By Christopher Hamlin
The recent Cholera outbreak in Haiti reminds us that this is not simply a disease of the distant and unsanitary past. The current outbreak is both unique and typical. Caused by a disease that has a long and devastating history, this Haiti outbreak has much in common with the outbreaks of the nineteenth century and twentieth century. History helps us keep in mind five key factors:
The Role of Media Coverage in our awareness of cholera: In our current age, as well as in the past, the combination of rapidity and deadliness has made cholera epidemics into media events. In fact, much of the tragedy of global diarrheal disease happens beyond the public gaze. Vibrio cholerae accounts for only a small fraction of global diarrhea deaths. The microbe is widely distributed around the world. Most cholera cases are mild, often they will be unnoticed. Unfortunately these, and particularly those many diarrhea deaths, have become part of our normal.
Epidemiological Monroe Doctrinism: In the months preceding the Haiti outbreak there were outbreaks in Pakistan (following floods) and in parts of Africa. Western hemisphere outbreaks are news because they seem to threaten the sanitary sanctity of the U.S. Some reporters ask outright whether cholera will come to us; others hint. But how serious a problem cholera is conceived to be usually depends more on where the outbreaks are than how many are affected.
“Withering Othering”: This is a phrase I used in the book to indicate the ease, which came to prominence in the nineteenth century, with which we use presumed sanitary status to group human populations. Cholera epidemics are occasions for magnifying distance between a clean “we” and a dirty “they.” Cholera is rightly associated with poor sanitation, along with the host of social, economic, political, and cultural factors that contribute to its spread. But often, blaming unsanitary conditions is an excuse to lose sight of that bigger story. Haiti has often served as default abjectness for the western hemisphere. When something bad happens, we shrug and say “Well, it is Haiti.” Cholera reinforces that abject ahistorical identity. I have taught a bit of Haitian history, am an admirer and minor collector of Haitian art, but certainly no expert. But the historian’s business is to explain both the perception of abjectness and the complicated antecedents of this cholera. Earthquake destruction is part of that latter story, but diarrheal disease was high in Haiti even before that. Haiti is a poor country, with a difficult political past. All this is coming to bear tragically in a large number of individual lives.
Pretense of Order: As an outside observer, most of the information I get is though press conference statements. In these, whatever has happened and however many have just died, is equalized as grey fact. Nothing ruffles bureaucratic prose, well organized web-sites, or well-dressed spokespersons. Effective response, it seems, requires emotional control, and, somehow, an overlooking of tragedy. This is not new – historians of epidemics will have often been struck by the disparity between the chaos of mass disease and the need to project that those in charge have things in hand — but I was shocked to see it happening. The cholera riots in Haiti too are wholly typical – people in cholera-stricken cities have rioted throughout the world both in the nineteenth and the twentieth centuries. Often, in various ways, the pretense of normal seems to be at the root of their anger.
Preparation and Distribution of Resources: Cholera’s status in modern public health is that of a deadly epidemic, which can potentially break out in tropical coastal communities world wide (especially in those on brackish estuaries), and spread very quickly from those sites. However, it can also be cured by cheap and low tech means, the chief of which is oral rehydration. The rapidity of spread, however, means that rehydrants need to be close at hand. I assumed that the response, particularly in urban areas of Haiti, would be more rapid and effective than it was. I expected that the likelihood of post- earthquake outbreaks of fecal-oral diseases would have led to stockpiling of ample rehydrants. While I do not know enough about what happened in that regard, I find it also important to reflect on the criteria used to assess the adequacy of response. There might have been more deaths, or fewer. Here history and biomedical ethics intersect. Somehow, decisions are made about how much to allocate to potential future epidemic crises as opposed to current needs. We need to realize too, that in practice, no matter what principles are being used to make that moral choice, institutional realities are likely to significantly affect access. There is no reason for surprise, perhaps, but opportunity for more realistic discussions of the complexities of accountability are needed.
Christopher Hamlin, Ph.D., is professor of History and History and philosophy of science at the University of Notre Dame, and honorary Professor London School of Hygiene and Tropical Medicine, He is the author of Cholera: The Biography. Read an excerpt here.