Cholera and coronavirus: why we must not repeat the same mistakes – The Guardian

We log in every day at 7.45am. One by one, we join an array of faces on our screens. We doctors arent used to video-conferencing like this, and still greet each other with excited waving hands. Since the coronavirus crisis began, these daily virtual meetings have proved an invaluable way to keep up to speed on clinical guidelines, in-house protocols and staff wellbeing all of which are changing every day.

But these meetings also bring us news that we take more personally: how many of our patients have symptoms? How many have tested positive? How many have died? These are important questions, for sure, but my public health training reminds me to think globally. The coming year will see developments that will allow us to bring the virus under control in the west, but what about in other countries? I cannot help but think of my relatives in India, and what this pandemic will mean for them not just now, but in the future. The really important question is not who will die of coronavirus tomorrow, but in 200 years time.

For coronavirus is not the only pandemic the world faces. There is another one raging right now. Since cholera first spread across the globe, two centuries ago, it has killed about 50 million people. In the time it takes you to read this article, another five people will have died from it. It is now mostly ignored in the west, but in other parts of the world, it has never gone away.

While I will surely be able to offer my patients in England a coronavirus vaccine in a year or two, and while western health systems will be reinforced to be more ready for a potential future outbreak, I worry that we may repeat the mistakes of cholera: conquering coronavirus everywhere except for the poorest parts of the world.

To reach my grandparents house in Bihar, in north-east India, you have to take a car from Patna airport across one of the longest river bridges in the world, the Mahatma Gandhi Setu. This bridge takes you north over the river Ganges, past Hajipur, a city famous for its fragrant bananas, and up to Darbhanga, near the border with Nepal. When I was a child, the road was so damaged by the regions regular floods and monsoons that the journey, which would take just two hours in the UK, took seven hours, bumping over gut-lurching potholes. Today, the road is smooth and elevated, giving a spectacular view of the areas lush flood plains. They provide the perfect conditions for cultivating the fruits mangoes, lychees and guava that still flavour my memories of visits to my grandparents.

The wet, semi-tropical conditions in the Ganges delta also make it a hotspot for water-borne diseases. And it is in northern India that cholera is thought to have originated several millennia ago, owing to the abundance of still water pools and Hindu ceremonies involving worshippers washing themselves in rivers. A 2,000-year-old inscription at a temple in Gujarat vividly describes the clinical picture of patients afflicted by severe cholera: The lips blue, the face haggard, the eyes hollow, the stomach sunk in, the limbs contracted and crumpled as if by fire.

In the 19th century, the scientist Max von Pettenkofer believed, incorrectly, that cholera required certain soils and environmental factors unique to India, and so thought that it could not be contagious or endemic in Europe. But the persistence of cholera in this area has less to do with climate and more to do with political choices.

Cholera is an infectious disease that turns on all the taps in your gut, so that water and salts pour out of your system, giving you copious watery diarrhoea that looks starchy, like rice water. This diarrhoea helps the infection spread between people, leaving a trail of victims so severely dehydrated that, if they dont receive treatment, they shrivel up like prunes within hours.

For centuries, cholera only caused localised epidemics in north-east India. That was until 1817, when one of these outbreaks, originating in Bengal, spread across the world, starting the first of seven cholera pandemics. But just as Wuhan cannot be blamed for the current Covid-19 pandemic, we cannot hold this region responsible for choleras spread, any more than North America should be blamed for the 2009 H1N1 swine flu pandemic, which originated in industrially farmed pigs. What the spread of these diseases has in common is international trade, and the movement of animals and people that comes with it.

Empire shaped the history of cholera, and it was the economic concerns of imperial powers that brought cholera to heel in the west. But if imperialism was crucial to providing the impetus to end cholera, it also produced a logic that divided the world and only eliminated the disease from one half.

In his book Plagues and Peoples, the historian William Hardy McNeill describes how the British army carried cholera overland into Nepal and Afghanistan, while British navy and merchant ships carried it beyond the Indian Ocean. That is how the first pandemic spread from the Bay of Bengal to south-east Asia, the Middle East, east Africa, and then to Europe by the early 1820s.

