City cholera outbreak must be taken seriously

THE cholera outbreak being contained at a fairly low level and centred amid a religious community in Buhera that does not willingly accept medical attention, with odd outbreaks as some visitors to Buhera bring back the infection, has suddenly become far more dangerous.

It has moved into a crowded city, Harare, and not just into a city, but into a single suburb of the city, Kuwadzana, and is no longer confined to single households or families, but seems to be spreading in a community.

It is early days yet, but around half the new 145 cases nationally have been reported from Kuwadzana and already a focus of 70 cases in a single suburb needs urgent attention.

Cholera should not be a threat to a modern city, or at least not a threat outside a single household where one person returned home with an infection and it spread to others in the household who perhaps took chances over personal hygiene.

But to spread to neighbours and others in the community should simply not be possible.

The fact that it is spreading shows up a number of problems. Cholera can only spread via excreta from an infected person to an uninfected person, the ease of spreading perhaps enhanced because cholera also produces acute diarrhoea, which makes it harder to contain.

The contamination can be on hands, and food can be contaminated if it has not been properly washed in safe water.

We know from bitter experience within Harare that cholera can spread very fast in a highly crowded environment in a large city, and since each cholera outbreak starts with just one case we can never be complacent when it starts, and especially when it escapes a single household or family.

While personal hygiene is obviously the first line of defence against cholera, this does require adequate supplies of clean and safe water, enough for people to drink, wash themselves and wash their food, and does need safe disposal of sewage, so that contaminated waste is not lying or flowing around.

And here is where Harare can fall short. Water supplies are not adequate and the sewer network does have faults, and that combination is very dangerous.

It is still possible to beat back a wave of infection, but residents need to work far harder to do so, and however much they are willing to follow the hygiene recommendations they can miss out.

For example, posters suggesting people wash their hands thoroughly with soap under a running tap cannot be fully applied when the taps are dry.

People can still wash with soap, but have to use a bowl or a basin and water they have stored or have brought into their home in a bucket or drum. The hands will be clean, but not necessarily guaranteed free of infection.

The same problem can be seen when it comes to washing vegetables and other food. Some of that washing might just be spreading the infection in a bowl of water, rather than getting rid of it.

Bowl washing should not be ignored if it is the only choice; it is a lot better than doing nothing. But it is not the ideal way to cut the chain of infection.

Sometimes there is not even enough water to use bowls and drums and buckets. We saw that in

Mbare a couple of months ago, but the concentration of the urban borehole rigs assigned to Harare by the Presidential Borehole Programme did make a major difference and did mean that most people in Mbare could at least get a few drums of clean water within a few hundred metres of their home, hard work, but physically possible.

And that along with the public health appeals did push back the threat in that suburb.

Kuwadzana at least is a planned and developed suburb, in that the houses are connected to the water and sewer mains, even if these are not supplying water properly and even if the sewers are leaking.

At least something can be done in an emergency to make sure that the taps are on at least for some hours every day and that all sewer leaks and blocks are fixed promptly.

We assume some of the joint action being taken by the Ministry of Health and Child Care and the Harare Health Department is centred on these needs and that they can get through to the engineers and other technicians in the city administration that this must be the central focus in dealing with the outbreak.

The health professionals can give advice, but people need to be physically able to take that advice, and the doctors and nurses can treat the sick, but they cannot fix water pipes and sewers. Other units have to play their part.

Cholera around the world used to be a serious public health problem, and as cities suddenly exploded in size in the industrial revolutions of the 19th century, cholera epidemics became notorious and a major killer.

Those same engineers who built the railways and the factories defeated cholera by building the great trunk sewers, the water reservoirs and the huge networks of water pipes.

Making clean water available for all and ensuring all sewage was properly disposed of was the major revolution that made large cities inhabitable, and groups like Harare City Council simply need to apply these lessons as probably their most fundamental service.

We cannot have these continued outbreaks of cholera threatening the health of huge urban areas, simply because someone cannot maintain the water pumps and pipes.

Of course we need to deal with each rural outbreak as well, but in many cases this is easier because families are less likely to infect each other.

The fact that the Buhera outbreak was centred in a church community, where people meet and socialise and exchange food at church meetings did make it stickier, but even with the suspicion of modern medical treatment within that community, efforts to get people to act more carefully must have worked as the chains of infection were cut.

We hope that this surge of infection in Kuwadzana can also be contained, and that it will not explode, but it does require everyone in that suburb and Harare Metropolitan as a whole to do their part and not take risks with their own health and not do things that can spread the risk to other people in their communities.

As with all public health matters, none of us are safe unless all of us are safe, and that in turn means all of us need to make sure everyone, as well as ourselves, can be safe.