tag:theconversation.com,2011:/us/topics/cholera-12736/articlesCholera – The Conversation2024-03-12T10:29:52Ztag:theconversation.com,2011:article/2248912024-03-12T10:29:52Z2024-03-12T10:29:52ZWhat’s behind the worldwide shortage of cholera vaccines? For starters, they’re only made by one company<p><em>In February 2024 the World Health Organization announced southern Africa was suffering the deadliest <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">regional outbreak</a> of cholera in at least a decade. At the epicentre of the disaster were Malawi, Zimbabwe and Mozambique, where cholera cases surged more than <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">four-fold</a> between 2022 and 2023. Over 1,600 deaths were reported in the three countries.</em></p>
<p><em>Already 2024 is threatening to be another devastating year for cholera in the region as warmer weather and unusually heavy rains and storms have fuelled the disease’s spread. Zimbabwe, Mozambique and Malawi have reported more than <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">13,000</a> cases of the disease so far in 2024.</em></p>
<p><em>Cholera bacteria are spread by eating or drinking food or water contaminated by the faeces of an infected person. Oral vaccines help contain outbreaks and limit the spread of the disease. But there is a worldwide shortage of the vaccines.</em></p>
<p><em>From January 2023 to January 2024 there were urgent requests for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00467-7/fulltext">76 million doses</a> of the oral cholera vaccine from 14 nations. Only 38 million doses were available. Stockpiles <a href="https://reliefweb.int/report/world/global-cholera-vaccine-stockpile-runs-empty-16-countries-report-outbreaks">ran dry</a> at the beginning of 2024.</em></p>
<p><em>Nadine Dreyer spoke to vaccinologist Edina Amponsah-Dacosta about the impact of the vaccine shortages and what is being done to secure stockpiles for future outbreaks on the continent.</em></p>
<h2>The world’s oral cholera vaccine stockpile has run dry. Why?</h2>
<p>Unlike routinely administered vaccines, such as those for measles, the cholera vaccine is developed on a needs basis: during outbreaks and humanitarian crises, for example. </p>
<p>There’s <a href="https://www.pih.org/article/why-global-cholera-vaccine-shortage-goes-unnoticed-despite-high-demand#:%7E:text=There's%20limited%20funding%20to%20purchase,by%20EuBiologics%20in%20South%20Korea.">limited funding</a> to purchase cholera vaccines, and as a result there’s limited production. </p>
<p>There is only one vaccine recommended for mass vaccination during cholera outbreaks, <a href="http://eubiologics.com/eng/sub2_1.php">Euvichol-Plus</a>.</p>
<p>The vaccine is manufactured exclusively by EuBiologics, a global biopharmaceutical company based in Seoul in South Korea.</p>
<p>The company has limited manufacturing capacity. So when there is a spike in the need for the vaccine, demand outstrips production.</p>
<p>So there is usually only a limited stockpile available. </p>
<p>Traditionally we haven’t had several countries experiencing outbreaks at the same time like we are currently seeing in <a href="https://www.afro.who.int/health-topics/disease-outbreaks/cholera-who-african-region#:%7E:text=Since%20the%20beginning%20of%20the,case%20fatality%20ratio%20of%202.4%25.">southern and eastern Africa</a> as well as in parts of the <a href="https://who-global-cholera-and-awd-dashboard-1-who.hub.arcgis.com/">eastern Mediterranean, the Americas and south-east Asia</a>.</p>
<p>This is one of the main reasons for the current shortage.</p>
<p>EuBiologics has identified certain steps in the manufacturing process that could be refined and shortened, while ensuring that the vaccine remains safe and effective.</p>
<p>A low-cost, simplified version, <a href="https://www.ivi.int/euvichol-s-simplified-formulation-of-oral-cholera-vaccine-licensed-by-korean-regulatory-agency/">Euvichol-S</a>, has been approved by the World Health Organization and will help ease the shortage. Over 15 million doses of Euvichol-S are expected in 2024. </p>
<h2>What is being done about the vaccine shortage in southern Africa?</h2>
<p>There have been several strategies to fight the outbreak.</p>
<p>Firstly, in October 2022 the <a href="https://www.who.int/news/item/19-10-2022-shortage-of-cholera-vaccines-leads-to-temporary-suspension-of-two-dose-strategy--as-cases-rise-worldwide">WHO temporarily suspended the standard two-dose vaccination regimen</a> in favour of a single dose to stretch existing supplies.</p>
<p>Two doses provide up to two or three years’ protection, but one dose is still safe and effective. With one dose we’re able to deliver some level of safety up to one year or just a little bit more, hopefully enough time to beat the current outbreaks.</p>
<p>Secondly, countries like Zambia and Zimbabwe have taken steps to prioritise vaccine distribution to areas that need them the most. </p>
<p>An example of a priority area would be one devastated by droughts or floods with a high transmission rate and no access to safe drinking water and sanitation.</p>
<p>Last year, cholera cases surged in Malawi and Mozambique following <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season#:%7E:text=Last%20year%2C%20cholera%20cases%20surged,and%20ended%20in%20mid%2D2023.">Cyclone Freddy</a>, the longest-lived tropical cyclone in history. It traversed the southern Indian Ocean for more than five weeks in February and March. </p>
<h2>Is progress being made to develop more cholera vaccines?</h2>
<p>In Africa less than <a href="https://www.dst.gov.za/index.php/media-room/latest-news/4149-boosting-local-vaccine-manufacturing-capacity#:%7E:text=Africa%20produces%20less%20than%201,critical%20vaccines%20to%20save%20lives.">1%</a> of doses of all vaccines are locally manufactured.</p>
<p>During the COVID-19 pandemic African countries were forced to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276532/">back of the queue</a> for life-saving COVID-19 vaccines. It taught us that we need to have our own local manufacturing capacity.</p>
<p>In the case of cholera we are seeing that we cannot rely on just one manufacturer in South Korea when most of the outbreaks are happening in several African countries.</p>
<p>The problem has been recognised and there are steps to rectify it. There has been a lot of investment in expanding the cholera vaccine manufacturing <a href="https://www.dst.gov.za/index.php/media-room/latest-news/4149-boosting-local-vaccine-manufacturing-capacity">capacity</a>. </p>
<p>Two manufacturers are coming into play globally, one in South Africa and one in India.</p>
<p><a href="https://www.ivi.int/biovac-signs-deal-with-ivi-to-develop-and-manufacture-oral-cholera-vaccine-for-african-and-global-markets/">Biovac</a>, a biopharmaceutical company based in Cape Town, has received investment capital to develop vaccinations for cholera and other diseases.</p>
<p>It has concluded a ground-breaking licensing and technology transfer agreement with the <a href="https://www.biovac.co.za/wp-content/uploads/2022/11/Biovac-IVI-OCV-Technology-Transfer-Press-Release-23-Nov-2022.pdf">International Vaccine Institute</a>, a non-profit international organisation headquartered in South Korea, for the manufacture of the vaccine.</p>
<p>The first batch of vaccines will undergo clinical trials from 2024 to 2025, with licensing expected from 2026. This means we won’t see locally manufactured cholera vaccines until after 2026.</p>
<p>In India, pharmaceutical company <a href="https://www.science.org/content/article/world-s-stockpile-cholera-vaccine-empty-relief-way">Biological E</a> plans to manufacture the simplified version of Euvichol-plus. </p>
<p>But vaccination is not a replacement for the provision of safe drinking water, adequate sanitation and good hygiene practices.</p><img src="https://counter.theconversation.com/content/224891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edina Amponsah-Dacosta receives research funding through Gilead Sciences' Research Scholars Program. </span></em></p>The world’s stockpile of cholera vaccines has run dry, bad news for cholera-ravaged southern Africa. Why is this and what is being done to address vaccine shortages in Africa?Edina Amponsah-Dacosta, Research Officer / EIDM Specialist, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2197232023-12-13T10:59:52Z2023-12-13T10:59:52ZClimate change risks triggering a spike in infectious disease outbreaks: three reasons why<p>Climate change is our planet’s most immediate existential threat, and will likely only worsen for the foreseeable future. </p>
<p>Among its numerous adverse effects on human health, there is strong evidence linking climate change to <a href="https://www.science.org/doi/10.1126/science.1239401">infectious disease</a> outbreaks. </p>
<p>A recent analysis revealed that of 375 infectious diseases affecting human beings, 218 <a href="https://www.nature.com/articles/s41558-022-01426-1">(58%)</a> can be aggravated by climatic hazards. </p>
<p>It is no longer a question of “if”, but “when” an epidemic will be triggered or amplified by climate events.</p>
<p>It’s vital that swift, decisive action is taken to mitigate the impending public health crisis worsened by climate change. </p>
<p>We are part of the <a href="https://climade.health/">Climate Amplified Diseases and Epidemics consortium</a> launched in early 2023. The consortium is made up of leading molecular biologists, epidemiologists, ecologists and evolutionary biologists. </p>
<p>We engaged with hundreds of scientists from around the world to compile a report, the <a href="https://climade.health/cop28-report">Climate Change and Epidemics 2023 Synthesis</a>, which was launched in Dubai at COP28.</p>
<p>The team members who led the compilation of the report are from the <a href="https://climade.health/wp-content/uploads/2023/11/CLIMADE_COP28Report.pdf">global south</a>.
This is important, as the global south is likely to suffer the largest health effects from climate change.</p>
<p>The report identified three main reasons why climate change may aggravate infectious diseases.</p>
<ul>
<li><p>Increases in temperature and changes in <a href="https://ugc.berkeley.edu/background-content/precipitation/">precipitation patterns</a> create conditions for disease vectors, such as mosquitoes, to flourish and expand their distribution ranges.</p></li>
<li><p>More frequent extreme climatic events such as floods can cause surges of infections, for example by contaminating drinking water with faecal matter.</p></li>
<li><p>Climate-driven migration by people and their livestock can trigger outbreaks of infectious diseases.</p></li>
</ul>
<h2>How are diseases linked to climate change?</h2>
<p>Rising temperatures may create environments conducive for the spread of certain types of pathogens and their vectors. </p>
<p>For example, rising temperatures may increase the breeding rate of disease <a href="https://e360.yale.edu/features/dengue-fever-climate-change">vectors</a>, such as mosquitoes, and the infectious agents they carry, and expand their distribution ranges to new areas. </p>
<p><a href="https://www.health.ny.gov/diseases/communicable/arboviral/fact_sheet.htm#:%7E:text=Arboviral%20disease%20is%20a%20general,such%20as%20mosquitoes%20and%20ticks">Arboviruses</a>, which are transmitted by mosquitoes or ticks,
<a href="https://www.who.int/news-room/fact-sheets/detail/chikungunya#:%7E:text=Chikungunya%20is%20a%20mosquito%2Dborne,meaning%20%E2%80%9Cto%20become%20contorted%E2%80%9D.">chikungunya</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue#:%7E:text=Overview,body%20aches%2C%20nausea%20and%20rash.">dengue</a> now occur in South Asia, South America and Europe in previously unaffected areas.</p>
<p><a href="https://www.nicd.ac.za/diseases-a-z-index/west-nile-fever/">West Nile virus</a> infections can now be acquired <a href="https://www.mdpi.com/1999-4915/12/4/448">north of the Alps</a>. </p>
<p>The changing climate increases the risk for many types of <a href="https://iopscience.iop.org/article/10.1088/2752-5295/ac6e7d/pdf">extreme events</a> such as floods, storms and droughts.</p>
<p>Extreme weather conditions often trigger the displacement of humans and animals, and impair the provision of essential supplies, medical care and transport. </p>
<p>This is particularly true of waterborne pathogens such as cholera. The world is currently in the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON437">seventh cholera pandemic</a>. </p>
<p>In 2022 and 2023, following two severe tropical storms causing widespread flooding and destruction, <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON435">Malawi</a> experienced the deadliest outbreak of cholera in the country’s history. </p>
<p><a href="https://iopscience.iop.org/article/10.1088/2752-5295/ac6e7d/pdf">Droughts</a> also cause infection-related problems. People and their livestock may be forced to use unsafe water sources with higher concentrations of contaminants including water-borne pathogens. Hepatitis E outbreaks occur under conditions of <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-e">water stress</a>.</p>
<p>Lastly, climate change may lead to large-scale displacement and migration of people and animals. The ongoing <a href="https://alliancebioversityciat.org/stories/el-nino-here-what-it-and-what-can-we-do">El Niño phenomenon</a> will likely produce severe drought in some regions of the world, potentially spurring mass temporary and permanent migrations. </p>
<p>This can lead to more and closer interactions with wildlife, which increases the risk of spillover of pathogens, including <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182890/">novel ones</a>. </p>
<h2>Looking after the vulnerable</h2>
<p>Developing countries are more at risk of climate disasters. They also have <a href="https://climade.health/wp-content/uploads/2023/11/CLIMADE_COP28Report.pdf">less adaptive capacity</a> and preparedness to respond, leaving them highly vulnerable. </p>
<p>We call on governments, academic institutions and health organisations to expand genomic surveillance capabilities for early detection and to monitor the spread of infectious diseases. </p>
<p>Vulnerable communities are <a href="https://unfccc.int/sites/default/files/resource/Considerations%20regarding%20vulnerable.pdf">disproportionately affected</a> by climate change. These populations should be prioritised by investing in resilient healthcare systems and disaster preparedness measures. </p>
<h2>Saying no to ‘climate doomism’</h2>
<p>Rather than falling for <a href="https://yaleclimateconnections.org/2022/05/on-climate-doomism-heart-mind-reasons-to-resist-it/">“climate doomism”</a>, which tends to paralyse rather than trigger action, we prefer to learn from what has been achieved during the COVID-19 pandemic.</p>
<p>These achievements include novel epidemiological and infection control tools, including self-testing or smartphone apps, <a href="https://www.nicd.ac.za/diseases-a-z-index/disease-index-covid-19/surveillance-reports/weekly-reports/wastewater-based-epidemiology-for-sars-cov-2-in-south-africa/">wastewater epidemiology</a> and <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/genomic-surveillance.html#:%7E:text=Genomic%20Sequencing%3A%20Scientists%20use%20a,changes%20may%20affect%20public%20health.">genomic sequencing</a> to track the evolution of the agents that cause the disease.</p>
<p>Substantial capacity consisting of skilled people and adequate facilities has been built in much of the global south. This shows what is possible when the world works together. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/qi72DGfodJM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure><img src="https://counter.theconversation.com/content/219723/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prof. Wolfgang Preiser receives funding from various scientific grant funders, directly and indirectly, incl. South African NRF, PRF, NHLS-RT and more. He is affiliated with the University of Stellenbosch and South African National Health Laboratory Service (NHLS).</span></em></p><p class="fine-print"><em><span>Tulio de Oliveira receives funding from the South African Medical Council, the Rockefeller Foundation, the National Insitute of Health (NIH), the European Commission and other charities and government funding agencies. He is affiliated with the Centre for Epidemic Response and Innovation (CERI), Stellenbosch University, South Africa and the Genomics Surveillance Unit (GSU), Wellcome Sanger Institute, U.K.</span></em></p><p class="fine-print"><em><span>Cheryl Baxter, Houriiyah Tegally, and Monika Moir do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Heat, floods and droughts create conditions for pathogens and their vectors.Wolfgang Preiser, Head: Division of Medical Virology, Stellenbosch UniversityCheryl Baxter, Head Scientific Research Support, Stellenbosch UniversityHouriiyah Tegally, Senior Data Analyst, Head of Data Science at Centre for Epidemic Response and Innovation (CERI), Stellenbosch UniversityMonika Moir, Postdoctoral Researcher of Pathogen Genomics, Stellenbosch UniversityTulio de Oliveira, Director: KRISP - KwaZulu-Natal Research and Innovation Sequencing Platform, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2181332023-11-23T11:45:14Z2023-11-23T11:45:14ZIf Kenya wants to help Haiti, it should push for colonial reparations not send in the police<p><em>As the security situation in Haiti deteriorates, <a href="https://www.reuters.com/world/kenyas-parliament-approves-police-deployment-haiti-2023-11-16/">Kenya</a> has offered to lead a new sort of UN mission to the country from 2024. In early October, the UN Security Council <a href="https://www.theguardian.com/world/2023/oct/02/haiti-un-security-force-kenya-gangs">authorised a Multinational Security Support mission</a> led by Kenya to confront the paramilitary-style gangs that control the capital city of Port-au-Prince and other parts of the Caribbean country.</em> </p>
<p><em>We asked <a href="http://www.jennygreenburg.com/research.html">Jennifer Greenburg</a>, who researches the effects of peacekeeping interventions in Haiti, some questions.</em></p>
<h2>What is the context in Haiti?</h2>
<p>The Multinational Security Support mission is a new form of international intervention. It’s authorised under <a href="https://www.un.org/en/about-us/un-charter/chapter-7">Chapter Seven</a> of the UN Charter. However, it’s not formally a peacekeeping mission, which would be composed of peacekeeping forces and (theoretically) regulated according to <a href="https://peacekeeping.un.org/en/standards-of-conduct">UN standards of conduct</a>.</p>
<p>The reticence to call this intervention a peacekeeping mission is a product of recent history. The <a href="https://www.aljazeera.com/opinions/2019/10/15/as-the-un-leaves-haiti-its-victims-still-wait-for-justice">last major UN peacekeeping mission</a> in Haiti – known by its French acronym <a href="https://peacekeeping.un.org/en/mission/minustah">Minustah</a> and which ran from 2004 to 2017 – was responsible for <a href="https://www.fidh.org/IMG/pdf/KeepingthepeaceJusticiaGlobal-4.pdf">killing civilians</a>. Peacekeepers fired machine guns from helicopters in the name of combating gangs in 2005. </p>
<p>Further, after Haiti’s devastating 2010 earthquake, faulty sanitation practices at a UN peacekeepers’ base introduced a <a href="https://law.yale.edu/sites/default/files/documents/pdf/Clinics/Haiti_TDC_Final_Report.pdf#page=6">cholera</a> strain in the country that killed at least 10,000 people. </p>
<p>Peacekeepers also <a href="https://www.hrw.org/news/2020/01/11/un-peacekeeping-has-sexual-abuse-problem">raped</a> and <a href="https://theconversation.com/they-put-a-few-coins-in-your-hands-to-drop-a-baby-in-you-265-stories-of-haitian-children-abandoned-by-un-fathers-114854">sexually abused</a> Haitians.</p>
<p>It’s no mystery why nobody wants to see blue helmets arrive in Haiti again. </p>
<p>The new mission is to be led by Kenya with troops participating from other Caribbean countries, such as Jamaica, the Bahamas, Antigua and Barbuda. The US has <a href="https://apnews.com/article/haiti-violence-united-nations-4acd3429d1bd84020efac538ba6c8746">pledged</a> US$100 million. </p>
<p>More than <a href="https://apnews.com/article/haiti-gang-violence-un-report-killings-5d3f7ff272b7303852869dfc67692a23">2,700 people</a> in Haiti have been reported murdered and 1,472 kidnapped in the eight months to June 2023, according to the UN. The numbers are likely to be higher. They don’t include indirect deaths caused by inadequate access to healthcare and nutrition, which is exacerbated by insecurity.</p>
<h2>What will the Kenyan police confront in Haiti?</h2>
<p>The question of whether they will go is still not decided.</p>
<p>Kenya’s <a href="https://www.bbc.com/news/world-africa-67437951">parliament</a> has approved the mission but a court hearing on its constitutionality is scheduled for 26 January 2024. </p>
<p>If Kenya does deploy to Haiti, its police officers will confront a <a href="https://www.cornellpress.cornell.edu/book/9781501746994/street-sovereigns/">complex</a> web of <a href="https://www.pbs.org/newshour/world/gangs-take-control-in-haiti-as-democracy-withers">more than 200 paramilitary-style criminal gangs</a>. They control territory across the capital city of Port-au-Prince and many other areas of the country. </p>
<p>Haiti’s insecurity and poverty are rooted in its punishment for winning freedom from racial slavery in 1804. <a href="https://theconversation.com/when-france-extorted-haiti-the-greatest-heist-in-history-137949">France forced Haiti</a> to <a href="https://www.nytimes.com/2022/05/20/world/americas/haiti-history-colonized-france.html">repay</a> French slaveholders. This instigated a cycle of indebtedness and is how Haiti became, in the words of Haitian poet <a href="https://www.usip.org/publications/2008/12/toward-end-poverty-haiti#:%7E:text=In%20July%202006%2C%20Haitian%20poet,as%20described%20in%20the%20media.">Jean-Claude Martineau</a>, the only country with a last name: “the <a href="https://www.worldbank.org/en/country/haiti/overview">poorest country</a> in the western hemisphere”.</p>
<p>Security was already in crisis before the 2021 <a href="https://theconversation.com/slain-haitian-president-faced-calls-for-resignation-sustained-mass-protests-before-killing-164131">assassination of de facto president Jovenel Moïse</a>. Today, gangs control about <a href="https://apnews.com/article/haiti-gangs-democracy-at-risk-7ddcea955fdd364e2b574e28daa71d03">two-thirds</a> of the country, which has a population of <a href="https://data.worldbank.org/indicator/SP.POP.TOTL?locations=HT">11.6 million</a>. </p>
<p>There are more <a href="https://nacla.org/news/2021/political-anatomy-haiti-armed-gangs">guns</a> in Haiti now than before the last peacekeeping mission that ended in 2017. Like Haitian police, Kenyan police may find themselves <a href="https://www.theguardian.com/world/2023/feb/02/haiti-cops-outgunned-gangs">outgunned</a> by gangs who control (and trade in) vast troves of weapons.</p>
<p>Without in-depth knowledge of a complex and volatile situation, Kenyan police will somehow have to distinguish civilians from gang members, and gang members from police. </p>
<p>The notorious leader of the “G-9 Family and Allies”, <a href="https://www.aljazeera.com/news/2022/10/21/who-is-haitis-sanctioned-gang-leader-jimmy-barbecue-cherizier">Jimmy “Barbecue” Chérizier</a>, is a former police officer. Lines between police, government and gangs are deliberately blurred. </p>
<p>Chérizier is one of multiple gangsters, police officers and government officials implicated in the <a href="https://hrp.law.harvard.edu/wp-content/uploads/2022/10/Killing_With_Impunity-1.pdf">2018 massacre</a> of at least 70 civilians.</p>
<p>After the assassination of <a href="https://www.bbc.com/news/world-latin-america-57762246">Moïse</a>, the same political party responsible for this and <a href="https://web.rnddh.org/massacres-in-bel-air-and-cite-soleil-under-the-indifferent-gaze-of-state-authorities/?lang=en">multiple other massacres</a> remains in power. It continues to collude with gangs. </p>
<p>The Kenyan mission is allegedly coming to Haiti at the <a href="https://www.aljazeera.com/news/2023/10/3/why-kenya-volunteered-to-lead-un-mission-to-haiti">request</a> of the Haitian government. But this government <a href="https://nacla.org/haiti-jovenel-moise-assassination-social-movements">doesn’t represent Haitian people</a>. It has massacred civilians by supplying gangs with information, weapons and uniforms through the police. </p>
<p>There is also a language issue: Kenyan troops speak English and Swahili. Haitians speak Krèyol and French.</p>
<h2>What are the concerns about Kenya’s police?</h2>
<p>The security support mission to Haiti will largely comprise Kenyan police, whom Kenyan civilians have described as treating them “<a href="https://theworld.org/stories/2016-05-23/police-officers-treat-nairobi-neighborhood-atm-machine-residents-say">like ATM machines</a>”. Extrajudicial <a href="https://web.archive.org/web/20230601015425/https://www.matharesocialjustice.org/who-is-next/">executions</a>, <a href="https://theconversation.com/the-art-of-bribery-a-closeup-look-at-how-traffic-officers-operate-on-kenyas-roads-185551">extortion</a> and <a href="https://www.citizen.digital/news/kenya-police-have-killed-15-people-injured-31-in-covid-19-curfew-enforcement-ipoa-334522">abuse</a> are well-documented practices of the police force now charged with restoring legitimate policing in Haiti. </p>
<h2>What’s in it for Kenya?</h2>
<p>Kenya stands to benefit economically from leading the mission. In September, the US and Kenya signed a <a href="https://apnews.com/article/kenya-united-states-haiti-defense-austin-ed1496d72b426011f3e8a36a971ca12d">defence agreement</a> that gives Kenya resources and support to fight <a href="https://theconversation.com/why-al-shabaab-targets-kenya-and-what-the-country-can-do-about-it-87371">Al-Shabaab</a>. </p>
<p>Kenya’s own <a href="https://mod.go.ke/kenyas-peace-keeping-missions/#:%7E:text=Kenya%20has%20however%20remained%20cautious,little%20in%20peace%20enforcement%20operations.">defence ministry</a> has publicly stated that UN missions provide</p>
<blockquote>
<p>a rare opportunity to obtain UN allowances that are ordinarily not offered by the KDF (Kenya Defence Forces). </p>
</blockquote>
<p>Peacekeeping missions have also been an opportunity to gain international <a href="https://www.academia.edu/86172749/The_Strong_Arm_and_the_Friendly_Hand_Military_Humanitarianism_in_Post_earthquake_Haiti">credibility</a>, as my research in Haiti has shown. </p>
<h2>If not policing, what’s the best approach to solving Haiti’s crisis?</h2>
<p>Change in Haiti will not come through yet another UN or <a href="https://foreignpolicy.com/2023/11/07/haiti-kenya-invasion-gang-war-united-states/">outsourced</a> US intervention. </p>
<p>Speaking after UN approval of the Haiti mission, Kenya’s president William Ruto <a href="https://www.youtube.com/watch?v=boCWMX3t0h8">said</a> Haitians were being punished for “choosing to be free human beings”. He was referring to the <a href="https://www.britannica.com/topic/Haitian-Revolution">country’s independence in 1804</a>. </p>
<p>In 2013, Britain agreed to <a href="https://www.theguardian.com/world/2013/jun/06/uk-compensate-kenya-mau-mau-torture">compensate</a> 5,228 Kenyans who were tortured during the Mau Mau uprising against the colonial regime in the 1950s. Although the money hardly restores the dignity and livelihoods lost through colonialism, the decision to settle and award each claimant approximately US$4,000 is historic. </p>
<p>Real change for Haiti would begin with reparations. </p>
<p>If international bodies would only listen, <a href="https://www.haitiwatch.org/home/commissionforhaitiansolution">Haitian groups</a> representing broad swathes of civil society have been <a href="https://theworld.org/stories/2021-11-22/it-us-haitians-find-solution-haiti-crisis-adviser-says">vocal</a> about <a href="https://akomontana.ht/en/home/">what they want</a> and their <a href="https://www.democracynow.org/2023/10/4/haiti_united_nations_forces">opposition</a> to a Kenyan-led intervention. </p>
<p>Money owed and respect deserved would be a more productive first step forward than <a href="https://jonathanmkatz.com/bigtruck">recycling</a> <a href="https://www.rutgersuniversitypress.org/killing-with-kindness/9780813553634/">pages</a> from the international community’s <a href="https://us.macmillan.com/books/9781250284679/aidstate">playbook</a>. We need only look at Haiti today to see what violence this playbook has wrought.</p><img src="https://counter.theconversation.com/content/218133/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Greenburg receives funding from the Carnegie Corporation of New York. She has previously received funding from the National Science Foundation, the Social Science Research Council, the Association of American Geographers, Stanford University, the Watson Institute for International and Public Affairs at Brown University, and the Department of Geography and the Graduate Division at the University of California, Berkeley. She is the author of At War with Women: Military Humanitarianism and Imperial Feminism in an Era of Permanent War (Cornell University Press).
</span></em></p>The security situation in Haiti must change – but another UN intervention may not be the way this happens.Jennifer Greenburg, Lecturer in International Relations, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2082092023-06-27T10:32:12Z2023-06-27T10:32:12ZCholera: vaccines can stop the spread, but the biggest deterrent is clean water<figure><img src="https://images.theconversation.com/files/533991/original/file-20230626-15-fqsnjg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A member of the Syria Immunization Team holding cholera vaccinations.
