Ep 4 The Poop Show

As we passed along the reeking banks of the sewer, the sun shone upon a narrow slip of the water. In the bright light, it appeared the color of strong green tea, and positively looked as solid as black marble in the shadow. Indeed, it was more like watery mud than muddy water. And yet we were assured that this was the only water the wretched inhabitants had to drink. As we gazed in horror at it, we saw drains

Well, I want to say two things. Yes, One, I support the use of the words privy and night soil.

Both night soil, by the way, is human feces used as compost poop poopy poop poop.

Also, that's disgusting. That's my second point.

So I'm going to give you a little context to that. That came from an article describing the ground zero of eighteen forty nine's cholera outbreak in London.

That was London.

It was London.

That's a city, and it was that just whoop.

Everywhere there are a lot of cities that continue to be very poor sanitation just due to lack of funds for public health infrastructure. Oh my god, Welcome to this podcast Will Kill You.

Episode four. Today we're talking about cholera. I'm Aaron and I'm also Aaron.

And before we get into the meet of this week's episode, we want to ask you, dear listeners.

Dearest darling listeners.

To rate, review and subscribe.

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You know where to find us see some growdy photos, and also get our drink recipes.

Oh yeah, that's important. Yeah, okay, Arin, Yeah, I want to hear about cholera. Now tell me all about it.

Let's talk about it as it turns out, which I did not know before doing this research. Colera is really complicated. It's a complicated little bug. Yeah. So I'm going to hit on the real basics of the biology of this disease. And I want to encourage y'all to read more. Or heck, if you research cholera and I get it wrong, give us a shout out. Let me know that we're so incorrect about things.

We are open to being corrected, very open.

Okay, So cholera. Cholera is a disease that's caused by a bacteria called Vibrio cholera, which is a facultative pathogen. So that means that in addition to causing disease in humans, it also can persist in the environment and reproduce in the environment, usually in water, especially brackish water, so like at river mouth near the ocean, and things like that is where it persists.

Can you give me an example of an obligate pathogen smallpox? Okay, So smallpox, it can exist in the environment, but it can only persist if there is a human host for it to infect.

Exactly, it can't reproduce without infecting a host, whereas cholera can actually reproduce in the environment. But there are also bacteria, maybe leprosy bacteria, which also can't reproduce without being in a host. It's also an obligate pathogen.

Rocky Mountain spotted fever, Yeah, definitely.

Right, cool, Okay. So generally cholera is transmitted fecally orally, which means you have to ingest fecally contaminated water or food, especially shellfish which live in water. Really yeah, itcky because a lot of shellfish are filter feeders, so they just filter all the poop out of the water and then you eat it. Yeah, you wanna get some clams after this,

I think I actually read something about how people who take anti acids, yeah, have higher chances of getting cholera. Yeah, I preempt you.

No, not at all. I wasn't going to talk about that, but I definitely saw that too. So if you lower the acidity in your stomach, it makes it easier for the cholera to get through that really harsh environment. Super cool.

I've also heard something about that along the same lines with stomach cancer.

Oh really, just because there's like various bacteria that can be associated with stomach cancer.

No, well, potentially that, but also because acid will kill off the more like bad cells basically earlier.

Oh that's really interesting.

And so if you don't have that pressure, Yeah, I don't know. I mean this is all like me, this is what scientists shouldn't do, which is just reading abstracts of.

Things should happen though, Okay. And the other reason that there's a really high infectious dose is that after a cholera bacteria survives your stomach, it actually has to swim all the way through the rest of your gi tract and into your small intestine. So it has a little flagellum, which is a tail. So these bacteria actually look like spermes, a little sperms that.

They make giant microbes of cholera. I think that did really cute.

