Cholera - a 19th century world tour

I'm Jonathan Roberts. Welcome to Pandemics Past and Present. I'm Danny, perfect for water for your mum. Use the addresses you give me to draw a black mark each death. The pump is located here, the center of the outbreak. Every physician in the world agrees that the colour is of a measmic nature. Fordue respects her, we can offer that our narrow views prevent us from discovering new truths. Do it again, I'll rig your eyes out! You value your medical reputation, I'd suggest. I haven't talked to her, but I do not want her to be the poor health. No, it is. No, it is. And our business has not been the due point of colour. It's a business easy, so I'll be asking you to have a measmic nature. It's a devil, it's a devil, it's a devil, it's a devil, it's a devil, it's dying! This is the film trailer for the movie Snow. Complete with heavy cello and some dramatic moments based on the real life of the English physician John Snow. The banging that you hear at the end there is Dr. Snow smashing the handle of the broad street pump, while at the same time being threatened by an angry neighbor. This is a depiction of one man's attempt to stop the worst colour epidemic that ever hit the British Isles. John Snow is undeniably one of the heroes of medical history, if judged by the total number of lives throughout history that he saved by waging his battling in that darn water pump. But Snow is just one small part of an epic struggle between humanity and cholera, one that has lasted for millennia, with a great climax during a series of global pandemics that occurred in the 19th century. Perseveral millennia, cholera have flagellated around the stagnant waters of the Indian subcontinent, taking advantage of people who are forced to drink from its unclean habitat, and then through a great stroke of luck the bacteria managed to fling itself off the Indian subcontinent and around the world, colonizing the muck and mire of civilisations everywhere. What providence gave cholera this opportunity? Well, the British Empire, of course. There's nothing like rural Britannia to put visions of the mighty merchant fleets of imperial Britain into your mind. It was those ships applying the oceans of the world that brought cholera and John Snow together. Yep, it was Pax Britannica, the era of peaceful commerce after the Napoleonic wars, that allowed a gram negative, comas-shaped bacterium to become a major character in international affairs, a specter that would haunt not only Asia, but also Africa, Europe, and the New World. In fact, historians like to think of the global cholera outbreaks of the 19th century as the first modern pandemics, because they followed the contours of power established by a British imperial rule. Indeed by following cholera's tracks, we can learn a little bit about the history of capitalism, colonialism, sanitation, epidemiology, and germ theory. And that is the modest plan of action for this podcast. But first, it should be said that no one should ever get cholera. Why? Because you can only get infected if one, you ingest food or water infected with fecal matter from a person with cholera, or two, you eat free-standing cholera bacteria from the gills of seafood. And, even if one of these two things happen, you can still only get it if it survives its trip down your digestive tract. Most of the bacteria will die when they make contact with the hydrochloric acid in your stomach, or will be killed later by your immune system in the lower intestine. But if you do get it, it has a very rapid incubation period. Within 12 hours, you can find yourself bedridden, though it usually takes two to five days. On the first day, you will experience vomiting and diarrhea like you have never had them before. Vibrio cholera secretes a toxin in the small intestine that interferes with digestion and the absorption of water and salts, producing the infamous rice water stool, which literally gushes out of the bowels. Each emission contains millions of bacteria, which, if not disposed of properly, can infect the water supply. That means cholera can travel and set up camp anywhere it can find mildly warm, stagnant or brackish water, which makes it what historians call the quintessential disease of filth. On the second day, your body will become quickly dehydrated, resulting in such painful muscle cramping that you will simply not be able to get out of bed. And vomiting and purging will continue, and not a lead to some ruptured capillaries in the face. And on third day, if you look in the mirror, you'll notice that your skin has darkened into a blueish hue, and that your eyes have sunken back into your head. If you talk, your voice will be unrecognizably husky. This is where the melancholia stage begins. Extreme malaise within difference to your fate. Shortly afterwards comes the final stage of total dehydration, no urine and blood running as thick as tar, and then come the convulsions and then death, usually technically from kidney failure. Your corpse will be lying there, often in the stench of its own filth. It's a miserable way to die. So at this point, you probably need some positive news and a good high five, but I'm