Cholera control and anti-Haitian stigma in the Dominican Republic: from migration policy to lived experience.

As cholera spread from Haiti to the Dominican Republic, Haitian migrants, a largely undocumented and stigmatized population in Dominican society, became a focus of public health concern. Concurrent to the epidemic, the Dominican legislature enacted new documentation requirements. This paper presents findings from an ethnographic study of anti-Haitian stigma in the Dominican Republic from June to August 2012. Eight focus group discussions (FGDs) were held with Haitian and Dominican community members. Five in-depth interviews were held with key informants in the migration policy sector. Theoretical frameworks of stigma's moral experience guided the analysis of how cholera was perceived, ways in which blame was assigned and felt and the relationship between documentation and healthcare access. In FGDs, both Haitians and Dominicans expressed fear of cholera and underscored the importance of public health messages to prevent the epidemic's spread. However, health messages also figured into experiences of stigma and rationales for blame. For Dominicans, failure to follow public health advice justified the blame of Haitians and seemed to confirm anti-Haitian sentiments. Haitians communicated a sense of powerlessness to follow public health messages given structural constraints like lack of safe water and sanitation, difficulty accessing healthcare and lack of documentation. In effect, by making documentation more difficult to obtain, the migration policy undermined cholera programs and contributed to ongoing processes of moral disqualification. Efforts to eliminate cholera from the island should consider how policy and stigma can undermine public health campaigns and further jeopardize the everyday 'being-in-the-world' of vulnerable groups.

Tainted commons, public health: the politico-moral significance of cholera in Vietnam.

In October 2007, a series of cholera epidemics broke out in Hanoi, interrupting a moment of economic triumphalism in post-transition Vietnam. In seeking the source of a refractory disease associated with poverty and underdevelopment, officials, media, and citizens not only identified scapegoats and proposed solutions, they also endorsed particular visions of moral conduct, social order, and public health. Controversy over cholera, a potent politico-moral symbol, expressed an imaginary of "tainted commons" (i.e., an emergent space of civil society and small-scale entrepreneurship from which the state has partially withdrawn, while still exercising some measure of scrutiny and control). The ambiguities of this situation permitted the state to assume moral postures, evade responsibility, and deflect criticism to convenient targets. Prevalent outbreak narratives thus played on anxieties regarding specifically classed and gendered social groups, whose behavior was imagined to contravene ideals of public health and order.

Comparing sociocultural features of cholera in three endemic African settings.

BACKGROUND: Cholera mainly affects developing countries where safe water supply and sanitation infrastructure are often rudimentary. Sub-Saharan Africa is a cholera hotspot. Effective cholera control requires not only a professional assessment, but also consideration of community-based priorities. The present work compares local sociocultural features of endemic cholera in urban and rural sites from three field studies in southeastern Democratic Republic of Congo (SE-DRC), western Kenya and Zanzibar. METHODS: A vignette-based semistructured interview was used in 2008 in Zanzibar to study sociocultural features of cholera-related illness among 356 men and women from urban and rural communities. Similar cross-sectional surveys were performed in western Kenya (n = 379) and in SE-DRC (n = 360) in 2010. Systematic comparison across all settings considered the following domains: illness identification; perceived seriousness, potential fatality and past household episodes; illness-related experience; meaning; knowledge of prevention; help-seeking behavior; and perceived vulnerability. RESULTS: Cholera is well known in all three settings and is understood to have a significant impact on people's lives. Its social impact was mainly characterized by financial concerns. Problems with unsafe water, sanitation and dirty environments were the most common perceived causes across settings; nonetheless, non-biomedical explanations were widespread in rural areas of SE-DRC and Zanzibar. Safe food and water and vaccines were prioritized for prevention in SE-DRC. Safe water was prioritized in western Kenya along with sanitation and health education. The latter two were also prioritized in Zanzibar. Use of oral rehydration solutions and rehydration was a top priority everywhere; healthcare facilities were universally reported as a primary source of help. Respondents in SE-DRC and Zanzibar reported cholera as affecting almost everybody without differentiating much for gender, age and class. In contrast, in western Kenya, gender differentiation was pronounced, and children and the poor were regarded as most vulnerable to cholera. CONCLUSIONS: This comprehensive review identified common and distinctive features of local understandings of cholera. Classical treatment (that is, rehydration) was highlighted as a priority for control in the three African study settings and is likely to be identified in the region beyond. Findings indicate the value of insight from community studies to guide local program planning for cholera control and elimination.

New culprits and old threats in infectious diseases: the work of disease detectives.

The A.J. Orenstein Memorial Lecture, Medical School, Univ. of the Witwatersrand, Johannesburg, 12 August 2009

A cholera epidemic among the Nicobarese tribe of Nancowry, Andaman, and Nicobar, India.

Cholera has not been reported from the Andaman and Nicobar Islands in India. In October 2002, an outbreak of diarrhea occurred among the Nicobarese tribe of the Nancowry group of islands. The outbreak affected 16 of the 45 inhabited villages of three islands with an attack rate of 12.8% and a case fatality ratio of 1.3%. Vibrio cholerae O1 El Tor was isolated from 18 of the 67 patients tested. A study conducted in one of the villages indicated that the outbreak was started there by a person who traveled to a nearby village where an outbreak was occurring. No specific water source could be identified as the source of infection because persons consuming water from all wells were affected. Water samples from 55 sources were tested and 38 of them were contaminated with Escherichia coli. The possible sources of V. cholerae are effluents from ships or poachers from neighboring countries where cholera is endemic.