Murderer or martyr?

This is a photo of Mahrosu Jantarawadee, 31, a Malay-Muslim insurgent who last month led a raid on a remote military base in Thailand’s war-torn southern provinces. The marines stationed there were waiting for him, and Mahrosu and 15 other militants died in a hail of bullets and shrapnel.

Peace talks begin in Malaysia today in a bid to end this brutal nine-year conflict that has now killed more than 5,300 people. In Bacho, the district where the abortive raid took place, Mahrosu is hailed as a shahid or martyr who died fighting a holy war to protect his religion and culture from a Thai Buddhist government.

The internet has projected his heroic status far beyond Bacho’s rice fields and rubber plantations. A Che Guevara-style print of his face has been posted and re-posted on Facebook. “Your good deeds were as fragrant as jasmine flowers,” runs a folk song written after his death and popularized on YouTube.

The Thai military’s response to the martyrdom of Mahrosu has been carefully calibrated. It wants the world to know it has eliminated a militant whose “good deeds” include bomb and gun attacks that killed at least 25 people, one of them a Bacho schoolteacher who was shot dead in front of his seven-year-old daughter. But it doesn’t want to feed the Mahrosu myth. “We have never regarded Mahrosu’s side as the enemy,” a Bacho marine commander, who refused to crow about foiling the Bacho raid, told me. “We are all Thais.”

Thai soldiers should understand the mechanics of martyrdom by now. The oldest shahid in Bacho’s graveyards were buried there in 2004, after soldiers and police dispersed a protest at a town called Tak Bai. Eighty-five Muslim men and boys died, mostly by suffocation after they were piled four or five high in army trucks. Tak Bai helped radicalize a whole new generation of insurgents, who soon gave the Thai military more of its own dead to honor.

Please read my story on the conflict for Reuters or watch Thailand’s Tropic Gulag, a documentary I co-produced with Orlando de Guzman.

Tun Aung, a practicing medical doctor and Islamic leader, was arrested in June 2012 after clashes between Buddhists and Muslims in Rakhine State killed at least 80 people. He was accused of inciting unrest in the town of Maungdaw, although Amnesty International said credible eyewitness reports suggested that Tun Aung “actively tried to defuse the violence.”

He was not allowed to choose his own lawyer, nor to meet privately with his state-appointed one, “giving him no chance of a fair trial,” says Amnesty. Even so, Tun Aung was sentenced to a total of 15 years in jail.

Seven of them were for offenses under the Emergency Provisions Act (1950), one of a number of laws “commonly used to arbitrarily detain activists or criminalize dissent” under Myanmar’s old junta, according to the Assistance Association for Political Prisoners (AAPP). These laws, which still remain on Myanmar’s books, help create “an environment conducive to politically motivated arrests,” says AAPP. At least 200 dissidents remain behind bars, says the group.

Amnesty has designated Tun Aung a prisoner of conscience and called for his immediate and unconditional release. He could be granted a presidential amnesty “before too long,” reported The Irrawaddy. Maybe. Or President Thein Sein could decide that keeping 200 or so people behind bars is no big deal. After all, Myanmar’s more developed Southeast Asian neighbors still routinely incarcerate citizens for their political views.

Indonesia has about 76 prisoners of conscience, most of them jailed for peaceful political expression in the restive provinces of Papua and Maluku, says Amnesty. At least 31 activists and dissidents were jailed in Vietnam in the first nine months of 2012 alone, estimated Human Rights Watch. And dozens—perhaps scores—are serving lengthy sentences in Thai prisons under draconian laws that forbid even mild criticism of the country’s monarchy.

The house looks unwelcoming, and perhaps it’s meant to. It is painted a penitential shade of beige and ringed by a high fence topped with razor wire. “To protect against enemies,” said a guard through a mouthful of betel juice, before shutting the heavy wooden gate that separates Naypyitaw’s famous new resident, Aung San Suu Kyi, from a curious world.

Suu Kyi rented the house after she and 42 other National League for Democracy (NLD) candidates won seats in April by-elections. I visited Naypyitaw twice to research my Special Report for Reuters on the Nobel Peace Prize laureate.

Men in green arrive at parliament

The parliamentary complex is, like the city itself, sprawling and half-deserted. Suu Kyi walked its well-polished hallways with a slow, loose-limbed stride not often seen in public, where her bodyguards must hustle her through media scrums, and where fans sometimes lunge or yank her aside. She seemed at home there.

