Local government officials say cholera outbreaks across Katsina, Zamfara, Bauchi and Kano states in northern Nigeria have killed 97 people in the past two weeks, making it the worst outbreak in the north for several years, according to an official from National Primary Healthcare Agency (NPHA) in Abuja.

More than 60 people have died in Zamfara state in the past two weeks, according to Tukur Sani Jangebe, Zamfara’s state commissioner for religious affairs.

“It is quite alarming and it is quite unusual for northern Nigeria. If up to 100 people have died from cholera in just two weeks, you can only imagine how many more are affected by the disease,” an official from the government-run NPHA who requested anonymity, told IRIN.

National government officials have not yet publicly stated if the outbreaks across the separate states are related, or provided figures on the number of affected people.

Jangebe said the death toll may be higher as reports of new infections are still coming in.

In Katsina state in the villages of Makadawa and Kagadama, 20 people, mostly women and children, have died while 30 others have been hospitalised according to local government chairman Masur Usman Murnai. Another nine people have died in Nabardo village in Bauchi state since 13 September, with 40 more affected, according to Garba Sale, a primary health care coordinator. Kano State’s health commissioner Aisha Isyaku Kiru told IRIN five people have died of cholera in the state within the past week.

Dirty water

Across northern Nigeria, heavy rains have washed dirt, rubbish, sewage and other contaminants into ponds and open wells in affected villages where the majority of people get their water, according to Sani Ibrahim, an epidemiologist at Kano state’s Bayero University.

“Torrential rains have been recorded this season and have washed lots of dirt into ponds and open wells. This is in contrast with last year where we had scanty rainfall and no recorded cholera outbreaks,” he said.

Response

In Katsina state, Murnai told IRIN local officials have been running an awareness campaign to urge people to pay close attention to household hygiene and to boil all drinking water.

Health coordinator Sale said in Bauchi state a health surveillance team has been sent to Nabardo village to analyse and disinfect drinking water sources.

In Zamfara state, the local ministry of water resources is trying to find ways to provide clean drinking water to affected communities to halt the spread of the deadly disease, according to local commissioner Jangebe.

But Halliru Salisu, coordinator of a network of Muslim groups in the state, says local government officials were slow to admit the cholera crisis and slow to respond.

Cholera is a bacterial intestinal tract infection that leads to vomiting and diarrhoea, and if untreated, can be deadly.

In March 2008, at least 35 people died of cholera in the towns of Madurdi and Oturkpo in southern Nigeria.

IRIN 

On a hot afternoon at Jamestown beach, once considered to be one of Accra’s most famous beaches, 25-year-old Francis Cudjoe and his three friends squat in the open air while in conversation.

They are defecating in full view on the beach, and they are not alone. Off in the distance, one can spot many more residents dropping their pants, squatting and freeing their bowels.

Shortly after they leave, ocean waves wash away their waste.

With four million people without access to a toilet and 4.5 million with no sewage facilities, the World Health Organization (WHO) and UN Children’s Fund (UNICEF) recently ranked Ghana the fourth most unsanitary country in Africa in a total of 52 judged, and the second dirtiest out of 15 West African countries.

The two organisations monitor African countries’ sanitation services.

This ranking has rallied local environmental organisations to clamour for more radical governmental action on Ghana’s deteriorating sanitation record.

For the local Coalition of NGOs in Water and Sanitation (CONIWAS), “the ranking should serve as a reality check for authorities who act as if all is well,” says Executive Secretary Patrick Apoya.

He says Ghana has a “national sanitation crisis” and calls on the government to declare a “national emergency.”

Desperate measures

Walking down the beach, one has to carefully pick one’s steps to avoid stepping in faeces.

“The beach has been where I have come [to do this] since childhood - I can’t stop. In any case even if I want to stop, there is no alternative,” Cudjoe tells IRIN.

With no toilet facilities, people turn to bushes, drains, fields and even outlawed pan latrines to defecate.

The pan latrine is a portable toilet made up of a bucket around which is fitted a wooden frame or seat with a hole in the middle.

When the bucket is full, users pay somebody to dump it in a waste centre. Eventually the waste is pumped out to the sea.

Ghana’s Supreme Court banned the use of these latrines in July 2008, saying they violated people’s dignity, and ordered city authorities to arrest and prosecute users.

