When Dr. Firdausi Qadri thinks about the number of cases of cholera in the world today—that ancient disease that still kills tens of thousands each year—she's frustrated. "It's a disgrace that we see so much cholera today, including in countries that haven't had the disease for many years," she says. Qadri has studied and fought the scourge for much of her decades-long career with the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b for short).
Within the last six months, 30 countries have reported cholera outbreaks, ranging from Haiti to Lebanon to Mozambique. A few factors appear to be fueling this latest global outbreak: lack of clean water, infrastructure degradation, political instability, climate change and lack of resources due to other medical emergencies like mpox and COVID-19 that have consumed attention and funds.
Cholera is a bacterial disease that causes diarrhea. If untreated with rehydration solutions and/or antibiotics, it can kill people within hours. There's also a vaccine, and because of soaring global demand for it, the World Health Organization (WHO) made the unprecedented decision last fall to recommend a single dose instead of the regular two-dose regimen to help stretch the limited supply.
The icddr,b has a long history of studying how to battle and prevent cholera. NPR sat down with Qadri, age 71, a key leader of that work to discuss the history of humanity's battle against the bacterium, what lessons the global health community has drawn from that fight, and where she finds hope. The following interview has been edited for clarity.
What does it tell us that so many countries have witnessed a cholera outbreak within the last year?
Cholera is such an ancient disease, and it is a synonym of poverty. It is a disease that's so closely tied to the water you drink, public sanitation, lack of hygiene measures, and a lack of knowledge of hygiene.
Bangladesh has never been able to recover from cholera, ever. We had the worst epidemic ever in 2022, based on the number of patients being treated at the icddr,b hospital for the disease. In 60 years, we have not seen so much cholera. For people like us who are working in this field, we want to be successful, but we keep failing. Our water is contaminated.
The remedy we use in the short term is a vaccine. For an overall remedy, you need a country with good water, sanitation, education, and a good surveillance system to know where the disease is.
Tell me about the role this center has played in developing the cholera vaccine now used throughout the world.
Previously, there were injectable vaccines that did not work very well. (Because the bacteria bind to cells in the gut, an oral vaccine is best.)
The oral cholera vaccine was developed with a lot of collaborative effort from all over the world, starting in the late 70's with field trials in the 80's. Ultimately, the WHO recognized the vaccine's safety and quality in 2001. But it was mostly tested and improved upon here in Bangladesh. That's because if you want to look at the efficacy of the vaccine and the immune response it generates, you need to have a population that you can study where the disease is circulating.
In addition, our work showed that in Dhaka's urban slums, if you give this vaccine to people, they could receive protection from cholera for four years. We've also demonstrated that if you give zinc to children, you can improve their immune response to the cholera vaccine.
The vaccine is 60-70% directly protective for ages five and above.
But we've found that when it comes to young children, the vaccine is less efficacious. It's a developing country problem because the kids here are often malnourished and stunted. Their microbiome is full of problematic bugs. They have one infection after another so the response of their gut is not good. For that reason, children here do not respond well to any oral vaccines — cholera, rotavirus, polio, etc. It comes down to where you live. If you give a vaccine to a child in Sweden and one to a child in Bangladesh, there will be a major difference in response rates.
Why are there not enough cholera vaccines?
We have a cholera vaccine stockpile, but the supply is always scarce. That's because vaccine production is tricky — it's expensive and vaccines have to be very carefully made for human consumption. Also, cholera has increased, and so the demand has increased for people asking for vaccines. In Bangladesh, we will need 179 million doses in our country in the next five years. Who's going to give this to us?
As for the WHO's decision to reduce the recommended dosing, I would say people should go for two doses. But a single dose is better than not receiving any vaccine. However, it won't work well for those under 5. You should give them two doses of vaccine.
You've done a lot of work with the Rohingya — a group displaced from Myanmar into Bangladesh. What were you able to achieve with that population?
So that has been a remarkable success story.
