Interview of Renaud Piarroux
Défis Humanitaires : Can you remind our readers what cholera is, which still causes victims in many countries?
Renaud Piarroux : Cholera is a diarrhoeal disease which essentially results in diarrhoea and vomiting. In the most severe forms, major dehydration can lead to shock and even death. It is a disease that is due to a bacterium that is found in humans and also in drinking water and food after human contamination.
Défis Humanitaires : In 2022, we faced everywhere a strong increase of cholera and its victims in the world, why and what to do?
Renaud Piarroux : There are indeed more cases of cholera, in any case last year there were more cases of cholera than in previous years. This is linked to various situations, for example the war situation that took place in Syria and even in Lebanon in the refugee camps, it is also linked to the resumption of cholera in Africa, and also a resumption of cholera in Haiti. So, each time, it is the specific local contexts that have led to a significant increase in the disease over the last year. What should we fear? It is that these diseases remain as neglected as they are now and that there is no response to this health problem that has re-emerged in many countries in the last year.
Défis Humanitaires : Is there a link between this renewed cholera epidemic and the COVID-19 pandemic?
Renaud Piarroux : There may be a link insofar as many of the resources that were allocated to health and communicable diseases went to Covid-19, and therefore human and material resources were lacking for the treatment of many other diseases and it is not only cholera, it is the same problem with malaria, tuberculosis, measles. In the end, it is more a flow of resources that has gone to Covid and that has been lacking for other diseases.
Défis Humanitaires : How can we fight against cholera in order to save lives?
Renaud Piarroux : When there is an epidemic, we must first treat the people. In the case of cholera, this is all the more important because the disease can be fatal very quickly, but if we treat and rehydrate, either orally or by perfusion in the least serious cases, we can save the patients. The first thing is obviously to rehydrate and treat the patients. After that, the fight against transmission must use a range of tools and the best way is to use the whole range. It goes from securing the supply of drinking water, information, hygiene education and vaccination, knowing that none of these tools alone can control an epidemic. In particular, the vaccine against cholera is not as effective as the vaccine against yellow fever or measles. It is all these tools that must be applied as a matter of urgency. And also, we would not have cholera if we had an adequate supply of drinking water to the populations everywhere in the world.
Défis Humanitaires : Can we say that access to drinking water is the best remedy for cholera?
Renaud Piarroux : Yes, in fact, cholera epidemics only occur where populations do not have access to drinking water. Sanitation also plays a role but it is essentially drinking water. If we manage to bring clean water, we solve the cholera problem. There are other diseases that need sanitation, but the most important point of impact is drinking water, then sanitation.
Défis Humanitaires : Non-drinking water causes other so-called waterborne diseases because they come from unsafe water. Do you have any examples?
Renaud Piarroux : Among the diseases, there are infantile diarrhoeas, some of which are viral, others bacterial or even other microbes that can act. It all depends on the context, but in most cases, the supply of drinking water is a determining factor. It is not the totality, for example, we had in France, we always have epidemics of Rotavirus which are transmitted whereas we have drinking water, simply by hygiene of the hands. Drinking water does not guarantee the absence of waterborne diseases. You can also get sick from eating contaminated food. There are also hepatitises that you can get from water, there is amoebiasis, there are intestinal worms, there are different diseases that you can get.
Défis Humanitaires : At the 78th World Health Assembly in May 2018, the Assembly passed a resolution to end cholera worldwide and decided on a 2030 roadmap. Where do we stand today? What can we think of this resolution?
Renaud Piarroux : Nothing. I don’t expect anything from this resolution, we can always say that we are going to do it, but the reality is that the means are insufficient to reach these objectives.
Défis Humanitaires : This World Health Assembly had even decided to reduce the number of cholera-related deaths by 90% by 2030. Are we on the right track to reach this goal?