”I don’t know about ‘at home,’ but my dog seems to like this place,” she told me, hurrying up the steps of the Lower House building. (Her dog, Tai Chi Toe, is a gift from her son Kim Aris.)

In Myanmar’s half-cocked democracy, the constitution reserves a quarter of parliamentary seats for military delegates. Most are mid-ranking army officers, all are men. They keep their distance from Suu Kyi, and not only because she wants to re-write the constitution and eject them from parliament. They’re also star-struck. “They want to make friends with her, but they are a little shy,” said NLD spokesman Ohn Kyaing.

The military delegates wear uniforms and occupy one side of the chamber in a solid block of green. Suu Kyi sits nearby, ramrod-straight, studiously taking notes. Most of the MPs applaud the speaker’s pronouncements, but not Suu Kyi. “Why should she clap?” said her personal assistant Dr Ma Nge, watching with me from the press gallery. “This is work.”

By Orlando de Guzman & Andrew Marshall

If you don’t like hospitals—and who apart from health professionals does?—then you’ll hate Dhaka Hospital during one of the Bangladesh capital’s regular cholera epidemics.

Last October, when we filmed Dhaka’s Cholera Wars for Al Jazeera, the emergency ward was seething with men, women and children, many of them severely dehydrated and fighting for life. Patients moaned as nurses connected them with intravenous needles to bags of saline. Hospital orderlies pushed away trolleys piled with buckets of diarrhoea and vomit.

And all the while more patients arrived, by wheelchair or stretcher, or half-carried by fretful relatives, until they spilled out into makeshift wards set up in the parking lot.

It looked like pandemonium, but it wasn’t. The Cholera Hospital, as locals call it, is efficient and deceptively high-tech. (Look closely, and you’ll see that medical staff track each patient with handheld computers.) And it is unrivaled at treating large numbers of patients with potentially fatal diarrhoeal diseases such as cholera. “If you arrive alive at our hospital,” its director Mark Pietroni told us, “then you leave alive.”

We quickly realized that what we were filming was not a hospital, but a factory of miracles. Its staff save thousands of lives.

Dhaka has two cholera outbreaks each year: roughly, one before and one after the monsoon. Left untreated, cholera can kill in hours and it spreads quickly, which is why it so terrifies people. “You can start being ill at ten the morning and be dead by two in the afternoon,” says Pietroni. But treat it promptly, and even the sickest patients make a full recovery. Patients who were stretchered into Dhaka Hospital were walking out—albeit gingerly—within 24 hours.

Dhaka Hospital is part of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), a world leader in its field. One morning, while filming around the centre’s sprawling compound, a grey-bearded figure shambled past. “That’s Richard Cash,” explained a staff member in a reverential undertone. “He should have a Nobel prize.”

Now 70 years old, Cash pioneered the use of oral rehydration solution (ORS), a simple mixture of salt, sugar and water, to treat cholera and other diarrhoeal diseases. ORS is thought to have saved more than 50 million lives.

Today, ORS is the primary weapon in Dhaka Hospital’s fight against cholera. Treatment is free, but that doesn’t mean only the poorest go there. So do affluent Bangladeshis, who know the hospital’s no-frills appearance belies a standard of care offered almost nowhere else. We often saw sick children cradled by mothers in fine sarees and gold jewellery.

While we were filming in Bangladesh, another cholera epidemic was raging in Haiti, which had been devastated by a powerful earthquake in January 2010. By late October, the Caribbean country had reported about 3,800 cases and 280 deaths, a mortality rate of more than 7%. During the same period, Dhaka Hospital probably treated at least half that number of cholera patients, and we didn’t hear of a single death.

We left Bangladesh with a new appreciation for the staff of Dhaka Hospital and the ICDDR,B—and for the people of the world’s most densely populated large country. The poverty of Bangladeshis, and the disasters they endure, are well-documented. We hope that Dhaka’s Cholera Wars also shows their courage and resilience in the face of an age-old disease.

Watch Dhaka’s Cholera Wars on Al Jazeera

MEET COLONEL FISH SAUCE
By Orlando de Guzman & Andrew Marshall

We nicknamed him, rather cruelly, “Colonel Fish Sauce,” after the pungent staple ingredient in Thai cooking. The Royal Thai Army had invited us to film its drug rehabilitation program at a vast military base outside Bangkok, and the colonel’s bizarre advice to young drug users seemed to embody all that was wrong about the place.

