I’ve always thought that if Bill Gates really wanted to make his mark, he should build sewer systems in the developing world (and provide endowments to maintain them). Because I’m getting tired of reading excellent articles like this:
The recent outbreaks of cholera in Haiti, Pakistan, and Zimbabwe suggest that our current global action plans against cholera are failing. This issue contains two important articles that will help inform our discussions on ways to respond to the global cholera situation. Cholera is a severely dehydrating illness caused by Vibrio cholerae, a Gram-negative organism. V. cholerae exists in environmental aquatic reservoirs, and, as a result, cholera is not an eradicable disease, but it is controllable. Humanity has recognized seven cholera pandemics since 1817, all originating in Asia. The most recent pandemic began in 1961 in Indonesia, making it at half a century the longest cholera pandemic on record. As opposed to burning out after 5-20 years as all previous pandemics have done, this pandemic, if anything, seems to be picking up speed. Cholera outbreaks are occurring with increasing frequency and severity, as demonstrated by the recent major outbreaks in Nigeria, Angola, Pakistan, Vietnam, Zimbabwe, and now Haiti. This is on top of all the endemic infections that largely go “unnoticed”. In fact, cholera is now endemic in approximately 50 countries worldwide, and V. cholerae infects 3-5 million individuals each year, killing approximately 100,000, only a minority of whom die in outbreaks that garner media attention.
The simple reason we don’t have shigellosis or cholera outbreaks in the U.S. is that we don’t have to drink our own shit. But, in the developing world, sewer systems are too often not an option:
One of the constant refrains I always hear is that diarrheal diseases, such as shigellosis, cholera, and other bacterial dysenteries, could be easily solved if there were adequate potable water and sanitation. That’s completely correct. It’s also completely unrealistic, as a recent editorial by Lorenz von Seidlein in Tropical Medicine & International Health argues.
The problem is that this ‘ultimate’ solution of massive infrastructure investment often means that foreign governments and NGOs are discouraged from effective, short-term solutions. One such solution is the oral cholera vaccine (‘OCV’). While it is a highly effective vaccine, public health officials in developing nations have had very little success in generating the finances needed for an OCV program.
Cholera outbreaks are blamed on the healthcare system–and thus, the healthcare officials. Sanitation improvements (pipes, sewage treatment, water filtration), when even possible, often fall under a different ministry over which the health officials have no say. Considering that most developing nations face larger health crises, such as AIDS, it would be impossible to galvanize a mass movement to deal with the problem of cholera by a massive investment in sanitation and water infrastructure (if such grassroots mobilization is even possible in the political environment). Consequently, healthcare officials have no choice but to advocate for strategies like the OCV.
Before you blithely dismiss this political reality, just think about how long it took for many mass public health movements, such as smoking prevention and AIDS prevention, to become effective in the U.S. where resources are not desperately scarce.
Like I said, let’s build some sewers.
Cited article: Ryan ET, 2011 The Cholera Pandemic, Still with Us after Half a Century: Time to Rethink. PLoS Negl Trop Dis 5(1): e1003. doi:10.1371/journal.pntd.0001003