Cholera is an
infectious non-bloody watery diarrhea that originated in South East Asia. It
got its name from the Greek word khole
meaning bile or rain gutter. The latter sense of the word highlights the
voluminous water loss from the diarrhea that can, within a few hours, cause
coma and death1. An affected
person can lose 20 liters of water in one day. The manifestation of the disease
is not mentioned in any books from antiquity until 1502 when it was first
reported by Portuguese soldiers visiting India1. At first, low
population density and the lack of global travel kept the disease restricted to
South East Asia. There, in this region, the disease would repeatedly strike particularly
after religious gatherings where large numbers of people congregated. So severe
was the devastation caused by this disease in South East Asia that in 1769,
with no known treatment for the disease, French soldiers reported a cholera
epidemic in India that killed 60,000 people1.
Cholera remained
restricted to the region around India until 1783 when British soldiers took it
to Sri Lanka and caused an epidemic there.
The disease was taken out of South East Asia in 1817 when infected
European soldiers carried it back to their homeland after contracting it in
India. From Europe, the disease spread to other parts of the world,
particularly to places where European soldiers conquered and ensured trade with
Europe. These soldiers did not knowingly
spread the disease. They simply carried a pathogen with them to wherever they
went. Between 1817 and 1823, Persian and Turkish soldiers helped spread the
disease throughout the Middle East. When the disease arrived in Africa, it was
called the disease of traders because if primarily affected people along the trading
routes to the Middle East and along ports trading with Europe. In Europe, the
disease became known as the disease of the poor and of cities because it primarily
affected people living in high density settings with poor sanitation.
Once cholera was taken
outside of South East Asia in 1817, it became known as a pandemic because it
affected people from around the world with one notable exception, Haiti. The first cholera pandemic which started in
1817 did not affect Haiti because following the Haitian Revolution (1791-1804),
the superpowers of the world imposed an embargo on the country. This embargo
had the devastating effect of preventing Haiti from benefiting from scientific
advancements being made around the world. At the same time, the isolation had
the beneficial effect of preventing infected cholera carriers from coming to
the country.
Since 1817, seven cholera
pandemics have struck the world. Most often, these waves of pandemics
originated from religious gatherings in Mecca where visitors acquired the
disease and then returned to their native countries to unknowingly spread it. Once this pattern was recognized, it gave
rise to the germ cell theory and to the now common practice of quarantining ill
people at ports of entry.
The second cholera
pandemic struck from 1829 to 1851. Again
this second wave did not affect Haiti because of the country’s isolation and
because of additional measures taken by President Boyer in 1832 to protect
Haiti’s ports from potentially infected carriers2. The effectiveness
of these measures led Thomas Madiou, a Haitian historian, to write in the 1840’s
that: “It must be observed that cholera has never entered Haiti, even when it
raged all around our island, in St. Thomas, Puerto Rico, Jamaica, and Cuba, in
the Lesser Antilles and the Greater Antilles alike.” In addition, during these
years, the total population of Haiti was fewer than 500,000. The resulting low population density helped to limit the spread
of the infection even if a few infected people managed to enter the country.
Moreover, the strain of cholera that caused previous epidemics in the Americas
is not well adapted to the Caribbean climate and this is why even on the other
islands where the infection was known to have been introduced, the disease did
not persist in the environment to repeatedly infect people. In other words, the
old Cholera Vibrio El Tor bacteria never became endemic to the Caribbean.
During the 5th
Cholera pandemic which took place between 1891 and 1895, President Florvil
Hyppolite again published a protocol to help prevent the introduction of cholera
into Haiti as the disease was again ravaging Europe and the United States2. Again, the Haitian government’s intervention
helped to prevent the introduction of the disease to Haiti but for reasons
having more to do with the poor survivability of the cholera bacteria in our
climate, the country remained free of the disease.
More recently, the 7th
cholera pandemic struck Asia in 1961, then Africa in 1970, and arrived to the
Americas in 199110 where it spread from Peru and infected one
million people in South America, between 1991 and 1993, killing one percent of
those affected. At the onset of the
epidemic in Latin America, 30% of affected people died. As knowledge of its
treatment became more widespread, the mortality rate dropped to 1%4.
The World Health Organization (WHO),
which first came into existence from the international effort to contain the
spread of cholera, braced for the arrival of the 7th pandemic to
Haiti and to the Caribbean. Fortunately, the region never became affected by this
cholera strain which now lives in the Gulf of Mexico but does not survive in
the Caribbean.
The cholera now
affecting Haiti is caused by a new and more virulent strain known as Cholera Vibrio
El Tor 01. This new strain may be more adaptive to the Haitian climate. We will know this for certain if the disease
remains in Haiti over a long period of time. The more virulent strain of cholera now
present in Haiti was genetically fingerprinted and it is more related to the
South East Asian strain than to the strain now present in the Gulf of Mexico
and in other regions of the Americas. In writing about this, the New England
Journal of Medicine took care to avoid the politically charged position of citing
the country of origin of the disease and instead explained: “The Haitian epidemic is probably the result
of the introduction, through human activity, of a V. Cholerae strain from a
distant geographic source.”