Not probably as cute as Gerardia, because that's the cutest. Oh, it's so cute. It looks like a little rostafarian. So once the little spermy bacteria get to your small intestine, they attach themselves to your intestine wall and they begin producing cholera toxin. And this is what actually makes you sick. So it's not the bacteria alone, it's the fact that the bacteria produces this toxin. And what's super crazy and cool about this toxin is that it is actually produced

They look really cool.

They are really amazing. One time in college, we got like Hannah paint and we were all painting Hennah and my roommate Jocelyn, who's awesome, painted the most beautiful bacteria phage on her arm and I was like, that should be a I want to it's beautiful.

Oh that's great.

Yeah. So anyways, this bacteria phage has basically inserted part of its genome into the cholera genome, and that is what's actually producing this toxin, which is super interesting to me.

That's fascinating.

Yeah.

And also, are you going to tell me how how this toxin works because I need to know. Yeah.

So, basically, this toxin essentially prevents your body from absorbing any water and forces you to push out all of the water in your body out of your intestine, which means you're basically pooping water.

Oh my gosh.

Yeah, I'll talk more about it in just a minute.

Okay.

So the incubation period, which we've talked about before as the period from when you get infected until when you show symptoms for cholera, is about one and a half days.

Wow, that's very fast.

They're super fast little swimmers and they usually attach themselves to your small intestine within twelve to seventy two hours of infection, so they're super quick. And another thing that's interesting is that there's kind of a range of symptoms. So some people who get infected are almost entirely asymptomatic, some people have a rather mild infection, and the ones that we'll talk about the most today have very very

Oh my god, are you serious?

I'm totally serious.

I have so many questions right now. Yeah, how long can you live by pooping out?

A leader?

Of fluid an hour.

I'm so glad you asked, because I did some research. So we have four and a half to five liters of blood in our body, right, and that's the fluid that's the most available for you to get water out of. Oh, if you think about that, whoa, right, and then we've got another fifteen of fluid or maybe ten liters of fluid that's surrounding all of our cells. That's that we call it interstitial fluid in between our cells. Right, So

Whoa, Oh my god. Yeah, So is this where the disease got its characteristic symptom?

It does?

And what's that called?

It's called rice water steol.

Why is it called that?

Because the poop that you're pooping out is literally all bacteria. It's just like tons of bacteria and water and dead cells.

And it looks like what murky flaky.

It looks like. So if you took a bag of rice and you soaked it and then you drained the rice out.

And what are we drinking right now? Actually, because we forgot to do quarantinies. You're really so right about that.

Tonight we're drinking rice water stool.

Oh I can I provide a little correction. We're drinking a quarantini that we named rice water stool. It actually is composed of cholera bacteria. No, just kidding. It's composed of rum chatta.

About one and a half ounces of rum chatta chai, three ounces of chai concentrate or a really strong chai tea, and.

A half an ounce of whiskey.

Yep, feel free to add more whiskey. It'll just look more realistic.

Because it will curdle. Yeah, but the most important part of this recipe is to gently warm it to body temperature. It's actually pretty delicious.

It's surprisingly good, you guys. I don't like warm drinks that are like alcoholic, but this is its taste.

It's perfect for this time of year.

It is. It's really oh, happy Thanksgiving.

Happy Thanksgiving.

Yeah, rice water stool cheers cheers with our mugs. So severely ill patients will have poop that is literally a trillion individual bacteria per gram of poop. Whoa, whoa, yeah, whoa is right? I did that like one hundred times to make sure I was getting the number right. It's absolutely ridiculous.

Which also makes sense why epidemics happen and are so easy to spread.

And the other reason is because, like I said, not everyone gets the severe illness, So people who have a mild illness are still pooping out about a million bacteria program of poop, and even patients who are completely asymptomatic can be shedding about ten to one hundred thousand bacteria program of poop.

That's really interesting.

