Where Have You Hidden the Cholera?
In Mozambique and around the world — and throughout history — cholera outbreaks have caused riots. Why? And what does it have to do with bicycles?
Where Have You Hidden the Cholera? / Longreads, April 5, 2018
Stones and brickbats were thrown at the premises, several windows were broken, even in the room where the woman, now in a dying state, was lying, and the medical gentleman who was attending her was obliged to seek safety in flight. Several individuals were pursued and attacked by the mob and some hurt. The park constables were apparently panic struck, and incapable of acting.
— Liverpool Chronicle, June 2, 1832
Rioting and social unrest in response to cholera was not entirely confined to Britain. Civil disturbances arose in Russia in 1830, and were followed elsewhere in mainland Europe in 1831. In Hungary, castles were attacked and nobles murdered by mobs who believed the upper classes were responsible for cholera deaths.
— Gill, Burrell, and Brown, “Fear and Frustration”
It was a story of bicycles.
— Domingos Napueto
In October 2010, a government laboratory in Port-au-Prince confirmed Haiti’s first cholera case in nearly a century. The Ministry of Health quickly flooded the airwaves with spots urging residents to wash their hands and treat their water. International observers who were surprised that cholera would resurface after such a long absence reacted skeptically at first, but the disease’s path of devastation quickly proved them wrong. The outbreak tore through the central plateau and up and down the coast of the Gulf of Gonâve, the bay that forms the hollow middle of Haiti’s horseshoe-shaped map. Four thousand five hundred people died, and nearly three hundred thousand fell ill.
Cholera was a second, shattering blow to a country already crippled by an earthquake that had struck earlier that year, destroying much of the capital and leaving more than a hundred thousand people dead. Where had the disease come from? Had the jostling of tectonic plates during the earthquake unleashed cholera-carrying waters in the Gulf of Mexico? Had benign strains of the cholera bacterium already present in Haiti somehow morphed and become virulent? Suspicions quickly fell on a contingent of Nepalese soldiers with the United Nations Stabilization Mission in Haiti, MINUSTAH, whose camp was in Mirebalais, near the outbreak’s start, and where sewage was said to have leaked into a tributary of the Artibonite River. Cholera outbreaks occur in South Asia every single year, and it was presumed that UN soldiers had unwittingly carried the pathogen with them to Haiti.
The UN waved off the accusations, but protesters reacted violently. “The reason we are protesting is because the UN is doing illegal things in the city,” a man named Marcel Jean told a TV crew in Cap Haïtien, where the airport was shut down and barricades of burning tires were erected in the street. “They bring the U.N. to give us security, but this is not security. This is devastation.” A police station and cholera treatment center were burned to the ground.
People threw stones at UN trucks and looted warehouses belonging to the World Food Programme.
Presidential elections, first delayed by the shattering earthquake that had laid waste to the Haitian capital earlier in the year, again seemed in doubt.
“The way in which the events unfolded leads to the belief that the incidents had a political motivation, aimed at creating a climate of insecurity on the eve of the elections,” MINUSTAH said cryptically in a press release. “MINUSTAH calls on the population to remain vigilant and not let itself be manipulated by the enemies of stability and democracy in the country.”
Presidential candidates insisted otherwise: “The Nepalese [peacekeepers] are their target,” the politician Lesley Voltaire said of the protests. “People believe the cholera came from Nepal.”
It would take five more years for the UN to admit fault. What people had been saying all along turned out to be true — albeit unintentionally, UN peacekeepers had brought cholera to Haiti.
There were other victims of the violence that accompanied cholera, too: by one account, more than forty voodoo priests were killed by mobs who believed them to be responsible for spreading the disease.
But inevitably, our view of the protests anxious people led against the UN’s cholera outbreak — and the destruction they visited on human targets — is colored by the fact that they turned out to be right. The purpose of this essay is to ask what difference it would make for them to be wrong.
* * *
From the campaign for polio eradication in Pakistan to efforts to contain the Ebola epidemic in Sierra Leone, violent responses to public health interventions have become a tragically familiar part of health crises around the world. Nowhere has the phenomenon been more consistent than in cholera outbreaks in northern Mozambique.
