PERS PE C T IV E U.S.

Health Insurance Coverage and Financing

policymakers curtail the power our health care system. Constrain- www​.­nytimes​.­com/​­2021/​­03/​­10/​­upshot/​­covid​
-­bill​-­health​-­gap​.­html).
of health care monopolies to ing the growth of costs while re- 2. Kaiser Family Foundation. Employer-
drive up costs and do more to ducing inequities in access and sponsored coverage rates for the nonelderly
limit health care prices across outcomes will require new but by age. 2019 (https://www​.­kff​.­org/​­other/​­state​
-­indicator/​­nonelderly​-­employer​-­coverage​-­rate​
our array of public and private difficult reforms. -­by​-­age/​­?current ​­Timeframe= ​­0&sortModel​­=​
coverage systems, virtually every- Disclosure forms provided by the authors ­%7B%22colId​­%22:%22​­L ocation%22,%22​
one’s access to affordable care is are available at NEJM.org. ­sort%22:%22asc​­%22%7D).
The series editors are Erin C. Fuse Brown, 3. Urban-Brookings Tax Policy Center. Brief-
at risk. J.D., M.P.H., Aaron S. Kesselheim, M.D., J.D., ing book: key elements of the U.S. tax sys-
Our patchwork system of M.P.H., Debra Malina, Ph.D., Genevra Pitt­ tem. May 2020 (https://www​.­t axpolicycenter​
man, M.P.H., and Stephen Morrissey, Ph.D. .­org/​­briefing​-­book/​­how​-­might​-­t ax​-­exclusion​
health coverage is not going
-­employer​-­sponsored​-­health​-­insurance​-­esi​-­be​
away anytime soon. However, the From the McCourt School of Public Policy, -­reformed​-­0).
primary reason mil- Georgetown University, Washington, DC. 4. DeNavas-Walt C, Proctor BD, Smith JC.
An audio interview Income, poverty, and health insurance cov-
with Prof. Corlette
lions of Americans This article was published on December 17, erage in the United States: 2010. Census Bu-
is available at NEJM.org remain uninsured or 2022, at NEJM.org. reau, September 2011 (https://www2​.­census​
have insurance cov- .­gov/​­library/​­publications/​­2011/​­demo/​­p60​-­239/​
1. Kliff S. A $22,368 bill that dodged and ­p60​-­239​.­pdf).
erage that leaves them financial- weaved to find a gap in America’s health sys- DOI: 10.1056/NEJMp2206049
ly exposed is the high costs in tem. New York Times, March 10, 2021 (https:// Copyright © 2022 Massachusetts Medical Society.
U.S. Health Insurance Coverage and Financing

Cholera in Haiti, Again

Cholera in Haiti, Again

Richard P. Wenzel, M.D.​​

C holera is a severe diarrheal

disease caused by a toxin pro-
duced by Vibrio cholerae that leads
100 patients a day, observing their
facial expressions that revealed
complete physical and emotional
kills patients are delays in receiv-
ing rehydration therapy.
A new outbreak of cholera
to life-threatening losses of fluid exhaustion, deeply sunken eyes, anywhere merits our attention.
and electrolytes. According to dry mucous membranes, and re- Cholera was visited on the people
the World Health Organization markable loss of skin turgor. of Haiti for the first time in
(WHO), the gram-negative, curved, There is no fever with cholera. 2010, months after the country
rod-shaped bacterium has been Most of our patients lost about had weathered a devastating earth-
responsible for seven pandemics 10% of their body weight, which quake. The disease’s emergence
in the past 200 years. The current correlated with our measure- was traced to infection carried by
pandemic began in 1961 with the ments of a plasma specific grav- U.N. security forces from Nepal,
global spread of the El Tor O1 ity of 1.035 or more (normal where cholera is endemic. The
variant. El Tor (or Al-Tur) is a city value, 1.025) and indicated severe 2010 outbreak had lethal con­
on the Sinai peninsula where the dehydration. sequences, with an estimated
variant was isolated in 1905; it had With limited resources, simple 820,000 cases and 10,000 deaths.
once been the site of an Ottoman protocols saved lives: we placed Cholera appeared to have been
quarantine station for pilgrims the patient on the canvas cholera eliminated from Haiti in 2019,
returning from the Hajj. Today, cot with a hole for the buttocks only to resurface in 2022.
the variant is estimated to infect above a calibrated collection buck- Now, two timely letters to the
1.3 million to 4.0 million people et, infused a quantity of IV fluid editor (both online November 30)
each year, causing 21,000 to based on the patient’s weight provide updates on the resurgence
140,000 deaths.1 (e.g., 5 liters for a patient weigh- of cholera in Haiti. The letter by
Early in my training, I volun- ing 50 kg), then kept up with Severe et al. outlines the misera-
teered to manage the care of losses by measuring and replac- ble and chaotic social–political
hospitalized patients with chol- ing the ongoing watery discharg- situation in Haiti that is aggra-
era during separate outbreaks in es containing flecks of cells and vating a cholera resurgence and
the Philippines and Bangladesh. mucus (“rice-water stool”). Near- has disproportionately affected
We clinicians saw as many as ly every patient survived. What undernourished children. The age

