born official with decades of UN experience, primarily in food assistance in Latin America, Medrano is committed to ending an outbreak that has killed more than 8,500 in Haiti and hundreds more across the region (it has now spread to the mainland, with a sustained outbreak in Mexico). 

Frustrated by the lack of funding, and concerned about the future of a deadly outbreak, he sat down with me (via Skype) for an interview in which he addressed the disease, the struggling efforts to fight it, and the UN’s ultimate responsibility in ending the crisis. Here’s a transcript of our conversation, which I’ve edited for length and clarity:

Pedro Medrano Rojas, UN Senior Coordinator for the Cholera Response in Haiti: Hello, Jonathan. It’s a pleasure to meet you over Skype.

JK: Yes! I appreciate your taking the time to speak with me today.

PM: Well, I’ve read a lot about you. I read your book, your articles, so it’s important, I think, to have this discussion. I’m not sure if I’m able to answer all your questions though. [laughs] Well certainly you know Haiti much more than I do. I have been there many times. I think you know I was in charge of the World Food Programme [in Latin America and the Caribbean] in the past, so I was dealing with Haiti for the last six years. Every year we had a major emergency. After the earthquake I was there too.

JK: Right. So I should ask first—and I think you’ll be able to answer this—what is your role as cholera envoy and how did the position come to be created?

PM: The secretary general asked me to coordinate the response of the UN [to cholera] in Haiti. As you know, we have a kind of a silent emergency going there. It’s not in the news … There is donor fatigue. There is the issue of competing demands, with the international community facing many challenges in different parts of the world … So we have established, internally, a UN steering committee with the membership of all of the most important players. All of the UN principals are part of this … This is very much in line with the commitment we have to ensure that we stop the transmission, that we have less and less number of cases, and more importantly, fatalities.

“We are a reflection of what the international community wants us to do in Haiti,” Medrano says.

JK: And when did you begin the job?

PM: Four months ago, in September last year.

Since then I have been twice in Haiti. I have been with our partners there. I have met with our major partners in the NGO community, bilateral organizations: [the] World Bank, Inter-American Development Bank, USAID, [U.S. Centers for Disease Control and Prevention], medical doctors, medical corps, [International Federation of the Red Cross]. All the major actors on the ground. We are also working now with the government of Haiti to establish a high-level committee to address jointly the whole issue of the cholera response … as well as how we deal with the families affected and communities affected by cholera … We hope that we will be establishing this committee at the end of this month, beginning of next month.

JK: In your interview with Agence France-Presse in January, the reporter summarized your position as saying that “legal wrangling over the epidemic had to be put aside in order to tackle the sweeping advance of the disease.” Is that an accurate summary of your views, and if so what did you mean by it?

PM: I would like to stress this because I think it’s important: For the legal issue, we have a process and this will go its own way. In parallel to that—and I think what is important, it’s our major concern—is to deal with the cholera.

Now it is not because we want to forget about the legal issue. It’s not that we don’t want to deal with the legal issue, or that because of our response, or what we are trying to do … [or that] we want to have the legal issue away from us. No, I am just saying, we have two things here: I am not dealing with the legal issue; I am dealing with the response. We will have plenty of opportunities to continue to discuss the legal issue. But at this stage … when we have an epidemic like this, which is the largest in the whole hemisphere, we need to deal with the response. That’s the meaning of what I said.

JK: But the thing is, at every stage of the epidemic since October 2010, the UN’s media response—its response to questions about the cause of the epidemic—has been that there would be time to discuss it later, that we had to focus now on the epidemic. It’s now been more than three years. So are you saying that the time to discuss the UN’s responsibility in causing the cholera epidemic in Haiti has come, but an office different from yours is handling it? Or are you saying that time still hasn’t come? And if so, when will it?

PM: What I am saying is we have a legal issue, and it’s going parallel [to the response to the epidemic]. I am not dealing with the legal issue. I am dealing with the response. That’s it. In the past we had the claim—and you know the whole process—and we have now the legal case before the federal court. And it’s going its way. 

The only thing I said is … [that] I am dealing with the response: How can we make sure we get less cases, and a decrease in fatalities as soon as possible … I am more concerned with what is required now in terms of the medical response, water and sanitation, how can we accelerate progress, how can we play this situation role with our partners, how we engage better with the government, with the donor community. I am mindful that we have a legal case, we have to do [our work] in parallel deal with the legal issue. But it’s not what I’m doing.

JK: So if I wanted to ask someone at the UN questions about this, who would I direct my questions to? Who’s dealing with the legal case?

PM: It’s the under-secretary [general] for legal affairs, Miguel de Serpa. They are now dealing with the issue before the federal court in Manhattan.

