The 1991 Cholera Epidemic in Peru: Not a Case of Precaution Gone Awry
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Risk Analysis, Vol. 25, No. 3, 2005 DOI: 10.1111/j.1539-6924.2005.00617.x Perspective The 1991 Cholera Epidemic in Peru: Not a Case of Precaution Gone Awry Joel Tickner1 ∗ and Tami Gouveia-Vigeant1 The precautionary principle calls on decisionmakers to take preventive action in light of evi- dence indicating that there is a potential for harm to public health and the environment, even though the nature and magnitude of harm are not fully understood scientifically. Critics of the precautionary principle frequently argue that unbridled application of the principle leads to unintended damage to health and ecosystems (risk tradeoffs) and that precautious decision making leaves us vulnerable to ”false-positive” risks that divert resources away from “real risks.” The 1991 cholera epidemic in Peru is often cited as an example of these pitfalls of the precautionary principle. It has been mistakenly argued that application of the precaution- ary principle caused decisionmakers to stop chlorinating the water supply due to the risks of disinfection byproducts (DBPs), resulting in the epidemic. Through analyses of investiga- tions conducted in the cities of Iquitos and Trujillo, Peru, literature review, and interviews with leading Peruvian infectious disease researchers, we determined that the epidemic was caused by a much more complex set of circumstances, including poor sanitation conditions, poor separation of water and waste streams, and inadequate water treatment and distribution systems. The evidence indicates that no decision was made to stop chlorinating on the basis of DBP concerns and that concerns raised about DBPs masked more important factors limiting expansion of chlorination. In fact, outside of Peru’s capital Lima, chlorination of drinking water supplies at the time of the epidemic was limited at best. We conclude that the Peruvian cholera epidemic was not caused by a failure of precaution but rather by an inadequate public health infrastructure unable to control a known risk: that of microbial contamination of water supplies. KEY WORDS: Cholera; Peru; precautionary principle; risk tradeoffs; water disinfection 1. INTRODUCTION scientifically. Taking a cautious approach to manag- ing uncertain environmental risks requires (1) exam- The precautionary principle calls on decision- ining risks and benefits of a wide range of alternative makers to take preventive action when evidence indi- approaches to meeting a particular social need; (2) cates that there may be a potential for harm to public shifting the responsibility for documenting the risks health and the environment, even though the nature of and alternatives to a technology from government and magnitude of the harm are not fully understood agencies to those who stand to benefit from that tech- nology; and (3) involving the communities that will 1 Lowell Center for Sustainable Production, University of be affected by any decision to act or not act.(1) Massachusetts–Lowell, Lowell, MA, USA. ∗ Address correspondence to Joel Tickner, Lowell Center for Sus- Critics of the precautionary principle frequently tainable Production, University of Massachusetts–Lowell, One claim that the principle is anti-science. We have re- University Ave., Lowell, MA, USA; joel email@example.com. sponded to this claim elsewhere by arguing that 495 0272-4332/05/0100-0495$22.00/1 C 2005 Society for Risk Analysis
496 Tickner and Gouveia-Vigeant the precautionary principle calls for expanded scien- health and diverts public health resources from the tific tools for the characterization and prevention of handling of such dangers.”(9) complex risks.(2,3) These same critics also argue that Analyses by the EPA and others have found that applying the precautionary principle in real-life sit- DBPs, most notably trihalomethanes, do present un- uations leads to unintended damage to health and certain, though real, human cancer and reproductive ecosystems, known as risk tradeoffs, as well as false risks.(13,14) Thus effective chlorination of drinking wa- positives, where decision making is based on unwar- ter, while reducing substantially the risk of cholera, ranted fears or unnecessary alarms.(4) A risk tradeoff may increase cancer or reproductive health risks. In occurs when action to control one risk inadvertently countries such as Peru, where cholera and other in- results in the creation of a new and potentially more fectious diseases remain a real threat, it would seem problematic risk; and a false positive occurs when an prudent to accept a small cancer risk as an unfortunate exposure appears to increase risk, when in fact the consequence of an effective method of preventing two are not related. cholera, although in the long term, the risk tradeoff In this commentary, we present a case study might also stimulate a search for safer means of dis- of an often cited example of how the precaution- infecting drinking water. But the question we investi- ary principle can result in risk tradeoffs with ad- gated is: Did concern for the risks from DBPs in any verse health consequences: the 1991 cholera epidemic way contribute to the cholera epidemic of 1991? If so, in Peru. In late January 1991, Vibrio cholerae was then we might conclude that the case illustrates a se- identified among patients presenting at northern Pe- rious unintended consequence of a “precautionary” ruvian coastal hospitals. By the end of 1991, over effort to avoid DBP risks. 