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A political ecology approach to cholera

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Title:
A political ecology approach to cholera a case study of Cameroon
Creator:
Barnes, Genevieve
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
ix, 80 leaves : col. ill. ; 28 cm.

Subjects

Subjects / Keywords:
Cholera -- Cameroon ( lcsh )
Political ecology -- Cameroon ( lcsh )
Cholera ( fast )
Political ecology ( fast )
Social history ( fast )
Social conditions -- Cameroon ( lcsh )
Cameroon ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (M.S.)--University of Colorado Denver, 2011. Environmental science
Bibliography:
Includes bibliographical references (leaves 75-80).
General Note:
Department of Geography and Environmental Sciences
Statement of Responsibility:
by Genevieve Barnes.

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University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
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785826978 ( OCLC )
ocn785826978

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\ (' A POLITICAL ECOLOGY APPROACH TO CHOLERA: A CASE STUDY OF CAMEROON By Genevieve Barnes B.A., Tulane University, 2005 A thesis submitted to the University of Colorado Denver in partial fulfillment of the requirements for the degree of Masters of Science Environmental Science 2011

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This thesis for the Master of Science degree by Genevieve Brooks Barnes has been approved by Gregory Simon Peter Anthamatten Brian Page Date

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Barnes, Genevieve Brooks (M.S., Environmental Science) A Political Ecology Approach to Cholera: A case study of Cameroon Thesis directed by Assistant Professor Gregory Simon ABSTRACT Cholera is an acute diarrheal illness caused by intestinal infection with the Vibrio cholerae bacterium. Relatively speaking, cholera is an easily preventable and treatable disease, requiring fluid replacement and access to clean water; despite this, the World Health Organization estimates that there are 3-5 million cholera cases each year, and that it is the cause of 100,000-120,000 deaths annually. Cholera continues to be a problem in the West African country of Cameroon, where cases are reported regularly and have actually increased in magnitude since 2004. A political ecology approach is used to explain why a disease that is easily preventable and treatable still exists. The use of three perspectivesgeographic, historic and power relations-are used to look at the four main categories of political ecology: social, political, economic and environmental. There are two goals to this approach: (1) to develop insight into potential causes for the continuation of outbreaks beyond the traditional epidemiological understanding, and (2) to contribute to the larger discourse of political ecology. This aims to contribute to political ecology's current movement beyond its historical focus on land ownership so it may be used to further understand the trans-dimensional relations of politics, society and economics and their effects on the environment in terms of disease. This abstract accurately represents the content of the candidate's thesis. I recommend its publication. Signed ;J l/ Gregory Simon

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DEDICATION I dedicate this thesis to my family; my grandparents that started a legacy for the pursuit of education and to my parents who encouraged me and supported me as I followed my own interest.

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TABLE OF CONTENTS Figures .............................................................................................................................. viii Tables ................................................................................................................................. ix CHAPTER 1. INTRODUCTION TO CHOLERA ........................................... ..... ........... ...... .......... . ... 1 History of Cholera ...................................................................................................... 1 First Pandemic ............................................. ................ ...................................... 1 Second Pandemic ............................................................................................... 3 Third Pandemic ................................ ............................ ....... ......... ..................... 3 Seventh Pandemic ............................................................................................. 5 Vibrio Cholerae ................................................................................ ............... ........... 5 Structure/ types ...... ......... .................................... ............ ....................... ........... 5 Symptoms ........................................................................................................... 6 Treatment ............ ......... ..................... ........... .................................... ... .............. 7 Environment ....................................................................................................... 7 Transmission of Cholera ........................................................................................... 8 Primary Sources ........... ...................................................................................... 8 Secondary Sources ............................................................................................ 8 Studies of Cholera ..................................................................................................... 9 2. RESEARCH DESIGN .................................................................................................... 12 Political Ecology ... ... ... ... ... ... ... ... ... ... . ... ... ... ...... ... ... ...... ... ... ... ...... ... ... ... ... ... . . .. . . . . 12 v

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Why a political ecology approach? .................................................................... 13 How have others framed the political ecology approach? ............................ 15 Categorizing this study ............................................................................................... 16 Description of three lenses ................................................................................. 17 3. CAMEROON ................................................................................................................. 19 Geographical Information .......................................................................................... 19 Historical Information ................................................................................................. 22 German Rule ......................................................................................................... 23 WWI ...................................................................................................................... 25 French Rule ........................................................................................................... 26 British Rule ............................................................................................................ 28 WWII and UN Charter ................................................................................ 30 Federation to Republic ........................................................................................ 31 Present Day Cameroon .............................................................................. 33 Patterns of Cholera in Cameroon ............................................................................. 33 4. POLITICAL ECOLOGY ANALYSIS OF CHOLERA IN CAMEROON .............................. 39 Studying Cholera ......................................................................................................... 39 Uneven Power and Prosperity in Development and Geography ..................... 41 Geographic Lens .......................................................................................................... 43 Global Warming ................................................................................................... 43 Vulnerability of Cameroon ................................................................... 45 Drivers of Climate Change .................................................................... 48 International Trade .............................................................................................. 51 Global Regulation ......................................................................... 52 Cameroon and the Global Market ................................................ 53 The effects on Cholera ................................................................... 56 Power Relations ............................................................................. 56 vi

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Historical Lens .................................................................................................... 58 Marginalization and Cholera ....................................................................... 59 Colonialism and Marginalization ................................................................. 60 Role in Global System ..................................................................... 61 Marginalization within ................................................................... 62 Power Relations ............................................................................. 63 5. DISCUSION AND CONCLUSTION ........................................................................ 65 Political Ecology and Cholera ............................................................................ 66 Understanding Cholera ............................................................................... 66 The Discourse of Political Ecology ..................................................................... 66 Limitations of the Study .................................................................................... 67 Recommendations for Future Research ........................................................... 67 APPENDIX A. CASE REPORT DATA ............................................................................................. 69 BIBLIOGRAPHY ...................................................................................................................... 75 vii

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LIST OF FIGURES Figure 1. Map of Cameroon Provinces ............................................................................. 20 2. Cases by year 1971 -2010 .................................................................................. 34 3. Provinces at greatest risk ................................................................................... 36 4. Cases by climate region 1971 1991 .................................................................. 37 5. Economy Cycles .................................................................................................. 51 viii

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LIST OF TABLES Table 1. Quality of life indicators ..................................................................................... 22 2. Population of Cameroon .................................................................................... 38 3. Literature Review by Category .......................................................................... 40 4. Political Ecology Analysis .................................................................................... 41 5. C02 producers vs. population ............................................................................ 48 ix

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CHAPTER 1 INTRODUCTION TO CHOLERA Cholera is an acute diarrheal illness caused by intestinal infection with the Vibrio cholerae bacterium; it is a virulent disease with a short incubation period of two hours to five days and can remain in fecal matter of infected persons for up to 2 weeks, even if the patient does not present symptoms (The World Health Organization n.d.)The World Health Organization (WHO) estimates that there are 3-5 million cholera cases each year, and that it is the cause of 100,000-120,000 deaths annually. There are three diseases, including cholera, for which the WHO requires notification when medical providers encounter them. However, due to poor surveillance systems and frequent under-reporting, the actual number of cases is believed to be much higher. Frequent under-reporting is thought to be most likely motivated by trade sanctions and the economic threats of decreased tourism to areas where cholera cases are present (ibid). History of Cholera1 First Pandemic Since 1817, there have been 7 cholera pandemics. The first pandemic, known as "Asiatic cholera", originated from a long-endemic source in the lower Ganges River and spread to other areas of India and the Indian subcontinent, from eastern Asia all the way to the west of the Russian empire. As the British army and navy marched to claim more territories in 1 All information provided in this section comes from (Hays 2005) unless otherwise indicated. 1

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Asia, the pandemic spread to new areas as troops fell ill. While actual mortality numbers are not known, they are considered to be quite high. It is historically significant to note, that Europeans, during this time, made exaggerated estimates of death numbers that caused a fear of a "New Black Death in the West", which affected responses to future cholera pandemics. In Europe, cholera held as much fear as the plague, and the understanding of the time was that cholera was a result of individual moral failures. Prior to 1817, the term "cholera" had a much more generic meaning in the medical community than it does today, as it referred to any severe diarrheal illness. During this time period, cholera was not understood as an infectious disease; the Indians explained the rapid and severe spreading of the illness as a result of a problem in their three humors (wind, bile and phlegm) of the body, which followed medical tradition. Indian tradition explained that the problem arose from the environment; angry gods could create disease directly or create diseases indirectly by influencing the environment or by affecting the climate. The former was an attempt to explain the rapid spread; it could be assumed that the gods had been angered by the expansion of the British into their territory, for example. The latter explained the seasonality of the cycles of endemic cholera. On the other hand, the British blamed the spread of cholera amongst their troops on the "dirty" Indian camp followers and considered the 'global' spread as a result of assimilating India into 'the world'. Ironically, while both understandings of the spread of cholera are biologically incorrect, there is a grain of truth to each; cholera does have a very strong correlation to environmental conditions such as climate, one form of transmission is through soiled hands, and it is rapidly spread through increased global interconnectedness (Constantin de Magny, et al. 2008, Hays 2005, Kimball 2005}. 2

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Second Pandemic The second cholera pandemic, occurring between 1827 and 1835, also originated in India; however, this time the pandemic moved up into western Russia, through Europe, all the way to London, and eventually across the ocean into Montreal, New York, New Orleans and as far south as Mexico. By this time, the understanding of cholera and new ideas of how it spread began to develop, however there was little agreement on its underlying cause. It was thought to be caused by marginalized members of society and new immigrants due to their poor hygiene practices and difference in smell. Therefore, the solution was believed to be in the 'cleansing ofthe environment'. This brought about a huge change in European hygiene practices through policies of trash removal from cities, quarantines of the sick, and the establishment of health boards to look more closely at the problem. This pandemic also created a social division between the wealthy and the poor. The wealthy western population saw the pandemic as being caused by the dirty poor and savage Indian's, while the poor believed cholera to be a hoax put on by the elite to suppress their upward movement. The policies of sanitation affected the poor the most in Europe; rapid trash removal left fewer opportunities for scavengers to find food and clothing, thus affecting their livelihood. Significantly larger numbers of poor became ill which resulted in a division of class in the West that was much more distinct than it was previously. Third Pandemic The third pandemic lasted from 1839-1856, and once again started in India and moved west to Europe, North America, North Africa (Egypt). This pandemic marks the first time the disease reached South America and the islands of the Caribbean. The era brought about a change in civil engineering and regulation of noxious emission from industry, removal of human waste and trash from streets, and a focus on individual hygiene. It was during the third pandemic that the association between cholera and contaminated water was made 3

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through the research of Dr. John Snow. Dr. Snow is considered the 'father' of epidemiology and his studies of cholera in London were revolutionary in understanding the transmission of cholera. Through an epidemiological study, Dr. Snow deduced that the source for the 1955 London outbreak was from a single water pump, the Broad Street pump. For the first time the link of cholera to water was made, however, the general population at this time continued to focus blame on the poor and minority races, with a focus on individual responsibility for avoiding cholera infection. Over the next century, three more cholera pandemics occurred, affecting a larger proportion of Asia, North and East Africa, Europe, Central and South America. During the fourth and fifth pandemics, North America was minimally affected and incidences were quickly contained. New York public health measures became a model for cities worldwide and are the core of today's public health policies. Along with improved sanitation, there was a rapid increase in the understanding and nature of disease. Cholera became the test subject for germ theory in the 1880's and 90's, and the bacteria V. cholerae was identified as the cause for the illness. Cholera's global spread and virulence had become such an international problem that it was a top priority with the development of an International Sanitary Commission, whose duty it was to monitor Muslim pilgrimages. With improved transportation such as trains and steamboats, increasing numbers of Muslims were making the pilgrimage to Mecca at a much faster rate; they were seen as being carriers of cholera and were burdened with responsibility for the spread. During this time period, race and religion were highly associated with the perpetuation of cholera. As a result, quarantine and individual passenger isolation of ships coming from countries known to have an outbreak became common practices. At the 1903 Paris Convention an international agreement was signed by 24 nations which committed the signing nations to notify the world when a cholera or plague outbreak was present. The agreement laid out a response plan in which the infected country would be quarantined from the rest of the world and ships coming from those 4

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countries would be quarantined, with crew, cargo and steerage passengers isolated for 5 days as decks were washed and the health was evaluated. Seventh Pandemic 1961 brought about the beginning of the modern era's cholera pandemic. Unlike all previous pandemics, the seventh pandemic started in Indonesia and spread to the Asian continent. From there, it traveled to the Soviet Union, Arabian Peninsula, East Africa, and, for the first time, to West Africa. By the end of 1970, eleven West African countries had reported cases of cholera that killed approximately SO% of infected persons. While it is fully accepted both that V. cholerae is the bacterium which causes cholera, and that V. cholerae is considered endemic on most continents, the illness is often associated with poor tropical nations that lack proper sewage disposal and access to clean water. Vibrio Cholerae Structure/ types Vibrio cholerae is a gram-negative, curved rod that has a single flagellum used for movement (Finkelstein 1996). It is classified by biochemical tests and then subdivided into serogroups that are determined by the presence of the 0 antigen. Of the 200 serogroups, only 01 and 0139 cause cholera epidemics (Sack, et al. 2004). V. cholerae grows well on most lab media including nutrient rich broth and agar, it also easily grows on meat extracts. While it tends to prefer more alkaline media, it will continue to grow in mild acidic media. When grown in a laboratory, grayish and opalescent colored colonies will appear within 1824 hours. This coloring is unique to other bacteria that are commonly found in stool, thus helping with identification and isolation of the bacterium in patients (Coleman 2003). 5