“Eat lots of fish sauce,” he urged the men, who sat on the ground next to the colonel’s well-shined boots. “It replaces calcium and makes you sweat. The drugs come out with your sweat.”

Get caught on a minor drugs charge in Thailand, and you will likely be detained at a military-style boot camp like this, run by the armed forces or police. The one we visited for Al Jazeera’s “101 East” program is fairly typical. There, guarded by officers from an artillery regiment, a hundred or so men underwent the army’s version of rehab: four months of dawn-to-dusk military exercises.

They are not alone. Every year, hundreds of thousands of drug offenders end up at boot camps across Asia. Some camps are brutal: detainees at facilities in China, Vietnam and Cambodia have been subjected to torture and forced labor, reports Human Rights Watch. All are ineffectual: relapse rates hover between 60% and 95%, reports the World Health Organization. So why do most Asian governments still favor them?

One charitable answer: out of sheer panic. Asia is awash with a highly addictive drug called methamphetamine. The pill form is often known by its Thai name yaba (“crazy medicine”), while the purer, crystalline form is called ice, shabu, or speed. According to the United Nations Office on Drugs and Crime, it is now the “first choice drug” in China, Japan, Taiwan, and much of Southeast Asia.

Every year, police in these countries seize millions of yaba pills and hundreds of kilos of ice. But this still represents only a tiny fraction of what Asia produces and consumes. With law-enforcement agencies proving incapable of shutting off the supply, then reducing demand is paramount. But the repressive rehab policies favored by most Asian governments have barely dented it.

Methamphetamine can be eaten, smoked, snorted, or injected. Euphoric highs—the drug boosts energy, self-esteem and sexual pleasure—are often followed by crashing lows. Withdrawal symptoms can include fatigue, anxiety, paranoia, insomnia, loss of appetite, and depression.

Addiction is hard to treat. There is no methadone-like substitution drug. (Fish sauce is no help.) Heavy users can take months or even years to recover. Dependence is best treated with psychosocial and other behavioral therapies, which require time, money, and expertise.

It is cheaper and easier to incarcerate men at army camps and march them up and down for four months, often much longer. If high relapse rates don’t bother Asian governments much, it’s because boot camps aren’t really designed to rehabilitate users. They are designed to punish users, and thereby demonstrate that a government is tough on drugs.

Asians are sick of the havoc that methamphetamine is wreaking on families and communities. They desperately want solutions, and politicians are always happy to promise quick fixes. The Association of Southeast Asian Nations, for example, absurdly insists that its 10 member countries will be “drug free” by 2015. Good luck. In 2009, more than 135,000 people were arrested on drug-related charges in Thailand alone.

Detention centers were partly designed to decriminalize users and keep them out of Asian prisons already overcrowded with drug offenders. Sure, most boot camp detainees don’t get criminal records. But they are stigmatized, cut off from their families and jobs, and eventually released back into drug-saturated societies with no real-life training to help them stay clean.

One surprising exception to this is Malaysia. Surprising, because this Muslim-majority nation isn’t exactly famous for its progressive policies. (Recently, one state sent dozens of schoolboys to a boot camp to address their “effeminate tendencies.”) The Global Commission on Drug Policy recently urged world leaders “to articulate publicly what many of them acknowledge privately”: that repressive strategies don’t work. Zuraidah Mohamed, who last year took charge of Malaysia’s National Anti-Drugs Agency (NADA), has done exactly that.

“We’ve been in this compulsory [drug rehab] business for 28 years,” she told us. “The result is not encouraging at all. Something had to be done.” That something is what NADA calls Cure & Care Clinics. Drug users report to these clinics voluntarily and are treated as patients with a chronic, relapsing disease. At a clinic outside Kuala Lumpur, we filmed a group therapy session in which Malaysian men and women sat in a circle with counselors and discussed what triggered them to relapse into drug use. The difference between this spirited session and the one run by Colonel Fish Sauce couldn’t have been more striking.

NADA now runs seven Cure & Care Clinics and plans to open another 10 by 2013. Skeptics note that Malaysia still has 20 compulsory rehab centers, where conditions can be appalling—inmates rioted and set fire to one in Johor state just last week. But NADA’s change of direction remains a laudable exception in a region where the trend is still toward increasing compulsory rehab. Methamphetamine is Asia’s favorite high, but repressive and counterproductive drug policies are proving just as hard a habit to kick.