Yes, the biggest range. I mean, obviously there's a huge range in the number of bacteria program of poop. But also people who are severely ill are not just shedding while they're having massive diarrhea. They're shedding for up to one to two weeks after symptoms have alleviated, and people who have mild illness are shedding for less time, and people who are asymptomatic tend to shed for only about a day or two. Okay, so yeah, it's crazy. It's they're just tons and tons of this bacteria that are

Or many places today, right, if.

You're say, pooping in a river and then drinking from that river downstream, or even if you you know, have like an outhouse or something, but that hole is near a well or upstream of a river, you're just spreading that infection like wildfire. What else do you want to know? So treatment for cholera, well, the good news is that treatment for cholera color is a very treatable disease. So the World Health Organization basically calls for oral rehydration solution,

Well, and cholera has kind of done that, Like if you have a severe infection of cholera, it pretty much has taken over your entire intestine right way.

Yeah, And the other thing is that because this is a bacteria that can persist in the environment, antibiotic resistance is a real concern.

And it's really kind of cool that it can be treated with just rehydration there, right.

Yeah, it's generally like a fairly short course of disease. The severe cases without treatment, fatality rate is about fifty percent. With treatment it can be as low as one percent, which is amazing.

What about a vaccine?

So there is an oral cholera vaccine. There are actually three different types of ocvs, and who does have a stockpile of these in case of severe outbreaks and emergencies, which we'll probably talk more about when we talk about what's happening with cholera today.

That's good that there's a vaccine.

Yeah, it's great.

Do you know anything about whether it provides long term?

As far as I know, it's not long term, but it is short term, and so that's why it's generally used in case of outbreaks.

Yeah.

So, I mean I feel like that's pretty much the biology of cholera? Am I right?

You better be?

I hope, I am.

So can I tell you about the history? Then?

Oh?

I cannot forking?

Wait, Okay, it's a good one. Good. I mean they're all good. Well, yeah, but this is a good one.

It's a I think, as we are both epidemiologists, this is especially close to our heart. Am I right?

Yeah, because you can't really talk about the history of cholera without talking about the birth of epidemiology as a field. The struggle for germ theory to prevail over my asthmatism, which is Okay, this word is miasmatim. I'm not saying my asthma. Just fyi, it's not my asthma. Yeah. And also the role that modern sanitation practices have played and continue to play in reducing disease burdens.

Yeah, definitely huge.

But let's start a little more simply than that. Let's start with what we know about the origins of the bacterium itself. Since cholera doesn't leave any physical mark on the body that would remain after death, you can't really detect it and skeletal remains the way that researchers have been able to with like leprosy and smallpox, what else we've mentioned.

I had never thought about that. Yeah, that is so interesting.

It's really cool to look at how you can trace the physical evidence of certain bacteria, because this means that we have to rely more on ancient texts and writings which may or may not refer to the same disease that we call coller today.

Oh that's so interesting.

Yeah, it makes the history of cholera a little murky.

Oh, just like.

The first mention of cholera comes from the father of western medicine himself, Hippocrates, in around five hundred BC, he uses the word cholera to describe an intestinal illness that causes diarrhea. In fact, it's thought that the word cholera itself comes from the Greek word for gutter kalidra. Yeah. Yeah, yeah, that's so cool. So he may have chosen this word cholera to describe the way poop water gushes out of you if you have cholera, Oh my god, like the

To day, every time, every time.

So it wasn't until the early eighteen hundreds that the word cholera was directly linked to one disease caused by one organism, the cholera bacterium. Cool. Yeah, eighteen hundreds, eighteen hundred.

From Hippocrates to the eighteen hundreds.

It was just in the Indian subcontinent. Interesting in fact, until eighteen seventeen, cholera was confined entirely to India.

Wow, when it.

Would pop up occasionally and cause an epidemic, particularly during religious pilgrimages.

Wonder why I wonder?

Oh, I'm about to tell you, because during these pilgrimages there would usually be a lot of people in a very small place, and so a disease like cholera, which relies on high population density, can really take hold and tear through a population.

Just thousands of people shedding trillions at bacteria and they drinking.