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Vibrio choleroe has a broad growth temperature range of 18"C to 38"C and grows optimally at human body temperature of 37.5"C. The bacterium can survive when frozen in ice for 3-4 days however they are killed within an hour at 60"C and die instantly in boiling water at 100"C. They can continue to live in a number of complex environments, such as contaminated water, cloth, or food products, for days (Coleman 2003). Knowing the growth patterns helps to prevent spread and also to deal with epidemics in communities. Symptoms Symptoms of cholera manifest after a short incubation period that ranges between two and forty-eight hours or as long as five days from the first exposure and infection with V. cholerae. Symptoms are characterized by sudden onset of watery diarrhea, often one liter in the first movement and several liters in the hours following (Finkelstein 1996). The abrupt loss of fluid in the body can lead to hypovolemic shock, which results from the heart's inability to circulate enough blood through the body due to dehydration and subsequently decreased overall blood volume. This can cause organ failure and even death if the patient is not rehydrated in a timely manner (Heller 2010). The symptoms of hypovolemic shock can be any combination of cool, clammy skin, confusion, anxiety, decreased urine output, general weakness, pallor, rapid breathing, uncontrolled sweating and, in late stages, unconsciousness. Diarrhea is generally accompanied by vomiting, muscle cramps, lack of skin elasticity, and a weakening of the pulse (Finkelstein 1996). Symptoms last from two to seven days from time of onset. While death is not a direct result of infection, it may result from an illness secondary to rapid and significant fluid loss such as uremia or high levels of nitrogenous waste products in the blood (Dugdale n.d.). Loss of water may be so rapid that danger of death may occur a few hours after onset, therefore, secondary illness and subsequent death are the results of inadequate, slow or improper treatment. 6

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Treatment Cholera treatment is very basic. It consists of fluid and electrolyte replacement therapy that is directly proportionate to the rate of fluid loss. Usually, fluid loss is measured by using calibrated waste receptacles or buckets in more medically underprivileged areas. Rapid fluid replacement is the key to preventing hypovolemic shock and/or death; without treatment there is a 50% case-fatality rate (Sack, et al. 2004). Treatment becomes more difficult in rural settings where there is a lack of access to clean, non-contaminated water and medical treatment. Without proper rehydration with non-contaminated water and/or nutrient rich rehydration therapy, the human body does not have the ability to flush the vibrio from the system. There are cholera vaccinations; however, the regions that most need them are the least likely to be able to afford them or gain access to the medicine. Environment Until the early 21st century, it was believed that cholera was spread only by the fecal-oral rout via contaminated food and water sources, and that the global movement of people and commodities accounted for the movement and spread of cholera around the world (Sack, et al. 2004). While there was a corollary understanding of phytoplankton plumes and outbreaks, the initial mode of infection of cholera in a community was not understood. However, studies have since found, and it is now generally recognized, that V. cholerae is part of the natural flora of coastal and estuarine microbial ecosystems that resides in copepod species of zooplankton hosts (Constantin de Magny, et al. 2008). V. cholerae is found primarily in PH-neutral aquatic environments such as rivers, bays, estuaries and the open ocean, and they flourish in relatively warm water temperatures. 7

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Transmission of Cholera The understanding of the transmission of cholera has gone through a number of modifications since the first pandemic. Since John Snow's discovery of cholera's link to water, and Koch's explanation of germ theory, more in-depth studies have been completed that have expanded knowledge of the mode of transmission of cholera in communities. There are both primary and secondary sources for transmission. Primary sources Cholera has long been linked to water and seasons; however, the reason behind the seasonality of outbreaks was not clear until the early 21st century. It is now known that the seasonal cycle of cholera outbreaks is linked to the rise in water temperatures that leads to phytoplankton plumes and zooplankton proliferation. During warm seasons the population of zooplankton increases, V. cholerae attach to the carapace and the guts of copepods, a small type of crustacean. Drinking of untreated water that contains just a few infected copepods can cause an outbreak. Any organism that consumes V. cholerae carrying copepods becomes a potential human vector for the transmission of cholera; as infected copepods are ingested and passed up the food chain, there is potential for human infection from a fish that was infected. Communities considered to be endemic with cholera where raw fish, shellfish, seaweed and kelp consumption is common, are at a greater risk for outbreaks of cholera (Mintz, Popovic and Blake 1994). Secondary sources Secondary source transmission comes from the fecal-oral route (Mintz, Popovic and Blake 1994). The process of transmission, however, is diverse; the most notable of which is poor infrastructure. Without separation and treatment of wastewater, fecal matter makes its way 8

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quickly back into the water systems that are used for bathing, drinking and cooking. Poor hygiene practices, such as failure to wash hands after going to the bathroom, not bathing regularly, and consumption of food at room temperature, can all be factors in secondary transmission of cholera. Regions with endemic cholera that are also in low-lying areas have an increased risk of exposure without proper infrastructure. Soils in these flood plains tend to be characterized by low filtration rate and are close to ground water; even with septic tanks, fecal matter may still leak into the ground water (Borroto 1997). Studies on Cholera Environmental and social causes for cholera have been closely examined since the first western outbreak in the early 1800's. Understanding of cholera epidemiology and the role of the environment continues to grow, with the majority of research being conducted in Bangladesh, India and in latin America. While there are a few studies on specific epidemics in Cameroon, there is not much information or analysis on the overall trends of the epidemics that have taken place in Cameroon since the 1960's, nor are there studies of cholera that utilize an integrated approach environmental, political, social and economic causes for outbreaks in a specific location. The literature reviewed were chosen based on the date of research, and if they were analyzing or explaining causes for continual outbreaks and death rates. In the early 1990's there was a large growth of research and understanding of the ecology around V. cholerae. Research prior to the 1990's does not account for this understanding and is largely irrelevant. Research also needed to seek causal links; there is lots of research on the vibrio itself, but less on why certain areas of the world are dramatically more affected by cholera than others, when most vibrio research indicates that it is endemic in most major bodies of water around the world. 9

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The end of the 20th century and beginning of the 21st century ushered a new understanding of the role of the environment in perpetuating outbreaks. A study completed by Huq et al. (1983) found a relationship between V. cholerae and plankton. Subsequent research found that V. cholerae attaches itself to the interior gut of cope pods, which can help protect it from seasonal changes. Some research found statistically significant correlation between climate and cholera epidemics (Constantin de Magny, et al. 2008). In addition, other studies have found strong correlations between cholera and climate, specifically water temperatures (R. R. Colwell1977, R. R. Colwell1996, Paz 2009). These authors justify the significance of their findings in the greater understanding of perpetuating cholera outbreaks through a social link to the environment. Through examination of where the vibrio resides in copepods, studies found that increases in sea levels cause tidal intrusion of costal areas. This could lead to increased human contact to V.cholerae through incidental ingestion of copepods in untreated water (Constantin de Magny, et al. 2008). Along the same lines, other research argues that the perpetuation of cholera outbreaks can be attributed to increased human population and demand on water resources which will results in a higher exposure rate (Borroto 1997), also noting that cultures that eat raw or undercooked flora and fauna are at higher risk of exposure to primary sources of V. cholerae. This study also attributes climate change and sea level rises to the perpetuation of cholera outbreaks. The authors link outbreaks to economic situations. The study argues that low-income areas that cannot afford proper sanitation systems will experience increased exposure to cholera via secondary sources in potable water and food (ibid). Another study explains that climate change affects sea levels and water temperature enhancing the understanding of the seasonality of cholera (Lipp, Huq and Colwell 2002). Copepods flourish in warmer water; therefore as sea temperature increases so will the number of cope pods and the number of vibrios in the water, thus improving the odds of incidental ingestion. The study also argues that if an area uses one water source for multiple purposes, chances for exposure are higher. In developing countries with limited funds to 10

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devote to infrastructure, common water use practices for a single body of water frequently includes bathing, cooking and fecal waste disposal. The multiple uses of water in this way increases secondary infection through the fecal-oral route of exposure. Places with poor infrastructure and sanitation systems are the most vulnerable. A study of cholera in Peru in 1991 uses social and economic factors in conjunction with environmental influences in order to understand the reason for a sudden outbreak (Seas, et al. 2000). The assessment found that the El Nino phenomenon proliferated the vibrio already present along the coastline, triggering the outbreak which spread "by the well-known means of contaminated water and food" (ibid). lower socio-economic classes are at the greatest risk of exposure because they are the most likely to drink untreated water. In these cases, cultural practices may promote the ingestion of uncooked or undercooked flora and fauna that are likely to be contaminated. Global interconnectedness also played a role in the spread of cholera in Peru through vessels transporting goods from areas with endemic cholera as they emptied contaminated bilge water as they enter ports, introducing bacteria to new areas. Potential social causes for the perpetuation of cholera in Africa are increased migration for employment, access to food, and security, which can cause a sudden increase in the use of water in a particular area (Gaffga, Tauxe and Mintz 2007). This migration strains water resources and increases concentrations of V. cholerae. Political unrest and war can lead to sudden migration as well resulting in the development of refugee camps. Due to the nature of migration and the establishment of camps, this can often put a strain on resources or even disrupt access to clean water, proper waste disposal and healthcare. Additionally, poor nutrition amplifies the death rate from infection. Gaffga, Tauxe, and Minz (2007) argue that a lack of proper infrastructure, water systems and sanitation makes clean, potable water less accessible to the masses and increases the likelihood of exposure to V. cholera. low income areas that have limited access to clean water and/or health care and treatment will have increased exposure and contamination (ibid). 11

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CHAPTER 2 RESEARCH DESIGN The purpose of this thesis is to explore the complexity of causes for cholera outbreaks in developing countries with a case study of Cameroon using a political ecology approach. The field of political ecology examines the effects of environmental issues and change through the relationship between political, economic and social factors; it is an integration of political economy theory and ecological social sciences (Peet and Watts 2004). Born out of critique of anthropologic ecology or "cultural" ecology, political ecology seeks to fill a void in the analysis of environmental issues by not only considering social-environmental interactions, but also by looking at how politics influences change in these systems. Political Ecology Paul Robbins states that political ecology is, "empirical, research-based exploration to explain linkages in the condition and change of social/environmental systems, with explicit consideration of relations of power'' (Robbins 2004). Robbins provides a review of the history and development of political ecology, arguing that problems in other fields of study on environment is a lack of integrated concepts, methods and theories to understanding problems and developing solutions. In his review of research he states that there are four main 'theses' of political ecology: degradation and marginalization, environmental conflict, conservation and control, and environment identity and social movement. He demonstrates 12

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how each thesis works to answer multiple questions about social and environmental change as it relates to power and control (ibid). According to Raymond Bryant (1997), political ecology is based on the idea that environmental changes results from the relationship between actors--such as states, businesses, NGO's--and the physical environment. He argues that politics need to be considered when looking at third world environmental research; that the understanding of historical power relations will explain areas of environmental problems that were previously not understood. Like Robbins, Bryant expresses a great need to include power relations or politics in understanding environmental issues and claims that without their inclusion, in environmental studies, a piece of the puzzle is missing. Why a political ecology approach? Jonathan Mayer (1996) and Brian King (2010) discuss the benefits of a political ecology approach to understanding health and disease. Mayer argues that political ecology has the potential to pick up where medical geography and cultural ecology leave off by looking at how politics can affect the presence and location of disease. Meanwhile, King notes that a political ecology approach would contribute to the understanding of disease by looking at how health fits within political, economic, cultural and environmental systems. King questions a group's inherent increased vulnerability to disease by looking at decision making processes and understanding disease as an institutional problem rather than a local one, he evaluates the 'placement' of disease. Mayer, on the other hand, focuses on how politics, power and human-environment interactions shape the emergence of disease in a given area. Meredeth Turshen (1977) provides an example analysis of disease by using the political ecology approach in her work, 'The political ecology of disease'. She starts with an assessment of how ideas of disease developed from scientific theory and methodology in 13

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the 1600's. Health and disease are seen as a particular ailment; with proper upkeep of an individual, similar to that of a car, an individual can be healthy, or absent of disease. She describes the development of the study of disease, moving beyond the microbial level to socio-cultural understanding in medical ecology. Like King and Mayer, Turshen provides explanation for why medical ecology is not adequate for understanding the entirety of health problems. She states, "By dismissing political and economic factors as irrelevant, it suffers from a failure to consider the relation of people to the environment in all its complexity" (ibid). She goes on to provide specific examples of how politics and economics can affect the presence of disease by looking at historical colonization of the land and political changes in the capitalist system, based on a Marxist view. Turshen explains the effect of the sanitary reform movement in Europe, which not only had a huge impact on cholera outbreaks, but also paved the way for institutionalized health policies. However, she argues that public health reforms, "were won only as a direct result of the class strugglepiecemeal legislation granted grudgingly by parliament and resisted by industrialists" (Turshen 1977). This description of power struggle flows through Robbins' four theses and provides a bases for looking at the role of colonization in the promotion of cholera in Cameroon. As Bryant suggests, environmental change occurs because of interactions among key actors in a community. When looking at the continued outbreaks that are occurring in Cameroon, it will be important to consider the role of power and politics, both historically and currently. While Turshen focuses specifically on the political effects to health, she subsequently describes the role of society and economics in influencing politics. This example provides an analytic framework for understanding the social, political, environmental and economic interactions for understanding cholera in Cameroon. 14

