07.07.2023 | History of Medicine

Cholera as a blueprint for pandemics

Cholera was the first modern pandemic. It has shaped how we think about the emergence and global interconnectedness of disease and infection, as well as about countermeasures. A workshop at the OeAW examined the socio-ecological history of cholera in the Indian Ocean.

The first documented outbreak of Asiatic cholera in Bengal (red) and the subsequent spread to England (1817 to 1831). © Lombard, D in 1831, Bibliothèque Universelle des Sciences et Arts, COLLBN Port 144 N 169 Leiden University Libraries

If untreated, cholera is deadly in 20 to 70 percent of cases. Cholera is a notifiable disease caused by a highly mobile bacterium that leads to severe diarrhea with a large loss of fluids. In the seventh cholera pandemic, which has been ongoing since 1961, outbreaks have repeatedly occurred worldwide.

In May, a workshop on cholera took place at the Austrian Academy of Sciences (OeAW). In an interview, OeAW medical anthropologist Eva-Maria Knoll and Indian medical historian Vivek Neelakantan, who is currently a guest researcher at the Academy, explain the parallels to COVID-19 and how cholera outbreaks are related to a strained water supply. These research activities are part of the Appraising Risk project funded by the Canadian Social Science and Humanities Research Council and based at the Indian Ocean World Center at McGill University in Montreal. This project focuses on climate-related risks in the Indian Ocean in the past and future.

Cholera was the first pandemic of the modern age and shaped how we think about pandemics now.

Where and when did cholera first emerge?

Vivek Neelakantan: Until the discovery of the cholera bacterium by Robert Koch in 1882, the etiology and nosology of cholera was unclear. In India, cholera was personified as a goddess; known as Ola Bibi in Bengal; or as Mari Aai in parts of western India. The people ask for her protection, bringing her food offerings. In 1817 we find the first documented case of cholera in Bengal. From there, the pathogen migrated to Bombay, on to Asia Minor, Afghanistan, Mauritius, Manila – it spread in different directions. This was the first documented cholera pandemic in history.

Why is cholera so important for pandemic research?

Eva-Maria Knoll: The first documented case also represents the emergence of a new way of thinking in science about how diseases arise and how they spread, how infection occurs and how it can be combated. Cholera was the first pandemic of the modern age and shaped how we think about pandemics now. A key reason why cholera is a productive workshop topic is the multi-dimensional nature of the disease. Cholera is very persistent; it is endemic, epidemic and pandemic. It has been suspected in the human body but also outside in the environment of the Ganges Basin. It is local, linked to poverty and unsanitary living conditions, but also global. Nobody was safe from it. Wealthy people were affected too.

Do you have an example?

Knoll: In 1873 there was a cholera epidemic in Vienna that killed almost 3,000 people. This occurred while Vienna was hosting a world exposition, aiming to showcase itself as a city of innovation. The outbreak prompted a sudden exodus of visitors who hastily departed and canceled their reservations. However, there were also some positive developments. Thanks to the efforts of OeAW member Eduard Süß, construction of the first Vienna mountain spring pipeline, designed to bring safe drinking water from the Alps to Vienna, was expedited. Therefore, the Academy of Sciences is an ideal location for our workshop.

Cholera is always linked to poverty; does that make it difficult to keep it under control?

Neelakantan: Many cholera cases go unreported because the disease is stigmatized and reflects poorly on the affected country. Various crises are straining water supplies and contributing to an increase in cases, such as the climate crisis in the 2022 Gujarat outbreak. In Haiti in 2010, the trigger was a severe earthquake. In 2016, there was an outbreak of cholera in Yemen as a result of the civil war.

Many cholera cases go unreported because the disease is stigmatized and reflects poorly on the affected country.

How many deaths have there been altogether?

Knoll: The WHO estimates 1.4 million cases annually and 21,000 to 143,000 deaths and has a goal of ending cholera by 2030. With vaccinations, electrolytes, antibiotics, clean drinking water and hygienic as well as economic standards, cholera can be easily brought under control. It’s a provision issue; no one should have to die from it anymore.

Are there parallels to the COVID-19 pandemic?

Neelakantan: History does not repeat itself, but there are similar disagreements regarding quarantine of infectious diseases. In colonial times, the Bombay government advocated quarantining incoming ships, but the Raj authorities opposed this measure. Similarly, during the COVID-19 crisis, there was no consensus between the Indian central and state governments on the implementation of lockdowns.

Knoll: Scientist David Arnold has described cholera as the original pandemic of the modern era. It laid the foundation for how we, both in science and in the public, think about pandemics as a global phenomenon that affects everyone. Cholera first highlighted the interconnectedness of global crises, as well as spurring international cooperation to develop a vaccination. Given these parallels, it comes as no surprise that there were constant references to cholera during COVID-19.


At a glance

Vivek Neelakantan is a medical historian and currently a guest researcher at the Institute for Social Anthropology (ISA) of the OeAW. His research focuses on India, Indonesia and the Philippines and on the history of international health organizations.

Eva-Marie Knoll is a researcher at the Institute for Social Anthropology (ISA) of the OeAW.