afraid that cholera has not yet been eradicated. In fact, it has presented more bodies of water around the world than it has ever been, and it continues to kill as many as 100,000 people a year around the world. We do, however, have an effective vaccine, and we do actually have a cure, which is a combination of oral rehydration therapy and antibiotics. So like I said, no one should ever get cholera, and anyone who does get cholera should probably be fine. We'll get to the probably part of that sentence at the end of the podcast. cholera may be the oldest disease known to mankind because the sushura-sahida, a Sanskrit text dating from approximately 5th century BC, mentions an illness with cholera-like symptoms. However, it is difficult to trace this type of illness historically because the type of stomach problems cholera causes can be caused by other pathogens too. We do know, however, that cholera probably was around on the Ganges River hundreds of, if not a couple thousand years ago. This is evidenced by a series of shrines to the goddesses of Olavedi and Olabibi, deities that promised protection from the disease. Some of these shrines became pilgrimage sites during times of epidemics, which as you can imagine only made things worse. Greek Hippocratic texts also name a similar disease, and it's from these ancient works that we get the name cholera, a word that associates the disease with humoral theory, a theory that held that health was a balance of blood, flam, black bile and yellow bile. cholera was understood to be an excess of yellow bile, sufficient to cause illness, which was known as cholera morbus. Vomiting and diarrhea occurred as a means of expelling that cholera, so we can imagine ancient Greek physicians encouraging the evacuation of the stomach and the bowels, probably making things much worse for their patients in the end. The idea of cholera as an imbalance of humor was held for centuries, even during the 19th century outbreaks, so we have to make sure not to judge too harshly the mistakes of past physicians. They simply did not know that a tiny, tiny germ was responsible for the disease. We don't have that much information about cholera from the ancient times, but there is a hint that it may have traveled along Arab trade routes in the Indian Ocean about a thousand years ago. Because it seems to have taken on the Arabic name Hachiza at some point during the Middle Ages. Now, that name might have just been a name for a dysentery in general, it's difficult to tell. And if it did break out along the Arabic trade routes of the Indian Ocean, we really know little of the havoc that it must have wreaked. What we do know is that when the Portuguese arrived in India, they encountered a disease in Goa called Mordesien, which meant something like a dog's death or maybe not, so we don't exactly know. But the sentiment is probably right on there. It matches the misery of the disease. From this first encounter came more instances of possible cholera outbreaks in the Indian Ocean and even in Europe where strange occurrences of dysentery seem to point to cholera as a culprit. However, nothing is confirmed. It was only at the end of the Napoleonic Wars when shipborn traffic increased exponentially in numbers and speed. And that all of the pathogens of the world had a unique opportunity to travel around the globe. within months. As sailing ships began to give way to steam ships and as ports connected to inland cities via railroads, the world was becoming interconnected as never before, and Vibrio cholera was ready to do some globe-draug. But it would take another literally explosive event to launch cholera onto the world stage. In 1815 on the small island of Sambawa and what is now Indonesia, a mountain called Tambora erupted suddenly, shooting millions of tons of magma, rock, and ash into the sky around it, and rocketing sulfate aerosols into the stratosphere, almost 20 miles above the earth. These fine particles dim the sky around the globe, creating the so-called "year without a summer" in 1816, disrupting water flows and crop production for several years. In 1817 a severe drought in India forced people to seek out water supplies from some unorthodox sources, stagnant pools where cholera lay waiting, and the biggest epidemic of cholera so far in human history began. The outbreak started in Calcutta and began to work its way up the Ganges to Delhi, killing as many as 10 million people in one year. It so happened that this new epidemic of cholera coincided with a new era of colonization. The creation of the so-called "British Raj" – Raj is a term taken from Hindi, meaning to "rule", which was something like the imposition of a new type of direct control over the people and activities of India. The immense wealth of what is now Pakistan, India, Bangladesh and Sri Lanka fell into British hands in the form of cotton, silk, sugar, opium, textiles, tea, spices, and even some of the British crown jewels. Along with its resources, the British inherited sovereignty over more than 200 people, ten times the number of the inhabitants of the British Isles. To keep the goods moving, British administrators, who were a bit thin in numbers on