JK: What is the status of the $2.27 billion cholera eradication project that the UN put its name on in December 2012?

PM: So, this is the national plan of the [Haitian] government. [Note: Several news agencies incorrectly reported at the time that the plan was a UN initiative; my colleague Tom Murphy and I clarified the issue here.

In the first two years the purpose—the objective—was to raise $450 million. … We [now] have, I think, $250 million—half of the resources we needed for the first three years. So we’re still raising resources for the first two years. [Note: After the interview, Medrano’s staff revised those numbers slightly, saying that $448 million was required for 2013 and 2014, of which $209 million, or 46 percent, has been mobilized.] 

I think that where we are concerned is two things: I think that when it comes to water and sanitation, you are aware this is key to eliminating cholera. It’s not just the medical parts. This, in my view, is very slow, particularly where it comes to the investment in the areas where we have a high prevalence of cholera. We are working now with the Inter-American Development Bank so as they can redirect their resources to those areas. But those are investments for infrastructure, and they take time. So we are asking if we can have intermediate types of interventions that can ensure access to safe drinking water and basic sanitation infrastructure—not necessarily to have to wait for 10 years to have the pipes and all the infrastructure, but to have in the meantime at least the investments to make sure that we have Aquatab purification tablets … et cetera, so things that can be used in a kind of intermediate way.

JK: But just so I’m clear, the figure that you gave—that was $250 million committed?

PM: Yes.

JK: Two-five-zero. And is that pledged or disbursed?

PM: Out of this, all is pledged and committed, except for $70 million from the Inter-American Bank that needs to disburse.

JK: So only $180 million has been disbursed and another $70 million has been “committed?”

PM: Yes. [Note: Medrano’s staff later said another $29.1 million has been pledged but not disbursed.]

JK: But when the plan was announced in 2012, [UN Secretary-General] Ban Ki-moon announced $215 million in bilateral donations. So basically, in a year and change, there’s only been an additional commitment of about—$35 million? Is that right?

PM: You are well aware that we have different sources of funding … It is easy for us when it comes to humanitarian [funding]. We are dealing more in an emergency mode. When it comes to more developmental type of things, this takes more time because we are thinking in terms of investments—meaning long-term investments. So in the meantime what we have are major programs of the World Bank to support, for example, the government of Haiti with the payment of salaries, [the] health system, and we have also the whole issue of surveillance—I think it was taken care of by UNICEF, [the Pan-American Health Organization], and CDC.

When it comes to the UN part, I think that we were not able to raise more than a third of the resources we needed last year. We acknowledge that … And we hope that we are going to get this money as soon as possible. That is my work. I am trying to get it.

[Note: Medrano’s staff adds, “The total amount required for 2014 is $40 million. To date, the only funding committed for the plan comes from the UN Central Emergency Response Fund for the amount of $6 million, which will not become available until March 2014. This is vastly insufficient to meet urgent needs.”]

JK: Clearly you guys are not meeting your funding targets for this program.

PM: That is correct.

JK: Why is it so difficult to raise money for this?

PM: [Sighs.] Two things. I think that we have the donor fatigue with Haiti. I think that the whole issue we have with the fiscal environment is not good, not here [in the United States], not in Canada, not in Europe. The resources are moving to other crises we have around the world, and every year you have more crises—you have the Philippines, you have South Sudan, you have Central African Republic….

More important, I think the fact—and I would like to stress this, I want to be very frank with this—the fact is, for many people [it seems like] this is not an emergency. Major donors think this is not an emergency anymore … This is one of the reasons why I am saying: This is a major epidemic in the Western Hemisphere. And it’s an emergency. We need to understand that it is not acceptable to have this. We are very active in meeting with Latin American groups for example to engage them more, because so far their response so far has been very limited except for Cuba and Brazil. The rest of the region needs to move to support this in a more, let’s say, forceful way ….

It is not the UN that will solve the problem of cholera in Haiti. We need to do it together.

JK: That said, there are a lot of people out there who say that because the evidence shows that the United Nations itself brought this disease to Haiti, where it had not existed before, that it is the UN’s responsibility to take the leading role in funding the response. Is it possible that part of the reason why other donors aren’t coming forward is because they think that it should be the UN’s responsibility to pay for the cleanup?

PM: Yes, but I think we need to clarify: First of all … The UN is not a company. We have the resources the international community would like to put at our disposal. The resources we have [are] a function of how much support we get from the member states … We allocate, we do a lot of fundraising, but I think what’s more important is to convince member states about the gravity of the situation.

But the UN is not—I mean, we don’t have the resources. Because these are voluntary contributions, we don’t have assessment provisions for this. It’s not that we have the budget to say here we have $10 million, $20 million. Even the money we have for the peacekeeping operations is for a specific purpose, and we cannot use it for humanitarian issues. In a way, we are a reflection of what the international community wants us to do in Haiti.