Water per gram.

Yeah, per gram. Isn't that crazy.

That's a lot of that's a lot of poop. It explains why it spread so rapidly. Really, the world in eighteen seventeen was pretty perfect in terms of opportunities for color pandemics.

So you were just going to leave it at perfect. I was like pretty perfect.

I mean, yeah, women had the right to vote everywhere, Global population density was higher than it had ever been in eighteen seventeen, and trade routes were really well established.

So basically bringing the furthest reaches of the world to the doorstep. You know, you could go anywhere, much more rapidly than you ever had before or ever could before. But something happened in eighteen seventeen to tip the scales from colera epidemic to color a pandemic. Maybe one or two colera victims hitched a ride on a ship or a caravan heading east. Who knows, and they continue to shed the collar of bacteria even if they felt okay.

Can you remind us the difference between an epidemic and pandemic for those people who maybe haven't listened to every one of our episodes.

Basically all the difference between epidemic and pandemic has to do with spatial scale, So epidemic is a lot smaller regional outbreak, and epidemiologists tend to define pandemic as being either countrywide or global multiple countries. Yeah. In any case, Cholera raged for the next seven years in India, China, the Philippines, Mediterranean countries, et cetera, all of which had probably except for India, had never seen the disease before.

Oh Man, so no immunity, no immunity.

People were dying all over the place. It was really bad. And this marked the start of the first of seven cholera pandemics that historians and epidemiologists describe, and they would happen one right after the other pretty much in all corners of the world. Yeah, I'm not sure how they defined like the edges.

I was trying to find that too, and I couldn't.

So. I mean, so we're currently in the seventh pandemic right now, and that started a little bit later, which we'll get into more later in the episode. The rest of them were sort of almost separated by a year or two. How could you say?

I wonder if it's just that if reports dropped below a certain level, then they considered that epidemic or pandemic over and then the next one started or whatever.

I mean, that could be it. It's not like we're eputy me all just start anything.

What we are.

During the third pandemic in Walks. One of the heroes of this story.

Could just keep going. I'll saying it, John Snow.

No, this is not fantasy disease ecology crossover fan fiction.

Oh that'd be great though, I mean, let's start it.

This dude's name really was John Snow, but this John Snow was an English physician being in London in eighteen fifty four when a cholera epidemic broke out. Ooh, allow me to set the stage for you, Aerin.

Thanks.

Okay, close your eyes closed. It's eighteen fifty four.

Okay, I'm probably wearing like a large dress and a corset.

You probably smell really bad because bathing.

Was never showered.

Yeah, never showered. You're living in London, Oh, I might, along with two point five million other people. Okay, let me give it. Let me give a little perspective. The population of London today is eight point seven oh million.

Okay, so just a few friends and I.

Yeah, but the city has never been bigger in terms of population density, and as a result, it's been unable to keep up with the rapid population waste output. Oh yeah, and there's no solution. The vast majority of people were just tossing out their poop, their food scraps, and their dead pets or other animals into open cesspools that led to the sewer, which was often right next to a water pump. Oh, I got not a water pump for drinking water. I really appreciate that.

Thinks I was just trying to get in the mood.

Also, horse poop was everywhere.

Oh god.

Yeah. The waste problem of London and other populous cities at the time was so enormous that there was an entire industry based on sorting through the stuff that got tossed out. Wow, bone pickers.

I was gonna say pickers, So that's pretty close.

Bone pickers.

Yeah, night soil men, oh, just shoveling through the poop.

They would collect the poop and then use it for fertilizer. Cool sewer hunters. These were actual names.

I feel like I could be a sewer hunter.

Yeah, you could be.

I feel like I feel like that's a profession that I could do.

Would you want to?

I don't know.

Well, you can be just kidding.

Yeah.

So and that that was just to name a few. There were many more like in that same ilk.

Wow.