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How have others framed the political ecology approach? Like Robbins, several others provide a broad framework for looking at political ecology using a collection of studies and a defined set of theses within the field. Zimmerer and Basset use a geographical approach to political ecology that is centered on two major theses/themes: social-environmental interaction, and the political ecology of scale (Zimmerer and Bassett 2003). These two themes are further divided into five foci of study: (1) protected areas and conservation, (2) urban and industrial environment, (3) ecological analysis and theory in resource management, (4) geospatial technology and knowledge, and (5) north-south environmental histories. This discussion will focus on the north-south environmental histories. Using their geographically-centered perspective of political ecology in analysis of northsouth environmental histories, Zimmerer and Basset (2003, 13) state that the questions are closely connected to the field of environmental history by accounting "for the recent past framed at the decades-long scale and, when called for ... the time scale of colonial precedents". While none of the studies used to define their focus specifically relates to this research, the concept of history's role in the present is critical to understanding cholera. Meredeth Turshen used this same focus of history in a political ecology approach of disease. Peet and Watts', description of political ecology focuses a great deal on power and control and the entities that wield them. They define political ecology as, "seek[ing] to understand the complex relations between nature and society through careful analysis of social forms of access and control over resources-with all their implications for environmental health and sustainable livelihoods" (Peet and Watts 2004, 4). Through this definition they divide the study of political ecology into two headings, 'knowledge, power and practice', and 'justice, governance and ecological democracy'. Under those two headings they discuss four foci of political ecology, discourse and practice, institutional and governance, conflict and struggle, and movement. The institution and governance focus will be looked at more closely. 15

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'Institution and governance' refers to the debate over the role of communities and participation in the environmental governance. This focus explains the role of power and control and land degradation through studies on land management practices by looking at who governs land and how. The author does this by comparing and contrasting U.S. national parks with the implementation of a national park in East Africa (Peet and Watts 2004, 195 213). The link between the two is based on the state's assertion of property rights over the land and the sound science that supports the creation of a reserve area. This creation of nature does not take into consideration either what was destroyed to make it, or the lives of local people that were dramatically altered. The focus on institution and governance is ultimately a question of power and control in the sense that it is determined by who has the power, and why and how they use it. In both cases, the ideology of preserving nature was present; however the cost at which this was done was not accounted for. Categorizing this study There are two main goals for examining a case study of cholera in Cameroon using a political ecology approach: to develop insight into potential causes for the continuation of outbreaks beyond the traditional epidemiological understanding and to contribute to the field of political ecology by testing its suitability for understanding the historical and trans-national dimensions (politics, society, economics and environment) of disease. In order to analyze existing research on cholera and provide structure to this research, the theories of political ecology have been simplified into four categories for understanding cholera outbreaks: political causes, social causes, economic causes and environmental causes. The interactions between these four categories are examined in order to appreciate the complexity of a nation's effort to overcome endemic cholera. In addition to the four categories, links between the geographies, histories, and power relations among political entities will also be examined. These lenses are based on the existing political ecology 16

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approaches as described by Robbins (2004), Peets and Watts (2004), and Zimmerer and Basset (2003). The four categories were chosen based on the readings and understanding of political ecology. Political ecology is distinct because it takes into account political factors that are often overlooked in other fields such as cultural ecology, which looks at human responses to environmental change. The term, "political" is defined as "pertaining to or concerned with politics", while "ecology" has a dual definition as follows: '1) the study of the relationships between living organisms and their environment and 2) the study of the relationships between human groups and their physical environment' (Merriam-Webster 2011). When these meanings are combined into one subject, four categories of political ecology reveal themselves. Description of two lenses The implementation of the following two lenses is used in to limit the scope of analysis and enable a clearer understanding of the complexity surrounding cholera outbreaks. Only two lenses were chosen. In theory, however, any number of lenses could be used to understanding the four categories. Each lens will be described briefly below to outline their use and the manner in which they fit together. Geographical lensThe intended purpose of this lens is to look at the spatial location of cholera outbreaks in Cameroon and then to place them in their global context. Cholera outbreaks in Cameroon will be evaluated based on the actions of the global population leading to global warming and the establishment of international trade. This lens will discuss the affects of global warming on cholera, looking into the driving force behind it, and the role of international trade in the promotion of cholera. 17

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Historical Lens-The historical lens functions as a counterpart to the geographic lens; it uses the history of Cameroon and of Cholera outbreaks to understand why specific locations are more vulnerable beyond their physical characteristics. Under this lens, discussions will look at the role of marginalization within the country and within the world order and how Cameroon's history has promoted the continuation of cholera. Each lens will focus on the role of power relations in driving the presence of cholera over time and space. Power relations go hand-in-hand with both the geographic and historical lenses. The discussion of power relations will provide explanations for the reason that the events discussed in the geographic and historical section impact the prevalence of cholera. This discussion of power relations in terms of geography and history is what defines this study as a political ecology approach. 18

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CHAPTER 3 CAMEROON Geographical Information Cameroon is a small, triangle-shaped sub-Saharan Country in North West Africa that acts as a dividing line between West and Central Africa2 With a total land mass of 475,440 sq km, slightly larger than the state of California, Cameroon had an estimated population of 19,711,291 in 2010, with the highest population density in three main urban centers of Yaounde, the capital, Doula, the main costal port, and Garoua in the north. The country is divided into 10 provinces, the Extreme North, North, Adamawa, North-West, South-West, Littoral, West, Centre, East and South, each with their own administrative center (Fanso 1989, 175). The country has a varied climate, which changes with the terrain. It has a tropical climate along the coast, but becomes semiarid and hot further inland to the north. Annual rainfall is 1604mm, or approximately 63in. Cameroon is often described as 'Africa in Miniature' due to the fact that the country contains all five geographic zones found in Africa; mountains, desert, rain forest, savanna grassland, and ocean coastland, and is used by the tourism industry to attract tourists (Delancey and Delancey 2000, 16). 2 Information in this section comes from (The Central Intelligence Agency 2010) unless otherwise cited. 19

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---...-y .._.CIPIIII --Qpilll Figure 1: Map of Cameroon Provinces 20

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It is estimated that there are 250 ethnic groups in Cameroon which are categorized into five large regional-cultural groups: Cameroon Highlanders (31%), Equatorial Bantu (19%), Kirdi (11%), Fulani (10%), Northwestern Bantu (8%), Eastern Nigritic (7%), and other African (13%), non-African less than 1% (The World Bank n.d.). 2011 data estimates that the country has a population growth rate of about 2.12%. Christianity and Islam are practiced by 40% and 20% of the population, respectively, while the other 40% of the population follow various indigenous African religious doctrines. There is no data available to the public on income by province within the country of Cameroon. The last census was completed in 2005, but the results were not released until April of 2010, and the only numbers that were released were population statistics. In June of 2006 the Cameroon Tribune, one of the country's news papers, published that the country's National Institute of Statistics found unemployment at 9.3 percent (NYUYLIME 2006). Interestingly, other world data sources indicate this number to be much higher at 30 per cent (Index Mundi n.d., The Central Intelligence Agency 2011). Table 1 shows well-being indicators complied from World Bank data. The World Bank provides the percentage and also ranks each country for every category for all countries surveyed. The final column indicates whether this ranking is good, poor or average. With the exception of water pollution, Cameroon is ranked poor for all categories. 21

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Table 1: Quality of life indicators w.llbelnllnllallan Score ........ Population in Rural areas j49% out of 193 -Pri mary education completion 162% 101 out of 148 Poor !Adult Literacy Rater (+15 years of age) 167.9% out of 121 Poor ivil and political liberties p.s 127 out of 140 Poor Urban access to electricity (2009) -Poor Rural access to electricity (2009) -Poor Fresh water pollution p.o5 tons/cubic km out of 69 !Good Life Expectancy 164 out of 168 poor Infant Mortality Rate (2011) live births -Poor Physicians per 1000 people p.19 out of 148 Poor Intestinal disease death rate 34.5% out of 141 Poor !Access to adequate sanitation 62% out of 129 Poor !Access to clean drinking water 121 out of 147 Poor lcreated from (The World Bank n d.) Ranking is based on all countries surveyed Historicallnformation3 The current boundaries of Cameroon began negotiation with the German annexation of Cameroon in 1884. Prior to the annexation, the country was made of up of ethnic communities with established settled and nomadic traditions. While there was no established government in this area, there was a network of connectedness between different ethnic groups, and no community was isolated from its neighbors. The economy is speculated to have been largely subsistence based, with markets for the exchanging of natural resources, crops and manufactured goods. While a lot took place after the 1884 3 Historical information comes from a Cameroon history textbook for secondary and college students in Cameroon (Fanso 1989), with additional input from cited sources. 22

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annexation, this historical overview will be divided into timeline groups of German rule, WWI, French and British Rule, WWII, and independent rule (Federation to Republic). The manner in which Cameroon developed through these time periods in terms of social, political, economic and environmental development, directly affects cholera outbreaks in present day Cameroon. Through the course of the country's development there are six key factors important to the political ecology approach to cholera: (1) A legacy of marginalization in the world order and within the country; (2) colonial differential treatment of areas within the country; (3) an economy based on resource extraction; (4) environmental degradation; (5) an economy dependent on Europe; and (6) poor infrastructure connecting rural to urban areas. German Rule German governance in Cameroon started with the annexation in 1884; however, a German trade presence existed as early as the 1840's with an established trade post on the coast in 1868. At the time of the annexation, both the French and British were attempting to lay claim to the costal region. The German's action came as a shock to both countries; however it was done with tentative support of several influential indigenous persons based on signed treaties and agreements. Discussion and negotiation of the annexation continued among the three European powers until the Berlin West African Conference in 1885, when the first negotiated boundaries for Cameroon were set, and it was agreed that Cameroon belonged to the Germans. The first 20 years of German rule were marked by exploration and expansion of the interior, the 'conquering' of indigenous people, and forced allegiance and the signing of a treaty of protection with Germany. The German rule was not readily welcomed and within months of the Berlin West African Conference, Germany had disregarded any clause in the treaty of annexation that protected the current coastal'middle man' trade scheme with the interior 23

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without white interference that had existed since the first arrival of Europeans on the coast. German rule in Cameroon lasted from 1884 until1914 with the onset of the First World War While the Germans were not a favored governing power by the people living in the established boundaries of Cameroon, they did pour relatively large amounts of money into the development of infrastructure, education, and industry in the country. By 1911, there were numerous government schools; 413 Protestant schools and 112 Catholic schools with 22000 and 10000 students, respectively. Despite the limitation of enforcement, the Germans made attending school the concern of both the parents and the students. By 1910, a decree specified that students must remain in school for a full term or pay for the costs of that term. Incentives were given to students to attend a higher education agricultural school through free education, free board for first and second year students and monthly allowances for second years. However if a student did not complete a term, they were charged for each year of education. The expansion and focus on education and agricultural studies lead directly into the economic development under German rule. The economy was transformed into three major sectors; plantation agriculture, transportation and communication networks, and trade. The transportation and communication networks were directly linked to trade, and plantation agricultural development. The Germans established connected roads and railways as ways to move trade goods from plantations to ports and improved water transport through the river systems. Some rivers were made navigable through clearing of trees, brush sandbars and any other barriers, while others were rerouted to connect with roadways. Infrastructure development was primarily in areas that could be exploited for goods, leaving the grasslands or field lands and most of today's north and extreme north provinces neglected. Additionally, the Germans established a botanical Garden in Victoria, which acted as experimentation of various tropical plants in order to discover which ones had the most potential value for exploitation. Primary exports established on these plantations continue 24

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into the present with goods such as cocoa, bananas, tea rubber, and palm oil. Much of the work completed by the Germans set the foundation for Cameroon's current economy base. A relatively large amount of development was achieved under German rule; however, it was at a cost to the indigenous people. Traders, plantation owners, and government officials competed for the scarce labor force that was reluctant to leave their homes. As a result, force was deemed necessary to cultivate the required number of workers and established a labor system marked by cruel and harsh control (Delancey and Delancey 2000, 3-4). Through this process of forced labor, ignoring treaties with indigenous populations, and a regional focus on infrastructure development which favored agriculturally rich zones, the Germans set the stage for Cameroonians to become a marginalized population and for regional marginalization within the country. WWI World War I and the years immediately following was a period of transition for Cameroon. In the onset of the war, both British and French troops invaded the country as Germany struggled to maintain its territories. Eventually the British and French succeeded in the cessation of hostile German troops, and it was decided that Cameroon would be divided and become territories of France and Britain. France received four-fifths of Cameroon while Britain took control of the territory along the eastern frontier of Nigeria. It was decided under the constitution of the League of Nations, without input from Cameroonians, that Cameroon would be placed under mandatory powers and be administered on behalf of the League of Nations. This meant that both British and French administration of Cameroon was under the guidance of the League of Nations and must meet the requirements of the dictated articles. 25