Every year since 1998, cholera season in Mozambique has brought a rash of violence that spreads like the disease itself. Convinced they are being poisoned by the people treating their water, farmers and fishermen across northern provinces attack the health workers trying to prevent cholera’s spread and the machinery of their efforts. Government nurses have been beaten and bound with rope. Health centers have been burned to the ground as angry crowds blocked roads demanding to know, “Where have you hidden the cholera?” They are still waiting for an answer.
Explanations for the violence often center on a simple misunderstanding: that the Portuguese words for chlorine, or cloro, and cholera, cólera, are close enough to cause confusion.
“I know where the problem is,” one NGO employee told me confidently in Nampula. Ailton Muchave had spent years working on WASH (water, sanitation, and hygiene) programs for the Christian charity World Vision alongside the provincial government’s health and sanitation agencies. “In Portuguese, you have the word cloro, for the substance that treats water. But people who only speak dialect,” as local languages are often called, “when they hear cloro, they don’t make the distinction.”
Imagine a health team from outside the community shows up during an outbreak to spread messages on cholera prevention, Muchave explained, and “an agent will say, ‘to get rid of cholera, we need chlorine.’” He pantomimed the reaction with a frown. “The people are perplexed. They think, ‘But chlorine causes cholera!’”
“When you say cloro, they think cólera, and that’s where the problem begins,” José Eduardo Miguel, a technician with the Red Cross in Nampula, told me. To reduce the confusion, he explained, the Red Cross office in Nampula had adjusted its strategy during outbreaks. They no longer distribute generic chlorine — the cheapest option for water treatment — but branded Certeza chlorine solution. In some places, they had switched off chlorine altogether, distributing bleach instead.
Do you really think that the chlorine/cholera explanation is sufficient? I asked Miguel. “Acho que não,” Miguel replied. I don’t think so. “There is probably some other cause, something hidden.”
“It could be ignorance,” Ailton Muchave mused in response to the same question, “but it could also be political.”
That politics plays a role seems incontrovertible: cholera violence has been concentrated in areas with strong Renamo support. The worst episodes have occurred on either side of elections, times of high tension when the state apparatus controlled by Frelimo seems most transparently to function as a political party rather than a government. The targets of violence are not random scapegoats, but the specific people and places — of and associated with the government — tasked with responding to public health crises.
Even today, after close to twenty years of episodic cholera-related violence, it’s not hard to find people who do think chlorine is to blame for the disease, or who speak of cholera as an invention of the political class. But hanging the explanation on cloro and cólera or on misinformation spread by Renamo obscures a more important question. How is it that so many Mozambicans have come to believe NGOs and government workers are out to kill them?
* * *
Some of the worst violence in recent memory took place along Nampula’s coast in 2009. The year before, parts of the region had been flattened by Cyclone Jokwe, which uprooted cashew trees and washed fishing boats out to sea on its way to leaving tens of thousands of people homeless in one of the poorest areas of Mozambique.
Domingos Napueto, a compact, muscular man with a baby face and a high voice, led efforts by the Red Cross to survey the damage in the district of Mogincual. When a German delegation visited a month later, a project was approved to distribute cashew seedlings and mosquito nets and to train locals in building houses that stood a better chance of surviving a storm. Volunteers chosen for the effort were given bicycles to help them cover the long distances between communities where they were helping with construction.
Napueto had been a Red Cross volunteer since the end of the civil war. He had a day job doing supplies and inventory at the district health center in Liupo, and many of his fellow volunteers were also drawn from the ranks of the civil service — health workers, teachers, and so on.
Volunteers pitched in 10 meticais a month to support the organization, but they also acted as a conduit for aid from the International Federation of the Red Cross. As people returned to areas they had fled because of the fighting, Napueto and a handful of colleagues organized distributions of oil, cornmeal, and bales of used clothing and gave away hoes and machetes to farmers trying to start over.
In 1992 and 1993, hundreds of people in coastal Nampula suffered an outbreak of konzo, or tropical ataxic neuropathy, a form of paralysis caused by cyanide poisoning; Napueto said Red Cross volunteers responded with education and outreach about the disease, as they would do later for sanitation and hygiene. Cassava, the staple crop in Nampula, is drought-tolerant and does well in poor soil, but it can also contain toxic levels of cyanide that have to be leached out by rinsing, drying, or fermenting the crop. Konzo occurs in periods of drought or war, when people are forced to subsist on a diet of bitter cassava alone, or eat it raw.