</span> <span class="attribution"><span class="source">Anas Alkharboutli/picture alliance via Getty Images</span></span></figcaption></figure><p><em>South Africa has experienced outbreaks of cholera since January. The worst was in May in Hammanskraal, north of Pretoria, where <a href="https://www.gov.za/speeches/health-update-response-cholera-outbreak-south-africa-8-jun-2023-0000">nearly 30 people</a> died. Cholera is a bacterial disease which spreads via the faecal-oral route mostly through ingestion of contaminated food and water. It causes severe diarrhoea and dehydration, and in extreme cases death. The source of the outbreak in Hammanskraal is still not known. The World Health Organization (WHO) <a href="https://www.gtfcc.org/wp-content/uploads/2020/05/gtfcc-cholera-outbreak-response-field-manual.pdf">recommendations</a> for responding to a cholera outbreak include ensuring that communities have access to safe drinking water and sanitation, and treating sick people quickly. Oral cholera vaccines may be considered to contain ongoing outbreaks and to limit the spread. These vaccines have not been administered during the current outbreak in South Africa. The Conversation Africa spoke to vaccinologists Edina Amponsah-Dacosta and Julie Copelyn about the cholera vaccine and other ways to curb the outbreak.</em></p>
<hr>
<h2>Where do vaccines fit into the picture? How do they work?</h2>
<p>Poor access to safe water and sanitation are the key driving factors behind cholera transmission. Ensuring access to clean potable water, adequate sanitation and promoting hygiene practices are critical to preventing the disease. </p>
<p>Vaccinations are a <a href="https://pubmed.ncbi.nlm.nih.gov/29555219/">complementary</a> prevention and control strategy. These are particularly useful in endemic areas, outbreaks and humanitarian crises.</p>
<p>The aim of vaccination is to prevent infection with the bacterium that causes cholera: <em>Vibrio cholerae</em>. Vaccination can also reduce the risk of severe illness that requires hospitalisation. </p>
<p>The first widely used cholera vaccines were injectable formulations. They were first developed in the late 19th and early 20th centuries. But they had <a href="https://doi.org/10.1002%2F14651858.CD000974.pub2">side effects</a> like headaches, malaise, nausea, fever and rash and offered only limited immune protection.</p>
<p>In the <a href="https://pubmed.ncbi.nlm.nih.gov/21498389/">1980s</a> these vaccines were replaced by safer and more effective oral cholera vaccines. </p>
<p>The WHO has prequalified two types of oral cholera vaccines for commercial use globally. (This means it has assessed and assured their quality, safety and efficacy.) The prequalified vaccines consist of inactivated strains of <em>V. cholerae</em> only (Shanchol™ and Euvichol®); or in combination with a harmless form of the bacterial toxin (Dukoral®). Exposure to these inactivated or “killed” bacteria trigger the body to generate an immune response in the gut mucosa - the primary site of infection. This immune response is protective against future infection with the bacteria.</p>
<p>Studies have <a href="https://www.mdpi.com/2076-393X/9/12/1482">shown</a> that oral cholera vaccines are effective at preventing disease in the person who is vaccinated. It can also confer <a href="https://www.mdpi.com/2076-393X/9/12/1482">indirect or herd protection</a> by reducing the spread of <em>V. cholerae</em> within a highly vaccinated community. </p>
<p>New generation <a href="https://www.annualreviews.org/doi/abs/10.1146/annurev-micro-041320-033201">oral and injectable cholera vaccines</a> are currently in development.</p>
<h2>Who should be vaccinated and when?</h2>
<p>The decision to vaccinate should be informed by your level of risk, and how frequent and widespread the outbreak is.</p>
<p>The best time to administer oral cholera vaccines is before a person is exposed to the bacteria. </p>
<p>The WHO <a href="https://pubmed.ncbi.nlm.nih.gov/29555219/">recommends</a> vaccination with oral cholera vaccines in areas where cholera occurs regularly and in areas where there could be large outbreaks or epidemics of cholera. This includes humanitarian crisis situations. In such settings, access to safe water supplies and adequate sanitation may be hampered. Widespread vaccination is required in these settings to interrupt further spread of cholera.</p>
<p>In countries where outbreaks aren’t frequent, such as South Africa, mass vaccination against cholera is not necessary. Vaccination is not a replacement for provision of safe drinking water, adequate sanitation and good hygiene practices.</p>
<p>Under the current circumstances in South Africa, vaccination should be limited to those at high risk: people in continuous direct contact with cholera patients, working with laboratory specimens, or frequently exposed to contaminated food and water.</p>
<p>After complete vaccination it takes the body seven to 10 days to produce protective antibodies. Scientific evidence on how long this protection lasts is still developing. <a href="https://doi.org/10.3390/vaccines9121482">Existing evidence</a> suggests that immune protection from oral cholera vaccines could last for up to three years. </p>
<h2>What else can be done to avoid cholera?</h2>
<p>During sporadic cholera outbreak situations such as the current outbreak in South Africa, the priority should be early detection and appropriate management of people who have been infected. Water, sanitation and hygiene interventions must be implemented immediately in affected communities to interrupt further spread. </p>
<p>Such interventions include making safe drinking water accessible in instances where the water supply may be contaminated or unreliable, improving sanitation, and raising awareness about the importance of frequent hand-washing with soap and clean water. In addition, active disease surveillance must take place to monitor transmission patterns. </p>
<p>The current cholera outbreak in South Africa is a rude awakening. It suggests that the country may not have adequately applied the <a href="https://pubmed.ncbi.nlm.nih.gov/11203732/">lessons</a> learnt from <a href="https://www.nicd.ac.za/assets/files/CommDisBullMay09_Vol0702.pdf">previous outbreaks</a>. The most recent major outbreak affected all nine provinces with 1144 laboratory-confirmed cases and 64 deaths recorded between November 2008 and April 2009. </p>
<p>This is a reminder of the inequities and gaps in social development, as well as the unacceptable state of the country’s <a href="https://theconversation.com/cholera-in-south-africa-a-symptom-of-two-decades-of-continued-sewage-pollution-and-neglect-206141">wastewater treatment systems</a>. </p>
<p>Ultimately, if effective control of cholera is to be achieved, local authorities must execute their responsibility of ensuring that all citizens have access to safe water supply and adequate sanitation. </p>
<p>In addition, supporting cholera control efforts in neighbouring countries will reduce the risk of importation. This will require prioritisation in the African public health agenda backed by intensified investments in water, sanitation and hygiene interventions and oral cholera vaccines. </p>
<p>Fortunately, the South African-based bio-pharmaceutical company Biovac <a href="https://www.dst.gov.za/index.php/media-room/latest-news/3812-biovac-signs-deal-to-develop-and-manufacture-oral-cholera-vaccine-for-african-and-global-markets">recently secured the rights</a> to manufacture oral cholera vaccines. This is a significant step in meeting the growing demand for the vaccine across the region.</p><img src="https://counter.theconversation.com/content/208209/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The aim of vaccination is to prevent infection. In addition, vaccination is intended to reduce the risk of severe illness.Edina Amponsah-Dacosta, Research Officer / EIDM Specialist, University of Cape TownJulie Copelyn, Senior lecturer, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2055152023-06-15T06:09:04Z2023-06-15T06:09:04ZMeasles and whooping cough outbreaks in South Africa: a sign of low vaccination coverage, experts warn<figure><img src="https://images.theconversation.com/files/530906/original/file-20230608-12385-a4sqhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Caregivers are conflicted about vaccinating their children. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>The concentrated global effort to use vaccination as a public health intervention began in <a href="https://www.who.int/news-room/fact-sheets/detail/immunization-coverage">1974</a>. Since then, vaccination has changed our lives. Worldwide, in the decades 2000-2020, childhood vaccination led to the reduction of deaths in children under 5 by 50% to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31891-9/fulltext">5.4 million deaths</a> per year. Vaccination currently averts more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32657-X/fulltext">5 million deaths</a> each year <a href="https://www.youtube.com/watch?app=desktop&v=vfAcG_ur27g">worldwide</a>. These are deaths that would have been caused by measles, whooping cough, tetanus, polio, diphtheria, pneumonia, rotavirus diarrhoea, and other <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32657-X/fulltext">vaccine-preventable diseases</a>. But in recent months there have been numerous outbreaks of these diseases. Scientists from the South African Medical Research Council explain why these diseases continue to threaten children’s health in the country.</em></p>
<hr>
<h2>The country currently has outbreaks of several diseases. What are they?</h2>
<p>There is an increased spread of <a href="https://www.nicd.ac.za/south-african-measles-outbreak-update-2023-9-june-2023/">measles</a> in South Africa now.</p>
<p>Measles is a highly infectious disease that spreads through droplets. It is the second most frequently reported disease outbreak in Africa after cholera. It accounts for 11.5% of all reported disease <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/infectious-disease-outbreaks-in-the-african-region-overview-of-events-reported-to-the-world-health-organization-in-2018/A504999B25CBA5E179B951FABB8CFE53">epidemics on the continent</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-a-history-of-the-measles-virus-and-why-its-so-tenacious-130262">Explainer: a history of the measles virus and why it's so tenacious</a>
</strong>
</em>
</p>
<hr>
<p>Children who have not been vaccinated against measles are at high risk of the disease and its complications. These include pneumonia, brain damage, and death. Measles is one of the most dangerous but preventable childhood diseases. Up to <a href="http://www.samj.org.za/index.php/samj/article/view/6196/4933">10% of children</a> under five years of age who develop measles die from complications of the disease. </p>
<p>An effective vaccine against measles has been available for decades. A child requires two doses of the measles vaccine to develop protective immunity against the disease. The two doses of the measles vaccine are given at 6 and 12 months of age in South Africa. At least 95% coverage of 2 doses of the measles vaccine is required for herd immunity against <a href="https://www.who.int/news-room/fact-sheets/detail/measles">measles</a> and protect those who aren’t able to get vaccinated.</p>
<p>Another highly infectious disease that has recently seen an increase in cases in South Africa is pertussis, also referred to as <a href="https://www.nicd.ac.za/an-increase-in-pertussis-cases-13-dec-2022/">whooping cough</a>. Pertussis spreads easily from person to person through droplets produced by coughing or sneezing. Complications of whooping cough include pneumonia, seizures, brain damage, and death. The best way to prevent pertussis is through <a href="https://www.who.int/health-topics/pertussis#tab=tab_2">vaccination</a>. </p>
<h2>These diseases are preventable. What’s behind the spread?</h2>
<p>The resurgence of vaccine-preventable diseases in South Africa is due to immunity gaps caused by low vaccination coverage. A <a href="https://www.health.gov.za/wp-content/uploads/2022/03/National-EPI-Coverage-Survey_Final-full-report-Dec-2020.pdf">national survey</a> conducted from July to December 2019 found that only 81% of children had received all their vaccine doses scheduled up to 12 months of age in South Africa. This percentage has increased only slightly to <a href="https://www.who.int/data/gho/data/themes/topics/immunization-coverage">82%</a> since then, according to estimates from the World Health Organization (WHO) and the United Nations Children Fund (UNICEF).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/south-africas-immunisation-record-risks-being-dented-by-anti-vaccination-views-153549">South Africa's immunisation record risks being dented by anti-vaccination views</a>
</strong>
</em>
</p>
<hr>
<h2>What’s the cause of the gaps in immunisation?</h2>
<p>Over the last two years, routine immunisation services and coverage of essential childhood vaccines have been disrupted. And many <a href="https://www.who.int/news/item/24-04-2023-global-partners-announce-a-new-effort-the-big-catch-up-to-vaccinate-millions-of-children-and-restore-immunization-progress-lost-during-the-pandemic">catch-up vaccination efforts</a> have been postponed due to the COVID-19 pandemic. This has led to an increase in the number of children who are unvaccinated or under-vaccinated. </p>
<p>The country’s low vaccination coverage is due to both <a href="https://doi.org/10.1002/14651858.CD013265.pub2">supply and demand issues</a>. These relate to the provision of vaccines and the population’s decision to vaccinate. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378923/pdf/CD013265.pdf">Structural barriers</a> such as vaccine availability and access to health facilities are well known to reduce vaccination coverage. </p>
<p>Research also <a href="https://www.tandfonline.com/doi/pdf/10.1080/21645515.2018.1460987?needAccess=true&role=button">suggests</a> that social and psychological factors, such as concerns about the safety and efficacy of vaccines, influence decisions around vaccination. Some caregivers are conflicted about vaccinating their children. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/unpacking-parents-reasons-for-not-vaccinating-their-children-why-it-matters-171527">Unpacking parents' reasons for not vaccinating their children: why it matters</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-05/mhst1-1201.pdf">Vaccine hesitancy</a> represents a motivational state of being conflicted about or opposed to vaccination. Evidence from several studies conducted in South Africa has shown a significant <a href="https://www.tandfonline.com/doi/pdf/10.1080/14760584.2021.1949291">increase in vaccine hesitancy</a>. This has had a dramatic impact on routine immunisation services and ultimately reduced vaccine coverage over the years.</p>
<h2>What steps can be taken to close these gaps?</h2>
<p>Globally, many initiatives exist to improve childhood immunization, especially in low- and middle-income countries. Within the context of the Immunization Agenda 2030 (IA2030) programme, WHO, UNICEF and Gavi, are launching the <a href="https://www.who.int/news/item/24-04-2023-global-partners-announce-a-new-effort-the-big-catch-up-to-vaccinate-millions-of-children-and-restore-immunization-progress-lost-during-the-pandemic">“Big Catch-Up”</a> initiative. This initiative aims to support countries like South Africa to plan and implement intensified efforts to bolster immunisation. It has three main objectives: </p>
<ul>
<li><p>to reach children who missed vaccination during 2020-2022 for catch-up vaccination</p></li>
<li><p>to restore vaccination coverage to the last best coverage in 2019 </p></li>
<li><p>to strengthen immunisation programmes to reach the under-vaccinated and unvaccinated children. </p></li>
</ul>
<p><a href="https://bmjopen.bmj.com/content/bmjopen/12/11/e058258.full.pdf">Interventions</a> that are focused on improving the healthcare system include cold-chain infrastructure improvements to ensure availability and access to vaccines. Some other <a href="https://www.tandfonline.com/doi/epdf/10.1080/21645515.2016.1221553?needAccess=true&role=button">interventions</a> that can improve uptake of vaccines include using motivational posters or flyers, sending reminders (messages or letters), and material or monetary incentives to caregivers or pay-for-performance schemes for healthcare workers providing vaccinations to children. </p>
<p>Informing and providing education to caregivers and healthcare workers has also been <a href="https://bmjopen.bmj.com/content/bmjopen/12/11/e058258.full.pdf">effective</a> increasing vaccination in children in cases where parents were hesitant. However, not enough research is done on interventions to dispel misinformation and misconception regarding immunisation, which is one of the leading causes of vaccine hesitancy.</p><img src="https://counter.theconversation.com/content/205515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Duduzile Ndwandwe receives funding from the South African Medical Research Council. She is affiliated with Eh! Woza, a non-profit Organization for public engagement. </span></em></p><p class="fine-print"><em><span>Charles Shey Wiysonge and Lindi Mathebula do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Over the last two years, routine immunisation services and coverage of essential childhood vaccines have been disrupted.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilDuduzile Ndwandwe, Deputy Director and Specialist Scientist , South African Medical Research CouncilLindi Mathebula, Project Manager, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2075382023-06-14T13:34:37Z2023-06-14T13:34:37ZWater quality in South Africa: reports show what needs to be fixed, and at what cost<figure><img src="https://images.theconversation.com/files/531921/original/file-20230614-15-99hkpp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Michele Spatari /AFP via Getty Images</span></span></figcaption></figure><p>The citizens of Hammanskraal, a small town north of South Africa’s capital, Tshwane, have been dealing with the deaths of 23 residents from cholera since 23 May 2023. Tests to find the source are continuing. The initial assumption by residents and authorities was that poor quality water led to the outbreak. In one week in May, 163 patients were <a href="https://www.gov.za/speeches/minister-joe-phaahla-updates-cholera-outbreak#:%7E:text=The%20current%20outbreak%20of%20Cholera,returned%20on%2030%20January%202023.">admitted</a> to the Jubilee Hospital with diarrhoea and vomiting.</p>
<p>In 2019 the South African Human Rights Commission <a href="https://www.sahrc.org.za/index.php/sahrc-media/news/item/2089-water-warning-for-hammanskraal-residents-issued-by-sahrc">confirmed</a> what residents already knew. The samples the commission drew from Temba Water Treatment Works, Kekana Primary School, Refentse Clinic and Hammanskraal Secondary School revealed that the water was unfit for human consumption.</p>
<p>Hammanskraal illustrates a much wider and deeper problem in the country. The problem is highlighted by <a href="https://ws.dws.gov.za/IRIS/latestresults.aspx">reports recently released</a> by the Department of Water and Sanitation. These watch reports give an update on the status of water treatment, wastewater treatment and water losses. The Blue Drop, Green Drop, and No Drop Watch Reports each present an interim analysis of the deteriorating status of water services in the country.</p>
<p>These latest reports are welcomed and place the spotlight on South Africa’s capability to deal with water resources. The reporting programme was <a href="https://www.gov.za/speeches/minister-senzo-mchunu-release-blue-drop-watch-report-no-drop-watch-report-and-green-drop">introduced</a> in 2008. The reports were not published since 2014.</p>
<p>However, recent Drop Water Reports suggest a fresh leadership is emerging within the Department of Water and Sanitation. And, from the language in the introduction, the department appears to be better positioned than before in demanding greater accountability from municipalities as well as offering them support. </p>
<p>All three reports are very specific in identifying the condition of treatment plants and water infrastructure. They identify what needs to be fixed or maintained and at what cost. This level of intent hasn’t been visible before.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/south-africas-drinking-water-quality-has-dropped-because-of-defective-infrastructure-and-neglect-new-report-207267">South Africa's drinking water quality has dropped because of defective infrastructure and neglect – new report</a>
</strong>
</em>
</p>
<hr>
<p>It is also worth recognising how some municipalities are performing well in difficult circumstances. The Linton water treatment works in the Nelson Mandela Bay municipality is a good example. The city and region have been in the grip of prolonged drought <a href="https://www.globalcitizen.org/en/content/south-africas-nelson-mandela-bay-water-crisis/">since 2015</a> but have managed to achieve excellent water quality standards. </p>
<p>The reports are the first stage in informing actions and mitigation measures. Overall they identify the need for better governance, monitoring and reporting and an improvement of systems.</p>
<h2>Latest update</h2>
<p>The summary findings of the Department of Water and Sanitation’s reports recently <a href="https://www.gov.za/speeches/minister-senzo-mchunu-release-blue-drop-watch-report-no-drop-watch-report-and-green-drop">released</a> are as follows:</p>
<ul>
<li><p>The <a href="https://ws.dws.gov.za/IRIS/releases/BDWR.pdf">Blue Drop Watch Report</a> is about microbiological and chemical water quality. It shows that only 38% of water treatment systems achieved excellent microbiological water quality for more than 99% of the time, while 11% achieved good microbiological quality between 97% and 99% of the time. The remaining 51% of 151 water supply systems in the sample had poor to bad microbiological water quality status. The majority of treatment plants (71%) failed to achieve chemical compliance. But in 2012 only <a href="https://www.gov.za/speeches/minister-senzo-mchunu-release-blue-drop-watch-report-no-drop-watch-report-and-green-drop">10% of municipalities</a> had bad or poor microbiological water quality. The decline is staggering.</p></li>
<li><p>The <a href="https://ws.dws.gov.za/iris/releases/Report_DPW_Rev02_29Mar22_MN%20web.pdf">Green Drop Watch Report</a> identified 334 municipal wastewater treatment works that showed a general deterioration from medium (65.4%) status of compliance to high risk (70.1%). More evidence of decline. What’s more, the Department of Water and Sanitation <a href="https://www.dws.gov.za/documents/Watch%20Reports%206%20June%202023sp7.pptx">issued</a> directives to these failing municipalities with plants in a critical state, but only 50% responded with plans to address the issues at these plants. </p></li>
<li><p>The <a href="https://ws.dws.gov.za/IRIS/releases/NDWR.pdf">No Drop Watch Report</a> is the final element in a volley of bad news. It accounts for the country’s water losses from leakages and non-revenue water. The report refers to the situation in 2015 when it was estimated that 35% of South Africa’s water was unaccounted for; new estimates in the most recent report suggest that it has risen to around 50%.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cholera-in-south-africa-a-symptom-of-two-decades-of-continued-sewage-pollution-and-neglect-206141">Cholera in South Africa: a symptom of two decades of continued sewage pollution and neglect</a>
</strong>
</em>
</p>
<hr>
<h2>Overwhelming challenges</h2>
<p>South Africa’s <a href="https://www.gov.za/documents/national-water-act">National Water Act 36 of 1998</a> was hailed by the <a href="https://www.wrc.org.za/wp-content/uploads/mdocs/14%20Water%20law%20p%2038-41.pdf">international community</a> as one of the most progressive, radical and admired legislative measures worldwide. </p>
<p>It established the right to clean water for everyone. And it addressed the issue of equality of access.</p>
<p>But in the intervening years the well-intentioned legislation has been hobbled by poor strategic planning, limited investments and governance.</p>
<p>The Department of Water and Sanitation <a href="https://ws.dws.gov.za/iris/releases/Report_DPW_Rev02_29Mar22_MN%20web.pdf">acknowledges</a> that water services are being hampered by several factors. These include:</p>
<ul>
<li><p>a lack of funding, </p></li>
<li><p>vandalism and theft, </p></li>
<li><p>sewage losses before reaching the treatment works, </p></li>
<li><p>construction and contractor issues such as not meeting deadline or quality objectives, </p></li>
<li><p>lack of cooperation by municipalities, </p></li>
<li><p>lack of capacity among Department of Water and Sanitation enforcement officials, and </p></li>
<li><p>ongoing deterioration of infrastructure, processes and effluent quality. </p></li>
</ul>
<h2>Way forward</h2>
<p>The Watch Drop Water interim reports confirm that the government recognises the scale of the problems. The water and sanitation minister, Senzo Mchunu, <a href="https://ws.dws.gov.za/IRIS/latestresults.aspx">confirms</a> that the reports identify the urgent need for better governance, monitoring, reporting, operating procedure and investment in infrastructure. Revealing the truth and reporting the evidence is a step in the right direction.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/basic-water-services-in-south-africa-are-in-decay-after-years-of-progress-185616">Basic water services in South Africa are in decay after years of progress</a>
</strong>
</em>
</p>
<hr>
<p>But there needs to be greater cooperation between the Department of Water and Sanitation and municipalities that are struggling to deliver services. Provincial governments are important bridge builders in improving cooperation, but it is going to take a lot more determination from multiple stakeholders, including the private sector, academia and willing citizens. Cooperation comes in many forms, but is most likely to be strengthened by an approach to governance that is open to collaboration, innovation, strategic leadership and transparency in reporting. Transparency is one reason why the watch reports are necessary and critical to inform the public and the department.</p>
<p>Lastly, South Africa needs to build a stronger economy as a key priority so that it can invest in water infrastructure and services. It should be obvious that better investment in water infrastructure and services means better healthcare and prevention of diseases.</p><img src="https://counter.theconversation.com/content/207538/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Winter does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Good legislation has been undermined by poor planning, limited investment and governance, but recent water reports suggest the government recognises the scale of the problems.Kevin Winter, Senior Lecturer in Environmental & Geographical Science, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2072672023-06-09T13:16:47Z2023-06-09T13:16:47ZSouth Africa’s drinking water quality has dropped because of defective infrastructure and neglect – new report<figure><img src="https://images.theconversation.com/files/531085/original/file-20230609-15-h066xs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The report shows decline in the status of the country's water supply.</span> <span class="attribution"><span class="source">Michele Spatari / AFP via Getty Images</span></span></figcaption></figure><p>A report <a href="https://ws.dws.gov.za/IRIS/latestresults.aspx">released</a> by the South African government paints a grim picture of the country’s water resources and water infrastructure as well as the overall quality of its drinking water.</p>
<p>The Blue Drop Watch Report – an interim report because it only assessed a sample of the facilities across the country – focused on the condition of the drinking water infrastructure and treatment processes from a technical standpoint. It also reported on water quality. </p>
<p>The issues of <a href="https://ws.dws.gov.za/IRIS/releases/GDWR.pdf">biggest concern</a> that it identified included a collapse of the country’s wastewater treatment works and a sharp rise in the number of local authorities that are failing to meet minimum compliance standards.</p>
<p>The report records continued overall decline in the status of the country’s water supply services. The findings point to a culture of neglect, non-compliance and systemic collapse. The current cholera outbreak in the country should, therefore, come as no surprise. The interim report shows dysfunctional local municipalities and non-compliant wastewater treatment works.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cholera-in-south-africa-a-symptom-of-two-decades-of-continued-sewage-pollution-and-neglect-206141">Cholera in South Africa: a symptom of two decades of continued sewage pollution and neglect</a>
</strong>
</em>
</p>
<hr>
<p>The systemic collapse has been attributed to poor operation, defective infrastructure, the absence of disinfection chemicals, lack of monitoring and an overall lack of operating and chemistry knowledge.</p>
<p>The report shows that the Department of Water and Sanitation issued non-compliance letters to 244 wastewater treatment works in 2022. But only 50% had responded almost a year later.</p>
<p>The report shows a clear and rapid decline in the performance of local government. But only 43 out of <a href="https://www.gov.za/about-government/government-system/local-government#:%7E:text=supporting%20service%20delivery.-,Municipalities,and%20providing%20infrastructure%20and%20service.">205</a> local municipalities have asked for assistance from the department. They are able to ask for financial support and assistance to help with capacity building and skills development. </p>
<h2>Drinking water quality</h2>
<p>Only a test sample of some of the country’s facilities was conducted. Assessments were made of 151 water supply systems – <a href="https://ws.dws.gov.za/IRIS/releases/2021_BD_PAT_report_final-28Mar22_MN_web.pdf">out of the total 1,186</a> – managed by 140 local municipalities. In addition, 26 water boards and bulk water service providers were assessed. The assessments were done between November 2022 to February 2023. </p>
<p>Most of the treatment plants in the sample were found to be failing to produce acceptable drinking water according to the <a href="https://vinlab.com/wp-content/uploads/2022/10/SANS-241-2015-1.pdf">SANS 241:2015</a> drinking water standards.</p>
<p>Over 60 systems (41%) of the sample had bad water quality. Another 13 systems (9%) had poor water quality. This meant that it didn’t meet clean water <a href="https://alabbott.co.za/wp-content/uploads/2020/02/abbott_sans_241_test_requirements.pdf">standards</a> because of high levels of contaminants such as wastewater and excrement. </p>
<p>Contaminated water poses acute health risks. It is responsible for water-related illnesses such as cholera. </p>
<p>Only 50% of the assessed treatment plants produced drinking water of a suitable quality not contaminated by sewage or other pathogens or chemicals.</p>
<p>A number of water supply systems were flagged as being in a critical condition, requiring urgent intervention. </p>
<p>The report also noted that 11 of the 140 municipalities that were assessed had no water quality monitoring systems in place or no evidence of any water testing. </p>
<h2>Wastewater treatment works</h2>
<p>Wastewater treatment works are assessed in accordance with the set <a href="http://www.salga.org.za/Documents/Municipalities/Guidelines%20for%20Municipalities/Hints_and_Tips.pdf">Green Drop audit standards</a>. Of the total 850 wastewater treatment works assessed, 334 (39%) received scores below 31% and were placed under regulatory surveillance. Overall, the country’s wastewater treatment works are in a poor to critical state, posing significant risks to public health and to the environment.</p>
<p>South Africa’s Wastewater Treatment Works Preliminary Report Card:</p>
<ul>
<li><p>208 are at critical risk (24%) – indicating dysfunctional and unsatisfactory performance, with major corrections required. </p></li>
<li><p>250 are at high risk (29%) – indicating partial functionality and unsatisfactory performance, with major corrections required. </p></li>
<li><p>Half are in poor to bad condition. This is up from 10% in the 2014/2015 auditing period.</p></li>
<li><p>The North West province recorded the highest proportion of wastewater treatment works at critical risk (60%), followed by the Northern Cape (59%) and the Free State (44%). Limpopo has 38% of its plants at critical risk and 48% as high-risk plants, placing the bulk of its treatment facilities in a vulnerable state.</p></li>
</ul>