Watch Asia’s Speed Trap on Al Jazeera’s 101 East program.

It was not the first time I was confused with Andrew MacGregor Marshall, a Reuters veteran of 17 years until his resignation in June 2011.

And it certainly won’t be the last. In January 2012, I joined Reuters as Special Correspondent, Thailand and Indochina. In a bid to distinguish myself from illustrious namesake, I write under the byline “Andrew R.C. Marshall.” (My Reuters blog is here.)

There are many differences between me and Andrew MacGregor Marshall. Here is one: he is writing a critical biography of Thailand’s King Bhumibol Adulyadej, based on U.S. diplomatic cables acquired via WikiLeaks; I am not.

Here is another: I live in Bangkok, where I can be jailed for up to 15 years for offending the Thai royal family; he lives in Singapore, where he cannot.

In May 2011, a U.S. citizen was arrested in Thailand for allegedly posting a link on his blog to a banned biography of King Bhumibol. So forgive me if I don’t post a link to my namesake’s new website. I urge you to google “Andrew MacGregor Marshall” instead.

But my favorite response was an article on a travel website called www.atvisit.com. “Why the Beautiful Kuta Beach Bali to be Dirty With Garbage?” reads the headline. “Kuta beach is one beach which is known by its exotic,” it continues. “But why commencement the period of Dec 2010 to April 2011 there is extravagant increase of trumpery?” It ends with the solemn advice, “Act with for not littering.”

Kuta is not the only beach reviewed by the site. It also considers those of the Bahamas. Xanadu beach is “not uncomfortably huddled,” Mather Town is “an excellent abode for those who savor converging locals,” and Taino offers “all the tralatitious pastimes.” And don’t miss Golden Rock, which boasts “stunning hot sands on the boundary of a spectacularly dismal actress.”

The site belongs to an Indonesian called Herry Hendro. In another era, Hendro’s linguistic exuberance would mark him out as Surabaya’s answer to James Joyce. In fact, he writes in Indonesian and his computer puts it into English. His site demonstrates the limitations—or, if you like, the thrilling possibilities—of Google Translate.

For Hendro doesn’t restrict himself to tropical beaches. Here is his appraisal of the Kendall Hotel near Massachusetts Institute of Technology: “A breakfast strike, wireless internet, and a conceding to FITCORP suitableness edifice use are included with your stick. Additionally, meeting rooms are accessible for your byplay or ethnical events.” The hotel is “utterly situated as a propulsion disc for exploring the area or conducting line in either Beantown or University.”

Hendro also pays tribute to Saltspring Island, in British Columbia, which is famous for its “showy anaesthetic characters” and “the factual, old-fashioned sumptuosity” of its lodgings. But be warned: your voyage from the mainland could be hampered by an “unforesightful shipping fuckup.”

EAT, PRAY, DUCK: BALI’S ONGOING WOES
Trash, traffic and trigger-happy cops. Isn’t Bali supposed to be paradise?

By Andrew Marshall

The annual monsoon transforms Bali. Rain sweeps across slumbering volcanoes. Moss thickens on ancient temple walls. Rivers swell and flush their trash and frothing human waste into the sea off Kuta Beach, the island’s most famous tourist attraction, where bacteria bloom and the water turns muddy with dead plankton. “It happens every year,” shrugs Wayan Sumerta, a Kuta lifeguard, who sits with his love-struck Japanese girlfriend amid dunes of surf-tossed garbage. So why, in early March, did the Bali authorities warn tourists that swimming there for over 30 minutes could cause skin infections? The lifeguard tenderly strokes his girlfriend’s naked leg. “I guess some people just have sensitive skin,” he says.

Itchy ocean? Just add it to Bali’s growing list of seemingly intractable problems: water shortages, rolling blackouts, uncollected trash, overflowing sewage-treatment plants and traffic so bad that parts of the island resemble Indonesia’s gridlocked capital Jakarta. And don’t forget crime. In January, amid a spate of violent robberies against foreigners, Bali police chief Hadiatmoko reportedly ordered his officers to shoot criminals on sight. You’ve heard of the Julia Roberts movie Eat Pray Love, which was partly filmed in Bali? Now get ready for its grim sequel: Eat Pray Duck.