The rainy season of 2008–9 was shaping up to be another difficult time. Exacerbated by drought, the damage from Cyclone Jokwe had produced a terrible harvest for many farmers in the area, and local officials were bracing for a return of the disease in the midst of widespread hunger.
Meanwhile, cholera outbreaks sparked unrest in other parts of northern Mozambique. In Pemba, Cabo Delgado, an angry crowd had burned down three cholera treatment tents set up on the beach in the midst of an outbreak there, forcing two local officials to take refuge in the police station. In another Cabo Delgado town, eight people were beaten up for distributing chlorine and spreading cholera prevention messages, accused of spreading the disease.
In Mogincual, Napueto recalled, people had heard vague rumors about the violence, or listened to cholera prevention messages on the radio, but the Red Cross had never encountered any overt hostility. As Napueto’s colleagues told me, before the bicycles, “we’d never had any problems with jealousy — but from that time until now, they’ve never gotten it out of their heads.”
The first signs of trouble came on a Friday in January when Napueto accompanied a group from the provincial office of the Red Cross to a coastal community outside Quinga to watch the construction of a demonstration home. They were clearing a lot for the house when morning prayers let out at the mosque, Napueto said, and a group of irate young men approached them. “They said, ‘We don’t want your house here,’” Napueto recalled. “‘You didn’t come to help us. You came to bring us diseases.’”
As the confrontation threatened to degenerate, the delegation left and told the volunteers to postpone work for the time being. The house did not need to be built at all, or it could be built another day.
* * *
Juma Raimundo, a Red Cross volunteer who was living in Curuhama, remembers the day in February when the first cholera cases showed up in Mogincual.
The Red Cross had learned of an outbreak spreading in a neighboring district the day before. Volunteers were in the midst of planning a chlorine distribution when people from affected areas began trickling in on foot, terrified at seeing their neighbors racked by fatal, uncontrollable diarrhea. Several people died on arrival.
Raimundo’s village, Curuhama, began to empty out as people fled. Those who could afford the fare walked out to the main road and hailed motorcycles and trucks to Liupo. One man from Curuhama told me that even some relatives of those who died fled “like ants before a flood.” Some stayed to assist neighbors and loved ones in burying the dead — with no protective equipment. Others looked for a culprit.
Raimundo mans the health post in Quinga, a picturesque town on a hillside three miles from the Indian Ocean. Once upon a time, under the Portuguese, Quinga was the administrative seat of the district, and the town square is still dominated by the pastel pink and blue skeletons of a dozen or more large art deco buildings, their roofs long gone, with a scattering of tailors and cigarette sellers making use of the shelter afforded by their overhung porches. You can still make out “Tribunal,” or courthouse, written on the facade of one, and imagine “Correios” painted above the entrance of the old post office.
Raimundo waved me inside and had me sit behind the doctor’s desk while a young woman stood on the steps with a tiny coughing baby swaddled in a capulana. When the first cholera cases appeared in Curuhama, Raimundo said, people became uneasy and approached the líder comunitário (community leader) to express their suspicion that the Red Cross might be involved. “‘We’ve lived here for so many years, and we drank the water without becoming sick,’” they argued.
There had been PSAs on the radio there explaining the basics of the disease and spreading prevention messages too, but, if anything, that made people more suspicious. As one young woman participating in a focus group on cholera violence told a sociologist years earlier: “I think the problem is that the radio anticipated that there would be a cholera outbreak this year, which made people say, how can they know a disease is coming on such and such a day?”
In Curuhama, “When the outbreak began, people felt the Red Cross volunteers already knew it would,” Raimundo explained. The community leader tried to dissuade them from accusations against the Red Cross, but he was beaten up for his trouble. On February 25, the mob grew to something like two hundred young men from Curuhama and surrounding villages, Raimundo estimated, as they burned down houses belonging to volunteers.
The secretary of the Quinga chapter of the Red Cross, Cassiano Muquinone, had gone to Liupo by bicycle the day before to get chlorine water treatment solution — called Certeza, or “certainty” — to distribute. When he returned, he was tied up, beaten, and locked with two other volunteers inside a house as it was set on fire. The ultimatum given, as recounted by a provincial representative for the Red Cross at the time, was this: “Either you take out the cholera, or you’ll die.” Muquinone and one other person were killed in the attacks, and several were badly injured.