The court also ordered the government to build public toilets across the capital and subsidise the construction of toilets in private homes, measures that have yet to be implemented, according to CONIWAS.

Health and economic toll

About one kilometre away from Jamestown beach, women selling food at Makola market in central Accra are surrounded by heaps of refuse. An unbearable stench pervades the air as green fluid seeps from the refuse onto the road.

According to the government’s Environmental Health and Sanitation Directorate (EHSD), Ghana can only manage 30 percent of the daily waste its residents generate.

Such conditions lead to up to eight deaths an hour, estimated Minister of Health Courage Quarfhigah.

Every year, the health ministry reports more than 400,000 out-patient cases of sanitation-related diseases, including diarrhoea, typhoid, cholera and hepatitis, which lead to about 65,000 deaths.

Alias Sory, director general of Ghana’s health services, told IRIN costs are mounting. “Increasingly, the country’s health facilities are being overwhelmed by sanitation related diseases. The cost to the nation is unbearable.”

Dirty streets and beaches can repulse tourists, according to acting executive director of the Ghana Tourist Board, Martin Mireku. “Tourists who come here are not used to such things [defecation on beaches], it’s repulsive and has the potential to drive them away, and the time to act is now.”

Tourism provides 25,000 jobs in Ghana, and contributes more than US$1 billion to the annual economy, representing five per cent of the annual Gross Domestic Product (GDP), according to Mireku.

Criminalising public defecation

But some in the government dispute the figures, saying the problem has been overstated. “We are not saying we don’t have a sanitation problem, but we are certainly better than most of our African colleagues,” said Maxwell Kofi Jumah, the second in command at the Ministry for Local Government, the ministry responsible for monitoring sanitation facilities.

Despite this assessment, the national government is starting to take the issue more seriously, according to CONIWAS’ Apoya. It has drafted what will be the country’s first national sanitation policy, which Apoya anticipates will be approved by late 2008.
 
Alongside legislation, the national sanitation ministry plans to crack down on sanitation offenders. Working with the justice ministry, government officials plan to employ sanitation watchdogs to punish people who defecate in public spaces, who litter, or who do not maintain sanitary conditions at home by fining or arresting them.

Working in all 138 metropolitan, municipal and districts assemblies across the country they will send out a clear message, according to Apoya: if you unload here, you pay a fine.

But this measure cannot solve the problem said Accra-based teacher John Appiah. "This is putting the cart before the horse - we don't even have public litter bins anywhere in the capital. They are just desperate to prove that they are doing something about a really bad situation and it's just covering up for their failure."

IRIN 

At least 50 cholera cases have been recorded in Benin’s capital Cotonou since 24 July, according to local hospital officials.

These cases have been reported in the capital’s eastern districts of Enagnon, Dedokpo, and Segbeya, neighbourhoods that lack clean drinking water, waste disposal services, and indoor plumbing.

The government has set up a treatment centre next to Ayélawadjè health centre in eastern Cotonou to provide free medical assistance to affected people.

On Wednesday, more than 100 people gathered at the centre. One health worker who spoke with IRIN anonymously because he was not authorised by the Ministry of Health to comment on the outbreak said: “We have been seeing more and more patients in recent days. For the moment, we have things under control. We are the asking the population to help us fight the disease by observing basic sanitation rules.”

Dr. Paul Yada, an epidemic specialist at the African regional office of the World Health Organization (WHO), said while efforts like this camp are helpful to halt the epidemic, cholera is not only the responsibility of health officials.

He says cholera is most quickly spread in run-down urban areas that lack clean water sources or indoor plumbing. Yada says often, faeces in open spaces mixes with heavy rains, trash, dirty riverbeds and a neighbourhood’s castaways, forming a river of waste that infects a community’s drinking water.

“To really solve this problem, you need more people at the table than just health officials, and you need more resources,” says Yada.

The Benin government has renewed an education campaign on sanitation and what to do at the first signs of cholera infection.

Yada says countries’ responses to cholera outbreaks tend to be fast, but that follow up is poor.

“After an epidemic, people stop these education campaigns. The problem is, you cannot change someone’s behaviours in one week. You cannot stop teaching about sanitation just because the rains stop. This needs to go on year round. ”

Cholera is a recurring problem in much of sub-Saharan West Africa. Cases spike with the annual rains that generally fall between June and September, but infections happen year round.