<p>Other major issues reflected in the report were: </p>
<ul>
<li><p>Only 25 systems (17%) achieved excellent water quality and 20 systems (13%) good water quality, while 106 systems (70%) failed to achieve chemical compliance. A worrying 83 systems (55%) have bad water quality compliance and 23 systems (15%) have poor water quality compliance. </p></li>
<li><p>Under 40% of systems were compliant on microbiological parameters (pathogens and bacteria such as faecal coliform, E. coli and cholera). Just over 10% were partially compliant. </p></li>
<li><p>Only 5% of plants were in a state of high compliance. The rest were in a poor or critical condition (64%) or had some degree of compliance (31%).</p></li>
<li><p>Water losses within municipal water reticulation systems had <a href="https://ws.dws.gov.za/IRIS/releases/NDWR.pdf#page=56">increased from 35% in 2015 to 50% in 2023</a>. This means that 50% of water is lost within the system before reaching consumers. </p></li>
</ul>
<h2>Next steps</h2>
<p>The findings of the report come as no surprise. Recent <a href="https://www.news24.com/news24/southafrica/news/cholera-outbreak-death-toll-rises-to-31-with-all-but-2-fatalities-in-gauteng-20230608">cholera outbreaks</a> in Gauteng and Free State provinces have been a warning sign that the country’s water is contaminated.</p>
<p>The current state of affairs was predicted two decades
ago by numerous researchers and experts, consistently having highlighted the deterioration of South Africa’s already scarce water resources, dilapidated infrastructure, poor water governance and management, lack of service delivery and the overall threat to the country’s water security, calling for urgent action.</p>
<p>The Department of Water and Sanitation has recently proposed the development of a <a href="https://www.timeslive.co.za/news/south-africa/2023-06-06-south-africa-seeks-water-investment-with-new-procurement-office/">Water Partnership Office</a>, a new procurement office, in an attempt to address the continued water issues. The initiative is still in its developmental phase, but the government hopes it will facilitate private investment in the water industry. </p>
<p>But government will have to regain the trust of private institutions before they will be willing to invest in water infrastructure projects.</p><img src="https://counter.theconversation.com/content/207267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anja du Plessis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The primary reasons for the systemic collapse include poor operation, defective infrastructure, the absence of disinfection chemicals, and lack of monitoring.Anja du Plessis, Associate Professor and Water Management Expert, University of South AfricaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2061412023-05-23T13:57:02Z2023-05-23T13:57:02ZCholera in South Africa: a symptom of two decades of continued sewage pollution and neglect<figure><img src="https://images.theconversation.com/files/527707/original/file-20230523-19-l65bm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Preventing cholera is more than just making sure your hygiene practices are in order.</span> <span class="attribution"><span class="source">Michele Spatari / AFP via Getty Images</span></span></figcaption></figure><p><em>South Africans have <a href="https://www.sowetanlive.co.za/news/south-africa/2023-05-23-families-still-on-tenterhooks-over-cholera-outbreak/">expressed outrage</a> at the deaths of at least 15 residents of Hammanskraal, in the city of Tshwane. The deaths were caused by <a href="https://www.nicd.ac.za/diseases-a-z-index/cholera/">cholera</a> – a diarrhoeal disease caused by Vibrio cholerae bacteria. The disease can be fatal if left untreated. The bacteria produces a toxin in the small intestine. This causes the secretion of enormous amounts of water, leading to diarrhoea and a rapid loss of fluids and salts <a href="https://www.mayoclinic.org/diseases-conditions/cholera/symptoms-causes/syc-20355287#:%7E:text=A%20bacterium%20called%20Vibrio%20cholerae,fluids%20and%20salts%20(electrolytes).">(electrolytes)</a>.</em></p>
<p><em>The bacteria are shed in the stools of people who are infected. People get infected when they come into contact with or consume water that has been contaminated with the bacteria. Cholera is closely linked to inadequate access to clean water and sanitation facilities. Preventing it requires more than practising individual hygiene. Areas typically at risk include peri-urban slums and rural areas where the minimum requirements of clean water and sanitation have not been <a href="https://www.who.int/news-room/fact-sheets/detail/cholera">met</a>.</em></p>
<p><em>The cholera outbreak in Hammanskraal is not limited to that area: the reported cases are part of a wider outbreak in South Africa as well as the wider southern African region. Prof Anja du Plessis, a research specialist in water resource management, believes that the crisis could have been averted. She explains to The Conversation Africa’s Ina Skosana.</em></p>
<hr>
<h2>What is behind this crisis?</h2>
<p>The current cholera outbreak is not necessarily an issue of potable water. It’s the result of a combination of factors. These include dysfunctional and non-compliant wastewater treatment works, mismanagement, under-investment and misappropriation of funds. Along with the lack of political will and action over the past two decades, these factors have formed a perfect storm. It is a legacy issue which has been emphasised by <a href="https://link.springer.com/book/10.1007/978-3-031-24019-5">myself</a> and other <a href="https://www.news24.com/news24/opinions/analysis/anthony-turton-a-tsunami-of-human-waste-inundates-our-rivers-and-dams-and-its-a-security-issue-20220303">researchers</a> since as far back as 2002.</p>
<p>The health crisis we are seeing can be attributed to the legacy of sewage pollution across the country because wastewater treatment works are in poor or critical condition due to under-investment and mismanagement. </p>
<p>More than <a href="https://ws.dws.gov.za/iris/releases/Report_DPW_Rev02_29Mar22_MN%20web.pdf">80%</a> (105 of 115) of wastewater treatment systems have been identified to be in a critical state. These water treatment plants require urgent intervention and rehabilitation. The partial or the complete lack of functioning wastewater treatment works is accompanied by significant negative implications for public health, the environment as well as socio-economic development and growth. It should be managed in a proactive way to ensure that people receive potable water in line with the <a href="https://foodconsulting.co.za/the-importance-of-sans-241/#:%7E:text=The%20South%20African%20National%20Standard%20(SANS)%20241%20Drinking%20Water%20Specification,physical%20properties%20of%20the%20water.">South African National Standard 241</a> for drinking water. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/river-of-bacteria-a-south-african-study-pinpoints-whats-polluting-the-water-150551">River of bacteria: a South African study pinpoints what's polluting the water</a>
</strong>
</em>
</p>
<hr>
<p>South Africa has made progress in expanding access to water infrastructure on a national level. However, access to water has declined in <a href="https://www.statssa.gov.za/publications/P0318/P03182019.pdf">five of its nine</a> provinces between 2002 and 2019. Only <a href="https://www.statssa.gov.za/publications/P0318/P03182019.pdf">64%</a> of households are estimated to have a reliable and safe water supply service. </p>
<p>And having access to water supply infrastructure does not guarantee reliable and safely managed water supply. The water might not be of suitable quality for drinking and/or cooking.</p>
<h2>What is needed for water to be potable?</h2>
<p>Drinking water is considered to be potable when it has been filtered and treated in various processes. The water must be free from contaminants and harmful bacteria or pathogens. Water is suitable when it is safe for both <a href="https://byjus.com/chemistry/potable-water/#:%7E:text=Potable%20water%20is%20the%20water,for%20both%20cooking%20and%20drinking.">drinking and cooking</a>. </p>
<p>Non-potable water can taste normal (like potable water) but can cause serious health problems – in this case, <a href="https://www.who.int/news-room/fact-sheets/detail/cholera">cholera</a>.</p>
<h2>What other issues are at play?</h2>
<p>The country’s continued sewage crisis, which has now led to a cholera outbreak, is largely due to non-functional municipal sewage systems. More than 90% of the total 824 treatment plants across the country release raw or partially treated sewage directly into the country’s already scarce <a href="https://www.dws.gov.za/niwis2/">water resources</a>. </p>
<p>The Vaal River is a good example. It has been reported to be “polluted beyond acceptable levels” by the South African Human Rights Commission, significantly affecting the environment, socio-economic growth and <a href="https://www.dailymaverick.co.za/article/2021-04-29-government-must-urgently-deal-with-south-africas-deepening-water-crisis/#:%7E:text=1-,South%20Africa's%20water%20resources%20are%20at%20a%20critical%20point.,we%20don't%20act%20now.&text=It%20is%20predicted%20that%20the,fewer%20than%2010%20years%20away">endangering people’s health</a>.</p>
<p>Additionally, a total of 151 municipalities are close to collapse. And 43 municipalities have already collapsed and require immediate <a href="https://businesstech.co.za/news/government/627336/151-municipalities-in-south-africa-on-the-brink-of-collapse-treasury/">intervention</a>. Major issues include weak governance, alleged corruption, and poor management of assets, operations and maintenance. There aren’t enough experienced individuals with suitable qualifications. There has also been a lack of accountability and political will over the past two decades. These issues within municipalities have led to the failure of wastewater treatment works. Some have reached crisis levels. </p>
<p>The combination of dysfunctional or non-functional municipalities and dilapidated wastewater treatment works has significantly affected the most vulnerable populations. Most of these people live in informal settlements and urban slums, and are defenceless against water-related illnesses. </p>
<p>The main factors behind the country’s sewage crisis and cholera outbreak are:</p>
<ul>
<li><p>lack of maintenance of basic infrastructure at local government level</p></li>
<li><p>lack of capacity and suitable skills</p></li>
<li><p>lack of implementation and enforcement of existing legislation and policy</p></li>
<li><p>lack of accountability. </p></li>
</ul>
<h2>What must be done now?</h2>
<p>South Africa’s water quality scores as “tolerable” in terms of microbiology standards and “unacceptable” by operational standards. This shows poor wastewater treatment works <a href="https://www.dws.gov.za/niwis2/dwq2">performance</a>. </p>
<p>The microbiological score indicates the possibility and presence of immediate unacceptable health risks. On a national scale the bacterial and/or pathogen concentration values exceed the numerical limits specified in <a href="https://alabbott.co.za/wp-content/uploads/2020/02/abbott_sans_241_test_requirements.pdf">SANS 241</a>. In other words the total Coliforms count per 100ml is above the set standard of 10 counts per 100ml. </p>
<p>The unacceptable level for operations indicates that the operation of treatment systems and risk to infrastructure is of concern and not efficient. The data emphasises the non-functioning and overall neglect of wastewater treatment works. </p>
<p>To improve prevention and response to health crises, such as the current cholera outbreak, the government needs to test supplied drinking water, from all sources, on a frequent basis to establish compliance and be clear about the results as well as the amount and extent of cholera cases across the country. </p>
<p>The current state of drinking water supplied across the country also needs a critical evaluation. The country can simply not afford the continued dysfunction of municipalities and wastewater treatment works. </p>
<p>Reactive management, lack of political will, transparency and unaccountability over the past two decades have contributed to the current state of affairs. The cholera outbreak in Hammanskraal could have been avoided and prevented if necessary actions had been taken.</p><img src="https://counter.theconversation.com/content/206141/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anja du Plessis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The current cholera outbreak is not necessarily an issue with potable water. It’s the result of a combination of factors including dysfunctional and non-compliant wastewater treatment works.Anja du Plessis, Associate Professor and Water Management Expert, University of South AfricaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2036002023-04-19T15:58:28Z2023-04-19T15:58:28ZCholera cases are on the rise – and Europe shouldn’t be complacent about the risk<figure><img src="https://images.theconversation.com/files/521581/original/file-20230418-18-ha9se.jpg?ixlib=rb-1.1.0&rect=13%2C0%2C9172%2C5164&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-illustration-cholera-pathogens-dark-polluted-757078444">Christoph Burgstedt/Shutterstock</a></span></figcaption></figure><p>Cholera, an infection that causes <a href="https://www.nhs.uk/conditions/cholera/">severe diarrhoea</a> and can be deadly, is once more spreading in several low-income countries. In its latest update on the disease, the World Health Organization (WHO) noted that the global situation has further <a href="https://www.who.int/publications/m/item/multi-country-outbreak-of-cholera--external-situation-report--1---28-march-2023">deteriorated in recent months</a>.</p>
<p>The 24 countries currently reporting outbreaks are spread across Africa, the Caribbean, and south Asia. Since WHO’s <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426">December 2022 report</a> new cholera outbreaks have been reported in Burundi, South Africa and the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON437">Dominican Republic</a>. Cases are also now being reported from north-west Syria, in areas not under Syrian government control.</p>
<p><strong>Geographical distribution of cholera cases reported worldwide, February 2022 to February 2023</strong></p>
<figure class="align-center ">
<img alt="A map showing the geographical distribution of cholera cases reported worldwide from February 2022 to February 2023." src="https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=463&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=463&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521372/original/file-20230417-14-nfktmv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=463&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">European Centre for Disease Prevention and Control, Communicable Disease Threats Report, 2023</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>African countries reported 26,000 cases and 660 deaths in the first four weeks of this year compared to nearly 80,000 cases and 1,863 deaths during the <a href="https://www.afro.who.int/news/new-cholera-cases-africa-surging-fast-reach-third-2022-total-month">whole of 2022</a>. </p>
<p>When we look at global infections, cases <a href="https://www.who.int/publications/m/item/multi-country-outbreak-of-cholera--external-situation-report--1---28-march-2023">reported to the WHO</a> up to mid March number almost 339,000 resulting in 3,287 deaths. For most countries represented, these figures include cases and deaths only for 2023, though for some countries they include cases and deaths from all or part of 2022 as well. </p>
<p>While this makes quantifying increases difficult, global cases in recent months appear to be significantly higher compared with <a href="https://apps.who.int/iris/handle/10665/362852?search-result=true&query=WER+cholera&scope=%2F&filtertype_0=relationserie&filter_relational_operator_0=contains&filter_0=Weekly+Epidemiological+Record&rpp=10&sort_by=dc.date.issued_dt&order=desc&page=3">previous years</a>.</p>
<p>And the true numbers are likely to be much greater as <a href="https://pubmed.ncbi.nlm.nih.gov/31326254/">under-reporting</a> is a known problem for cholera. A large proportion of cases are not diagnosed and some countries may be reluctant to report that they are experiencing a cholera outbreak.</p>
<h2>Symptoms, treatment and prevention</h2>
<p>Cholera causes <a href="https://emedicine.medscape.com/article/962643-overview">watery diarrhoea</a> that can be so profuse that the stool loses its brown colouring, giving the diarrhoea a characteristic “rice water” appearance. Death, when it occurs, can be very rapid, within a few hours after the onset of symptoms. It’s usually due to dehydration or electrolyte imbalance. </p>
<p>Cholera affects children more frequently than adults and if affected, children are also more likely to die. Children who are <a href="https://www.unicef.org/stories/cholera-is-endangering-children-globally">malnourished</a> are at greater risk of severe disease and death from cholera.</p>
<p>Notably, some countries are reporting particularly high death rates during this surge. From 2000 to 2010 the global case fatality rate varied between 2% to 3%, but since then it gradually fell to a <a href="https://worldhealthorg.shinyapps.io/page1cholera_global_overview/">low of 0.2% in 2019</a>. Across all African countries the case fatality rate is now 2.2% and over 3% in <a href="https://www.who.int/publications/m/item/multi-country-outbreak-of-cholera--external-situation-report--1---28-march-2023">Malawi, Nigeria and Tanzania</a>. </p>
<p>Deteriorating <a href="https://unstats.un.org/sdgs/report/2022/progress-chart/">food security in many countries</a>, especially in Africa, could be driving this increased mortality rate.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-yemen-can-learn-from-the-historical-experience-of-cholera-85021">What Yemen can learn from the historical experience of cholera</a>
</strong>
</em>
</p>
<hr>
<p>In terms of treatment, the top priority is to rehydrate patients either using an oral rehydration salt solution, or in more serious cases, with an intravenous solution. Antibiotics may shorten the duration of the diarrhoea and can be given in people who are <a href="https://emedicine.medscape.com/article/962643-overview">more severely ill</a>. </p>
<p>The are several cholera vaccines available and <a href="https://pubmed.ncbi.nlm.nih.gov/31879125/">more in development</a>. The vaccines in current use are given orally. Estimates of the vaccines’ effectiveness vary somewhere <a href="https://www.gov.uk/government/publications/cholera-the-green-book-chapter-14">between 65% and 85%</a>. Vaccination doesn’t give lifelong protection – booster doses are needed every two years. </p>
<h2>From history to the modern day</h2>
<p>Cholera was historically centred around the <a href="https://www.who.int/news-room/fact-sheets/detail/cholera">Ganges delta in India</a>. But it spread from there in a series of global pandemics, the first one <a href="https://en.wikipedia.org/wiki/1817%E2%80%931824_cholera_pandemic">starting in 1817</a>. These pandemics were responsible for <a href="https://www.who.int/news-room/fact-sheets/detail/cholera">millions of deaths</a> around the world, including in Europe.</p>
<p>The current and seventh pandemic <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426">started in 1961</a> and is now the longest lasting cholera pandemic in history. It has caused several waves of infection.</p>
<p>The main risks for cholera are usually linked to poor hygiene, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6090371/">poor sanitation</a> and contaminated drinking water. Most infections are due to the consumption of <a href="https://www.cdc.gov/cholera/general/index.html">contaminated food and drinking water</a>. Transmission directly from one person to another is uncommon.</p>
<h2>Why the current surge?</h2>
<p>The WHO has identified the main drivers behind this <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426">cholera surge</a> to include extreme weather events such as cyclones, flooding and drought, along with humanitarian crises, conflict and political instability. They’ve also cited inadequate supplies of cholera vaccines and added pressures on health services due to, among other things, the COVID pandemic.</p>
<p>Indeed, cholera is one of the diseases likely to become more <a href="https://iwaponline.com/jwh/article/18/2/145/71985/Water-sanitation-and-hygiene-risk-factors-for-the">common under climate change</a>, largely as a result of its effects on water and sanitation through more frequent floods and droughts. Outbreaks of cholera often follow major natural disasters such as earthquakes, as experienced by <a href="https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1003967">Haiti in 2010</a>, and floods, as in <a href="https://iwaponline.com/jwh/article/6/3/323/7846/Factors-determining-vulnerability-to-diarrhoea">Bangladesh in 1998</a>. </p>
<p>Wars can also trigger cholera epidemics as seen <a href="https://jidc.org/index.php/journal/article/view/31865306">in Yemen</a> from 2016. Similarly, following the break-up of the Soviet Union there was a large epidemic of cholera across countries that were <a href="https://www.bmj.com/content/309/6958/827.2">previously member states</a>. </p>
<p>Cholera so often follows wars and natural disasters largely because of the damage to water and sanitation infrastructure leading to <a href="https://www.worldvision.org/clean-water-news-stories/what-is-cholera-facts">contamination of drinking water</a>. People may also be displaced during wars or after disasters and be be forced to live in temporary housing with inadequate water and sanitation. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9934351/">Food insecurity</a> also follows such disasters, which we know increases the risk of severe cholera.</p>
<figure class="align-center ">
<img alt="A child suffering from cholera in Yemen in 2017. He is lying on a bed." src="https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=482&fit=crop&dpr=1 754w, https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=482&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/521585/original/file-20230418-24-2gamo3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=482&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Yemen experienced a significant cholera outbreak beginning in 2016.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/taiz-yemen-29-june-2017-child-1514978873">akramalrasny/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Assessing the risk in Europe</h2>
<p>If case numbers continue to increase or even continue at current levels we will likely see more cases globally this year than at any time in the past three decades. </p>
<p>Case numbers were very high in <a href="https://apps.who.int/iris/handle/10665/362852?search-result=true&query=WER+cholera&scope=%2F&filtertype_0=relationserie&filter_relational_operator_0=contains&filter_0=Weekly+Epidemiological+Record&rpp=10&sort_by=dc.date.issued_dt&order=desc&page=3">2017 and 2019</a> but almost all of these cases were in war-torn Yemen. Now cases are increasing on multiple continents. </p>
<p>Cholera only really spreads when water and sanitation infrastructure fails, and this is a very marginal risk in high-income countries. At present the main risk for Europeans will be for travellers to areas where epidemics are occurring. </p>
<p>For anybody travelling to a country with local transmission of cholera, it would be wise to seek advice on whether vaccination may be appropriate. Regardless, it’s important to follow strict food and water hygiene practices when in a <a href="https://travelhealthpro.org.uk/factsheet/56/cholera">cholera-affected country</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-cholera-continues-to-threaten-many-african-countries-197799">Why cholera continues to threaten many African countries</a>
</strong>
</em>
</p>
<hr>
<p>The nearest countries with cholera epidemics are Lebanon and north-west Syria. These border on Turkey, which has just suffered a <a href="https://qz.com/cholera-outbreak-syria-and-turkey-vaccine-shortage-1850109340">major earthquake</a>. </p>
<p>Further, war is continuing in Ukraine and more than one million people in the country no longer have <a href="https://www.unicef.org/press-releases/14-million-people-without-running-water-across-war-affected-eastern-ukraine">access to running water</a>. So we cannot afford to be complacent about the risk of cholera in Europe.</p><img src="https://counter.theconversation.com/content/203600/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Hunter consults for the World Health Organization. He receives funding from National Institute for Health Research, the World Health Organization and the European Regional Development Fund.</span></em></p>According to the WHO, the global cholera situation has deteriorated.Paul Hunter, Professor of Medicine, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2015692023-04-18T20:01:07Z2023-04-18T20:01:07ZDiseases gave us the rise of Christianity, the end of the Aztecs and public sanitation. How might future plagues change human history?<figure><img src="https://images.theconversation.com/files/517613/original/file-20230327-27-ualse4.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4439%2C3183&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Elena Mozhvilo/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“Every once in a while a book lands on your desk that changes the way you perceive the world you live in, a book that fundamentally challenges your understanding of human history.” So began the blurb that came with this book. Aha! I thought. The usual advertising hyperbole, a gross exaggeration. </p>
<p>Yet <a href="https://www.penguin.com.au/books/pathogenesis-9781911709053">Pathogenesis</a> <em>did</em> challenge much of my understanding of world history. Who knew that if it wasn’t for an Ebola-like pandemic in the 2nd century CE, Christianity would never have become a world religion? Or that if it weren’t for retroviruses, women would be laying eggs rather than having live births? (According to the book’s author, a retrovirus inserted DNA into our ancestor’s genome that caused the placenta to develop.)</p>
<hr>
<p><em>Book review: Pathogenesis: How germs made history – by Jonathan Kennedy (Torva)</em></p>
<hr>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=923&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=923&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=923&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1160&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1160&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517614/original/file-20230327-20-1geds5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1160&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>However, this is not another book of Amazing Facts: it is a work of scholarship, with nearly 700 references and notes. At the same time, it is very readable, and even amusing at times. </p>
<p>Many books have been written about the impact of disease on civilisation. I have even written my own modest <a href="https://medium.com/@adrian.esterman/infectious-diseases-and-their-impact-on-civilisation-4eb8ac72cc5b">essay</a> on the topic. However,
Pathogenesis delves deeply into the social history of the world. </p>
<p>Jonathan Kennedy has a PhD in sociology from the University of Cambridge, and his sociological bent comes through strongly. In eight chapters, and some 350 pages, Kennedy takes us on a whirlwind tour of social history, describing how infectious diseases have shaped humanity at every stage. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/viruses-are-both-the-villains-and-heroes-of-life-as-we-know-it-169131">Viruses are both the villains and heroes of life as we know it</a>
</strong>
</em>
</p>
<hr>
<h2>‘It’s a bacterial world’</h2>
<p>Kennedy starts by describing the three great branches of living organisms, <a href="https://theconversation.com/from-peaceful-coexistence-to-potential-peril-the-bacteria-that-live-in-and-on-us-104110">bacteria</a>, <a href="https://microbiologysociety.org/why-microbiology-matters/what-is-microbiology/archaea.html">archaea</a>, and <a href="https://www.britannica.com/science/eukaryote">eukaryotes</a> – it is the latter that contains all complex life forms, including humans. However, fewer than 0.001% of all species are eukaryotes. </p>
<p>Bacteria, on the other hand, are the dominant life form on this planet. As Kennedy puts it, “it’s a bacterial world, and we’re just squatting here”. </p>
<p>Our own species, <em><a href="https://theconversation.com/rethinking-homo-sapiens-the-story-of-our-origins-gets-dizzyingly-complicated-99760">Homo sapiens</a></em>, arose some 315,000 years ago, living for the most part in Africa. At the same time, human species such as Neanderthals and <a href="https://theconversation.com/dna-from-elusive-human-relatives-the-denisovans-has-left-a-curious-mark-on-modern-people-in-new-guinea-196113">Denisovans</a> spread out into Europe. However, about 50,000 years ago, <em>Homo sapiens</em> burst out of Africa and spread across the world, while all other human species simply vanished. There are many <a href="https://www.scientificamerican.com/article/how-homo-sapiens-became-the-ultimate-invasive-species/">theories</a> as to why and how this occurred – for example, perhaps <em>Homo sapiens</em> were just smarter. </p>
<p>However, Kennedy proposes his own theory. Because <em>Homo sapiens</em> lived primarily in Africa, they were exposed to many pathogens, and eventually acquired genetic changes that gave them some protection. The exodus out of Africa exposed other species to these pathogens, causing their demise. </p>
<p>He describes the <a href="https://theconversation.com/who-were-the-mysterious-neolithic-people-that-enabled-the-rise-of-ancient-egypt-heres-what-weve-learned-on-our-digs-121070">Neolithic</a> revolution, which took place about 12,000 years ago and which saw the change from hunter-gatherers to farmers. Because of their nomadic existence in small groups, hunter-gatherers tended to be relatively healthy, with an average lifespan of 72 - better than the average lifespan in some countries today! </p>
<p>It has always been assumed that this revolution was a good thing, bringing better nutrition and more leisure time. However, in Kennedy’s view, the Neolithic revolution led to the emergence of despotism, inequality, poverty and backbreaking work. He describes how settlement and the farming of domestic animals led to the emergence of zoonotic diseases – that is, <a href="https://theconversation.com/preventing-future-pandemics-starts-with-recognizing-links-between-human-and-animal-health-167617">diseases spread by animals</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Settlement and the farming of domestic animals led to the emergence of diseases spread by animals.</span>
<span class="attribution"><span class="source">kallerna/Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/disease-evolution-our-long-history-of-fighting-viruses-54569">Disease evolution: our long history of fighting viruses</a>
</strong>
</em>
</p>
<hr>
<h2>Plagues and social upheavals</h2>
<p>In a chapter on ancient plagues, Kennedy quotes from Monty Python’s <a href="https://theconversation.com/life-of-brian-at-40-an-assertion-of-individual-freedom-that-still-resonates-114743">The Life of Brian</a>: </p>
<blockquote>
<p>All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?</p>
</blockquote>
<p>He points out that Roman cities were, in fact, “filthy, stinking and disease-ridden”, and goes on to describe the great plagues <a href="https://theconversation.com/how-3-prior-pandemics-triggered-massive-societal-shifts-146467">that weakened the Roman Empire</a>. The first was the Antonine Plague, possibly caused by smallpox. This was followed some 70 years later by the Plague of Cyprian from AD 249-262, which led to the splitting of the Roman Empire and the rise of Christianity. </p>
<p>Kennedy completes this chapter with a description of the Plague of Justinian, caused by bubonic plague. The massive deaths caused by this epidemic led to the demise of the Roman Empire, and the Muslim conquest of the Middle East. </p>
<p>In the period 1346–53, the <a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Black Death</a> tore through North Africa and Europe, killing an <a href="https://en.wikipedia.org/wiki/Black_Death">estimated</a> 75 million to 200 million people. Kennedy describes the devastation and huge social upheavals that resulted from this pandemic. Until then, the Roman Catholic Church dominated society. But:</p>
<blockquote>