Raimundo himself was bound, beaten, and forced to drink Certeza by the capful as neighbors turned aggressors interrogated him. “You better talk now and tell us where the cholera is coming from,” he recalled being told. Raimundo managed to free himself during the night and left for Liupo on foot early the next morning.
* * *
As the ordeal unfolded, Domingos Napueto’s information came to him from wounded Red Cross volunteers who arrived one by one, first at the hospital in town, and then, with no other port of call, in his tiny thatch-roofed home across the street, where fourteen terrified volunteers ultimately took refuge.
The first word arrived with a volunteer who had had the good fortune to be away from home when the disturbance started, Napueto said. He returned at dinnertime after restocking on medical supplies in Liupo, and he was warned people were coming for him. When they did, he escaped out his back door and walked in the bush through the night, returning to Liupo the following afternoon.
From here, accounts of the next several weeks began to diverge. Had the police heard about the destruction in Curuhama in real time over the radio or from volunteers who fled? Did reinforcements come from Nampula straightaway, or only twelve or even twenty-four hours later? Who exactly was involved, and why?
“When something like that starts to spread,” Napueto told me, “everyone speaks in his own way.”
Paulo Ipo, a lanky Liupo policeman who was among the first to respond to the cholera violence, recalled his own experience with a kind of breezy matter-of-factness you might expect from an officer at the end of a weeknight patrol. He, too, pinned the disturbances on the chlorine/cholera misunderstanding.
At the time, Ipo said, the police force in Liupo did not have a truck of its own, so they piled into a pickup belonging to the provincial department of agriculture and headed for the coast. They reached a mostly deserted community near Curuhama and stopped at the ransacked house of a Red Cross volunteer, whose wife was still there cowering in fear, and whose equipment — first aid supplies, tarps, and so on — had been strewn around the yard.
According to one report, police made a handful of arrests and picked up three wounded Red Cross volunteers to take back to Liupo. On their way, though, they had to stop at a small bridge that had been blocked with logs. When the officers got out, they were met by a group of cholera vigilantes who seized their guns and their truck, attacked two policemen, and forced the whole group to flee on foot. A unit of the Força de Intervenção Rápida — Mozambique’s equivalent of a SWAT team — came from Nampula and went back again.
By the afternoon of February 26, the district police commander in Liupo was reassuring reporters that calm had returned to the area. But after that, Ipo said, “the situation generalized.”
Protests and vandalism continued over the ensuing weeks, with logs and stones dragged across the roads and “checkpoints” set up by groups of angry residents to keep health workers from getting to areas affected by the cholera outbreak. Or, in the words of Manuel Tadia, a man who proudly told me he’d been one of the checkpoints’ main instigators, “to defend our area.”
Sporadic violence continued too. In a neighboring district, Angoche, where cholera raged on, people burned the houses of thirteen Red Cross volunteers and turned with machetes and spears on policemen who were protecting health workers accused of spreading the disease. One officer was killed and disemboweled; two others were badly injured.
On March 14, a mob marched out of a community near Curuhama, holding Sandra Assuate — a Red Cross volunteer they accused of spreading cholera — hostage. Her description of the ordeal is tragically similar to what Juma Raimundo had seen in Curuhama weeks earlier: “I found myself faced with about 50 people all armed with machetes,” she told members of a legislative commission investigating the incident later, asking, “Where have you hidden the cholera?”
Assuate’s captors undressed her, tied her up, and marched her to a house ten miles away, torturing her by setting a fire around her before leaving to deliberate about whether to kill her. Police discovered her just in time, buried alive up to her neck.
The social contagion brought on by cholera-related violence seemed to have overtaken the disease itself. Staff at a medical clinic in Quinga abandoned their patients out of fear of being attacked. The district education director, Agostinho Mendes, said fifteen schools had shut down after the lion’s share of their students stopped showing up. Just as they had during the war, families fled the violence and hunger of the countryside to take refuge in Liupo and other larger towns.
* * *
When I visited Mogincual for the first time, in 2012, I was anxious to see what scars had been left by the outbreak and ensuing violence. Similar if less widespread unrest has followed cholera around the region every year since 1998. Usually, as in Angoche and Mogincual, unrest moved in concert with the scale of the outbreak, though sometimes it arose in places with no cholera cases at all.
