“No cool helicopters” to save those at risk of cholera

An ongoing pandemic of cholera puts at risk the lives of thousands of people around the world, as shown by a growing number of outbreaks in different regions. In order to address it, there is a need for a strong health system response, adequate supply of cholera kits, vaccines, and improved surveillance, apart from access to safe water and sanitation

March 23, 2023 by Nafis Faizi
Cholera outbreak Malawi
Cyclone Freddy increases risk of cholera in Malawi’s already strained health system. (Photo: WHO Malawi)

Cholera, a bacterial infection that is entirely preventable with access to clean water and sanitation, has lately seen a resurgence in many countries. The rising incidence and geographical spread of cholera since 2021 is an indication of the resurgence in the ongoing pandemic of cholera, which started in 1961. 

The global incidence of cholera has been very low since the 1990s, barring a few countries in Africa and Asia. Since 2021, 23 countries have reported cholera outbreaks; in 2023, that number has risen to 29. This comprises 13 new countries that had no outbreaks in the past three years or more. The number of countries that have reported an outbreak could very well be an understatement, as there is widespread under-reporting and an absence of reporting systems. The rise in mortality—currently at 1.9%—is also worrisome. It is at its highest in the last decade, well above acceptable limits. At present, all six World Health Organization (WHO) regions are reporting outbreaks, mostly limited to countries with social and engendered vulnerabilities. 

Inequality leads to global health security threats

Cholera is a clear sign of inequality and has continued to affect the poorest countries, especially those with poor social development, wars, conflicts, and other humanitarian emergencies. While the Global North was busy stockpiling COVID-19 vaccines and researching imaginary threats such as Disease X, the cause of the next pandemic, cholera continued to take lives in Syria, Somalia, Afghanistan, parts of Pakistan, and among Rohingya refugees in Bangladesh, among others. 

In Kenya, Yemen, Haiti, Nigeria, Malawi, Philippines, and the Democratic Republic of Congo, the number of people dying of the disease is higher than the acceptable value. The acceptable value, according to WHO, is 1% deaths among all the patients who have been infected with cholera. 

The indifference to poor access to safe water and sanitation and conflicts in the Global South is momentarily interrupted if the disease is found in other places. One such interruption happened when Israel found traces of toxigenic Vibrio cholerae 01 in the Yarmuch stream. As expected, Israel has been successful in limiting the spread of the disease after the discovery. And, as expected, most of the countries mentioned earlier have not been able to do the same.

The resurgence of cholera is now a global health security issue, linked with the ongoing global refugee and climate crises, which increase the risk of further spread. Less than 50 years ago, the international conference in Alma-Ata declared that the “existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.” 

In reality, this gross inequality seems acceptable and thriving, as new wars, conflicts, and climate disasters continue after the initial deadly waves of COVID-19. Safe water and sanitation is continuously included among global goals and targets, from the Millennium Development Goals (MDG) to the Sustainable Development Goals (SDGs). Yet the reach of these goals remains skewed within countries, some of which are affected by this resurgence of cholera. The WHO estimates that 24% of all deaths in 2016 were due to modifiable environmental factors, and about 300,000 deaths from a lack of access to clean water and sanitation alone. 

Strong and resilient health systems are needed to address outbreaks in the midst of social and economic crises, or where many live in dire conditions. A health system is resilient if it protects human life and produces good health outcomes for everyone, even during a crisis or in its aftermath. This has been discussed at length since the beginning of COVID-19.

But the adaptation intrinsic to resilient health systems in times of crisis is only possible if the same system is able to respond well to routine health problems. Raising the resilience dividend—the ability to respond in good and bad times both—needs long-term investments as much as short-term ones. As the recent case of the cholera outbreak in Malawi shows, firefighting alone is of little help. When the resilience dividend is low, a need arises to create war metaphors, to gather the attention of the so-called global community. The Pandemic Treaty, the International Health Regulations, and other policies are increasingly framing many humanitarian medicine threats as global health security crises for this reason. 

Read: Stopping cholera in Malawi: firefighting measures are not enough

Hans Rosling illustrated this tendency using an incident from Nepal’s deadly earthquake in 2015 in his book ‘Factfulness’: 

“For ten days or so in 2015 the world was watching the images from Nepal, where 9,000 people had died. During the same ten days, diarrhea from contaminated drinking water also killed 9,000 children across the world. There were no camera teams around as these children fainted in the arms of their crying parents. No cool helicopters swooped in. Helicopters, anyway, don’t work against this child killer (one of the world’s worst). All that’s needed to stop a child from accidentally drinking her neighbor’s still lukewarm poo is a few plastic pipes, a water pump, some soap, and a basic sewage system. Much cheaper than a helicopter.” 

The resurgence of cholera is a global concern posing a significant threat to public health and economic stability. Poor reporting and surveillance of cholera also poses a challenge, despite it being a notifiable disease under International Health Regulations. But this recent resurgence is also an opportunity to think deeply in terms of humanitarian biomedicine. The ongoing cholera resurgence needs a strong health system response, adequate supply of cholera kits, vaccines, and improved surveillance, apart from access to safe water and sanitation. Many places affected by cholera are also dealing with the effects of climate change, other health threats, political instability, wars, and conflicts, which are straining the already vulnerable health systems. The political and moral obligations of the so-called globalized world must be to address these pathogenic, social, environmental, and political vulnerabilities that continue to claim lives from preventable diseases like cholera.

Dr Nafis Faizi is a faculty of Community Medicine and epidemiologist at Aligarh Muslim University, India. His research and policy interests include health systems and policy research.

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