Saving Lives in a Time of Cholera
A health worker was disinfected after bringing cholera victims to a grave near Port-au-Prince, Haiti, in November 2010. Photo Credit: Damon Winter/The New York Times
The New York Times, April 11, 2012, by Tina Rosenberg – Cholera is on the rise around the world. Last year, according to Unicef, West and Central Africa had “one of the worst ever” cholera outbreaks. An outbreak in Haiti sickened 1 in 20 Haitians and killed more than 7,000 people. The World Health Organization estimates that there are between three million and five million cases of cholera each year, and between 100,000 and 120,000 deaths. New and more virulent strains are emerging in Asia and Africa, and the W.H.O. says that global warming creates even more hospitable conditions for the disease.
In most parts of the world, the last few months have brought a respite. But April is the start of the rainy season, which is also the cholera season.
Cholera should not be a terror. It is easy to treat if you know how. Countries that live permanently with endemic cholera, like Bangladesh, see fewer than one death per 100 cases. But in recent epidemics in Zimbabwe, Somalia and Haiti, death rates in some areas have been reported at 10, 20 or even 50 percent. In countries unfamiliar with the disease, people don’t know the steps to take or have the tools they need.
With cholera, speed matters. It can kill very quickly — in a few hours if victims are already malnourished. And since the incubation period for the cholera bacteria can be as short as two hours, it spreads fast.
Until now, early action has been nearly impossible. Governments, fearing stigma and a loss of tourism, often cover up cholera, and international organizations sometimes go along with the fiction. Even when governments do call cholera by its name and start inviting international help and expertise, the W.H.O. and Unicef are bureaucracies — and such invitations can come weeks after a widespread epidemic is under way.
A new partnership between two organizations that battle cholera will make it possible to get supplies and knowledge to cholera-stricken areas much faster. Early next month, AmeriCares, a United States-based aid group that specializes in airlifting medical supplies into disaster zones, will finish assembling a group of pallets containing everything necessary to treat 15,000 cases of cholera.
AmeriCares says it can get those pallets from the assembly site in the Netherlands to anywhere in the world within 48 hours. The know-how will be brought — also at top speed — by doctors and nurses from the International Center for Diarrheal Disease Research, Bangladesh, the world’s leading cholera experts. Instead of waiting for an invitation from a government or international organization, the center will bring the medical help in right away, alongside AmeriCares. “Until now, we’ve waited for an invitation from the World Health Organization or Unicef or the local medical authorities to come in,” said Mark Pietroni, the center’s medical director. “That’s sometimes six weeks late.”
This is increasingly the future of disaster management: prepositioning to get what’s needed to where it’s needed earlier. Instead of buying and shipping food stocks after a crisis begins, for example, the United States Agency for International Development and the World Food Program are increasingly buying food during harvests, when it is cheaper, and storing it near potential crisis zones, much of it in W.F.P.’s huge warehouse in Mombasa, Kenya.
Bangladesh is famous for its nongovernmental organizations — the Grameen Bank and the anti-poverty giant BRAC are the most widely known. But the Center for Diarrheal Disease has achieved just as much. The center invented oral rehydration solution, a packet of salt and sugar that mothers can mix with clean water and give to a child with diarrhea. That packet saves the lives of some three million children a year.
Despite its name, the center works on a lot of problems — nutrition, H.I.V. and reproductive health, to cite a few. At its headquarters in the Dhaka, the Bangladeshi capital, it has trained more than 27,000 people from 78 countries. At its main field site in the subdistrict of Matlab, about 30 miles from Dhaka, the center has been collecting demographic data for more than 40 years. Interviews with a population that is now about 250,000 have provided researchers with key information: for example, the fact that 63 percent of child deaths are because of diseases preventable with vaccination. The results of the center’s health research in the area guide programs that have significantly reduced child mortality around the globe.
But in Bangladesh, the center is known as the Cholera Hospital. During the cholera season the center treats 1,000 people a day. “Cholera is a Bengali disease, coming from the Ganges delta,” Mr. Pietroni said. “The treatment is also a Bengali treatment.”
The center has redesigned and been an evangelist for the cholera cot — a cot made of a plastic tarp with a hole in the middle and a bucket that goes beneath. Without such cots, doctors and nurses in cholera wards find themselves wading through pools of infectious stool. And center’s staff have traveled to epidemics around the world, training local health officials, doctors and nurses.
Their most important message is the importance of early and massive hydration — if a patient is too weak to drink, then IV solution is necessary. “The biggest mistake is that patients do not get enough hydration fast enough,” Mr. Pietroni said. “You have to give huge amounts of IV fluid in the first three hours — seven or eight liters. In Dhaka at the end of April you see people with IVs in each arm and leg. But as soon as the patient can drink, you switch them to oral rehydration.”
Flooding patients produces Lazarus-like effects. People who come in barely showing a pulse are sitting up and drinking just a few hours later. This September, in the midst of an outbreak in Somalia, two doctors and a nurse from the center gave a five-day cholera course in Mogadishu. “They did have an outbreak, but conditions in Somalia are really ripe for a really large, Haiti-scale outbreak, and it hasn’t happened so far,” said Gregory Anderson, a program officer for the Conrad Hilton Foundation, which gave a grant to AmeriCares and the center to provide training and supplies in Somalia and Kenya.
AmeriCares and the center realized they needed each other during their work in Haiti. “AmeriCares had the capacity to send things, but sometimes lacked the expertise,” said Alejandro Cravioto, the executive director of the center. “And when groups like us arrive, sometimes we have enough to work with, and sometimes we don’t. This was an obvious fit.”
In many cholera outbreaks, AmeriCares is already there: 70 percent of the disasters they respond to are water-related, like floods and tsunamis, and cholera usually follows two or three weeks later. Now, as soon as cholera is suspected, AmeriCares will ask a local partner to invite the Center for Diarrheal Disease. The center’s job is to confirm that the disease is cholera, work with a hospital to set up a treatment clinic — often a tent on the grounds — and, most important, train local medical personnel. AmeriCares handles the logistics: “We’d work with the ministry of health to get duty-free clearances,” said Ella Gudwin, vice president for emergency response. “We’d look at the generator, the supply chain, the availability of materials, where the water is coming from.”
AmeriCares and the Center for Diarrheal Disease are employing an idea — a preventive, proactive approach to disaster — that is starting to get attention. The project was highlighted as particularly promising at the Clinton Global Initiative meeting in 2011. “This has definitely not been philanthropy’s role in the past,” said Mr. Anderson of the Hilton Foundation. “It’s been a very reactive sector. But we’re very focused on it. The return on investment is much better.”
Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book is “Join the Club: How Peer Pressure Can Transform the World.”