300,000 cases of cholera were identified, though sur- Through literature reviews, interviews with prisingly, the mortality rate resulting from cholera- Peruvian and U.S. experts, and an examination of induced dehydration was less than 1% due to the the evolution of the epidemic in two cities, Trujillo rapid interventions undertaken by the Peruvian and Iquitos, we examine three key questions: (1) Was public health community.(5–8) The epidemic quickly there a decision to stop chlorinating Peru’s water spread to neighboring Brazil, Colombia, Ecuador, supplies as a result of concern over DBPs? (2) Did and further up the coast to Guatemala, Panama, and this decision result in the 1991 Peruvian cholera epi- Mexico, resulting in more than 1.3 million cases of demic? and (3) Was this a failure of the precautionary cholera in the years 1991–1995.(6,7) While consump- principle? tion of raw seafood was originally suspected as the We argue in this article that the Peruvian cholera vehicle for the transmission of cholera, contaminated epidemic was caused by a much more complex set drinking water was an important factor in the rapid of circumstances that were unrelated to concerns dissemination of the disease.(5) over the uncertain health risks caused by exposure to Miller and Conko,(9) among others, have argued DBPs. Financial and administrative difficulties, out- that the Peruvian government stopped chlorinating dated and inadequate water treatment equipment drinking water supplies in the country following the and pipes, unsanitary water storage conditions, con- publication of U.S. EPA reports on the health risks sumption of contaminated food, and lack of ade- of disinfection byproducts (DBPs), out of concern for quate sewage disposal are a few of the important this newly recognized hazard.(10) A 2004 commentary factors that contributed to the spread of cholera by C. T. Howlett, Director of the U.S. Chlorine Chem- in Peru. Indeed, the evidence indicates that there istry Council, summarizes this argument: “In Peru, in never was a decision to “stop” chlorinating the the early 1990s public health officials responded to drinking water. In addition to infrastructure limita- an antichlorine campaign by stopping proper chlo- tions, events outside of Peruvian control, such as rination of their drinking water. The results were dumping of cholera-contaminated bilge and global predictable and horrific. Within months, a cholera epi- change, may have helped advance the reintroduction demic swept through the country, eventually causing of cholera to Peru after a century of living cholera 1.3 million cases of illness and 13,000 deaths.”(11) The free.(15) main source for this assertion is a single-page 1991 news article in the journal Nature.(12) The epidemic 2. EXAMPLE OF INADEQUATE has been cited as an example of how “implementa- INFRASTRUCTURE: TRUJILLO, PERU tion of the precautionary principle is often hazardous because it draws the attention of consumers and pol- Salzar-Lindo and colleagues conducted an inves- icymaker from known, significant dangers to human tigation of the water supply and cholera epidemic
The 1991 Cholera Epidemic in Peru 497 in Trujillo, Peru’s third largest city.(5) Prior to the to be a major source of cholera transmission in cholera epidemic, the city’s drinking water came from research conducted by Salzar-Lindo et al.(5) They 43 wells dug approximately 60 feet into the ground. found a cholera attack rate more than one and a Trujillo’s engineers in charge of the system believed half times higher among those whose primary water that the water was pristine and thus there was no source was tanker trucks (3.14%) compared to those need to chlorinate, particularly given concerns about who primarily accessed water through an in-home risks from DBPs. However, they failed to account tap (1.97%).(5) for the fact that 35% of the city’s water was sup- plied by public standpipes (water access points), or by 2.2. Inadequacies in the Water Distribution System tanker trucks, using city water.(5,16) These distribution methods could result in unintended contamination of It appears that Trujillo’s engineers in charge of drinking water during storage. the drinking water system did not consider the effect Despite the decision not to chlorinate, the san- that the old, poorly maintained, and illegally tapped itary conditions under which water was obtained distribution pipes (where as much of 40% of the city’s and stored offered insufficient protection from water- water supply was being lost) could have on the sys- borne diseases such as cholera. In particular, the water tem as a whole.(5,17) Many of the pipes were installed distribution system was vulnerable to contamination in the 1950s and had not been updated.(5) Leaks were as a result of clandestine taps in the pipes, leaks due to not always properly repaired. Due to frequent water inadequate and irregular maintenance, electrical out- shortages, clandestine taps were an important prob- ages that shut off water pumps, and postdistribution lem. It became a practice for residents to locate a wa- contamination during storage.