Cholera or the plague?

Picture this: you’re having a chat with a friend who is complaining about being stuck between a rock and a hard place. Except we’re in Flanders (Belgium) and she says it's like having to “choose between the plague and cholera”. Any other person would probably not give it a second thought, but if you’re a medical translator – well, you take a deep dive!

The Citizens of Tournai, Belgium, Burying the Dead During the Black Death of 1347–1352 from Chronicles of Gilles Li Muisis (1272–1352), Abbot of the Monastery of St. Martin of the Righteous, f. 24v., Royal Library of Belgium, Brussels, Belgium.

The expression is apparently only used in Belgium and in France (“choisir entre la peste et le choléra”). It seems to be one of the many expressions that Belgian Dutch has adopted from French, since the expression is not commonly used in the Netherlands.

Now ideally of course, the situation doesn’t present iself, but what if we had to choose between the plague and cholera? Well, apparently we should go with cholera!

Cause and bacteria

The plague is caused by the bacterium Yersinia pestis, while cholera is caused by Vibrio cholerae. Although both are bacterial infections, they affect the body in very different ways. Plague primarily infects the lymphatic system and bloodstream, whereas cholera targets the small intestine.

Transmission

• Cholera: in most cases, the bacteria are transmitted through contaminated drinking water or food. They produce a toxin in the small intestine that causes fluid and salts to leak through the intestinal wall, resulting in severe, watery diarrhea. Vomiting can also be one of the symptoms. Rapid dehydration can lead to organ failure and ultimately death.

• The plague: the bacteria are transmitted through the bite of infected fleas or contact with a patient's bodily fluids. It can manifest itself in three forms, of which bubonic plague is the best known and most common. Typically, lymph nodes swell into large and painful abscesses. The disease is usually accompanied by fever, headache, chills, and weakness. In addition, the skin and other tissues may turn black and die (which is why the disease is also known as the ‘Black Death’).

Treatment

• Cholera is easier to treat and less deadly. If you manage to get enough fluids by drinking or through an IV, the risk of dying is pretty much non-existent. Without treatment, about 30-50% of all cases would result in death.

• While the plague is estimated to have wiped out one-third of the European population in the 14^th century, it is now much easier to treat thanks to the invention of antibiotics. But: the disease has always been deadlier than cholera. Whereas in pre-antibiotic times the plague was fatal in 60-70% of cases, mortality in recent decades has remained around 10%. However, much depends on the type of plague and how long the disease has been present before antibiotic treatment begins. The fact is that plague is often diagnosed late, because it is not something that doctors immediately think of.

  
  

Occurrence

• Cholera outbreaks still occur regularly, for instance in Yemen a few years ago. Typically, such outbreaks occur in places where water supplies are poorly developed. If people have unclean drinking water, cholera can spread very easily.

• The plague is rarer. According to the World Health Organization, there are still 1,000 to 2,000 new cases each year, mostly isolated cases. However, they do mention that the actual number is probably higher. In Western Europe, the plague has not been diagnosed for more than 80 years. In the United States, an average of 7 cases have been reported each year in recent decades.