the ground, had to try to maintain the health of the population. cholera was seen as a major threat to the power of the Raj, so the British scrambled to do what they could to stop it, primarily by the tried and true methods of quarantine. They attempted to stop the movement of people in and out of infected areas, imposed regulations on pilgrimages, and suppressed attempts by local viders and hakems – those are the local healing classes of India – to fight the disease. None of these interventions worked very well because they were done half-heartedly, and locals really weren't ready to put up with such draconian measures. With so few soldiers on the ground, it was difficult for the British to micro-manage such a large population. The threat of rioting and rebellion always hung in the air, so as a plan B, British officials did what any self-aggrandizing colonizing nation would do, they blamed the victims. They began to label Indians as filthy and backward, and even gave the disease the moniker "Aziatic cholera". You might be thinking that this name rhymes with something you've heard at a news conference about COVID-19. A Trump is taking a page out of the British colonial playbook here, attaching a geographic location to an epidemic disease, for similar reasons that the British did so, to deflect attention away from a failure to stop the spread of the illness. In the case of British India, the demographic boom generated by colonial contact had created an increasingly dire sanitary situation in port cities. Using the moniker "Aziatic" also reinforced cultural diets that divided white Britons from the other peoples of the world, creating a hierarchy of the sanitary, imperial citizen, and the unsanitary imperial subject. This type of racial ecology, which began during the cholera epidemics of the 19th century, reverberated around the British Empire for decades to come, and we still hear the echoes in the voice of President Trump today. In 1918, cholera leapt across the ocean to the Middle Eastern Africa, causing outbreaks in places like Alman, Muscat, Zanzibar, and even Armenia. But this was just a warm-up expedition. Several pandemic bursts followed in the 1830s, in the 1850s and 60s, in the 1870s, and between the 80s and the 90s. By that time, it had reached every corner of the globe, killed millions and millions of people, and worse yet settled into ponds, salt flats, lagoon and sewage dumps, all along the temperate and tropical coastlines. The cholera diaspora had settled down to stay. So alarmed were European imperial powers by the ferocity of cholera that they initiated several international sanitary conferences to study the problem. The first was held in Paris in 1851, and subsequent meetings were held in Constantinople, Vienna, Washington, Rome, and several other locations. The goal was to standardize international regulations, and the meetings led to lengthy debates about the relative merits of hygiene, sanitation, and quarantines. Anything that would prevent cholera's spread, were they a success? Not really. The delegates failed to agree on quarantine regulations, and the disease continued to spread. British delegates, in particular, opposed both the microbial explanation of cholera and various quarantine measures proposed to control it. This isn't surprising considering they had the most to lose from any restriction on global commerce. However, the meetings did lead to some shipping quarantines, which were modestly effective in some places. Other improvements coming out of the conferences included the development of poor laws to improve housing, marketplace reforms to ensure clean food supplies, and first and foremost, the gradual recognition that keeping waste water separate from sources of clean water could prevent disease. Shocking, but true. These changes took place in Europe first, but they eventually took hold in the colonies too. In India, the British implemented piecemeal sanitary improvements were funding was available, to say where taxes could be expropriated to pay for it. These improvements benefited British merchants, sailors, and soldiers first, but as the decades of colonial rule wore on, sanitary officials did bring in clean water and adequate sewage disposal to many of the cities in India. In Calcutta, for example, the city that was regarded as the homeland of cholera, the British built a brick sewer network in 1865. It was similar to those in the UK, and it was expensive to build and was followed in 1869 by a filtered water supply. These changes brought down instances of cholera deaths dramatically, despite the city's continuing rapid growth in population. Similar changes were made in Bombay and Delhi, but for the most part, people in the countryside were still left to fend off the disease themselves. Incrementally, similar practical improvements were made by sanitary officials around the world, and over the decades cholera became less of a scourge. Moreover, the meetings that had started in Paris in 1851 had inaugurated a new sort of global sanitary discourse, which included a universalized notion of the human body as something that's vulnerable to disease, regardless of geographic or genetic background. This