In 1831, cholera reached the north-east of England, the region where I grew up. One of the first victims, in Sunderland, was a 12-year-old girl called Isabella Hazard. Her illness was characteristically swift: she was entirely well one evening and dead the next afternoon. She was an early victim of the first of a series of waves of the disease that caused pandemonium in 19th-century Europe. Port cities, crucial to trade, were affected particularly badly.

It is hard to imagine the panic created by the Blue Death, as cholera was nicknamed, because at the time its cause was a total mystery. The most common theory that the disease was associated with bad airs (or miasmas) inspired desperate experiments to control it. In Kingston, Jamaica, for instance, British colonial officers tried to banish the disease by firing cannons through the streets to destroy the morbific power that lurked in the dark alleys.

So cholera went on, unabated, in wave after wave of pandemics throughout the 19th century, causing millions of deaths, mainly in poor neighbourhoods. The working classes rioted across Europe, suspecting the disease was a conspiracy by the ruling elite, who they thought were poisoning them. In the 1830s, the revolutionary Mario Adorno accused the Bourbon royal family of concocting a devilish plot bent on poisoning the people of Sicily with cholera, as part of his attempt to topple them.

But disasters like pandemics are never just destructive they also induce change, and often spark scientific developments and social reforms. The European imperial powers eventually started pouring resources into discovering the true cause of the disease, primarily to prevent the catastrophic economic downturns that accompanied every fresh outbreak. This investment led to three major developments that helped end cholera in the western world: reforms that improved public health, to stop populations getting the disease in the first place; the discovery of new medicines, to prevent and treat the disease; and international cooperation, to unite against a common enemy.

In 1813, Frances Snow gave birth to her first child, John, in York. She and her husband, William, who worked at the local coal yard, raised John in one of the poorest parts of the city. Like Bihar in India, the area John grew up in was regularly affected by flooding, when the River Ouse broke its banks.

When John became a doctor, he grew sceptical of the idea that cholera was caused by miasmas. Instead, he suspected it had something to do with water. He famously proved his theory in 1854, during an outbreak in Soho which killed 616 people. He created a dot map of all the cholera cases in the area and spoke to the families to understand their daily habits, meticulously doing what we would today call contact tracing. He discovered that nearly everyone who had been afflicted used the same water pump on Broad Street. Snow had the handle of the pump removed, making it unusable, which led to a sharp decline in cholera cases in Soho. It was later found that this particular well was shallow and had been contaminated by a nearby cesspit. In one elegant experiment, Snow had unveiled the spectre of cholera, which had haunted him since his childhood: the cause was just plain old dirty water.

This was a problem for colonial powers, because their cities and colonies were unsanitary places. Rapid industrialisation had impoverished both English and Indian rural workers, triggering mass migrations to cities for work. Provided with no public amenities, these new migrants built makeshift homes in unhygienic and polluted slums. Snows revelations led to the creation of Improvement Trusts and a Commission for Public Health in major cities across India, and these did improve the sanitary conditions, but largely only for British expats and colonial officers. By the end of British rule, clean water was available to nearly all British citizens in India, but only 1% of Indians outside the colonial walls.

Today, more than half of Indian households have no access to any kind of formal sanitation, meaning that they must defecate in the open, and 70% of sewage is untreated when it re-enters rivers and streams. As a result, up to 30,000 people in India die from cholera every year. Those who can afford it resort to digging their own water wells, deep into the ground. Given the trouble and expense my grandparents went to do this, I know the fact that their well-water still gives me an upset stomach, forcing me to drink bottled water when I visit, brings them great shame. But it isnt their fault; there is only so much individuals can do when their government refuses to invest enough to ensure clean water for all its people.

John Snows discovery was the first step towards halting cholera. But as the pandemic continued to ravage Europe, effective medicines were needed to prevent and treat the disease. And those could only be developed once scientists understood how dirty water made us sick.

