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Imagine that you are a health care provider working in a refugee camp in Goma during July 1994.

Almost a million Rwandan refugees arrive in Goma in the 4 days between July 14th and the 17th.  On July 19th, the first case of cholera presents at your tent hospital.  In a short time, up to 6,000 cases present in your region in a single day.  You are well-trained in infectious diseases and electrolyte management after years of practice in your home country’s elite hospital, but you are overwhelmed and never have been forced to treat such numbers of patients facing impending death.  Despite your best intentions, at least 12,000 people succumb to cholera; many patients fail to make it to the hospitals and their remains litter the sides of roads.

Some refugees even fake cholera symptoms so that they can get access to clean water.  Case fatality rates (CFR) range from 1.5% to a disastrous 11.5% percent.  By most measures, the refugee crisis and the outcome of the outbreak is a complete disaster.  The CFR in a well-handled outbreak should be less than 1%. This is a true story, and several scientific papers were published in an attempt to ascribe blame to government officials, NGOs, and physicians.

What has been learned is that sometimes disasters are just too big to handle, and the COTS program was created to bring together 30+ years of expertise to provide a ‘to the point’ guideline as an effective means of preventing failures like those in Goma.  Although Oral Rehydration Solution (ORS) has become well established for treating acute watery diarrhea, cholera and shigellosis are diseases that will continue to plague our planet as long as there is poverty and political instability.

2013 hosted ongoing cholera outbreaks in Bangladesh and Haiti, as well as emerging outbreaks across the African Subcontinent.  Our goal is for the COTS program to transfer the basic tools required to conquer situations in the future like those in Goma, Haiti, and now, Sierra Leone.

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