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This time period was marked by transition from German to French and British administrative rules and the transition of the countries becoming Anglo and Franco-phone and with corresponding education systems. By 1922, the divided Cameroons were being developed independently from one another without consideration for the preexisting cultural and social networks between the two newly established territories. French Rule French rule from the end of World War I to the start of World War II oversaw progress with education and health services, though little economic development occurred. Politically, Cameroon was considered a 'B' category territory, meaning that they were not able to stand and function independent of direct French administration. Under this policy, colonial rule categorized the people into two groups with different legal statuses. Les sujets, subjects, were persons that were held to the standards of native law and custom, while les citoyens, citizens, were held and administrated according to European law. This division continued through to the rights that each group was allotted, affecting positions of leadership, education levels, and separation of courts for judiciary matters. Primary political matters were in the hands of French citizens with little knowledge of local customs and traditions. There were regional variations within the defined judicial system. A larger amount of French oversight was given to the regions with economic prosperity, while the north and grassland regions were left to self governance, since population was lower and they did not provide economic benefits. It should be noted that the 'neglected' regions were the same regions neglected by the Germans during their rule and were primarily the Muslim communities in the current day Extreme North Province. 26

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Social progress was made in terms of education and medical services during this time period. The main goal of the French education system was to spread knowledge of the French language and to restrict the number of highly educated to what was needed for administration and commercial production. Compared to other French African colonies, the opportunity for primary education was significantly higher. Medical advancement during this time period was primarily based on the work of a French doctor who set out to eradicate sleeping-sickness from the country. Because of this, he established a network of mobile treatment centers which significantly decreased the mortality rate. This model was then transferred and used as a multi-purpose medical service in addition to the establishment of hospitals and clinics around the country. In the initial years, treatment was forced upon patients. This treatment focused on areas with established infrastructure or access by road trains or boat, meaning that large regions of the country were provided with little to no medical service. Economic and infrastructure development was comparatively modest, because of the restrictions of the League of Nations. Cameroon's status as a French territory was tenuous and little capital was put into economic development in the country. The potential benefits were seen as too risky, and so the plantations established by the Germans were liquidated and sold. By 1925, only 40 out of 366 different properties were nationalized. Productions on these plantations were increased for cocoa, bananas, palm products, and rubber, while at the same time more than 200,000 hectares of forest were used for commercial purpose. The French also made an effort to improve the infrastructure and agriculture production and extend commercial activity through the use of forced labor. All subject status persons were required to give 10 days of unpaid work a year to a project. If the subject decided to stay on the project, they were to earn a minimal fixed rate for estimated completed work. However, the system began to be exploited by tribal chiefs, and the incentive was taken away and forced labor was used exclusively. This movement to forced labor took men from homes leaving families without the major food provider and protector. Under the French 27

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rule, marginalization, environmental degradation, continuation of the establishment of the resource extraction based economy and a dependence on Europe were reinforced. British Rule The British area of governance was a small region along the shared coast with Nigeria, another territory of Britain. The location of the territory is the current North-West and South-West provinces. The thought was that British Cameroon would eventually be assimilated into to Nigeria. However because of the League of Nations mandate, the governor of Nigeria ordered that the administration would follow the laws of German Cameroon, as they were known, or according to the laws of Nigeria where the administrating officer had previously been appointed. Revenue for the administration of each province came from direct taxation, of which the majority went to the colonial administration and the rest remained with district officers for administration. Indirect rule was very successful in keeping most day to day authority in established local tradition with large scale guidance from the colonial authority. Unlike in French Cameroon, educational development was hindered and delayed until the mid 1920's. As soon as the British gained authority over the territory, they began efforts to switch the German schools to English schools, unlike the French, who had introduced French to the people and allowed the education to continue in native languages. In addition to the language hindrance, the British also lacked qualified teachers to meet the demands of the population for education. It was not until1926 that the full Nigerian Education regulations were able to be implemented and focused on the "Three R's", Reading, wRiting, and aRithmatic, in addition to teaching English and practical training. The first secondary school to be opened in British Cameroon was not until1939 and was strictly for boys. Prior to the opening of this school, any parents wishing to send their children to secondary school had to 28

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send them to Nigeria, which had very limited openings for Cameroonians. This discrepancy in access to education still exists today. Medical development in the territory had somewhat better success. Shortly after taking control of the country, the British established medical posts which eventually became hospitals throughout the territory with appointed doctors and junior medical officers. The British also worked to get medical attention to remote parts of the country with the implementation of wayside clinics along the established roads, which had regular doctor visits on set days. While an effort was made to establish hospitals and provide medical attention to the remote areas, as with education, the British lacked adequate numbers of personnel to truly be effective. Economic development under the British was similar to the French, with a focus on continued agricultural development. Roughly 90 percent of the established German plantation acreage was in British Cameroon. An agricultural expert was assigned to the region to supervise the operation of the plantations along with medical staff and civil police to monitor and control the sanitation of the estates and the health of the workers. The majority of the plantations fell near and around Victoria and Kumb, which became the centers for economic growth. Due to the League of Nations mandate, plantations were attempted to be sold off to British companies, however almost all properties failed to be bought up. A second auction opened the land up to all Europeans, including Germans but not to Cameroonians who actually worked the plantations. Previous German plantation owners repurchased almost all the plantations. By the end of the 1920's, around 200-250 German plantation owners were in the territory, monopolizing economic activity. Due to this fact, port facility expansion for Tiko and Victoria was completed by the plantation owners along with a Wart for ocean steamers and a number of relatively clean laborer camps, shops and office buildings near the ports. The majority of exports and imports in British Cameroon were with Germany rather than Britain. The majority of investment in the country was by German plantation 29

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owners. Since the British put little investment in to Cameroon infrastructure, development was very minimal. By World War II, travel in the region still remained difficult. Development in British Cameroon during this time period can be summarized by minimal investment in the country to achieve the maximum exploitation of the regions resources again promoting the extractive industry. WW/1 and UN Charter The start of World War II began in 1939 with Germany's invasion of Poland and subsequent rejection of French and British demands to withdrawal from the country. However, prior to the official start of the War, Germany had denounced the Treaty of Versailles. In review, the Treaty of Versailles in 1919 was the official end of World War I which revoked Germany's territories and placed them under administrative rule of mandate countries. By denouncing the Treaty, Germany, among other things, laid claim to its former colonies, specifically Cameroon. The treaty had called on all mandatory powers to liquidate all German property and prevent nationals from returning to their former colonies. As was expressed earlier, the French meet the requirements of the Treaty, and by the start of World War II there were only approximately 60 German nationals in French Cameroon working for various French, British, and German trading companies. On the other hand, the British did not meet the terms of the treaty. Several events took place during this time period that pushed Cameroon towards sovereignty; the most significant of which was the 1944 Brazzaville Conference, when Cameroon was still under administration by France and Britain on behalf of the league of Nations. The Brazzaville Conference was led by General Charles De Gaulle, who received significant support and aid from the Cameroon people in keeping the Germans from reclaiming the territory. Since they showed such loyalty to the nation, De Gaulle wanted to host a 30

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conference to discus French colonial policy in Sub-Saharan Africa. A recommendation was made at Brazzaville to improve respect of and the progress of African life through focus on social, economic and political development of the country. Huge changes were recommended and made within five years of the conference in all three areas. Social recommendations included a uniform penal code, pension scheme, six-day 48-hour work week, and absolute freedom of labor. The French established a Labor Inspector Service, which regulated work for Africans, medical and health services were expanded and educated Africans were given earned economic and administrative freedom, gradually increasing with the potential to participate in public affairs. Economic recommendations encouraged large sums of French public money to be used for the rapid expansion of education and aid to establish strong industries. The economic recommendations called for a defined development plan encouraging the revitalization of the 'slum' areas with basic infrastructure. The Brazzaville conference began charting new territory for African colonies. It was determined that French Africa was a part of France and that African territories would be represented in the French Federal Assembly. Each colony would have representative assembly elected with universal suffrage under two electoral colleges. The true intent of these political recommendations was to make the colonies equal French participants, not leading towards self government or independence. This marks the first time that Cameroonians had any participation or say in their governance. After the end of World War II the UN charter established a Trusteeship between Britain, France, east and West Cameroon. The trusteeship was distinct from the League of Nations mandates, but still gave legal control of east and west Cameroon to France and Britain. Under the trusteeship, political development in French Cameroon flourished; by 1960, all the political activity resulted in an independent French Cameroon. On the other hand, in British Cameroon, little effort was made to advance the country. Cameroon continued to be linked to Nigeria politically and economically. In October of 1960, Cameroon voted to secede from Nigeria and it was determined that British Cameroon would become an 31

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independent nation. On February 11-12, 1961, following efforts ofthe British Cameroon Prime Minister, the UN mediated a plebiscite that established the reunification of the French and British Cameroons (Delancey and Delancey 2000, 221). In terms of economic growth in British Cameron during 1945-1961, little effort was made to foster development outside of the plantations. The economy was based on the plantations leased to the Cameroon Development Corporation (CDC), which produced palm tree oil and kernels, bananas, rubber, cocoa and tea. However, the corporation did not make enough money and relied heavily on the Nigerian government for capital, and Britain as their sole export and import market. During a time that was crucial for developing the market, prior to independence, British Cameroon made little progress in preparing for future growth. Federation to Republic On October 1, 1961 Cameroon was reunited to its original German protectorate territory to form the Federal Republic of Cameroon, except for small region along the Northern Nigerian-Cameroon border who voted to remain a part of Nigeria (Delancey and Delancey 2000, 231). Under the Federation constitution, the Anglophone and Francophone portions of Cameroon remained as separate states, Federated states of East and West Cameroon. The Constitution established the sovereignty of the federation in the people, with universal suffrage, and with the Federal authority in the hand of the President and the National Federal Assembly. Under the constitution, Cameroon was headed by an Executive President and assisted by a Vice-president, both of whom could not come from the same state. The constitution preserved the rights of the federated state of west Cameroon customary law courts and the house of chiefs, which had been established under German and British rules. It also enlarged The West Cameroon House of Assembly from 26 to 37 seats, while the East Cameroon House of Assembly held 100. It was not long before the development of 32

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what is known as, 'the Anglophone problem' developed. It is the view, on the part of the former British Cameroon, that they are a marginalized population in all aspects of the nation, from lack of political representation, unequal recognition of status, exploitation of their region and a fear of suppression of their cultural identity in language and educational system (Delancey and Delancey 2000, 29). Present Day Cameroon Cameroon is recognized as a sovereign democratic country, however has had the same government since 1982. Its economy relies on agriculture, timber and petroleum for its primary exports, with a 3% GDP growth rate (The Central Intelligence Agency 2011). Cameroon faces serious problems of endemic corruption, uneven distribution of income and a difficult climate for business (Foreign and Commonwealth Office 2011). Current travel warnings for visiting the county exist affecting the tourism industry, and commercial shipping industry. There have been attacks on commercial shipping vessels in the Gulf of Guinea, including the coastline of Cameroon around the Douala port, along with recent increase in violence in the limbe area of Cameroon including incidents of armed robbery in Yaounde. The most notable warning is of the cholera outbreak that has been ongoing since May of 2010. By the end of 2010 there were 10,759 confirmed cases with 657 deaths. In December 2010 all 28 districts within the Extreme North Province had declared and epidemic reporting 9,154 cases. Between January and April of 2011, 3,000 cases nationwide were reported with most occurring in the Center Province, littoral Province and the South West Province (Africhol 2011). The outbreak is considered still ongoing and final case numbers for 2011 have not been released. Patterns of Cholera in Cameroon Case data for cholera in Cameroon come from the World Health Organization's Weekly Epidemiological Report's from 1971 -2010 (The World Health Organization n.d.). Changes in 33

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reporting occurred during this 38-year span, becoming less specific as time passed. Location of cases are only available until1991, however where a noticeable pattern of location for outbreaks is visible, it is assumed that outbreaks continued in the same locations once specific reporting ceased. Figure 2 shows the patterns of outbreaks and number of deaths from 1971 to 2010. Cholera is generally cyclical in nature, which can be seen in the clustering of large outbreaks. As the graph suggests, these patterns of outbreaks are increasing in frequency with less time of low case numbers before large outbreaks with a general trend of larger outbreaks. Since the data are based on actual case numbers, increase could be partly related to population growth. 12000 10000 8000 6000 4000 2000 Total Ca!.es Total Deaths 0 Figure 2: Cases by year 1971 2010 The first reported cases of Cholera in Cameroon were in March of 1971 around the same time that the current pandemic reached the West African shores. That year, about 2000 cases were reported with a death rate of 15%. The first month of outbreaks were primarily in Littoral and Southwest provinces with four cases reaching as far inland as Center 34

