Amartya Sen famously said that famines do not occur in well-run, democratic countries. The same is almost always true for cholera epidemics.
Not long after Haiti's earthquake in January, public health officials warned that poor sanitation and lack of potable water were creating conditions ripe for an outbreak of infectious disease. They were right. In the last week, a cholera outbreak has swept this impoverished country, with more than 3,100 confirmed cases and 250 deaths reported so far. So why -- if we knew that there was a danger of cholera -- couldn't it have been avoided? In short, because disease and democracy often work in opposite directions: vulnerable populations and inadequate government action create both the conditions for cholera epidemics to emerge and to become unmanageable.
Cholera epidemics stem from the same basic cause: poor people living in crowded and unsanitary conditions, with inefficient public health monitoring and limited health care. Cholera is a bacterial infection caused by the ingestion of fecally contaminated water or food. When an outbreak starts, it gains momentum fast.
But another cause is government denial and cover-up. Governments don't want to admit the failure of health-care or surveillance systems, and they are afraid of the trade and travel sanctions that may result from a large outbreak. But inaction leads to larger epidemics: Treating a few cases of cholera with oral rehydration salts or intravenous fluids is relatively straightforward, managing hundreds or thousands of cases is not. With prompt and proper treatment, less than 1 percent of those infected die. Without a fast response, death rates of five percent or more are not unheard of.
Unfortunately, there are more than enough examples of this worldwide. In 2008, in Zimbabwe, a cholera outbreak infected more than 100,000 people. In the past few months, nearly 50,000 people have been infected in four central African countries. Nigeria has been hardest hit, with about 40,000 cases and 2,000 deaths. Other outbreaks have occurred in the past few years in Kenya and Iraq. Two weeks ago, in flooded regions of Pakistan, 99 confirmed cholera cases were reported. In fact, cholera is on the increase across the globe. Each year, an estimated 3 million to 5 million people are infected with cholera; 100,000 to 120,000 of them die.
Haiti was vulnerable to this outbreak not only because of the January earthquake, but also because the country's rural population has long been marginalized, which has continued during reconstruction. Though rural villages and towns absorbed hundreds of thousands of individuals displaced after the earthquake, they have been largely excluded from the aid response. In rural communities, the already-stretched food and water infrastructure, has been pushed to the limits, while the humanitarian response has focused more on the earthquake-affected areas near Port-au-Prince.
A second factor that predisposed Haiti to crisis was a weakened central government. Both prior to and particularly after the earthquake, the government was largely unable to deliver services. Instead, a precarious web of NGOs and relief organizations took on the job. This patchwork has supported water projects throughout rural Haiti, at various levels of functioning and disarray, meaning that communities often rely solely upon the charity of private groups. When projects fail, there is no accountability.