Sporadic cholera outbreaks are not unusual in most developing countries. The current outbreaks in Zambia and Malawi are a reminder of some of the challenges posed by infectious diseases in urban and semi-urban areas as well as rural communities. So, how does cholera come about?
Cholera is an infectious disease caused by bacteria, vibrio cholerae. The bacteria are introduced into the body through consumption of contaminated food or water. The bacteria are usually found in food and water contaminated with feaces. Hence in areas where there is poor sanitation, there is a high likelihood that water used for human consumption and cleaning food could be contaminated by human faecal matter. In areas where there is open defecation and water is collected from unprotected wells, rivers or lakes, the surface runoff (especially during the rainy season) collects faecal matter and deposits it in these water bodies. If this water is consumed without treatment with chlorine or boiling to kill the responsible bacteria, people are likely to contract cholera. For people living close to rivers and or lakes, defecating in water is one habit that perpetuates the spread of cholera. If the contaminated water source is not identified more people will be infected resulting into an outbreak.
The scenario described above is mostly common in rural areas where the availability of treated piped water is limited. But why are cholera outbreaks still occurring in urban and semi-urban areas for example in Lilongwe, Malawi, Lusaka, Zambia and Kinshasa, the Democratic Republic of Congo?
There had been a number of cholera outbreaks in London most of which had claimed a lot of lives. It is the outbreak in 1854 near Broad Street in London that brought up something unique and still applicable today. The outbreak killed over 600 people and it took the work of a physician John Snow to discover that contaminated water was the source of the outbreak. The district of Soho in London where the outbreak occurred was experiencing similar problems that we are experiencing today in most large cities in developing countries; influx of people into cities, with poor or lack of sanitary services to support the ever increasing population.
John Snow studied clusters of cholera cases to identify the source of the outbreak. Is it possible to apply the same theory that John Snow used to identify the sources of cholera in the affected areas? Apart from improving sanitation, are there efforts to find out what is the source of the cholera outbreaks?
Back to our towns and cities in developing countries, overcrowding in the cities has resulted in poorly designed settlements with poor sanitation facilities. These sanitation facilities include, waste disposal units, toilets, and sometimes safe water. Poor waste disposal, lack of clean toilets/latrines and safe drinking water have contributed to the spread of cholera. Flies from filthy toilets/latrines carry germs including bacteria responsible for cholera and contaminate fruits, and food that is not covered. If this contaminated food is consumed, that individual may contract cholera.
Take for example, in most informal settlements the food business is rampant. As people rush to work early in the morning they grab all sorts of food on the way. These include mangoes (in season in Malawi), boiled cassava, boiled maize, home-made traditional drinks (such as thobwa) that are re-packaged in bottles that have been used before, rinsed by the vendor and the drinks are then poured in these bottles. The challenge is what sort of water was used to clean the utensils holding the food, or the water used to clean the fruits, or the hands of the person serving/selling the food?
The food vending business in not only common in the informal settlements but also in the city markets, where food vendors prepare and sell food to the masses on the streets. The challenge with the markets in towns of most developing countries, is the waste that is lying around everywhere and flies that swarm these places. Poor sanitation in these market places could be a source of cholera.
Identifying the actual source of the disease is a huge task this could explain why Zambia, decided to ban gatherings and food vending in the city of Lusaka. While reducing the risk of spread of cholera this ban has affected the livelihoods of many who survive on selling various food products.
Food vending is a source of income for many families. It is a business that does not require huge capital investment to start hence can be carried out by any household as long as they have the food. Whether it is selling ready-made food, or fruits of all kinds, the food business brings the required needs for the household on a daily basis. The little money they make from selling the food, the family is able to put a meal on the table. Unless it is carried out on a large scale, this is a hand to mouth business and any shock could affect financial situation of the family. As such a ban like the one imposed in Lusaka Zambia, does not only prevent people from getting their daily snack or treat from the street/market but also deprives the food vendors of the needed income to sustain their households. To the food vendors, this is a hard blow as their lives depend on the money they make from their small scale businesses. To the government on the other hand, it is trying to fulfil its duty to reduce the risk of spread of cholera within the population.
The cost of the outbreak to the government and the population as a whole can never be underestimated. Cholera management, prevention and control requires a lot of resources both human and monetary. These hidden costs may never be visible to the public and the affected communities but they are there. For the cholera camp to run, the medicine and all necessary chemicals required to treat and disinfect all contaminated areas, the equipment used by the medical personnel, fuel and other transportation costs to transfer cholera patients to the camp, the list is endless.
On the community level, the loss of lives to cholera affects the family equilibrium. This could result in loss of livelihood, through death of the bread winner; loss of human capital, where the skills of the deceased are lost and loss of labour, where people are unable to tend to their farms and other businesses in order to take care of their sick family members.
Balancing the need to control and prevent the spread of cholera and how this affects livelihoods for small scale business owners and communities is no simple matter. The cost of prevention is cheaper than the cost of curing a disease. As the old saying goes “Prevention is Better than Cure”.
Let us work hard to prevent the spread of cholera in our communities. It begins with every individual, observing proper hygiene in our households, drinking and using safe water, keeping our surroundings clean, and making sure there is a toilet that is well kept and used will help reduce the spread of cholera and other diarrhoeal diseases.
For small scale business owners and food vendors, let us do our best to prepare and store the food we sell in clean environments, the lives of your customers depend on you, keep your food safe so that you have a healthy customer. A dead customer will not come to buy from you. Cholera prevention begins with you.
For governments, ensure that populations are provided with safe drinking water and are taught the right methods to keep their water safe from contamination.