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Public Health in the time of Cholera

The first pandemic of cholera occurred in the 1810s and was believed to have originated in the India/Bangladesh area where pools of still rice water facilitated its spread (5). Cholera itself can range in severity in its host, from a mild diarrhea to a level of fluid loss bordering on hemorrhage. Patients with cholera can lose up to 1L of water in their stool per hour and develop a hypovolemic shock within 24 hours of infection (6). When you think about it that’s an insane amount of diarrhea that you would have to pass in order to develop shock within hours of feeling ill but it can happen. In fact about 10% of patients who acquire cholera develop this severe form of disease (2). There are estimated to be around 2.8 million cases of cholera and 91,000 deaths every year world wide (1). That number of deaths used to be much higher, in fact it was close to 10% (consistent with the percentage of people who develop severe disease). Now that percentage is closer to 0.5-1%. What changed? Primarily the advent of fluid resuscitation. Since introduction of oral rehydration therapy (water sugar and salt) the mortality rate from cholera has dropped off dramatically. The process for treating a cholera patient frequently involves putting a bucket for stool under their cot, and a bucket for vomit, then measuring their output and giving them the same amount to drink. This saved lives, essentially giving hopped up Gatorade to people prevented them from dying. Now we can shorten the course of illness with the use of antibiotics (2) but the most important part of cholera treatment remains fluid resuscitation.

Part of Vibrio Cholera’s strategy for spread is that there is a high percentage of infectious organisms in a patient’s stool and these organisms are even more infectious than those found in the natural environment, frequently referred to as “hyperinfectious” in the early stages of infection (6). So if you can imagine someone just vomiting and pooping liters upon liters of infectious fluid everywhere in a place with limited sanitation and struggling healthcare facilities then you can imagine what happened in Haiti, when UN peacekeepers accidentally introduced cholera there when they arrived, and be concerned about what is happening in Yemen in the wake of their humanitarian crisis.

The UN peacekeepers first arrived in Haiti in 2004 after Aristide was ousted from his presidency. Their time in Haiti has been plagued with scandal including sex abuse and infamously in 2010 when peacekeepers arriving from Nepal brought cholera with them and spurred an ongoing epidemic which has killed at least 9,500 people and infected hundreds of thousands of Haitians (8). The devastation is made worse by the fact that it took until last year for the UN to acknowledge its role in this epidemic and pledge funding to help correct the problem (8). To date only a small portion of that funding has actually been raised.

In a statement on May 9th Doctors Without Borders (MSF) warned of a growing outbreak of cholera over the last few weeks in a war-torn Yemen. The MSF have treated 780 patients since the end of March with a sharp increase in the last two weeks (3).  Open conflict has been ongoing for the last two years between the Houthi rebels and the Saudi Backed government (though he origins of the conflict and initial uprising go back even further). Currently there are 14 million people in Yemen living without access to sanitation or safe drinking water (4). Part of the underlying problem is a combination of destruction of existing health infrastructure (via airstrikes) with inadequate access to food as well as restrictions on fuel imports (4). Only 45% of the 3,500 health facilities surveyed by the UN in November 2016 were fully functioning (4). Some global health organizations are calling the devastation caused by the breakdown of Yemen’s government the “largest humanitarian crisis in the world” (9). This is a perfect storm and without any large public health intervention it will likely brew for years causing death and devastation in its path.


  1. “The global burden of cholera” Ali, M et al, Bull World Health Organ. 2012, Mar
  2. CBC website general information on cholera
  4. Yemen crisis: Who is fighting whom?, 28 March 2017
  5. “turning the tide against cholera” Donald McNeil Jr. New York times 2/6/2017
  6. Cholera transmission: the host, pathogen and bacteriophage dynamic. Eric J. Nelson Nat Rev Microbiol Oct 2009
  7. After Bringing Cholera to Haiti, U.N. Can’t Raise Money to Fight It. Rick Gladstone for the NY times 3/19/201
  8. UN. Votes Unanimously to End Peacekeeping Mission in Haiti. BySOMINI SENGUPTAAPRIL 13, 2017
  9. Cholera Compounds Suffering in a Yemen Torn by War, Rick Gladstone for the NY Times 5/9/2017
This entry was posted in BMC.

One comment on “Public Health in the time of Cholera

  1. A nice review on the historical import of cholera, Jocelyn, and on its (unfortunate) continued role within global health. The discovery of ORS as a therapy was one of the first victories in the modern era for global health; the introduction of cholera into Haiti, one of the biggest iatrogenic failures of the international development system (particularly given the questionable necessity for MINUSTAH at that point – worth noting that the UN has voted to disband the peacekeeping mission at this time, due to the relative stability of the nation).

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