In Florence, a contemporary of Snows spent his days with his eye pressed up against the cold brass ring of a microscope that he himself had designed. Filippo Pacini was a professor of pathology and a pioneer in the kingdom of the tiny; he had a gift for the new art of microscopy and was naming previously undiscovered parts of the human body when he was only 19. He was convinced that the cause of many medical mysteries, like the ones that afflicted his sisters for most of their lives, could be found through careful observation with this powerful new tool.

Pacini studied the organs of four patients who had died of cholera. He pored over their intestines with his microscope, and noticed the same thing was wrong in each. The lining of their gut was highly abnormal: not pink and rubbery as it should be, but pale and coming off in floppy sheets, like soggy newspaper. When he teased apart this lining with a tiny probe, he noticed that multitudes of tadpole-like dots emerged from the tissue.

Pacini recognised that these dots which he called vibrios (commas), because of their shape must be the cause of cholera. He was the first person to observe for certain what had been speculated for centuries: that diseases could be caused by things too small to see by the naked eye. However, the scientific community failed to appreciate the value of his research, and his findings languished, largely ignored, for another three decades.

Pacini had discovered the germ, but it was not until the German physician Robert Koch himself discovered the comma bacillus in Egypt in 1883 that germ theory became popularised. During the following century, further research led to two crucial targeted therapies, based on breakthroughs by scientists from the Indian subcontinent shortly after it gained independence. In 1953, Hemanda Nath Chatterjee developed a simple mix of salt and sugar that could be added to water to safely replace the copious fluids lost as diarrhoea. The basic recipe is still used today.

Six years later, Sambhu Nath De discovered that cholera released a poisonous toxin, which deserved just as much attention as the bacterium itself. Using modest equipment in a laboratory in Kolkata, he showed that the bacteria were not needed to make people sick. If they were stewed in a soupy culture, then removed like whole spices even just the remaining broth was enough to cause life-threatening intestinal damage and give all the symptoms of the disease.

These discoveries transformed our understanding of cholera, and how it could be treated. They provided the basis of two new medicines: oral rehydration therapy, to replace lost salts; and a cholera vaccine, to induce an immune response against the bacteria and its toxin.

Today, its easy for westerners to get their hands on the most effective vaccine, Dukoral. Using it simply involves adding a vial of the liquid vaccine to water, together with a sachet of a granulated buffer that protects the vaccine from stomach acid. Its no harder than adding milk and sugar to tea. Two doses will induce an antibody response that will protect you for about five years. But Dukoral cannot be used in the areas where cholera is most prevalent, because they dont have access to clean water, so taking the medicine could actually put people at risk. Besides, it is unaffordable in those places; to earn enough to pay for two doses, the average Briton would have to work for less than an hour, while the average Indian farmer would have to work for three whole days.

There are other, cheaper cholera vaccines, such as Shanchol, which is manufactured by Shantha Biotechnics in India. This has the advantage of not needing any extra water, as it is poured directly into the mouth. But it is not as effective as Dukoral, as it does not protect you against the toxin, just the bacteria. Plus, it still requires two doses given two weeks apart. Thats hardly feasible for healthcare workers trying to cover vast areas of rural India.

There are many other obstacles to cholera vaccination programmes. To be effective, they must reach enough of the population to achieve herd immunity. This requires accurate surveillance, which is impossible without a strong and centralised public health system. Like the other countries where cholera is still endemic, India lacks this infrastructure, largely owing to the long shadow of colonial extraction, post-colonial debt, and loans granted by the IMF and the World Bank in the 1990s on the condition that the government reduce its spending, which led to cuts to public health and education programmes the very things that a society needs to haul itself out of the conditions that stoke cholera.

So although the World Health Organization (WHO) recommends the use of the cholera vaccine in areas where cholera is endemic, and despite the existence of an easy-to-use vaccine which is manufactured in their own country, my relatives in their remote village in Bihar have not had it. But if I, as a westerner, want to visit them for a week, I can easily get it in the UK.

Oral rehydration therapy and the cholera vaccine have greatly reduced choleras reach in subsequent decades, but it has not gone away completely. Two years after Sambu Nath Des seminal research, a new pandemic the seventh sprung up in Indonesia and took hold in Asia and north Africa. This pandemic is still ongoing. More than a billion people live in countries at risk of the disease which, by no coincidence, are some of the poorest countries on earth.