If you were to travel back in time to this London, the first thing you would notice was the putrid, pervasive smell of rotten filth.

Oh god.

And this London is the London that our hero John Snow experienced every day as he walked to patient's houses.

Wow.

Like the John Snow of HBO, this John Snow was also quiet and methodical, and he was also really curious.

Did he have a great jawline?

No, he didn't. Does the John Stow HBO? Yeah? Does he?

Oh my god, yeah, I feel.

Like he always has facial hair covering it.

In the early episodes he just had little wispys. He's got a good jawline, all right.

Anyway, while the epidemic, the color epidemic was raging, John Snow set out to do some detective work to see if he could track the pattern of spread to see where the outbreak originated and out he went, notebook and pen in hand doing so, uh, what do you call it? A cheerio?

Mike? Can I get a sample of your poop? Their love?

Kind of like that, kind of like that, but also shoe leather epidemiology, which is what it's a true it's actually like a real term. It's what people say to do when they do on the ground epidemiology.

Yeah.

So, when he went out to try to figure out what the cause of this outbreak was, what he was doing was interviewing people who had any sort of experience with cholera during that time, and what he was looking for was a common thread in all of their stories to see if he could find the cause of this horrible disease, and why was he so interested in this?

What poop poop everywhere?

Because he loved poop.

Uh No.

At the time, the prevailing thought was that all disease was spread by my asthma m ias ma, not my asthma, which is in other words, unpleasant atmosphere. This was what scientist physicians thought at the time caused all disease. The wind blew in the wrong way today, the foul I can't do.

A British accent. I should stop trying. Maybe, I don't know, I should really stop it.

It's better than I could ever do.

I was like really trying really hard to think of something to say there, and I just I'm gonna, yeah, we're.

Losing all listeners in the UK. Sorry loves Oh goodness. Yeah. So, basically, miasthmatists were people who believed that my asthma was what spread disease, and they thought that epidemics could be caused by the right weather conditions or proximity to the foul smell coming from the sewer. My asthma or my asthmatism to disease biology is kind of like astrology to personality psychology. It has it has a whiff of science. It has a whiff of science in its logic, but is mostly

Which is interesting when you think about it, just because they were probably getting so much poop water on their hands that it could have been that they had higher rates of disease just from being exposed. But I guess when you have exposure just across all boards then it's kind of it washes out well.

Or they could have been exposed in low enough dosages. That's very true that they would have had an increased resistance.

Yeah, that's true. Good point.

Instead, though the disease seemed to strike somewhat randomly. Entire families would be wiped out in some houses, seriously entire families, but others would be completely unscathed. To try to make sense of this, he mapped out the cases, which is not the first time that maps had been used to study disease. But it was one of the most remarkable.

I don't think I knew that. I thought that was like I thought so too. It was like the John Snow went his maps. It was like a big deal in all of our classes.

It is a big deal because of some of the techniques he used. Yeah, but there were maps that had been used by the miasmontist at the time to show, oh, cases.

Up on this hill versus down in this valley, and that kind of a thing, especially for malaria.

Right right. And so when he looked at the map, he saw a geographical component for sure, with most of the cases appearing in a certain neighborhood. But it was the anomalies that struck out to him. A woman across town who died during the peak of the epidemic with no other cases around her. A brewery smack dab in the area with the highest prevalence, but without any cases at the brewery itself. Oh yeah, what was going on?

What was going on?

Wow? During his interviews, Snow gathered info on daily habits of those afflicted with cholera, including where they got their water. You see, in eighteen fifty four, there was no indoor plumbing in London, and people got their water from public water pumps, some of which had a better reputation than others. The pump on broad Street was considered to be one of the higher quality pumps.

I'm just feeling so excited, but because this is such a fun.

Story, and some people went out of their way to load.

Up on the sweet, sweet.

