Haiti's two most prominent health care organizations are preparing a new assault on the country's deadly cholera epidemic: the dispatch of hundreds of workers to remote villages and gritty alleys in the capital to administer a vaccine against the raging disease.
But the pilot project, which has not yet secured the $870,000 it is estimated to cost, has set off a debate among some public health experts who question the wisdom of a program that will inoculate only 1 percent of the population and could deplete the world's stock of available cholera vaccine, potentially putting people at risk in other vulnerable places.
Experts also wonder whether it will even be possible to successfully administer a vaccine that must be given in two dosages two weeks apart. They contend the money is best spent cleaning up the waterways that have allowed cholera to flourish in Haiti.
"Everybody thinks it's going to do some good," said Richard Garfield, a professor of public health and nursing at Columbia University. "But it's hard to specify how much good and benefit will come out of that ... There are bigger-bang-for-the-buck activities out there."
Partners in Health, based in Boston, Massachusetts, and the Gheskio Center, a health nonprofit that has historically focused on AIDS, are joining in the vaccine campaign, hoping it will save lives.
Partners in Health co-founder, Dr. Paul Farmer, became an early advocate of the vaccine. A Harvard professor and special U.N. envoy, his opinion carries weight in Haiti, where he has been working to improve public health for more than 20 years. He's adamant that the vaccinations should be done for Haiti's poor regardless of the cost.
"It's been a joke to focus on how much it costs," Farmer said by telephone. "The Haitian cholera epidemic is the largest in the world."
Doctors Without Borders estimates it would cost up to $40 million to inoculate the entire country and points out that the immunity from the vaccine begins to wear off within three years.
"Money spent on vaccines should not come at the expense of money spent on permanent water and sanitation measures," Dr. David Olson, a medical adviser for Doctors Without Borders, wrote in an October press release.
The proposal for a vaccine campaign in Haiti surfaced soon after the disease emerged in October 2010, when U.N. peacekeepers from Nepal apparently triggered the contagion through an inadequate sanitation system installed near the country's largest river, the Artibonite, according to several studies.
The studies were cited as evidence in a claim announced Tuesday by the Boston-based Institute for Justice and Democracy in Haiti, which argues that the world body is responsible for the epidemic and should compensate more than 5,000 cholera victims.
Cholera, spread by water and contact with other people who have the disease, has sickened nearly 500,000 and killed more than 6,500, according to Haiti's Health Ministry. The disease causes rapid dehydration that can kill someone within hours but is easily treatable. In the first weeks of the outbreak, assistance poured into the country from Doctors Without Borders, Oxfam, Partners in Health, as well as many smaller groups.
Following the outbreak, public health experts discussed the possibility of introducing an oral vaccine but the administration of former President Rene Preval didn't want it unless the entire country of 10 million could be treated. The more pressing need was to combat a mortality rate that went as high as 5 percent. Dehydrated Haitians were dropping dead in the streets and hills as health workers scrambled to hydrate survivors in makeshift treatment centers.
At the time, there was only one vaccine available _ Dukoral, which is manufactured by the Dutch biopharmaceutical company Crucell N.V. The global supply was limited to about 250,000 doses. The vaccine, sold at $6 a dose, is used mostly by affluent travelers rather than people in cholera-infected countries.
In recent months, the vaccine option has grown more viable for several reasons. For one, the World Health Organization in September approved the use of a second vaccine, Shanchol, which is made by the French pharmaceutical company Sanofi Pasteur. The approval was needed so U.N. agencies like Unicef could procure the vaccine.
Plus, Haiti's new leaders, President Michel Martelly and his prime minister, Dr. Garry Conille, support the campaign.
In January, health workers will fan out in the Central Plateau and the capital, urging people to seek vaccinations and then documenting those who do. They aim to reach 80 percent of their targeted population living in those areas.
The project includes 200,000 doses of the vaccine currently available, its delivery to Haiti, health workers' salaries, and construction of a refrigerated facility to store Shanchol, according to Partners in Health. Each dose costs less than Dukoral, at $1.85, and altogether the cost will run about $870,000.
Peter Graaff, the Haiti representative of the World Health Organization, acknowledged complications associated with the program.
"Cholera vaccination is not the easiest form of vaccination," Graaff said in his Port-au-Prince office, pointing out the need for a second dose and refrigeration for the vaccine and the limited vaccine supply worldwide. "It's obviously one of a number of preventative measures."
Jon Weigel, a researcher for Farmer, counters the concerns of a follow-up dose by pointing to a successful vaccination program Partners in Health launched just before the January 2010 earthquake. Health workers sought to inoculate 3,000 girls with the Gardasil vaccine for human papillomavirus, the main cause of cervical cancer.
The distribution was relatively more complicated. It required three doses over a period of six months. Plus, chaos from the earthquake threatened to disrupt delivery of the final dose. The completion rate: 75 percent.
Coming up with the money shouldn't be an issue. Partners in Health is negotiating with donors though it would not identify them. The health care nonprofit is among the top recipients of aid in Haiti, and last year brought in $151 million for its work in 12 countries, according to tax returns filed with the U.S. Internal Revenue Service.
Weigel stressed efforts to develop Haiti's water and sewer systems, or to promote good hygiene, won't be ignored.
"We're not doing this at the exclusion of water and sanitation," said Weigel. "We really think that it's faulty logic to think that it's one or the other."
Farmer acknowledges the global shortage but believes the epidemic will spur pharmaceutical companies to increase supply.
"This is an oral vaccine that was designed to be used in poor countries," Farmer said. "This is the lowest-hanging fruit."
Still, Garfield and others say that the project poses some tough ethical dilemmas.
"It's not clear who gets in the life boat and who doesn't," he said.