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province. Outbreaks remained in these three provinces until June, in the middle of the wet season when a large outbreak of over 1000 cases occurred in the Extreme North province. The outbreaks continued in the Extreme North for the next five months along the Mayo, Cheri and Logo no rivers, all of which flow into Lake Chad, totaling around 1300 cases for the province. In 1971, fewer than 200 cases were reported in the Littoral province along the Wouri and Sanaga rivers. The Wouri River is the main drainage for the Wouri estuary and its banks are home to the city of Douala, the main port and largest populated city in Cameroon. Another 200 cases were reported in a small costal community of Victoria in the Southwest province. Finally, fewer than 100 cases were reported along the Nygon River in Center Region and South province at the start of the wet season. After the initial out break in 1971, few cases were reported until1985, when just over a thousand cases were reported in the West and Littoral provinces. The outbreaks occurred in cities near the Nkam River, the headwaters for the Moungo and Wouri rivers, along the Bamboutos Mountains. The outbreaks only spanned a four month period from June to October. The next major outbreak did not occur until1991 and was exclusively in the Extreme North province along the Mayo River. Fewer than 5,000 cases were reported with the highest case fatality rate for large outbreaks the country has seen to date at 18%. Outbreaks continued annual from 1992-1995 with 500-1500 cases being reported. In 1996, around 5000 cases were reported, with the majority occurring at the end of the wet season and beginning of the dry season. Unfortunately, the areas of occurrence are not known. Around 30004000 cases were reported each year between 1997 and 1999. Early 2000 saw very low case reporting, with fewer than 100 cases a year until 2004 when 8000 cases were reported in the Littoral and West provinces. Based on a summary report by the World Health Organization, it is known that the outbreaks started in an area north west of Douala, rapidly spreading until it reached the port city. Health officials were able to gain control over the outbreak by the end of March, however, with the onset of the rainy season in May a second outbreak started reaching its peak in mid-June (The World Health 35

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Organization 2009). In 2005 and 2006 reported cases dropped back down to between 1000-3000 cases each year, and by 2007 and 2008 no new cases were reported. However, cholera returned to the forefront in 2009 with 315 cases being reported in the Extreme North province with a case fatality rate of 13%. Percentage of Population affected by Cholera 19711991 Figure 4: Provinces at greatest risk Cean by Popullltion 0 000000%. IJ 0(1400),.. ... 000400!%--OOB:l!OI% 0341008'Figure 4 ranks each province based on the average number of cases by region per population of 1976, in order to determine the most at risk. Most cases took place after 1991 so rates are very low. The map also does not take into account access to medical facilities, potable water, sanitation stations or nutrient resources; it is strictly based on historical outbreaks. However, a report by the World Health Organization states that the last two large outbreaks, 2004 and the current one which started in 2009 are primarily affecting the 36

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Littoral Province, South West Province and the Extreme North Province. This matches the trend from the first few years of cases (The World Health Organization 2009). 4000 3500 .=moo 2500 2000 1500 1000 500 0 ., '" ::::J c: _I .-_ -, .TJT _.,tl;_ ". 4lJ > m :'i 4lJ :,.; .... ::I ::I ::::J ..... :>G Figure 5: Cases by Climate Region 1971 1991 ..D 0 t) a. 0 <.II ,. Cu ..D E 11.1 > 0 z .,..otal Cases, Nort'1e'n Province5 Total Cases, Sout"''e'n Provinces Figure 5 shows the seasonality of cholera in Cameroon. Patterns of seasonality are difficult to assess based on data for the entire country. Cameroon can be divided into two broad tropical climate groups: sahelian in the northern portion of the country and equatorial in the central and southern portion. Case numbers are therefore divided into two corresponding groups. The sahel ian climate of the north has a wet season from April to September with the remainder of the year dry. The equatorial south climate has two wet seasons, March thru June and August thru November, and two dry seasons, June thru August and November thru March (Atlapedia Online n.d.). While there is no data specifically on health care, income, access to sanitation and water by the provinces in Cameroon Table 2 shows the population of each province as of 2010 and the number of hospitals and /or pharmacies within that province. The table also indicates the total population of large urban centers within each province, where employment and alternative health care could be possible and the percentage of rural and urban populations. 37

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Table 2: Population of Cameroon TCII:al PlapLUIIGn In ._...111m ,..,._Miclc:al lM&ICenlas F'ele<i8B Pelca1111'.181 Aullra (:mi) Fadlllles (:mi) Uf:al(:mi) llnl(:mi) Adarrawa c 270,246 31% fP/c Central 3,a:B,014 2 2,CE4,DJ fB'/c 34% East 771,755 c 194,925 25% 75% Extreme North 3,11.1.792 c 496,876 18'/c 84% Uttoral 2,510,263 2 2,250,464 'D'/c 10'/c North l,fK/,959 a 392,749 23% 77% North\t\est 1,728,953 a 482,382 28% ll'/c South 634, 655 a 479,488 7fJ'/c 24% South\t\est 1,316,079 a 192,276 15% 85% V\est 1,720,017 a aD,829 35% ffio/c 03ta from this section was adapted from a dty JX)IJUiation website BRI NKHJFF n.d.) Historically there are three provinces that are the most prone to cholera outbreaks; the costal regions of the Littoral Province and South West Province and the lake Chad region in the Extreme North Province. Chapter 4, will help to explain why the problem looks the way it does through the use of Political ecology. 38

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CHAPTER 4 POLITICAL ECOLOGY ANALYSIS OF CHOLERA IN CAMEROON Studying Cholera Primary research on the perpetuation of cholera looks at socio-economic environments in an area. There is little previous research on the role of politics in perpetuating Cholera, and no studies specifically discuss the political ecology of cholera. Table 3 provides a breakdown of five studies of causes for cholera outbreaks and puts their findings in terms of the four categories of political ecology. These studies were chosen because they were the most relevant in explaining the human dimensions of cholera. Many other studies focus on the disease itself. Very few studies were found that look at cholera in Cameroon specifically, and no studies were found that look at the outbreaks as a whole in the country. The goals of this analysis are first, to provide an example of how political ecology can be used to examine a health problem, second, to show how a political ecology approach can advance our understanding of why cholera exists where it does, and finally, to provide insight into endemic cholera in Cameroon. 39

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0 i ] J '-----Constantin de Mw1v et al Born:lto, Rene et al1998 2008 Increase in population will The Ingestion of untreated/ increase demands on water unfiltered water could lead sources, i naease to inddental ingestion of contamination and increase cope pods and thus V exposure rate i n a population. cholerae endemic regions tha t eat raw or under cooked flora and fa una have higher ri s k of exposure si nee the vibrio uses these as host Poor sanitation s-,stems i naease sea>ndary sources of II. choleroe In potable water and food. Water te11"4"erature s are Increased sea levels and increasing and sea le\els are tidal intrusion of costal rising, inaeaslng the surface areas lead to increased area of water with a higher human contaa with V salinity, and more habitats for cholerae. CDpepods are \A brio. LDw lying areas with low hosts forV. cholerae, an filtration soils have an i nfectiye dose to caus e increased ri s k of exposure cholera can be found injust2 cooeoods -Table 3 : literature review by category Nkholas2007 Upp, Eri n et al 2002 Seas, c. et al 2000 Mgration, for e11"4"lovrnent, Water use for bathing, Ingestion of unfiltered and aa:::ess to food, serurityc:an cooking, and f ecal disposal i s untreated water Is mos t caus e sudden inaease in use convnon in d eveloping prevalent in lowsodoof water llllhich can strai n countries. This multi use of a eronomicgroups, s o are at resource and Increase water source i naeases the greatest ri s k of exposure. concentration of Vibrio. Poor exposure to V cholerae Cl.oltural practices ofte n nutrition wi II increase the promote the ingestion of death rate from cholera uncooked or unden:ooked flora and fauna. Personal hygiene in these groups tends to be I ess of a concern and increases seoondary source e>
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This chapter is divided in to three sections built around foci of study that are used to explain the perpetuation of cholera: uneven geographic, power and prosperity in development, geographical lens and historical lens. The first section will define and contextualize the concepts. The table below is a condensed outline for the analysis, using the geographic lens to look at the perpetuation of cholera over space and the historical lens to look at the perpetuation of cholera over time. Table 4: Political Ecology Analysis Geographical lens Historical lens 1. Economic drivers of climate change 1. Internal: Historical marginalization as 2. location of economic decision certain regions have attracted more Power relations making in global trade infrastructure investments. (Production) 2. External: Historical marginalization as Cameroon has functioned as a resource extraction zone under colonial rule. 1. Climate change is felt by the l.Uneven development within disempowered Cameroon particularly in Northern Vulnerability 2. Trapped in the cycle of uneven regions global economic development 2. lack of development for Cameroon compared to other nations. Costal and farming areas are more limited access to health care for susceptible to outbreaks treatment. Effects on lack education for prevention Cholera Minimal resources for investment in Unable to evoke change infrastructure Continuation of resource extraction I environmental degradation Uneven Power and Prosperity in Development and Geography In the book "Uneven Development", Smith states that inequality is inherent to the capitalistic economy (1984). He states, unevenness is "more systematically and completely an integral part of the mode of production" (98); "capitalism differs from other exchange economies in this: it produces on the one side a class who possess the means of production 41

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for the whole society yet who do not labour, and on the other side a class who possess only their own labour power which they must sell to survive" {48). Inequality is a natural byproduct of a capitalistic world order. This rationale explains why inequality exists, however does little to explain patterns. Smith argues that uneven development is a result of "social inequality blazoned into the geographical landscape". The concept of inequality is a social construct; when interlaid with capitalistic ideals of production, geographic inequality is produced. In a capitalist approach, it would make intuitive sense if the regions of the world with the easiest access to resources were the most productive, but this is not the case. Colonialism was derived as a solution to meet the needs of a large population that had limited resources; people migrated regions that lacked them. Regions where resources were plentiful did not necessitate this same congregation of populace. Colonial powers sought through the use of physical power by large militaries; regions were dominated and resources were extracted. Society has moved beyond colonialism, posing the question of why is there still social and political and environmental inequality. In this analysis of cholera, the factors of social, political, economic and environmental inequality will be presented as social constructs resulting from a colonial and capitalistic president. David Harvey suggests that this concept is a result of the neoliberal movement that came into practice in the late 1970's and early 1980's. Harvey defines neoliberalism as, "a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade" {Harvey 2007, 2). Within neoliberalism, state or government organizations frame political, legal, and economic structures support individual rights, trade and markets. The power of the overseeing bodies lies within them to facilitate and protect 42

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the most important economies. Within in this ideological framework, individuals turn over full authority to state organizations, while states, likewise, turn over full authority to international organizations, to regulate debt relief and protection of the collapsing of financial institutions (ibid, 72). Ultimately, this re-defines class power with poor countries, in effect subsidizing wealthy countries under the 'banner' of protecting the most important economies, serving to perpetuate present day inequality. Geographical Lens In order to look at the social, political, economic and environmental causes of cholera through a geographic lens, there needs to be a discussion around the concept of global interconnectedness. Societies are no longer confined or isolated to a small geographical space; a decision in one country can have an effect on other countries. This includes regulation decisions, production decisions, social ideals, environmental uses, and political deals. This concept is important in order to understand how two key issues, global warming and international trade, can affect cholera outbreaks in Cameroon. Using the concept of global interconnectedness and the understanding of neoliberalism today, the two discussions will consider how the four political ecology concepts are intertwined and could be potential causes for the perpetuation of cholera outbreaks in Cameroon. Global warming Global warming is a global phenomenon of increased surface temperatures which have significant effects on ecosystems, sea-levels, ice cover and sea temperatures (Stadudt, Huddleston and Kraucunas 2008). The warming of the climate system is affected by many different factors that are divided into natural warming and anthropogenic warming, or amplified warming. The earth naturally goes through warming and cooling cycles over 43

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millions of years, however, most scientists believe that the amplified rate of warming in the past recent decades is caused by human activity. Since the industrial revolution, greenhouse gas (GHG) emissions such as carbon dioxide, methane, nitrous oxide and halocarbons, primarily from the burning of fossil fuels for energy, industrial processes, and transportation, have increased significantly. Other sources of climate change from human activity come from the use of aerosols which act as a cooling effect for the earths surface by reflecting light away from the earth, the production and dispersal of soot from the burning of fossil fuel and vegetation, which acts as a surface insulator, and deforestation, which increases the amount of sunlight reflected and can cool the earth's surface (Stadudt, Huddleston and Kraucunas 2008). While indicators of global warming are monitored on a global level, the effects are visible in countries' and even cities' patterns of illness. Colwell et al. discuss the environmental and climatic factors that are the driving force behind the seasonality of and endemicity of V. cholerae and cholera outbreaks (Lipp, Huq and Colwell2002). The authors make the argument that while the fecal-oral route of infection explains why areas of poor sanitation are more vulnerable to cholera, incidental ingestion of copopods is another key source of exposure. The association of copepods and cholera is so strong that by monitoring algae blooms, where copepods reside, outbreaks can be predicted. Research found that water temperatures of 37 SC and a Ph of 8.5 was optimal for vibrio attachment and multiplication, with growth ranges of 164rC. In 1994. Colwell and Huq (1994) proposed a model of transmission based on physical and chemical characteristics of water. The model identifies six characteristics of water, (temperature, sunlight, rainfall, PH, dissolved oxygen tension, and salinity and other chemical nutrients) which affect algae growth, phytoplankton and zooplankton blooms, that become hosts to V. cholerae and creates an environmental reservoir of Vibrio cholerae. Using this model of water characteristics and what research suggests is changing as a result of global warming; a 44