Tasting water from the Broad Street pump. Unfortunately for them, because that's where all the colera came from. In his interviews, Snow heard Broad Street mentioned over and over again, and sure enough, when he marked the side of the Broad Street pump on his case map, he was basically marking the epicenter of the outbreak. Yeah, with cases just spilling out from there.

It's so cool.

Well, all told, seven hundred people living within two hundred and fifty yards of the Broad Street pump had died.

Seven hundred people.

Seven hundred people within two hundred and fifty yards.

Wow.

And on Broad Street itself, the population had literally been decimated. Ninety of its nearly nine hundred residents died.

That's ten percent.

Yeah, decimated, dang wow. Yeah. And the anomalies he noticed, well, the lone case far away from the pump was a woman whose sons brought her Broad Street water every week, as it was her favorite.

Oh yeah, isn't that more lady, and her son's just trying to be nice. Yeah, I'll bring you the best water, mama. That was better. That was better.

I don't think Snow told them eventually, I mean, which is probably a kindness. Yeah.

Probably.

And the workers at the brewery they never drank water during their shift, only beer.

Oh that's the moral of our story.

Yeah. And so Snow took his findings to the Board of Governors, who, actually, I was shocked about this, did something about it. They ordered that the handle of the Broadstreet pump be removed. Of course, by the time they actually removed it, it was pretty much over the epidemic. Still, it was a victory for germ theory that marked the birth of epidemiology, which is, as we've mentioned before, the

Yeah, I mean he was the king in the North after all, I mean, yeah, north of London.

Ben the knee ben the knee pe to germ theory.

Oh that was good. It's terrible. That was on the fly, I know it.

Yeah it was, and they probably agreed that. Yeah, cholera was transmitted by drinking contaminated water. John Snow was almost pretty much unique. Yeah in his assertion that that was how it was transmitted. But like Circe Lanister of Season seven Game of Thrones, they remained firm in their denial. Oh my god, cholera was transmitted by foul air slash. White Walkers weren't a real threat. I had to dig deep for that one.

That was good.

It wasn't until a couple of decades later that Snow would be vindicated, or until next season for the other John Snow we anticipate.

I just can't wait.

Oh it's like two years from now.

Yeah yeah. Yeah.

Sadly, Snow the epidemiologist would not live to witness his vindication.

Oh yeah, does he die of cholera? No, too bad.

He died of a stroke at the age of forty five.

Oh dear.

When the causative agent of cholera was described in eighteen eighty three, the germ theory had taken its rightful place on the iron throne of disease.

Biology, never going to stop. Nope.

And there were still though a few, more than a few miasmatists lingering on, and one of them pent and Coffer drank an entire flask of cholera bacteria to prove that it wasn't the causative agent of the disease.

Did he die? Did he die?

Unfortunately?

No?

No, he didn't get sick, probably though, because he had cholera as a youth, and so it didn't matter really either like.

A mild or an asymptomatic infection. Probably so he might have killed somebody else by pooping into dirty water, his bacteria filled poop. That's a great guy.

What was the same car Corf Pentan Coffer Coffer. Either way, though jerom theory had won, that guy is not. There's nothing that that guy could actually have done. And pent And Coffer met his death in a very game of thrones. Way, oh maybe I don't know if it's that game of thrones. After realizing that his entire scientific career was based on a fallacy because he spent so much energy promoting my asthmatism, he killed himself.

Oh now I feel really bad. Yeah, he's sad.

Yeah, that's really sad.

On a happier note, I don't know if you were going to mention this, but I'd just like to point out for all the fans out there that you can visit the Broadstreet Pump.

Yes you can.

There is a little monument to John Snow there and I want to go so badly. If you've been there or if you live near there, can you like tweet us a picture because it's one of my favorite things.

That would be incredible.

I love it.

Bucket list, bucket Lets not poop bucket list.

Night soiled bucket list.

Okay, back to cholera. Linking the spread of cholera to unclean water was a huge motivator for developing sewage systems, and in wealthier countries, the disease pretty much disappeared.