Most of Bali’s woes stem from a problem that rival resorts would love to have: too many tourists. In 2001, the island welcomed about 1.3 million foreign visitors. Ten years later — and despite bombings by Islamic extremists in 2002 and 2005 that killed 222 people, mostly Australian tourists — the island expects almost twice that number. And there are millions of Indonesian visitors too.

Hotels, shopping centers and restaurants are springing up everywhere to accommodate them. The cranes looming over Kuta are building at least three malls and a five-star hotel. But the less glamorous stuff — roads, power lines, sewers, parking spaces — often remains an afterthought. “The infrastructure is not keeping up with the development,” says Ron Nomura, marketing director at the Bali Hotels Association. The island’s lack of reservoirs, he says, is a case in point. “Can you believe there is this much rain and we don’t have enough water?”

When it comes to Bali, newspaper editors have a seemingly bottomless stock of “Paradise Lost?” headlines. Its rich Hindu culture is so distinctive that many people mistake the island for a separate country rather than a province of the world’s most populous Muslim nation. That Bali’s tourism industry has survived terrorism attacks and a global recession is a cause for pride. But amid unchecked growth and a creaking infrastructure, it is also a source of complacency. “It’s like Bali is slowly committing suicide,” says local journalist Wayan Juniarta.

Bali’s Governor I Made Mangku Pastika knows it. In January, he issued a moratorium on new construction in certain built-up areas, and later warned that his lush birthplace might turn into a “dry land full of concrete buildings.” Pastika is popular — he investigated the bombings as Bali’s then police chief — but his moratorium isn’t. “Some people says he’s trying to slow down Bali’s growth,” says Nomura. “That’s not necessarily true. What he’s looking for is more responsible growth.”

He probably won’t find it. Nobody I talked to reckoned that Pastika’s measures would influence who built what where. Bali’s spiritualism might be a bewildering blend of Hinduism, Buddhism and animism, but the island’s planning code is simple: if you build it, they will come.

And on the way, they’ll get stuck in traffic. Complaining about the congestion around the airport or in tourist areas like Kuta is now one of Bali’s newest pastimes. Even in Ubud, the seat of the island’s art and culture, once sleepy streets are clogged with buses carrying Chinese tourists, who visit the island in ever greater numbers. Vehicle ownership on Bali is rising at an annual rate (12.42%) that far outstrips the growth in new roads (2.28%), according to government statistics. “Traffic will get worse and worse,” I Made Santha, Bali’s traffic chief, predicted in February.

Equally damaging to Bali’s prestige is the perception among some expatriates that the island is increasingly unsafe. Lusiana Burgess, the 46-year-old Indonesian wife of a retired British pilot, was robbed and killed in her North Kuta home earlier this year and her murderer remains at large. An Australian woman awoke in her villa to be gagged and assaulted by four thieves. Then an American man was stabbed during another robbery attempt in Kuta. A week after that, police arrested and — following an apparent escape attempt — shot dead 34-year-old M. Syahri, from the neighboring island of Lombok, who was suspected of robbing a number of foreigners.

The statistics actually show a slight decrease in serious crime from 2009 to ’10. But Chris Wilkin, a former oil-company executive from the U.K. who retired in Bali six years ago, remains uneasy. “It was very quiet when I moved here,” he says. “It wasn’t a big attraction for the criminal classes. Now, with the boom, word has got round that there are easy pickings to be had.”

Wilkin, whose Indonesian wife rents villas to expats and knew Burgess, believes the threat of violent robbery will discourage foreigners from leasing properties in remote places. Investing in CCTV, intrusion alarms and bedside panic buttons may only “give a false sense of security,” he says. Recently, Wilkin accidentally set off his burglar alarm. Nobody went to investigate, not even the private security guards in his own complex.

Expat anxiety hasn’t dented Bali’s popularity among its core visitors, the Australians. And why should it? Officially, the Australian government still advises its citizens to “reconsider your need to travel” to Bali due to a “very high threat of terrorist attack,” yet more than a hundred flights arrive from Australia every week. The dangers to new arrivals are those commonly faced by tourists everywhere: dodgy food, motorbike accidents, and — as a sign at my Kuta hotel suggests (“No Jumping from Any Balcony into Pool Is Permitted”) — beer-fueled misadventure.

