While in medical school in Nigeria, I learnt a bit about cholera …that it is an infection caused by the bacterium Vibrio cholerae, and that the main symptoms include profuse watery diarrhea and vomiting, with the management being primarily with oral rehydration therapy (ORT) etc etc. The truth however is that I barely saw a case of cholera while practicing (…while aware of our limited diagnostic capacity). Cholera’s main relevance was in the historical context, and a good examination question.
Then I left Nigeria to study epidemiology. I learnt about the fascinating epidemiology of cholera. The disease spread by trade routes (land and sea) to Russia, then to Western Europe, and from Europe to North America. The beginning of modern epidemiology is credited to John Snow’s investigation into the famous London cholera outbreak in 1854. John Snow later used a spot map to illustrate how cases of cholera were centered around a water pump. He also used statistics to illustrate the connection between the quality of the source of water and cholera cases. He showed that the 2 water companies: Southwark and Vauxhall Waterworks Company were taking water from sewage-polluted sections of the river Thames and delivering the water to homes with an increased incidence of cholera. Snow’s study was a major event in the history of public health, and is widely regarded as the founding event of the science of epidemiology. The most amazing aspect of this bit of history is that the connection between water and illness was proven before the discovery of the bacterium “cholera” – indeed it was before the acceptance of what was then considered the “germ” theory of disease.
We can also look at Zimbabwe where between 2008 and 2009, the country faced one of the largest cholera outbreaks in recent history with over 4,000 deaths. Conventional wisdom was that Zimbabwe had such economic problems that one could rationalise this as a symptom of its broader challenges.
Why do I give this short historical perspective? Its just to say that cholera is one of the oldest diseases known to the medical profession, it can be prevented by the simplest of interventions – clean drinking water, it is treated by the simplest of interventions – water, sugar and salt. So when there is a huge cholera outbreak in Nigeria, with close to 400 deaths, in 2010 – one has to think how the nation’s public funds are being used when the International Airport in Abuja is apparently being renovated to celebrate 50 years of nationhood! My understanding is that the outbreak is still not under control. Even if it were, the next one is surely round the corner. Now it is time to sit back and think….
Why should we be having an outbreak of cholera in Nigeria in 2010?
Most medical textbooks will tell you that cholera is caused by a bacterium. What very few will tell you is that it is really a disease of poverty, and a failed society. Yet, one wonders why there was hardly any protest in the newspapers as the outbreak escalated. Our elite in Abuja, Lagos, Kano and Port Harcourt hardly said a word as they were not affected. When a patient does get cholera, there is still no reason in 2010 why the patient should die! Every single death should be treated as manslaughter. A failure of our health care services to provide the most basic of care – water, sugar and salt – for the most vulnerable in our society.
But even at best, the current response to cholera outbreaks tend to be reactive, in the form of an emergency response. While this approach prevents many deaths, it fails to prevent cases of cholera. Cholera is usually transmitted through faeces contaminated water or food. Outbreaks will continue to occur sporadically anywhere that the water supply, sanitation, food safety, and hygiene are inadequate. So why then is this not a priority for our governments in the affected states. In all their pronouncements on NTA network news at 9 pm every night (..at best a most painful experience to watch) – not once have any of the governors or commissioners taken responsibility.
When about 400 Nigerians died in air crashes in our Nigeria 4-5 years ago, the country was up in arms, the press was alive, it filled the national discourse. Investigative committees were set up, airlines were banned, airports closed, protests filled the streets. So why are Nigerians silent about the 400 men, women and children who have died of cholera in 2010? The answer is simple – they are poor, they do not read or write in newspapers, and are largely seen and unheard. They do not belong to the elite. They are forgotten, neglected, disenfranchised. Their
votes do not count. THEY DO NOT MATTER. A truly sad state of affairs.
We are all guilty – you and I!
But we can do something about it. As we move into the election season, lets us ask our politicians what plans they have for providing us with the basics, the very basics. As our president buys 3 jets for the presidential fleet – lets us remind him that people are dying in Nigeria, in 2010 – of cholera! Let us ask the senators representing these areas – where they have been. How often they have raised their voices in protest? If you are reading this blog – you will probably never have a challenge like cholera – but it is still our problem.
Let us put health back on the political agenda!
Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead
Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (www.epiafric.com), which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.