JK: I wonder if another issue is having an impact: You’ve got a lot of different agencies that have been more or less declaring victory over cholera in Haiti, pointing to the declining number of cases, etc. As you and I both know, it’s really not really true: In cholera epidemics, you tend to have a lot of deaths at the beginning and then the death rate falls, and then at some point the bacterium mutates and the death toll comes back up again. Do you think that’s part of why it’s been so difficult to get donors to appreciate this is an emergency—because they’re getting bad information that tells them the epidemic is under control when it very much is not?

PM: I agree with that … If major donors think it is not an emergency, then it is extremely difficult for us to raise resources … I agree we have made progress, but not—I don’t think it’s enough at all …

I am sure we can do it, to decrease the numbers if we have the resources. But I think we need to understand we have a major challenge here to convince people that it’s an emergency, that it’s unacceptable to have the high number of cases and fatalities in today’s world, and nobody should die because of this.

JK: Is there any way to eradicate cholera from Haiti without creating comprehensive water and sanitation infrastructure such as municipal sewer systems and waste treatment plants?

PM: I think we can use vaccines. We are now looking for vaccines to immunize 600,000 people. We hope to use them in the dry season [through early April] to vaccinate a large number of people.

JK: Which cholera vaccine are you talking about?

PM: Sanofi is the producer. The vaccine is Shanchol. It’s the same one that is used in South Asia and also some parts of Africa.

JK: And it’s effective against the strain that’s circulating in Nepal and Haiti?

PM: Yeah. It’s 60 percent to 70 percent effective.

JK: Where was the trial conducted?

PM: In Haiti! There, Partners in Health, they did [the study] with UNICEF and PAHO. There is literature on that. We vaccinated 100,000 cases, and there was a whole discussion based on the use of vaccine.

People say vaccine alone cannot solve the problem, so we have to use vaccine plus water, sanitation. I am saying, look, where do we have the threshold here? We want to have the pipes, we have to have the infrastructure—[but do] we have to wait for that or we have to do it in parallel? And I think we can do it in parallel.

JK: How much do you think the needed water and sanitation infrastructure that’s needed would cost?

PM: In total it’s about $1.6 billion.

I feel we have to use both [vaccine and infrastructure] … I think what we need to have is a combination of interventions in terms of preparedness for natural disaster, vaccine, distribution of aquatabs, etc. This can all go together … And at the same time we need to strengthen the health system, so, all this goes together.

There is not a silver bullet here.

JK: So what do you think the odds are that 10 years from now there’s going to be a comprehensive water and sanitation system in Haiti?

PM: I think this is our goal: To use this as an opportunity to rebuild infrastructure in this country: water, sanitation, and let’s make an effort to have, I mean, the coverage of as much as possible of the whole population.

JK: But do you think there’s going to be the money to do it in the next 10 years?

PM: Well, I want to be optimistic … To have a country [with] 80 percent of the population without access to basic sanitation—it’s unacceptable! I mean, in the last 10 years, Haiti went back in terms of coverage, in sanitation. [Note: Sanitation coverage in Haiti has declined since the 1990s, according to the Pan-American Health Organization. It is now estimated at about 17 percent.]

This was because the international community didn’t support Haiti in water and sanitation for different reasons, and plus we had the earthquake that destroyed the basic infrastructure they had. But even now I think we now we have today in Port-au-Prince a sewage disposal system that we didn’t have in the past. We must be aware of that, I suppose. This was not the case before the earthquake.

JK: One of the two new waste treatment plants built outside Port-au-Prince closed in early 2013 due to lack of funds. Has it reopened yet?

PM: Not yet. We hope that it will reopen. I think it will happen.

I [also] just visited the plant that is operating now. And it is still not full capacity.

JK: A cynic would look at this and say: What’s new about this? Donors weren’t investing in infrastructure in Haiti before, and they’re not investing in it now. The UN has put its name on this $2.27 billion plan, and so far only $250 million have been committed. It doesn’t seem like they need a new excuse. This is what they’ve been doing all along: not investing.

PM: Let me perhaps be more positive. First of all, I think everybody understands … the importance of water and sanitation—and latrines and all … What is really important is that we have here an opportunity …

In May, [I would like to have] a conference here in New York on water and sanitation. I would like to bring everyone around the table and to have a clear picture of what we would like to do with the government of Haiti. A clear picture in terms of what the country needs and to see—area by area, department by department—what is being done and where are the gaps. I would like to really mobilize the international community around this—and not only the UN, not only the financial institutions but also different types of partners: NGOs, bilateral, some foundations. I think that in today’s world to have a country with 80 percent of the population without coverage with the area of sanitation is unacceptable! …I want to be optimistic though. It is not because they have not done in the past, they are not going to do it now. And, by the way, I think it is in the interest of the whole Latin American region and the Caribbean region—and also of the United States.