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potential cause for perpetuation of cholera outbreaks in Cameroon can be linked back to global warming. Vulnerability of Cameroon While coastal land only accounts for 6.5 per cent of the total area in the country, it is home to more than four million people. There are at least 2.5 million people residing in the fast growing Douala metropolitan area, accounting for roughly 16 per cent of the total costal population, with the remainder residing in the Limbe, Tiko areas to the west and the Kribi, Sanaga-Maritime areas to the south of Douala (Asangwe 2007). These costal lowlands are the most vulnerable to the direct effects of global warming on cholera in the country. The 402 kilometer coastline of Cameroon is dominated by low-lying, swamp, beaches, creeks and lagoons with an extremely small elevation slope that is vulnerable to costal flooding. According to the 2007 IPCC Climate Change Synthesis Report, "Global average sea level rose at a rate of 1.8 [1.3 to 2.3] mm per year over 1961 to 2003 and at an average rate of about 3.1 [2.4 to 3.8] mm per year from 1993 to 2003." Because of these changes, events related to weather such as droughts, storms and coastal flooding are expected to increase in magnitude and the frequency (Asangwe 2007, Bernstein, et al. 2007). The coastal lowlands make up the sedimentary basin of Southern Cameroon and lie within the Littoral province. The lowlands are highly influenced by the estuarine systems of the Mungo and Wouri drainage basins which carry a massive supply of sediments and are affected by backwash of saline water from the Gulf of Guinea. This combined phenomenon is likely to be aggravated by the observed sea level rise resulting from global warming (Asangwe 2007). Unlike other costal waters, the gulf of Guinea does not have seasonal upwelling to cool the surface temperature; it remains warm year round, acting as perfect breeding ground for the vibrio bacteria (Folack and Gabche 2007). 45

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A literature review conducted by Rene Borroto in 1997 found that while warming will probably be less significant in tropical regions, water temperatures may rise to be closer to the optimal growing temperature, of 37SC, for V. cholerae, resulting in improved ecological conditions for vibrio growth (Borroto 1997). In addition to improved environments for growth, higher water temperatures will also increase the availability of zooplankton hosts, making the vibrio more likely to survive during interepidemic periods in these aquatic reservoirs. Borroto argues that primary and secondary transmission of cholera is likely to be enhanced as a result of the aquatic reservoirs of Vibrio cholerae. In fact, studies have already found that the lower courses of the rivers Mungo, Wouri and Dibamba have become inland extensions, by several kilometers, of the lagoons creating a larger potential vibrio growing habitat. In addition to the increased habitat for proliferation of V. cholerae, the soil in this region is composed of organic matter making it a stable structure and less prone to erosion however highly permeable (Encyclopaedia Britannica n.d.) Generally speaking, high permeability soils increases the chance of cholera, and other potential ailment causing organisms, to enter ground water (Borroto 1997). As a result, a number of cholera cases are found in the nearby cities and towns of the low lying costal region. In addition to the direct effects of global warming on cholera, indirect effects can be found in the form of health and well-being. In the Fourth Assessment Report of the Intergovernmental Panel on Climate Change (IPCC), there is discussion on the role of global warming on vulnerability of agricultural, economic and infrastructure development on the African continent. Agriculture is the main sector for employment and livelihood in Cameroon, accounting for a little more than 50 per cent of the GOP (The Central Intelligence Agency 2010). A study conducted by Malhi and Wright (2004) found a significant drying trend in Cameroon from 19601998 of +3.6 3.7 mm per decade ( p <10%), meaning a longer dry season and shorter growing season. In a country where poverty is high and a significant portion of the population relies on subsistence farming, a change in growing season or even variability in growing season can be cause for alarm. Subsistence farmers 46

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rely only on what they can grow in order to eat; if their crops can not grow because of temperature change or lack of water, they do not have access to food. Less access to food and nutrition increases mortality rate from and the ability to overcome cholera. In Cameroon, the coastal provinces are not the only places susceptible to cholera; in the Extreme North province, subsistence farming is common practice, and access to safe drinking water is reported to be around 30 per cent of the population (Neba 1987, 133).The Extreme North Province weather is dominated by a hot and dry climate with rainfall between 400-900 mm a year and a temperature range of 26oC to 28oC across the region (Neba 1987). The soil in this province is primarily black clay (alluvial soil) with lower iron content and rich in raw nutrient that makes it more fertile than a large portions of the south, but are susceptible to nutrient imbalances that limit and heed productivity (Encyclopaedia Britannica n.d., Neba 1987). Several rivers transverse this province feeding into both the Niger river basin and the Chad basin, fluctuating between high water in the wet season and low to no water in the dry season. The major river in this province, the Logone, experiences seasonal flooding allowing for rice crops, however almost completely dries up during the dry season (Gwanfogbe and Meligui 1983). The Logone is the primary tributary for Lake Chad, the largest lake in the northern region and a shared water source by three neighboring countries, Chad, Nigeria and Niger. Farming in the Extreme North Province is similar to many parts of sub-Saharan Africa, where farmers have resource constraints, seasonal variation, and a limited growing season which can be harshly affected by prolonged periods of droughts and floods (Boko, et al. 2007). In addition to environmental factors in the Extreme North, less than 30 per cent of the population has access to improved safe drinking water and only 5 per cent have access to adequate waste disposal (Unicef 2010). According to WHO between 2003-2009, 36 per cent of children under 5 years of age were suffering from moderate to severe stunting and 7 per cent were suffering from moderate to severe wasting (The World Health Organization 2009). Due to all these facts, food insecurity and poor nutrition are significant problems for 47

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the Extreme North population. Cholera is a relatively easy illness to treat, but successful treatment depends on quick access to clean water and nutrients. Global warming has the potential to disrupt or aggravate the already tentative lifestyle of the Extreme North province, which could increase incidence of, and mortality rate from, cholera. Drivers of Climate Change Cameroon's environment is more vulnerable to the adverse affects of climate change, yet is not a large producer of greenhouse gasses. This process of climate change, affecting those least responsible for climate change, is called "climate justice". This issue of social justice and climate change has been raised by Kasperson and Kasperon (2001), Cutter, Boruff and Shirley (2003) and the World Bank (2006). Through global interconnectedness, large economies encourage low-cost production, exploitation of natural resources and the perpetual movement of goods around the globe that ultimately results in global warming Table 2 shows a break down of the percentage of the population and the production amount of Green House Gasses (GHG) C02 equivalent per capita in 2000. Table 5 : C02 production vs. population .. ; I' !tons C02 per capita ' Largest 4 producers/ capita 19.7 16. 1 Remainder of the world f4.2 f--15 >5 !cameroon r0.25 > 0.7 (peak in 1983) !Data adapted from 2007 IPCC synthesis report and the World Bank, World Development indicators The main players in the global market that perpetuate the trend of low-cost, high-resource production are the consumer-based economies and those least sensitive to the effects of 48

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global warming. The short web film, 'the story of stuff, does a great job of portraying the cycle of the developed world's, specifically the United States', role in global warming through the use of 'stuff (Leonard 2007). While it was not the film's main goal, Leonard does discuss the social, political, economic and environmental role of the United States in GHG emissions and the exploitation of developing countries resources, influencing global warming and ultimately impacting cholera outbreaks. There are a few key arguments that Leonard makes which gives relevance of this film to the topic: (1) the developed world consists of consumers. Personal value is given based on what is owned and how new it is, pushing consumers to buy more (2) the more developed economy is based on an idea of perpetual consumerism, (3) the cycle is maintained through the cheap extraction of resources and production, (4) extraction is completed in developing countries who have fewer regulations (S) money is made from finished products, not raw resources. Developing countries like Cameroon are taking on all of the costs and not reaping any of the monetary benefits. While environmental degradation is occurring through resource extraction, most GHG emissions come from the production, use and disposal, which do not take place in the developing countries. Therefore, a country like Cameroon is hit twice by the negative externalities of the consumer economy. They lose their environmental protection through the extraction of resources, they make little economic gains and so cannot improve their infrastructure, which results in them being more vulnerable to global warming. Global warming is partially created from the production of goods that Cameroon does not have access to, which ultimately pushes them to use their environmental resources more. Figure 6 is a simplified diagram of how three cycles, (1) a consumer economy cycle, (2) a world health cycle, and (3) a developing world cycle, could potentially interact. The shaded box around an event indicates that the event results in green house gas emissions. The upper inside cycle shows a consumer economy, starting with "needs". In order to fulfill the needs of the consumer, resources must be extracted. The negative effects of the extraction 49

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may not be directly felt in the consumer economy. After extraction, resources are processed to produce a good which also results in GHG emissions. Once sold, the product is used and disposed of; these are the low-cost goods that drive the consumer economy. Use and disposal creates even more GHG emissions and a demand for more goods, bringing the consumer economy full cycle. The world health cycle encompasses part of the consumer economy cycle; however, the stages have different meanings. In the world health cycle start with resource extraction. This process weakens the overall global environment through GHG emissions and the disruption of biological processes. A weakened environment can lead to human health problems and create a need for new technology to 'fix' them. This new technology has to be produced, which can also result in a relatively small amount of GHG emissions. Once a technology is used and disposed of, if the health problems haven't been fixed, there is a need for more, which feeds back into more resource use. The consumer economy readily has access to the new technology created by the world health cycle. Cameroon, on the other hand, does not have this access, and thus Cameroon is never fully incorporated into the consumer and world health cycles. The Cameroon cycle shows the constructed dependence on resource extraction. As a way to participate in the Global economy, countries like Cameroon sell their natural resources. In addition to the being impacted by a weakened global environment, Cameroon also experiences a physically altered landscape which increases their vulnerability to global warming. Consequently, the country experiences the same health problems that derive from the world health cycle, but also experiences additional diseases such as cholera, because of the altered landscape. New technology is produced, but Cameroon does not have access to them, creating a need to grow the economy. This need for monetary resources drives the country to extract more resources and starts the represented cycle over. Other than resource extraction, in this example, Cameroon is not participating in the 50

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production of GHG emissions. This diagram shows that Cameroon is receiving the majority the negative externalities of GHG emission with little to none of the benefits. Health Problems Figure 6: Economy Cycles Developed World "Needs" -------Results in Green House Gas Emissions Need for Monetary Resources Vulnerable Environment '--------' c:=:; '-I _c_h_o_le_ra----' International Trade International trade contributes to the perpetuation of cholera in a developing country through the physical movement of goods and the regulations that dictate what goods can be moved and where. Controlling the spread of infectious diseases while protecting the sovereignty of nations is a major global health issue. As people and goods move rapidly around the world, an outbreak of an infectious disease in a country in Africa could potentially affect every other continent quickly. This is not a new problem for cholera, but the rate of spread today is much faster than before and the disease more virulent. The role of international trade on cholera will be discussed with two foci; around (1) the regulations put into effect to minimize the scope of pandemics and their unintentional 51

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targeting poorer nations through economic restrictions, and (2) the manner in which a poor nation has the ability to participate in the global economy. Global Regulation While there is no global government per se, policies and treaties signed by the United Nations member states are a type of global law. The UN system, including all its councils, gains its authority from its charter. The Charter document serves as a multilateral treaty; all signing nation-states are obligated to comply with mandates of the UN because they have agreed and signed over authority to the international organization (Cronin 2004). However, even nation-states that choose not to participate in the UN agreements can be affected by them due to the amount of nation-states and the weight of those nation-states in international systems. Within the UN system there are many organizations, committees, councils, programs and funds. Each has their own mandate under the UN's overarching commission. This work will focus only on the interaction of regulations for two organizations under the United Nations system--the World Health Organization (WHO) and World Trade Organization (WTO)--and how they affect small developing nation's health. In 1945 in a meeting in San Francisco, United Nations delegates discussed concern over the state of global health and how to best deal with illness that affected the world, the result of which the formulation of a global health organization. The World Health Organization (WHO) was born into existence through the signing ofthe WHO's constitution on April7, 1948. The goal of WHO is, "to improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health", this is achieved through the implementation of public policies for health, through promotion of health in communities with education and working with other national and international groups that are also focused on health (The World Health Organization 2007). 52

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The WHO is not a legal body and does not have authority over governments; however, their regulations do hold significant power. In order for a country to receive any assistance from the United Nations, the parent body for the WHO, they must agree to the WHO's International Health Regulations (IHR). The IHR is a voluntary contract which monitors, researches and aids in health issues around the world; the IHR provides a set of policies and regulations that set minimum health requirements for member states. All monitoring, research, and aid go towards enforcing those policies. Cholera is one of three diseases that are required to be reported under the IHR and that reporting can lead to travel and trade restrictions affecting the economic basis of the country. Due to this fact, it is estimated the actual cholera cases are much higher world wide. The World Trade Organization (WTO) was formed in 1995 from the General Agreement on Tariffs and Trade, GATT, with regulations going back to 1948 (The World Trade Organization 2011).The main roll of the WTO is to act as a forum for negotiations based off the set of rules or agreements that member nations signed and agreed to under GATT. The WTO's regulations have been effectively enforced for more than five decades. According to the WTO's website, it has helped countries that have faced trade barriers by using the negotiation forum, to liberalize trade; "But the WTO is not just about liberalizing trade, in some circumstances its rules support maintaining trade barriers-for example to protect consumers or prevent the spread of disease" (The World Trade Organization 2011). This means that a reported cholera outbreak may result in trade barriers on an export-based economy in order to prevent the spread of disease. While the WTO and the WHO both work to prevent the spread of diseases, they also strive to help smaller nations expand and prosper through participation in the global economy and improving overall health in the country. Each organization has their own set of regulations or agreements that are geared more towards their perspective missions around the prevention of the spread of diseases. The WTO states that, "the system's overriding purpose is to help trade flow as freely as possibleso long as there are no undesirable side-effects". 53