In the two decades after cholera first reached Europe, individual European nations, acting in isolation, tried in vain to prevent and contain it. But there was no point cleaning up port cities at great expense when you could not vouch for the sailors and cargo flowing through it. They eventually realised that a problem caused by globalisation required an international solution.

This led to the first example of global cooperation in order to combat a disease. In 1851, the first International Sanitary Conference, convening the major European imperial powers, was held in Paris. Still, it took time for all those gathered to reach a consensus, and the first International Sanitary Conventions were not adopted until 1892.

According to Anne-Emanuelle Birn, a professor at the University of Toronto School of Public Health, trade was the driving motive of these meetings, and public health just a necessary means. They proved successful: transnational interventions, such as quarantine and disease surveillance by international health bureaux, did bring down cholera deaths. These International Sanitary Conferences proved the power of international cooperation to improve health and boost the economy, and provided the blueprint for the Health Organization of the League of Nations, and later the WHO.

Perhaps the greatest achievement of this cooperation came in 1979, when smallpox was eradicated globally. But unlike smallpox, cholera has not been eradicated not because of some insurmountable biological hurdle, but because we have thrown our weight behind schemes that focus solely on cholera, rather than trying to end the poverty that makes such diseases likely. There are still about 3 million cases and 100,000 deaths from cholera every year, all entirely preventable. Based on recent estimates, from 1 January to 25 March of this year, cholera claimed more lives than the coronavirus. But we are saying so much about coronavirus and so little about cholera because coronavirus has broken the unwritten rule that dangerous infections should not befall those in the west.

A map of the places still struggling with cholera shows 47 countries in Central America, sub-Saharan Africa and southern Asia. This might seem to confirm that tropical countries are bound to nurture this bacteria, because of their warm climates and high population density. But the experience of the Marshall Islands, a remote Pacific archipelago that suffered a cholera outbreak at the end of 2000 and start of 2001, shows that there is nothing inevitable about where the disease takes its toll. As the University of Hawaii researchers Seiji Yamada and Wesley Palmer have shown, two neighbouring islands there experienced very different fates despite having similar climates and being just four miles apart.

The US maintains a military base on Kwajalein Island, where the menial labour is carried out by low-paid workers who live on another nearby island, Ebeye. Many of them are descended from refugees from other islands in the archipelago who were displaced by US weapons testing in the 40s and 50s. The housing and infrastructure provided to them on Ebeye by the military is not much better than a slum. The average household is home to nine people, so infections spread rapidly. The sewers pour their contents into lagoons where people swim and fish, and when it rains they overflow into the streets.

At the time of the outbreak, there was no running water on Ebeye. Furthermore, since the land there was not fit for agriculture, traditional Marshallese ingredients were unavailable, and nearly all food was imported, unhealthy and expensive, leaving many malnourished. It was a ship bringing food to the island that is thought to have started the outbreak of 2000-2001.

On Kwajalein Island, meanwhile, the residents are almost exclusively American expats who work for private military contractors. They live in detached villas with amenities like those of a beach resort, and the population density is 20 times less than that on Ebeye. Once the outbreak had begun, workers were only allowed to commute from Ebeye to Kwajalein if they could prove that they had received vaccination or prophylactic antibiotics. During the cholera outbreak, there were 400 cases and six deaths on Ebeye. However, on Kwajalein there was not a single case.

What made contracting cholera so likely on Ebeye and so unlikely on Kwajalein has nothing to do with climate or geography. There is no biological or environmental reason why cholera cannot be eradicated for good in Ebeye, and Bihar, and right across the world. It is not the knowhow that is lacking, but rather the political will to extend these benefits to all people.

It is now 200 years since the cholera pandemics began, more than 150 years since the bacteria was identified, and 60 years since an inexpensive treatment and vaccination regime was developed. And yet still this contagion is plaguing some countries as if none of that progress had ever happened. That is the real lesson of cholera.