JK: Well let me ask you about the United States—

PM: I hope you are not going to ask me to criticize the United States! [laughs]

JK: Well, there was a Center for International and Strategic Studies report on sanitation in Haiti last year. They were very critical of the U.S. government. They said it seemed there was not a focused response—there didn’t seem to be any overall strategy in the way the United States was dealing with the problem of cholera and sanitation in general in Haiti.

PM: I think we have to acknowledge the contribution [the U.S. is] doing in the area of [disease] surveillance, and CDC has played a very important role there. They have today a very good surveillance system in the country. I visited them in Haiti. USAID, the same—they are working through their [NGOs] and also their support of the [Haitian] government. I think the policy of the United States, particularly USAID, [is that] they don’t do cholera. They do health-related systems. We can look at this in a positive way if we stress the health-delivery system.

JK: What about the United Nations’ own facilities in Haiti? At the beginning of the epidemic, I was talking to a number of people at Turtle Bay about fixing the broken sanitation systems at the UN peacekeeping bases—especially the base in question that caused the epidemic. What’s happened with that?

PM: I think that we have certainly upgraded all the sanitation systems we have … This area is very much improved … not only in terms of how we are dealing with basic issues, for example disposal of waste and sewage. I think that what we are doing is upgrading, improving, all our sanitation facilities—not only in Haiti but worldwide. We are about to issue a report very soon of what we have done in this area in Haiti.

JK: And of course the base in question is now run by a different contingent entirely. The Uruguayans are there instead of the Nepalese.

PM: Yeah, the Nepalese are no longer there.

JK: But the Nepalese peacekeepers are still in Haiti. They’re just not at the base that caused the epidemic.

PM: That’s my understanding.

JK: So are peacekeepers now all trucking their waste to the new waste treatment plants? Are they still dumping it in sites right next to the bases but treating it differently? How have these been improved?

PM: It’s a completely different picture, Jonathan. Everything has improved. In terms of water, quality control, and disposal of waste, and septic tanks … everything we have done to improve the sanitation of the [UN military] camps, to the standards we feel that are required for this type of operations.

JK: So it seems like from looking at that, and again putting the legal question aside of what legal responsibility would imply, at this point the organization seems to be accepting the fact that the epidemic was caused by negligence on the part of the peacekeepers. And that seems to be the basis for a lot of these changes moving forward. Is that correct?

PM: Well, I think that I will put it in a different way. I think that we are learning from our—we are learning every day. We’re trying to improve every day. And I think that what we are doing is not because we are acknowledging—I don’t want to say that [it is] because we were negligent, or we have done in the past things that were not necessarily correct—I think we are doing it now. We are doing it! We are improving.

Because, you may recall, we have these recommendations from the independent panel. And we have committed to implementing those recommendations. We have committed ourselves … We are taking this very seriously. And I think that, we are doing—I would put it this way: We are always trying to learn how to do best our work. Let me know if I answered your question.

JK: Well, I mean, I understand that. But the thing that I’m trying to hone in on here is that, when you talk about things not having been done well in the past, is that an institutional acceptance that the United Nations caused the cholera epidemic in Haiti?

PM: No, it’s not because of that. I want, first of all, I would like to say—we have the recommendations of the panel. We have established a task force and we are looking at every single recommendation. Perhaps the mistake we have done was not to report entirely what we were doing, what we have done since the recommendations. And I think that is what we would like to do now, is just report what we have done.

But I don’t want to link this because we think we are guilty … This is a conclusion that I know that is there, I mean, and I don’t want to enter into that discussion. I don’t want to say that, because we feel that we are responsible for this, that we are doing everything different. No, we are doing it because we have to do it. Because we are learning from this type of thing. And I think that—and you have contributed to this by the way. [laughs] And you documented everything, and you wrote about it. And we listened! We are not here to say, well, everything we are doing is perfect. Mistakes can be made, and we can learn from those. But certainly it was never the intention of the United Nations to bring cholera in Haiti. 

Jonathan M. Katz is the author of The Big Truck That Went By: How The World Came to Save Haiti and Left Behind a Disaster. He was the Associated Press correspondent in Haiti from 2007 to 2011.

Cover graphic: Cumulative cholera cases in the region of the Americas as of epidemiological week (EW) 47 of 2013

Photo of Pedro Medrano Rojas: Pacific Health Summit Seattle, 2008/National Bureau of Asian Research