Wow.

Yeah, this the eighteen fifty four epidemic in London marked one of the last real epidemics in that area.

That's awesome.

Yeah, because they were able to isolate the reason why it was being transmitted and stop that.

That's great news.

Tea drinking also may have helped what boiled water. Oh isn't that crazy?

That's really cool. Yeah, just like beer, Just like beer.

On a sad note, the problem of waste management does not belong in the past by any.

Means, definitely not.

There are many economically poor countries today that are still struggling with waste disposal and sanitation practices where diseases such as cholera are still very prevalent. Yeah, And in these places, it's kind of like a positive feedback loop. So these countries are unable to maintain or build adequate sanitation infrastructure because of the expense, and then cholera can take hold more easily, which then reduces people's ability to work, which

Ye cycles, cycles, cycle cycles.

So Erin, I'm guessing that you've got some stuff to tell me about where we stand with cholera today.

I sure do.

So.

As you mentioned, we're basically currently in what is considered the seventh pandemic of cholera. So all the cholera in the world today can actually be traced back to a single origin that happened in nineteen sixty one. And so my guess is that for most of our listeners when they hear the word cholera today in twenty seventeen, they probably think Haiti.

Yeah, I do.

And it's likely because one of the most publicized outbreaks of cholera in recent history happened in Haiti in twenty ten. And if you haven't heard of it, or even if you have, this outbreak happened pretty directly as a result of UN peacekeepers who came to Hayda after the devastating earthquake that happened in January of twenty ten. And these peacekeepers had come from Nepal, where an outbreak of cholera had been happening, and they brought it with them.

Oh okay, I was wondering where they came from. Yeah, that had cholera.

Okay, So, So coolera has been endemic in Nepal for a very long time, in the whole Yeah, that whole region. And so the UN still hasn't technically admitted that they were responsible, really, even after epidemiological research and molecular strain typing of the cholera bacteria has pretty conclusively shown that that is where this epidemic came from. They did issue an apology in December of last year about the way that they handled Haiti after the earthquake.

That kind of sounds like.

But yeah, I'm sorry that you were hurt.

By what I said.

Yeah, that's kind of how like they didn't directly take the blame for it. But anyways, that's probably a story for it. In the outbreak in Haiti, which to be clear, is not over. It's still going on. Cholera is still a problem today. Over nine thousand people since twenty ten have died, and over seven hundred thousand people, which is about seven percent of the population of Haiti, have been sickened.

Oh my god.

And if you think of all of the hurricanes and everything that have been happening in the Caribbean at this time, like because cholera is a disease that is very strongly associated with contaminated sources of drinking water and lack of sanitation. Any time that you see destabilization of infrastructure, whether that's due to natural disasters or war man made conflicts, you

Interesting. Yeah, so, and this has to do with asymptomatic cases or so it's probably seeking treatment, probably both.

So, probably there are some asymptomatic cases, but a lot of it has to do with a lack of surveillance and a lack of reporting in a lot of areas. You also, because this is a disease that can strike so rapidly, you can have people falling ill and dying in remote areas long before they have time to get to a hospital facility or anything like that. Estimates of the number of deaths that likely happen each year due

Yeah.

So, in addition to estimating the number of cases of cholera, this study also looked at what the most important risk factors were. My voice correct, I noticed that, Yeah, unsexed post. Oh thanks, thanks, appreciate it. But unsurprisingly, the two most important risk factors. Do you want to guess what they are? The two most important risk factors for cholera in a country.

I think I'm going to try.

Okay, sanitation, definitely, water infrastructure, access to exactly the percentage of the population without sustainable access to improved sanitation and improve drinking water sources. And blood type and not blood type.

But there are there are differences in susceptibility to cholera with different blood types.

