It has been just over one year since cholera emerged in Haiti, the first time in perhaps 100 years. Since then, it has wreaked havoc within the country, whose water and sanitation infrastructure was already poor before the earthquake, while the displacement of upwards of a million people after the earthquake undoubtedly contributed to its rapid spread and impact. To date, the Ministere de la Sante Publique et de la Population (MSPP) – the Haitian ministry of health – reports that there have been a cumulative total of 473, 649 cases of cholera since the beginning of the epidemic, with 6,631 deaths, and a current average of 500 new cases a day. In short: this is the largest cholera outbreak in the world, and it’s not over.

Controversy has framed much of the health and humanitarian response to the earthquake and cholera outbreaks. Understandably so. Following the earthquake there was a massive outpouring of international aid – some of it well-implemented, a lot of it not so much.

More recently, controversy around the provision of a cholera vaccine in Haiti has emerged – notably, the tension between the provision of the vaccine as opposed to spending the money on improvements to water and sanitation. This is certainly a valid point. As MSF‘s David Olson said recently: “Money spent on vaccines should not come at the expense of money spent on permanent water and sanitation measures.”

Two cholera vaccines currently exist on the market – Dukoral (manufactured by a Dutch company – Crucell N.V.) and a more recently-approved vaccine called Shanchol (manufactured by Shanta Biotechnics – a subsidiary of Sanofi). Dukoral costs around $6 a dose, while Shanchol is about $1.85. It should be noted that both are effective, and a recent study in PLoS Neglected Tropical Diseases demonstrated good efficacy data for Shanchol in a large RCT.

Rolling out vaccination to all of Haiti’s population is not just difficult, it’s probably currently logistically impossible. There are simply just not that many doses of these vaccines available. Both vaccines are oral vaccines, which require a small, yet significant, amount of preparation in order to distribute (a reliable cold chain, some water, a buffer solution for Dukoral, etc.). Furthermore, both require 2 doses, spaced apart by several days. You could safely estimate that to vaccinate everyone in Haiti would require 20 million doses – there are currently far fewer than that available.

The current proposal for vaccination in Haiti will see one section of the population vaccinated as a trial, with the ultimate goal of vaccinating the entire population. Partners in Health, one of the lead agencies taking on this role thinks universal coverage can and should be done. Step 1 is to purchase 200,000 doses in order to vaccinate 100,000 people in certain high-risk areas or populations.

The controversy stems around exactly this: Only some people are getting vaccinated, while large segments of the population continue to have poor access to clean drinking water and adequate sanitation. Anyone working in public or population health will tell you that you have to address the determinants of health, like housing and sanitation, as well as provide essential medical/clinical care. As the Commission on the Social Determinants of Health so eloquently states: “…water-borne diseases are not caused by lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all…”

Moving forward, it is clear that a balanced approach continues to be needed. One that adopts universal principles for everyone in Haiti, and moves toward active case finding and aggressive treatment, reliable and safe water and sanitation systems, and greater preventative measures at the community level, including surveillance, education and community mobilization. There are no magic bullets – cholera is no exception.