new era of public health blurred the boundaries between nation and empire and allowed for institutions like the World Health Organization of the United Nations to emerge in the 20th century. It was a long haul for sure it took most of a century, but cholera truly did spur us as human beings to clean up our surroundings. But for my money, the most interesting outcome of cholera's first global tour is the emergence of a new type of historical character, the sanitarian. One of the best examples we have is Edwin Chadwick, who generated statistics on disease morbidity and mapped out death rates in British cities, culminating in the famous report on the sanitary condition of the laboring population, which was published in 1842. Chadwick pushed for government regulations on housing, water, sewage, and garbage disposal, arguing that the sickness and death caused by poor sanitation was actually more expensive than dealing with them as a public service. In particular, he argued, simply separating clean water from wastewater would dramatically reduce contact with myasmatic gases and liquids. British politicians responded positively to Chadwick's arguments, passing the Public Health Act in 1848, but the sanitarian had his detractors. Those who felt that myasmatic gases simply could not be controlled. They also didn't like the fact that Chadwick urged people to dump their garbage in the river Thames, which turned it into something of a muddy cesspool. In the USA, Chadwick's kindred spirit was Lemuel Shatic, from the newly industrializing city of Boston. Shatic wrote the report on the sanitary condition of Massachusetts in 1850, and in that book, he argued that the average length of human life could be extended, and its personal productivity augmented via good sanitation. And like Edwin Chadwick, he claimed that tens of thousands of cases of sickness could be prevented with simple measures taken to ensure clean water supplies. Shatic even wanted to step further, urging state government to educate people in the principles of sanitary science as part of the primary school education. Another major figure at mid-century, one that we shouldn't forget, was Florence Nightingale, who did much more than create a model for bedside manner for nurses. She also studied death rates from cholera and typhus among wounded British soldiers during the Crimean War in 1855, and demonstrated statistically that improved sanitation at hospitals led to a decrease in the death rate. Her publication notes on matters affecting health, efficiency, and hospital administration of the British Army is a classic document that has changed the construction of hospitals forever. But for those of you who like detective stories, the cholera epidemics of the 1800s offer us a character who is really something like Sherlock Holmes in his attention to detail. Of course, talking about Dr. John Snow, you know, the crazy guy who attacked that water pump. In 1845, Snow was studying outbreaks of cholera in London and, building on the conclusions of Chadwick, he came to believe that the disease was spread by a bodily fluids. The notion that human asksreecia as a contributing factor of illness was not new, but most physicians understood cholera to be caused by the putrefaction of soil, air, and water. So the direct link to human feces was usually lost in the whole miasma theory. In the summer of 1854 during London's third cholera epidemic, Snow conducted what he called the grand experiment. In the month of August, 200 people in a tiny part of the neighborhood of Soho were struck down by a massive outbreak of cholera, and Snow observed that the epidemic continued for 10 days, confined just to a few streets before it peedered out. The eventual death toll was over 600 people. To find out the source of the illness, Snow knocked on doors and asked residents which pump they drew their water from. He knew that there were two suppliers of fresh water to that neighborhood, the Lambeth Company and the Southern Convoxal Company. And as it turned out, both companies had been ordered six years earlier to draw their water from upriver in the temps, where the river did not yet mingle with garbage and sewage at the core of the city. The Lambeth Company had complied, but Southern Convoxal had not. Snow discovered that customers of Southern Convoxal were between eight and nine times more likely to die of cholera than those who drank water from the cleaner Lambeth supply. Snow then followed up by making a death map, looking up addresses where people had died and marking the deaths house by house on a street plan. What that visual proved was that all of the deaths were clustered in and around a pump on Broad Street, which drew on, you guessed it, dirty Southern Convoxal water. What he specifically noted was that the deaths either plummeted or stopped altogether at every point where it was easier to go to another pump other than that one on Broad Street. Confident of his findings, snow demanded an audience at a parish meeting of the board of guardians, these were the group of officials that were responsible for public health in that part of the city. He told them that polluted water from the Broad Street