Gargantuan Issue Of The International Journal Of Marks The End Of Editorship By George In This Issue Davey Smith and Shah Ebrahim

Last Publication Dated December 2016 Includes Debate On -3- Approaches To Causality In Epidemiology Brief Interview With

The last issue of the International Journal the hard copy were actually published Stephen Leeder of Epidemiology co-edited by George in Advance Access online over a Davey Smith and Shah Ebrahim period of 15 months from January -4- appeared in print in late March 2017. 2016 to March 2017. Epidemiologists It is a gargantuan issue even by the on Trump standards of the IJE which had grown Final Issue enormously in size in recent years. Travel Ban The final issue contains more than 75 The much awaited issue contains a articles, letters, and other published special section on causality in -5- items spread out over 500 pages. epidemiology where many articles Epi News Briefs

Many of the articles which appear in - Causality cont'd on next page -6- NCS Notice

-10- Epidemiologist Knighted In The French Legion Of Honor For His Work On In Notes on People

French officials announced earlier this To get this information, we called on -12- month that epidemiologist Renaud former UCLA epidemiologist Ralph Piarroux has been selected for the Frerichs who has had a longstanding On the Light Side Legion of Honor, the highest French interest in John Snow’s work on More Haiku order of merit for military cholera in London and in Piarroux’s and civil achievements. Since this is a work on cholera in Haiti. He is the rare honor for members of the well-known creator of a website about -14- profession, we sought to learn more John Snow and has more recently Marketplace about what Piarroux did to earn the authored a book entitled “Deadly award and how he came to be River” about the introduction of

nominated. - Knighted continues on page 7

April 2017 • Volume Thirty Eight • Number Four

-Knighted continued from page 1 findings of UN involvement in the origin were not immediately believed cholera into Haiti in 2010. or supported.

Following is Frerich’s account of But after six years of additional field Piarroux’s work which earned him the research, including development of a Legion of Honor and an update on the rapid response elimination strategy, recent progress being made to Piarroux learned in April 2017 that he eradicate cholera from Haiti after a had been nominated for the highest long delay in mounting aggressive civilian award offered in , Au "...the Haiti control efforts. Another story worth grade de chevalier in the Ordre national telling. has de la Légion d'honneur, or knighthood officially tallied in the National Order of the Legion of Special Report: 806,000 cholera Honor. Knighted French Epidemiologist And cases and 9,500

Cholera Elimination in Haiti Since its beginning, the Haiti epidemic deaths..." By Ralph Frerich has officially tallied 806,000 cholera cases and 9,500 deaths, the largest on- When cholera first appeared in Haiti going cholera epidemic in the world. in October 2010, there was scant Moreover, the United Nations has interest in CDC or PAHO in been severely criticized by legal and investigating how this never-before- human rights groups for refusing a seen disease had made its entrance. full apology and legal accountability Instead, the two international for bringing cholera to Haiti. institutions were dealing with treatment and care, assisting the Nomination overwhelmed Haitian society in addressing the epidemic. Wanting How did Piarroux’s knighthood honor immediate answers, the Haitian happen? In late 2016, Bernard government, with the help of the Meunier, President of the French French embassy in Port-au-Prince, Academy of Sciences, read Deadly reached out to -based River: Cholera and Cover-up in Post- “...truth is coming epidemiologist Renaud Piarroux. A Earthquake Haiti (Cornell University slowly while short while later, his three-week Press, 2016). The book told of complex investigation began. Piarroux’s discoveries and actions, organizations are written in close collaboration with the fighting for their Included in his findings was that Frenchman, providing an insider’s own survival, cholera was brought to Haiti by view of the workings and thoughts of United Nations peacekeepers from rather than a medical epidemiologist, more public tending to their , starting an epidemic via a professional and than sewage spill into the great river politician. Meunier contacted me in duties.” serving Haiti’s breadbasket. It then November 2016, thanking me for quickly spread throughout the writing the “well-documented book,” country. Given the image and power and noted, “truth is coming slowly of the United Nations, the apparent while complex organizations are indifference of the United States, the fighting for their own survival, rather counter theories of other , than tending to their duties.” Meunier and even a critique in The Lancet Infectious Diseases (1), Piarroux’s - Knighted continues on next page 7