Renaud Piarroux : If we want to achieve this result, we need to bring clean water to the most affected areas. In any case, we have to be very vigilant, we will not achieve this by vaccination alone. We have the current example of Malawi where the fight has been very focused on vaccination, but the vaccine is partially effective and especially effective temporarily. Last year, we had the worst cholera epidemic in Malawi’s history. So the real problem is the distribution of resources and the fact that populations are in a state of destitution and lack of access to drinking water. When this problem is solved, things will be much better, but as long as we leave entire sections of the world’s population in a catastrophic situation in terms of health, we should not be surprised to have cholera epidemics.
Défis Humanitaires : This year, from March 22 to 25, a UN Conference is dedicated to water, i.e. Goal 6 of the Sustainable Development Goals. In your opinion, what is the main issue at stake in this conference and what can we expect from it?
Renaud Piarroux : The challenge is to re-mobilize those who have the power to do something: the States and the major private actors, the foundations, etc. What we can do is to make sure that we have the means to do it. What we can do is explain the situation, but I think that what will happen is that we will realize that even if we are halfway there, we are not halfway there yet.
This can serve as a wake-up call, even if there hasn’t been this conference for 47 years, I was looking at other diseases, the number of times it was said, for example on tuberculosis, “we are going to halve the number of deaths by tuberculosis in a few years and we are going to set objectives because it is not normal that there are still 1.6 million people dying of tuberculosis every year”, but in fact we are not making any progress.
Overall, it is a management that is very focused on the interest of each nation and not focused on the interest of humanity. So, since the problems are managed in this way, it is very difficult to have enough means to intervene in the countries most affected by cholera or tuberculosis, which are the same countries.
Doctors treating cholera patients at a medical center in Nigeria. @KendraHelmer, USAID
Défis Humanitaires : At the 9th Water Forum in Dakar in 2022, the United Nations indicated that in order to reach the MDG 6 (water) in 2030, the financial means needed would have to be multiplied by 4 and by 23 in crisis situations. Will this conference re-mobilize all the actors, but also the resources needed to achieve this?
Renaud Piarroux : Given what has happened at other international conferences so far, I am not very optimistic that there will be a major mobilization followed by a significant financial investment. Unfortunately, the rich countries have realized that cholera is not a problem for them. Obviously, they let it happen.
Défis Humanitaires : You have worked a lot on cholera, particularly in Haiti and in the DRC, with actors such as humanitarian and development NGOs, international organizations and States, while participating in international conferences on water. What are the issues and challenges of humanitarian and development action in the face of crisis situations and cholera? Will this UN conference on Goal 6 Water succeed in respecting the commitments made by 195 States with the 17 Sustainable Development Goals 2015-2023, including universal access to drinking water?
Renaud Piarroux : The answer is in the question: try to move the lines through testimonies, by calling on the major players, with mixed success so far. The point is not to abandon the cause. Just because there has not been a major mobilization for health problems in developing countries so far does not mean that we should not ask for these things to be done every time.
Covid has also shown that what happens in a country, even at the other end of the planet, can concern us, so even if we do not directly fear cholera, the fact that a large part of humanity lives in deplorable sanitary conditions, finally, creates the basis for epidemics and even pandemics.
A child treated in isolation for cholera, Juba, South Sudan. @UN Photo/ JC Mcllwaine.
Défis Humanitaires : Would you like to say something in conclusion?
Renaud Piarroux : Simply to say that the important point that I see in this type of meeting is to challenge the people who have the capacity to make decisions. It is to shed light on what is going on and that we easily forget, because we don’t see it at home, we leave it aside until the day when we are confronted with a problem that we didn’t expect. What I hope is that there will be as much opportunity as possible to testify on the situation of access to water in developing countries.
Specialist in infectious diseases, particularly cholera, and in tropical medicine. Professor at the Faculty of Medicine of Sorbonne University. Member of the Pierre Louis Institute of Epidemiology and Public Health attached to INSERM and head of the parasitology department at the Pitié Salpêtrière Hospital.