Ms Nylander agrees that the high fatality rate could be because health systems are overwhelmed.

“Understaffing is a chronic issue in a number of countries in Africa and elsewhere in the Global South, and it’s particularly acute post Covid where a lot of health care workers have been lost for a number of reasons,” she says.

Ms Nylander also points to the global economic crisis hitting both governments and individuals. Governments are not investing in public services; overseas aid budgets have been slashed and the cost of living crisis means individuals in countries at risk of cholera may be scrimping on clean water and essentials such as soap.

Much of the work on cholera is emergency focused  – such as reactive mass vaccination and bringing in clean water in tankers. This may stop a current outbreak but does little to prevent future ones – as citizens in Haiti have found.

The Caribbean island finally declared itself free of the disease in 2019 after battling an outbreak that began in 2010. However, the disease re-emerged in February 2022 and since then there have been 850,000 cases.

“As with many infectious diseases, when a large proportion of the community is exposed the bacteria no longer has susceptible people to infect and outbreaks slow or stop, at least in the short term. There was a lot of action to reduce the risk of cholera in Haiti during previous outbreaks but it was very focused around cases and very short term. There were few infrastructure improvements in terms of water and sanitation so the conditions were still ripe for another outbreak,” says Dr Azman.

In countries with poor infrastructure there is always the risk of the disease being reimported, he says.

“If people don’t see cholera in their population they often let their guard down. That’s understandable because they have a lot of competing health priorities. And then all of a sudden there’s this explosion. Cholera does not stop at national borders so if you have cholera in a region all countries are at risk. Elimination in a single country in a region may be impossible without water and sanitation systems like we have in Europe and North America,” he says.

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