<p>During the Black Death and subsequent plague outbreaks, people looked to the Church for comfort. All too often they didn’t find it. </p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=486&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=486&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=486&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=611&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=611&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=611&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Black Death killed an estimated 75–200 million people in Europe and North Africa. Hugo Simberg Black Death.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This led to the rise of Protestantism, aided by the invention of the printing press - a shortage of labour encouraged the development of such labour-saving devices. Over the next 200 years, waves of plague repeatedly hit Europe. A quarantine system was developed in Venice, and <em>cordon sanitaires</em> established, to prevent movement of people between cities - ring any bells? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Did the Black Death give birth to modern plagues?</a>
</strong>
</em>
</p>
<hr>
<h2>Pathogens as New World killers</h2>
<p>In the period from 1500 onwards, white colonialists nearly wiped out indigenous people by infecting them. Kennedy starts with the early 16th century, when Spanish conquistador Hernán Cortés led an expedition to Mexico. His arrival <a href="https://theconversation.com/how-smallpox-devastated-the-aztecs-and-helped-spain-conquer-an-american-civilization-500-years-ago-111579">introduced smallpox</a>, which resulted in the total destruction of the Aztec Empire within just two years. However, this was just the start. </p>
<p>In the early 1530s, Mexico was hit by an epidemic of <a href="https://theconversation.com/measles-new-efforts-needed-to-stop-an-old-disease-13706">measles</a> that killed 80% of its population, making it the deadliest epidemic in recorded history. Over the following decades, across the whole of the Americas, the introduction of infectious diseases from Europe resulted in a 90% fall in the population. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hernán Cortés brought smallpox to Mexico, resulting in the total destruction of the Aztec Empire within two years, as illustrated in this 16th-century drawing of Aztec smallpox victims.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>However, during this period, it wasn’t just the New World that was profoundly affected by pathogens. On the west coast of Africa, explorers and would-be colonialists died in droves from <a href="https://theconversation.com/worlds-first-mass-malaria-vaccine-rollout-could-prevent-thousands-of-children-dying-169457">malaria</a> and <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">yellow fever</a>. </p>
<p>Interestingly, Kennedy starts his chapter on revolutionary plagues with the murder of <a href="https://theconversation.com/george-floyd-deserved-a-better-life-a-new-book-charts-his-trajectory-from-poverty-to-the-us-prison-industrial-complex-and-the-impact-of-his-death-182947">George Floyd</a> and the <a href="https://theconversation.com/the-black-lives-matter-movement-has-provoked-a-cultural-reckoning-about-how-black-stories-are-told-149544">Black Lives Matter</a> movement, before delving deep into the history of slavery. He describes slavery in Greek and Roman times, and the booming trade in slaves in the medieval Mediterranean. </p>
<p>The association between black Africans and <a href="https://theconversation.com/slavery-is-not-a-crime-in-almost-half-the-countries-of-the-world-new-research-115596">slavery</a> only began in the 15th century. In fact, only 3% of the 12.5 million humans trafficked across the Atlantic ended up in the United States. The most common destinations of the slave ships were the European colonies in the Caribbean, where African slave labour was first used more than a century before their shipment to North America. </p>
<p>Meanwhile, in the Caribbean, slave labour from tropical West Africa toiled on sugar plantations owned by the English, Spanish, French and Dutch. Yellow fever carried by mosquitoes wiped out many of the Europeans, including military garrisons, leading to slave revolts.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-a-slave-state-how-blackbirding-in-colonial-australia-created-a-legacy-of-racism-187782">Friday essay: a slave state - how blackbirding in colonial Australia created a legacy of racism</a>
</strong>
</em>
</p>
<hr>
<h2>Diseases ‘thrived’ in Dickensian habitats</h2>
<p>When Kennedy switches his focus to Britain, and the industrial revolution, he describes it as the change from a Thomas Hardy novel to one by <a href="https://theconversation.com/great-expectations-by-charles-dickens-class-prejudices-the-convict-stain-and-a-corpse-bride-159816">Charles Dickens</a>. The crowded and unsanitary conditions in working-class urban districts created new habitats, in which pathogens thrived. </p>
<p>Kennedy again evokes Monty Python to invoke the scenery of those days, reminding readers of the famous four Yorkshiremen sketch. The scene made me think of a different quote from the same sketch:</p>
<blockquote>
<p>You were lucky to have a house! We used to live in one room, all hundred and twenty-six of us, no furniture. Half the floor was missing; we were all huddled together in one corner for fear of falling!</p>
</blockquote>
<p>Every Epidemiology 101 course covers the story of <a href="https://www.newscientist.com/people/john-snow/">John Snow</a> (no – not the “Winter is coming” one!). <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section2.html">Two decades</a> before the development of the microscope, Snow examined cholera outbreaks to discover the cause of disease and how to prevent it. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=619&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=619&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=619&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=778&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=778&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=778&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">John Snow proved in 1854 that cholera is a waterborne disease: a London pub is named for him.</span>
<span class="attribution"><a class="source" href="https://www.geograph.org.uk/profile/6699">ceridwen/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>During the third UK cholera outbreak in 1854, Snow famously removed London’s Broad Street water pump, to demonstrate that cholera was a waterborne disease. For those interested, there is a <a href="https://londonspubswherehistoryreallyhappened.wordpress.com/2019/03/05/john-snow/">John Snow</a> pub in London. Kennedy, of course, includes this story in his book.</p>
<p>Kennedy points out that 3.5 billion people – half of the world’s population – have no access to proper toilets, while a billion don’t have clean drinking water and 1.5 million people, mainly children, die every year from waterborne diarrhoeal diseases. </p>
<p>We still have massive <a href="https://theconversation.com/explainer-why-cholera-remains-a-public-health-threat-74444">cholera outbreaks</a>, especially in areas where normal life has been disrupted by war or natural disasters. <a href="https://theconversation.com/tuberculosis-kills-as-many-people-each-year-as-covid-19-its-time-we-found-a-better-vaccine-151590">Tuberculosis</a> still kills 1.2 million people a year, despite the availability of antibiotics. Malaria kills another 600,000. </p>
<p>Finally in this section, he briefly covers <a href="https://theconversation.com/covid-hospitalisations-and-deaths-are-rising-faster-than-cases-but-that-doesnt-mean-more-severe-disease-187163">COVID</a>. He points out that not everyone in the world benefited from the medical advances that came about because of COVID, and the self-interested actions of high-income countries have deprived the poorer countries. As he puts it, “pathogens thrive on inequality and injustice”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fleas-to-flu-to-coronavirus-how-death-ships-spread-disease-through-the-ages-137061">Fleas to flu to coronavirus: how 'death ships' spread disease through the ages</a>
</strong>
</em>
</p>
<hr>
<h2>Future plagues</h2>
<p>Kennedy concludes by looking at future plagues. He points out humanity’s precarious position: we live on a planet dominated by bacteria and viruses. He believes our best chance of surviving the threat posed by pathogens will come from working collaboratively and reducing inequality both within and between countries. </p>
<p>Based on its title, I assumed this book would be about the role of pathogens in shaping civilisation. Instead, I found a social history of the world, with the odd foray into diseases and their influence on society. Nonetheless, I thoroughly enjoyed the book, and can highly recommend it to those with an interest in history, sociology and epidemiology.</p><img src="https://counter.theconversation.com/content/201569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrian Esterman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This whirlwind tour of social history describes how infectious diseases have shaped humanity at every stage. It suggests reducing inequality will give us our best chance of surviving future plagues.Adrian Esterman, Professor of Biostatistics and Epidemiology, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2028572023-04-17T14:24:32Z2023-04-17T14:24:32ZPredicting epidemics isn’t easy. We’ve created a global dataset to help<figure><img src="https://images.theconversation.com/files/520280/original/file-20230411-20-k6ve92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Countries around the world were not prepared to respond to COVID-19.</span> <span class="attribution"><span class="source">Andrew Wasike Shimanyula/Anadolu Agency via Getty Images</span></span></figcaption></figure><p>The world has recently seen a number of high-profile cross-border disease outbreaks and pandemics. The COVID pandemic and multi-country Mpox (monkeypox) outbreaks are just two examples. </p>
<p>But there is very little scientific evidence that would give a clear picture of how fast and how often infectious diseases spread across countries. A key challenge for creating global disease data is the scattering of information. Low-income countries have limited statistical capacity to keep track of disease outbreaks. And datasets from various countries are difficult to combine due to different reporting standards.</p>
<p>To get a better global picture of infectious disease patterns, our team of economists and statisticians set out to create <a href="https://www.nature.com/articles/s41597-022-01797-2">a global dataset</a>. We collected data from the World Health Organization’s <a href="https://www.who.int/emergencies/disease-outbreak-news">“Disease Outbreak News”</a> and <a href="https://covid19.who.int/">Coronavirus Dashboard</a>. </p>
<p>Disease Outbreak News contains information from health authorities and research networks about confirmed acute public health events or events of concern. They include any outbreak or rapidly evolving situation that may have negative consequences for human health and requires immediate assessment and action. Unfortunately, this information is mostly unstructured and is not produced for statistical purposes. It can’t be directly used for systematic analysis. To make such structured statistical information available, we relied on <a href="https://www.parsehub.com/blog/what-is-web-scraping/">web-scraping</a> techniques to extract when and where a particular infectious disease occurred. </p>
<p>Statistical restructuring of this data allowed us to paint a systematic picture of the spread of infectious diseases. Our findings are based on the statistical probabilities of disease outbreak, not the virulence. We found that most disease outbreaks were reported in African countries. High-income countries were significantly affected too – particularly during pandemics like the 2009 “swine flu” outbreak and COVID-19.</p>
<p>The presence of such pandemic events highlights the need for policy preparedness. By analysing how disease outbreaks spread across countries, health authorities can develop targeted measures to contain future outbreaks.</p>
<h2>What the data shows</h2>
<p>Our dataset contains information on over 2,000 public health events that have occurred in 233 countries and territories since 1996. These outbreaks involve 70 different infectious diseases. The figure below shows when those occurred. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=512&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=512&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=512&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=643&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=643&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520313/original/file-20230411-26-9f5d14.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=643&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Total frequency of outbreaks.</span>
<span class="attribution"><span class="source">Juan Armando Torres Munguía</span></span>
</figcaption>
</figure>
<p>No clear trend over time is visible: there are around 50 public health events that trigger a Disease Outbreak News announcement each year. Instead of an increase over time, temporary surges are visible in the context of the <a href="https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html">2009 “swine flu” influenza A(H1N1) pandemic</a> and COVID-19. These diseases were essentially global and accordingly triggered Disease Outbreak News in many countries. </p>
<p>Our data recorded only one disease outbreak announcement per country, year and disease. For example, COVID-19 in China is recorded once in 2019, once in 2020, and once in 2021. This means the data doesn’t show how serious a disease outbreak was, nor how many people were affected in one country. Instead, the data for each year reflects how many different diseases were recorded, and how many different countries were affected. This is useful from a policy perspective since all recorded outbreaks call for immediate action.</p>
<p>COVID-19 is the most prominent disease in the outbreak news announcements. Almost one third of the 2,227 health events recorded in our dataset concern COVID-19, closely followed by influenza cases of zoonotic nature. Cholera is the third-most recorded infectious disease, but much less frequent than COVID-19 or influenza (about 170 recorded outbreak news).</p>
<p>Countries with the highest records of infectious disease outbreaks are mostly large (in terms of size and population), close to the Equator, and have low or modest income levels. Africa accounts for almost 40% of recorded cases of outbreaks. And it’s home to the two most outbreak-prone countries: the Democratic Republic of Congo and Nigeria each recorded over 40 disease outbreaks since 1996. </p>
<p>High income levels don’t prevent outbreaks. Wealthier countries were affected despite their substantial financial means for public health measures. The US recorded the third highest number of disease outbreaks. France and the UK had over 20 unique disease outbreaks each. </p>
<h2>How the data is useful</h2>
<p>Our analysis shows that there is no clear global increase of infectious disease outbreaks over time. We rather observe temporary waves of single diseases that affect many countries. Public health systems hence need to quickly assess how threatening a disease outbreak in another country is and what measures should be taken to prevent their spreading across and within countries. </p>
<p>Effective public health responses will depend on how diseases usually spread geographically. And our dataset offers rich potential to analyse such spatial disease transmission. </p>
<p>Disease outbreaks are geographically related. Our statisticians tested whether disease outbreaks are randomly scattered around the globe or not. The results are depicted in the map below. A country that is coloured in a darker shade of green is more likely to contribute to cross-country spreading of diseases. Outbreaks are clustered geographically. These clusters – Northern America, Africa and South-/East Asia – provide a first glimpse of international disease transmission patterns. </p>
<p>But more research will be needed to better understand pandemic contagion pathways, which likely differ by disease. Our dataset will be a valuable resource for such analysis.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=236&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=236&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=236&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=297&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=297&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520315/original/file-20230411-16-mflczf.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=297&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Disease transmission map.</span>
<span class="attribution"><span class="source">Juan Armando Torres Munguía</span></span>
</figcaption>
</figure>
<h2>Policy preparedness</h2>
<p>A better understanding of how different infectious diseases spread across countries can help establish early warning mechanisms and response protocols. One could estimate how likely it is that an outbreak of a disease in one country will spread to another country and over what time period. </p>
<p>Policymakers could even put protocols in place where a certain disease transmission likelihood triggers a response measure (such as rolling out vaccines, or travel warnings). </p>
<p>Similarly, international organisations could use such spatial pandemic models to infer which other countries would most likely be affected by an outbreak, and focus resources accordingly. Chaotic health resource allocations, as was the case of the COVID-19 <a href="https://www.theguardian.com/world/2020/apr/28/face-masks-coveted-commodity-coronavirus-pandemic">masks</a> and <a href="https://press.un.org/en/2021/ga12367.doc.htm">vaccines</a>, could thus be avoided.</p><img src="https://counter.theconversation.com/content/202857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Konstantin M. Wacker collaborates in a research group that received funding from the ENLIGHT network. His investment portfolio includes minor shares of health companies (details under "disclosure" on his private website).</span></em></p><p class="fine-print"><em><span>Inmaculada Martínez-Zarzoso and Juan Armando Torres Munguía do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new global dataset shows there is no clear global increase of infectious disease outbreaks over time. And it can suggest which countries would most likely be affected by an outbreak.Konstantin M. Wacker, Assistant professor of economics, University of GroningenInmaculada Martínez-Zarzoso, Professor in Economics, Universitat Jaume IJuan Armando Torres Munguía, Research assistant, Georg-August-Universität Göttingen Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2002262023-04-11T12:04:46Z2023-04-11T12:04:46ZLooming behind antibiotic resistance is another bacterial threat – antibiotic tolerance<figure><img src="https://images.theconversation.com/files/519955/original/file-20230407-28-ddggzn.jpg?ixlib=rb-1.1.0&rect=0%2C3%2C2309%2C1292&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tolerant bacteria are dormant until an antibiotic threat has passed, then reemerge to conduct business as usual.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pseudomonas-aeruginosa-bacterium-illustration-royalty-free-image/1201441647">Christoph Burgstedt/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Have you ever had a nasty infection that just won’t seem to go away? Or a runny nose that keeps coming back? You may have been dealing with a bacterium that is tolerant of, though not yet resistant to, antibiotics. </p>
<p>Antibiotic resistance is a huge problem, contributing to <a href="https://doi.org/10.1016/S0140-6736(21)02724-0">nearly 1.27 million deaths worldwide in 2019</a>. But antibiotic tolerance is a covert threat that researchers have only recently begun to explore. </p>
<p><a href="https://doi.org/10.1371/journal.ppat.1008892">Antibiotic tolerance</a> happens when a bacterium manages to survive for a long time after being exposed to an antibiotic. While <a href="https://doi.org/10.1128/microbiolspec.VMBF-0016-2015">antibiotic-resistant</a> bacteria flourish even in the presence of an antibiotic, tolerant bacteria often exist in a dormant state, neither growing nor dying but putting up with the antibiotic until they can “reawaken” once the stress is gone. Tolerance has been <a href="https://www.doi.org/10.1126/science.aaj2191">linked to the spread of antibiotic resistance</a>.</p>
<p>I am a <a href="https://doerr.wicmb.cornell.edu/current-lab-members/">microbiologist</a> who studies antibiotic tolerance, and I seek to uncover what triggers tolerant bacteria to enter a protective dormant slumber. By understanding why bacteria have the ability to become tolerant, researchers hope to develop ways to avoid the spread of this ability. The exact mechanism that sets tolerance apart from resistance has been unclear. But one possible answer may reside in a process that has been overlooked for decades: how bacteria <a href="https://doi.org/10.3389/fmicb.2020.577564">create their energy</a>.</p>
<h2>Cholera and antibiotic tolerance</h2>
<p>Many antibiotics are designed to <a href="https://doi.org/10.1039/C6MD00585C">break through the bacteria’s outer defenses</a> like a cannonball through a stone fortress. Resistant bacteria are immune to the cannonball because they can either destroy it before it damages their outer wall or change their own walls to be able to withstand the impact. </p>
<p>Tolerant bacteria can remove their wall entirely and avoid damage altogether. No wall, no target for the cannonball to smash. If the threat goes away before too long, the bacterium can rebuild its wall to protect it from other environmental dangers and resume normal functions. However, it is still unknown how bacteria know the antibiotic threat is gone, and what exactly triggers their reawakening. </p>
<p>My colleagues and I at the <a href="https://doerr.wicmb.cornell.edu/">Dörr Lab at Cornell University</a> are trying to understand processes of activation and reawakening in the tolerant bacteria responsible for cholera, <em>Vibrio cholerae</em>. <em>Vibrio</em> is <a href="https://doi.org/10.3389/fitd.2021.691604">rapidly evolving resistance</a> against various types of antibiotics, and doctors are concerned. As of 2010, <em>Vibrio</em> is already <a href="https://doi.org/10.1016/j.vaccine.2019.06.031">resistant to 36 different antibiotics</a>, and this number is expected to continue rising.</p>
<p>To study how <em>Vibrio</em> develops resistance, we chose a strain that is tolerant to a class of antibiotics <a href="https://doi.org/10.3389/fpubh.2016.00231">called beta-lactams</a>. Beta-lactams are the cannonball sent to destroy the bacteria’s fortress, and <em>Vibrio</em> adapts by activating two genes that temporarily remove its cell wall. I witnessed this phenomenon using a microscope. After removing its cell wall, the bacteria activate even more genes that morph it into fragile globs that can survive the effects of the antibiotic. Once the antibiotic is removed or degraded, <em>Vibrio</em> returns to its normal rod shape and continues to grow. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/qCzCj4gQWLk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Normally rod-shaped <em>Vibrio cholerae</em> remove their cell walls and turn into globs in the presence of penicillin, enabling them to survive longer.</span></figcaption>
</figure>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Zyh6TpwJN0s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption"><em>Vibrio cholerae</em> revert back to their rod-shaped structure once the antibiotic threat is removed.</span></figcaption>
</figure>
<p>In people, this process of tolerance is seen when a doctor prescribes an antibiotic, typically doxycycline, to a patient infected with cholera. The antibiotic temporarily seems to stop the infection. But then the symptoms start back up again because the antibiotics never fully cleared the bacteria in the first place.</p>
<p>The ability to revert back to normal and grow after the antibiotic is gone is the key to tolerant survival. Exposing <em>Vibrio</em> to an antibiotic for a long enough time would eventually kill it. But a standard course of antibiotics often isn’t long enough to get rid of all the bacteria even in their fragile state.</p>
<p>However, taking a medicine for a prolonged period can harm healthy bacteria and cells, causing further discomfort and illness. Additionally, <a href="https://doi.org/10.3389/fcimb.2020.572912">misuse and extended exposure</a> to antibiotics can increase the chances of other bacteria residing in the body becoming resistant.</p>
<h2>Other bacteria developing tolerance</h2>
<p><em>Vibrio</em> isn’t the only species to exhibit tolerance. In fact, researchers have recently identified many infectious bacteria that have developed tolerance. A bacteria family called <a href="https://doi.org/10.1371/journal.pbio.1001928">Enterobacteriaceae</a>, which include major food-borne disease pathogens <a href="https://doi.org/10.1371/journal.pbio.1001928"><em>Salmonella</em></a>, <a href="https://doi.org/10.1128/AAC.01282-08"><em>Shigella</em></a> and <a href="https://doi.org/10.1038/s41598-021-85509-7"><em>E. coli</em></a>, are just a few of the many types of bacteria that are capable of antibiotic tolerance.</p>
<p>As every bacterium is unique, the way one develops tolerance seems to be as well. Some bacteria, like <em>Vibrio</em>, <a href="https://doi.org/10.1128/AAC.00756-19">erase their cell walls</a>. Others can <a href="https://doi.org/10.1038/nchembio.1754">alter their energy sources, increase their ability to move or simply pump out</a> the antibiotic.</p>
<p>I recently found that a <a href="https://doi.org/10.1128/jb.00476-22">bacterium’s metabolism</a>, or the way it breaks down “food” to make energy, may play a significant role in its ability to become tolerant. Different structures within a bacterium, including its outer wall, are made of specific building blocks like proteins. Stopping the bacterium’s ability to craft these pieces weakens its wall, making it more likely to take damage from the outside environment before it can take the wall down.</p>
<h2>Tolerance and resistance are connected</h2>
<p>Although there has been considerable research on how bacteria develop tolerance, a key piece of the puzzle that has been neglected is how tolerance leads to resistance.</p>
<p>In 2016, researchers discovered how to <a href="https://doi.org/10.1038/nmicrobiol.2016.20">make bacteria tolerant in the laboratory</a>. After repeated exposure to different antibiotics, <em>E. coli</em> cells were able to adapt and survive. DNA, the genetic material containing instructions for cell function, is a fragile molecule. When DNA is damaged rapidly by stress, such as antibiotic exposure, the cell’s repair mechanisms tend to mess up and cause mutations that can create resistance and tolerance. Because <em>E. coli</em> is similar to many different types of bacteria, these researchers’ findings revealed that, ironically, essentially any bacteria can develop tolerance if pushed to their limits by the antibiotics meant to kill them. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/pHLP5CZMnL4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Bacteria form large communities in biofilms.</span></figcaption>
</figure>
<p>Another recent key discovery was that the longer bacteria remain tolerant, the more likely they are to <a href="https://doi.org/10.1073/pnas.2209043119">develop mutations leading to resistance</a>. Tolerance allows bacteria to develop a resistance mutation that reduces their chances of being killed during antibiotic treatment. This is especially relevant to bacterial communities often seen in <a href="https://doi.org/10.2147/IDR.S379502">biofilms that tend to coat high-touch surfaces in hospitals</a>. Biofilms are slimy layers of bacteria that ooze a protective jelly that makes antibiotic treatment difficult and DNA sharing between microbes easy. They can induce bacteria to evolve resistance. These conditions are thought to mimic what could be happening during antibiotic-treated infections, in which many bacteria are living next to one another and sharing DNA. </p>
<p>Researchers are calling for more research into antibiotic tolerance with the hope that it will lead to <a href="https://doi.org/10.1128/mBio.02095-19">more robust treatments</a> in both infectious diseases and cancers. And there is reason to be hopeful. In one promising development, a mouse study found that <a href="https://doi.org/10.1126/science.1211037">decreasing tolerance also reduced resistance</a>. </p>
<p>Meanwhile, there are steps everyone can take to aid in the battle against antibiotic tolerance and resistance. You can do this by <a href="https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance">taking an antibiotic exactly as prescribed</a> by a doctor and finishing the entire bottle. Brief, inconsistent exposure to a medicine primes bacteria to become tolerant and eventually resistant. Smarter use of antibiotics by everyone can stop the evolution of tolerant bacteria.</p><img src="https://counter.theconversation.com/content/200226/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Keller receives funding from the National Science Foundation Graduate Research Fellowship Program and the National Institutes of Health (NSF GRFP #DGE-1650441 and NIH R01-AI143704)</span></em></p>Antibiotic resistance has contributed to millions of deaths worldwide. Research suggests that any bacteria can develop antibiotic tolerance, and possibly resistance, when pushed to their limits.Megan Keller, Ph.D. Candidate in Microbiology, Cornell UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1996822023-02-14T19:11:34Z2023-02-14T19:11:34ZSecondary crises after the Turkey-Syria earthquakes are now the greatest threat to life<p>The death toll from the Turkey and Syria earthquakes has continued to climb, with <a href="https://www.reuters.com/world/middle-east/survivors-ever-fewer-earthquake-rubble-turkey-syria-2023-02-12/">more than 37,000</a> lives lost. This staggering number is likely to grow even higher over coming days as the rubble is cleared. The disaster is now among the top five <a href="https://www.usatoday.com/story/graphics/2023/02/10/earthquake-turkey-syria-deaths/11210641002/">most deadly earthquakes</a> globally in the past two decades. </p>
<p>Much of the focus has centred on the immense loss of life in the immediate aftermath of the earthquakes. But many lives will still be at risk in the months to come. While <a href="https://doi.org/10.1007/s13753-019-00237-x">hard to track</a>, we know from other cases that death tolls rise because of a lack of adequate medical care, clean water and shelter following disasters. </p>
<p>These secondary crises can have devastating impacts, as past disasters around the world have shown.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/turkey-syria-earthquakes-shallow-depth-of-main-shocks-is-a-key-reason-why-theyve-been-so-devastating-199540">Turkey-Syria earthquakes: shallow depth of main shocks is a key reason why they've been so devastating</a>
</strong>
</em>
</p>
<hr>
<h2>Toll can soar long after disaster strikes</h2>
<p>In Puerto Rico after Hurricane Maria in 2017, the immediate official count of 64 fatalities was <a href="https://www.theguardian.com/world/2018/aug/28/hurricane-maria-new-death-toll-estimate-is-close-to-3000">adjusted to nearly 3,000</a> in the following six months. This tragic increase was attributed to deteriorating health conditions driven by the loss of infrastructure and basic services.</p>
<p>In northwest Syria, conflict spanning more than a decade has left infrastructure in tatters. The <a href="https://www.worldbank.org/en/news/press-release/2017/07/18/the-visible-impacts-of-the-syrian-war-may-only-be-the-tip-of-the-iceberg">World Bank estimated in 2017</a> that more than a third of Syria’s housing stock had been damaged or destroyed in the conflict. </p>
<p>In a sign of the precarious state of buildings before the earthquake, a <a href="https://www.abc.net.au/news/2023-01-22/syrian-building-collapse-aleppo-16-people-dead/101880890">five-storey building collapsed last month</a>, killing 16 people. Many blast-damaged buildings present an ongoing risk now that the quake has further destabilised them. </p>
<p>The earthquakes also come against the backdrop of a <a href="https://reliefweb.int/disaster/ep-2022-000310-syr">cholera outbreak</a>. The disease was already affecting parts of Syria, but had received little attention. </p>
