David Heymann
Head and Senior Fellow, Centre on Global Health Security

Health authorities in Haiti are scrambling to prevent an outbreak of cholera from taking hold in the beleaguered capital of Port au Prince, where more than 1 million people are living in refugee camps, struggling to recover from January's devastating earthquake. And again humanitarian groups from around the world are mobilizing to support the government and NGOs in this task.

The outbreak, confirmed last Friday, has killed more than 250 people and sickened more than 3,000. It is largely contained in communities along the banks of the Artibonite River north of the capital and reports of a slowdown in the number of deaths and new cases indicate the disease may be stabilizing. But should it take hold in the capital, the relatively squalid conditions in the Port au Prince camps are an ideal breeding ground for an explosion of cholera - one of the most feared diseases in the aftermath of a natural disaster. Authorities are bracing themselves for the worst, mobilizing all the resources they can to stave off another disaster by stepping up hygiene education and distributing soap, water purification tablets, bottled water and rehydration salts, while setting up a string of cholera treatment centres in case prevention fails and the outbreak turns into an epidemic.

The scenario is all too familiar. It is a fresh reminder to governments of the need to become better prepared to effectively manage infectious disease risks; and to the donor community to help developing country governments and NGOs build the necessary resilience in advance.

Paradigm must change

The paradigm remains the same - a major public health event with high mortality - (this time in a country that is still recovering from a natural disaster at the beginning of 2010) - and provision of humanitarian support after the earthquake from donor governments that (fortunately) react to the event. But the paradigm must change. There must be more support from donor countries in advance - to help developing countries build the resilience needed to prevent such public health threats. In the instance of Haiti, safe water and sanitation systems in advance of the earthquake could have prevented much human suffering and death. Translated into donor support during the years prior to the earthquake, there could have been attention to helping the government develop the resilience needed to rapidly recover from a disaster and to prevent the public health risks associated with unsafe water.

Cholera, an acute diarrhoeal disease which can kill in hours if left untreated, is one of those diseases for which much can be done to assess and manage risk in advance, both to prevent disaster and to facilitate effective response in the event of an outbreak. Real control over this ancient scourge will come not from waiting for outbreaks to occur and repeatedly mounting a crisis response, but from investment in comprehensive prevention and preparedness.

Much can be done for cholera resilience

Cholera, and how to control it, has been well understood for a long time. Starting in the early 19th Century, it swept across the globe in seven great pandemics, the last of which began in 1961. Improvements in sanitation and water quality in much of the world have reduced its impact in many regions, but it remains a major cause of death in the world today, infecting an estimated 3-5 million people a year and killing about 1 percent of those infected even if oral rehydration and other treatment measures are provided.

Today, it is intimately tied to development and without a concerted investment in robust sanitation and safe water, it will continue to dog vulnerable populations and spark appeals for emergency aid. The emergence of new strains that cause more severe illness, the increase in Cholera's resistance to antibiotics and the impact of climate change are likely to exacerbate the challenge. Attention urgently needs to be given to identifying risk hotspots in advance and intervening before a crisis occurs.