Being in the field of cholera, we know that whenever there are lots of people crowded together, combined with a lack of safe water and sanitation, that's a time that you can have outbreaks of disease.
In August 2017, we had this displacement of people from Myanmar to Cox's Bazar, Bangladesh, one of the highest areas for cholera. About 700,000 people came here at that time. So that September, five or six of us from icddr,b and the IEDCR took a flight to Cox's Bazar. It was bad. All the sanitation that we see now was not there then. We knew for certain there would be an epidemic.
So we came back and informed the Director General of Health Services. And then the government made its request to vaccinate the Rohingya people. In one day, we got a response from the WHO and they said, "We will send the vaccine." In another few days, the vaccine was in Dhaka on a chartered flight. Once it reached Bangladesh, most of the vaccine went to Cox's Bazar in refrigerated vans. So from then till now, there have been seven vaccination campaigns there with a total of six to seven million vaccine doses distributed, and no epidemics of cholera.
You've also done a fair bit of work on another bacterial disease called typhoid fever. Rates in Bangladesh are among the highest in the world.
Yes, it produces different symptoms from cholera — mostly many days of high grade fever. So a person with typhoid might think, "Do I have dengue? Do I have malaria?" You can get tested but so far, the tests are not so good. When the doctor tells people to get their blood tested, many will test negative even if they have typhoid. So we've developed a new immunological test, which we are trying to validate and use in the field.
So a [better] vaccine is needed. We're doing a lot of work on developing an injectable typhoid conjugate vaccine, which has involved big trials in Bangladesh. And we've shown that it's a very protective vaccine, even with a single dose. But now we have to implement it in Bangladesh.
Where do you find hope?
I have a lot of hope for Bangladesh. So much has happened in Bangladesh that didn't happen before. We used to not talk about cholera before. Now we talk about it. We are responding to cholera.
Take COVID. From nothing, within six months to a year, we became a country that was doing so much testing — 500 or more labs. In Bangladesh, we have more than 90% COVID vaccination coverage. Which countries have a success like that? We have vaccinated children down to five years of age.
There's still a lot of work to do. We want a typhoid vaccine. We want women to receive the HPV vaccine. We want everything. But it'll happen, I'm very, very positive.
How are your philosophy and outlook shaped by the teachings of Islam?
We're here to serve a purpose for a very short time in our life.
I pray five times a day and I believe in Allah and I believe in my religion. I don't see any conflict between Islam and research, vaccines or women working. My faith in God is very strong. And I believe whatever happens, happens for a purpose. If my results in the lab are bad, I will be honest. I will not publish false data. I teach that to my colleagues, to my young colleagues, to my mid-level colleagues. Poor results open a new door, and the next thing will be better.
Islam teaches me many things. It makes me very regular in my life. It breaks my day into five parts. Very early in the morning, I can do many things — my yoga, then my recitation from the Koran, then I go early to work. At night, I have to finish my night prayers, go to sleep and get up early in the morning. So that is a regularity in your life that really helps you in science and everything else.
Who was your inspiration?
My grandmother. I can never forget her. We share a name — Firdausi - and we almost share a birthday. We were both Aries. I was 31st of March, she was 1st of April.
We were three sisters. And she would be ready for us with good clothes — she could stitch very well. She would make cotton dresses for us. She would cook a lot for us. She would give us lunch to take to school. When we came home, there was good food on the table. There was always the incentive to make us feel we were important.
My grandmother was a very forward-thinking person. And she was a very powerful woman. She led the house. My grandfather (who was a teacher and headmaster) listened to everything she said. And she wanted girls to be educated. She educated my mother. In those days, it was very difficult for women to be educated. But my mother got educated. She went to good schools.
When my sisters and I were born, she wanted us to be educated also. No stones would be unturned for us to be properly educated to have a career. So I chose biochemistry, my elder sister chose medical science, and my middle sister studied English literature. So we all did something.
She made me feel that women can be powerful if they have a will to do something.
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