Mohammad Shubo is motionless when he is wheeled into the clinic. He had started experiencing diarrhoea and vomiting that morning; by evening, he had no pulse.
In an effort to rehydrate him quickly, the nurses give Shubo an IV of saline solution. His reanimation seems almost uncanny – within half an hour he is able to sit up and speak. He spends the next two days at the hospital to rehydrate and convalesce before returning to his cramped quarters. If Shubo had arrived at the clinic just 10 minutes later he would have died, a nurse says.
For those who have been fortunate enough not to see the effects of cholera first hand, David Sack, a professor of international health at the Johns Hopkins University Bloomberg School of Public Health, says Shubo’s case, which appears on a 2011 Al Jazeera documentary, gives “a good sense of the disease”. Thousands of patients develop the same symptoms as Shubo did, though not all are as lucky. Sack recalls a case from Uganda in which a woman was hospitalised with symptoms of cholera, but the hospital staff didn’t diagnose her properly, even though there was a cholera treatment facility on the hospital grounds. She was not closely monitored and died of dehydration overnight. Cases like this should never happen, Sack says. But clearly they do.
But these factors are hardly predictive. After the 2010 earthquake, for example, American epidemiologists concluded that Haiti was at low risk of a cholera outbreak; just a few months later, an epidemic was raging, in part because UN peacekeeping forces accidentally introduced the bacteria.
Years of political turmoil are fuelling the epidemic in Yemen. The situation is dire – the WHO estimates that nearly 250,000 people had been infected by the end of June, almost doubling previous estimates based on academic models. WHO officials are working with other non-profits and what remains of the national healthcare system to bring treatment to rural clinics to help people get treatment more quickly. This week, the International Coordinating Group allocated one million cholera vaccines to be sent to Yemen.
These strategies, along with education campaigns so people at risk of cholera know how to treat their water (by boiling, or with chlorine tablets), can reduce the incidence of the disease. But these advances don’t address the main problem: a lack of access to clean water. So the solution to eradicating cholera then, doesn’t lie in the health sector. “Yes, you need to treat patients and prevent death,” Legros says. “But the long-term solution is in the development sector – giving people long-term access to sanitation.” There are some countries in which this may soon be possible. But in others, such as South Sudan and Somalia, the prospect of bringing safe water to the entire population seems remote.
Until the day when everyone has access to clean water and sanitation, researchers will work to answer more questions about the disease. One that remains is how – or if – Vibrio cholerae persists in the environment. “In places like Chad or on the western African coast, we see almost no cholera cases for several years, then there’s a big outbreak. It’s difficult to explain,” Legros says. “Some people say there is a reservoir in the environment that is maintained over years, though we don’t know how, and suddenly it erupts again, though again we don’t know how.” Harris also wonders about how the evolution of Vibrio cholerae may have affected its virulence and ability to cause pandemics.
As researchers work to answer these questions, and as nations move slowly towards improved infrastructure, public health officials will have to combat new outbreaks.
“I would hope that people appreciate how significant and serious a threat [cholera] is,” Harris says. “For people who think it’s a historical disease, they should know that it is still an important cause of morbidity and mortality around the world.”