Death in The Time of Cholera

By Christine Gorman

Many doctors think of cholera as a kind of Lazarus syndrome. Victims are brought to a clinic or hospital with no apparent blood pressure or pulse, taking only shallow breaths. "But if there is any life left in them at all, we can bring them back," says Dr. David Sack, associate professor of international health at the Johns Hopkins School of Public Health. Sadly, thousands of people in Latin America will not be revived in time and will die of the disease, which robs the body of fluids through severe diarrhea and vomiting. Last week the first epidemic of cholera on the South American continent in this century was raging in several countries. The epidemic, which started in Peru and is spread through contaminated food and water, has surged into several neighboring countries, overwhelming medical resources in many areas and striking mostly the very poor in shantytowns, mountain villages and remote jungle settlements.

Already 165,000 have developed the affliction, and more than 1,200 have died. By one estimate, as many as 6 million people may fall ill over the next three years, with the death toll reaching 40,000. Two weeks ago, Brazil reported its first cases, in the Amazonian jungle on the border with Peru. In the U.S., health officials revealed last week that four people in the New York ( City area became ill after eating improperly cooked crabmeat that had been illegally brought into the country from Ecuador. (Excellent public sanitation should, however, prevent a U.S. outbreak.) "We just can't hold the epidemic within the present limits," says Carlyle Guerra de Macedo, director of the Pan American Health Organization. "Most likely we are going to have cholera in all of Latin America."

Health officials from nine different Latin American nations met in Sucre, Bolivia, last week to coordinate their efforts and issue an urgent call for international help. The World Health Organization (WHO) in Geneva announced the formation of a special cholera task force. In addition, France and the U.S. are sending supplies and medical staff to set up emergency clinics.

Scientists do not know exactly why cholera periodically explodes into epidemics. The bacteria that cause it are part of the aquatic ecosystem, helping to break down dead shellfish. Cholera germs travel up the food chain by attaching themselves to plankton, which are eaten by fish and then by people. Studies by Rita Colwell, professor of microbiology at the University of Maryland, suggest that a plankton bloom, a rapid growth like the one reported off the coast of Peru earlier this year, may help trigger epidemics.

Quick treatment can easily save lives. Large amounts of a simple solution of sodium and potassium salts and sugar can rapidly replace the body's fluids. If patients are strong enough, they can drink the lifesaving mixture instead of receiving it intravenously. Antibiotics speed up the recovery time. Unfortunately, in Latin America, distributing medicines can be difficult, especially in remote areas.

Even so, the epidemic may not be as devastating in other countries as it has been in Peru. "The country where cholera strikes first is always hit the hardest," claims Dr. Baldur Schubert, head of Brazil's National Commission for the Prevention of Cholera. "We've had time to prepare for the disease." The Brazilian government has distributed 450,000 illustrated pamphlets on the Amazon border to teach people how to combat cholera by boiling drinking water and washing one's hands after defecating. Authorities have also allocated $6 million to build public toilets in the area. In Colombia the folk troupe Los Natales is performing a modified version of traditional dances to teach sanitary habits.

If the efforts fail, however, the disease could continue its eastward march and strike such major coastal cities as Sao Paulo and Rio de Janeiro, which are teeming with favelas, or slums. "That would be disastrous," says Afonso Infurna Jr., vice president of the Brazilian commission. "Health and hygiene conditions are already poor, and the disease could spread rapidly." Although Infurna and other commission officials predict they will contain the infection, they admit that the cost of treating a full-scale epidemic would be high -- on the order of $600 million.

Relief efforts in Peru have been hampered by a strike among health-care workers. When Bolivia tried to send doctors to the Andean village of Puno, where an outbreak was beginning, the medical team was asked to stay home. Finally the strikers allowed a limited number of Bolivian technicians to disinfect Puno's sewage pipes with chlorine.

Even with the staunchest efforts, cholera's march through Latin America could mean trouble for years to come. Before the massive outbreak that spread from Asia in the 1960s, cholera was rarely seen on the African continent. Now, however, it reappears there every year and claims hundreds of lives. The only effective solution is good public sanitation. "We know that these diseases are basically problems of drinking water and sewage," says Health Minister Camilo Gonzalez Posso of Colombia. "Until we attack those fundamental needs, we will always be vulnerable to tropical diseases turned plague." But according to the WHO, providing safe water and sewage treatment in Latin America could cost $50 billion over the next decade -- a staggering sum for countries that are already deeply in debt and struggling with the problems of crushing poverty.

With reporting by John Maier Jr./Rio de Janeiro