The cholera bacteria is spread through contaminated food and water. If not treated, the first symptom of diarrhoea can lead to kidney failure, dehydration and death.

Last year, toward the end of Africa’s rainy season, ministers of health from across the continent signed an agreement to develop comprehensive action plans to fight cholera.

WHO representative Yada says none have been submitted to WHO’s regional office in Congo Brazzaville for funding.

IRIN 

Bad hygiene and lack of adequate sanitation facilities in northern Uganda, a region still recovering from two decades of conflict, have fuelled the spread of the Hepatitis E viral infection in several districts, a senior official said.

"The major challenges are inadequate access to safe water, unhygienic disposal of faeces, poor personal and domestic hygiene," Steven Malinga, the Health Minister, told IRIN on 7 August.

The disease is spread along the faecal-oral route and outbreaks tend to be linked to contaminated water or food supplies. Mortality rates are generally low, ranging from 0.5 to 4 percent, but can rise to 20 percent among pregnant women in their third trimester. According to the UN World Health Organization, an infected person develops fever, headache, general weakness, muscle pains and eventually yellow eyes and yellow urine.

Since October 2007, when it was initially identified in Kitgum District, the disease has spread to Gulu, Pader and Yumbe districts, and claimed a total of 104 people, mainly pregnant women, across northern Uganda.

Health officials, however, said the overall number of reported cases had started declining, although there was still concern over a resurgence as new areas were reporting infections.

Sources at the district epidemic taskforce in Kitgum – the epicentre of the outbreak - said their assessment indicated a reduction in cases reported at health centres, but they were puzzled by new cases reported from areas that had not recorded any previous cases.

"The current trend is that the number of cases is coming down, but we still see some new sub-counties recording cases. We have tried to contain the situation, but with the coming rainy season, which seems to promote infection, we don’t know what will happen," an officer, who requested anonymity, said.

He said 72 percent of the recorded fatalities among the more than 6,500 cases reported were women. "Because women have lower immunity during pregnancy, cases of Hepatitis E are severe and have caused more death among them," he explained, adding that some cultural beliefs that bar pregnant women from using latrines had made matters worse.

"Most of the women will just [relieve] themselves in the open, which is a good breeding ground for the Hepatitis E virus," the officer told IRIN.

In Kitgum, where formerly displaced people were returning to their villages, returnees faced a lack of water and sanitation facilities.

"We lack resources for water and sanitation," the Kitgum official said. "We also lack resources for social mobilisation, incentives for sensitisation and for the health teams that visit the villages to educate people about the proper way of living."

An emergency 10 billion Uganda shilling (US$6 million) plan to fight the epidemic in northern Uganda has been launched and the health ministry hopes it will help eliminate the virus. The plan focuses on teaching residents about proper hygiene, improving sanitation through construction of boreholes and pit latrines in the remaining displaced people’s camps, and monitoring infected people to ensure they are treated.

IRIN

A cholera epidemic sweeping across Guinea Bissau has now infected 1,077 people - three-quarters of them in the capital Bissau - and killed 25, leading experts to ask why lessons from previous epidemics have not been taken on board.

Cholera killed 400 people and infected 25,000 across the country in 2005. “We wrote reports and made many recommendations to the government after the 2005 cholera outbreak but none of them were ever implemented, and so we are left to start all over again,” said Augostino Betunda, joint director of services at the Bissau centre of epidemiology, which is charged with diagnosing the disease.

Since then, water and sanitation infrastructure in the capital has hardly improved, according to Betunda, and still only one in five people can access piped water in the capital.
Instead most city-dwellers construct cheap wells for themselves. “Everyone builds their own wells in this country and they can only afford to build cheap ones, which then fall into a state of disrepair and allow toxins to pass through them, infecting the well water,” said Betunda. The few public wells the government has built are in rural areas.

Experts from UN agencies and non-governmental organisations (NGOs) are developing a new set of long-term recommendations to improve the water and sanitation infrastructure in Guinea-Bissau so that the country can avoid future epidemics. But a water specialist in Bissau is worried it will not spark the change that is needed.

“It is always the same problem. We do evaluations, we do reports with lots of conclusions, but in the end it often just comes down to lack of money and poor organisation,” he told IRIN.

