Cholera is working its way through Haiti. It is killing people and terrifying everyone. Medical help and money has been pouring in -- not enough money, the United Nations says, but a lot of money, a lot more money than has been flowing for a much worse health problem.
In the first six weeks of the cholera outbreak in Haiti, more than 2,000 people died. During the same time, many more people in poor countries around the world died from the other health problem, an estimated 210,000. But hardly anyone noticed.
"This is a silent killer," said David Winder, an international aid executive in Washington who has been dealing with public health for decades.
Cholera and the bigger problem are cousins. Both are forms of diarrhea. But the more common forms of diarrhea are far more widespread and far more deadly. Cholera kills about 120,000 people a year; the more common forms of diarrhea kill 15 times more people, about 1.8 million a year, 5,000 a day. Hard to believe when you live in the United States or Europe; but in poor countries diarrhea is a persistent killer.
Cholera gets the headlines for good reason. It can kill in hours rather than days as with other kinds of diarrhea. "It's very dramatic," said Dr. Gordon M. Dickinson, a University of Miami specialist on infectious diseases at the Veterans Hospital in Miami. People become dehydrated, go into shock and die. The other forms of diarrhea kill the same way. But there is more time to react.
Children are the main victims. More of them die of severe diarrhea than from HIV/AIDS, malaria and measles all together. Yet the problem has not captured the imagination.
"People think of diarrhea as a temporary illness associated with something like bad food," said Brenda McIlwraith, a spokeswoman for WaterAid, a non-profit organization in London, working to reduce diarrhea around the world.
Very little progress is being made. In Haiti, "diarrhea is here all the time," said Christian Lindmeier, a spokesman for the World Health Organization in Port-au-Prince. In the first wave of cholera deaths, he said by telephone, people thought "it was just another diarrhea" and they did not seek treatment.
Cholera and the other forms of diarrhea are preventable. "We know how to deal with these diseases," said Dr. Claire-Lise Chaignat, the head of the World Health Organization's Global Task Force on Cholera Control in Geneva. The bacteria, parasites and viruses that cause the diseases travel in drinking water. They get into the water and, sometimes, food, along with human waste, as sewage and on dirty hands. All that needs to be done to fix the problem is to provide clean drinking water, basic toilets and some tips on hygiene.
But the scale of the problem is staggering. About 1 billion people do not have clean drinking water, the United Nations estimates, and 2.6 billion, nearly 40 percent of the world's 7 billion people, don't have toilets.
It could take $50 billion dollars to put a big dent in the problem. No one is sure. But right now, Mr. Winder, the head of WaterAid in America, says spending "is far below what's needed."
The United Nations anticipates spending $164 million to tamp down a cholera epidemic that may sicken as many as 400,000 Haitians. Only about 20 percent of the money had been raised as the epidemic settled in. But it is a real spending target. And that is a lot of money in proportion to total spending in Haiti on public health.
Spending that kind of money in advance in Haiti on clean water and toilets would have saved lives. It would have made it harder for cholera to get going. It would have been the right thing to do economically, too. Half the hospital beds in the poor countries are filled with patients with severe diarrhea. That is a daily recurring cost. Improving sanitation would reduce those costs. It would also reduce days lost at work and from school.
Doctors and engineers may know how to solve the diarrhea problem, but every day there is evidence that it is not easy. Hundreds of aid agencies are working on it, but the work is piecemeal and sometimes counter-productive. In some places, Dr. Chaignat said, the people responsible for health and water "rarely talk to each other. The health sector doesn't understand the water sector and vice versa."
So the plague of diarrheal diseases grinds on. The people suffering most have no political clout. They are poor and they die quietly. Sometimes they make it to hospitals. But often they die in huts and shacks and out-of-the way places. One at a time. You don't hear about it.