From The New England Journal of Medicine

Stories in the Time of Cholera (not to be confused with the novel Love in the Time of Cholera, by Nobel laureate Gabriel Garcia Marquez) is a sociological analysis of a cholera outbreak in the delta region of the Orinoco River in eastern Venezuela in 1992 and 1993. One of the authors, Charles L. Briggs, Ph.D., trained in social anthropology and sociolinguistics and is professor of ethnic studies at the University of California, San Diego. He has worked in Venezuela since 1986 and is conversant in Warao, an indigenous language. He met his wife, coauthor Clara Mantini-Briggs, M.D., M.P.H., during the epidemic's early stages. Together they visited the delta, conducted interviews, evaluated health conditions, and collected graphic narratives (e.g., "We were shitting, the guy was shitting, shitting, shitting, shitting, and when he shitted again he passed out. `I'm going' -- those were his last words"), which provide the substance of this profusely footnoted, illustrated, and heavily referenced book. The authors' thrust is that "medical profiling" is both racist and "a prescription for institutional failure and human suffering." Having worked in cholera epidemics in the Philippines (1961), Calcutta, India (1962), Vietnam (1963), Thailand (1966), and Taiwan (1967), I am keenly aware of the difficulties in controlling outbreaks and delivering medical care when resources are limited or lacking. In fact, cholera occurs in epidemic proportions only under those conditions. The current great pandemic of cholera, widely regarded as the seventh, started in 1961 and entered the Western Hemisphere, for the first time in a century, by means of an explosive outbreak in Peru in January 1991. (Many of us had predicted earlier [Finkelstein RA. Cholera. CRC Crit Rev Microbiol 1973;2:553-623] that cholera would enter South America from Africa -- not from the west -- in the 1970s.) By year's end, Peru had reported more than 300,000 cases. The case fatality rate was less than 1 percent, owing to early and effective medical intervention. (Untreated, cholera may kill as many as 70 percent of people who have it, and the case fatality rate is many times higher in Africa.) Cholera then metastasized through South America and Central America, following routes of human transportation, and arrived in Venezuela, as reported in the book, in November 1991. It quickly reached the delta region of the Orinoco River, where it was encountered by Briggs, and where, he says, "nine of my closest friends had died. The survivors were terrified." It can now be stated categorically that deaths from cholera are due to failures in health care delivery. Why these failures occur is a major subject of the book. Treatment consists of vigorous replacement of the fluid and electrolytes that are lost in the voluminous cholera stools. Replacement can be performed either intravenously (when required) or orally (with solutions of oral rehydration salts [ORS] or their locally prepared equivalents). The "cholera cot" (a canvas cot with a hole cut in it and situated over a bucket) is a useful device to "keep score." The authors accuse public health officials of failing to inform and deliver health care to the indigenous population, or indigenas, as opposed to the upper-class, nonindigenous people, or criollos -- the "unsanitary" as opposed to the "sanitary" citizens. The authors regard this failure as a manifestation of racism, imply that it was intended to deflect the blame for the outbreaks from the institutions to the victims, and suggest that it contributed to the persistence of cholera in Venezuela. The indigenas were completely ignorant about cholera. They had no idea how to treat it (vernacular medicine [i.e., shamanism] was totally ineffective) or how to prevent it (they had no concept of the germ theory or of point-of-use water purification, which could have been decisive), and panic ensued. They descended on cities, where they were rejected or incarcerated. The authors claim that the victims were regarded as the cause of the outbreak by public health authorities and the press. The equation "barrio = poor = dirty = cholera" is, unfortunately, too true. Cholera has always been regarded as a social disease. It is vastly underreported. Countries do not like to report it because of its commercial impact -- they prefer to blame it on their neighbors -- and because of variations in the definition of a case. The authors recognize this problem but offer few helpful suggestions. Rather, they criticize administrators, health care deliverers, and epidemiologists, and they take a long time to do it. Richard A. Finkelstein, Ph.D.
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"[T]he authors tell an epidemiological horror story in a straightforward style." -- Library Journal