Haiti may thankfully be spared the heavy impact of Tropical Storm Emily, as the storm seems to have weakened as it hit Hispaniola’s mountains. Health workers and others have been tracking the storm’s progress with trepidation, as it was heavy rains in June that led to a resurgence in cholera cases. Unfortunately, even a weakened storm may still bring strong rains, and more cholera. The PBS Newshour's Talea Miller reported yesterday:

A tropical storm bearing down on Haiti threatens to make daily life more miserable for tens of thousands homeless still living in tent camps and could deepen the cholera epidemic that has already killed more than 5,800.

Tropical Storm Emily was on a path toward the Dominican Republic and Haiti Wednesday, and forecasts predicted heavy rains and possible flooding -- perfect conditions for the spread of water-borne diseases like cholera.

"[The weather service] is talking about possibly 10 inches in Haiti. That's a huge amount of water," said Julie Sell, spokesperson for the Haiti mission at the American Red Cross. "In a country where people are frequently using the same water sources to bathe, [such as] as a toilet, and to drink, the last thing you want is standing water."

But missing from the report was any mention of the role the U.S. government played in undermining Haiti’s provision of potable water. As described in great detail elsewhere, the U.S. government, under the Bush administration, directed the Inter-American Development Bank, in a highly unusual move, to withhold loans to the Aristide government that would have provided hundreds of millions of dollars for a potable water project, among other purposes. The Aristide administration was even forced to pay interest on the loans, despite their non-disbursal (in other words, the “loans” actually took money from Haiti while offering nothing in return).

Haiti’s relative lack of sanitary water was the principle reason that so many health workers feared the consequences were a water-borne disease such as cholera to emerge. As Partners in Health’s Joia Mukherjee explains in a new interview with Caribbean Journal, the after-effects of the earthquake, combined with heavy rains, made the cholera outbreak much more devastating:

the cholera epidemic …started in St Marc, and that was the site for a lot of displaced people. But they were tented refugees, not in camps. The majority of displaced people, or a huge number, were staying with already very poor relatives in very overwhelmed situations with very poor sanitation. I think that’s one of the many reasons we saw the cholera epidemic in that region — that the system of clean water was woefully inadequate already, and then was put under an enormous amount of stress by the number of people.

That, coupled with the drastic decline in NGOs providing cholera treatment (as we’ve previously noted) over the past six months (from 128 in January [PDF], to 48 as of July 25 [PDF], according to the Health Cluster) meant that the large number of cholera cases (over 300,000 so far) was entirely predictable. As the American Red Cross’ Julie Sell explains in the PBS report: “There are some aid organizations that have had to pull out of Haiti or dramatically reduce their activities due to lack of funding. That's been a concern for the Haitians.”

In her Caribbean Journal interview, Mukherjee outlines what PIH sees as an effective roadmap for bringing cholera under control and reducing mortality as much as possible:

We feel very strongly that one priority is absolutely developing municipal water and sanitation in Haiti. That has to be a key part of Haiti’s reconstruction. Two, we have to have health facilities that work, so we can treat people. Three, we have to really be paying, training and supervising an army of community helpers that can do an education in the community. And four, very importantly, we feel that the cholera vaccine has to be rolled out in Haiti, if we’re going to prevent tens of thousands of deaths. That last part is, oddly, somewhat controversial, because they don’t know what the strategy would be. In public health, as is often the case, the sense is that it’s too big, too expensive, too hard. We think nothing is harder than seeing an entire community devastated by cholera. Whatever it is that is hard, we can do that, because the alternative is huge, unnecessary death.