Right, Weirdly, Yeah, what blood type you are can actually affect the likelihood that you get infected with cholera and how severe the case is once you are infected. That's so weird, it's super weird. So people who are blood type OH like me, like me, I'm abe you're so rare, I'm so common. So people who are type OH are less likely to get infected with cholera, which sounds great, uh huh, But if they get infected, they actually are much more likely to have severe symptoms. Okay, that's a bummer,

Interesting.

So one hypothesis is that this is at least in part because there is selection against this blood type because it's associated with higher risk of severe symptoms.

I've always wondered about the geographical distribution of blood types.

It's really interesting. We were just looking at maps of that like, yeah, it's so weird that there's I had no idea there was such a range in distribution that's huge. And so in Latin America, for example, there's a really high prevalence of blood type. Oh, so all of like North and South America is like really high prevalence of blood type. Oh, and so we see much more severe disease due to cholera. You have greater need for rehydration

That is really fascinating. Yeah, So how worried do we need to be about cholera?

It's a good question.

It's a tricky one.

It's a tricky one. I would say overall, the biggest thing that we can do to prevent and majorly reduce the burden of cholera is improve access to sanitation and water worldwide. And that's something that's very doable. It just honestly takes investment, you know, right to make that happen.

People on the ground going out and trying to help create clean water sources exactly. The Gates Foundation is big and trying to do that.

There are a lot of organizations that are doing that that I wish I had looked up the names of all of them. So maybe what we'll do is post on our Facebook page some of the organizations that are doing really great work on both sanitation and water improvement.

The Carter Center, which last episode I kept saying was the Carter Foundation. I was confusing with the Gates Foundation. It's pretty close actually, the Carter Center. They also do a lot of work in terms of reducing the burden and neglected tropical diseases in countries.

Yeah, so yeah, I say overall, cholera definitely is still prevalent in a lot of parts of the world. It's still something that's killing people every day, and it doesn't need to be, which is what's really sad about it is that it is treatable and it's preventable.

Could it be eradicated?

That's a really good question. It's an interesting question. I don't know, to be honest, because it can persist in the environment. I think it would be really really hard. There are some interesting therapies out there that we don't have time to get into that could make a really big dent, because in theory, if you could eliminate this bacteria phase from the cholera then you're not going to be having symptomatic infections, so then it just becomes another

Wouldn't that be wonderful?

It would be really wonderful.

Is that it? What books did you read?

Okay?

This week?

I've got a few. If you want a big overview of cholera itself, there's a book called Cholera the Biography by Christopher Hamlin. And if you want to learn more about the non HBO john snow, you should check out The Ghost Map by Stephen Johnson. It's a pretty thrilling book actually about the race to try to find out what was the cause of cholera, the quite frankly shocking

And most of the information about the biology of cholera I got from this really interesting paper called Cholera Transmission, the Host, Pathogen and Bacteria phage Dynamic by Neilson at All in Nature Reviews Microbiology that was published in two thousand and nine. It's a really nice review paper, and there's a bunch of other ones out there as well.

Before we go, I thought of the most brilliant idea to me. Kit Harrington, who plays John Snow in HBO's Game of Thrones, needs to play John Snow, the epidemiologist in a.

Biopic that would be really funny.

I'm serious.

I mean, are you listening, kit, Are.

You listening screenwriters everywhere?

Yeah, I mean we gave you this. We gave you a plug last episode, you know, the Smallpox movie. We're basically doing your jobs for you.

Yep, yep, you're welcome. Welcome, and speaking of more, thanks and welcomes. Thank you to Bloodmobile, who provided the music for this and all of our episodes.

Yep, thanks, you're the best Bloodmobile, and.

Also a big thank you to the band Cholera, who let us use their song The Answer to Infection as the fade out song at the end of this episode. It's awesome. You guys should totally check them out.

Just wait for it. It's so good.

Once again, rate review and subscribe.

Yep, we'll do it again. We'll tell you more, and thanks so much for listening. We hope you are having fun because we are. Wash your hands, you filthy animals.