There are fears that coronavirus is now distributed so widely that, like cholera, it may be here for the long haul. It is not yet known whether this current coronavirus, Sars-CoV-2, will eventually mutate to cause milder, cold-like symptoms, like the four endemic coronaviruses; or instead go the way of the first Sars coronavirus and remain as a deadly, but contained, infection. In either scenario, Sars-CoV-2 or a similar future virus could, like cholera, be eliminated only from the richer parts of the world, and left to circulate, with deadly consequences, in the worlds poorest regions.

The world will eventually recover a semblance of normality by adopting the same three techniques we used against cholera: prevention of transmission, targeted treatments and global cooperation between nations. But as we saw with cholera, all three strategies can exacerbate global divides, if they are applied selectively to protect only the richer half of the world.

There are signs that this is happening already: from richer countries buying up so much extra personal protective equipment that poor countries will be unable to obtain or afford enough to protect their health workers; to the outsourcing of coronavirus clinical trials to poor countries, like India, that will be less able to afford the vaccine once it is developed; to poor countries becoming blind spots in the worlds gaze on coronavirus, because they lack the digital infrastructure necessary to collect comprehensive data about their outbreaks.

It is hardly news that we live in an unequal world. In the 90s, global health experts began to refer to the so-called 10/90 gap, based on the fact that only 10% of health research funding was addressing the health problems that affected 90% of the worlds population. At the time, diarrhoeal diseases accounted for 7.2% of global disease burden, but attracted only 0.06% of health research investment. The 10/90 gap has remained largely unchanged. But with this new pandemic, we have an opportunity to put that right.

Just as cholera gave birth to global health, coronavirus should trigger its latest reboot. Richard Smith, the former editor of the BMJ, has compared the stages of global health since the first cholera pandemics to the updates of an operating system. I welcome what he calls Global Health 4.0: namely, research and policy led by researchers and activists from poor countries. And while the WHO has not always lived up to its lofty goals, nor managed to achieve eradication of cholera as it did for smallpox, the solution is not to weaken it, as per Donald Trumps removal of funding, but the opposite: it needs much more funding, and more independence from corporate donors, if it is to help tackle the socio-economic conditions that make us sick.

Besides the basic moral argument for a system of public health and international cooperation that benefits all people, it is also in everyones interests, because as long as infections blight poor countries, they will continue to pose a threat to the west, too. The Nigerian global health scholar Obijiofor Aginam has written that enormous sacrifices must then be made by the developed world to confront mutual vulnerability. Coronavirus has reminded us, once again, of this mutual vulnerability.

To prevent further pandemics, Aginam calls for a communitarian globalism: a bottom-up approach, based on ideals of fairness, justice, and equitable distribution of scarce but moderate global resources. We have already seen glimpses of this kind of solidarity in the current crisis: from the communist government in Kerala giving food and shelter to migrant workers; to the Somalian doctors offering their help in crisis zones such as Italy; to Cuba allowing an infected British cruise ship to dock to receive timely medical care by its doctors.

There are, of course, important differences between coronavirus and cholera. The fact that coronavirus has a higher transmission rate than cholera, for instance, will make curbing its spread particularly challenging. But the lesson from cholera holds nonetheless. If we allow global health to be funded and governed by the old colonial logic that is embedded in its current structures, then the story will play out as it did for cholera.

For now, I will continue to worry about my patients and colleagues in England, and how many of them will succumb to this virus. But while there are certainly better and worse ways to respond to the crisis here in the short term, history will judge us not just on who dies from coronavirus today, but in the centuries to come.

For when my patients die during a pandemic in one of the richest countries in the world, it is of course a tragedy, but I can take comfort in the fact that it is an exceptional one, and that every effort is being made to prevent further such deaths. A much bigger moral failing would be if there are still people in the poorest parts of the earth dying of coronavirus in 2200. In 50 years time, when I take the road north through Bihar to my ancestral home, I hope I will be able to buy a bunch of bananas in Hajipur without wearing a mask, and fill my nostrils with their sweetness.

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Cholera and coronavirus: why we must not repeat the same mistakes - The Guardian