(5,17) ter pipe, make a crack or a hole in the line so that water could be drained into buckets, and then reseal the holes with pieces of paper wrapped in plastic.(5,16) These leaks and illegal taps allowed untreated sewage 2.1. Poor Sanitary Conditions of Water Access and microorganisms to enter the system, thus contam- Approximately 143,325 people obtained drinking inating water.(5,17) water from standpipes, clandestine breaks, or tanker In addition, researchers noted that the Trujillo trucks.(5) Those without in-home tap access typically system was not operable an average of 10 hours per stored water in inadequately covered barrels outside day because electrical outages prevented the pumps their homes. Smaller bucketfuls and cupfuls of water from running. When water does not flow continually were brought into the home on a daily basis by sub- through the pipes, inadequate levels of water pres- merging hands and arms into the water. Those with sure are maintained. Inadequate water flow allows access to running tap water also stored water in bar- unsafe water and microorganisms to seep into the sys- rels as a back-up source for those times when water tem from the holes (from clandestine breaks), leaks, service was not available, as water was provided to and cracks in the pipes, thus exposing residents to the system for only approximately 14 hours per day. dangerous bacteria and pathogens.(5,17) Households at a greater distance from the central sys- tem could rely on running water for only 1 to 2 hours 2.3. Actions Taken to Address the Problem per day.(5,16) In one study, researchers determined that water Almost immediately after the cholera outbreak samples taken from storage barrels had the greatest began in February 1991, chlorination was initiated in number of total and fecal coliform counts (an indica- Trujillo’s water supply. However, efforts to fix the de- tion of contamination) while water taken from wells teriorating water distribution system as well as mon- and from the distribution pipes had lower counts.(16) itoring for fecal coliforms and residual chlorine (to This suggests that water generally became contam- examine the efficacy of the water treatment system) inated while being stored in barrels. In addition were not undertaken. Despite chlorination and ag- to the potential for water to become contaminated gressive national educational efforts to encourage from inadequately covered barrels, pathogens, bac- home disinfection of drinking water through boil- teria, and dust could contaminate water when res- ing, bleach, and chlorine tablets (only partially ef- idents’ unclean hands and arms were plunged into fective because of high energy costs and difficulties the barrel during water retrieval, exposing others in distribution of chlorine tablets), cholera returned to cholera.(16) Stored contaminated water was found to Trujillo in the summer of 1992, albeit resulting in
498 Tickner and Gouveia-Vigeant about one-quarter the number of cases as in 1991. This 3.2. Inadequacies in the Water Distribution System suggests that contamination of the water supply per- The design of the water distribution system was sisted, though disinfection efforts were successful in such that water was pumped directly to the pipelines, reducing the number of cases.(5) although the city is flat and the system would have operated more effectively and efficiently if water were pumped through elevated service reservoirs.(5) This 3. EXAMPLE OF POOR SANITATION design flaw caused households close to the treatment PRACTICES: IQUITOS, PERU plant to have tap water 24 hours a day, while house- Iquitos, Peru is a city of 285,000 people located holds further out had tap water only 0 to 1 hour a in the Amazon jungle. The primary drinking water day. As was the case in Trujillo, lack of water in the source in Iquitos was a nearby river, from which distribution pipes allowed for infiltration of contami- water was pumped to the city. Residents of Iquitos nated groundwater. Water was further contaminated accessed drinking water from in-home taps (50%), from seepage of raw sewage due to the fact that much public standpipes or shallow wells (33%), and di- of Iquitos lacked sewers.(5) As in Trujillo, illegal taps rectly from the river (18%).(5) Chlorination was used in water distribution pipes were common, increasing to treat water distributed through in-home taps and the potential for contamination of the system.(5,17) standpipes. However, as in many parts of Peru, the For those accessing water from standpipes, additional water disinfection and distribution system of Iqui- contamination was likely as a result of barrel storage tos faced particular vulnerabilities, including inade- without further disinfection. quate settling, filtering, and chlorination, as well as leaks and electrical outages that unexpectedly turned- off pumps that maintained water pressure in the 3.3. Poor Sanitary Conditions of Water Access system.