Inside a cholera treatment centre in Somalia

Southern and East African countries are facing a severe cholera outbreak that is exposing the failure in public sanitation and the impact of government neglect.

Last year, there were more than 109,442 cholera cases resulting in 1,708 deaths in 12 countries in the Eastern and Southern Africa Region (ESAR), according to the UN children’s agency, UNICEF.

Since the beginning of 2018, there have been more than 2,009 cases and a further 22 deaths in seven countries – Angola, Kenya, Malawi, Mozambique, Somalia, Tanzania, and Zambia.

Zambia has been among the hardest hit, with the waterborne disease killing more than 74 people since October last year.

Cases have been centred on the capital, Lusaka. To contain the outbreak, the government banned street food vending and public gatherings, which triggered violent protests by traders.

The World Health Organization says that while sporadic cases of cholera are regular occurrences in Zambia during the five-month rainy season, 2017 exceeded the average annual caseload.

The government and the WHO blame poor waste management and inadequate personal hygiene for the contamination of water and food in the townships, which has driven the epidemic.

The government’s response has been to call in the army to help enforce control measures, clean markets, and unblock drains. It also launched an oral vaccine programme with a target of immunising one million people, and the number of cases is now beginning to fall.

Failing record

Zambia, as a lower middle-income economy, lies in the middle of a range of countries caught in the surge of cases in the region, from struggling Mozambique to relatively prosperous Kenya.

“In the last four weeks of 2017 alone, Zambia reported 217 new cases of cholera including 11 deaths, Tanzania 216 new cases including eight deaths, Mozambique 155 new cases, and Kenya 44 new cases,” UNICEF’s regional WASH (Water, sanitation and hygiene) advisor for Eastern and Southern Africa, Suzanne Coates, told IRIN.

But by far the worst-affected countries have been war-debilitated Somalia and South Sudan, with 72 percent and 16 percent respectively of the total cholera caseload.

Beyond the ESAR region, the Democratic Republic of Congo is experiencing the worst cholera outbreak since 1994, with 55,000 cases and 1,190 deaths reported in 24 out of 26 provinces last year, according to Médecins Sans Frontières.

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Coates noted that while progress has been made on access to improved WASH services over the years, no country in the region managed to meet the 2015 Millennium Development Goal on water and sanitation – to halve the proportion of the population without access to sustainable water services and basic sanitation.

Latest WHO and UNICEF estimates indicate that only 53 percent of ESAR citizens have access to basic water services; 30 percent to basic sanitation; just 20 percent to basic hygiene; and that 21 percent of people still practice open defecation.

“So, in the region, we still have more than 148 million people using unimproved drinking water sources, over 108 million still practising open defecation, and over 300 million with no handwashing facility,” said Coates.

“Strategies to prevent and respond to cholera outbreaks are known and are effective and have helped [other] countries effectively control cholera outbreaks,” she added.

Spending needed

Tackling the risk factors requires a developmental response and long-term investment. “Cholera outbreaks will unfortunately recur as long as these factors are not addressed,” said Coates.

Zimbabwe’s cash-strapped government has struggled to make those investments in sewerage infrastructure and water management systems, with cholera outbreaks becoming more frequent since the early 1990s when the economy first stalled.

Large outbreaks occurred in 1999 and 2002, with the deadliest between August 2008 and July 2009 – a cumulative total of 98,592 cases and 4,288 deaths.

Oxfam Zimbabwe WASH coordinator Abigail Tevera said poor inter-ministerial coordination and a lack of commitment to enforce existing regulations also derails efforts to prevent outbreaks.

Four people have so far died from cholera in Zimbabwe, with over 200 cases of typhoid – a similar waterborne disease – confirmed by 16 January.

Portia Manangazira, the director of Epidemiology and Disease Control in Zimbabwe’s Ministry of Health and Child Care, acknowledged that the public health and sanitation situation in the country was “appalling”, and the nation could do much better to stop “creating” avoidable health crises.

“There have also been no resources to identify high-risk groups and protect them with vaccination, the second layer of population protection when primary prevention has failed,” Manangazira told IRIN. “For this reason, the threat of both cholera and typhoid forever looms.” - IRIN