Emergency measures

In the short term the UN children's fund (UNICEF) is trying to control the spread of the disease in the capital under the coordination of the Ministry of Health, and an emergency team of non-governmental organisations.

They are disinfecting wells in contaminated areas and the city’s eight reservoirs with bleach; and are sending teams house-to-house to inform people how to disinfect their wells, to spread public health messages and to distribute bleach.

The problem is that with almost daily heavy rains, this bleach is quickly diluted and it needs to be reapplied regularly to have any impact. But Nicolas Le-Goff, a water consultant with UNICEF is hopeful the slow-reacting disinfection solution they are using should only need to be reapplied once a week.

Identifying the source

Meanwhile government partners are pushing for better diagnostics of the source of the disease. The epidemiological centre has sent teams out across the city to try to establish if it is being passed mainly through contaminated food, water, or other methods, but Le-Goff says these surveys do not ask enough questions to give them the answers they need.

While the surveys ask people’s name, address, age and gender, “they need to cover where they have travelled, what is their main water source, what they have eaten, which markets they frequent, whether they have participated in traditional practices involving food and drink,” he told IRIN.

For Betunda the centre cannot improve its diagnostics capacity without more money. The centre runs on no electricity – it has a generator but it was never installed because they cannot afford the fuel to run it - and up to 80 percent of the centre’s budget has to go on staff salaries. “We weren’t paid last month, but we did get our salaries in May,” Betunda said brightly.

There is “next to no” budget for water and sanitation in the government budget, according to a government official, and while UNICEF installs water systems in health centres and schools, and NGO the International Committee for the Red Cross has improved water supplies in some towns and cities, there is no agency that has made water infrastructure its one and only priority.

But for Betunda, ultimately it is up to the government to take the reins. “It is the government’s responsibility to build up water infrastructure here - and if they don’t do it what else can we do,” he exclaimed, adding “Why are people always left to fend for themselves in this country?”

IRIN

Quality healthcare is a luxury often beyond the reach of those who live in Nairobi’s slums, such as mother-of-seven Grace Awour Opondo.

"When you are sick you buy medicine from the local shops," Opondo told IRIN. "If you are lucky you recover because the medicine is not usually the right one.

"Sometimes there is no medicine even in the hospitals, so they send you out with a prescription," she said. "Then the chemists are expensive so often one has to make do without the medicine."

According to Sakwa Mwangala, a programme manager with the African Medical and Research Foundation (AMREF), the fact that people are squatting on government land often prevents them from accessing essential services. Slums are regarded as informal illegal settlements, which means they are underserved in terms of infrastructure development and access to basic amenities.

"Government health facilities are also not easily accessible for most slum residents," said Mwangala, who heads AMREF's Kibera integrated healthcare programme. Kibera, on the southwestern edge of central Nairobi, is one of the largest and most densely populated slums in sub-Saharan Africa.

Most people operating health “facilities” in the slums are quacks, he said. “There is a lack of quality control, with the people in most of these clinics lacking skills."

The urban poor fare worse than their rural counterparts on most health indicators, according to a report, Profiling the burden of disease on the residents of Nairobi slums prepared by the African Population and Health Research Center (APHRC).

Pneumonia, diarrhoeal diseases and stillbirths account for more than half the deaths of children under-five, while HIV/AIDS, tuberculosis, interpersonal violence injuries and road traffic accidents account for more than two-thirds of deaths among people aged five years and older, stated the report.

The poor health status of slum children is in part due to continuous exposure to environmental hazards coupled with a lack of basic amenities.

"The chances of one becoming sick are high because of the poor sanitation; most of the houses are also poorly ventilated," according to Leonard Wawire, a teacher in the Mathare slum.

"Here, there are no trees to clean the air; any plant growing is usually growing out of waste," Wawire said.

Prevention measures

Eliya Zulu, APHRC’s deputy director of research, told IRIN it was important to adopt a holistic approach to healthcare for the urban poor, one that focused as much on prevention – through improved nutrition and immunisation against major childhood diseases – as on treatment.
“Increasingly, most people in the urban areas are living in deplorable conditions yet it is generally assumed that the better hospitals and schools are in the urban areas,” Zulu said.

When conducting general health surveys, urban areas tend to rank better than rural areas in terms of the health indicators. This, however, failed to bring into focus the health situation of the urban poor, he said.

