Via Americas Quarterly, a long, informative article by Jonathan Weigel and Paul Farmer: Cholera and the Road to Modernity: Lessons from One Latin American Epidemic for Another. The article provides very useful historical perspective on cholera in the western hemisphere, and argues that clean water and good sewers are not the only solution. Excerpt:
Water and sanitation initiatives in the early and mid-1990s surely deserve a good deal of credit for slowing the cholera epidemic in Central and South America, as do medical teams across the region that sought out patients and provided rapid treatment.
As we have seen, however, a close look at the context and course of the 1990s epidemic casts doubt on the claim that improved water and sanitation was exclusively, or even primarily, responsible for the decline of cholera by the end of the decade.
There is profound biosocial complexity associated with all epidemics of infectious disease.59 Such complexities are greater in settings of poverty and political upheaval (such as Peru, Guatemala and many countries in Central and South America in the early 1990s).60
The association between V. cholerae outbreaks and climatic factors further complicates the extent to which public health initiatives can claim full credit for the decreases in cholera incidence. A perhaps equally compelling narrative explains such decreases as the natural course of the epidemic.61
One 1998 review on the prospect of eradication in Latin America (co-authored by one of the architects of Mexico’s successful cholera control endeavors) put it this way: “V. cholerae’s tight link to the water environment, plankton and marine fauna, along with its particular biological and genetic imprints, defies any eradication strategy designed to break the biological chain supporting cholera ecology and its transmission dynamics.”62
How to Curb the Tragedy
One of the few firm conclusions that can be drawn from accounts of the 1990s epidemic in Latin America is that claims of causality about the ebb and flow of cholera will always be fraught with biosocial complexity.
There is a great deal about the decline of the previous Latin American epidemic that is still not well understood. How might this history guide ongoing efforts to control cholera in Haiti and other endemic and epidemic settings around the globe?
Given the uncertainties associated with the rise and fall of cholera in Latin America, and indeed the uncertainties associated with every manifestation of epidemic and endemic cholera around the world, an integrated, comprehensive approach using every control tool available is the most sensible response to cholera in Haiti and elsewhere.
Fortunately, we have proven means of diagnosing, preventing and treating cholera. No one would dispute the fact that rapid treatment efforts and provision of clean water and sanitation should be the bulwark of the response to cholera in any setting.
Since the mid-nineteenth century, improved water and sanitation systems have been the foundation of public health. Building such systems in Haiti would help control not just cholera but also other pathologies of poverty, including malnutrition and waterborne diseases like hepatitis A and poliomyelitis.
Improving water and sanitation infrastructure, such as sewage-treatment plants and municipal water systems, would require substantial investment and time. These infrastructure improvements are sorely needed in Haiti.
But vaccination, though far from perfect, can protect the most vulnerable; it has an important complementary role to play in controlling cholera. A national strategy to implement all of these interventions could reduce mortality and transmission so that cholera would no longer be a serious problem in Haiti.