Cholera is a perennial disease, with its first recorded lethal outbreak dating back to 1817 in Jessore, India. Fast forward 206 years and cholera, an avoidable infectious disease, not only persists, but is surging, especially as an aftershock to human-made and natural disasters. After the recent devastating earthquakes in Turkey and Syria, the next calamity to brace for in this region is the spread of cholera. And yet, for a longstanding disease with a lifesaving vaccine that costs approximately $1.50 per dose, how is it that we have left so many people, especially children, vulnerable?
A highly virulent disease, cholera is caused by the ingestion of water or food contaminated with the Vibrio cholerae bacterium, that can lead to acute diarrhea, severe loss of fluids, risk of shock, and even death within a few hours if left untreated. While cholera can affect anyone, symptoms manifest more severely in children and carry a higher risk of fatality. Though both preventable and treatable, the World Health Organization (WHO) classifies cholera as a global threat to public health and estimates annual loss of life of up to 143,000 people, skewed toward those in the poorest countries where access to safe water and food may be unreliable. Last year, countries such as Haiti, Pakistan, Cameroon, Ethiopia, Malawi, Lebanon, and Syria, experienced a rise in cholera cases and deaths.
Healthcare Ramifications of the Turkey and Syria Earthquakes
By recent estimation, the death toll from the earthquakes in Turkey and Syria has amassed to more than 50,000 people, however, the United Nations expects this count to increase as relief efforts continue, compounded by indirect death and disease, such as cholera.
Over the past six months, 77,561 suspected cases of cholera were reported in Syria, with approximately half of these cases in opposition-held areas in the northwest where access to health services, hygiene, and sanitation are scant. Now, with the earthquake, this already precarious outbreak is anticipated to be even more exacerbated as ravaged infrastructure is further decimated. According to the United Nations Office for the Coordination of Humanitarian Affairs, today, 2.1 million people in the northwest of Syria live in districts that are considered at-risk for contracting cholera, while at the same time, 37 health facilities were reported destroyed from the earthquake.
Not only does the country have to deal with the imminent risk of cholera but also the permeation of risk, including the potential for the disease to reach the Turkish border. Though Turkey had not recorded any recent cases of cholera prior to the earthquake, now it is also exposed to the possibility of an outbreak. For both countries, cholera comes as another catastrophe on top of mounting crises such as displacement in wintertime, mental health trauma, injury, loss and separation, and other harm. However, cholera is one such plight that could have been avoided, or at the very least, can still be mitigated.
The Need to Address the Cholera Crisis
For treatment, cholera can be successfully remedied with the prompt administration of a rehydration solution, antibiotics, or zinc as needed. For protection, the WHO currently recognizes three oral cholera vaccines: Dukoral, Shanchol, and Euvichol-Plus. While Dukoral is mainly used for travel, Shancol and Euvichol-Plus are generally used in humanitarian circumstances. Historically, the global supply of these vaccines used in exigent conditions was produced by two manufacturers; however, two years ago, one announced that it would be exiting the market by the end of 2023.
Taking a step back, a clear gap emerges: disasters are on the rise, the incidence of cholera outbreaks is spiking, cholera is not a new disease that we do not understand, the global cholera vaccines market is valued at $191M by 2030, and yet the global supply of cholera vaccines is dwindling. Why?
In public health, cholera is known to be “a disease of poverty” and according to the WHO, an indicator of inequity. Simply, the market for cholera has not been perceived as investable enough and has been sidestepped to other immunization opportunities. Arguably, however, as proven yet again by the recent earthquake in Turkey and Syria, the time to solve the crisis of cholera is now—the need is indisputable and the solution is essential. As disasters, conflicts, and crises will continue to loom, eradicating cholera—which has been predictably shown to follow these events—is an opportunity and responsibility for both public and private sector to collaboratively address. After 206 years, we should do better—we must do better.