Cholera: a challenge for the 21st century

World Heolth r 50thYeor, No. l, .lonuory-Februory 199/ Cholerq: o chqllenge for the 2lsl cenlury tlorio Jleiro Becouse of the millions of deoths thof cholero hos coused over lhe yeors, fhe diseose's ossociotion with disoster hos become legendory, provoking o deep- seoted feor in the minds of mony people. he dramatic modern history of cholera began in I 8 17, when the disease spread from India to trigger what we now recognize to have been the first of seven pan- demics. Yet Hippocrates, as long ago as the 5th and 4th centuries BC, and Galen, in the 2nd century AD, de- scribed a disease similar to cholera although we cannot be certain that it was the same. The first known description of cholera came from a Portuguese historian, Gaspar Correa. Inhis Legends of India, he described a disease "worse than poison", known locally as moryxy, an epi- demic which in the spring of 1543 killed so many people in Calicut (now called Kozhikode), India, that "it was impossible to bury them". Many other reports about a devastat- ing disease which scythed its way through India followed that of Correa, proving the existence of periodic waves of cholera throughout history. In 1817, cholera started its first deadly world tour. During that first pandemic, the disease spread from India to the Arabian peninsula before following the trade routes of the period to reach Africa and the Mediterranean shores. The total number of victims can never be known, but we know that more than 100 000 perished on the island of Java alone. In the second pandemic (1829- 1849), cholera spread for the first time throughout Europe and the Americas, sowing terror and leaving thousands of victims in its wake, like the 5000 who died in the New Orleans area of Louisiana, USA. The most devastating year in the history of the disease was probably 1854, when it killed more than 23 000 people in the United Kingdom. Because of the millions of deaths that cholera has caused over the years, the disease's association with disaster has become legendary. Few diseases, apart from plague, have provoked for genera- tions such deep-seated fear in the minds of so many people. Even today, because of its past history, cholera can still cause excessive reactions of panic, shame and disorder. Since those terrible years of cholera, we have made great progress in understanding the disease, its causes and how to prevent and treat it. While it no longer poses a threat to countries with a minimum of healthy living conditions, cholera is still a challenge for countries where access to safe drinking-water and adequate sanitation cannot be guar- anteed. The fear this disease arouses has put pressure on many countries to improve their sanitation. In 1996, cholera was responsible for more than 200 000 cases and 5000 deaths throughout the world. Although these figures are less dra- matic than those recorded during the epidemics of the past century, they Some coses of dehydrotion due to cholero r equi re i nlrovenous rehydt otion. Pholo: Keyslone @. are totally unacceptable since - by contrast with the other pandemics - we do today have the means of pre- vention and treatment. Cholera is a disease that is closely linked to poverty; fighting to control it means fighting to control poverty itself. Will we win the fight against cholera in the 2lst century? I Dr Morio Neiro is Coordinotor of lhe Globol Tosk Force on Cholero Control, in the Diseose Surveillonce ond Control Unit of the Division of Emerging ond other Communicoble Diseoses Surveillonce ond Control, World Heolth Orgonizotion, l2l I Genevo 27, Switzerlond