Cholera Strikes Again!

By Willie T. Ong, MD, MPH

Cholera is back. In 2003, an outbreak of diarrhea cases baffled not only the health department but the country as well. As of October 31, 2003, there were 242 reported cases of diarrhea and four deaths from at least eight streets in Tondo, including Capulong, Velasquez, Varona, Raxabago streets and Dagupan extension. Many patients were confined at the San Lazaro Hospital for treatment.

Confirmed cholera cases numbered 29. According to the DOH Press Release, rectal swabs from patients showed that many were positive for cholera vibrio. Others were positive for Salmonella typhi (cause of typhoid fever) and E. coli indicating sewage contamination.

"It is an outbreak most probably due to sewage contamination of the water lines," says Health Secretary Manuel Dayrit. Blame goes to (1) old, leaking water pipelines, (2) illegal connections and (3) low water pressure.

The Philippine Water Vigilance Network, a non-government organization had blamed the Maynilad Water Services Inc. (MWSI) for this public health disaster. The Tondo water pipes are old but the company said they don�t have the funds to repair them yet. To curb this outbreak, MWSI has employed stopgap measures such as adding chlorine to the water, increasing the water pressure and repairing faulty lines.

The Manila Health Department, led by Mayor Lito Atienza, also started rationing water but many residents refuse to use them. Dr. Rachel Garcia, director of the National Capital Region, is frustrated by the residents� refusal to use these safe water outlets. Unaware of the dangers of tainted water, residents still use tap water because "it is more convenient." Boiling water still entails too much time and additional costs. Moreover, the Filipino culture of eating with poorly-washed hands still continues to this day.

Politics, as well as cultural issues, plays a part in this outbreak. The government downplayed this disaster by calling it a "cluster of cases" instead of an outbreak. The term cholera was rarely mentioned in newspapers as the terms gastroenteritis, diarrhea, or a mysterious "gastro" disease bannered the headlines. It�s hard to blame the officials for this ploy because of the obvious economic implications of having a cholera outbreak in these modern times.

Problems with Philippine Water Supply

According to latest statistics, 23.7% of the Philippine population have no access to safe water supply and 30.7% have no sanitary toilets. The worst sanitation data can be found in the Autonomous Region of Muslim Mindanao, where 38.4% have no access to safe water and 57.2% have no toilets.

This is hardly surprising as our water pipes still date back to the American time. After the war, the Americans established the Balara water facility to supply their military installations. Quezon City, Pasig and Fort Bonifacio were former American military facilities.

According to Sec. Elisea Gozum of the Department of Environment and Natural Resources, the Philippines lacks a proper sewage system, which is present in less than 5% of our urban centers. And many of these were those built by the Americans before the war.

The combination of no safe water, no toilets and lack of sewer system explains why diarrhea is persistently the number one cause of morbidity in the country with 866,411 reported cases in year 2000. Is it no wonder that cholera has struck again?

Parallels of History: The Cholera Epidemic of 1902

History repeats itself, at least partly. In the 1902-1904 cholera epidemic, there were 200,222 persons were confirmed killed from deadly cholera. Such was the enormity of this "gastro" epidemic, arguably the worst recorded epidemic in Philippine history.

1. Same disease: The offending bacterium, then and now, is called Vibrio cholerae. It is transmitted by ingestion of contaminated food and water. An infected person would suffer uncontrollable diarrhea leading to quick dehydration and death. The person�s excrement is highly infectious and must be properly disposed of.

2. Similar culprit: In the early 1900�s (just like today), people were not educated on how to prevent cholera from spreading. The contaminated water supply, rampant defecation in the rivers, and lack of access to hospitals contributed to the rapid spread of the disease from house to house.

3. Same outbreak source: Then Secretary of Interior Dean Worcester traced the cholera source to the unsanitary shanties of the Farola district in Tondo. Health Secretary Manuel Dayrit also traced the outbreak to eight streets in Tondo.

4. Different approach: In 1902, Worcester immediately ordered American soldiers to quarantine the entire Tondo district and burn down the infected nipa huts. In fear and confusion, the Filipinos valiantly tried to escape thinking the Americans were out to destroy them. Gossip spread that their houses were being destroyed to make room for future dwellings of rich Americans. Some Filipinos even accused the Americans of poisoning the wells.

Today, we use no such harsh measures to contain cholera, or should we say "gastro" disease. We use a culturally sensitive approach, and a little bit of cover-up to show that all is well with our health scenario.

With the lessons of history behind us, which do you think is the better approach?