In the time of cholera

 

 

F or nearly a decade, Rotarian Ron Haller has traveled to Zimbabwe to provide medical services, including immunizing children against polio. He has forged close relationships with other Rotarians and health officials there, and two years ago, he and Joe Fortier went to the town of Chinhoyi for the opening of a clinic that their Rotary Club of Orange, Calif., USA, helped establish.

Last fall, they got an urgent e-mail from Zimbabwe. “It was a plea for help,” says Haller, a former medical administrator, recalling the message from Chris Molam, past governor of District 9210, which covers four countries in southern Africa. “His e-mail said people were dying in the streets.” The killer was cholera, a bacterial illness capable of snuffing out lives in a matter of hours.

In the industrialized world, cholera lives mostly on the pages of history books – outbreaks were common in the United States and Europe in the 19th and early 20th centuries – but in the developing world, cholera still “ranks depressingly high” on the list of critical public health issues, says Karl Hofmann, president and CEO of Population Services International, a Washington, D.C.-based nonprofit that works to alleviate health problems in developing nations.

Cholera’s toll is vastly underestimated, the World Health Organization says. In 2007, 178,000 cases and 4,031 deaths were reported by governments, but WHO officials believe that in reality, millions were infected with Vibrio cholerae , the bacterium that causes cholera, and that 120,000 died.

“People want to cover it up. They don’t want to discuss it,” says Hofmann. Governments may fear that the stigma associated with the conditions that produce cholera outbreaks will damage opportunities for trade and tourism. “In the absence of good information, even with the best treatments that we have, often it’s hard to get a handle on an epidemic.”

Consuming water or food contaminated with the bacterium can cause diarrhea in a matter of hours. About 20 percent of infected people develop diarrhea so severe, they rapidly become dehydrated. Without prompt treatment – a simple rehydration solution of salt, sugar, and clean water or, in some cases, antibiotics – cholera can be fatal. “The thing that attracts attention to cholera is that it kills adults, and very few forms of diarrhea will do that,” says Rob Quick, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC).

Modern sanitation and water treatment systems keep cholera at bay, but a number of scenarios – natural disasters, civil wars, massive population migrations, overfilled refugee camps, or government failures – can allow a cholera outbreak to take hold among vulnerable populations who can’t easily obtain the simple but lifesaving treatment. Still, conditions need to be “pretty abysmal by today’s standards,” says Eric Mintz, leader of the CDC’s diarrheal diseases epidemiology team.

Consider the level of deterioration necessary for the disease to gain a foothold. In 2005, after Hurricane Katrina pummeled the U.S. Gulf Coast, public health experts were concerned about the potential for cholera outbreaks. The brackish floodwaters created an environment where the bacterium thrives – “It prefers places where rivers come close to the sea,” Mintz says – sanitation systems were disrupted, and people were displaced. Even so, the availability of resources such as hand sanitizers and bottled water thwarted cholera. “Things were bad, but they weren’t bad for long enough to have an outbreak,” notes Mintz.

High-risk breeding grounds for cholera often develop in areas where sanitation and water-treatment systems have been established but not well maintained. “The water either is not treated, or it’s treated but all of the chlorine residual is exhausted by the time it gets to the pump because of all the breaks in the pipes,” Mintz explains. “Or the sewage lines run on top of the water lines, and both have lots of holes – this is where epidemic cholera is right at home.”

In some regions, water is safe to drink but becomes contaminated through improper home storage. That was the case during a cholera epidemic in South America in the early 1990s. Quick enlisted the help of the Rotary Club of Estes Park, Colo., USA, in which his father, Robert, was a member. The Rotarians raised money to produce a mold that could be used to manufacture large, safe plastic water containers for households in Bolivia. The containers, when used with a disinfectant such as chlorine or bleach, protect stored household water from contaminants that cause cholera and other waterborne diseases. The system has been so effective that Population Services International promotes it in South America and Africa.

When cholera broke out in Zimbabwe in August of 2008, the organization began to distribute chlorine tablets for water treatment. Six months after the outbreak began, WHO reported that nearly 80,000 people had been infected and more than 3,700 had died. This epidemic will eventually spend itself, Mintz says, noting that survivors will acquire immunity for a time, but young children and infants in particular will still be vulnerable. “What worries me is the people who remain there may still be drinking water that’s unsafe and putting their lives at risk.”

Rebecca Voelker is a Chicago-based freelance writer and associate managing editor for the Journal of the American Medical Association.