<p>After the 2010 Haiti earthquake, a <a href="https://www.gtfcc.org/news/cholera-surveillance-in-haiti/">cholera outbreak brought in by humanitarian workers</a> took almost a decade to stamp out. There were more than 820,000 cases and nearly 10,000 lives lost. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/un-finally-apologises-for-bringing-cholera-to-haiti-now-it-must-match-its-words-with-funds-69828">UN finally apologises for bringing cholera to Haiti – now it must match its words with funds</a>
</strong>
</em>
</p>
<hr>
<p>Last week’s earthquake has also occurred amid freezing winter conditions. Many displaced families are out in the cold after losing their homes. Temperatures in Kahramanmaraş – the epicentre of the <a href="https://theconversation.com/turkey-syria-earthquakes-a-seismologist-explains-what-has-happened-199340">magnitude 7.8 earthquake</a> – and across quake-affected regions are plunging to -5°C at night. </p>
<p>Erecting adequate shelter to protect people from the cold must be a central focus of the evolving humanitarian response. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1623689222593937408"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/turkey-syria-earthquakes-a-seismologist-explains-what-has-happened-199340">Turkey-Syria earthquakes: a seismologist explains what has happened</a>
</strong>
</em>
</p>
<hr>
<h2>Syrians were already in dire need</h2>
<p>The situation in Syria was already dire before the earthquake. In northwest Syria, <a href="https://www.unocha.org/story/todays-top-news-t%C3%BCrkiye-and-syria-ukraine">90% of the 4.6 million people</a> living there already were relying on humanitarian assistance to meet their basic needs. </p>
<p>Humanitarian access to northwest Syria remains <a href="https://www.brookings.edu/blog/order-from-chaos/2023/02/08/northwestern-syria-needs-humanitarian-assistance-getting-it-there-must-be-a-priority/">complicated</a>. There has been only a single aid border crossing, at Bab al-Hawa, brokered by the United Nations Security Council. As a sign of the difficulties accessing opposition-held areas of Syria, only <a href="https://reliefweb.int/report/syrian-arab-republic/north-west-syria-situation-report-11-february-2023-enar">two aid conveys</a> had been able to cross from Turkey in the past week. </p>
<p>UN aid chief <a href="https://www.un.org/sg/en/content/profiles/martin-griffiths-0">Martin Griffiths</a> <a href="https://twitter.com/UNReliefChief/status/1624701773557469184">admitted shortcomings</a> in reaching those in need: </p>
<blockquote>
<p>We have so far failed the people in north-west Syria. They rightly feel abandoned. Looking for international help that hasn’t arrived.</p>
</blockquote>
<p>Over the weekend, the United States approved a <a href="https://www.theguardian.com/world/2023/feb/10/us-syria-sanctions-exemption-earthquake-relief">180-day exemption on sanctions</a> for disaster aid to Syria, paving the road for alternative pathways to reach opposition-held areas. However, Syrian government calls for all humanitarian assistance to be delivered through the government are fraught with issues given its track record of <a href="https://www.hrw.org/report/2019/06/28/rigging-system/government-policies-co-opt-aid-and-reconstruction-funding-syria">diverting aid</a> over the past decade. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/turkey-syria-earthquake-assad-blames-west-as-agencies-struggle-to-get-aid-to-his-desperate-people-199691">Turkey-Syria earthquake: Assad blames west as agencies struggle to get aid to his desperate people</a>
</strong>
</em>
</p>
<hr>
<h2>A long road to recovery</h2>
<p>As rescue operations stretch into the second week, communities are already looking toward recovery. Turkish President Recep Tayyip Erdoğan has <a href="https://www.bloomberg.com/news/articles/2023-02-08/erdogan-vows-building-blitz-to-renew-quake-hit-areas-within-year">promised to rebuild areas</a> hit by the earthquakes within a year. Syrian communities face the added challenge of rebuilding from conflict. </p>
<p>Lessons from similar disasters teach us affected communities have just started on a long road towards recovery and rebuilding.</p>
<p>As the continued challenges of humanitarian access make clear, it is important for local organisations working in northwest Syria to be at the centre of the response. The Syrian Red Crescent, Syrian Civil Defence (White Helmets) and other local organisations have played a vital role during the past decade of conflict and will no doubt do so again in coming weeks and months.</p>
<p>The recent earthquakes offer an opportunity to <a href="https://theconversation.com/turkey-syria-earthquake-how-disaster-diplomacy-can-bring-warring-countries-together-to-save-lives-199329">break through political barriers</a> that have stifled rebuilding in Syria. However, the underlying vulnerability that compounded this disaster will not be resolved quickly. It is deeply embedded in social and political systems in both Syria and Turkey. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/turkey-syria-earthquake-how-disaster-diplomacy-can-bring-warring-countries-together-to-save-lives-199329">Turkey-Syria earthquake: how disaster diplomacy can bring warring countries together to save lives</a>
</strong>
</em>
</p>
<hr>
<h2>What can you do to help?</h2>
<p>It can be tempting to donate goods, but consider <a href="https://www.theguardian.com/world/2023/feb/08/turkey-and-syria-earthquake-how-and-where-to-donate-in-australia-to-help-the-victims">giving cash</a> to support humanitarian efforts, instead of sending physical items. Cash allows humanitarian organisations to adapt to rapidly changing needs, while also giving households flexibility to decide on their own priorities. </p>
<p>The <a href="https://crisisrelief.un.org/t/syria-cross-border">Syria Cross-Border Humanitarian Fund</a> is enabling humanitarian partners, particularly Syrian organisations on the ground, to access some of the hardest-to-reach areas affected by this disaster.</p><img src="https://counter.theconversation.com/content/199682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aaron Opdyke consults for the Global Shelter Cluster on disaster recovery.</span></em></p>The focus of efforts to save the lives of earthquake victims needs to shift to the emerging threats from disease and lack of clean water and shelter.Aaron Opdyke, Senior Lecturer in Humanitarian Engineering, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1977992023-01-14T09:53:17Z2023-01-14T09:53:17ZWhy cholera continues to threaten many African countries<figure><img src="https://images.theconversation.com/files/504431/original/file-20230113-17-bb62ey.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Key to preventing cholera is a good supply of water.</span> <span class="attribution"><span class="source">Getty images</span></span></figcaption></figure><p><em>Many African countries are periodically affected by outbreaks of cholera. For instance, Malawi’s current outbreak, the <a href="https://www.bloomberg.com/news/articles/2023-01-12/worst-cholera-outbreak-in-decades-kills-750-people-in-malawi">worst</a> in two decades, has claimed <a href="https://www.theeastafrican.co.ke/tea/rest-of-africa/cholera-outbreak-kills-620-in-malawi-4073880#:%7E:text=Malawi%20has%20recorded%2018%2C222%20cholera,Health%20Minister%20Khumbize%20Chiponda%20announced">hundreds</a> of lives and forced the closure of schools and many businesses. Cholera deaths have now been <a href="https://www.bloomberg.com/news/articles/2023-05-22/south-african-capital-hit-by-cholera-outbreak-with-10-dead">reported</a> in South Africa too.</em></p>
<p><em>Microbiologist Sam Kariuki, the director of Kenya’s Medical Research Institute, explains what cholera is and why it’s so hard to control in Africa.</em></p>
<h2>Why is cholera still such a big issue for African countries?</h2>
<p>Cholera is a disease <a href="https://www.gtfcc.org/research/cholera-prevention-preparedness-and-control-in-kenya-through-hotspot-mapping-genotyping-exposure-assessment-and-wash-oral-cholera-vaccine-interventions/">caused and spread by</a> bacteria – specifically <em>Vibrio cholerae</em> – which you can get by eating or drinking contaminated food or water. </p>
<p>It’s an <a href="https://books.google.co.ke/books?id=qpjshPr7HVcC&pg=PA197&lpg=PA197&dq=cholera+and+bangal&source=bl&ots=4htxUE4c61&sig=S52TKJb0YKHttBcyNZt2jJRtLcY&hl=en&sa=X&redir_esc=y#v=onepage&q=cholera%20and%20bangal&f=false">old disease</a> which has mostly <a href="https://www.ncbi.nlm.nih.gov/pubmed/2857326">affected</a> developing countries, many of which are in Africa. Between 2014 and 2021 Africa <a href="https://reliefweb.int/report/world/who-and-partners-revamp-war-against-cholera-africa">accounted for</a> 21% of cholera cases and 80% of deaths reported globally.</p>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/why-cholera-continues-to-threaten-many-african-countries-197799&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p>In several African countries, cholera is the leading cause of severe diarrhoea. In 2021, the World Health Organization <a href="https://reliefweb.int/report/world/who-and-partners-revamp-war-against-cholera-africa">reported</a> that Africa experienced its highest ever reported numbers – more than 137,000 cases and 4,062 deaths in 19 countries.</p>
<p>It has persisted in Africa partly because of <a href="https://www.washingtonpost.com/politics/2022/01/28/is-africa-losing-ground-battle-water-sanitation/">worsening</a> sanitation, poor and unreliable water supplies and worsening socioeconomic conditions. For instance, when people’s incomes can’t keep up with inflation they’ll move to more affordable housing – often this is in congested, unsanitary settings where water and other hygiene services are already stretched to the limit.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/kenyas-urban-poor-are-being-exploited-by-informal-water-markets-144582">Kenya's urban poor are being exploited by informal water markets</a>
</strong>
</em>
</p>
<hr>
<p>In addition, in the last decade, many African countries have witnessed an <a href="https://www.afdb.org/en/documents/africas-urbanisation-dynamics-2022-economic-power-africas-cities">upsurge in population migration</a> to urban areas in search of livelihoods. Many of these people end up in poor urban slums where water and sanitation infrastructure remains a challenge. </p>
<p>Displaced populations – a major concern in several African countries – are also very vulnerable to water and food contamination. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504400/original/file-20230113-17-rju7ae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sadiki Sabimana, an internally displaced person, holds water he believes is contaminated with cholera, in the DRC’s Masisi area.</span>
<span class="attribution"><span class="source">Alexis Huguet/AFP</span></span>
</figcaption>
</figure>
<p>It’s important to control cholera because it can cause severe illness and death. In mild cases cholera can be managed through oral rehydration salts to replace lost fluids and electrolytes. Severe cases may require antibiotic treatment. It’s vital to diagnose and treat cases quickly – cholera can <a href="http://www.who.int/mediacentre/factsheets/fs107/en/">kill within hours</a> if untreated. </p>
<p>In 2015, it was <a href="https://bmjopen.bmj.com/content/11/3/e044615">estimated that</a> over one million cases in 44 African countries resulted in an economic burden of US$130 million from cholera-related illness and its treatment. </p>
<h2>What’s missing in the response?</h2>
<p>African governments must acknowledge that the burden of cholera is huge. In my opinion, governments in endemic areas don’t recognise cholera as a major issue until there’s a big outbreak, when it’s out of control. They treat it as a once off. </p>
<p>The burden of cholera could get worse unless governments put measures in place to control and prevent outbreaks. They need to address water and hygiene infrastructure. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cholera-how-african-countries-are-failing-to-do-even-the-basics-74445">Cholera: how African countries are failing to do even the basics</a>
</strong>
</em>
</p>
<hr>
<p>There must also be community engagement. For instance, widespread messaging that encourages hand washing, boiling water and other preventive measures. Community health <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6503a7.htm">extension workers</a> are key in getting these messages across and distributing supplies during an outbreak.</p>
<p>For the most vulnerable populations we must apply oral cholera vaccines. Data on cholera hotspots from surveillance studies will be vital to ensure critical populations are targeted first. </p>
<p>There are various brands and variation of the oral cholera vaccine, and they are all easy to administer because they are taken orally. They have an effectiveness rate of <a href="https://www.cdc.gov/cholera/vaccines.html#:%7E:text=The%20vaccine%20manufacturer%20reports%20Vaxchora,3%E2%80%936%20months%20after%20vaccination.">between</a> 60% to 80% but require a yearly booster. There’s not been a concerted vaccination campaign in many countries, however, because governments are not taking the prevention and control of the disease seriously. </p>
<p>Finally, the issue of drug resistance needs to be addressed. Drug resistance has made it possible for these cholera strains to stay longer in the environment. </p>
<p>I was part of a team that conducted a <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074829">study</a> in Kenya which found that bacteria that causes cholera has become resistant to some antibiotics. Some types of drug resistance are caused by a natural interaction of the <em>Vibrio cholerae</em> bacteria with other drug resistant bacteria in the environment. </p>
<p>The overuse of antibiotics also contributes to drug resistance. Government agencies should develop ways to monitor the use of antibiotics and restrict their prescription. Regulation of antibiotic use in animals should also be improved. Healthcare workers also need to be trained in the proper use of antibiotics.</p>
<h2>Have there been any recent advances?</h2>
<p>One important one has been the development of rapid diagnostic tests that can be used by health workers in the field. These kits are available at costs far lower than lab culture costs. Using them makes it possible to confirm outbreaks promptly so treatment can be initiated. </p>
<p>In addition, more countries are now adopting the oral cholera vaccine for prevention and control. </p>
<p>What is lacking is a concerted effort for all endemic countries – which I consider to be all countries in sub-Saharan Africa – to have joint measures to tackle cross-border transmission and persistence of cholera outbreaks. </p>
<p>Some countries are still in denial about outbreaks. This is partly due to fears about repercussions on trade and tourism. But in an interconnected world this attitude isn’t helpful. </p>
<p>I am optimistic that we can control cholera in African settings. In the short term this could be done through raising awareness among vulnerable populations and interventions like the oral cholera vaccine.</p>
<p>In the long term African countries need improved water hygiene infrastructure, housing and enhanced socioeconomic conditions. But there must be a strong will by relevant government ministries to work together to realise these goals.</p><img src="https://counter.theconversation.com/content/197799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Kariuki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Cholera has persisted longer in Africa largely due to worsening hygiene and sanitation situations in urban areas.Samuel Kariuki, Chief Research Scientist and Director, Centre for Microbiology Research, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1930772022-11-10T13:41:45Z2022-11-10T13:41:45Z8 billion people: Four ways climate change and population growth combine to threaten public health, with global consequences<figure><img src="https://images.theconversation.com/files/494155/original/file-20221108-12-bg01z4.jpg?ixlib=rb-1.1.0&rect=522%2C226%2C3071%2C2166&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infectious diseases like COVID-19 top the list of health concerns.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-elderly-man-a-resident-of-the-sprawling-township-of-news-photo/1211082728">Marco Longari/AFP via Getty Images</a></span></figcaption></figure><p><em><a href="https://theconversation.com/ocho-mil-millones-de-personas-asi-amenazan-a-la-salud-publica-el-cambio-climatico-y-la-superpoblacion-194421">Leer in español</a></em></p>
<p>There are questions that worry me profoundly as a population- and environmental-health scientist. </p>
<p>Will we have enough food for a growing global population? How will we take care of more people in the next pandemic? What will heat do to millions with hypertension? Will countries wage water wars because of increasing droughts? </p>
<p>These risks all have three things in common: health, climate change and a growing population that the United Nations determined <a href="https://www.un.org/en/desa/world-population-reach-8-billion-15-november-2022">passed 8 billion</a> people in November 2022 – double the population of just 48 years ago.</p>
<hr>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/8-billion-people-four-ways-climate-change-and-population-growth-combine-to-threaten-public-health-with-global-consequences-193077&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<hr>
<p><iframe id="b54Xw" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/b54Xw/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In my <a href="https://www.health.pitt.edu/people/ant-2">40-year career</a>, first working in the Amazon rainforest and the Centers for Disease Control and Prevention, and then in academia, I have encountered many public health threats, but none so intransigent and pervasive as climate change. </p>
<p>Of the multitude of climate-related adverse health effects, the following four represent the greatest public health concerns for a growing population.</p>
<h2>Infectious diseases</h2>
<p>Researchers have found that <a href="https://theconversation.com/58-of-human-infectious-diseases-can-be-worsened-by-climate-change-we-scoured-77-000-studies-to-map-the-pathways-188256">over half of all human infectious diseases</a> can be worsened by climate change.</p>
<p>Flooding, for example, can affect water quality and the habitats where dangerous bacteria and vectors like mosquitoes can breed and transmit infectious diseases to people.</p>
<p>Dengue, a painful mosquito-borne viral disease that sickens <a href="https://www.cdc.gov/dengue/about/index.html">about 100 million</a> people a year, becomes more common in warm, wet environments. Its R0, or basic reproduction number – a gauge of how quickly it spreads – <a href="https://doi.org/10.1016/S0140-6736(22)01540-9">increased by about 12%</a> from the 1950s to the average in 2012-2021, according to the 2022 Lancet Countdown report. Malaria’s season expanded by 31% in highland areas of Latin America and nearly 14% in Africa’s highlands as temperatures rose over the same period.</p>
<figure class="align-center ">
<img alt="Rows of beds, some covered with mosquito nets, fill a warehouse-like space. Doctors visit with some of the patients." src="https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients rest in a makeshift dengue ward at a hospital during a severe outbreak in Pakistan in 2021.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patients-take-rest-on-beds-arranged-inside-a-makeshift-news-photo/1235932771">Arif Ali/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Flooding can also spread waterborne organisms that cause <a href="https://doi.org/10.1186/s12879-020-04961-4">hepatitis</a> and <a href="https://doi.org/10.1136/bmj.39503.700903.DB">diarrheal diseases</a>, such as cholera, particularly when large numbers of people are displaced by disasters and living in areas with poor water quality for drinking or washing. </p>
<p><a href="https://doi.org/10.1371/currents.dis.7a2cee9e980f91ad7697b570bcc4b004">Droughts</a>, too, can degrade drinking water quality. As a result, more rodent populations enter into human communities in search of food, increasing the <a href="https://doi.org/10.3390/pathogens11010015">potential to spread hantavirus</a>.</p>
<h2>Extreme heat</h2>
<p>Another serious health risk is rising temperatures. </p>
<p>Excessive heat can <a href="https://www.who.int/news-room/fact-sheets/detail/climate-change-heat-and-health">exacerbate existing health problems</a>, such as <a href="https://doi.org/10.1111/all.14177">cardiovascular</a> and respiratory diseases. And when heat stress becomes <a href="https://www.cdc.gov/niosh/topics/heatstress/heatrelillness.html">heat stroke</a>, it can <a href="https://www.mayoclinic.org/diseases-conditions/heat-stroke/symptoms-causes/syc-20353581">damage the heart, brain and kidneys</a> and become lethal.</p>
<p>Today, about 30% of the global population is exposed to potentially deadly heat stress each year. The Intergovernmental Panel on Climate Change estimates that percentage will rise <a href="https://www.ipcc.ch/report/ar6/wg2/about/frequently-asked-questions/keyfaq3/">to at least 48% and as high as 76%</a> by the end of this century.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=599&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=599&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=599&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Where climate change affects human health.</span>
<span class="attribution"><span class="source">Centers for Disease Control and Prevention</span></span>
</figcaption>
</figure>
<p>In addition to lives lost, heat exposure was projected to have resulted in <a href="https://www.thelancet.com/infographics-do/climate-countdown-2022">470 billion potential work hours lost</a> globally in 2021, with associated income losses totaling up to US$669 billion. As populations grow and heat rises, more people will be relying on air conditioning powered by fossil fuels, which <a href="https://www.iea.org/news/air-conditioning-use-emerges-as-one-of-the-key-drivers-of-global-electricity-demand-growth">further contributes to climate change</a>.</p>
<h2>Food and water security</h2>
<p>Heat also affects food and water security for a growing population.</p>
<p>The Lancet review found that high temperatures in 2021 <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01540-9/fulltext">shortened the growing season</a> by about 9.3 days on average for corn, or maize, and six days for wheat compared with the 1981-2020 average. Warming oceans, meanwhile, can kill shellfish and shift <a href="https://doi.org/10.1111/gcb.14512">fisheries that coastal communities rely on</a>. Heat waves in 2020 alone resulted in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01540-9/fulltext">98 million more</a> people facing food insecurity compared with the 1981-2010 average.</p>
<figure class="align-center ">
<img alt="A woman standing in a field examines a stalk of sorghum" src="https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A farmer in Zimbabwe switched to sorghum, a grain crop that can thrive in dry conditions, as drought withered other crops in 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/angeline-kadiki-an-elderly-who-is-a-sorghum-farmer-inspects-news-photo/1130994283">Jekesai Njikizana/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Rising temperatures also affect fresh water supplies through evaporation and by shrinking <a href="https://e360.yale.edu/features/andes-meltdown-new-insights-into-rapidly-retreating-glaciers">mountain glaciers</a> and <a href="https://www.ioes.ucla.edu/project/climate-change-sierra-nevada/">snowpack</a> that historically have kept water flowing through the summer months.</p>
<p>Water scarcity and drought have the potential to displace almost <a href="https://unstats.un.org/sdgs/report/2022/goal-13/">700 million people by 2030</a>, according to U.N. estimates. Combined with population growth and growing energy needs, they can also fuel geopolitical conflicts as countries face food shortages and compete for water.</p>
<h2>Poor air quality</h2>
<p>Air pollution can be <a href="https://theconversation.com/extreme-heat-air-pollution-can-be-deadly-with-the-health-risk-together-worse-than-either-alone-187422">exacerbated by the drivers of climate change</a>. Hot weather and the same fossil fuel gases warming the planet <a href="https://www.lung.org/clean-air/climate-change/climate-change-air-pollution">contribute to ground-level ozone</a>, a key component of smog. That can exacerbate allergies, asthma and other respiratory problems, as well as cardiovascular disease. </p>
<p>Wildfires fueled by hot, dry landscapes <a href="https://doi.org/10.1126/sciadv.abi9386">add to the air pollution health risk</a>. Wildfire smoke is laden with tiny particles that can travel deep into the lungs, <a href="https://www.epa.gov/wildfire-smoke-course/why-wildfire-smoke-health-concern">causing heart and respiratory problems</a>. </p>
<figure class="align-center ">
<img alt="Three school girls with backpacks walk through smog along a road while covering their mouths with handkerchiefs." src="https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Smog in New Delhi, India, is an ongoing problem. It got so bad in 2017 that the city temporarily closed its primary schools.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/indian-schoolchildren-cover-their-faces-as-they-walk-to-news-photo/871511920">Sajjad Hussain/AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>What can we do about it?</h2>
<p>Many groups and medical experts are working to counter this cascade of negative climate consequences on human health.</p>
<p>The U.S. National Academy of Medicine has embarked on an ambitious <a href="https://nam.edu/programs/climate-change-and-human-health/">grand challenge in climate change, human health, and equity</a> to ramp up research. At many academic institutions, including the University of Pittsburgh’s School of Public Health, where I am dean, climate and health are being embedded in research, teaching and service.</p>
<p>Addressing the health burden on low- and middle-income countries is pivotal. Often, the <a href="https://www.ncbi.nlm.nih.gov/books/NBK525226/">most vulnerable</a> people in these countries <a href="https://sdgs.un.org/goals/goal13">face the greatest harms from climate change</a> without having the resources to protect their health and environment. Population growth can <a href="https://doi.org/10.1289/EHP10384">deepen these iniquities</a>. </p>
<p><a href="https://www.paho.org/en/news/19-8-2022-eu-and-paho-supporting-nine-caribbean-countries-integration-health-national">Adaptation assessments</a> can help high-risk countries prepare for the effects of climate change. Development groups are also leading projects to <a href="https://www.cgiar.org/">expand the cultivation of crops</a> that can thrive in dry conditions. The <a href="https://www.paho.org/en">Pan American Health Organization</a>, which focuses on the Caribbean, is an example of how countries are working to reduce communicable diseases and advance regional capacity to counter the impact of climate change.</p>
<p>Ultimately, reducing the health risks will require <a href="https://www.unep.org/resources/emissions-gap-report-2022">reducing the greenhouse gas emissions</a> that are driving climate change. </p>
<p>Countries worldwide <a href="https://unfccc.int/process/the-convention/history-of-the-convention#Essential-background">committed in 1992</a> to reduce greenhouse gas emissions. Thirty years later, global emissions are <a href="https://www.unep.org/events/publication-launch/emissions-gap-report-2022">only beginning to flatten</a>, and communities around the world are increasingly suffering extreme heat waves and devastating floods and droughts.</p>
<p>The <a href="https://unfccc.int/event/cop-27">U.N. climate change talks</a>, which in my view aren’t focusing enough on health, can help bring attention to key climate impacts that harm health. As U.N. Secretary-General António Guterres noted: While we celebrate our advances, “at the same time, it is a reminder of our shared responsibility to care for our planet and a moment to reflect on where we still fall short of our commitments to one another.”</p>
<p><em>Samantha Totoni, a Ph.D. candidate at the University of Pittsburgh School of Public Health, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/193077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Lichtveld does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The human population has doubled in 48 years, and worsening climate change has left the world facing serious health risks, from infectious diseases to hunger and heat stress.Maureen Lichtveld, Dean of the School of Public Health, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1938672022-11-06T10:50:26Z2022-11-06T10:50:26ZHow climate change influences the spread of disease – four essential reads<figure><img src="https://images.theconversation.com/files/493454/original/file-20221104-25-m7lhsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Darren Stewart/Gallo Images via Getty Images</span></span></figcaption></figure><p>Climate change has led to <a href="https://www.epa.gov/climate-indicators/weather-climate">extreme weather events</a> such as floods and drought. These events have become more frequent and more severe. Natural disasters associated with climate change have a devastating effect on people’s lives, destroying homes, roads and others key infrastructure. </p>
<p>They also put <a href="https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health#:%7E:text=Climate%20change%20is%20already%20impacting,diseases%2C%20and%20mental%20health%20issues.">people at risk</a> of injury and death, and alter the prevalence and distribution of illnesses and infectious diseases. </p>
<p>Over the years, health and climate researchers have written important articles for The Conversation Africa highlighting the links between climate change and diseases in people. Many have also proposed solutions. We’ve pulled together four essential reads.</p>
<h2>Impacts of climate on everyday life</h2>
<p>Most people don’t experience extreme weather events like floods. But record peaks in temperature have an impact on everyday life in subtle ways. Inequalities drive these impacts. People who are poor are already vulnerable to ill health and malnutrition. </p>
<p>Medical anthropologist Lenore Manderson explains how changes in weather patterns have knock-on effects on health. For instance, changes in water supply can affect commercial food and subsistence production. This in turn affects food security and the price of food. Diet affects health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-global-warming-is-adding-to-the-health-risks-of-poor-people-109520">How global warming is adding to the health risks of poor people</a>
</strong>
</em>
</p>
<hr>
<p>The health problems associated with climate change need a whole-of-society solution. Many diseases are related to inadequate water availability. Researchers and officials have to work closely together to improve basic service delivery and fill knowledge gaps. </p>
<p>Manderson argues that experts in social, biological and physical sciences as well as the humanities and arts need to come up with ways to interrupt disease transmission in the context of global warming. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/climate-change-water-and-the-spread-of-diseases-connecting-the-dots-differently-103111">Climate change, water and the spread of diseases: connecting the dots differently</a>
</strong>
</em>
</p>
<hr>
<h2>Impacts on infectious disease</h2>
<p>It’s difficult to predict where droughts will happen. But research suggests that some areas of Africa are likely to see more intense and longer droughts. </p>
<p>Infectious diseases such as cholera are linked to droughts. People in displacement camps and those living in settings with poor sanitation are most at risk of the illness. </p>
<p>Researcher Gina Charnley argues that the most effective way to reduce the impacts of drought and resultant cholera outbreaks is to alleviate population vulnerabilities before the hazard occurs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/droughts-create-fertile-ground-for-cholera-plans-are-needed-to-face-more-dry-periods-170660">Droughts create fertile ground for cholera. Plans are needed to face more dry periods</a>
</strong>
</em>
</p>
<hr>
<p>As climate change increases the risk of epidemics and disease outbreaks, it is up to government authorities to provide the services needed to prevent and treat infectious diseases – especially in vulnerable communities. </p>
