09/01/2024
Getting the Cholera fight right: Leading from the front.
By: Prof Wilbroad Mutale, MD, MPhil, PhD
Professor of Public health, University of Zambia School of Public Health.
As a doctor, it causes me much pain to see the loss of life from preventable causes such as cholera. Us doctors know that some things you cannot do much about or you may know very little about something so your response is limited. This is not the case with Cholera.We know so much about it that it should not kill anyone.
John Snow in 1854, made a major contribution to fighting cholera when he was able to demonstrate a link between cholera and the contaminated drinking water through his pioneering studies in London. That was it! No one should die from cholera from then on!
You don’t have to be a doctor or be educated to know this. It is public knowledge.
But why have we failed to deal with the evil we know can kill if left unchecked, 170 years after Snow’s discovery, 60 years after Zambian independence?
Why do we still have people without clean water and adequate sanitation in the national capital, Lusaka? Why do we still have compounds and residential areas where no human being should live?
Why do we allow flooded toilets and pit latrines every rainy season and keep hoping it will not lead to cholera? Why do we allow unplanned settlements when it is against the law for a good reason?
Like I said, this is very painful to see in this time and era, Zambia has good resources available to tackle this compared to other countries in the region, including peace, stability and predictability. Yet we just cannot provide clean water and sanitation to our own people. Unfortunately, the medical fraternity end up bearing the brunt of the epidemic as sick people and dead people must pass through our hands and so we are forced to respond as if we can actually control a cancer which has spread. We are simply dealing with symptoms and not the root cause in the fight against cholera. We have all good intentions, including a master plan to end cholera by 2025, but how far have we come in 2024, a year before the deadline?
Cholera is a social problem that manifests its ugly face as a medical emergency creating fear and anxiety. Put diarrhea and vomiting aside, these can be managed in most cases, but what we have failed to deal with as a nation is the social determinants of cholera, namely water and sanitation, housing, and inequalities.
It seems to me that inequalities have been normalized with shanty compounds being taken as a normal place to be born and die. Our future generation is being told that its okey to live in a place without toilets and water. Its okey to live in flooded shanty compound every rainy season as long as you do not get cholera!! It is not okey and it is embarrassing for a rich nation, which is not at war, to be in a situation where 500 people are admitted each day with cholera and numbers are rising. It should not happen and must not happen.
The question that you might ask me, what can we do then? Excellent question!
The answer lies in the presidency and his cabinet not the ministry of health. That is where all the answers have been sitting for the past 60 years even as I write this, I believe the solution is very close. While the ministry of health is mopping up, it is possible to close the tap.
Here is my suggestion:
1) The president should form an inter-ministerial emergency committee which he should head. Here, he will need ministers to sit with him as members, supported by technocrats. Not the other way round. Key in this are the following Ministries: local government, infrastructure and housing, water and natural resources and health. The ministry of health should play an advisory role, not leading this cholera elimination program.
2) Make a plan on how you will re-settle the people in cholera hot spots and make temporary shelters whilst exploring options and contractors that can partner with government to make new affordable housing in Kafue or Chongwe with proper access to water and sanitation. It is cheaper to do this and give free housing than to keep fighting cholera and losing lives every year.
3) The president must make all ministers and their respective ministries accountable, not accepting any excuses. Those working with water, sanitation and housing should be given adequate support and resources to do their jobs well - executing immediate, contingency and long-term plans. It is also critical that innovation is allowed, and that Ministry of finance be allowed to prioritize cholera elimination as doing this is equal to national development. A country fighting cholera every year is unlikely to develop.
4) The case fatality rate is very high in the current cholera outbreak (4%) when it should be less than 1% if patients and families are aware and seek care early. That’s where we are losing it! While opening big cholera centres is a good thing, about 50% are dying from home. The president must order deployment of mobile emergency multi-disciplinary teams to be stationed in hot spots, with medical teams within 1-2 kms reach so that whoever has symptoms can quickly go and get medication and fluids in these units. These must also be used as entry points for community awareness with loudspeakers attached and environmental heath teams doing surveillance and community mapping. We already have mobile hospitals at the ministry of health, these can move into cholera hot spots.
5) Use church leaders more since we are a Christian nation, and most patients are church members somewhere. Let the church leaders receive Cholera prevention information and resources from CDF to do something around their church catchment area and among their church members. People listen to and trust their church leaders, so they will believe cholera messages coming from their own church leaders.
6) Continue other initiatives, but with better coordination and active research to know what is working and what is not working and how we can maximize on the good things we are doing.
7) Lastly, we as citizens must do all we can to help and support each other. What do you have in your hands that God has gifted you? Please use this to protect someone from Cholera or help someone with cholera or help someone fighting cholera on our behalf, whilst staying safe.