2300 n engl j med 387;25 nejm.org December 22, 2022

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 PE R S PE C T IV E Cholera in Haiti, Again

distribution of people with chol- could be imported on one of sev- of life on a small planet chal-
era in the 2010 outbreak was eral daily nonstop flights from lenged by climate change, harm-
more representative of the entire neighboring Haiti. Few U.S. phy- ful deforestation, rapid interna-
Haitian population. The risk fac- sicians have experience treating tional air travel, the creation of
tors for infection this time around cholera, and the children in our megacities, civil strife and war,
include poor hygiene, lack of safe poorest neighborhoods might well and increasing interactions be-
drinking water, poverty, and mal- be vulnerable. tween people and many nonhu-
nutrition. Neighborhoods con- I don’t think we should wait man species. It is likely that
trolled by gangs have no doubt for cholera to reach U.S. shores these individual crises interact in
created formidable barriers to before we commit to strengthen- a way that exacerbates their indi-
early rehydration, and the closing ing public health structures and vidual effects. The most worri-
of some hospitals owing to a processes that would allow us to some outcome would be a poly-
lack of fuel has limited the op- withstand not just a cholera out- crisis — with multiple system
tions for treating severely dehy- break but also a variety of other failures in the realms of energy,
drated patients. unexpected pandemics. Key ini- international security, finance,
In a second letter, Rubin et al. tiatives might include working to and transportation — that over-
report data from their phenotyp- boost vaccine acceptance in gen- whelms the available resources
ic and genetic examination of iso- eral, developing and implement- that could enable us to cope.2
lates collected in 2010 and 2022; ing plans for minimizing poverty Public health and political lead-
the findings show strong simi- and food insecurity, and enhanc- ers, in partnerships with other
larity between these two sets of ing access to medical care. At the systems experts, need a renewed
isolates. Control isolates from a same time, we need to invest in social contract that entails un-
circulating strain in Bangladesh partnerships aimed at control- usual cooperation, driven by em-
were found to be distinct from ling the sources of pandemics in pathy and social values.
the Haitian isolates. The investi- distant countries in order to The resurgence of cholera in
gators’ findings raise several ques- minimize global spread. These Haiti is yet another reminder that
tions about the resurgence of the efforts could include the creation in our closely connected world,
same strain after a period with- of international teams of first re- we cannot ignore the infectious
out cases: Is the El Tor variant sponders that are sanctioned by misfortunes of other countries
more likely than earlier variants the WHO, the Centers for Dis- and the complex interactions
to survive in the brackish waters ease Control and Prevention, and among them. It is in our best in-
off Haiti, or more likely to be various governments and are terest to engage early, offering
carried for longer periods by supplied with adequate quanti- assistance and expertise, while re-
asymptomatic people? What ex- ties of IV fluids, antibiotics, and examining our own public health
actly triggered the resurgence? vaccines. strengths and shortcomings.
We have no data on population A key lesson from the ongo- Disclosure forms provided by the author
immunity according to age to ex- ing Covid-19 pandemic is that are available at NEJM.org.

plain the high proportion of pe- science alone cannot control a From the Department of Internal Medicine,
diatric cases. pandemic. Leadership is essen- Virginia Commonwealth University, Rich-
mond.
Both letters provide insights tial: decisions need to be made,
into a cholera resurgence occur- trust earned, clear messaging This article was published on November 30,
2022, at NEJM.org.
ring in a situation of severe so- preserved, the means of control
cial instability, and they are of succinctly articulated, and the 1. World Health Organization. Cholera.
substantial medical and scientific public educated and inspired to March 30, 2022 (https://www​.­who​.­int/​­news​
-­room/​­fact​-­sheets/​­detail/​­cholera).
interest. Moreover, cholera ampli- act. Timing is critical. Early ef- 2. Lawrence M, Janzwood S, Homer-Dixon
fied in any community is a threat forts to trivialize the scope of the T. What is a global polycrisis? And how is
to communities globally. Even the Covid pandemic in the United it different from a systemic risk? Cascade
Institute, September 16, 2022 (https://
United States — with its strong States delayed the urgent steps cascadeinstitute​.­org/​­technical​-­paper/​­what​-­is​
medical system, excellent hygiene, needed to contain it, and we all -­a​-­global​-­polycrisis/​­).
and knowledge about rehydration suffered the consequences. DOI: 10.1056/NEJMp2214763
— is at risk for cholera, which Pandemics are a natural part Copyright © 2022 Massachusetts Medical Society.
Cholera in Haiti, Again

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