The seventh cholera pandemic in modern history has killed millions of people in the Global South since its outbreak in Indonesia in 1961. Over the last few months, there have been several notable cholera outbreaks.
War-torn Yemen experienced the biggest epidemic of recent times, with almost one million cases and over 2,000 deaths. The Democratic Republic of Congo is in the throes of its worst outbreak in 20 years, which has killed approximately 1,000 people.
In Zambia, there have been at least 70 fatalities in recent weeks. The government responded by banning public gatherings and street vending, as well as closing government offices and schools. The countermeasures have helped to slow the epidemic but provoked riots in the capital, Lusaka.
As cholera has been more or less eliminated from Europe and North America, the pandemic has until now received relatively little attention from global health actors. But at the end of last year, the Global Task Force on Cholera Control – a WHO-led coalition of UN agencies, NGOs, and academic institutions – vowed to reduce cholera cases by 90 percent by 2030.
The historical record suggests that achieving this aim is possible: Cholera was the chief public health problem for European governments in the mid-1800s, but had all but disappeared by the turn of the century. Nevertheless, the WHO et al must overcome some massive obstacles if they are to achieve their objective.
Cholera is passed on when people consume water or food contaminated with carriers’ excreta. It first spread from its endemic haunts in northern India after the East India Company army invaded the Maratha Empire in 1817. The bacteria travelled on trade routes to the rest of the world.
Cholera reached Europe in the early 1830s, where the rapidly growing towns provided favourable conditions for its spread. With no known treatment, victims would lose a quarter of their bodily fluids from vomiting and diarrhoea in a few hours before dying from dehydration.
Inequalities between rich and poor were at their peak in mid-19th century Europe and cholera disproportionately affected the urban working classes who lived in crowded, unsanitary conditions. Outbreaks brought latent social tensions to the surface, resulting in widespread riots.
Richard Evans, former regius professor of history at Cambridge University, describes cholera as the “classic epidemic disease of Europe in the age of industrialisation.” Yet it hardly touched the continent after 1900. How did this turnaround come about, and what can be learned from it?
The demise of cholera in Europe was the result of intervention by increasingly powerful and well-resourced states to provide cities with clean water and effective sewage systems. Several factors coalesced in the second half of the 19th century to make this possible.
Scientific advancements underlined the need for public sanitation measures. In the mid-1800s, it was widely believed that cholera spread through exposure to bad air. In 1854, English physician John Snow demonstrated that cholera was a water-borne disease by tracing the source of an outbreak to a pump on Broad Street in London. Thirty years later, German scientist Robert Koch identified the comma-shaped cholera bacteria in the intestines of deceased patients.
Along with scientific progress, there were major political changes happening in Europe. The late professor Christopher Bayly neatly captures how cholera outbreaks shocked political and economic elite: “It seemed as if the horrid filth and turbulence of the Orient had infected the seamy underworld of the European city.” This horror precipitated broad-based support for sanitation reforms. Those of a progressive bent were motivated by compassion for the wretched of the earth. Conservatives were concerned that the unhealthy poor were neither productive workers nor good soldiers and could be tempted to start a revolution.
So, can the Global Task Force on Cholera Control succeed in their goal of reducing cholera cases by 90 percent?
In theory, cholera is easy to prevent and treat today. Outbreaks don’t occur where the population has access to clean water or vaccines. Those who contract cholera recover quickly when treated with antibiotics and oral rehydration therapy.
The WHO et al will, nevertheless, struggle to meet its target. Contemporary cholera outbreaks are a manifestation of a deeper malaise, just as they were in mid-19th century Europe. Epidemics occur because of the failure of political actors to provide the world’s poorest people with safe drinking water, adequate sanitation, and rudimentary healthcare.
In the Democratic Republic of Congo and Yemen, this failure is, in large part, due to civil wars. Zambia, however, is a different case; it does not suffer from an ongoing armed conflict.
Driven by copper exports, its economy has boomed in the last two decades, with income per capita increasing fourfold since 2000. But economic gains have failed to benefit many Zambians. According to World Bank data, 57.5 percent live on less than $1.90 a day, 35 percent don’t have access to safe water, and 56 percent don’t have decent sanitation.
The failure of the Zambian state to provide for its citizens’ basic needs can be traced to a number of interconnected factors, including the colonial legacy of weak institutions, International Monetary Fund neoliberal conditionalities that discouraged investment in public health, and corruption that costs the state budget an estimated $3bn a year.
Cholera disappeared from Europe because increasingly strong and well-resourced states intervened to improve the living conditions of the urban working class. Many states in the Global South have neither the will nor the capacity to build water, sanitation and health systems. Moreover, it is unlikely that donor countries will help because they are far more concerned with the potential threat posed by airborne diseases such as Ebola.
Challenging this iniquitous neoliberal system is beyond the remit of global health actors, but as long as it prevails their role will be limited to treating the symptoms of our sick society. In this sense, it is quite likely that unless there is a tremendous political change in the Global South, the WHO and its partners will be unable to eradicate cholera in the coming decades.