- Loss of life after a disaster comes in three waves
• Death from immediate strike
• Death delayed hours or days as a result of injuries or complications of injuries suffered during original event
• Death from diseases & illnesses that arise as a result of breakdown of water & sanitation infrastructure (example: Cholera)

- Not a disease of the past, continues to cause considerable suffering and needless deaths
- > 130,000 cases & 2,200 deaths reported to the World Health Organization in 2005
- True numbers are much higher
- Poor surveillance & fear of international sanctions → serious under reporting of actual cholera cases
- Risk of cholera epidemics intensified during manmade & natural disasters, which we are experiencing in abundance
- Almost completely a third-world disease
• Only 5 US cases reported by the CDC in 2004, 4 of them acquired outside the US
• Several million cases & 120,000 deaths in Africa & Asia and to a lesser extent in Latin America

- Necessary improvements to infrastructure and surveillance systems
- Educating ourselves can help understand why it is such a significant global threat

- Curved bacterium called Vibrio cholera
- Lives best & thrives in watery environments where temperature, nutrients & salt concentration levels match with its needs. Bacterial cell explosively productive
- When a human is exposed to it through contaminated water & the human does not have access to clean water for rehydration or antibiotics → death within 24 hours
- ← massive fluid loss caused by the bacteria's destructive effect on intestinal lining
- First outward sign of disease is sudden and explosive watery diarrhea called rice water stool ← white specks floating in stool were originally thought to look like rice (actually bits of lining from the small intestine)
- Under right conditions, has the ability to spread rapidly by fecal contamination of the water supply, combined with a desperate human population that lacks resources & sometimes knowledge to accurately respond & protect themselves

- First well described cholera epidemic: India 1817. Spread rapidly throughout Southeast Asia & Middle East. John Snow, 19th century English physician: it spread “along the great tracks of human intercourse, colonialism and global trade”
- Second pandemic 10 years later → Europe and & the Americas
- By 1833 the English lost more than 20,000 lives
- Struck twice again in 20 years and claimed 30,000 lives in London alone in 1854
- 1883 German physician Robert Koch identified Vibrio cholerae under the microscope

- Disturbance in the environment like contaminated air
- Prejudice and bias “medical opinion was unanimous in agreeing that the intemperate, the imprudent, the filthy were particularly vulnerable. To die of Cholera was to die of suspicious circumstances”
- John Snow through a series of brilliant tracking and mapping exercises was able to connect the deaths in the London neighborhood after the 1848 epidemic to a contaminated water pump. Snow pointed to water then, and again when cholera returned in 1854
- Robert Koch identified Vibrio cholerae in 1883. This discovery + further advances with germ theory → scientific basis for investments in safe water, sanitary systems & public health surveillance over the next 100 years. It became obvious that these measures were key to preventing cholera

- Same answer as 150 years ago: they occur because human infrastructure fails
- WHO labels the avoidance of cholera as one of the key indicators of social development
- Truths that we cannot ignore:
• Cholera is now almost exclusively a disease of the developing world; it affects more than 50 nations a year, mainly in Africa.
• One sixth of our global citizens lack access to clean safe water and two fifths lack access to proper sanitation
• These two realities are linked

- We must build out water & sanitation infrastructure in high-risk areas. This proved critical in reducing cholera rates in Latin America. Without infrastructure there cannot be health, without health there cannot be progress
- Effective surveillance & response capabilities are key. Somalia between 1995 and 2000 experienced up to 17,000 cases of cholera with each seasonal outbreak. In response, the WHO, several NGOs and Somalian aid coordination board established early warning system → put in place mechanisms for rapid investigation of suspected outbreaks, cholera task forces set up in each region & emergency supplies stocked in high-risk areas → between 2000 and 2001 number of cholera cases declined by 76%. With systems such as this in place, we can anticipate and prepare for outbreaks & control them once they hit. Cholera is a treatable disease if victims quickly receive large amounts of liquids and antibiotics
- We must continue to explore and focus on new vaccine strategies. We currently have safe and effective oral vaccines for use by individuals & health personnel but there's work left to be done when it comes to mass vaccination as a public health strategy as the populations who need immunization the most are just not getting them

We know more about cholera than many other diseases, including what causes it and how to treat it, so if cholera continues to exist it's because we as humans have simply failed

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