An Ancient Scourge Strikes Again

Thousands of cholera cases alarm the Middle East

The first cases were reported in Syria and were followed quickly by others in Lebanon, Jordan, Kuwait, Saudi Arabia and Iran. By last week, almost the entire Middle East was in the grip or under the threat of an ancient and dreaded scourge: cholera. Thousands of cases and scores of deaths were registered, but the official figures in several countries were deliberately understated--for reasons of national pride, trade and tourism. Says Dr. Reinhard Lindner, a World Health Organization (WHO) communicable disease expert: "Cholera is the hush-hush disease of our time. It bears the stigma of dirt and ignorance."

The epidemic seemed most severe in Syria, where 3,000 cases, with 68 deaths, were recorded by last week. The government requested and received help in the form of drugs and advisers from WHO, and the U.S. donated $25,000 worth of emergency supplies to Damascus. Syria denied responsibility for being the original source of the outbreak. It put the blame on Lebanon, where Syrian soldiers on peace-keeping duty in devastated Beirut were said to have picked up the disease and carried it back to Damascus and their native villages. That may be true, but the rapid spread of the disease did not speak well for Syrian medicine and sanitation. Indeed, President Assad rebuked his health authorities for their poor performance. They responded by closing swimming pools, public beaches, fruit juice and ice cream parlors, and many restaurants. Proprietors of the restaurants that remained open were warned that any violation of food laws could mean immediate imprisonment. To add to the troubles, Syria's agriculture was threatened with disaster as its bumper crops of fruits and vegetables were blackballed by markets from one end of the Arab world to the other.

Lebanese officials meanwhile admitted to knowing of only 20 cases in their country (unofficial estimate: 100). Jordan announced 314 cases, Saudi Arabia 17. Israel had three, all West Bank residents, one of whom had traveled to Jordan. While Turkey remained silent about the disease within its borders, a woman who had just arrived in Nijmegen, The Netherlands, from the Turkish city of Erzurum was hospitalized with cholera. The four other cases in Europe also involved victims who had been traveling in either Turkey or Iraq. Opposition politicians in Turkey accused the Ankara government of hiding the news that 34 children had died of cholera.

Cairo insisted that Egypt was still cholera free, and took the precaution of checking travelers from affected countries. Hundreds who did not have up-to-date vaccination certificates were quarantined; cholera can incubate in the body for as long as five days before symptoms appear. Incoming planes were fumigated as soon as they landed. The health ministry launched a massive campaign to inoculate 13 million Egyptians. Authorities burned every garbage heap they could find in Cairo and Alexandria.

What has all the Arab countries jittery, especially Saudi Arabia, is that during the next few months millions of Muslims will be making the pilgrimage to the holy shrine in Mecca. Cholera has already appeared near Medina on one of the routes followed by the faithful coming from as far away as Indonesia and the Indian subcontinent, where cholera is endemic. (Israeli authorities have arranged with Jordan to cooperate in the immunization of 5,000 Muslims living in Israel or occupied territories who will be making the pilgrimage.) Arab governments are so concerned that this week they will hold a 20-nation meeting in Cairo to decide on the best protective measures. The comma-shaped bacterium (Vibrio cholerae) responsible for cholera finds its natural breeding ground in the human bowel, and is excreted in the feces. The disease can be contracted only by drinking--or bathing and washing in--water containing human fecal matter, from fruits or vegetables contaminated by such water, or from food prepared by unclean hands. If all the world's water supplies could be cleaned up, cholera could be virtually wiped out. But that is a visionary goal, and the only preventive now is a vaccine that is no more than 50% to 70% effective, and that only for about six months.

However, there are sensible precautions that can help avoid infection. The Center for Disease Control in Atlanta is advising U.S. tourists in cholera areas to: 1) drink only bottled water that is carbonated (which makes it acidic enough to kill the bacteria); 2) carry chlorine or iodine disinfectants to treat water where the carbonated variety is unavailable; 3) eat no fruit that anyone else has peeled, but peel it themselves; 4) eat no vegetables or other foods that have not been thoroughly and freshly cooked and served promptly.

The days when cholera was fatal in 50% of cases or more have long passed. (Before 1930, for example, cholera epidemics in India regularly took more than 300,000 lives a year.) Physicians now know that the shock and threat of quick death from cholera result from the massive loss of body fluid--as much as several gallons a day--through diarrhea. They can prescribe antibiotics, especially tetracycline, which may shorten the duration of the diarrhea. The dehydration can also be reversed, and the patient rehydrated, with a simple solution containing common salt, baking soda, potassium chloride and glucose. If the patient is conscious and not vomiting too severely, he can take the solution orally. Otherwise, fluids must be given intravenously. Either way, if treatment is begun promptly, it can reduce the cholera death rate to near zero. The major obstacle to universal use of the lifesaving solution is that the poorer countries, which need it most, have difficulty obtaining sufficient medication and training enough nurses and technicians to administer it. Thus, while effective sanitation can prevent the disease, and treatment for a near-certain cure is available, cholera remains a grim threat to man.

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