The problems of the urban poor have often been overlooked while rural areas are seen as more vulnerable to shocks.

"In the rural set-up there is a sense of normalcy; you can have your toilet, the community also has a stream from which they draw their water - this is not the case in the slums," Mwangala of AMREF said.

Many deaths in the slums are caused by preventable and treatable conditions, according to the APHRC report; inadequate sanitation encourages the spread of skin and waterborne diseases.

In a bid to improve sanitation in Kibera, a Kenyan NGO, the Umande Trust, is running a project that not only provides quality toilets for residents but also transforms human waste into biogas and liquid fertiliser.

Residents in areas such as Katwekera and Laini Saba in Kibera, pay two shillings (three US cents) to use the toilets and showers, according to Josiah Omotto of the Trust. For a subscription of 80 shillings ($1.19) a month, households get unlimited access to the facility.

The buildings’ basements house bio-digester domes, which turn human waste into methane and liquid fertiliser.
According to Omotto, these help reduce the local use of firewood. Already, he said, the methane from the facility in Laini Saba was being used for fuel by a local nursery school. There are plans to construct similar facilities in other slums to supply the gas to residents living near the facilities.

So far, at least 500 residents are benefiting from each facility.

The division of environmental health in Kenya's Ministry of Health is finalising policy documents aimed at ensuring that 90 percent of households have access to, and make use of, hygienic, affordable, functional and sustainable toilet and hand-washing facilities.

The policies also aim at reducing the national rate of preventable sanitation-related diseases by half.

IRIN 

Earlier this month the Department of Health in Gauteng Province confirmed that two people living in the Chicken Farm informal settlement in Kliptown, an area in Soweto, had died after contracting the waterborne disease.

"The source of the infection has not been established, but an urgent investigation is underway to establish the source, identify and treat possible cases, and ensure no further spread of this illness," a spokesperson for the provincial health department, Zanele Mngadi, told IRIN.

Cholera is an intestinal infection causing acute diarrhoea and vomiting and, if left untreated, can cause death from dehydration within 24 hours. It is easily treatable with rehydration salts.

Deeper issues

Soweto residents point to deep-seated problems related to poor sanitation facilities and the lack of access to potable water. Patra Findane, national organiser for the Coalition Against Water Privatisation (CAWP), a pressure group agitating for free water for all in Soweto, said many more Kliptown residents were showing symptoms associated with cholera. Findane said there had been unconfirmed reports of a third case this week.

A joint statement by CAWP and the Kliptown Concerned Residents (KCR) read: "While it is a shock to everyone in the community to lose one of its members, it should not be a surprise ... the government's neglect of pleas for emergency intervention to combat the social and environmental crisis makes it fully responsible for her death." The statement was issued after members of the groups had visited the family of one of the two confirmed cases of cholera.

"Residents live in fear as they wonder who is next," the statement commented. "Despite all efforts undertaken by the poor residents of Kliptown to get its attention, the City continues to turn a blind eye."

Findane said local government's failure to adequately improve basic services delivery to a neglected township that is more than 100 years old had likely been the main contributing factor to the outbreak of the disease.

The informal settlements of Soweto have no sewage or drainage systems and the bucket system of human waste disposal is still widely used, despite promises by the government that the practice would be eradicated by the beginning of 2007.

Failing to isolate the source

Last week Johannesburg Water, the local utility, said the results of recent tests of the area's water supply confirmed that Kliptown's water was cholera-free and safe to drink.

Municipal spokesperson Baldwin Matsimela said the City of Johannesburg's Environmental Management System, which is part of Johannesburg Water and is responsible for sampling and monitoring surface water, took samples in Kliptown on 28 March and 8 April.

The samples tested negative for cholera on both occasions, and more samples were taken on 11 April but tests on these were also reported as negative for cholera.

"In addition, drinking water samples were taken from the informal settlement in the Kliptown area and the results were cleared of any contamination," Matsimela said.

Findane doubted this. "They say there is no cholera here, but all over Kliptown there are posters and field-workers from different local clinics warning people about the threat of cholera infection. So why should we believe the current cholera outbreak has nothing to do with terrible conditions the people live in, and that it is not a big problem?" he asked.

The CAWP has called on the Department of Water Affairs and Forestry, the Department of Health and Johannesburg Water "to immediately act on the crisis in Kliptown. Without water and sanitation more people will continue to fall ill in this community."

