Epidemiologist Knighted In The French Legion Of Honor For His Work
On Cholera In Haiti
announced earlier this month that epidemiologist Renaud Piarroux has
been selected for the Legion of Honor, the highest French order of
merit for military and civil achievements.
Since this is a rare honor for members of the profession, we sought to
learn more about what Piarroux did to earn the award and how he came
to be nominated.
get this information, we called on former UCLA epidemiologist Ralph
Frerichs who has had a longstanding interest in John Snow’s work
on cholera in London and in Piarroux’s work on cholera in Haiti. He is
the well-known creator of a website about
Snow and has more recently authored a book entitled “Deadly River”
cholera into Haiti in 2010.
Following is Frerich’s account of Piarroux’s work which
earned him the Legion of Honor and an update on the recent progress
being made to eradicate cholera from Haiti after a long delay in
mounting aggressive control efforts. Another story worth telling.
French Epidemiologist And Cholera Elimination in Haiti
By Ralph Frerich
When cholera first appeared in Haiti in October 2010,
there was scant interest in CDC or PAHO in investigating how this
never-before-seen disease had made its entrance. Instead, the two
international institutions were dealing with treatment and care,
assisting the overwhelmed Haitian society in addressing the epidemic.
Wanting immediate answers, the Haitian government, with the help of
the French embassy in Port-au-Prince, reached out to Marseille-based
epidemiologist Renaud Piarroux. A short while later, his
three-week investigation began.
Included in his findings was that cholera was brought
to Haiti by United Nations peacekeepers from Nepal, starting an
epidemic via a sewage spill into the great river serving Haiti’s
breadbasket. It then quickly spread throughout the country. Given the
image and power of the United Nations, the apparent indifference of
the United States, the counter theories of other scientists, and even
a critique in The Lancet Infectious Diseases (1), Piarroux’s
findings of UN involvement in the origin were not immediately believed
But after six years of additional field research, including
development of a rapid response elimination strategy, Piarroux learned
in April 2017 that he had been nominated for the highest civilian
award offered in France, Au grade de chevalier
in the Ordre national de la Légion d'honneur, or knighthood in
the National Order of the Legion of Honor.
Since its beginning, the Haiti epidemic has officially
tallied 806,000 cholera cases and 9,500 deaths, the largest on-going
cholera epidemic in the world. Moreover, the United Nations has been
severely criticized by legal and human rights groups for refusing a
full apology and legal accountability for bringing cholera to Haiti.
How did Piarroux’s knighthood honor happen? In late
2016, Bernard Meunier, President of the French Academy of
Sciences, read Deadly River: Cholera and Cover-up in
Post-Earthquake Haiti (Cornell University Press, 2016). The book
told of Piarroux’s discoveries and actions, written in close
collaboration with the Frenchman, providing an insider’s view of the
workings and thoughts of a medical epidemiologist, more public health
professional and scientist than politician. Meunier contacted me in
November 2016, thanking me for writing the “well-documented book,” and
“truth is coming
slowly while complex organizations are fighting for their own
survival, rather than tending to their duties.” Meunier learned more
of Piarroux’s 30-year career and on-going efforts and achievements in
Haiti via research articles and the book epilogue at
www.deadlyriver.com. In the coming months he submitted Piarroux’s
name as a candidate for knighthood in the Legion of Honor, formally
accepted and officially posted on April 14, 2017 (2).
As noted in Deadly River, when cholera in Haiti
began, Piarroux was the department chief of the laboratory of
parasitology and medical mycology at academic Hôpital de la Timone
in Marseille, France, as well as a professor at the medical school of
Université d’Aix-Marseille. Through his service on humanitarian
missions in Afghanistan, Comoros, Honduras, Ivory Coast, and the
Democratic Republic of the Congo, and his PhD studies in microbiology
and tropical medicine, Piarroux had developed an interest in and a
deep understanding of how cholera spreads through regions and
communities—and of how epidemics can be controlled and even
eliminated. In 1999, the Médecins du Monde team he was leading
actually eliminated cholera from Grande Comore, the largest island in
the Comoros nation off Africa’s east coast. But it was the African
country of Madagascar, an island nation similar in many ways to Haiti,
which offered the best example of a cholera elimination strategy.
Cholera had come to Madagascar in 1999 after decades of
absence. The disease plagued the country for three years and was then
eliminated. Early on, local health efforts had resorted to several
control efforts, including a reporting system to identify suspicious
cases and deaths, immediate treatment (including intravenous
rehydration), public education, and disinfection of houses. Mass
immunization was never part of the weaponry. Piarroux and his Haitian
team reasoned the pathogenic form of Vibrio cholerae would not
become rooted in the Haitian environment independent of human
amplification, and that with the quick treatment of existing cases, a
rapid response approach similar to that in Madagascar could be
effective in Haiti. They developed the method which featured rapid
case finding and treatment using a map-based surveillance system, and
treatment, education and water purification tablets issued to those
living in surrounding households to interrupt further spread.
Following local turmoil and management problems, the
rapid response elimination effort in Haiti slowed for a while but then
gathered steam following Hurricane Matthew in October 2016. UNICEF had
become a major supporter of the effort, yet as documented in a recent
report (3), the number of rapid response teams throughout the nation
in early 2016 had dwindled to 32. They increased the number to 47 just
prior to Hurricane Matthew, when cholera had again exploded in the
southwestern region of the country.
In the weeks that followed, 41 additional rapid
response teams were mobilized, bringing the national number to 88. The
epidemic peaked at over 1,400 suspected cholera cases per week
immediately after the hurricane but then dramatically declined, aided
a few weeks later by a limited one-dose (of a two-dose vaccine)
immunization program in the hardest hit area.
the end of the sixth week in 2017, the number of weekly cases had been
reduced to nearly 200 and according to government statistics, there
were only a handful of deaths.4
The collaborative elimination effort of Piarroux and his Haitian
colleagues continues. But like John Snow in the mid-1800s, it appears
that they have found their pump handle, hopefully leading to the end
of Haiti’s epidemic.
Lancet Infectious Diseases. Editorial, “As Cholera Returns to Haiti,
Blame is Unhelpful.”
Vol. 10, no. 12 (2010): 813.
Légion d’honneur, Le Figaro, April 17, 2017.
UNICEF, Haiti Humanitarian Situation Report, 2017-02, March 7, 2017.
Ministere Sante Publique et de La Population (MSPP), Direction
d’Epidémiologie de Laboratoire et de Recherches (DELR). Rapport du
Réseau National de Surveillance, Sites Choléra. 6ème
Semaine Epidémiologique, 2017.