(5) Residents of impoverished Barrio Belén, repre- senting 18% of Iquitos residents, live in houses built on stilts at the mouth of the Itaya River, an Amazon 3.1. Inadequacies in Water Treatment System River tributary. There were no systems for human Water treatment in Iquitos consisted of coag- waste disposal in Barrio Belén: thus raw sewage was ulation, settling, filtration, and chlorination. Inves- dumped from houses into the river below. Residents tigators found that coagulants were applied only of the area would take their drinking water directly infrequently and the settling tanks were inadequate from the Itaya River. The Hospital de Apoyo de to allow for proper settling of debris, including or- Iquitos, which was providing care for most of the ganic matter.(5) However, filtering of organic matter cholera cases in the city, also dumped its raw sewage is an essential step in water treatment for pathogen into the Belén River upriver from Barrio Belen, fur- removal and critical for disinfection with chlorine to ther contaminating the river and exposing residents be effective.(17) Filtering had not been conducted for to cholera.(5) Approximately 60% of all cholera cases some time due to the lack of proper filters. in Iquitos occurred in shanty towns, with investigators Chlorine was applied manually and intermittently estimating that most of these cases occurred in Barrio in Iquitos.(5) Water testing for residual chlorine and Belén.(5) bacterial contamination also was not conducted reg- ularly.(5) If done consistently, water testing results 3.4. Actions Taken to Address the Problem might have signaled to water officials that not enough chlorine was being used to maintain a residual ef- Efforts to improve the Iquitos water supply sys- fect needed to kill bacteria further down the distribu- tem were not initiated until mid-1991 some months tion system. Bacteriologic water tests were also not after the first cases of cholera in the city. While chlo- regularly conducted, due to broken equipment, but rination at the water treatment plant was increased, tests conducted within months after the epidemic be- total chloroform counts were still unacceptably high gan revealed that water at the point of exit from the in September 1991. Investigators found that the pro- treatment plant was unsafe for drinking due to to- longed epidemic in Iquitos, which lasted continuously tal coliform counts.(5) Such testing would have indi- (though with significantly fewer cases) through 1992, cated the need for additional chlorination or in-home was the result of the “complex and unsolved prob- disinfection. lems of the water supply system of that city and the
The 1991 Cholera Epidemic in Peru 499 extremely unsanitary living conditions of a large pro- Peruvian researchers concluded that “the find- portion of the population.”(5) Given the local condi- ings in this study reveal that the water supply sys- tions, local health workers noted that more aggres- tems had not been properly built, maintained, or sive home-based chlorination and water boiling would operated in Trujillo and Iquitos, resulting in drink- have been critical in controlling the epidemic. ing water of poor quality before the onslaught of the Peruvian cholera epidemic in early 1991. Water was either insufficiently disinfected (or not disinfected at 4. CHLORINATION IN PERU’S all) before distribution or it became contaminated CAPITAL, LIMA during distribution or storage in households . . . . Even Anderson noted that local water officials in if water were properly treated and disinfected be- Lima, Peru’s capital and largest city, decided to stop fore distribution, the poor conditions of the water chlorinating many of Lima’s wells based on DBP lines, proliferation of clandestine connections, and the concerns.(12) However, evidence indicates that chlori- lack of continuous pressure in the distribution sys- nation in Lima was never stopped and the city was not tem . . . would easily contaminate the water.”(5) an epicenter of the epidemic. Peruvian researchers noted that the head of that city’s water treatment 5.1. Other Factors Influencing the 1991 works was surprised to hear about the lack of chlorina- Cholera Epidemic tion outside of that city and stated that the DBP cancer risks were of minimal concern to him compared to the In addition to limited infrastructure for safe water necessity of providing safe drinking water.(18) provision and waste management, several other fac- tors may have played important roles in the 1991 epi- demic, including (1) chlorine resistance of the strain of 5. DISCUSSION—INCREASED cholera implicated in the epidemic; (2) transmission CHLORINATION WOULD HAVE of cholera through food; and (3) globalization and SIGNIFICANTLY REDUCED, BUT NOT global climate change. These are discussed briefly. HAVE PREVENTED OR STOPPED THE The strain of cholera isolated from patients in CHOLERA EPIDEMIC Peru, Vibrio cholerae O1, El Tor, has been found to The case examples of Trujillo and Iquitos illus- produce an exopolysaccaride that can make the bacte- trate the multiple causes of the 1991 cholera epidemic ria more resistant to chlorine. In addition, it was a “ru- in Peru. An important conclusion of the researchers gose” colony variant, meaning that it forms clumps. who examined cholera cases in Trujillo and Iqui- Chlorine can kill the outer layers but has difficulty tos was that even if chlorination and other treat- in penetrating the entire colony. The end result is ment methods had been widely employed, water still that chlorination is much less effective than for other would have been contaminated as a result of (1) in- cholera strains.