A new terminal at Bali’s shabby airport is due for completion in 2013. But unless other infrastructure is improved, this will serve only to channel yet more tourists onto a critically overburdened island. For now, however, such doubts are largely forgotten in the rush to cash in on the Bali boom. “Goodness shouts, evil whispers,” runs an overused Balinese proverb. But money talks.

For the Balinese reaction to this story, please see Read With For Not Laughing

Tay Za on ice

Harder than you’d think. Two Burmese military helicopters reportedly tried and failed to extract tycoon Tay Za (right), a close business crony of Gen. Than Shwe and the owner of Air Bagan, and five others from Ice Mountain in Kachin State, where his helicopter was forced to land in bad weather on Monday. The first helicopter, dispatched by the Burmese army and thought to be Russia-made Mi-6, threatened to trigger an avalanche with its giant five-bladed main rotor and had to be withdrawn.

With apparently no aircraft of his own to save him, Tay Za’s company Htoo Trading urgently hired helicopters from India, Cambodia and Thailand. Thailand, in the form of an intrepid Thai company called Advance Aviation, got there first.

Advance Aviation (“Where Sky And Safety Meet”) dispatched not a Soviet-era behemoth, but a nippy EC-130 helicopter, usually hired out for about $2,000 a hour. “We had no idea whether we’d succeed,” says Noppaporn Nasylvanta, who runs sales and marketing for the company, “but we wanted to try.” The EC-130 arrived in northern Burma on Wednesday evening. Tay Za and his party spent another night on Ice Mountain before the EC-130 lifted them to safety in three sorties around noon today.

The first sortie took away the injured. Tay Za, who was on the second flight, is reportedly in “good health“—news that will no doubt disappoint many of those who envy his immense fortune.

Cholera kills 120,000 people every year, estimates the World Health Organization. Could mass vaccination—now being tested in Bangladesh’s cholera-prone capital—prove a new weapon against an old disease?

By Andrew Marshall

DHAKA — Anita Ashfaqunnesa skips over a ditch oozing with raw sewage, her spotless white shawl trailing behind her like a superhero’s cape, then squeezes between shacks built on an old rubbish dump. Three years ago, she explains, this slum in northern Dhaka didn’t exist. But with hundreds of thousands of rural job-seekers pouring into Bangladesh’s capital every year, it now teems with families, and the water they use for drinking, cooking and bathing comes from pipes that run alongside, and often through, the sewage ditches. That’s why the area’s oldest living resident is not a person, but a disease. “Cholera is a common ordeal here,” says Anita, 33. “People don’t fear it, but they are happy to hear there’s a vaccine coming to prevent it.”

Anita is one of a small army of field workers collecting household data for the biggest oral cholera vaccination program in history. It starts on Feb. 17 and will involve 240,000 residents in Mirpur, the district that reports most of Dhaka’s cholera cases. Two-thirds of them will receive two oral doses of a cheap new Indian-made vaccine. “We think of it as a demonstration project rather than a trial,” says Dr. Stephen Luby, Bangladesh country director for the U.S. Centers for Disease Control (CDC). “We don’t have a big question in our minds over whether this vaccine is going to prevent cholera. What we’re trying to do is illustrate the feasibility of using it as a public health intervention.”

Mass vaccination could be a new weapon against an old disease. In Zimbabwe, where cholera claimed 5,000 lives in 2008 and 2009, a swift vaccination program could have cut the death toll by 40%, calculated the authors of a study published in Jan by PLoS Neglected Tropical Diseases. Such results are avidly followed in Haiti, where cholera has killed about 3,800 people and sickened 189,000 since October. A committee that includes experts from the CDC and the World Health Organization (WHO) recently recommended a small-scale cholera vaccination project. This rankled Haitian health officials, who want millions to be protected against a disease that foreign peacekeepers almost certainly brought with them after last year’s earthquake.

Anita Ashfaqunnesa in Mirpur

Nobody in Bangladesh disputes the origins of the disease. The Ganges delta, which India and Bangladesh straddle, is cholera’s homeland. Six of the seven pandemics since the 19th century have originated here. Every year, WHO estimates, there are 3-5 million cholera cases and up to 120,000 deaths worldwide. Dhaka’s dilapidated water and sanitation systems provide ideal conditions. Bounded by rivers that are too filthy to purify, the city pumps up nearly all its water from hundreds of deep wells. It is never enough, especially when those pumps need electricity to run, and Bangladesh is plagued by power shortages too. With no positive pressure in the water pipes, sewage and other contaminants easily leak in.

