THE cholera epidemic that began a year ago in South America has not spread as fast as health and sanitation professionals had predicted, thanks to quick governmental response.
But these professionals warn that the region must begin investing heavily in sewage- and water-treatment infrastructure to avert public health crises.
"In emergency terms, the [Brazilian] government has been doing a good job of putting out fires," says Julio Cesar de Magalhaes Alves, technical director of the Sao Paulo state Center for Disease Control. "But basic infrastructure, which demands a great deal of money, should have been invested in, regardless of cholera. If this had been done, we wouldn't have cholera."
Returning Latin America and the Caribbean to the ratio between population and services that existed 15 to 20 years ago will cost $200 billion, according to the Washington-based Pan-American Health Organization (PAHO). Rodolfo Rodriguez, the PAHO representative in Brazil, says such funds would have to be spent at a rate of $20 billion a year for about a decade - the equivalent of 3 to 4 percent of each nation's gross national product.
Until last year, cholera had been absent from the Latin American region for about a century, although it has been reported in Asia since 1963. But during the past decade or so, official investment in basic infrastructure and social services in Latin America and the Caribbean dropped significantly.
With worsening conditions and greater poverty, cholera returned in an epidemic beginning in January 1991 on Peru's Pacific coastline. It spread quickly over the Andes mountains to the Amazon region because of poor sanitation and inadequate health care, in addition to the Peruvian custom of eating raw fish. The cholera germ is said by medical authorities to thrive in polluted water, but is killed by cooking or chlorination. Peru has reported 300,000 cases, though most of the ill have survived.
Most South American countries have seen only a few cases arising in episodes that have come under rapid control. Brazilian health officials were at first especially worried, since the Amazon region is one of the nation's poorest, with most residents using river water for all personal needs. But Baldur Schubert, president of the National Cholera Commission, considers Brazil's 1,203 cases and 20 deaths since April to be a relatively low number.
"Peru was taken by surprise," he notes. "When Brazil was informed of the epidemic Feb. 2, we immediately began to invest in a national prevention and control program." Last year, Dr. Schubert says Brazil spent at least $60 million on preventing cholera. The government sent 250 health professionals to Peru both to help out and to train to help in Brazil's fight. It also sent 1,500 technicians to the Amazon region and more in other locations. Laboratories and latrines were set up, and chlorine was distribu ted. Ports and airports were scrutinized.
At the moment, there are no cholera cases in the Alto Solimes Amazon region, where the disease first appeared in Brazil. There have been few cases outside the Amazon, with only two in Rio de Janeiro, both of them soldiers on leave from Amazon duty.
Food exports, initially a source of concern in many countries, have not been found to carry cholera, experts say, because of quality control and packaging. Overall, there has been a positive reaction in Brazil produced by the epidemic, Schubert says.
"It has raised consciousness in society, about sanitation, and stimulated [the spread of good] personal hygiene and food habits," he says. Meanwhile, PAHO has worked for lasting solutions that include developing a country-by-country analysis and action plan, including the required financing and potential financing sources, to be presented at a meeting of Latin American and Caribbean health ministers in Washington in September.
The situation is critical, Mr. Rodriguez points out, considering that United Nations figures indicate close to 190 million people in the region are still living in poverty, and there could be as many as 300 million by the year 2000.