Myron Echenberg, the author of the Herskovits award-winning Colonial Conscripts: The Tirailleurs Sénégalais in French West Africa (1991), has also written two important works on the history of the black plague (Black Death, White Medicine: Bubonic Plague and the Politics of Public Health in Colonial Senegal, 1914–1945 [2002] and Plague Ports: The Global Urban Impact of Bubonic Plague, 1894–1901 [2007]). In Africa in the Time of Cholera, he continues his research into the historical epidemiology of Africa.

His introduction describes the ecology of the Vibrio cholerae bacterium, the etiology and progress of human infection by the bacterium, and the life-saving oral rehydration therapy (ORT) that has been known to be an effective intervention for several generations. It familiarizes the reader with the basic science of cholera. The rest of the book is organized into two parts. The first provides an overview of Africa's experience with the first six cholera pandemics, from 1817 to 1947. The author describes the early nineteenth-century networks of international trade and patterns of warfare and pilgrimage that facilitated the diffusion of the First Pandemic (1817–26) from the Ganges Delta to other parts of Asia, the Indian Ocean islands, and the eastern African coast. The Second Pandemic (1828–34) had broader purchase, circling much of the globe. In Africa, the major impact began in Algeria, where French troops inadvertently introduced the disease, and then spread to neighboring Morocco and Libya. The Third Pandemic (1839–61) was more devastating than the first two, and the peoples both of North Africa and eastern Africa (from Egypt to Mozambique) were affected. The Fourth Pandemic (1863–79) and Fifth Pandemic (1881–96) reached sub-Saharan West Africa, striking the Senegal and Gambia River valleys; and the Fourth Pandemic also spread south from Egypt more deeply into eastern Africa, reaching Zanzibar which lost an estimated 70,000 people to the disease in 1869–70. The Sixth Pandemic (1899–1947) touched lightly in Egypt and did not affect other African regions.

What were the medical and political responses to these first six pandemics? Echenberg explores the medical responses to epidemic cholera in Europe and the United States that include the rise of sanitarianism, efforts at containment by quarantine, and, during the Sixth Pandemic, the use of ORT. In West Africa, both the French and Malinke political authorities tried to enforce quarantine to stop the movement of people into and out of affected areas, but these efforts had no success. In Ethiopia, royal efforts to stop the progress of cholera from the coast similarly failed. In Zanzibar, the pioneer epidemiologist James Christie reasoned that polluted water absorbed by the alimentary canal was the cause of the disease, but his masterwork, Cholera Epidemics in East Africa (1876), that Echenberg considers to be of comparable importance to the mid-nineteenth century researches of John Snow on cholera in London, remained largely unknown.

The second part of the book is devoted to the Seventh Pandemic (1961 to the present), centered in Africa. The Seventh Pandemic was caused by a new biotype of the cholera pathogen that was less virulent, and it took place during an era of new medical and biological understandings of the disease and the effective, inexpensive means to treat it. (In 1978, ORT was hailed by The Lancet as ‘the most important medical advance this century’ [p. 103].) Oral cholera vaccines were also developed, but they were expensive and worked only for a short time.

Nonetheless, the Seventh Pandemic was devastating for Africa, owing to the proliferation of risk factors since the mid-1970s. The two major sets of changing risk factors were ecological and political. In the Lakes Chad, Tanganyika, and Malawi, the cholera bacillus established a home. It became an endemic disease, capable of epidemic outbreaks. The unsettled political environment in the Democratic Republic of the Congo nurtured infections, particularly in refugee camps in which vulnerable civilians were exposed to the pathogen. The political and military destabilization of Mozambique by the South African apartheid government destroyed the primary health care network there, and the armed conflicts displaced large populations who became vulnerable to a host of infections including cholera.

The author highlights the fact that cholera risk is also a function of public health policy choices, and he uses evidence from Senegal, post-apartheid South Africa, and Angola to illustrate that the privatization of access to water has exacerbated the risks of cholera infection. An entire chapter is devoted to the collapse of the public health system in Zimbabwe, in which he paints a portrait of cholera in a ‘failed state’. He makes a persuasive case that investments in clean water and decent sanitation are to be far preferred to a dependence on expensive emergency relief measures.

Africa in the Time of Cholera is a major contribution to the history of Africa and to the medical literature on infectious disease. It is the first to draw together the outlines of the first six global cholera pandemics and the first to explore Africa's experience with the Seventh Pandemic, during which cholera has primarily become an African disease. It will become a standard reference for scholars and policy analysts who strive to understand the reasons for cholera outbreaks within Africa and across the globe.