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Ann Marie Kimball outlines how the WTO achieves this in her book, Risky Trade (Kimball 2005). She states that there are five agreements that can be linked to the emergence of epidemics, the GATI, TBT, SPS, TRIPS and GATS. However participation in these agreements, especially for developing countries, could actually impede economic development because of built-in health precautions. It sets up a lose-lose situation; either Cameroon reports cholera cases with negative economic impacts, such as bans on exports or loss in tourism, or they do not report outbreaks and suffer negative health impacts such lack of medical assistance and less investment from international organizations. Cameroon in the Global Market Cameroon currently participates in the global market and is a signing member of the WTO. Their participation in these organizations affects the perpetuation of cholera through the concepts presented by David Harvey. The WTO was born in the era of neoliberalizm and follows the tradition of protecting the most important economies; however, this can have negative effects on less important economies, such as Cameroon. The publicized advantage of being a member of the WTO for small countries like Cameroon is that membership should give the country an opportunity to negotiate trade with larger countries in a transparent manner and decrease pressure from larger economies to make unfair deals. However extraction-based economies have little protection from the WTO. They add no value to goods and no WTO rules specifically regulate international trade of natural resources. Additionally, there are gaps in regulation and a general lack of understanding of how the rules apply to specific situations, leaving Cameroon without protection for its largest industry. The WTO also does not have authority to regulate natural resources prior to extraction or harvesting, meaning that they do not act as the mediating body for contracts of extraction (Bacchetta, et al. 2010). What the WTO does for extraction-based economies is promote 54

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free-trade with larger economic markets with the idea that shared economic freedom will stimulate a natural supply and demand curve. One such agreement exists between the European Union (EU) and Cameroon. In 2007 Cameroon started negotiations for an Economic Partnership Agreement (EPA) with the European Union signing an interim EPA in 2009. This stated goal is to promote trade, 'through trade development, sustainable growth and poverty reduction' (The European Trade Commission 2011). EPA's are targeted and established for small economy countries, with a 15-year implementation plan. The EPA with Cameroon stipulates the following (ibid): Cameroon exports to the EU will be tariff-and duty-free A Gradual liberalization between 2010-25 up to 80 per cent of EU imports into Cameroon An exclusion of Cameroonian sensitive sectors from liberalization for the remaining 20per cent of EU imports (Cameroonian sectors still needing protection from EU imports, e.g. farm products like meat, flour and dairy products) EU infrastructure support to foster cross-border trade with regional neighbors EU support to help fragile economic sectors and exporters meet EU import standards A study conducted by Bussse and Grobmann (2007) of the trade and fiscal impacts of EPA's in West Africa found that while implementation will increase trade and decrease trade barriers, they will also increase preferred imports from the EU by around 21 per cent, and as a result of preferential tariff treatment, government revenue will actually decline by 4 to 9 per cent on average. This assumes that EU importers will also decrease costs with the elimination of tariffs. However other studies on EPA's indicate concern that the narrowing of the market in African countries might actually entice companies to increase, rather than decrease, the cost of goods (Perez and Karingi 2007). The study found that tariffs account for a significant portion of the government expenditure budget and therefore, by participating in an EPA, will require measurements be made to offset the decrease in revenue from trade liberalization. 55

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The effects on Cholera As noted previously, cholera is a treatable and preventable disease. Countries that are vulnerable to endemic cholera, like Cameroon, are low income economies that have limited resources to improve health care and sanitation. In theory, improved access to the global market will increase revenue for the economy, which will increase the ability for infrastructure development. However, due to their limited ability to protect themselves in the global economy and because of best practice agreements like EAP's, the countries are stagnated in their poor economic situation. International organizations such as the WTO protect trade between large economies; but their rule of law does not reach extraction oriented nations. Natural resource extraction and agriculture are the primary export industry in Cameroon, but without the protection from the WTO they are vulnerable to exploitation. Power Relations As table 4 illustrates, power relations under this lens stem from the economic drivers of climate change and from the location of economic decision-making in global trade. Smith suggests that uneven development is a result of the capitalistic economy, by which some regions of the world take on all the negative externalities while other regions accept all the benefits. Two conditions are necessary for Cameroon to be unequally affected by climate change, both of which are a product of power relations: (1) excessive production of goods and accumulation of raw materials and (2) the relegation of Cameroon as a laborer in the global market. 56

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Global warming is the result of increased production of capital. Smith points out that the purpose of capitalism is to centralize capital to increase its accumulation (Smith 1984). This process is accomplished only through the division of labor and pursuit of raw materials. Through the division of labor and this pursuit, specific economies take on a larger role in environmental degradation. These same economies are producing more efficiently, leading to more capital. In the middle of this race for accumulation are the laborers, or in this case, Cameroon. The point could be argued that Cameroon had the same opportunity to become part of this cycle, however, the reality is that as capitalism was developing, Cameroon was locked in colonial stagnation. Prior to the annexation of Cameroon to Germany, the 'country' was made up of tribes that acted independently, but worked to support each other. They used the land to meet the needs of the people through, farming, hunting gathering, etc. This is not to say that if this way of life had continued that the problems of cholera in Cameroon would not exist, however, the actions of the Germans, French and British affected the vulnerability of the country. The Germans worked to build up a trade network of raw resources to be used within their own country; because of this they cultivated large pieces of land for plantations with the direct intent of exploiting the land for profitable products to be shipped back to Europe. They went as far as to develop a research center to investigate which are the best crops to grow and how to use the land most efficiently The process of colonialism is an example of what Smith refers to when he discusses the importance of accumulation of goods (Smith 1984). Cameroonians might have not been so dramatically affected if they had been treated like German patriots. The social inequality that was assigned to the native population, first with the Germans and later with the French and British, relegated them to the 'laborer' position in society, ultimately formulating the structures for its current uneven development. 57

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Power relations and climate change have affected cholera outbreaks in Cameroon through development of capitalism and the consequent social order. The drivers of climate change are the consuming economies, while the effects are universal it is the societies that labor to produce goods for consumption and lack the means to consume the products that feel the effects most dramatically. In the case of Cameroon, global warming affects costal and farming areas, increasing susceptibility to illness and cholera The affects of international trade on cholera in Cameroon lies in the location of its economic decision-making power. International trade agreements favor nation states that produce goods rather than extract materials. At the same time, The World Trade Organization aims to protect the largest economies from collapsing. Resource-rich regions of the world are the "laborer's" that Smith refers to, they provide their own power in order to survive. This has caused Cameroon to become trapped in the cycle of uneven economic development; they extract resources in order to procure capital to invest in infrastructure but are not protected by global regulation so can not participate heavily in the global economy. Uneven development, climate change and international trade are related under the structure of power relations that increases Cameroon's vulnerability to cholera outbreaks. Even though Cameroon does not heavily participate in the global economy and does not have financial resources to tackle health issues like cholera, they are disproportionately impacted by the consequences of the global economy through increased vulnerability to climate change, which ultimately lead to increased levels of cholera. Historical lens The historical lens furthers our understanding of why cholera exists where it does in a temporal context. This lens examines the occurrence of marginalization in development for the country as a whole during colonialism and the marginalization within the county, today. Looking at the role of marginalization and cholera will further our understanding of why 58

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Cameroon is more vulnerable to the systems discussed under the geographic lens. Marginalization is the process in which a portion or group is relegated to an unimportant or powerless position within a larger whole (Merriam-Webster 2011). Marginalization and Cholera The association of cholera with marginalized populations is not new. In 19th century Europe, the establishment of new sanitation practices benefitted the wealthier classes and alienated the poor, who relied on scavenging as their main source of livelihood. The poor were also readily blamed for continuing the spread. In the early 20th century, it became common practice to quarantine ships by requiring the crew and steer passengers to stay on board, while releasing the wealthy passengers. Presently, countries that are most likely to have cholera are also the countries that stand to be affected the most for a loss of income, and thus, are the most deeply impacted by trade sanctions. Marginalized populations today are the most at risk for health problems and because of their position in society, lack of economic freedom, political influence and environmental condition, they are least likely to overcome health problems. In fact, for those same reasons, the marginalization of populations will perpetuate poor health. This is not unique to lower economic nations, even within larger economies with significantly more access to health care and social programming; there are disparities in health between segments of the population (Zaidi 1988, Marmot 2005). The Center for Disease Control and Prevention (CDC), the main health board for the United States Department of Health and Human Service, states that, "health disparities are differences in health outcomes between groups that reflect social inequalities" (Center for Disease Control and Prevention 2011). These social inequalities are income level, education, poor environmental conditions and limited access to health care facilities. While there is no mention of the term "marginalized", this inability to overcome health issues is the result of 59

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unequal participation or ability to participate in the government system because of lack of education, because of limited resources, and because of geographic location. The role of non-medical causes for heath disparities can be explored in Cameroon's cholera outbreaks. Most recently, the Extreme North has experienced the most cases. The Extreme North is one of the most marginalized segments of the population in Cameroon and its environment makes it the vulnerable province in the nation. A small country in West Africa with little influence in the global systems, with a small GDP, a small military force, a low education rate and an economy based of resource extraction and agricultural, is marginalized and is at an increased risk for disease. The events that took place during colonization fostered Cameroon's marginalized position in the global systems results in increased vulnerability to poor health and cholera outbreaks. Colonialism and Marginalization Cameroon, as it exits today, is a compilation of border negotiations with little regard for pre existing geographic, ecological or social entities. During the 'rush for Africa,' colonial powers in Europe pushed to gain the maximum amount of territory with the most natural resources. The practice of colonialism, the domination or the subjugation of one people to another that were expected to benefit European powers economically and strategically, leads directly to the marginalization, on a global scale, of former colonies today (Kohn 2010). Other authors have discussed exacerbated marginalization in today's society as a result of globalization trends (Gabriel1997, Molua 2002), however the practices that took place in Cameroon, first with the Germans than with the British and French, such as enslavement of indigenous populations and forced labor, along with status' of a lesser class all paved the way for an unequal roll in the global systems. 60

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Role in Global System Cameroon, like most African countries, was put at a disadvantage for participation in the global economic system because of their social, political, economic, and environmental marginalization. In order to 'conquer' the territory that is now known as Cameron, the Germans first needed to create alliances with the chiefs, in which the Germans were given access to the Port of Duala and the allegiance of the people, however, they were not to move to the interior. The indigenous population wanted to maintain their role as middle men and regulate the flow of natural resources. However, the Germans disregarded any clauses in the annexation treaty that were written to protect the middlemen. This move clearly indicated that the indigenous population's political representation was viewed as unimportant and powerless against the Germans. Indigenous culture in Cameroon was based on family and community prior to the arrival of the Germans. The community worked together to care and feed themselves, they did not traditionally leave to work and then return with money. The Germans had a hard time cultivating a labor force to work on plantations, in the construction of the infrastructure and as mover of goods. Once again, the Germans saw the indigenous population as something they owned and could do with as they willed, and forced workers from their homes and force them to work under cruel and harsh conditions. The Germans were not the only group that limited the development of Cameroon, the French and British also considered the indigenous population to be of a lesser status. This can be seen in the class system that was established after WWI. The country as a whole was ranked as a 'B status' colony, which meant that they were treated as a colony that was not able to operate independently. This condescending perception and the powerlessness of the indigenous population perpetuated the idea that they were lesser or unimportant in the world scheme. Additionally, Cameroonians were given different legal status from the French colonists in order to preserve the existing legal proceedings, keeping the indigenous 61

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population from participating in the governing of their nation and giving all the political control to the settled population. In British Cameroon, a significant percentage of the land was used for large plantations that were worked by Cameroonians for economic benefits reaped by the primarily German plantation owners. After WWI, when the British were given mandatory powers by the League of Nations, they attempted to auction off all the existing plantations in Cameroon. Cameroonians, who had been working the land and to whom the land was most likely originally obtained, were not allowed to participate in the auction. This action marginalized the indigenous population, relegating them to labors, powerless to run a plantation and putting them in a position of not being able to overcome their economic status. All three colonial powers exploited the lands in Cameroon. They were used strictly for their crops, and their timber. Little to no attention was given to how the goods were obtained, as long as they were obtained relatively quickly and in large quantities. Through their methods of economic development, all three powers established the precedent for a resource-based economy. While French offered higher education to the indigenous population, it was only for agriculture, which helped to further of the production of the land. Resource extraction zones have historically received little profit from the resources. Profits are generated in other parts of the world that manufacture and sell the items. This legacy plays out today, insofar as Cameroonians do not have the capacity to adequately prevent and mitigate cholera outbreaks. Marginalization within Although historical decisions led to a form of development that has largely hindered growth comparable with North America, Europe, or Southeast Asia, notable economic development did occur in a few concentrated areas. This has led to highly uneven economic progress within Cameroon. 62

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The mandate status implementation after WWI further divided the country because there was significant disparity in how British and French Cameroon were being managed. The French, like the Germans, primarily focused their attention on the regions around Yaounde, where Plantations were developed and restructured after the liquidation of the preexisting German plantations, and a little in the Doula port. Education efforts were mostly with the intention of introducing French across the territory. Due to the 'subject' status of Cameroonians, higher education of the general population was not a priority. Higher education was an option for a few Cameroonians who were trained to work in administration and commercial production all jobs located in Yaounde and Douala. While the French attempted to establish mobile health care unit, due to lack of infrastructure in what is now North and Extreme North provinces, advanced health care was limited. Primary care used existing traditional Muslim practices. The French also continued the legacy of forced labor, removing young men from their homes to contribute to infrastructure development in the central and costal part ofthe territory. Power Relations The concept of marginalization would not exist without the influence of uneven power relations. By definition, marginalization connotes a lack of power. Power relations helps explain how a population becomes marginalized. Prior to the annexation treaty, the individual tribes within Cameroon held power. Through the course of the annexation, the manipulation and subsequent transfer of control of territories between France and Britain, the power of these tribes had been diminished and in some cases nullified. Cameroonians were exploited for their resources. The power to mange natural resources shifted from tribal leaders to colonial leaders. As a result, colonial powers stripped Cameroon of their ability to generate and maintain profits. 63