<p>Medical entomologist Andrew Githeko warns that weak public health institutions at the frontline of disease outbreaks are highly vulnerable to the effects of climate change. Policy responses should be expanded to include other stakeholders, increased capacity to evaluate risk and adequate resources.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/response-to-climate-change-is-critical-as-risk-of-disease-outbreaks-grows-70066">Response to climate change is critical as risk of disease outbreaks grows</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/193867/count.gif" alt="The Conversation" width="1" height="1" />
Natural disasters associated with climate change put people at risk of injury and death, and alter the prevalence and distribution of illnesses and infectious diseases.Moina Spooner, Assistant EditorIna Skosana, Health + Medicine Editor (Africa edition)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1927502022-10-19T15:17:03Z2022-10-19T15:17:03ZFloods in Nigeria: building dams and planting trees among steps that should be taken to curb the damage<figure><img src="https://images.theconversation.com/files/490321/original/file-20221018-4535-2h6fgi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Floods have hit 27 of Nigeria's 36 states this year. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/men-steer-a-dugout-canoe-past-a-flooded-house-following-news-photo/1033290244?phrase=floods%20in%20nigeria&adppopup=true">Sodiq Adelakun/AFP via Getty Images </a></span></figcaption></figure><p><em>Nigerians are no strangers to flooding. In some parts of the country, flooding is an annual event. But the intensity varies from one year to the next. In some years, the effects are minimal, in others, devastating. The 2022 floods have caused massive damage, like those experienced in <a href="https://reliefweb.int/disaster/fl-2012-000138-nga">2012</a>. Ten years ago more than 7.7 million people in 32 out of 36 states were affected. The recent floods have <a href="https://www.africanews.com/2022/10/15/heavy-flooding-in-nigeria-claims-at-least-500-lives-and-displaces-14m//#:%7E:text=About%20500%20people%20are%20believed,from%20all%20walks%20of%20life.">affected 1.4 million people</a> in 27 states. Water researcher Nelson Odume explains what’s responsible for the flooding and what Nigeria should do to prevent future occurrences.</em> </p>
<h2>Causes of flooding in Nigeria</h2>
<p>There are different types of flooding. One is <a href="https://www.caro.ie/knowledge-hub/climate-action-adaptation/flooding/fluvial-flooding">fluvial flooding</a>, which occurs when rivers overflow their banks. </p>
<p>The second is <a href="https://www.studysmarter.co.uk/explanations/geography/coasts-geography/coastal-flooding/">coastal flooding</a>, which occurs when water from the marine environment submerges low-lying adjoining lands. </p>
<p>The third is <a href="https://www.jrf.org.uk/report/pluvial-rain-related-flooding-urban-areas-invisible-hazard">pluvial flooding</a>, which occurs due to intense, heavy rains. </p>
<p>In Nigeria, the three types of flooding are <a href="https://www.tandfonline.com/doi/full/10.1080/00207233.2022.2081471">interrelated</a> because the peaks of all three flooding types can coincide seasonally. </p>
<p>Some of the <a href="https://theconversation.com/nigeria-has-a-flooding-challenge-heres-why-and-what-can-be-done-169044">principal causes of flooding in Nigeria</a> are rapid urbanisation, poor spatial planning and poor solid waste management, including drainage systems being used as dump sites.</p>
<p>Nigeria’s population has been growing rapidly – <a href="https://www.worldometers.info/world-population/nigeria-population/#:%7E:text=The%20current%20population%20of%20Nigeria,the%20latest%20United%20Nations%20data.">it’s currently estimated to be over 200 million</a> from <a href="https://www.google.com/search?q=nigeria+population+in+2000&oq=nigeria+population+in+&aqs=chrome.6.0i512j69i57j0i512l5j69i60.8505j0j7&sourceid=chrome&ie=UTF-8">122.3 million in 2000</a>. There has also been rapid urbanisation in the last six decades. Today <a href="https://www.tandfonline.com/doi/full/10.1080/15487733.2021.2004742">about 55% of the population lives in urban centres</a>. </p>
<p>The rapid population growth combined with urbanisation and poor spatial planning means that people are building on flood-prone areas such as river banks, wetlands and low-lying areas. </p>
<p>Another consequence of poor spatial planning is that storm water and drainage systems are built that aren’t fit for purpose. In many of Nigeria’s cities, <a href="https://www.researchgate.net/publication/312458086_Flood_menace_in_Nigeria_impacts_remedial_and_management_strategies">the storm water systems are inadequate to handle flooding peaks</a>. As a result, communities living downstream are sometimes flooded. </p>
<p><a href="https://www.ingentaconnect.com/content/jswt/jswt/2018/00000044/00000002/art00008;jsessionid=2chpgg2pc0a7r.x-ic-live-01">Poor solid waste management</a> is a key contributor to the problem of flooding. Often, drainage systems are used as dump sites, blocking the flow of water.</p>
<p>Another factor has been a <a href="https://www.researchgate.net/publication/272469245_An_analysis_of_rainfall_patterns_in_Nigeria#:%7E:text=While%20the%20vegetation%20map%20of,area%20is%20experiencing%20slight%20increase.">change in rainfall patterns in the country</a>, particularly an increase in extreme events. Rainstorms lasting up to five days are becoming more common. And it’s <a href="https://link.springer.com/article/10.1007/s10661-016-5549-z">predicted that they will increase</a> due to climate change. These extreme rainstorm events cause serious flooding.</p>
<p>Another feature of the country that adds to flooding risk is that it has numerous rivers, including transboundary river systems such as the Rivers Niger and Benue. Poor water infrastructure developments such as dams, reservoirs and bank protection contribute to the annual flooding.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-flooding-in-nigeria-is-an-increasingly-serious-problem-82272">Why flooding in Nigeria is an increasingly serious problem</a>
</strong>
</em>
</p>
<hr>
<p>For example, <a href="https://www.thecable.ng/nema-13-states-to-record-heavy-flooding-as-cameroon-opens-lagdo-dam">the release of excess water from the Lagdo Dam in Cameroon</a>, which often contributes to flooding in Nigeria, was supposed to be contained by a dam, the <a href="https://www.nigeriainfo.fm/port-harcourt/news/morningcrossfireph/nigeria-floods-what-happened-to-the-dasin-hausa-dam/">Dasin Hausa Dam in Adamawa State</a>, north-east Nigeria. But after more than 40 years the dam still isn’t complete. </p>
<p>Many of the rivers in Nigeria are poorly managed and regulated. Siltation of major rivers such as the River Niger, as well as removal of vegetation from river banks and wetlands for agricultural purposes, are all outcomes of poor water resources management which have also contributed to flooding.</p>
<h2>The impact</h2>
<p>The most important consequences are socio-economic, health-related, ecological and cultural. </p>
<p>Socio-economic consequences include the loss of lives, emotional and psychological distress, and destruction of property, social amenities and infrastructure worth billions of naira. </p>
<p>For example, <a href="https://www.reuters.com/world/africa/death-toll-widespread-nigeria-floods-tops-500-ministries-2022-10-14/">the 2022 flooding</a> has claimed the lives of more than 500 people, destroyed more than 200,000 homes and left around 90,000 homes under water. It has also displaced over 1.4 million people. The congregation of people in camps for the internally displaced and their separation from their ancestral homes and loved ones often causes emotional and psychological trauma. This gets little attention in the Nigerian scientific literature. But <a href="https://www.tandfonline.com/doi/full/10.1080/13548500903483478">empirical evidence suggests</a> that victims of natural disasters such as flooding often suffer emotional and psychological trauma. </p>
<p>Another effect of flooding is the loss of economically productive time, which may cost the economy billions of naira daily. </p>
<p>Flooding has been linked to an increase in the number of people contracting water-borne diseases such as <a href="https://reliefweb.int/report/nigeria/deadly-floods-niger-and-nigeria-affect-75000-children-and-leave-communities-disarray">cholera</a>. Due to poor sanitation infrastructure, floods can distribute faecally contaminated water. Widespread outbreaks of cholera in Nigeria in 2010 <a href="https://link.springer.com/chapter/10.1007/978-3-030-72196-1_14">were linked</a> to exposure to contaminated water after flooding. </p>
<p>Another consequence is ecological and environmental. <a href="https://www.tandfonline.com/doi/full/10.1080/10406638.2017.1403329">A study</a> has shown that flooding tends to increase the spread of chemical pollutants in soils on floodplains.</p>
<p>Flooding also destroys <a href="https://www.theguardian.com/environment/2020/apr/01/the-losses-could-be-profound-how-floods-are-wreaking-havoc-on-wildlife-aoe">wildlife habitats</a>, depletes fishery stock and alters biodiversity and ecosystem functions critical to socio-economic development.</p>
<h2>What should Nigeria do?</h2>
<p>The country can address the flooding menace and minimise its effect through a multi-pronged approach.</p>
<p>First, a combination of hard infrastructural solutions and ecosystem-based adaptation should be pursued. Examples include the construction of dams and reservoirs to hold excess water, riverbank protection, construction of levees and spillways, appropriate drainage systems and storm water management regimes, and dredging of some of the major rivers in Nigeria. </p>
<p>Of particular interest is the completion of the Dasin Hausa Dam in Adamawa State and prioritisation of an appropriate stormwater management regime. </p>
<p>Examples of ecosystem-based solutions could include reforestation in important river catchments, planting native vegetation on flood plains that have been claimed for cropping, and creating riparian buffers through vegetation. </p>
<p>Each of these options would need to be carefully studied and implemented.</p>
<p>Nigeria also needs to strengthen its regulatory, governance and institutional capacity in the area of spatial planning, regional cooperation on transboundary water resources management, emergency response time, flood prediction, and enforcement of environmental and spatial planning laws. </p>
<p>Building on flood plains must be avoided at all costs. Awareness raising, education and disaster risk communication and messaging need to be strengthened to minimise flooding effects in Nigeria. The Nigerian Hydrological Services Agency, the <a href="https://nimet.gov.ng/">Nigerian Meteorological Agency</a> and the <a href="https://nema.gov.ng/">National Emergency Management Agency</a> are all important institutions that need resources and capacity to avert flooding in Nigeria.</p><img src="https://counter.theconversation.com/content/192750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nelson Odume receives funding from Water Research Commission, National Research Foundation, International Science Council, Network of Africa Science Academies, European Union, GIZ. </span></em></p>Nigeria must adopt a multi-pronged approach to address its flooding menace and minimise the effects.Nelson Odume, Associate professor, Rhodes UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1913952022-09-28T12:32:45Z2022-09-28T12:32:45ZLouis Pasteur’s scientific discoveries in the 19th century revolutionized medicine and continue to save the lives of millions today<figure><img src="https://images.theconversation.com/files/486616/original/file-20220926-26-u8ycb1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8764%2C5689&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Louis Pasteur was a pioneer in chemistry, microbiology, immunology and vaccinology.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/louis-pasteur-royalty-free-illustration/1176911773?adppopup=true">pictore/DigitalVision Vectors via Getty Images</a></span></figcaption></figure><p>Some of the greatest scientific discoveries haven’t resulted in Nobel Prizes.</p>
<p><a href="https://doi.org/10.1111/j.1469-0691.2012.03945.x">Louis Pasteur</a>, who lived from 1822 to 1895, is arguably the world’s best-known microbiologist. He is widely credited for the <a href="https://www.ncbi.nlm.nih.gov/books/NBK24649/">germ theory of disease</a> and for inventing the process of pasteurization – which is named after him – to preserve foods. Remarkably, he also developed <a href="https://doi.org/10.1111%2Fj.1365-2249.2012.04592.x">the rabies</a> and <a href="https://www.cdc.gov/anthrax/basics/anthrax-history.html#">anthrax</a> vaccines and made major contributions to <a href="https://www.vbivaccines.com/evlp-platform/louis-pasteur-attenuated-vaccine/#">combating cholera</a>.</p>
<p>But because he died in 1895, six years before the first <a href="https://www.nobelprize.org/">Nobel Prize</a> was awarded, that prize isn’t on his resume. Had he lived in the era of Nobel Prizes, he would undoubtedly have been deserving of one for his work. Nobel Prizes, which are awarded in various fields, <a href="https://www.nobelprize.org/the-nobel-prize-organisation/#">including physiology and medicine</a>, are not given posthumously.</p>
<p>During the current time of ongoing threats from emerging or reemerging infectious diseases, from <a href="https://www.contagionlive.com/view/virus-spillover-and-emerging-pathogens-pick-up-speed">COVID-19</a> and polio to <a href="https://theconversation.com/what-is-monkeypox-a-microbiologist-explains-whats-known-about-this-smallpox-cousin-183499">monkeypox</a> and <a href="https://doi.org/10.12703/b/9-9">rabies</a>, it is awe-inspiring to look back on Pasteur’s legacy. His efforts fundamentally changed how people view infectious diseases and how to fight them via vaccines. </p>
<p>I’ve worked in <a href="https://rodneyerohde.wp.txstate.edu/">public health and medical laboratories</a> specializing in viruses and other microbes, while <a href="https://www.health.txstate.edu/cls/">training future medical laboratory scientists</a>. My career started in virology with a <a href="https://scholar.google.com/citations?user=8XtvOZ8AAAAJ&hl=en">front-row seat to rabies detection and surveillance</a> and zoonotic agents, and it rests in large part on Pasteur’s pioneering work in microbiology, immunology and vaccinology. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A black and white illustration of Pasteur with a group of patients." src="https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=492&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=492&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=492&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=618&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=618&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486641/original/file-20220926-8928-88tfgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=618&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An illustration of Louis Pasteur, right, supervising the administration of the rabies vaccine at the Pasteur Institute in Paris in 1886.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-illustration-shows-french-biologist-louis-pasteur-right-news-photo/1266883710">Library of Congress/Interim Archives via Getty Images</a></span>
</figcaption>
</figure>
<h2>First, a chemist</h2>
<p>In my assessment, Pasteur’s strongest contributions to science are his remarkable achievements in the field of medical microbiology and immunology. However, his story begins with chemistry. </p>
<p>Pasteur studied under the <a href="https://www.britannica.com/biography/Jean-Baptiste-Andre-Dumas">French chemist Jean-Baptiste-André Dumas</a>. During that time, Pasteur became interested in the origins of life and worked in the field of <a href="https://www.pasteur.fr/en/institut-pasteur/history/early-years-1847-1862">polarized light and crystallography</a>. </p>
<p>In 1848, just months after receiving his doctorate degree, Pasteur was studying the properties of crystals formed in the process of wine-making when he discovered that <a href="https://www.nytimes.com/2017/06/14/science/louis-pasteur-chirality-chemistry.html">crystals occur in mirror-image forms</a>, a property known as chirality. This discovery became the foundation of a subdiscipline of chemistry known as <a href="https://doi.org/10.1002/hlca.201900098">stereochemistry</a>, which is the study of the spatial arrangement of atoms within molecules. This chirality, or handedness, of molecules was a “<a href="https://doi.org/10.1007/BF03401596">revolutionary hypothesis</a>” at the time. </p>
<p>These findings led Pasteur to suspect what would later be proved through molecular biology: All life processes ultimately stem from the precise arrangement of atoms within biological molecules.</p>
<h2>Wine and beer – from fermentation to germ theory</h2>
<p>Beer and wine were <a href="https://ageofrevolutions.com/2016/12/05/intoxication-and-the-french-revolution/">critical to the economy of France</a> and Italy in the 1800s. It was not uncommon during Pasteur’s life for products to spoil and become bitter or dangerous to drink. At the time, the scientific notion of “spontaneous generation” held that life can arise from nonliving matter, which was believed to be the culprit behind wine spoiling. </p>
<p>While many scientists tried to disprove the theory of spontaneous generation, in 1745, English biologist <a href="https://royalsocietypublishing.org/doi/pdf/10.1098/rstl.1748.0072">John Turberville Needham</a> believed he had created the perfect experiment favoring spontaneous generation. Most scientists believed that heat killed life, so Needham created an experiment to show that microorganisms could grow on food, even after boiling. After boiling chicken broth, he placed it in a flask, heated it, then sealed it and waited, not realizing that air could make its way back into the flask prior to sealing. After some time, microorganisms grew, and Needham claimed victory. </p>
<p>However, his experiment <a href="https://pubmed.ncbi.nlm.nih.gov/17940406/">had two major flaws</a>. For one, the boiling time was not sufficient to kill all microbes. And importantly, his flasks allowed air to flow back in, which enabled microbial contamination.</p>
<p>To settle the scientific battle, the French Academy of Sciences sponsored a contest for the best experiment <a href="https://doi.org/10.1080/00033798800200281">to prove or disprove spontaneous generation</a>. Pasteur’s response to the contest was a series of experiments, including a <a href="https://doi.org/10.3389%2Ffimmu.2012.00068">prize-winning 1861 essay</a>. </p>
<p>Pasteur deemed one of these experiments as “unassailable and decisive” because, unlike Needham, after he sterilized his cultures, he kept them free from contamination. By using his now famous swan-necked flasks, which had a long S-shaped neck, he allowed air to flow in while at the same time preventing falling particles from reaching the broth during heating. As a result, the flask remained free of growth for an extended period. This showed that if air was not allowed directly into his boiled infusions, then no “living microorganisms would appear, even after months of observation.” However, importantly, if dust was introduced, living microbes appeared.</p>
<p>Through that process, Pasteur not only refuted the theory of spontaneous generation, but he also demonstrated that microorganisms were everywhere. When he showed that food and wine spoiled because of contamination from invisible bacteria rather than from spontaneous generation, <a href="https://doi.org/10.3389%2Ffimmu.2012.00068">the modern germ theory of disease was born</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/OXdbQ1JkX7c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Pasteur’s discoveries resonate to this very day.</span></figcaption>
</figure>
<h2>The origins of vaccination in the 1800s</h2>
<p>In the 1860s, when the silk industry was being devastated by two diseases that were <a href="https://www.pasteur.fr/en/institut-pasteur/history/middle-years-1862-1877">infecting silkworms</a>, Pasteur <a href="https://doi.org/10.1111/j.1469-0691.2012.03945.x">developed a clever process</a> by which to examine silkworm eggs under a microscope and preserve those that were healthy. Much like his efforts with wine, he was able to apply his observations into industry methods, and he became something of <a href="https://doi.org/10.3390%2Fbiom12040596">a French hero</a>.</p>
<p>Even <a href="https://www.biography.com/scientist/louis-pasteur">with failing health</a> from a severe stroke that left him partially paralyzed, Pasteur continued his work. In 1878, he succeeded in identifying and culturing the bacterium that <a href="https://doi.org/10.3389/fimmu.2012.00068">caused the avian disease fowl cholera</a>. He recognized that old bacterial cultures were no longer harmful and that chickens vaccinated with old cultures could survive exposure to wild strains of the bacteria. And his observation that surviving chickens excreted harmful bacteria helped establish an important concept now all too familiar in the age of COVID-19 – asymptomatic “healthy carriers” can still spread germs during outbreaks.</p>
<p>After bird cholera, Pasteur turned to the prevention of <a href="https://rarediseases.org/rare-diseases/anthrax/">anthrax</a>, a widespread plague of cattle and other animals caused by the bacterium <em>Bacillus anthracis</em>. Building on his own work and that of German physician <a href="https://doi.org/10.12816/0003334">Robert Koch</a>, Pasteur developed the concept of the <a href="https://doi.org/10.3389/fimmu.2012.00068">attenuated, or weakened, versions of microbes</a> for use in vaccines.</p>
<p>In the late 1880s, he showed beyond any doubt that exposing cattle to a weakened form of anthrax vaccine could lead to what is now well known as immunity, dramatically reducing cattle mortality.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A computer-generated image of the rabies virus, colored brown in this illustration and resembling a pinecone." src="https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486643/original/file-20220926-25-dha566.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The deadly rabies virus. Although preventable by vaccination, rabies still kills approximately 59,000 people worldwide every year.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/rabies-virus-illustration-royalty-free-illustration/1191008423">Nano Clustering/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<h2>The rabies vaccine breakthrough</h2>
<p>In my professional assessment of Louis Pasteur, the discovery of vaccination against rabies is the most important of all his achievements. </p>
<p>Rabies has been called the “<a href="https://www.goodreads.com/book/show/13403051-rabid">world’s most diabolical virus</a>,” spreading from animal to human <a href="https://doi.org/10.12703/b/9-9">via a bite</a>. </p>
<p>Working with rabies virus is incredibly dangerous, as <a href="https://www.elsevier.com/books/rabies/wilson/978-0-323-63979-8">mortality approaches 100%</a> once symptoms appear and without vaccination. Through astute observation, Pasteur discovered that drying out the spinal cords of dead rabid rabbits and monkeys resulted in a weakened form of rabies virus. Using that weakened version as a vaccine to gradually expose dogs to the rabies virus, Pasteur showed that he could effectively immunize the dogs against rabies.</p>
<p>Then, in July 1885, Joseph Meister, a 9-year-old boy from France, was severely bitten by a rabid dog. With Joseph facing almost certain death, his mother took him to Paris to see Pasteur because <a href="https://www.pbs.org/newshour/health/louis-pasteurs-risky-move-to-save-a-boy-from-almost-certain-death">she had heard</a> that he was working to develop a cure for rabies.</p>
<p>Pasteur took on the case, and alongside two physicians, he gave the boy a series of injections over several weeks. Joseph survived and Pasteur shocked the world with a cure for a universally lethal disease. This discovery opened the door to the widespread use of Pasteur’s rabies vaccine around 1885, which <a href="https://doi.org/10.3390%2Ftropicalmed2020005">dramatically reduced rabies’ deaths in humans and animals</a>. </p>
<h2>A Nobel Prize-worthy life</h2>
<p>Pasteur once famously <a href="https://www.nhlbi.nih.gov/directors-messages/serendipity-and-the-prepared-mind">said in a lecture</a>, “In the fields of observation, chance favors only the prepared mind.” </p>
<p>Pasteur had a knack for applying his brilliant – and prepared – scientific mind to the most practical dilemmas faced by humankind.</p>
<p>While Louis Pasteur died prior to the initiation of the Nobel Prize, I would argue that his amazing lifetime of discovery and contribution to science in medicine, infectious diseases, vaccination, medical microbiology and immunology place him among the all-time greatest scientists.</p><img src="https://counter.theconversation.com/content/191395/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney E. Rohde has received funding from the American Society of Clinical Pathologists (ASCP), American Society for Clinical Laboratory Science (ASCLS), U.S. Department of Labor (OSHA), and other public and private entities/foundations. Rohde is affiliated with ASCP, ASCLS, ASM, and serves on several scientific advisory boards. See <a href="https://rodneyerohde.wp.txstate.edu/service/">https://rodneyerohde.wp.txstate.edu/service/</a>.</span></em></p>On World Rabies Day – which is also the anniversary of French microbiologist Louis Pasteur’s death – a virologist reflects on the achievements of this visionary scientist.Rodney E. Rohde, Regents' Professor of Clinical Laboratory Science, Texas State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1890132022-08-19T13:23:58Z2022-08-19T13:23:58ZSewage alerts: the long history of using maps to hold water companies to account<figure><img src="https://images.theconversation.com/files/480104/original/file-20220819-16-b02bpa.png?ixlib=rb-1.1.0&rect=0%2C0%2C2396%2C1196&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.sas.org.uk/map/">Surfers Against Sewage</a></span></figcaption></figure><p>Southern Water was handed <a href="https://www.gov.uk/government/news/record-90m-fine-for-southern-water-following-ea-prosecution">a record fine</a> of £90 million in July 2021 after pleading guilty to illegally discharging sewage along the rivers and coastline of Kent, Hampshire and Sussex. More than a year later, the headlines have not improved for Britain’s embattled water companies who have recently discharged more sewage close to <a href="https://www.bbc.co.uk/news/science-environment-62574105">dozens of beaches</a>. </p>
<p>The Environment Agency has called on water company executives to face <a href="https://www.bbc.co.uk/news/science-environment-62163182">jail</a> due to the ongoing <a href="https://environmentagency.blog.gov.uk/2022/07/18/water-company-environmental-performance-hits-new-low/">failings</a> on environmental performance. And with the onset of drought, complaints about <a href="https://www.gov.uk/government/news/environment-secretary-meets-with-water-company-chief-executives">leaky water pipes</a> have gone from a trickle to a stream. </p>
<p>Maps by conservation organisation <a href="https://theriverstrust.org/key-issues/sewage-in-rivers">The Rivers Trust</a> and campaign group <a href="https://www.sas.org.uk/map/">Surfers Against Sewage</a> lay bare the extent of sewage dumping into rivers and the sea. They have proved to be a highly effective tool, not just to warn of the risks to bathers but also to provide evidence of environmental damage. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two annotated maps of SE England" src="https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480071/original/file-20220819-1510-e90ge9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Recent sewage dumps in rivers (left) and along the coast (right) in south east England.</span>
<span class="attribution"><a class="source" href="https://theriverstrust.org/key-issues/sewage-in-rivers">The Rivers Trust (left) and Surfers Against Sewage (right)</a></span>
</figcaption>
</figure>
<p>These maps <a href="https://storymaps.arcgis.com/stories/be1b37aeaacb49aa9be621f5e4064e4b">pull together data</a> from sensors along the sewage network that detect discharges, making it clear where the worst offenders are and encouraging users to contact their local MP requesting more rapid action on sewage discharge. They are easy to share on social media and on <a href="https://www.bournemouthecho.co.uk/news/20666637.interactive-map-shows-sewage-released-near-dorset-beaches-last-48-hours/">local news sites</a>, they have inspired <a href="https://twitter.com/Feargal_Sharkey/status/1559806907359035392">viral tweets</a> and they make for awkward viewing for the water companies themselves.</p>
<p>This is not the first time maps have been used to hold private water companies to account. Some of the most famous maps of mid-19th century London, when it was gripped by successive outbreaks of cholera, helped reveal the cause of the deadly illness and identify the water companies responsible.</p>
<h2>Deadly supply</h2>
<p>John Snow was a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960830-2/fulltext">renowned physician</a> who walked the streets of London during the 1854 cholera epidemic, recording the deaths in grim detail. He mapped the cases, revealing clusters around a communal water pump in Broad Street, Soho, which confirmed his theory that cholera came from dirty water. He duly <a href="https://www.ph.ucla.edu/epi/snow/removal.html">removed the pump handle</a>, the outbreak in that area stopped and the rest – as they say – is history. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="annotated map of Soho" src="https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480087/original/file-20220819-24-rofdj1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Snow’s map showed cholera cases were clustered around a water pump.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/uxgfjt62/items">John Snow / Wellcome Collection</a></span>
</figcaption>
</figure>
<p>At least, that’s the simple version many people are already familiar with. In fact, the story is much more complex because Snow’s theory that the cholera pathogen was waterborne was not accepted by most scientists or policymakers at the time. He needed more proof. Snow therefore devised a “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2413309/#:%7E:text=In%20Snow's%20%E2%80%9Cgrand%20experiment%2C%E2%80%9D,a%20relatively%20unpolluted%20area%20upstream.">grand experiment</a>”, which hinged on the way different areas of London were served by different water companies. This meant he could compare one supplier against another in a kind of natural experiment. Snow knew that cases of cholera were not randomly distributed across the city. As he showed in Soho, they tended to be grouped together. So what if some water companies had more cases than others?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Shaded map of London" src="https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480088/original/file-20220819-1510-176vis.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Snow’s map showed some water companies were safer than others.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/uqa27qrt/images?id=eh993559">'On the mode of communication of cholera', John Snow / Wellcome Collection</a></span>
</figcaption>
</figure>
<p>Snow mapped out where Londoners were being supplied by the Southwark & Vauxhall Company (blue-green) and by the Lambeth Company (red, while brown areas are a mixture of both) during the same epidemic. Lambeth had recently stopped drawing its water from the Thames, which was hugely polluted at the time as it was the <a href="https://historicengland.org.uk/images-books/archive/collections/photographs/the-great-stink/">main route for sewage</a> to leave London. Its customers were dying from cholera at a rate of 37 per 10,000. Meanwhile, Southwark & Vauxhall was still extracting the polluted water, and their customers were dying at a rate of 317 per 10,000. </p>
<p>This should have proved once and for all that cholera was spreading thanks to foul water supplied into Londoners’ homes. But it wasn’t emphatic enough to trigger decisive change. Worse, a <a href="https://iiif.wellcomecollection.org/pdf/b24399474">government report</a> in 1856 commended the “considerable improvement which had taken place in the … supply of the water to the Metropolis”.</p>
