The long term solution for controlling cholera extends beyond antibiotics and vaccines : History books provide answers

Can cholera be eliminated?  Waldman and his colleagues, offer solutions taken from the history books, which requires sufficient investment by the global development community. We discuss their answers  - access to clean drinking  water and  safe basic sanitation. Looking at global health in general, we  discuss how this approach might  eradicate cholera and a host of other diseases that blight human health whilst alleviating poverty and ensuring sustainable development. 


Cholera, an acute intestinal infection caused by consumption of food or liquids contaminated with the bacterium Vibrio cholera, elicits the same fear today, as it did in the past. A dangerous disease, it affects children and adults, killing patients within hours. Malnourished children or HIV infected individuals are at a greater risk of death if infected. WHO figures indicate 3–5 million cholera cases per year and 100000–120000 deaths. Whilst only the epidemics, as recent as the one in Haiti in October 2010, gain notorious press coverage, it is a common occurrence in the developing world. Last October, when I visited Kerala, cholera was in the news  with confirmed cases in the state's capital.

Cholera cases in Trivandrum in October 2012 were linked to the drinking water supplied in the region.

In their recent article in NEJM, Waldman, Mintz and Papowitz cut to the chase on how cholera can be effectively controlled. Whilst giving due credit to the current developments in cholera control in the medical arena- use of  antibiotics, treatment procedure ( aggressive oral or parenteral rehydration and treatment with zinc) and  use of an improved two-dose oral cholera vaccine which had success in pilot trials, they present a lasting solution for  prevention of the disease taken from the pages of the history books. Safe sanitation and clean drinking water eliminated cholera in North America and Northern Europe and this is the route for eradication of the disease, the authors propose.

Cholera control starts with access to clean water and safe sanitation. Image courtesy Sam Stephen

However, the problem is that what  we in the developed nations take for granted-clean water and access to sanitation, is inaccessible to around 1.1 billion people globally who do not have access to improved water supply sources and 2.4 billion people  who do not have access to any type of improved sanitation facility. Guaranteeing clean water and improved sanitation is a difficult proposal complicated by a  glut of hurdles  which are technological, societal, behavioural, political and economical to name the main ones. Cholera, the authors say ‘is as much a symptom as a disease’. It is ‘a symptom of insufficient investment' by the global development community in offering access to safe water and improved sanitation for the marginalised.

The fact is that, cholera is only one of the hosts of diseases that are waterborne.  Access to clean drinking-water and sanitation are the two most powerful environmental determinants of health which go hand in hand. Take the example of diarrhoeal disease,  it is inextricably linked to waterborne infections, and is responsible for 2 million annual deaths. Babies, children and adults malnourished and with impaired immunity are particularly susceptible. Estimates indicate that 2,000 children die daily from diarrhoeal diseases, which are spread through poor sanitation and hygiene.

Hand washing instructions in a communal toilet facility in the UK. Image courtesy Sarah Stephen

The UN Committee on Economic, Social and Cultural Rights in November 2002,  on the right to water stated that “The human right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses.” Universal access to sanitation is, “not only fundamental for human dignity and privacy, but is one of the principal mechanisms for protecting the quality” of water resources.Safe and clean drinking water and sanitation was declared as a human right ‘essential to the full enjoyment of life and all other human rights’ by  the United Nations General Assembly through Resolution A/RES/64/292 on 28 July 2010. Furthermore, in April 2011, the Human Rights Council adopted, through Resolution 16/2,' access to safe drinking water and sanitation as a human right: a right to life and to human dignity'.

In 2000, 189 nations made a pledge (Millennium Development Goals) to free people from extreme poverty and multiple deprivations. Goal 7, target 10 of the MDG  aims by 2015, to halve  the proportion of people without sustainable access to safe drinking water and basic sanitation. 'Safe drinking water and adequate sanitation are crucial for poverty reduction, crucial for sustainable development and crucial for achieving any and every one of the Millennium Development Goals',  a statement by Ban Ki-moon, UN Secretary General says.This goal is expedient now than ever before.

 

References:

http://www.who.int/mediacentre/factsheets/fs107/en/index.html

http://www.who.int/water_sanitation_health/hygiene/en/

http://www.nejm.org/doi/full/10.1056/NEJMp1214179?query=featured_home
http://www.who.int/water_sanitation_health/diseases/diseasefact/en/index.html
http://www.who.int/water_sanitation_health/facts_figures/en/index.html

 http://www.who.int/water_sanitation_health/mdg1/en/index.html

http://www.un.org/waterforlifedecade/pdf/human_right_to_water_and_sanitation_media_brief.pdf

http://www.undp.org/content/undp/en/home/mdgoverview.html

http://dailypioneer.com/nation/99107-cholera-makes-a-comeback-in-kerala.html

Waldman RJ, Mintz ED, & Papowitz HE (2013). The Cure for Cholera - Improving Access to Safe Water and Sanitation. The New England journal of medicine PMID: 23301693