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Geography, History and Power Relations The role of power in historical and geographical studies is an essential part of a political ecology analysis; it can not be separated from either of the lenses and is the driving force behind history and geography today. The drivers and effects of global warming and economic disparities and marginalization do not just happen; they are the result of a calculated push and pull for power. Power relations determine which countries have the power to release large amounts of carbon dioxide, which control trade laws that favor commodity-based economies over resource-based economies, and which are marginalized in the global economic system. Most power negotiations stem from colonization and the implementation of western ideologies in Cameroon. Cameroon was targeted for its potential resources, and then exploited once systems of power and control had been established. The movement towards marginalization within the country was perpetuated by economic power by the giving of privileges, such as education, health care, and infrastructure, to those in areas where resources could be exploited. The fostering of economic growth ultimately supports economic power, strengthening the cycle of marginalization. During the time of colonialism, the Cameroonian community had certain levels of environmental and social power; they were not subservient bystanders that just let the colonials take their country from them. While the population was not a unified country, the tribes formed a connected network of communities. The methods of colonization broke up this network, through forced labor and negotiation with the interior, effectively disrupting the existing system and taking advantage of the resources. This progressive processes of marginalizing the Cameroonian population and the failure of colonial power to adequately equip them to participate independently in the global market set the stage for Cameroon as a marginalized economy in the global system. While power relations are not a direct cause for the perpetuation and magnification of cholera in Cameroon, they were the driving force for marginalization during colonization and today. 64

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CHAPTER 5 DISCUSION AND CONCLUSIONS This thesis set out with two goals; first, to provide further insight into the drivers of continued cholera outbreaks in a developing country, beyond traditional epidemiological evaluations; second, to contribute to the larger discourse of political ecology by providing an example of a political ecology approach to understanding a disease. These were achieved through the use of a case study on cholera outbreaks in Cameroon. The flow of the thesis provided evidence of the medical and social importance of cholera, examined the discourse of political ecology and its new movement towards understanding diseases, and provided the outline for a political ecology analysis of cholera in Cameroon. The third chapter looked at the geography and history of Cameroon specifically focusing on key factors that contribute to the vulnerability of the country. Finally, chapter four combined the information from the first three chapters to provide a discussion of the political ecology of cholera in Cameroon. The importance of this research lies not with finding solutions to cholera but in providing a new way to look at cholera in order to address the root causes of the illness rather than treatment of it. 65

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Political Ecology and Cholera Understanding Cholera A political ecology approach for looking at a pandemic disease like cholera is useful because it provides information about the continued existence of the disease, despite so much knowledge about prediction, prevention, and treatment. Cholera is not a difficult disease to prevent or treat, yet there are still and estimated 3-5 million cases with 100-120 thousand deaths each year (The World Health Organization n.d.). A political ecology approach can explain why cholera continues to develop, why it develops where it does and why it may continue to be a problem in the context of local and global economic systems, both current and historic. This thesis used two lenses, geographic and historic, to look at the interactions of the four categories of political ecology on the perpetuation of cholera in Cameroon. The geographic lens looked closely at the role of globalization on global warming, international trade, and the vulnerability of Cameroon to cholera as a result. The historic lens looked at the colonial development of Cameroon in establishing the country as a marginalized society, leading to the country's vulnerability as a whole. The historic lens also looked at the role of colonialism on marginalization within the country and discussed how focused development in certain parts of Cameroon actually increased the vulnerability to cholera in other areas-which happen to be where most cases occur. The discourse of Political Ecology This thesis provides an example of a political ecology approach to studying disease. The political ecology analysis used was developed from a literature review of the definition of political ecology and how others framed political ecology studies. Five seminal texts were looked at to support the use of a political ecology approach to looking at cholera. The five 66

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texts all looked at cholera, but none explicitly discussed the interplay of all four categories of political ecology on cholera. This thesis aimed to bridge the four categories by looking at the role of power over time and across space intertwining, history, geography, and power relations. Limitations of the Study No primary data was collected for this research, data on outbreaks in the country came from the World Health Organization's (WHO) Weekly Epidemiological Reports (WER) and reports of major outbreaks on the WHO's publication website. Analysis of the history and the current state of affairs in the country came from a secondary school text book, written by a Cameroonian for Cameroonian students with supplemental information from a historical dictionary on Cameroon. The scope of the project limited the depth of the political ecology analysis under each lens and by no means covered all relevant topics. However, it is important to reiterate that this study provides an in-depth look at possible contributing factors to cholera in Cameroon beyond epidemiological studies. In addition, the summary of texts on political ecology and its trends were limited. The review of seminal text was based on authors and editors that were referenced most often; however, they may not encompass a complete analysis of the current discourse in political ecology. Recommendations for Future Research Because of the scope of the project, the topics within each lens were a cursory overview. Each lens on it own could be a research project, depending on the depth in which it is covered. There are benefits to a focused approach; with a more in depth review, potential 67

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solutions could be proposed. This study tests an approach for understanding links and drivers of cholera outbreaks. A number of different lenses could be used to examine cholera. Each lens could provide different conclusions or causes for the continuation of cholera. Even within the lenses used a number of other questions could be asked. For example, within the historical lens it would be interesting to look at the historical treatment of cholera within the county and how that has developed over time compared to how wealthier nations have dealt with outbreaks. Further research could be completed on the societal aspects of the different communities. It would be interesting to look at the difference between the politics around water ways in the different communities in Cameroon, focusing on the main tributary for Lake Chad and compare it to the use of the tributary for the port of Douala. The arbitrary borders of a country make it easier to find information, but using a more in depth understanding of the political ecology around cholera may be achieved by looking at the different river basins and how they cross the political boundaries. For example, compare cholera outbreaks in the Chad River basin and the Niger River basin, based on the social, political, economic and environmental conditions in each basin. The river basins flow into multiple political boundaries which can increase stress on the water source. The usefulness of looking at the effects of the increased stress on the basins in contributing to cholera within one single political boundary would be very interesting and may help to explain the continuation of outbreaks. 68

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APENDIX A CASES REPORTED DATA Year Month City region Cases Deaths Case Fatality Rate 1971 March Mefou Center 3 0 0% 1971 March N'Kam Center 1 0 0% 1971 April Mefou Center 2 0 0% 1971 April N'Kam Center 36 2 6% 1971 April Nyong-etCenter 2 1 50% Kelle 1971 May Nyong -etCenter 6 2 33% Kelle 1972 February N'Kam Center 3 0 0% 1972 April N'Kam Center 3 1 33% 1973 February N'Kam Center 2 0 0% 1973 June Mefou Center 1 0 0% 1971 June Diamare Extreme North 1 0 0% 1971 June Logone -etExtreme North 824 112 14% Chari 1971 July Logone-etExtreme North 169 57 34% Chari 1971 July MayoExtreme North 34 8 24% Danay 1971 August Diamare Extreme North 1 0 0% 1971 August Logone-et Extreme North 23 5 22% Chari 1971 August MayoExtreme North 197 26 13% Danay 1971 September MayoExtreme North 48 5 10% Danay 69

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1971 October MayoExtreme North 6 0 0% Danay 1971 Novembe r Mayo Extreme North 4 0 0 % Danay 1971 May Margui -Extreme North 1 0 0 % Wanda I a 1972 Janua ry Logone et Extreme North 1 2 2 1 7 % Chari 1972 January Lomet Extreme North 2 1 50 % Djerem 1972 January Mayo -E xt r eme North 1 0 0% Danai 1991 June Extreme North 634 46 7 % 1991 July mayo -Ext r eme North 759 126 1 7 % Danai 1991 September D i amare Extreme North 3560 729 20% 1971 March SanagaLittoral 15 0 0 % Maritime 1971 Ma rch Wouri Littoral 23 0 0 % 1971 Apr il Sanaga-Littoral 1 4 0 0 % Maritime 1971 April Wouri Littoral 57 4 7 % 1971 May SanagaLittoral 2 1 50 % Maritime 1971 May Wouri Littoral 47 5 11% 1971 June Wouri Littoral 8 0 0 % 1971 Jul y SanagaLitto ral 1 0 0 % Mari t i me 1971 July Wou ri Littoral 7 0 0 % 1971 Augu st SanagaLitto ral 1 5 2 13% Maritime 1972 January Wouri Littoral 61 6 10 % 1972 February SanagaLittoral 1 0 0 % Mariti me 1972 February Wouri Littoral 24 1 4 % 1972 Marc h Wouri Littoral 20 1 5% 1972 April SanagaLittoral 2 1 50 % Maritim e 1972 April Wouri Littoral 55 4 7 % 70

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1972 May SanagaLittoral 1 1 100% Maritime 1972 May Wouri Litt oral 30 0 0% 1972 June Wouri Littoral 13 0 0% 1972 July SanagaLittoral 2 0 0% Maritime 1972 July Wouri Littoral 23 3 13% 1972 Aug ust Wouri Littoral 2 0% 1972 Septembe r Wouri Littoral 8 0 0% 1972 October Wouri Littoral 10 2 20% 1972 November Wouri Littoral 7 0 0% 1973 January Wouri Littoral 13 1 8% 1973 February Wouri Littoral 11 0 0% 1973 Apr il Kumba Littoral 14 4 29% 1973 April Wouri Littoral 46 1 2% 1973 June Wouri Littoral 30 1 3% 1973 July SanagaLittoral 2 1 50% Maritime 1973 July Wouri Littoral 41 0 0% 1973 August Wouri Littoral 2 0 0% 1973 September Wouri Littoral 3 0 0% 1973 November Wouri Littoral 5 0 0% 1974 July Wouri Littoral 21 1 5% 1975 June Wouri Littoral 1 0 0% 1985 June Moungo Littoral 486 72 15% 1985 October Littoral 246 22 9% 1974 September Extreme North 28 10 36% 1974 Octobe r Extreme North 23 5 22% 1971 May Bamoun North 1 1 100% 1972 February Bamoun North 1 0 0% 71

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1971 April Kribi South 3 0 0% 1971 May Kribi South 2 1 50% 1971 March Kumba South West 7 5 71% 1971 March Victoria South West 39 1 3% 1971 April Kumba South West 29 5 17% 1971 April Mungo South West 1 0 0% 1971 April Victoria South West 30 0 0% 1971 May Victoria South West 14 0 0% 1971 June Victoria South West 11 0 0% 1971 July Kumba South West 2 0 0% 1971 July Victoria South West 33 2 6% 1971 August Victoria South West 11 0 0% 1971 September Victoria South West 9 0 0% 1971 October Victoria South West 18 1 6% 1971 November Victoria South West 7 0 0% 1972 January Mungo South West 23 4 17% 1972 January Victoria South West 6 0 0% 1972 February Mungo South West 1 0 0% 1972 February Victoria South West 6 0 0% 1972 March mungo South West 2 0 0% 1972 April Mungo South West 8 0 0% 1972 April Victoria South West 2 0 0% 1972 May Mungo South West 8 0 0% 1972 May Victoria South West 9 3 33% 1972 June Mungo South West 23 5 22% 1972 July Kumba South West 6 0 0% 1972 July Mungo South West 8 1 13% 72

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1972 July Victoria South West 2 0 0% 1972 September Kumba South West 2 0 0% 1972 October Mungo South West 2 0 0% 1972 November Mungo South West 3 0 0% 1973 January Victoria South West 1 0 0% 1973 April Victoria South West 20 0 0% 1973 June Victoria South West 7 0 0% 1973 July Victoria South West 10 0 0% 1973 September Victoria South West 1 0 0% 1971 April Haut-Nkam West 1 0 0% 1972 April HautWest 1 0 0% N'Kam 1985 September Bamboutos west 354 17 5% 1992 September Manyu South West 211 17 8% 1992 November South West 94 3 3% 1992 December South West 38 1 3% 1992 July Mifi West 393 23 6% 1992 May 353 10 3% 1996 March 128 6 5% 1996 June 515 18 3% 1996 August 2844 206 7% 1996 November 1229 105 9% 1997 January 1980 240 12% 1997 July 425 21 5% 1997 August 665 40 6% 1997 December 619 119 19% 1998 July 417 53 13% 1998 September 589 60 10% 73

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1998 October 100 0 0% 1998 November 2508 202 8% 1999 January 993 1 0% 1999 May 1584 26 2% 2001 September 158 3 2% 2002 November 66 8 12% 2004 February 720 13 2% 2004 March 715 24 3% 2004 April 306 2 1% 2004 May 243 0 0% 2004 June 2048 26 1% 2004 August 1260 5 0% 2005 February 428 3 1% 2005 March 69 1 1% 2005 May 62 3 5% 2005 June 153 0 0% 2005 September 1434 43 3% 2005 October 701 60 9% 2006 March 334 7 2% 2006 August 588 28 5% 74

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