Thursday, October 28, 2010


Haiti, wrecked by a massive earthquake in January, is now struggling with an epidemic of cholera that has spread through camps of earthquake refugees and into the nation's capital of Port-au-Prince. Dr. Jon LaPook, medical correspondent for CBS News, has probably done the best job I've seen of describing the horrific, disgusting toll this disease takes on the human body and on the societies it moves through.
I spoke to a middle-aged man, Robert Raphael, whose family lives between St. Marc and Gonaives. Over the past week he has lost a brother, niece, nephew, and "five or six" cousins to cholera. Five or six—he'd lost count.
They clearly need more doctors and nurses, but seemed to have enough oral rehydration solution and IV fluids for now. They obviously need specialized supplies like "cholera beds"—cots with holes cut in them for easier defecation. I asked an 8-year-old named Ritchie if it was hard to "faire toilette" in public (it's all out in the open), and he looked embarrassed and said, "Yes." That got to me.
The bug behind this devastation—the bacterium Vibrio cholerae—is a fascinating and frustrating creature. Fascinating, because of its role in the development of epidemiology and what we're still learning from it. Frustrating, because it ought to be relatively simple to treat and prevent infection. We know what to do to help a cholera victim survive. All it takes is access to clean water and the most basic medical supplies. The trouble here isn't science, it's poverty.
Cholera is, essentially, the worst food poisoning you can possibly imagine. In fact, it's related to Vibrio vulnificus, a bacteria that tends to infect people via undercooked seafood.
After you ingest the cholera bacteria, it'll hang out in your gut for a few days before symptoms kick in. Once they do, though, cholera can kill you within hours. How? I'll be blunt: Massive, constant diarrhea that drains the body of fluids and electrolytes and leaves victims looking like glassy-eyed, hollow-cheeked corpses before they actually are.
Nobody knows exactly how old cholera is, but, from a pop-culture perspective, it's inextricably linked to the 19th century, when several pandemic waves took cholera from its roots in the Indian subcontinent to being the first global killer—taking advantage of increased trade and immigration to strike Asia, Europe, the Middle East, Africa and the Americas.
And it was a complete mystery. At the time, disease was thought to spread via "bad air", a pre-germ theory explanation for the patterns left by person-to-person contact. But cholera didn't seem to fit. The doctor could visit a house riddled with the disease, and walk away unscathed. And, yet, at the same time, cholera swept through whole neighborhoods—usually the poor ones—killing hundreds, or thousands.
You probably know the story of Dr. John Snow. During the 1854 cholera epidemic in London, Snow took the radical and now-laughably-obvious step of mapping cholera deaths throughout the city. He found that the outbreaks centered around nexus points, which lined up with public water pumps—specifically, the pumps that sourced their water from the downstream end of the Thames. And that's how we learned a valuable lesson. Preventing cholera is easy. All you have to do is make sure that people don't have to drink water that's been contaminated with sewage.
Today, cholera is all but non-existent in developed countries. Not because we're immune. Not because we have access to a miracle drug. It's simply about money. Money, and the will to build public sanitation systems that treat the poor and the wealthy to an equal level of separation between what we drink and what we excrete. After all, there were water services in Dr. Snow's time, but they were heavily divided by class. The wealthy drew their drinking water from upstream and dumped their sewage below that point, where it made its way to the public wells used by everybody who couldn't afford the better water.
Malaria is often what we talk about when we talk about diseases of poverty. But simple diarrhea kills more people every year. Cholera is only one part of that.
And it is all about the money. What kills you isn't so much the diarrhea, itself, but the loss of fluids and essential salts and minerals. Replace enough of those, soon enough, and people tend to survive. This is a disease that can be cured with Brawndo. (It's got what cholera victims crave!) In fact, one of the greatest public health inventions of the 20th century—and, perhaps, the most underrated—is the pre-mixed Oral Rehydration Therapysachet—little packets containing dried mixtures of mostly sodium and glucose. Pour a packet into clean water, and you have an instant treatment for cholera. This is pretty much all that stands between a bout of cholera meaning a really bad, gross week, and a bout of cholera meaning death.
Cholera is a disease of poverty. But it's also a disease that prefers warmer water, high salinity, and algae blooms for ideal growth conditions. This fascinating NPR story talks about cholera's connection to the environment. In some parts of the world, it's even demonstrated a seasonal pattern. Does that mean cholera is also a disease of climate change? Maybe. But also maybe not. There are a lot of unknowns, a lot of potential factors involved in the spread of cholera, and scientists are only starting to tease all those threads apart.
Right now, people are dying in Haiti not because we don't know how to save them, but because of a lack of access, both to clean water and to Oral Rehydration Therapy. In other words, they are dying not because of a disease, but because of poverty.
How You Can Help: 
• Donate to Doctors Without Borders and help get Oral Rehydration Therapy to people who need   it.  There is a GIF link on the upper right hand corner of this blog that allows you to donate directly to Doctors Without Borders! 
• Donate to World Vision, which does both medical work, and helps bring clean, safe drinking water to communities around the world. 
• Donate to Water.Org, a charity devoted to water infrastructure projects.
Some Other, Related Links:
• Fault activity indicates that
 Haiti is at risk of more, and possibly larger, earthquakes 
• Fascinating piece explaining how cholera can hide, dormant in a population for years, waiting for a sanitation crisis to attack 
• Cholera at The Bacteria Museum 
• The Climate Connection: How warming oceans can influence the spread of cholera 
• Interesting information on what the toxin produced by cholera bacteria does in the human body and why it causes diarrhea


Laci the Chinese Crested said...

This is yet another aspect of the shame which is Haiti. How could a nation be allowed to be so poor and bereft of its natural resources?

microdot said...

I wanted to write about the politics and the cynical incompetent greed of the Haitian government. It is as if they are waiting for the population to decimate itself as if that was a solution to their social problems.
The world wants to help, but until the present Haitian government is deposed, you can be assured that a lot of the aid that gets pumped in by normal sources is siphoned off by the president and his cronies...

I wrote a lot about the evolution of the present situation in Haiti and who bears the responsibility, but there have been so many other humanitarian crisis in the world since then that our limited collective attention span seems to have been diverted from this ongoing tragedy.

At this point in time, it isn't important to point fingers. We have to start being effective.

steve said...

I'm in nursing school and as you can imaging - I come across a lot of patients that have similar issues (mostly infection with hospital acquired C-diff). Intractable diarrhea! There is a solution to intractable diahrrhea - it's called euphamistically "The Fecal Management System". Basically it is a long plastic bag / tube that has a pneumatic balloon in the narrow opening so that it can be secured where it needs to be secured - then it's just a huge poop shoot... the greatest invention ever! But the problem is - is that it costs TWO THOUSAND DOLLARS A POP! So even in America - we have this awesome solution to disease management related to diarrhea - but we don't / can't use it because it costs so much. Come the fuck on! It's a plastic bag with a donut shaped balloon on one end! If you shipped a plane load of fecal management systems to haiti - it would solve the Cholera problem.