-Knighted continued from page 7 years and was then eliminated. Early

learned more of Piarroux’s 30-year on, local health efforts had resorted to

career and on-going efforts and several control efforts, including a reporting system to identify achievements in Haiti via research articles and the book epilogue at suspicious cases and deaths,

www.deadlyriver.com. In the coming immediate treatment (including months he submitted Piarroux’s name intravenous rehydration), public as a candidate for knighthood in the education, and disinfection of houses. “...Piarroux had Legion of Honor, formally accepted Mass immunization was never part of developed an and officially posted on April 14, 2017 the weaponry. Piarroux and his interest in and a (2). Haitian team reasoned the pathogenic form of Vibrio cholerae would not deep Background become rooted in the Haitian understanding of As noted in Deadly River, when cholera environment independent of human how cholera in Haiti began, Piarroux was the amplification, and that with the quick spreads through department chief of the laboratory of treatment of existing cases, a rapid regions and and medical at response approach similar to that in communities..." academic Hôpital de la Timone in Madagascar could be effective in Marseille, France, as well as a Haiti. They developed the method which featured rapid case finding and professor at the medical school of treatment using a map-based Université d’Aix-Marseille. Through his service on humanitarian missions in surveillance system, and treatment,

Afghanistan, , , education and water purification , and the Democratic tablets issued to those living in Republic of the Congo, and his PhD surrounding households to interrupt studies in and tropical further spread. medicine, Piarroux had developed an interest in and a deep understanding Intervention Implementation of how cholera spreads through Following local turmoil and regions and communities—and of how can be controlled and management problems, the rapid "...the Médecins even eliminated. In 1999, the Médecins response elimination effort in Haiti du Monde team du Monde team he was leading actually slowed for a while but then gathered he was leading eliminated cholera from Grande steam following Hurricane Matthew actually Comore, the largest island in the in October 2016. UNICEF had become eliminated Comoros nation off ’s east coast. a major supporter of the effort, yet as documented in a recent report (3), the cholera from But it was the African country of number of rapid response teams Grande Madagascar, an island nation similar in many ways to Haiti, which offered throughout the nation in early 2016 Comore..." the best example of a cholera had dwindled to 32. They increased elimination strategy. the number to 47 just prior to Hurricane Matthew, when cholera had Example again exploded in the southwestern region of the country. Cholera had come to Madagascar in 1999 after decades of absence. The In the weeks that followed, 41 disease plagued the country for three additional rapid response teams were

8 - Knighted cont'd on page 9

-Knighted continued from page 8

mobilized, bringing the national number to 88. The epidemic peaked at 1 Lancet Infectious Diseases. Editorial, over 1,400 suspected cholera cases per “As Cholera Returns to Haiti, Blame is week immediately after the hurricane Unhelpful.” but then dramatically declined, aided Vol. 10, no. 12 (2010): 813. a few weeks later by a limited one- 2 LeClerc J-M. Légion d’honneur, Le "...it appears that dose (of a two-dose vaccine) Figaro, April 17, 2017. they have found immunization program in the hardest 3 UNICEF, Haiti Humanitarian their pump

hit area. Situation Report, 2017-02, March 7, handle..." 2017. By the end of the sixth week in 2017, 4 Ministere Sante Publique et de La the number of weekly cases had been Population (MSPP), Direction reduced to nearly 200 and according d’Epidémiologie de Laboratoire et de to government statistics, there were Recherches (DELR). Rapport du only a handful of deaths.4 The Réseau National de Surveillance, Sites collaborative elimination effort of Choléra. 6ème Semaine Piarroux and his Haitian colleagues Epidémiologique, 2017. 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

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