pump was to blame for the latest cholera outbreak and demanded that they remove the pump. Being good believers in the Myazmatheri, they thought snow was a little bit off his rocker and they refused. So what did John Snow do? Well, like the movie trailer tells us, he sort of lost his marbles. Legend has it that snow stormed out of that meeting and either ripped off, broke off, or locked up the handle of the offending pump, stopping the disease from spreading. Now, this story is not confirmed by any written source, but it's wonderfully dramatic. Unfortunately, snow's thesis was not immediately accepted because, although he have claimed to have seen white, flocculent particles in the offending water supply under a microscope, no one had yet isolated vibrio cholera and proven that it was the pathogen that caused the disease. And also people just believed in the Myazmatheri anyway. Snow died a few years later, convinced he was right, but having made only really a ripple in the larger fight against cholera. However, he was later celebrated as an early prototype of a new sort of medical professional, the sanitarian physician, and is sometimes referred to as the father of epidemiology. Which reminds me, I've been meaning to ask if any of you listeners have read Gabriel Garcia Marquez's novel Love in the Time of cholera. I hope some of you have, because if you had read that book, you'll remember the favorite character of mine. No, it's not the pale and one florentino Areza, that's the guy who falls desperately in love with the beautiful Firmina Daza. Areza is the one who becomes lovesick, and you know, since there's an epidemic going on in the city that's in Cartagena and Colombia, everyone thinks he has cholera. I should probably need a passage from the book just so I can remind you about it. After florentino Areza saw Firmina Daza for the first time, he lost his voice and his appetite and spent the entire night tossing and turning in his bed. But when he began to wait for the answer to his first letter to her, his anguish was complicated by diarrhea and green vomit. He became disoriented and suffered from sudden fainting spells, and his mother was terrified because his condition did not resemble the turmoil of love so much as the devastation of cholera. A florentino survived that sickness, it wasn't cholera, and florentino and Firmina are just the main characters of the book. They are of little interest to this podcast, which is about pandemics. The character that I want to talk about is Dr. Juvenile Urbino, the famous physician who Marquez introduces as a sanitarian. Quote, soon after he had completed his course of specialized studies in France, Dr. Juvenile Urbino became known in his country for the drastic new methods he used to ward off the last cholera epidemic suffered in the province. While he was still in Europe, the previous one had caused the death of a quarter of the urban population in less than three months. Among the victims was his father, who was also a highly esteemed physician with his immediate prestige and a sizable contribution from his own inheritance. He had founded the medical society, the first and for many years the only one in the Caribbean provinces, of which he was the lifetime president. He organized the construction of the first aqueduct, the first sewer system, and the covered public market that permitted fields to be cleaned out of Las Animas Bay. What a hero? Now wonder he was able to steal Firmino away from Florentino. Okay, yeah, he's a loathsome character in many other ways, but I love the way that he epitomizes the physician scientist sanitarian, this historical archetype, born of the fight against cholera, and there's one of these people in almost every city around the world. As just an aside here, Marquez kind of made a mistake in this book. He conflates cholera with love sickness. Technically, this is incorrect. According to humoral medical theory, cholera is an excess of anger and yellow bile, while an excess of mellem cholera, a black bile, would be better associated with someone so deeply in love. Of course, we allow Marquez's poetic license. Now, Urbino and his ill-grilled generalists, but at the same time that they were rising to prominence, another group of medical professionals was emerging, and this was a different group, a cadre of laboratory geeks, who would soon become renowned as the so-called plague busters of the 19th century. The first of these that we should probably mention since we're talking about cholera was the Italian anatomist Philippopuccini, who retreated into his laboratory during an epidemic in Florence in 1854 and managed to isolate vibrio cholera that same year. His publication on the topic should have taken the world by storm, but his ideas were unfortunately obscured by widespread support for myasmatheri, particularly in his homeland of Italy. It just wasn't the right time. It seems for cholera to be named and claimed by medical science. That would have to wait until 1883, when esteemed and ambitious bacteriologist Robert Koch once again identified vibrio cholera. Not surprisingly, Koch's competitors at the Institute pastor in France were also on the hunt for the