<p>A decade later, and eight years after Snow’s death, London was suffering another cholera outbreak. The man charged with finding its cause during the summer of 1866 was <a href="https://www.britannica.com/biography/William-Farr">William Farr</a>, a statistician who had criticised Snow’s ideas. Even so, Farr was struck by how concentrated the cases appeared to be in East London and his mind must have turned to Snow’s grand experiment.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Annotated map of London" src="https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480086/original/file-20220819-24-x8epqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The 1866 deaths were mostly in the area served by East London Waterworks.</span>
<span class="attribution"><span class="source">William Farr / Wellcome Collection / additional annotations by James Cheshire</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>By mapping the cases, Farr showed that they fitted neatly within the area served by the East London Waterworks Company. Inhabitants of the area were complaining about the quality of their water, with some even <a href="https://wellcomecollection.org/works/n43vz8sh/items?canvas=203">finding eels</a> in their pipes. A representative of the company wrote to the Times newspaper reassuring customers that “not a drop of unfiltered water has been supplied”. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Old advert with text" src="https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=804&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=804&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=804&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1010&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1010&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480080/original/file-20220819-1510-z357im.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1010&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Farr’s work informed public health campaigns in 1866.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/n2ykxrzm/images?id=t6fq6u6a">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>But in <a href="https://wellcomecollection.org/works/n43vz8sh/items?canvas=25">his report</a>, Farr found that in July of 1866 water levels were running low so a sluice was opened to allow homes to be supplied by stagnant water from a reservoir that the company had said was no longer in use (because the water within it had not been filtered). Farr was finally convinced that Snow had been right about the origins of cholera, and his map offered irrefutable evidence that East London Waterworks was guilty of supplying water that had caused the deaths of nearly 6,000 Londoners. It was to be London’s last cholera outbreak. </p>
<h2>The power of maps</h2>
<p>The maps of Snow and Farr were essential for guiding reforms that won better sanitary conditions in the growing city. Today, we live in an era where maps are created from data that they could only dream of, allowing us to see the national picture in real time and pinpoint who is pouring the most effluent into our streams. For the Victorians the fight for safe drinking water was a matter of life and death, but we too can use maps to make the case for a cleaner environment.</p>
<p>As I look at today’s maps of sewage discharges I can’t help but think of a letter the influential scientist Michael Faraday <a href="http://faculty.humanities.uci.edu/bjbecker/plaguesandpeople/week8d.html">wrote to the Times</a> in the summer of 1855, where he sets out his concerns about the dire state of the Thames after a boat trip along it: </p>
<blockquote>
<p>I have thought it a duty to record these facts, that they may be brought to the attention of those who exercise power or have responsibility in relation to the condition of our river … If we neglect this subject, we cannot expect to do so with impunity; nor ought we to be surprised if, ‘ere many years are over, a hot season give us sad proof of the folly of our carelessness.</p>
</blockquote><img src="https://counter.theconversation.com/content/189013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Cheshire receives funding from UKRI. </span></em></p>These maps have gone viral – here’s what they owe to 19th century cholera campaigns.James Cheshire, Professor of Geographic Information and Cartography, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1855472022-06-22T14:53:07Z2022-06-22T14:53:07ZAt what point is a disease deemed to be a global threat? Here’s the answer<figure><img src="https://images.theconversation.com/files/470226/original/file-20220622-23-p5dnh3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Whenever there is an outbreak of a disease in the world – such as <a href="https://theconversation.com/monkeypox-this-is-an-entirely-new-spread-of-the-disease-184085">monkeypox</a> – it is up to the World Health Organization (WHO) to consider what sort of weight to give it, including whether or not it constitutes a public health emergency of international concern.</p>
<p>Global efforts to manage epidemics are documented as far back as <a href="https://www.historytoday.com/archive/black-death-greatest-catastrophe-ever">the black plague in Europe in the 14th century</a>. Since that time, rules have been developed and honed to keep up with the emergence of new diseases as well as with the growing complexities of a world that’s increasingly connected.</p>
<p>There are many diseases that can affect large numbers of people. But not all diseases are considered public health emergencies.</p>
<p>The <a href="https://theconversation.com/whats-the-difference-between-pandemic-epidemic-and-outbreak-133048">seriousness of an epidemic</a> is a function of several factors.</p>
<p>These <a href="https://www.sciencedirect.com/science/article/pii/S002074891400234X">include</a> the degree of contagiousness and potential for rapid spread, severity of infection, case fatality rate (the number of infected people who die), availability of vaccines or treatment (it’s more serious if there are none), impact on travel and trade, and the socioeconomic context.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-drc-ebola-outbreak-was-declared-a-global-emergency-and-why-it-matters-121991">Why the DRC Ebola outbreak was declared a global emergency and why it matters</a>
</strong>
</em>
</p>
<hr>
<h2>What it triggers</h2>
<p>Declaration of a “public health emergency of international concern” by the WHO triggers a number of things.</p>
<p>The first is that it signals a commitment to provide international resources for the response.</p>
<p>The second is that it enables other provisions of the <a href="https://www.who.int/features/qa/emergency-committees/en/">International Health Regulations</a>. These originated from the International Sanitary Regulations of <a href="https://apps.who.int/iris/handle/10665/85636">the mid 1900s</a>, which were used to control cholera epidemics. At this time, there was increasing awareness of the social and economic effects of epidemic diseases across borders, as well as concern about undue interference with trade.</p>
<p>In 1969 the regulations were <a href="https://africacdc.org/download/international-health-regulations/#:%7E:text=The%201969%20Regulations%2C%20which%20initially,the%20global%20eradication%20of%20smallpox.">renamed</a> the “International Health Regulations” by the WHO. They were then modified in 1973 and 1981. But even then they provided a framework for only 3 diseases – cholera, yellow fever and plague. The principles behind them was</p>
<blockquote>
<p>maximum security against the international spread of diseases with a minimum interference with world traffic.</p>
</blockquote>
<p>In 1995, formal revision commenced to expand the scope of the regulations with six proposed categories of <a href="https://www.asil.org/insights/volume/8/issue/8/revision-world-health-organizations-international-health-regulations">reportable syndromes</a>:</p>
<ul>
<li><p>acute haemorrhagic fever syndrome,</p></li>
<li><p>acute respiratory syndrome,</p></li>
<li><p>acute diarrhoeal syndrome,</p></li>
<li><p>acute jaundice syndrome,</p></li>
<li><p>acute neurological syndrome, and</p></li>
<li><p>other notifiable syndromes.</p></li>
</ul>
<p>In addition, five factors were proposed to determine if a cluster of syndromes was urgent and of international importance. These were rapid transmission in the community, unexpectedly high case fatality ratio, a newly recognised syndrome, high political and media profile, and trade or travel restrictions.</p>
<p>The last revision to the regulations was done in 2005 following the <a href="https://www.asil.org/insights/volume/8/issue/7/sars-and-international-law">SARS epidemic of 2003</a>.</p>
<p>The five substantive changes from the prior version were:</p>
<ul>
<li><p>a dramatic expansion of the scope of the regulations,</p></li>
<li><p>the creation of obligations on states to develop minimum core surveillance and response capacities,</p></li>
<li><p>granting WHO the authority to access and use non-governmental sources of surveillance information,</p></li>
<li><p>granting WHO the power to declare a public health emergency of international concern and to issue recommendations on how states-parties deal with it; and</p></li>
<li><p>the incorporation of human rights concepts into the implementation of the regulations.</p></li>
</ul>
<p>The regulations set down how an emergency will be managed. This includes setting up a roster of experts appointed by the Director General of WHO in all relevant fields of expertise. Then an emergency committee is drawn from this roster for advice. The committee has to decide on a range of issues to do with managing the epidemic. This includes whether an event constitutes a global emergency and when it should be ended.</p>
<h2>More than a health issue</h2>
<p>But the regulations can only go so far. Many countries cannot comply with them due to lack of resources.</p>
<p>Many of the problems of global emergencies are not specific health problems, but relate to civil society, community engagement, law and order and border control. In the 2014 Ebola epidemic, for example, a health promotion team <a href="https://www.washingtonpost.com/news/to-your-health/wp/2014/09/18/missing-health-workers-in-guinea-were-educating-villagers-about-ebola-when-they-were-attacked/">was massacred in Guinea</a> because local people were fearful of outsiders coming to their village. During COVID-19 we also saw civil unrest in some countries. All of these issues are considerations for the WHO when deciding whether to declare a public health emergency of international concern.</p>
<p><em>This is a revised extract from an article <a href="https://theconversation.com/why-the-drc-ebola-outbreak-was-declared-a-global-emergency-and-why-it-matters-121991">previously published</a> by The Conversation Africa written by C Raina MacIntyre and Obijiofor Aginam.</em></p><img src="https://counter.theconversation.com/content/185547/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre has consulted for or been on advisory boards in the last year for Sanofi, GSK, Bavarian Nordic. She is on the WHO COVID-19 Vaccine Composition Technical Advisory Group and the WHO SAGE Ad Hoc Working Group on Smallpox and Monkeypox. She receives funding from NHMRC and MRFF. </span></em></p><p class="fine-print"><em><span>Obijiofor Aginam does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The seriousness of an epidemic is a function of several factors, including the degree of contagiousness and potential for rapid spread.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyObijiofor Aginam, Principal Visiting Fellow & Former Deputy Director, International Institute for Global Health (UNU-IIGH), United Nations UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1821632022-05-10T13:49:59Z2022-05-10T13:49:59ZCommunity dialogue can show the way to meeting water needs: a South African case<figure><img src="https://images.theconversation.com/files/461597/original/file-20220505-21-k1sbzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to clean water is essential in preventing a number of infections. </span> <span class="attribution"><span class="source">Riccardo Mayer/shutterstock </span></span></figcaption></figure><p>About 842,000 people die every year from diarrhoea in <a href="https://www.sciencedirect.com/science/article/pii/S1438463918310484?via%3Dihub">rural communities</a> because they lack <a href="https://www.sciencedirect.com/science/article/pii/S1438463918310484?via%3Dihub">safe water</a> and <a href="https://washdata.org/sites/default/files/documents/reports/2019-07/jmp-2019-wash-households.pdf">adequate sanitation</a>. Water and sanitation are essential in preventing a number of other infections and hygiene-related diseases.</p>
<p>In South Africa, severe shortages of water and difficulties in accessing it have led to regular <a href="https://www.tandfonline.com/doi/abs/10.1080/09718923.2014.11893279">protests</a> in <a href="https://www.researchgate.net/publication/337244789_Exploring_service_delivery_protests_in_post-apartheid_South_African_municipalities_A_literature_review">municipalities</a> across the country. <a href="https://www.news24.com/News24/bushbuckridge-residents-protest-over-lack-of-water-20170613">Bushbuckridge</a>, a rural sub-district, is one.</p>
<p>The Bushbuckridge local municipality is among the driest areas in South Africa. Rainfall is low but the area is susceptible to occasional flooding. And the municipality <a href="https://zingelaulwazi.org.za/water-crisis-deepening-in-bushbuckridge-part-1/#:%7E:text=In%20the%20last%20ten%20years,getting%20worse%20day%20by%20day">struggles to supply potable water</a> to most villages in the area.</p>
<p>Within the municipality is the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429877">Agincourt</a> health and demographic surveillance site, a research programme established in 1992 to better understand population health in rapidly transitioning societies. The research population consists of 120,000 people living in 31 villages in 21,500 households. About 23% of households have no regular source of income and this has an impact on health. </p>
<p>Evidence <a href="https://pubmed.ncbi.nlm.nih.gov/31837832/">suggests</a> that involving marginalised <a href="https://pubmed.ncbi.nlm.nih.gov/31075120/">communities</a> in <a href="https://pubmed.ncbi.nlm.nih.gov/29062494/">setting priorities and designing collective action</a> can lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220489/">improved health outcomes</a> and ensure a more responsive and equitable health system.</p>
<p>But it is unclear how best to ensure <a href="https://www.cambridge.org/core/journals/primary-health-care-research-and-development/article/effective-and-meaningful-participation-or-limited-participation-a-study-of-south-african-health-committee-legislation/6F7F2276B2345E282E414658DC58A7A5#">effective and meaningful participation</a> in practice.</p>
<p>The Agincourt public health observatory provides an opportunity to try out approaches.</p>
<p>We engaged a cross-section of the community in Agincourt in a participatory action <a href="https://www.vapar.org/papers-and-reports">research process</a>. The aim was to find out which health topic was their priority and what they could do about it. The participants included community and religious leaders, traditional healers, community health workers, clinic committee members and family members. They were involved in decision making from the beginning of the process. This presented an opportunity to learn and to exercise control over decisions and actions affecting their lives. </p>
<h2>Water as a priority</h2>
<p>The participants as co-researchers identified lack of safe water as a priority health concern. They nominated women of reproductive age as a group whose voices were excluded, and recruited them to expand the process of exploring the topic. </p>
<p>Participants held weekly meetings where they used participatory action research methods and tools:</p>
<ul>
<li><p>ranking and voting to identify priority health topics</p></li>
<li><p>a “<a href="https://urbact.eu/problem-tree#:%7E:text=The%20PROBLEM%20TREE%20is%20a,shared%20understanding%20of%20the%20issue.">problem tree”</a> to understand lack of water from different perspectives</p></li>
<li><p><a href="https://www.siyavula.com/read/maths/grade-10/probability/14-probability-02">Venn diagrams</a> to identify different actors and their interaction and influence</p></li>
<li><p><a href="https://www.yourarticlelibrary.com/hrm/action-research-model-of-organisation-development-explained-with-diagram/35317">action pathways</a> to show steps towards desired goals through interconnected events. </p></li>
</ul>
<p>Participants talked about what was causing and contributing to their water challenges, what the impacts were, and what actions were needed most. They also took photographs and used these to define and share their experiences. These were a way to document, reflect on and communicate water issues in the community.</p>
<p>They said they often went without piped water for a long time. Infrastructure was unreliable or unavailable. Service delivery was inadequate. Water sources were informal and unregulated sources. Droughts added to the problem of poor supply. They all said they urgently needed a water tap in each household. </p>
<p>Participants also shared what they knew about interconnected social, behavioural and health impacts. Infectious diseases such as schistosomiasis, cholera, typhoid, and other intestinal infections were linked to lack of safe water. They reported on how lack of safe water compromised sanitation and the safety of women and girls. It contributed to hunger and malnutrition, and caused social unrest and protests. </p>
<p>Women and children had the biggest burden of collecting water. Participants said that water shortages drove people into poverty as time for work and education was lost. The physical strain of carrying water was also reported to affect health. </p>
<p>Participants attributed lack of safe drinking water to many issues. These included climate change, illegal connections, and poor planning by the government. Water was reported as being “stolen” through illegal connections and unmaintained infrastructure. Participants said municipalities took a long time to respond to issues raised by communities. </p>
<h2>Collective action</h2>
<p>Stakeholders representing rural communities and the authorities then collectively developed a local action plan. Their discussions centred on improving agency, control and power, and rebuilding a sense of community ownership. They committed to behavioural change and reorganisation of existing services and these actions were monitored through followup visits. </p>
<p>The local action plan was partially achieved, with three out of seven action items completed:</p>
<ul>
<li><p>river clean-up campaigns</p></li>
<li><p>awareness campaigns</p></li>
<li><p>dialogue between the communities and municipality. </p></li>
</ul>
<p>The greatest accomplishments were creation of dialogue in perceived safe spaces and collective implementation promoting mutual understanding and learning.</p>
<p>A key theme that emerged from the discussions was the value of partnerships between sectors. This was due to the cross-cutting nature of water as a resource, and its impact on health, economy, education, environment and social life. </p>
<p>It can’t be left to the department of water and sanitation alone to make water policy and to develop interventions. Sustainable solutions require other sectors to get involved too.</p>
<p>Embedding the process in an established public health observatory helped to create a neutral, mediated space for inclusive meaningful participation. </p>
<h2>Reflections and looking ahead</h2>
<p>Interactive workshops increased familiarity, ownership, and control of the process, and built mutual understanding relationships and trust. Facilitation was key in ensuring that discussions were focused, substantive, inclusive and respectful. Facilitators made sure that people’s experiences and knowledge were represented. The workshops were co-designed with participants, and located at suitable venues, times and dates. </p>
<p>Including stakeholders throughout the process (priority setting, design, implementation) has the potential to bridge the gap between theory and practice through production of relevant evidence for policy and planning. </p>
<p>Our process emphasised that allowing local voices to be heard in safe spaces increased people’s capacity to solve problems, learn and gain confidence. As one community stakeholder put it:</p>
<blockquote>
<p>There have been a lot of service delivery protests in communities, but they did not accomplish much; everyone realised that it is time to shift our ways of thinking and initiate dialogue, unite and collaborate and create sustainable partnerships to solve community problems.</p>
</blockquote><img src="https://counter.theconversation.com/content/182163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathleen Kahn receives funding from the South African Medical Research Council, UK Medical Research Council, Department of Science and Innovation SA, and the National Institute on Aging of the National Institutes of Health (NIH), USA</span></em></p><p class="fine-print"><em><span>Lucia D'Ambruoso works for the University of Aberdeen, Scotland, UK. She receives funding from the Health Systems Research Initiative from Department for International Development (DFID)/ Medical Research Council (MRC)/ Wellcome Trust/ Economic and Social Research Council (ESRC) (MR/N005597/1, MR/P014844/1) . She/she is affiliated with the University of the Witwatersrand, Johannesburg.</span></em></p><p class="fine-print"><em><span>Jennifer Hove and Rhian Twine do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Evidence suggests that involving marginalised communities in setting priorities and designing collective action can lead to improved health outcomes.Jennifer Hove, PhD student in the school of public health, University of the WitwatersrandKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandLucia D'Ambruoso, Senior Lecturer in Global Public Health, University of AberdeenRhian Twine, Honorary Senior Researcher in the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1760942022-02-06T14:51:45Z2022-02-06T14:51:45ZA better post-pandemic future means not giving in to COVID-19 now<figure><img src="https://images.theconversation.com/files/444498/original/file-20220204-19-1pps5k9.JPG?ixlib=rb-1.1.0&rect=1002%2C1060%2C4836%2C3259&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Normalizing the use of masks by vulnerable people during flu season could save many lives, even after the threat of COVID-19 has receded.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/a-better-post-pandemic-future-means-not-giving-in-to-covid-19-now" width="100%" height="400"></iframe>
<p>This is no time to give in to COVID-19.</p>
<p>It’s understandable that after two years, everyone is tired of being afraid, staying home, wearing masks and queueing up for rounds of vaccines and tests. </p>
<p>With the <a href="https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html#a9">virus finding the unvaccinated in greater numbers</a> — as expected — and breakthrough infections affecting the vaccinated, a spirit of resignation threatens to take hold. </p>
<p>Some are even suggesting it would be best to <a href="https://www.cbc.ca/news/canada/saskatchewan/opinion-covid-omicron-isn-t-inevitable-public-health-neudorf-1.6317723">stop trying, or even accelerate the spread of the virus to get it over with</a>, in the same way parents of yesteryear used to <a href="https://globalnews.ca/news/5084208/chickenpox-parties-vaccine-health-experts-warn/">put healthy and infected kids together to get chickenpox</a> and be done with it. </p>
<p>They had no idea their “chickenpox parties” would ultimately <a href="https://doi.org/10.1001/archinte.1995.00430150071008">lead to painful, sometimes debilitating, shingles outbreaks</a> for many later in adulthood. </p>
<h2>Omicron’s impact</h2>
<p>Even if Omicron infections are <a href="https://www.ctvnews.ca/health/coronavirus/omicron-may-be-less-severe-in-young-and-old-but-not-mild-who-1.5729956">typically milder than previous variants, there remains considerable uncertainty</a> around the long-term consequences of COVID-19. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&rect=226%2C289%2C4686%2C2878&q=45&auto=format&w=1000&fit=clip"><img alt="Health Minister Jean-Yves Duclos in the foreground looking at an image of Chief Public Health Officer Theresa Tam on a video screen" src="https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&rect=226%2C289%2C4686%2C2878&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=458&fit=crop&dpr=1 754w, https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=458&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/444482/original/file-20220204-25-c97apq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=458&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chief Public Health Officer of Canada Dr. Theresa Tam is seen via videoconference as Minister of Health Jean-Yves Duclos looks on during a news conference on the COVID-19 pandemic and the omicron variant on Jan. 7, 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>Further, the impact of a huge wave of any infection is severe, even when it is mild for many. We are seeing the devastating effects of <a href="https://www.cbc.ca/news/business/labour-omicron-workers-staffing-1.6305189">infected workers being absent</a>, not only in health care and long-term care, but also in businesses and schools that can’t run properly or in some cases at all.</p>
<p>As researchers in molecular virology and viral immunology, we are here to say in no uncertain terms that it would be wrong to give up now. </p>
<p>Vaccines have helped us to avoid near certain disaster during the current Omicron wave. The <a href="https://doi.org/10.1056/NEJMc2119270">number of deaths and devastating illnesses would be much, much higher</a> without them.</p>
<p>Already, we know that <a href="https://doi.org/10.1371/journal.pmed.1003773">long COVID, with its sometimes very serious physical and mental health consequences</a>, is shockingly common among COVID-19 patients, with symptoms affecting as many as one in three. We are also seeing some evidence that children are <a href="https://doi.org/10.1001/jamapediatrics.2021.5801">more likely to develop Type 1 diabetes</a> after COVID-19. Those are not risks we can afford, either.</p>
<p>Our society may have become complacent about infectious diseases, <a href="https://www.globalhealthnow.org/2021-12/dangerously-unprepared-new-report-faults-countries-pandemic-readiness-again">even without COVID-19</a>. Here in Canada, we have been lucky to live in a time when <a href="https://immunize.ca/learn-about-immunization">vaccines are so successful</a> that almost no other public health measures have been necessary to protect us from infections like smallpox, polio and tetanus that have plagued humanity for most of its natural history.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/silver-lining-could-covid-19-lead-to-a-better-future-134204">Silver lining: Could COVID-19 lead to a better future?</a>
</strong>
</em>
</p>
<hr>
<p>Pandemics have always <a href="https://www.nationalgeographic.com/magazine/article/how-devastating-pandemics-change-us-feature">changed and improved the way people live afterwards</a>. Cholera led to sewers and clean water. Yellow fever and influenza pandemics gave rise to the concept of public health. </p>
<p>Our new “normal” can be much healthier, with only the most subtle of changes. </p>
<h2>A healthier ‘normal’</h2>
<p>Last year there was <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2021-47/issue-10-october-2021/national-influenza-annual-report-canada-2020-2021.html">barely any influenza</a>, and the common cold went on hiatus because COVID-19 precautions also happened to provide a barrier to those familiar infections. The near absence of influenza probably saved about <a href="https://ipac-canada.org/influenza-resources.php">3,500 lives in Canada</a> alone, and those benefits can continue.</p>
<p>If we normalize <a href="https://doi.org/10.1016/j.lana.2021.100015">mask-wearing by vulnerable people</a> during peaks of influenza or other seasonal infections, we can save thousands of lives globally, even after the threat of COVID-19 recedes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a hat and a face mask looking at a sign illustrating COVID-19 prevention measures" src="https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=434&fit=crop&dpr=1 600w, https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=434&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=434&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=545&fit=crop&dpr=1 754w, https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=545&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/444500/original/file-20220204-19-ol6twv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=545&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Continuing to use preventive measures like hand washing and face masks after the COVID-19 pandemic ends could help prevent other infectious diseases.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>We learned early in the pandemic to wash our hands better and more frequently, which protects us from many forms of infection. Let’s keep it up. Likewise, improvements to building ventilation are long overdue and will continue to benefit our collective health going forward.</p>
<p>We have learned to stay home when we are sick, perhaps finally <a href="https://wmhp.cmhaontario.ca/workplace-mental-health-core-concepts-issues/issues-in-the-workplace-that-affect-employee-mental-health/presenteeism">shedding the warrior mentality of slogging through infections</a> as if it were somehow more productive than staying away from the workplace. It isn’t, especially when one outbreak can pull down a whole organization. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-year-of-covid-19-has-illuminated-the-urgent-need-for-paid-sick-days-154224">A year of COVID-19 has illuminated the urgent need for paid sick days</a>
</strong>
</em>
</p>
<hr>
<p>Now, there are much better ways to work remotely for those whose jobs permit it. The requirement to isolate when ill has also renewed public discussion around the need for improved paid sick leave policies to support vulnerable workers. Adopting these policies would improve the lives of many in the years to come.</p>
<p>COVID-19 has exponentially raised public awareness of infection control due to its constant intrusion into our everyday lives over the past two years. That can pay off in other ways, if we decide to take advantage of all the tools we have and lessons we have learned out of necessity. </p>
<p>All of this is certainly not to say COVID-19 is good. Far from it. But we can benefit from what we have learned so far, and we certainly should not give up now.</p>
<p>We have proven, effective tools. Using these tools effectively can keep us healthy, protect the most vulnerable members of our communities, allow businesses to operate safely and accelerate our return to “normal.” Simply being tired of the pandemic is not reason to let it burn through the population.</p><img src="https://counter.theconversation.com/content/176094/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Mossman receives funding from the Canadian Institutes for Health Research and the Natural Sciences and Engineering Research Council. </span></em></p><p class="fine-print"><em><span>Matthew S Miller receives funding from the Canadian Institutes of Health Research, the New Frontiers Research Fund, the Natural Sciences and Engineering Council of Canada, and the Ontario Research Fund.</span></em></p>After two years of COVID-19, it’s understandable that many people are weary of infection prevention measures. But simply being tired of the pandemic is no reason to let our guard down.Karen Mossman, Professor of Medicine and Vice President, Research, McMaster UniversityMatthew S Miller, Associate Professor in Biochemistry & Biomedical Sciences, M.G. DeGroote Institute for Infectious Disease Research, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1725962022-01-05T16:02:17Z2022-01-05T16:02:17ZA competitive cooking show puts a humble fermented rice dish on the global stage<figure><img src="https://images.theconversation.com/files/436732/original/file-20211209-25-116pmlz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A growing interest in fermented foods may direct people to a Bengali fermented rice dish.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/a-competitive-cooking-show-puts-a-humble-fermented-rice-dish-on-the-global-stage" width="100%" height="400"></iframe>
<p>It was Kishwar Chowdhury, a competitor and second runner-up on the 13th season of <em>MasterChef Australia</em>, <a href="https://www.indiatimes.com/entertainment/originals/meet-kishwar-chowdhury-who-is-making-aloo-bhorta-panta-bhat-popular-in-masterchef-australia-544845.html">who made a dish called panta bhat internationally famous</a>. A rather humble dish from eastern India (Assam, Odisha and West Bengal) and Bangladesh, one could never have imagined it achieving such a level of critical acclaim.</p>
