NEW YORK — The news cycle tends to focus on countries where deadly, fast-spreading outbreaks of cholera are a relatively recent phenomenon — such as Yemen and Haiti — but the deadly diarrheal disease has long been a regular occurrence in Bangladesh.
Patients with cholera appear every day at the International Centre for Diarrhoeal Disease Research, Bangladesh, or icddr,b, hospital in the country’s capital Dhaka, according to chief physician Azharul Islam Khan, constituting a routine part of their worck — not cause for crisis. For the past several years, Khan and other colleagues at the icddr,b hospital and research center have begun to extend their knowledge of preventing and treating cholera to health teams in some of the world’s most vulnerable and dangerous places.
Some governments refuse to acknowledge cholera outbreaks in their country, leaving the humanitarian actors working to respond to the health crisis on a political tightrope.
There’s a process Khan follows when he conducts his visits to places such as Syria, or welcomes teams visiting from Yemen. In a recent phone interview, Khan explained what’s involved with addressing cholera in a variety of settings, and what needs to be rethought. The conversation follows below, edited for length and clarity.
Can you walk me through how your work training people on cholera response typically plays out?
For every mission we have been on, starting in particular in 2009 with Zimbabwe, we have been there on the call of the Global Outbreak Alert and Response Network, which is part of the World Health Organization. We go there as advisers and we train [local] trainers, usually doctors, nurses, and some allied health care professionals. And we do hands-on training in different areas. We talk with the administration officials, we visit the cholera treatment centers, and we see how they are running the centers, practically, in terms of critical management and infection control.
We have been to Rwanda, Zimbabwe, Mozambique, the Philippines, Papua New Guinea, South Sudan, Haiti, and Pakistan. We have been to Sierra Leone twice, to Somalia twice and to Kenya three times. We have been to Iraq five times and to Syria in 2014, 2015, and 2016.
When you go to different countries, are there particular first steps you tend to follow to understand and respond to a cholera outbreak?
We have specific terms of reference that we follow from WHO. So, we usually go and meet the health ministries and WHO officials. We take stool and water samples from different sectors of the environment. We talk and ask people in particular about what a family does at home when diarrhea is there, and we try to understand their promotion and practice of using Oral Rehydration Salts. In Papua New Guinea, people were asking me to give them tablets for water, or ORS, in whatever form, to protect themselves before they contract diarrhea. People have misconceptions and people do not have clear conception of using ORS. People do not know when to send patients to a treatment facility.
Altogether, what we try to do is have meetings with policymakers to focus policy on the practical problems. Then, we train health providers, we meet with administration officials, and we try to keep the media and health ministry officials onboard so they understand that we are never trying to establish their [health] system. We are there to provide them only with technical assistance.
How common is the issue of lack awareness about prevention in areas where there are outbreaks?
That’s pretty common. In Haiti, when we went in 2010 they had had the earthquake, so they were already devastated and before they could recover, the cholera epidemic came after 100 years [of absence from the country]. The doctors were very good, but with the sudden outbreak there was a, absence of logistics making the situation chaotic. In any chaotic situation, you find all the NGOs jumping in, somebody sitting on stockpiles of ORS, somebody sitting on stockpiles of vaccines, and someone on intravenous fluids and antibiotics, but there is a lack of coordination.
What are the best practices you have taken from your own work in Bangladesh, and do you find there is a strong understanding of the disease there?
“Being a country with 160 plus million people, we are doing fairly well with diarrhea control, I must say.”— Azharul Islam Khan, chief physician at the icddr,b hospital
In Bangladesh you see ORS promotion where icddr,b has taken the lead and this has played a major role. Altogether, there has been no formal scaling up of ORS, but the word of mouth spreads, and we have 84 percent ORS coverage [of the country], which indicates that people know there is always diarrhea and cholera in Bangladesh — and whenever there is diarrhea, we need to take ORS, available at the smallest shops. Being a country with 160 plus million people, we are doing fairly well with diarrhea control, I must say.
How quickly do cholera patients require medical intervention?
The management of cholera is not magic science. It is timely science. Say, we administer intravenous fluid to someone with cholera, [which] otherwise may result in death in four to six hours or 10-12 hours due to the depletion of fluids. We are always prepared in terms of logistics and expertise.
In 2007, we had a massive flood which inundated more than 50 percent of our districts and at the icddr,b hospital we saw 45,000 [medical] cases in two and a half months, of which around 40 percent were cholera cases.
What do you think is most important to stress when you meet with people you are training, and communities impacted by cholera?
“Promotion of ORS, timely referral of a patient, and avoiding indiscriminate treatment of antibiotics.”—
Promotion of ORS. It is the universal solution to the treatment of diarrheal diseases. Promotion of ORS, timely referral of a patient, and avoiding indiscriminate treatment of antibiotics. Antibiotics definitely have a role, but it is second rate to intravenous fluids. Antibiotic reduces the duration of the episode and the transmission into the community. We often see ORS being given, but there is sometimes the issue of overuse, and multiple use, of antibiotics.
Given the geographic range of your trainings, and reports of cholera’s appearance in new areas, do you view it as a chronic epidemic that will continue to resurface?
If you look at developing countries and countries at war, cholera outbreaks happen because of poor environmental conditions, lack of proper hygiene, and food handling and spoiled foods. No decontamination, or lack of hygiene, no use of soap, and lack safe water — all of this combines to an outbreak of diarrheal disease. In Bangladesh, the water supply and sewage infrastructure is not perfect and it will take another couple of decades before we can open the tap and drink water from that. That situation occurs in other either poor or developing countries.
Have you seen a boost in the need and requests for cholera training over the last few years?
It depends. Whenever there is an outbreak, we like to have an increased number of sessions, but we also say that for those countries where cholera is endemic it is good to have capacity building and then carry out an infrastructure training two years later, to see how people move. If you go to Somalia after six months, you find the providers we are training have all moved on to another country with a better job. A big part is sharing experiences and the coordination and the distribution of logistics. At the end of any mission, we put together a set of recommendations, based on that country’s experience with us, and we give it to WHO and health ministry officials so they can follow up on this.