(19–21) adequately constructed and failing water treatment Even optimal chlorination could not have pre- systems; (2) poorly maintained distribution systems vented the spread of food-borne cholera. It is be- with leaks and illegal taps and secondary contamina- lieved that the epidemic began through consump- tion from storage; (3) inadequate waste and sewage tion of contaminated seafood, particularly under- treatment, which resulted in contamination of drink- cooked and raw seafood.(5) Shellfish and crustaceans ing water supplies; and (4) intermittent electricity, in particular are likely to become contaminated with which resulted in limited operation of treatment sys- cholera after consuming contaminated plankton.(22) tems and inadequate pressure in water distribution Eating food prepared with contaminated water (such systems. Some contamination problems (illegal taps as juices) as well as consumption of fruits and veg- and leaks) could have been addressed through main- etables irrigated with contaminated water were other tenance of an adequate disinfection residual, but oth- sources of food-borne cholera dissemination. In some ers (pressure fluctuations and contamination of stor- parts of Trujillo, water from clandestine breaks in age containers) would have been more difficult to ad- sewage lines was used to irrigate crops, such as cab- dress as these are problems in chlorinated systems as bage, lettuce, carrots, and watermelon. The food- well. Thus, many of the factors contributing to the borne transmission of cholera is evidenced by a study cholera epidemic in Iquitos, where limited chlorina- that found an association between the consumption tion did occur, would not have been completely ad- of raw or undercooked cabbage that had been irri- dressed through additional chlorination. gated with sewage water and going to a party (where
500 Tickner and Gouveia-Vigeant contaminated foods might be served) and cholera.(16) Peru, health risks from cholera and other water-borne However, most of the cases, as well as the rapid spread pathogens and microbial risks clearly outweighed the of cholera, can be best explained by contamination of risks from DBPs. Thus, while no decision was made to drinking water.(5,16) halt chlorination, the question remains as to whether There continues to be a debate about how cholera concerns over DBPs (and the cancer and reproductive was reintroduced to Latin America after nearly a risk tradeoffs) discouraged officials from expanding century of living cholera free (there had been no epi- chlorination efforts. demic cholera in Peru in the 20th century and this United States Environmental Protection Agency may have contributed to the lack of acquired specific experts working in Peru did find a reluctance on the immunity in the population).(6,8) There is some evi- part of the Peruvian Minister of Health to push for dence that a vessel from Asia dumped its contami- new or increased chlorination, based on DBP con- nated bilge into the harbor of Lima.(23) Researchers cerns.(21) Similar concerns were noted by Peruvian found that “DNA testing of the Latin American researchers interviewing water treatment plant en- cholera strain shows that it is genetically similar— gineers in various Peruvian towns, for example, in although not identical—to a cholera strain common Trujillo.(18) But the experiences in Trujillo and Iqui- in Bangladesh, and that this strain has been isolated in tos make it clear that there were ample reasons to samples of ballast, bilge, and sewage from cargo ships expect cholera, once introduced into the population, active in the area.”(23) to spread rapidly through an inadequate water distri- Finally, there is some evidence suggesting that bution system, regardless of attitudes toward chlori- global climate variations can affect cholera epidemics. nation risks on the part of public health officials. The El Niño warming effect on ocean waters can pro- Additionally, the reluctance to expand chlorina- mote plankton blooms, in which cholera bacteria can tion efforts seems to be more complex than simply thrive, especially with high levels of sewage that pro- concerns about DBPs. Peruvian researchers have vide needed nutrients to the microbes.(23–25) It is pos- noted that the reluctance expressed by some authori- sible that V. cholerae lay dormant for a number of ties appears to result from the inherent constraints of years before El Niño raised temperatures in the wa- a poor country, including practical and economic diffi- ters to a level at which the bacteria could be infectious culties, inadequate supplies of chlorine, logistical dif- to humans, particularly in Peru where the population ficulties in purchasing enough chlorine, and improper lacked immunity to cholera.(15) machinery.(18) DBP concerns may have simply pro- vided a convenient rationale for the complex set of factors that limited expanded chlorination. 5.2. Was a Decision to Halt Chlorination Ever Made and Was That Precautionary? 