The Cholera Quandary
November 19, 2010
Cholera, an infection that ravaged populations in the 19th century, is still a problem for the world's poor, and is currently menacing countries on three different continents. What is needed to control cholera is not just clean water, but the will, transparency, and resources to do so.
Cholera is usually seen as one of the most devastating infections of the 19th century. Trade carried cholera from India to the great cities of Europe and the United States. Disease, fear, and political unrest spread in great waves that cost millions of lives. After much destruction, it was only with science and resources that certain populations were able to curb the epidemic.
Then, it was not clear that cholera is a waterborne bacterial infection causing severe diarrhea and vomiting, leading quickly to sometimes fatal dehydration. One of the most celebrated lessons in the history of public health involves a cholera outbreak in London in 1854 and efforts by John Snow - celebrated as the father of epidemiology - to control it. He was able to prove the outbreaks decimating communities spread from contaminated water. By the early 1900s, appropriate water and sanitation services had virtually eliminated cholera epidemics in the developed world.
Yet, cholera continues to be endemic in many countries, and risks seem to be rising as larger populations are crowded into unsanitary conditions. The World Health Organization (WHO) estimates cholera still causes 3-5 million illnesses and 100,000-200,000 deaths each year. Cholera is easily preventable with clean water and sanitation. If caught early, infections are treatable with inexpensive oral rehydration solutions. For much of the world, these options are unavailable or underused - the mere presence of cholera serves as an indicator of a country's socioeconomic status and health system capabilities.
Cholera continues to plague the world's poor, and is currently menacing countries on three different continents - Asia, Africa, and North America - raising tough questions about what is required to protect the world's vulnerable populations. We know how to predict the crisis of cholera, how to prevent outbreaks, and how to contain them when they occur. What is needed to control cholera is not cutting-edge technologies, but will, transparency, and resources - and where cholera appears, at least one of these three factors has failed.
Currently, cholera outbreaks in Pakistan, Haiti, and Nigeria are piling misery upon misery. Cholera in post-flood Pakistan comes as no surprise. When floodwaters left millions homeless and without access to clean drinking water in a region where cholera remains endemic, health officials might assume infected human waste would seep into water supplies and spread disease. What is apparent here is a lack of will and resources. Disease surveillance is especially vital in a post-disaster scenario where steps can be taken, such as treating water with chlorine, to prevent an outbreak. The inability of health networks on the ground to prevent and then detect cholera demonstrates cracks in the country's health system.
Haiti had been free of cholera for at least 50 years. Ten months after the devastating January 2010 earthquake, the disease struck and is spreading rapidly, having already reached Haiti's capital and its neighbor, the Dominican Republic. In recent weeks, over 11,000 people have become ill and at least 1,000 have died. Haiti lacked resources for basic infrastructure even prior to the earthquake; the cholera crisis is not only costing lives, but also diverting aid from "building back better." Regardless of the source of the cholera strain, if basic infrastructure and the resources to protect Haiti's vulnerable populations had been in place, cholera's re-emergence would have been far less devastating.
This particular outbreak draws attention to the practical and political challenges of identifying health risks in humanitarian workers and peacekeepers, many of whom come from developing countries themselves. Evidence suggests that peacekeepers from Nepal housed at a UN base may have been the source of the outbreak clustered around the Artibonite River. Cholera outbreaks frequently exacerbate frictions between communities and aid workers - suspicions that have led to riots and murder more than once in recent years. At least two people have been killed in Haiti in riots with peacekeepers during the past week. The decision by the UN to refrain from investigating whether the outbreak originated with peacekeepers may conserve resources for the race to stave off more cases, but does nothing to build trust between communities and foreign workers.
Nigeria, meanwhile, is experiencing its worst cholera outbreak since 1991, and the disease is crossing borders. An onslaught of cases raised the 2010 death toll so far to over 1,500 out of 40,000 cases - a mortality rate three times higher than the seasonal cholera outbreaks of 2009 and seven times higher than 2008. Despite Nigeria's oil wealth, most of the population is impoverished. According to the Nigerian Health Ministry, two-thirds of rural Nigerians lack access to safe drinking water, and fewer than 40 percent of people in cholera-affected areas have access to toilet facilities. A combined lack of will, transparency, and resources mean that cholera epidemics occur annually in clusters throughout sub-Saharan Africa.
A century and a half after John Snow's discovery, we know how to control cholera. Globally, the resources exist. The question remains, do we have the collective will? For those who lack clean water to drink and wash and even proper toilets, the "know-do" gap is not easily closed. The international community has shown repeatedly that it can confront cholera outbreaks like those in Haiti, Pakistan, and Nigeria in the midst of crisis - yet the question remains of how can those efforts carry into eliminating the conditions that fostered outbreaks in the first place? The answer is not as riveting as causes that often receive funding; the answer is basic infrastructure and resources. Roads, wells, clean water, toilets, education, and the willingness to recognize that if the foundation is not sound, nothing will be able to stand. Sometimes the simplest problems are the most difficult to solve.
Photo Credit: U.S. Army Sgt. Kornelia Rachwal gives a young Pakistani girl a drink of water as they are airlifted from Muzaffarabad to Islamabad, Pakistan. October 2005. (Tech. Sgt. Mike Buytas, U.S. Air Force).