Its economic-security activities for war-affected people in Acholi districts are being adapted to fit evolving needs. Also, the ICRC’s new cash-for-work and income-generating schemes will complement its large-scale seed distribution programmes, which came to an end in March 2008.

Households participating in the cash-for-work scheme will carry out projects chosen by their own communities, such as opening up land for cultivation and restoring infrastructure. On the completion of a project, participants will be paid in cash, at local rates. When people return home, they face a number of important challenges: for instance, limited income-earning opportunities and having to prepare land that has lain fallow for many years (as well as the competing claims of other essential tasks). "The cash will increase household income and help families to concentrate on important matters such as cultivating agricultural land,'' said Janet Angelei, the ICRC’s economic-security coordinator in Kampala. The sustainable-livelihood projects will also benefit the most vulnerable households – such as those headed by children, the elderly and the physically disabled – since the participants will be opening up land for them.

The cash-for-work projects will complement an income-generating scheme for vulnerable families. Groups of households will be provided with, for instance, irrigation pumps, brick presses and oil presses to enable them to increase their income. ”To ensure the sustainability of the scheme, the ICRC has procured simple, manually operated devices. This will eliminate expenses associated with fuel and costly spare parts,'' explained Fabien Pouille, the ICRC’s regional agronomist on mission in Kampala.

As a result of the Juba peace process, which got under way in July 2006 with the opening of peace talks between the parties at conflict, the humanitarian situation in northern Uganda has been improving steadily. An ever-increasing number of internally displaced people are returning to their home areas in northern Uganda and access to arable land continues to widen.

The ICRC, through its various water, sanitation and health programmes, is striving to improve living conditions for over 500,000 people - the internally displaced in their camps and returnees in their home areas in Acholi districts.

The World Bank, acting as an administrator for the Global Partnership on Output-Based Aid (GPOBA), today signed a grant agreement with Mozambique’s Water Supply Assets and Investment Fund (FIPAG) for US$6 million to increase piped-water access for poor households living in five cities: Beira, Maputo, Nampula, Pemba, and Quelimane. 

Under this grant, private service providers operating under lease contracts from FIPAG will connect an estimated 468,000 poor people to piped water supply through approximately 29,000 new yard taps; each is expected to serve around three households. 
The project is introducing an innovative Output-Based Aid approach, designed to ensure ownership and demand-driven service provision, and to set the basis for long-term operational and financial sustainability. All of the new connections will be pre-financed on an output-basis by the private operators.   FIPAG will be responsible for overseeing the project and will receive GPOBA payments only after independently verified delivery of functioning yard-taps and three months’ continued water supply.

“The GPOBA grant is an important boost to our efforts to extend access to safe, reliable water services to some of Mozambique’s poorest households. This, for sure, is a significant contribution towards achieving the MDGs and Mozambique Government targets,” said Nelson Beete, President of FIPAG.
Traditionally in Mozambique, household and yard tap connections have only been available to those who can afford to pay the connection costs (between US$167 and US$241). Currently, these costs are wholly funded by users and are not recovered through the water tariffs. The US$6 million in GPOBA subsidies, together with user contributions in the form of guarantee deposits, will pay for the final connections. The user contribution for each connection will be on average less than 10 percent of the actual connection cost.

“Having piped water close to hand will allow children to spend less time collecting water for their families and increase their chances of going to school,” said Luiz Tavares, Senior Water and Sanitation Specialist and the project’s manager for GPOBA and the World Bank.   “The GPOBA project will also help to reduce disease and death related to water-borne illnesses, and to improve financial viability and transparency in the water sector.”
The Global Partnership on Output-Based Aid (GPOBA) is a multi-donor trust fund administered by the World Bank.   GPOBA was established in 2003 to develop output-based aid (OBA) approaches across a variety of sectors including infrastructure, health, and education.   OBA subsidies are designed to create incentives for efficiency and the long-term success of development projects. 

GPOBA’s current donors are the UK’s Department for International Development (DFID), the International Finance Corporation (IFC), which is a member of the World Bank Group, the Directorate-General for International Cooperation of the Dutch Ministry of Foreign Affairs (DGIS), AusAid of Australia, and the Swedish International Development Cooperation (Sida).

The World Bank