6. CONCLUSIONS It is clear from various investigations that ade- quate treatment and chlorination of drinking water Multiple interconnected factors, including limita- supplies in Peru at the time of the cholera outbreak tions in basic public health infrastructure, contributed was limited at best. It is also clear from our review to the 1991 cholera epidemic in Peru. Even full chlori- that no decision was made to halt chlorination as a re- nation of drinking water in Peru probably would not sult of concerns over DBPs. Indeed, researchers note have prevented the epidemic, though more aggres- that the government was actually encouraging water sive preepidemic disinfection efforts would probably chlorination and education about drinking water con- have played an important role in reducing the magni- tamination and good sanitation practices before, and tude of the epidemic. While concerns were raised by more so, after the epidemic began. They encouraged some Peruvian health and water treatment authori- these particularly through the use of chlorine tablets, ties about DBPs, the evidence indicates that there was personal hygiene (hand washing), water boiling, and never a decision to “stop” chlorinating the drinking aggressive postepidemic chlorination of town water water (chlorination occurred in many locations) and supplies and hospitals.(5,18,26) that any reluctance to expand chlorination was more Research over the past 20 years has indicated that likely due to economic and infrastructure limitations. DBPs pose risks to human health.(13,14) Thus, con- The assertion that officials actually stopped chlorinat- cerns over DBPs cannot be considered a false posi- ing as a direct consequence of DBP concerns seems tive. However, it is evident that in a country such as to be more myth than reality.
The 1991 Cholera Epidemic in Peru 501 The Peruvian cholera epidemic case demon- to apply precaution and the well-documented impli- strates the importance in good public health practice cations for health, the environment, and the econ- of understanding the root causes of disease. In this omy.(29) Finally, they inhibit discourse on the means case there were multiple root causes of the cholera to improve science and public health decision-making epidemic, including the lack of proper disposal of hu- processes to prevent disease and avoid real risk man waste; limited and poorly maintained water treat- tradeoffs. Goldstein notes how well-intended, precau- ment and distribution systems; poor hygiene prac- tionary public health interventions can result in seri- tices resulting in contamination of food and water; ous adverse consequences.(30) Seeking to avoid creat- dumping of cholera-contaminated sewage in coastal ing new problems while solving existing ones needs to waters; and, quite possibly, global climate changes. be an important aspect in any application of precau- Many of these factors had existed for years. Perhaps tionary interventions. the most important root cause of the epidemic, how- The precautionary principle can serve as a use- ever, is poverty and the social and economic inequities ful tool to stimulate discussions on ways to improve and marginalization in many parts of the world that risk science and decisionmaking under uncertainty in inhibit access to clean drinking water. In the 1980s in order to more proactively reduce risks while stimulat- Peru there was massive migration to Lima and coastal ing innovation in safer processes and products. While cities caused by rural poverty and civil strife. Simulta- every decision tool, precaution included, will likely neously, the 1980s saw some of the lowest investments result in some failures, we believe that the cholera ex- in water treatment and sanitation in Peru’s history. ample has failed to adequately demonstrate the pit- Many of these cities lacked basic water infrastructure falls and failures of the precautionary principle. to deal with the influx of population and as a result less than 40% of Peru’s urban population, much of which lived in shanty towns, lacked potable water sources ACKNOWLEDGMENTS in their houses.(6) While the important health benefits We would like to acknowledge the support of of water treatment and sanitation had been known Dr. Eduardo Salazar and Dr. Huberto Guerra from to public health authorities for quite some time,(27) a the Universidad Peruana Cayetano Heredia in Lima, range of factors limited their application in this case. Peru, Mr. Kim Fox from the U.S. Environmental Pro- Unfortunately, too many public health profes- tection Agency, Dr. David Ozonoff from Boston Uni- sionals, decisionmakers, and others have considered versity, and Dr. David Kriebel from the University the 1991 cholera epidemic as a case of the pitfalls of Massachusetts–Lowell for their technical support of the precautionary principle. This is clearly not the in the preparation of this article. We also acknowl- case. The manner in which the Peruvian epidemic has edge the editorial assistance of Cathy Crumbley and come to be understood by some in industry, the me- Melissa Coffin of the Lowell Center for Sustainable dia, and public health officials and policymakers alike, Production. Funding for this article was provided by clearly demonstrates the need to have a holistic under- the V. Kann Rasmussen Foundation. standing of complex sets of events rather than simple sound bites that present only part of the story. 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