cause of cholera in 1880s. And so a race began. When they heard of a particularly severe outbreak in Alexandria in 1884, the two contending teams of French and German scientists descended on that Egyptian city, establishing temporary laboratories in an effort to be the first to isolate the cholera agent. The Germans were led by Koch himself, and the French team was guided by pastors most valued assistants, Emil Lu and Louis Toulier. Almost immediately, the French team found strange new microscopic structures in stained blood smears of patients with cholera. Excitement began to mount, and news of the possible identification began to spread, but before their preliminary findings could be confirmed, tragedy struck the French camp. Lu et-Toulier, the youngest of the team, at only 27 years of age succumbed within 36 hours to an explosive bout of cholera. His colleague, Emil Rou, reported to French newspapers the following, "We were obliged to hold him up to prevent his fainting. From this moment everything passed involuntarily and, in spite of the most energetic treatment, at 8 o'clock he was already more abundant. We employed strong frictions, rubbing his limbs. All of the French doctors were present, an iced champagne and subcutaneous injections of ether were given freely. In short, everything that could be devised was done to prevent a fatal issue." This was a very French way to die. Another legend has arisen around this episode. Apparently, Robert Koch, who had met Tullier once in Berlin, was called on by who in the middle of the night and asked to visit the French camp. Who and Koch put aside their differences for the moment and visited Tullier at his bedside. The young scientist looked up at Koch gasping for breath and apparently asked him, "Have we found it?" Koch said, "Yes, you have found it." And Tullier died happily. This would have been something of a noble lie from a future Nobel laureate. Nobody in the French camp had managed to isolate the Basilis and Koch had to travel to India actually before he was able to demonstrate that Vibrio cholera was responsible for the disease. But the story of the hunt for the cholera microbe gets even better. Even when Vibrio cholera was identified as a pathogen, many scientists in the late 19th century still did not believe that the illness was passed from person to person or even via microbes. Chief among the skeptics was a German scientist called Max von Pettincoffer, who absolutely refused to believe Koch or pastor's findings. Von Pettincoffer held to a localist/contagionist conviction. He believed that cholera spread through the air after a specific germ in the excrement of cholera patients reacted with other excrementitious matter in moist soil, thereby liberating an active principle into the air. That, he felt, was what caused the disease. So confident of his beliefs was von Pettincoffer that he offered to prove it. In 1892, in the company of several of his associates, he requested a flask of cholera bacteria from Koch's laboratory. And to everyone's amazement, he drank it. Amazingly, he suffered no ill effects. Why? Oh, he just don't know. He should have died. But he may have had enough acid in his stomach to kill the bacteria before it affected him. So anyway, cholera did not kill von Pettincoffer, and he went on to receive many awards for his works, sadly, though even though he was a celebrated scientist, he suffered from depression and he shot himself in 1901. He is now a marginal figure in the story of the sanitary revolution because the science of the plague busters had passed him by even before he died. Interestingly, in the same year that von Pettincoffer co-offed the cholera, Voldemort half-kind did the same, only by injecting himself with an attenuated form of the bacteria he didn't actually drink it. He also survived and then rushed off to India to risk the lives of approximately 25,000 volunteers in order to prove that it worked, who were these so-called volunteers, well mostly prisoners, soldiers, and tea plantation workers, along with a handful of white British Indian officials who seemed to game to try the vaccine after it didn't kill any Indians. The vaccination campaign, if we put aside all those notions of ethical clinical trials, was a riproaring success. There's no record of any contamination of the vaccine, nor does there seem to have been any death. And according to half-kind, the vaccine had a 70-80% success rate because those he had vaccinated were well protected during subsequent outbreaks. And you kind of have to admire half-kind for shooting himself up first before trying it on anyone else. He did the same with his plague vaccine later on and he survived and gained immunity, but further trials did lead to some deaths and he was subsequently dismissed from the medical services in India. He was later acquitted because it was found that it was actually an assistant who was responsible for the bad batch that had killed some of the test subjects, but he never did gain the fame again that he'd once had back in his collar of fighting days. Unfortunately for all you listeners who are looking for another disease or eradication high-five, like I said, I can't provide