The only thing Dhaka doesn’t lack is people. With 13 million residents and counting, it is a fast-growing megacity in the world’s most densely populated large country. New arrivals squeeze into already overflowing slums, or squat on wasteland with zero infrastructure. “Wherever there is human misery you will find cholera,” says Dr. Mark Pietroni, Medical Director of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) in Dhaka, which is implementing the vaccine project with the Bangladesh government. “It thrives on malnutrition, overcrowding and poor hygiene.”

Cholera outbreaks in Dhaka are as predictable as the seasons. There are two each year: roughly one before and one after the monsoon. Dhaka Hospital at the ICDDR,B treats thousands of cholera patients, who during outbreaks not only crowd its wards and hallways, but spill out into tents in the parking lot, forming what might be the world’s only hospital ward with speed bumps. Left untreated, cholera can kill in hours. But treat it promptly and properly, mainly with oral rehydration salts, and death rates are under 1%. At Dhaka Hospital, even the sickest patients make near-miraculous recoveries; arrive with just one breath, say locals, and you’ll leave alive.

But as Dhaka’s population grows, so does the hospital’s patient load. Every March and April, a thousand new patients a day is standard. “Cholera is a dreaded illness because of its rapid onset, severity and potential to cause outbreaks that easily overwhelm public health systems,” says Dr. Regina Rabinovich, director of Infectious Diseases at the Bill & Melinda Gates Foundation. “That’s why it’s important to invest in the development of new, more effective vaccines.”

Enter Shanchol, a two-dose vaccine produced by Shantha Biotechnics of Hyderabad and developed with funding from (among others) the Gates Foundation, which also gave $16.5 million to the ICDDR,B for the cholera vaccine project. Shanchol is safe and efficacious: a trial in the Indian city of Kolkata involving nearly 70,000 people showed that the drug gave 67% protection for at least 2 years. Just as importantly for mass vaccinations, it is cheap: its two doses cost about $3, or about a tenth the price of its only rival, the Dutch-made drug Dukoral. Shanchol is expected to get WHO approval this year.

Bangladesh’s state-run immunization programs are widely trusted, so persuading a cholera-weary populace to take the vaccine shouldn’t be hard. Some 80,000 adults and children will receive it; another 80,000 will receive the vaccine, plus active encouragement to treat household water and wash their hands with soap. But assuaging those who don’t get it might be trickier. This includes 80,000 people who will unknowingly receive a placebo, forming a control group that helps validate the project’s results. “That’s what we perceive is going to be our biggest problem: not everybody gets it,” says Luby, who was seconded from the CDC to head the ICDDRB’s Program on Infectious Diseases and Vaccine Sciences.

One of the project’s broader aims is to get a better idea of cholera’s mortality rate. “Right now most of the estimates that people throw around are quite speculative,” says Luby. Mortality at the ICDDR,B’s hospital may be less than 1%, but some patients are dead on arrival — negotiating this vast city’s gridlocked streets can use up precious hours — and others expire at home.

Mass vaccination has its critics. Today’s drugs do not offer long-term coverage or protect against every cholera strain. And even a cheap vaccine, in high quantities, is expensive and could divert resources from the only thing proven to eradicate cholera: improved water and sanitation infrastructure. (London suffered centuries of cholera epidemics until the Victorians built sewers.) Improving Dhaka’s infrastructure is vital, agrees Luby, but the task could take decades. The same is true for hundreds of cities in our rapidly urbanizing world, and indeed for disaster zones such as Haiti. While that infrastructure is being built or rebuilt, how do you protect a vulnerable population from cholera? Mass vaccination is one answer. “What we’re trying to do is generate some evidence on what’s feasible and cost-effective,” he says.

Participants in the Mirpur project will be monitored for years. But the vaccine’s impact could be felt as early as March or April, when the more severe of Dhaka’s biannual epidemics strikes. “That’s why we’re aiming to have this community immunized by the time that worst peak comes,” says Luby. Haiti — and the rest of the world — will be watching.

Correction: The people in the control group will not receive a placebo, knowingly or unknowingly. My apologies for the error.

Blog post: You’ve Got Cholera