“Ironically, there were no cases of cholera reported in Alto-Maganha,” reads a 2010 story describing cholera riots that destroyed a newly constructed health center in a town along the coast of Zambezia Province. “But there were outbreaks elsewhere in the province, and in neighbouring Nampula. So the Pebane district health authorities embarked on an education campaign, telling people how to avoid cholera.”
Within days, “a mob marched on the health centre, smashed all the windows, tore off the roof, and destroyed the medical equipment.”
When the governor visited the town two months later, residents apologized for destroying the clinic and asked him to rebuild it. “You used to complain that there were no health services here,” the governor, Francisco Itai Meque, replied. “When it was thought that the problem had been solved, you fell for the wave of disinformation and rose up against your own interests.”
Did anyone in Mogincual feel contrite, or somehow wiser for the tragic events of 2009? What, at bottom, had driven the resentment and suspicion that boiled over into such rage?
I got a ride to Curuhama on the back of a Chinese motorcycle belonging to Hermínio Alexandre, a community court judge in Liupo who had agreed to drive and translate. It was a luminous, cloudy day. A sprinkling of rain left the road a bright brick red, majestic mahogany trees rising on either side with a tangle of vines and underbrush below.
Past the crossroads leading to Quinga, Hermínio and I took one hopelessly zigzagging shortcut between cassava fields and gnarled cashew trees and nearly fell repeatedly. But we soon emerged in a wide lane of small matopi, or thatch-roofed shops, where we found the home of the líder comunitario, Gregorio Passarinho, at the bottom of a slender wooden flagpole.
Passarinho is in his fifties, lean and muscular and, at our meeting, circumspect, with a creeping hint of a smile that suggested a lingering expectation of my saying something impolitic or treading on precarious ground — which, of course, I was. Passarinho has a gray beard, hollow cheeks, and a long, refined nose that gives him the look of Jules Verne or some other nineteenth-century baron of ink sketches in profile.
That Passarinho was still living in Curuhama was remarkable to me. Less than three years earlier, he’d been rounded up and beaten alongside Cassiano Muquinone, the Red Cross volunteer who was ultimately killed, and left bound by the wrists for forty-four hours as his neighbors set fire to the houses all around him. Afterward, he’d spent three months recovering in the hospital.
Passarinho suggested speaking to a few people in the market. Was it necessary to gather them? he wondered. No, I explained, I found it easier to talk to small groups. Even so, he led me, my government credential letter folded between weathered fingers, to the steps of the fishmonger’s and proceeded to read the contents out loud in Makua for a crowd of fifty young men who had gathered to learn the purpose of a foreigner’s visit.
Anxious to keep a mellow mood, I said a few things myself: that I had no secrets, that I didn’t come to muck anything up, that I found it hard to do an interview with so many people at once, and I proposed to Passarinho that we begin by chatting on his verandah one-on-one.
“If the government didn’t have any power here,” he said, “the whole area would have been destroyed.”
Still, he’d returned to Curuhama to reclaim his neglected fields and resume his humble duties as líder comunitario, being a liaison to the district government and a first port of call for visitors.
There hadn’t been any trouble since. As Juma Raimundo put it, “The people who spent time in prison are the ones who keep everyone else calm.” When I asked Passarinho whether his neighbors’ views of cholera had shifted in the intervening years, he broke out laughing. Where do people think diarrhea comes from? I asked. “Even today,” he said, “people think diarrhea comes from the government, that only Frelimo knows. That’s exactly what they say: ‘Frelimo knows where it comes from!’”
Outreach and education work around hygiene has continued in Curuhama, he said, albeit with some careful parameters. “The government comes and talks about latrines, about cleaning wells, about hygiene, but they never say the word ‘cholera,’ ” Passarinho said.
After Passarinho and I spoke, I said I wanted to walk around the village to try to speak with people one-on-one, but I soon found myself on the porch of the fishmonger’s surrounded by a crowd. Once again, I explained that I was a reporter, not a politician, and that I’d like to just walk around and chat with people one-on-one or in small groups. But in Passarinho’s translation from the Makua, at least, everyone was too uneasy to do things that way: it would cause suspicion and gossip for me to have private interviews, they said. At an impasse, I proceeded to ask my questions of the group.
