Not-So-Bold Recommendation: Water and Sanitation will Eliminate Cholera | 

cholera

The elimination of cholera from countries does not require a new solution, say Drs. Ronald Waldman, Eric Mintz and Healther Papowitz in the New England Journal of Medicine. The United States and Northern Europe were able to defeat cholera without vaccines and antibiotics by ensuring improved sanitation and safe water access for all citizens. While the solution may be easy in theory, it is much harder in practice.

Ensuring safe water and improved sanitation is a difficult proposition. The technological problems are manifold — rapid urbanization and growing megacities are outstripping the existing municipal waterworks, which cannot keep up with construction and maintenance demands. In rural areas, treating drinking water with point-of-access and point-of-use solutions, including chemical and solar disinfection and safe water storage in the home, must be further expanded as an interim measure toward providing access to safe water sources.

The costs of improving and maintaining infrastructure in order to meet the MDGs can be daunting, depending on the technologies used; some estimates put these costs at well over $50 billion per year. To justify the expenditures that will be required, we need cost–utility analyses that are based on the best data possible, not just those that are readily available. These calculations should take into account the direct benefits of reducing diarrheal diseases and accompanying mortality and also other benefits, such as improved nutrition of children and lower rates of helminthic infection, hepatitis, and other diseases transmitted by the fecal–oral route.

Water and sanitation advocates will likely agree with the assertion by Waldman, et al., but point out some of the challenges to achieving safe water and sanitation for all. The article cites research that estimates it will cost $50 billion a year in order to install and maintain the necessary infrastructure to meet MDG 7 in developing countries. Even that means that access to safe water will be cut in half.

In short, it is going to cost a lot of money to ensure that every person has access to safe water and sanitation. The map from the article shows that the concentration of cases are in the very countries that have the worst access to water and sanitation. It is estimated that Haiti will need $2.2 billion over the next 10 years to defeat cholera. That is only one very small country.

Waldman, et al. make a strong case, but it could use some support through a cost-effectiveness analysis. In fact that is exactly what they call writing, “To justify the expenditures that will be required, we need cost–utility analyses that are based on the best data possible, not just those that are readily available. These calculations should take into account the direct benefits of reducing diarrheal diseases and accompanying mortality and also other benefits, such as improved nutrition of children and lower rates of helminthic infection, hepatitis, and other diseases transmitted by the fecal–oral route.”

Researchers recently published an article in Nature Scientific Reports that included a modeling of vaccination coverage. In it they say that only 46% of the Haitian population need to be vaccinated in order to “suppress transmission.” A vaccination campaign would not deal with the core issues of poor sanitation and unclean water, but it may do the trick to stem the spread of cholera in a way that is much faster and cost effective.

That is not to suggest that the two ideas should be considered mutually exclusive, rather it is to call for further information regarding what is the most effective way to rid the world of cholera.