<p>Panta bhat is cooked parboiled rice that is soaked in cold water and left to ferment. Very often it’s left overnight, although some may even ferment it longer. The rice is then eaten with accompaniments that can vary depending on the economic condition of the family or the individual — ranging from basics like mustard oil, raw onion and green chillies to more elaborate sides like fried fish, batter-fried veggies and potatoes. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/mOc1QdNHHEw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How to make panta bhat.</span></figcaption>
</figure>
<h2>Fermenting in pond water</h2>
<p>Ten years ago, panta bhat was <a href="https://dx.doi.org/10.1155/2014/764530">associated with several cases of cholera</a>. The dish is a rural staple and popular breakfast in eastern India and Bangladesh, but the use of contaminated water in the preparation of the rice created the perfect conditions for the development of disease. </p>
<p>Using pond water in making panta bhat <a href="https://doi.org/10.3329/jhpn.v29i5.8895">had been a major cause of the disease</a>. There were several public health campaigns that were specifically designed to prevent the villagers from using pond water, but they were often ineffective. </p>
<p>Despite its role in causing cholera, the popularity of the dish never declined. It’s a cheap meal that needs no refrigeration. Further, one can cook the rice in a pot and soak the leftovers in the same pot. Finally, it is not only cheap and convenient, but also needs very little time to make.</p>
<p>The role of panta bhat is so central to Bengal that there is a popular folkloric figure called Panta Buri — “old woman who eats panta” — who has many adventures after a thief steals her panta bhat. In order to seek justice for the theft, she goes on a long journey to meet the king. On her way, she meets many eclectic characters like a talking knife, a catfish, a bael (a native fruit species) and an alligator. While the characters change in different versions, <a href="https://golpojuri.blogspot.com/2019/12/panta-buri-bangla-golpo.html">the context of her journey remains the same</a>. </p>
<p>Panta bhat is a dish that reflects the soul of rural Bengal. Yet the dish has now made it to a very popular television show, and feeds into the <a href="https://www.forbes.com/sites/lizzysaxe/2019/02/06/fermented-foods-are-up-149-percent-as-long-as-theyre-unfamiliar/">growing interest in fermented foods</a>. </p>
<p>Panta bhat is an acquired taste — a penchant for fermented rice is certainly not as widespread as, say, fried potatoes. Immigrant chefs are now pushing us towards bolder taste, a taste that is defiant, and not overshadowed by past colonial ambivalence. </p>
<h2>Acceptance through food</h2>
<p>Increasingly, immigrants have become unapologetic about their culinary roots. For example, British-Ghanaian chef Zoe Adjonyoh actively discusses issues like colonialism and racism that <a href="https://www.foodandwine.com/chefs/chef-zoe-adjonyoh-is-not-here-to-summarize-african-food-for-you">influence how traditional cuisines are perceived and accepted</a>. Nadiya Hussein became popular after winning the 2015 season of <em>The Great British Bake Off</em>, and helped <a href="https://www.theguardian.com/tv-and-radio/2021/apr/18/nadiya-hussain-i-never-even-dreamed-of-being-a-part-of-all-this">popularize unique fusion foods through her writing and a series of television cooking shows</a>.</p>
<p>This interest in ethnic cuisines can also be seen in the growing number of food shows and documentaries like <a href="https://www.huffpost.com/entry/david-chang-ugly-delicious-asian-american-culture_n_5a85c109e4b0774f31d33120"><em>Ugly Delicious</em></a>, <a href="https://www.bloomberg.com/news/articles/2021-05-20/this-netflix-series-gets-to-the-heart-of-black-american-food-culture"><em>High on the Hog</em></a>, <a href="https://time.com/5896336/china-us-food-flavorful-origins-netflix/"><em>Flavorful Origins</em></a> and many others that show a growing interest in the subject and a curiosity about authentic culinary storytelling. </p>
<p>We have a very long way to go when it comes to embracing versatile tastes from non-western cultures. In 2019, American national security affairs professor Tom Nichols felt the need to openly disparage Indian food on Twitter.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1198349042683658241"}"></div></p>
<p>While it sparked a major controversy, <a href="https://www.bbc.com/news/world-us-canada-50550735">Nichols’ tweet exposed the fault lines of racism that so frequently get expressed in belittling immigrant tastes</a>.</p>
<p>But there is hope, and a lot of curiosity. Instead of trying to alter and adjust their cuisine to existing western standards, young immigrant chefs are learning about their culinary past, and slowly trying to integrate their unique flavours into the growing world of global cuisine in very honest, authentic ways.</p>
<p>Let’s face it, fermented rice with strong mustard oil and spicy green chillies is like a bold, raw taste of defiance.</p><img src="https://counter.theconversation.com/content/172596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aditi Sen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A rice dish’s debut on a cooking competition show reflects the growing acceptance of ethnic foods.Aditi Sen, Assistant Professor, History, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706602021-11-01T14:13:02Z2021-11-01T14:13:02ZDroughts create fertile ground for cholera. Plans are needed to face more dry periods<figure><img src="https://images.theconversation.com/files/429133/original/file-20211028-21-59ensr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/dried-out-dam-is-pictured-on-a-farm-in-piket-bo-berg-news-photo/932983846?adppopup=true">Wikus De Wet/AFP via Getty Images</a></span></figcaption></figure><p>Africa has a disproportionately <a href="https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003832">high burden</a> of cholera. The World Health Organization reports that between <a href="https://www.who.int/cholera/publications/global-roadmap.pdf?ua=1">40 million and 80 million</a> people in Africa live in cholera hotspots. Globally, disease outbreaks have more than tripled since 1980, with 1,307 epidemic events between 2011 and 2017. Cholera was the <a href="https://www.who.int/emergencies/diseases/managing-epidemics-interactive.pdf">biggest contributor</a> to this with 308 events. </p>
<p>This is particularly concerning, considering cholera is an under reported disease. </p>
<p>Cholera tracks with areas of high poverty and low access to safe drinking water, sanitation and hygiene. More than a third of people still don’t have access to water in central and west Africa and less than 40% have adequate sanitation, <a href="https://www.unicef.org/wca/what-we-do/wash">according to UNICEF</a>. </p>
<p>Children and women are facing particularly serious consequences to this inaction. This is because cholera is a major component to child mortality. In addition, young girls and women are primarily responsible for water collection, reducing the time available for work or education and exposing them to the risk of sexual violence.<br>
In a <a href="https://www.tandfonline.com/doi/full/10.1080/20477724.2021.1981716">recent paper</a> I looked at drought-related cholera outbreaks in Africa and the implications of an increase in dry periods as a result of climate change. <a href="https://www.imperial.ac.uk/people/g.charnley19">My research</a> is focused on infectious diseases, including cholera, which have several links and relationships to droughts. </p>
<p>I focused on the subject because droughts are generally an understudied natural hazard. This is perhaps due to their complexity involving meteorological, hydrological, agricultural and societal changes. I sought to collate historically reported risk factors and understand which regions had reported these drought-related outbreaks. I found a lack of literature on the subject but there were several inequities that were repeated and that must be addressed to support drought affected communities better, including food and water assistance. </p>
<h2>Climate change and cholera</h2>
<p>One consequence of a warming world is prolonged dry spells and periods of drought. And a known consequence of droughts and their associated risk factors are infectious disease outbreaks, which are worsened by malnutrition, poor access to water, sanitation and hygiene and population displacement. </p>
<p>These are perfect conditions for a rise in outbreaks of cholera.</p>
<p>It’s hard to predict where future droughts will happen. But available evidence <a href="https://www.sciencedirect.com/science/article/abs/pii/S0048969718324987?via%3Dihub">suggests</a> that some areas of Africa are likely to see more intense and longer droughts. How long and how intense, will likely rely on how countries adapt and respond, including the management of water. </p>
<p>Suggested mechanisms through which droughts may exacerbate the transmission of cholera include elevated concentrations of the pathogen, multi-use drinking water, reduced fuel for cooking and using alternative foods and water. </p>
<p>Cholera has known environmental and climatic links. But some <a href="https://www.medrxiv.org/content/10.1101/2021.07.16.21260629v1">research </a> has suggested these may only be important up to a certain threshold, then socio-economic conditions are needed to make the human-environment link. </p>
<p><a href="https://www.nature.com/articles/s41598-021-85146-0">Evidence</a> for this is clear in the areas which suffer from cholera outbreaks following climatological events. For example, Europe and North America have a long history of drought and dry spells but cholera outbreaks do not follow. This is because there is widespread access to safe drinking water and sanitation. </p>
<p>Drought and cholera outbreaks can also result in displacement, a risk factor commonly cited as causing infectious disease outbreaks. Displacement can help to spread cholera to new areas. For example, during the <a href="https://www.fao.org/3/X5558E/X5558e01.htm">Mozambican drought</a> in 1991-1992, over one million people were forced to seek refuge elsewhere. This resulted in an influx of refugees to Zimbabwe, which <a href="https://academic.oup.com/trstmh/article-abstract/90/4/378/1864864?redirectedFrom=fulltext">subsequently suffered</a> a fast-moving cholera outbreak. </p>
<p>Other population groups that suffer particularly badly in times of drought are nomadic communities and poorer rural communities. This is due to their reliance on agriculture, inability to afford alternative water sources and isolation from society.</p>
<h2>Mitigation</h2>
<p>I conclude in my paper that disasters don’t cause outbreaks. Rather its societal response, or the lack thereof.</p>
<p>Arguably the most fundamental way to reduce the impacts of drought and resultant cholera outbreaks is to alleviate population vulnerabilities before the hazard occurs. Such steps include:</p>
<ul>
<li><p>expanding access to water and sanitation, </p></li>
<li><p>alleviating poverty, and </p></li>
<li><p>reducing the marginalisation of groups. </p></li>
</ul>
<p>This would enable people to adapt better to a changing climate.</p>
<p>In addition multi-country drought response plans and water agreements are needed. How one country manages a water source can have a knock-on effect and drought rarely affects one country in isolation. </p>
<p>When cholera outbreaks do occur, the response needs to be rapid, due to its short incubation period - less than two hours to five days. </p>
<p>Oral cholera vaccines are an essential tool in controlling outbreaks, along with providing chlorinated water. </p>
<p>More awareness of the implications of drought on health are needed including enhanced research, technology, surveillance and forecasting to assess health under an interdisciplinary lens. Better drought diplomacy, which involves using drought-related activities to create <a href="https://onlinelibrary.wiley.com/doi/10.1002/9781118885154.dipl0086">fresh diplomatic opportunities</a> and not conflicts, is needed at all levels to improve the capacity to cope and offer effective solutions. </p>
<p>Communities also need to be consulted and encouraged in climate adaptation talks and negotiations.</p>
<p>The current <a href="https://pubmed.ncbi.nlm.nih.gov/29123067/">cholera pandemic</a> shows no signs of waning and remain unlikely while so many people live in conditions that allow its transmission. These issues will only be worsened as climate change progresses. A greater call to action is needed to provide the basic human right of water and sanitation.</p><img src="https://counter.theconversation.com/content/170660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gina Charnley receives funding from the Natural Environmental Research Council (NERC). </span></em></p>A consequence of a warming world is prolonged dry spells and periods of drought that can lead to infectious diseases like cholera.Gina Charnley, Research Postgraduate, Imperial College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1623412021-07-29T13:15:39Z2021-07-29T13:15:39Z5 ways climate-driven ocean change can threaten human health<figure><img src="https://images.theconversation.com/files/413603/original/file-20210728-21-3aqzwz.jpg?ixlib=rb-1.1.0&rect=13%2C58%2C2982%2C1913&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ocean waters are now warmer, more acidic and hold less oxygen. They're also stressed from overfishing and pollution. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span></figcaption></figure><p>Humans have a deep and complex <a href="https://oceanpanel.org/sites/default/files/2020-10/Human%20Relationship%20with%20the%20Ocean%20Full%20Paper.pdf">relationship with the sea</a>. It <a href="https://doi.org/10.1016/j.worlddev.2015.11.007">provides food</a> and <a href="https://fishbase.ca/Nutrients/NutrientSearch.php">essential nutrients</a>, <a href="https://dx.doi.org/10.4062%2Fbiomolther.2016.181">medicine</a> and <a href="https://doi.org/10.1016/S0308-597X(02)00045-3">renewable energy</a>. <a href="https://doi.org/10.1016/j.healthplace.2019.102212">People swim</a>, <a href="https://doi.org/10.1177%2F1049732314549477">surf</a> and <a href="https://doi.org/10.3390/ijerph17197238">scuba dive</a> in this “<a href="http://dx.doi.org/10.1016/j.marpolbul.2009.04.019">blue gym</a>.” It’s even an important part of therapeutic recreation, like <a href="https://doi.org/10.1080/07303084.2014.884424">surf therapy</a> for <a href="https://www.nytimes.com/2019/08/08/well/mind/catching-waves-for-well-being.html">war veterans and children with autism</a>.</p>
<p><a href="https://doi.org/10.1016/j.marpol.2009.08.006">Economies are also bound to the ocean</a>. Fishing, tourism, marine transportation and shipping bring jobs, income and food security, while serving culture and other <a href="https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1">social determinants of health</a>.</p>
<p>From our <a href="https://www.facebook.com/Littoral.Ulaval/photos/a.1954500618111079/3066356660258797/">ancestors to our children</a>, diverse human cultures, livelihoods and ways of life flow to, and from, the sea. But rising greenhouse gas emissions are changing the ocean and putting our health at risk.</p>
<p><a href="https://www.ipcc.ch/site/assets/uploads/sites/3/2019/11/03_SROCC_SPM_FINAL.pdf">Ocean waters are now warmer, more acidic and hold less oxygen</a>. Ocean ecosystems, already <a href="http://www.fao.org/state-of-fisheries-aquaculture">stressed from overfishing</a> <a href="https://www.nationalgeographic.com/environment/article/critical-issues-marine-pollution">and pollution</a>, face <a href="https://doi.org/10.1038/ncomms8615">escalating risks of further degradation</a>. With melting sea ice, rising sea levels and growing extreme weather events, <a href="https://doi.org/10.1139/facets-2020-0035">human health and well-being now face many threats</a>, most aimed at <a href="https://www.un.org/esa/sustdev/natlinfo/indicators/methodology_sheets/oceans_seas_coasts/pop_coastal_areas.pdf">coastal populations</a>.</p>
<h2>1. Hydrologic disasters</h2>
<p>Marked by their swift and destructive power, <a href="https://www.ipcc.ch/report/managing-the-risks-of-extreme-events-and-disasters-to-advance-climate-change-adaptation/">natural disasters</a> are becoming more extreme and more frequent with climate change. </p>
<p>For example, <a href="https://oceanservice.noaa.gov/facts/cyclone.html">tropical cyclones</a> (like hurricanes and typhoons), <a href="https://doi.org/10.1371/currents.dis.2664354a5571512063ed29d25ffbce74">which have killed about 1.33 million people</a> since the beginning of the 20th century, <a href="https://doi.org/10.5281/zenodo.4570334">are getting more intense with warming ocean waters</a>. The number of <a href="https://time.com/4946730/hurricane-categories/">Category 4 and 5 hurricanes</a> has <a href="https://doi.org/10.1007/s00382-013-1713-0">increased 25 to 30 per cent for each degree Celsius of human-induced global warming</a> since the mid 1970s.</p>
<p><a href="https://www.who.int/health-topics/floods#tab=tab_1">Storm surges, flooding</a> and physical trauma cause most fatalities and injuries. But in the wake of disaster, environmental and social conditions also threaten public health. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hurricane-damage-harms-the-most-vulnerable-reveals-inequality-and-social-divides-159678">Hurricane damage harms the most vulnerable, reveals inequality and social divides</a>
</strong>
</em>
</p>
<hr>
<p>Stagnant water and damaged wastewater systems can expose people to <a href="https://doi.org/10.1080/10937404.2019.1654422">toxins, bacteria and viruses</a>. Interruptions to <a href="https://doi.org/10.1017/dmp.2016.3">health care</a> and negative impacts on housing, employment and other social determinants of health subject people to <a href="https://doi.org/10.5670/oceanog.2006.62">distressing conditions</a> (such as crowded shelters and diplacement) beyond the <a href="https://doi.org/10.1017/S0144686X1600115X">trauma of the event</a>.</p>
<p>This can worsen <a href="https://doi.org/10.1093/epirev/mxi011">a broad spectrum of public health issues</a> — from <a href="https://doi.org/10.1016/j.emc.2018.07.002">infectious diseases</a> (like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438646/">cholera</a>, <a href="https://doi.org/10.3201/eid1707.101050">leptospirosis</a> and <a href="https://doi.org/10.1371/journal.pone.0131423">diarrheal diseases</a>) to <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">non-communicable diseases</a> (such as <a href="https://doi.org/10.1097/EDE.0000000000001337">cardiovascular</a> and <a href="https://doi.org/10.1017/dmp.2020.424">respiratory</a> conditions) to <a href="https://www.ncei.noaa.gov/news/hurricanes-take-heavy-toll-mental-health-survivors">adverse mental health</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/another-grim-climate-report-on-oceans-what-will-it-take-to-address-the-compounding-problems-123894">Another grim climate report on oceans – what will it take to address the compounding problems?</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://doi.org/10.1038/s41467-021-21777-1">An increase in hospitalizations</a> has been documented among <a href="https://doi.org/10.1289/EHP6976">disaster-affected populations</a> weeks, months and years later. </p>
<p>A well-studied example is Hurricane Katrina, which caused over 1,800 deaths in August 2005 <a href="https://doi.org/10.1097/DMP.0b013e31818aaf55">from drowning, injury and physical trauma</a>, but also led to <a href="https://doi.org/10.3390/ijerph16010074">an abrupt increase in heart conditions</a> and <a href="https://doi.org/10.1111/j.1939-0025.2010.01027.x">serious mental illness</a>. A decade later, <a href="https://doi.org/10.1016/j.socscimed.2019.112610">persistent mental</a> and <a href="https://doi.org/10.1017/dmp.2018.22">cardiovascular health issues</a> are among the reminders of the storm.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369797/original/file-20201117-13-180ibt9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><strong><em>This story is part of <a href="https://theconversation.com/uk/topics/oceans-21-96784">Oceans 21</a></em></strong>
<br><em>Our series on the global ocean opened with <a href="https://oceans21.netlify.app/">five in-depth profiles</a>. Look out for new articles on the state of our oceans in the lead up to the UN’s next climate conference, COP26. The series is brought to you by The Conversation’s international network.</em></p>
<hr>
<h2>2. Migration and displacement</h2>
<p><a href="https://www.ipcc.ch/srocc/chapter/chapter-4-sea-level-rise-and-implications-for-low-lying-islands-coasts-and-communities/">With the rise of global sea level</a>, <a href="https://doi.org/10.1038/s41598-017-01362-7">coastal flooding</a> is becoming more common and severe. Another <a href="https://doi.org/10.1038/s41598-020-67736-6">250,000 square kilometres of coastal land is projected to flood</a> by the end of the century, exposing tens of millions more people to risks. </p>
<p>Advancing ocean waters, erosion and thawing permafrost can make some <a href="https://www.ilo.org/dyn/migpractice/docs/261/Pacific.pdf">coastal settlements hard or impossible to live in</a>. <a href="https://www.oceanfdn.org/sites/default/files/forced%20migration%20alaskan%20community.pdf">The Yup'ik</a> village of <a href="https://www.nationalgeographic.com/science/article/climate-change-finally-caught-up-to-this-alaska-village">Newtok</a> (Niugtaq), for example, began the first phase of a planned relocation in 2019, after coastal storms and thawing permafrost began destroying the village. </p>
<figure class="align-center ">
<img alt="A single-storey house falling off a snow-covered shoreline into the ocean." src="https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/413607/original/file-20210728-15-1y7bdms.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An abandoned house sits on a beach after a storm in Shishmaref, Alaska, in 2005. Residents voted to relocate in 2016 due to the severe coastal erosion.</span>
<span class="attribution"><span class="source">(AP Photo/Diana Haecker)</span></span>
</figcaption>
</figure>
<p>While the newly relocated <a href="https://www.kyuk.org/post/after-moving-new-village-mertarvik-residents-say-they-are-healthier">residents have reported feeling healthier</a>, even proactive responses can lead to <a href="https://www.alaskapublic.org/2020/07/29/mertarviks-lack-of-a-commercial-airport-may-have-already-cost-lives/">new risks</a> to <a href="https://doi.org/10.1007/s10584-019-02382-0">health and well-being</a>. Relocations can lead to <a href="https://doi.org/10.1089/eco.2018.0021">distress and trauma</a> when residents have a strong attachment to a place. </p>
<p>The <a href="https://doi.org/10.1186/s12916-017-0981-7">health dimensions of climate-related migrations</a>, especially among those who <a href="https://theconversation.com/how-many-people-will-migrate-due-to-rising-sea-levels-why-our-best-guesses-arent-good-enough-145776">stay or are left behind</a>, have not received enough attention in research and policy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/climigration-when-communities-must-move-because-of-climate-change-122529">'Climigration': when communities must move because of climate change</a>
</strong>
</em>
</p>
<hr>
<h2>3. Sea ice decline</h2>
<p>Over the past 40 years, Arctic sea ice has become smaller and thinner. <a href="https://climate.nasa.gov/vital-signs/arctic-sea-ice/">Its overall extent</a> has declined about 13 per cent per decade, and its <a href="https://doi.org/10.1029/2009GL039035">thickness has decreased</a> by at least 1.75 meters. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A graph showing the downward trend in Arctic sea ice extent" src="https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=285&fit=crop&dpr=1 600w, https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=285&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=285&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=358&fit=crop&dpr=1 754w, https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=358&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/413384/original/file-20210727-14-6b1ps1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=358&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Arctic sea ice reaches its minimum each September. September Arctic sea ice is now declining at a rate of 13.1 per cent per decade, relative to the 1981 to 2010 average.</span>
<span class="attribution"><a class="source" href="https://climate.nasa.gov/vital-signs/arctic-sea-ice/">(NSIDC/NASA)</a></span>
</figcaption>
</figure>
<p>Sea ice is a <a href="https://doi.org/10.1098/rsbl.2016.0198">defining feature of life in the Arctic</a>. It provides a platform for <a href="https://doi.org/10.1002/9781118778371.ch25">travel and harvesting activities</a>, and shapes ecological processes that are at the foundation of local <a href="https://www.nirb.ca/publications/strategic%20environmental%20assessment/190125-17SN034-QIA%20Report%20Re%20Marine%20Based%20Harvesting-IEDE.pdf">cultures, economies, knowledge and food systems</a>. </p>
<p>The sea ice decline makes navigation <a href="https://sikuatlas.ca/index.html?module=module.sikuatlas.sea_ice">more dangerous and less predictable</a>. It can <a href="https://doi.org/10.1007/s10113-008-0060-x">change the timing and location of harvests, increase harvesting costs and reduce how much is harvested</a>. </p>
<p>This can lead to <a href="https://www.jstor.org/stable/41758937">less food and money</a>, more <a href="https://doi.org/10.1017/S1368980020000117">anxiety about food access</a> and <a href="https://doi.org/10.1017/S1368980020002402">greater reliance on less healthy imported foods</a>, negatively affecting <a href="https://www.itk.ca/wp-content/uploads/2021/07/ITK_Food-Security-Strategy-Report_English_PDF-Version.pdf">food security</a> and mental health.</p>
<h2>4. Seafood decline</h2>
<p>Seafood is a key source of protein and essential nutrients, especially where they’re in short supply from other <a href="https://doi.org/10.3390/ijerph17238818">locally accessible foods</a>. </p>
<p>But climate change is already <a href="https://doi.org/10.1111/j.1365-2486.2009.01995.x">driving species towards the North and South Poles.</a>. This may lead to <a href="https://doi.org/10.1038/534317a">serious declines in seafood catches by 2050</a> and negatively affect millions globally, with the most severe impacts in developing countries and among <a href="https://doi.org/10.1371/journal.pone.0166681">coastal Indigenous Peoples</a>. </p>
<figure class="align-center ">
<img alt="A red and gold salmon swimming" src="https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/413614/original/file-20210728-17-1xna163.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Warmer water temperatures are making salmon more susceptible to predators, parasites and disease — and they’re shrinking in size.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Projected <a href="https://doi.org/10.1371/journal.pone.0145285">declines of salmon and herring catches in British Columbia</a>, for instance, may lead to inadequate intakes of several vitamins, minerals and fatty acids <a href="https://doi.org/10.1371/journal.pone.0211473">for coastal First Nations</a>. When diets shift to processed foods, high in calories and sodium, the <a href="https://doi.org/10.1111/j.1753-4887.2011.00456.x">risk of developing Type 2 diabetes and cardiovascular disease increase</a>. </p>
<h2>5. Hazards in ocean waters, air and seafood</h2>
<p><a href="http://doi.org/10.5334/aogh.2831">The ocean is polluted</a> with mercury, industrial chemicals, pharmaceuticals, microplastics — and more. It also harbours many naturally occurring micro-organisms, like <a href="https://dx.doi.org/10.1128%2FMMBR.68.3.403-431.2004">flesh-eating bacteria and cholera</a>, and <a href="https://doi.org/10.1289/ehp.00108s1133">toxins</a>. </p>
<p>These can become dangerous to human health when ocean chemistry and temperature, and other marine ecosystem dynamics, are altered, which can lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016795/pdf/nihms-681151.pdf">shellfish poisoning</a>, <a href="https://theconversation.com/climate-change-and-overfishing-are-boosting-toxic-mercury-levels-in-fish-122748">mercury exposure and poisoning</a> and other illnesses. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/climate-change-and-overfishing-are-boosting-toxic-mercury-levels-in-fish-122748">Climate change and overfishing are boosting toxic mercury levels in fish</a>
</strong>
</em>
</p>
<hr>
<p>Climate change will <a href="https://doi.org/10.1111/gcb.13667">alter the distribution and severity of pollutants</a>. For example, <a href="https://doi.org/10.1016/j.tim.2016.09.008">infections from some strains of vibrio bacteria</a> may become more <a href="https://www.contagionlive.com/view/cluster-of-v-vulnificus-pops-up-in-previously-nonendemic-area">frequent and widespread</a> with warming waters. Even <a href="https://doi.org/10.1038/s41586-019-1468-9">rising methylmercury concentrations in tuna</a> have been linked to increasing sea water temperature.</p>
<h2>Navigating forward</h2>
<p>Despite the many connections between <a href="https://doi.org/10.1016/j.oneear.2020.05.013">ocean health</a> and human health, <a href="https://www.doi.org/10.1002/pan3.10038">global ocean governance</a> has rarely considered the latter. Policies like the U.S. <a href="https://uscode.house.gov/view.xhtml?path=/prelim@title33/chapter44&edition=prelim">Oceans and Human Health Act</a>, and related <a href="https://doi.org/doi:10.1186/1476-069X-7-S2-S1">research and training centres</a>, can bolster the collaboration and co-ordination needed across diverse agencies, sectors and disciplines to support healthy oceans and people. </p>
<p>This interdisciplinary infrastructure and capacity is needed to develop the information (like <a href="https://doi.org/10.3389/fmars.2021.631732">early warning systems</a>), policies, plans and management systems to mitigate and respond to emerging public health threats from the ocean. We must broaden the framing of ocean change <a href="https://bcgreencare.ca/climate-change-and-role-of-HA">from an “environmental issue” to one that includes human health</a> and <a href="https://www.oceanpanel.org/sites/default/files/2020-04/towards-ocean-equity.pdf">social equity</a>. </p>
<p>As the world turns to the ocean for “<a href="https://www.worldbank.org/en/news/infographic/2017/06/06/blue-economy">blue economies</a>,” “<a href="https://thewalrus.ca/blue-space-is-the-new-green-space/">blue spaces</a>,” “<a href="https://doi.org/10.1093/heapro/day103">blue health care</a>” and “<a href="http://dx.doi.org/10.2139/ssrn.3854678">blue prescriptions</a>,” it’s important to remember the ocean as a site of historic and enduring oppression, <a href="https://doi.org/10.1080/02614367.2019.1640774">exclusion</a>, <a href="https://ore.exeter.ac.uk/repository/bitstream/handle/10871/39233/Hydrophilia_Bell%20et%20al_accepted_CH10_2019.pdf?sequence=2">racism</a> and other violations of <a href="https://e360.yale.edu/features/lawless-ocean-the-link-between-human-rights-abuses-and-overfishing">human rights</a>. </p>
<p>For the health of the ocean and its peoples, <a href="https://oceannexus.uw.edu/our-community/un-decade-of-ocean-science-for-sustainable-development/">the ocean needs to become more equitable</a> — and that means reconciling and healing the histories and relationships of cultures, values and knowledge systems that all share the sea.</p><img src="https://counter.theconversation.com/content/162341/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tiff-Annie Kenny receives funding from the Canadian Institute of Health Research, ArcticNet, Sentinelle Nord (Apogee Canada) and Genome Canada.
</span></em></p><p class="fine-print"><em><span>Mélanie Lemire receives funding from Indigenous Services Canada, Health Canada, Crown-Indigenous Relations and Northern Affairs Canada (CIRNAC), Sentinelle Nord (Apogee Canada), Meopar, Genome Canada and Canadian Institute for Heath Research</span></em></p><p class="fine-print"><em><span>Malaya Bishop does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the climate changes, the ocean is also changing. And that’s putting our health at risk.Tiff-Annie Kenny, Adjunct professor, Faculté de médecine, Université LavalMalaya Bishop, Research Assistant, Department of Biology - Food Security, Climate Change, and Indigenous Health, L’Université d’Ottawa/University of OttawaMélanie Lemire, Associate professor, Department of Social and Preventive Medicine, Université LavalLicensed as Creative Commons – attribution, no derivatives.