How have things here been since 2009? Has your relationship with health workers changed? After a stirring silence, a man in a blue knit cap with a long goatee spoke up: “From 2009 up through today, we have been living happily, because things have changed.” What has changed? “From that time until now, that illness hasn’t returned.”
Where does that illness come from? Murmurs, nervous chuckles. “They want to know which illness you’re talking about,” Passarinho explained. The illness they call cholera, I said. “They are saying some people know where the illness comes from, but they’re afraid to say.”
How had the outbreak in 2009 affected life here? A volley of translations moved through the crowd, as the group churned in consideration of the question. I rephrased: in 2009, some very serious things happened here. Some people died, others were badly hurt, and others went to jail. That kind of thing doesn’t usually happen in a village. Has it changed what it is like to live here? More murmurs. Finally, if this illness were to return, do you think that your reaction here in Curuhama would be the same? This elicited a much firmer response. A man in Muslim dress in the back row spoke for his companions: “That depends on the spirit that enters the population at the time, whether it will provoke us to react a lot or a little.” What do you mean the spirit? “Whether we’ll be inclined to accelerate or remain calm.”
Will you go to the health center if you get diarrhea? The reaction was unanimous: “No! If you go to the health center, you’ll get worse and die.” Watching my expression strain the edges of earnest belief, someone made a comment Passarinho tactfully neglected to translate. Bit by bit, I and the crowd descended into a contagious fit of belly laughs. When it finally subsided, I forged ahead: would you go to the health center for other diseases? “Yes, we do, and you usually get better.”
How is it that the hospital would make you sicker for some things and less sick for others? “Perhaps the medicine for that illness does not exist. Perhaps they only have medicine for fever and headache.”
A young man piped up to say they would take up armas brancas — or “shiny weapons” like knives and spears — to fight those responsible if and when cholera returned to Curuhama. “If it’s the water, we’ll fight the water, if it’s wood, we’ll fight the wood, and if it’s a person we’ll fight them.” But how will you know? “We’re grown up,” he said. “We know how to tell who is evil.”
* * *
The only one-on-one interview I managed to secure with a perpetrator of Curuhama’s cholera violence was with Momade Mutumuara, a fifty-one-year-old farmer who invited me to sit on a straw mat outside his home surrounded by tall grasses and rows of fleshy cassava plants. Mutumuara had spent three months in jail in Angoche after the riots. He did not deny taking part in vandalism but said he hadn’t been convicted of participating in any actual violence and wouldn’t say exactly what he had done.
Even so, Mutumuara’s gripe with the Red Cross seemed deeply personal, a vendetta over a long record of neighborly grievances.
Mutumuara described Cassiano Muquinone, the Red Cross volunteer who was killed, as “showing off ” when he came to the village in a Red Cross jeep, asking for credit at Mutumuara’s barraca, or bar, and making jocular threats about bringing ill health on people in town. “At your barraca, he’d come in and say, ‘If you don’t give me what I need — patience, careful, watch out. You’ll get diarrhea.’ ”
Most telling of all, though, was Mutumuara’s response to the twelve bicycles given to Red Cross volunteers in Curuhama to assist with their work after Cyclone Jokwe, a subject he raised unprompted. “Could it be that the government only knows twelve people in all of Curuhama?” he asked. “Is that supposed to be help? If it’s help, it’s supposed to help everyone.”
This last gets at a fundamental question over the basic relationship of people in places like Curuhama with their government, which is to say, at best, almost none at all, and, at worst, a hostile one, with interactions perverted by patronage and bribery or run through with a kind of arrogance.
In 2002, a team of researchers led by the sociologist Carlos Serra undertook an ethnography of an even more destructive wave of cholera violence that swept across Mozambique in 1998–99. Serra called the resulting book Cólera e catarse, or “Cholera and catharsis.” In one exchange, in Memba, where residents had risen up to resist a water treatment campaign by Save the Children, a régulo explains their point of view as follows: “People ask the government to spray their cashew trees” — presumably to cut down on the losses from pests. “The government doesn’t do it, because they say it costs a lot of money. So then people start to question things: ‘They can’t spray our cashew trees, but they can find money for chlorine.’”