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.
By Sarah Kornblet – 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.
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
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,
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
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
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).