At the onset of the
epidemic in Haiti, the United Nations denied introducing the disease and
speculated that global climate change was the root cause of the epidemic and
that it was a disaster waiting to happen because of Haiti’s poor sanitary
conditions. But the fact is that disease
is caused by microbes. The world learned this from the germ cell theory, a
byproduct of the earlier cholera pandemics. No matter how squalid sanitary
conditions are in Haiti, the Haitian people would never have developed cholera
without its introduction into the country. In other words, Haiti got cholera in
the same manner that other regions of the world got it, through the importation
of the microbe, usually by and infected migrant. Again, this is the very reason
why quarantine procedures were established at ports of entry throughout the
world. Such policies were also a byproduct of previous cholera epidemics.
The epidemic in Haiti
began in October 2010, when a group of South East Asian soldiers arrived to
Haiti from Nepal, a country that had just experienced a cholera epidemic. According to locals, these United Nations
troops used a latrine adjacent to the Meye tributary of the Artibonite River
and the latrine allowed feces to overflow into the river. By October 20, 2010,
the first sixty cases reported in Saint Marc occurred in people living downstream
from the Nepalese base. On October 21,
2010, the Haitian government identified the problem as cholera. In the early days of the infection, maps localizing
affected cases helped to point to the Artibonite River, downstream from the UN
base as the epicenter of the disease.
Indeed, people in Haiti
had previously suffered from various infectious diarrheas caused by such
pathogens as E.Coli, Amoeba, and Shigella, but never before had they suffered
from the explosive diarrhea caused by cholera. The initial large number of
people who got sick from the disease helped to confirm that the people of Haiti
did not have immunity to this disease because they had not previously been
exposed to it. The thousands who got
suddenly sick overwhelmed the hospitals in the Artibonite region. Fortunately,
the world community, having learned from past cholera pandemics, assisted Haiti
in providing vigorous oral rehydration and intravenous fluid infusion to the
ill which saved countless lives.* Still,
by December 13, 2010, there were 112, 330 people affected by the disease and
2,478 deaths11. The total number
of people exposed to the bacteria will never be known because not everybody who
ingests the bacteria gets sick from it. People only become sick when the bacteria
survive the stomach’s acid to then enter the small intestine alive7.
The United Nations
understands the economic ramifications of having introduced a killer disease into
a resource restricted country where if the pathogen becomes endemic, it can
continue to kill people for an indefinite period. At first, the United Nations took cover and
denied responsibility as the people of the Artibonite pointed to the UN as the
source. Later, anti-UN protests and numerous well performed scientific journal
articles pointed to the bacteria as having come from South East Asia 6,9,12
and that forced the UN to name a commission to study its involvement in
introducing the disease. On May 6, 2011,
this commission published its conclusion and said that indeed the bacteria was
introduced by the UN12. The commission offered additional evidence for
this conclusion based on the time that it took infected feces to travel from UN
related sites to population centers along the river. This acknowledgement was particularly
embarrassing to the UN because one of its stated goals is to address the needs
of the 2.6 billion people worldwide that live without adequate sanitation6.
Only two years earlier, the UN had declared
2008 to be the year for sanitation and had made it its goal to decrease by half,
before 2015, the number of people worldwide living without adequate sanitation8.
The final report from
the independent UN experts phrased the UN’s introduction of Cholera into Haiti
in this way:
“The sanitation
conditions at the Mirebalais MINUSTAH camp were not sufficient to prevent
contamination of the Meye Tributary System with human fecal waste. It is clear
that: 1) there was potential for feces to enter into and flow from the drainage
canal running through the camp directly into the southwestern branch of the
Meye Tributary System; and, 2) there was potential for waste from the open
septic disposal pit to contaminate the southeastern branch of the Meye
Tributary System either by overflow during rainfall or contamination via animal
transport. MINUSTAH contracts with an outside contractor to handle human fecal
waste. Additionally, although residents report contractor trucks dumping feces
into the septic pit, it has been suggested there might have been an
unauthorized feces dumping directly into the Meye Tributary System (Piarroux,
2010)…The evidence does not support the hypotheses suggesting that the current
outbreak is of a natural environmental source. In particular, the outbreak is
not due to the Gulf of Mexico strain of Vibrio cholerae, nor is it due to a
pathogenic mutation of a strain indigenously originating from the Haitian
environment. Instead, the evidence overwhelmingly supports the conclusion that
the source of the Haiti cholera outbreak was due to contamination of the Meye
Tributary of the Artibonite River with a pathogenic strain of current South
Asian type Vibrio cholerae as a result of human activity.”12
Today, we know that for
cholera to have taken hold in Haiti, it needed a source as well as a conducive
environment. The UN base served as the source, introducing the bacteria from
Nepal into the Artibonite Valley. The
lack of safe water, the lack of adequate sanitation, and the lack of Haitian
immunity to the disease was the environment conducive to spreading the bacteria
and creating an epidemic across the country. Since the squalid conditions in Haiti have
been there for a long time, the critical new event was the introduction of the
bacteria.
With the origin of the disease
clearly established, the United Nations now needs to implement the
recommendations of its independent investigation and help Haiti get rid of the
infection by building a safe water supply and an adequate sanitation system. It
must do this as reparation for the hundreds of thousands of people sickened by
the disease and for the thousands who died and continue to die. The UN needs to
become a responsible partner in solving the problem of cholera in Haiti. It
played a crucial role in introducing the disease to the country in October 2010
and its initial firewall of denials obstructed the effort to get to the truth
about the origin of the disease in Haiti.
*Lessons learned from previous cholera pandemics benefited
Haiti greatly. Both oral hydration and intravenous IV fluid infusion were techniques
developed specifically for fighting cholera.
