Sunday, December 19, 2010


(Seattle Times) - by Frances Robles, The Miami Herald

Haiti's poor sanitation system makes the country vulnerable to a disease that first swept the United States and other parts of the world more than 150 years ago.

MIAMI — The cholera outbreak ravaging Haiti is part of a worldwide pandemic that began 50 years ago and should be easy to stop — with technology developed in the 1800s.

Haiti's poor sanitation system, however, makes the country vulnerable to a disease that first swept the United States and other parts of the world more than 150 years ago. The current global wave of cholera — the seventh in history — made its way from Asia to Africa to Latin America, and is back for its second strike at this hemisphere.

But as other countries in the region slowed the disease in its tracks by developing better sanitation and medical-response systems, Haiti was blindsided by an organism not seen in the Caribbean since 1850 which may have been introduced there by Nepalese troops serving as U.N. peacekeepers.

If history is a guide, the outbreak that has killed at least 2,000 people in Haiti could take thousands more lives there over the next several years before it is contained, experts said. The disease has stricken perhaps 100,000 people, and U.N. officials say the number of dead and ill may have been underreported.

"There shouldn't be those numbers of deaths in Haiti," said Chris Hamlin, a University of Notre Dame historian who wrote "Cholera: A Biography."

"This outbreak is surprisingly big to me," he said. "Most outbreaks are more immediately confronted. This is not rocket science."

Developing world
The word "cholera" was coined by the ancient Greeks, although they used it to describe a different illness, Hamlin said.

For years, the acute intestinal bacterial infection ravaged cities, killing 25 percent of its victims, many within hours.

"Cholera is still a regular feature of life in many parts of the developing world," said Robert Tauxe, deputy director of the Centers for Disease Control and Prevention's Division of Foodborne, Waterborne, and Environmental Diseases. "In the 19th century, it was a regular feature of life everywhere."

First detected in the Americas in 1832, the disease went up the Mississippi, down the Erie Canal and eventually swept New York tenements. By the 1850s, epidemics were sweeping the Caribbean, Latin America, Africa, Asia and Europe. In 1850, thousands died in London and in Hamburg, Germany.

"Back then, nobody knew how to treat it," Tauxe said from Haiti, where he is helping health-care providers battle the illness. "A quarter of the patients would die."

Today, cholera sickens 3 million to 5 million people a year, killing up to 130,000, said Peter Hotez, president of the American Society of Tropical Medicine and Hygiene, who wrote the book "Forgotten People, Forgotten Diseases."

"It's one of the fastest killers around," Hotez said. "It produces toxins that damage the intestines and takes all the water out of a person's body. A healthy individual can be practically at death's door in a very short amount of time. It's every bit as important as HIV, but has become one of those forgotten diseases."

The chief symptom, Hotez said: "diarrhea from hell."

In most countries, about 1 percent of the sick die. In Haiti, the death rate is 4 percent, suggesting either patients are waiting too long to seek help or authorities have not managed to get adequate treatment and hydration supplies where they are needed most, experts said.

The current pandemic first was detected in 1961, Tauxe said. It languished in Asia for 10 years, and then spent a decade wreaking havoc in Africa.

"It affected almost all the inhabited world, except for maybe Australia," said Tauxe, who began working on the disease in 1984. "We started waiting, thinking: When is it going to arrive in the West?"

The answer: January 1991, when cholera came to Chancay, a village near Lima, Peru. The disease spread through Latin America and took a decade to contain. Dozens of passengers on South American flights would arrive in the United States sick.

"It was severe. It came to every country in Latin America except Paraguay and Uruguay," said University of California, Berkeley, anthropologist Charles Briggs, author of "Stories in the Time of Cholera," which chronicled the epidemic's toll among the indigenous people of Venezuela.

Experts agree cholera is wildly unpredictable. When the disease swept Latin America, sickening 1 million people in the first five years, the Caribbean was left unscathed.

"The Caribbean braced for it, and it didn't come even though people were dying in Venezuela, just seven miles from Trinidad."

That's one reason Haiti was so unprepared for the current outbreak. While Peruvian doctors, like those in Bangladesh, became world masters at treatment, Haiti's health corps had virtually no training in the disease, experts said.

"Cholera in this millennium should kill no one," Briggs said. "It is easily prevented with clean water and easily treated with IVs. Cholera is still one of the clearest, most persistent and most repugnant ways to demonstrate the gaps between the haves and the have-nots."

Nepalese troops
The source of Haiti's cholera outbreak is hotly debated. Witnesses reported seeing a sewage pipe at the Nepalese camp leaking into the river, and a French doctor has written a report that The Associated Press said traces the outbreak to the Nepalese troops.

But the United Nations has not endorsed the report's findings, and the Nepalese deny any of their troops are sick. The peacekeepers' possible role in the outbreak touched off rioting last month.

Cholera epidemics in the United States waned in the late 1800s, when sewage treatment and clean drinking-water systems were widely installed.

It took Latin America most of the 1990s to develop the infrastructure to the point that, although cases of cholera pop up from time to time, "it just does not find fertile ground to explode in," Tauxe said.

Cases in the United States are rare, and usually related to a less severe strain from undercooked Gulf Coast seafood.

In Haiti, conditions are ripe for cholera to linger for years and to make a significant comeback in other places in the hemisphere with extreme poverty and a lack of clean water, public-health experts said.

History shows a key element to containing epidemics is having lots of clean water at hand, not just to prevent the illness in healthy people, but to treat the sick.

"Haiti," Briggs said, "is a powder keg for cholera."

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