Epidemic cholera struck Peru in January 1991, and spread rapidly. The national cholera case-fatality rate (CFR) was less than 1% in the first six months of the epidemic, but in some rural areas, the CFR exceeded 10%. We investigated cholera mortality in the rural Amazon region, an area with a CFR of 6.3%. We conducted a case-control study, comparing 29 decedents with 61 survivors of recent cholera-like diarrheal illness in 12 villages with a combined CFR of 13.5%. Of 29 decedents, 28 (96%) died in the village or en route to a health facility. Death occurred within 36 hours of illness onset for 83% of the decedents. In 11 (92%) villages, the first or second recognized case was fatal. Death was associated with receiving treatment only at home (odds ratio indeterminate; 95% confidence interval 3.5, indeterminate). Treatment with oral rehydration salts (ORS) was not protective against death for patients who received treatment only at home. Treatment with homemade sugar-salt solution (SSS) was also not protective; fewer than one-third of respondents knew the correct SSS recipe. Most decedents experienced multiple barriers to health care. Cholera victims died rapidly and early in village outbreaks, and few patients had access to health care. Provision of threatened villages with ORS supplies and education in their use before cholera strikes is essential to reducing cholera mortality in this region.