it. Despite worldwide vaccination programs, starting with half-kind's vaccine and ending today with the highly effective ducorooral vaccine, cholera has not been eradicated. It may never be because, as we know, it still lingers in the tidal flats and lagoons of the world, waiting for a crisis that will allow it to strike. Nevertheless, cholera should be easy to deal with today because it can be treated with broad spectrum antibiotics and even in the absence of those medicines, cholera can be treated with cheap oral rehydration therapy packets. It's this kind of dried gatorade powder that you just simply add to clean water. But sadly, this disease is still killing many people currently at the rate of 100,000 per year. Why? Well, because it's so opportunistic, when disaster strikes in the form of a flood and earthquake, a typhoon, a hurricane, civil war, people are often forced to seek water from dubious sources. We heard about this already, and it leads to rapid outbreaks. We have to remember that cholera can lay you out in a day and kill you in three, so it sometimes overwhelms medical systems during these emergencies. It also seems to be more and more resilient in the 21st century, perhaps due to a changing climate that keeps it cozy warm in its favorite pools of filth. You might recall the three major outbreaks of recent memory all in the 21st century, Zimbabwe, Haiti, and Yemen. Zimbabwe is a classic example of cholera popping up to claim victims in a failed state. Under the dictatorship of Robert Mugabe, the fortunes of Zimbabwe dwindled rapidly in the 1990s and citizens of the country found themselves living in a country that they barely recognized, one with a collapse to healthcare system, with failing water supplies, and with damaged sewer systems. Food shortages became a regular fact of life in the country, and cholera began to pop up occasionally as the country stumbled into misery and then broke out in force in 2008 and 2009, infecting 120,000 people and killing almost 6,000. The worst hit spot was the capital of Harare, which had previously been ranked as one of the most sanitary cities in Africa. On the heels of Zimbabwe came the outbreak in Haiti, which began to spread after the devastating earthquake of 2010. The epidemic started in a rural area of the country on the upper Artybonyte River, where people still draw their water in buckets. It so happened that cholera spread down the river from a United Nations camp of Nepalese aid workers, who had allowed their sewage to flow into the river. From the Artybonyte River, the disease spread rapidly overwhelming Porto Prince and the other cities of Haiti. Poor sanitation before the earthquake was bad enough, but afterwards water and sewage systems were disrupted and a lack of money to buy soap and bleach led to the rapid spread of the disease. Aid doctors and nurses who were there to help people after the earthquake gave out antibiotics and oral rehydration therapy packets where they could, but many people were still homeless and were unable to get clean water or get themselves to clinics. Hundreds simply died in the streets trying to make their way to the hospitals. There were 650,000 cases in total, comprising 5% of the total population, with 8,300 deaths. A class action suit was actually filed by some of the victims of the epidemic in a U.S. federal court, accusing the United Nations of gross negligence and misconduct. The UN claimed that it was legally immune because it took steps to stop the spread of the disease, and the case was actually thrown out in 2017. And the third contemporary outbreak is Yemen, which started with the Civil War in 2016, and has continued during a famine created by a Saudi-imposed embargo on food imports. More than 1.2 million cases have been reported, with 2,500 people dead, half of them children, children who are so weak with malnutrition that they were easily overtaken by the disease. The battle between the Saudi-led coalition and the Houthi independence movement has led to airstrikes that have damaged hospitals, water supplies, and sewers. The government of Yemen can no longer afford to pay for garbage collectors, sanitation workers, nurses, or doctors. International aid agencies have responded, but they've struggled to treat patients during the military conflict. The cholera epidemic will likely continue until the war ends. Which in conclusion points out a disjuncture that has been around since the birth of the global cholera pandemics. No matter how much we pray, plan, research, and respond, cholera seems to find a way in. In the end, how different is it really from a dangerous miasma? lurks in the mire, and all it needs is a catalyst to set it off. Bon Pettenkoffer and the contagionists searched in vain for a catalytic principle that triggered the epidemic. Or perhaps they should have just looked in the mirror. When we ride off the conqueror and make war, leaving our neighbors to starve, all we need to do is look over our shoulder, and we can expect that other horsemen of the apocalypse, cholera, to be riding right along with us. [Music] This podcast is mixed and edited by the Digital Media Zone team at Mount St. Vincent University.