A tale of inequality, insufficient sanitation, and political dynamics as poverty-related disease sweeps through Zambia

By Charles Mafa

As the cholera epidemic in Zambia continues to capture headlines as we enter 2024, it is crucial to acknowledge that this current crisis, which once spared no one—be it rich or poor—and instilled fear in 19^th century towns and cities, has now evolved into a disease closely linked with inequality. In the current context, the occurrence of cholera outbreaks mirrors the geographical distribution of poverty and marginalisation.

According to the Ministry of Health, there have been over 7,800 reported cases, resulting in more than 300 deaths and over a thousand admissions since the first case was documented in October of last year.

Cholera constitutes a significant global health challenge and remains endemic in Africa and Asia, particularly in areas with inadequate access to improved water and sanitation.

The disease can be contracted by consuming food or water contaminated with the vibrio cholerae bacterium. Cholera is characterised by the sudden onset of acute watery diarrhoea, which, if untreated, can rapidly lead to severe dehydration and death.

According to the US-based National Center for Biotechnology Information, an estimated 1.4 billion people worldwide are at risk of cholera. In 2016, out of 132,121 reported cases, 54% were from Africa, 32% from Hispaniola, and 13% from Asia.

Cholera History in Zambia

Zambia has a history of cholera outbreaks, first reported in 1978, with major epidemics in 1991 (approximately 13,000 cases), 1992, and 1999 (over 11,000 cases each). Between 1999 and 2013, significant outbreaks occurred annually in the capital city, Lusaka. Another cholera outbreak hit Lusaka in 2017–18, resulting in an estimated 5,414 cumulative cases and a mortality rate of 1.8%.

Despite being fully aware of the imminent cholera situation, government leaders waited until the outbreak emerged to step out of the comfort of their air-conditioned offices and get involved. Their participation has been confined to visiting cholera centres and streets, where they caution traders about the risks of conducting business in open markets that lack proper water and sanitation facilities.

The link between cholera and poverty

Cholera persists, and outbreaks frequently recur in the same geographical areas, highlighting that current strategies are not effectively controlling it.

The correlation between cholera and poverty is not accidental. The disease disproportionately affects communities already struggling with a lack of clean water, inadequate sanitation facilities, and poor hygiene practices. Furthermore, it has a significant impact on areas burdened by conflict, limited access to healthcare, and malnutrition.

Take the example of Kanyama – the sprawling unplanned Lusaka township where the majority of reported cases have emerged. Here, a significant portion of residents grapple with recurrent flooding, inadequate drainage, and a lack of toilets.

In fact, most residents use plastic bags to relieve themselves during the night. They find it more convenient because some toilets are up to 200 metres away from the house.

The ongoing cholera outbreak in Lusaka and throughout the country, characterised by deaths and hospitalisations, underscores profound concerns about inequality and emphasises the need for more robust social development initiatives.

Conford Moonga, aged 49, shared with MakanDay the myriad challenges faced by him and fellow residents in Kanyama. These challenges include the lack of access to clean and safe drinking water, compounded by an inadequate road network.

Over the past nine years, Moonga and his family have been reliant on water sourced from a nearby shallow well located right beside their residence. He detailed that, due to his unemployment, obtaining chlorine consistently for water treatment poses a formidable hurdle.

Residents express concerns that lack of space and poor soil conditions pose challenges to constructing latrines, and an irregular road network has exacerbated a severe drainage problem.

Andyson Chama, the zone coordinator for Garden Motel in Kanyama Constituency (another unplanned settlement), echoes Moonga’s sentiments, emphasising that whenever cholera outbreaks occur in the country, Kanyama is never spared.

He highlighted that the absence of a market compels traders to sell on the streets, where they operate without designated toilets or proper waste disposal areas, resulting in unsanitary conditions and difficulties in managing garbage disposal.

The well-established links between poor sanitation and poor health are not unique to Kanyama. Experts stress that basic sanitation involves ensuring the separation of human excreta from any contact with people or animals.

In Kanyama, the overused existing latrines attract vermin, and during the rainy season, overflowing sewage contaminates wells, leading to waterborne diseases such as diarrhoea, dysentery, and cholera.

The situation in Kanyama represents a countrywide challenge. A snapshot of the water and sanitation situation in Zambia, as per the 2018 Demographic and Health Survey (DHS), reveals the following statistics:

• 64 per cent of the population use basic drinking water services (87 per cent in urban areas, 49 per cent in rural areas)
• 33 per cent of the population use a basic sanitation service (41 per cent in urban areas, 28 percent in rural areas)
• 10 per cent of the population practices open defecation (1 per cent in urban areas, 16 per cent in rural areas)
• 24 per cent of the population has access to basic hygiene services, i.e. a handwashing facility with soap and water (36 per cent urban, 15 per cent rural)

While the government has made strides in improving water and sanitation in urban areas, the same progress is lacking in unplanned, high-density peri-urban settlements like Kanyama.

The cost of cholera

Cholera not only has a huge human cost in terms of the number of lives lost, it also inflicts a huge economic burden on countries.

On average, cholera costs the world an estimated $2 billion per year in treatment and hospitalisation as well as the related loss to productivity, according to a report by WaterAid, an international non-governmental organisation, focused on water, sanitation and hygiene

Most efforts to control cholera currently focus on emergency response to outbreaks, including household water treatments and temporary water, sanitation and hygiene services in cholera treatment centres. This costs an estimated $5 to $10 US per person, according to Water Aid.

While these measures may decrease the number of cases and deaths, they do not prevent the onset of the disease initially, primarily due to the absence of enduring access to clean water, adequate toilets with hygienic waste disposal, and proper hygiene practices—such as handwashing with soap—in the areas most severely impacted.

Nevertheless, the economic rationale for investing in sustainable, long-term water, sanitation, and hygiene programmes is evident.

Ensuring communities have long-term, sustainable access to clean water, decent sanitation and hygiene may cost as little as $40 per person, as estimated by Water Aid. Beyond addressing the root cause of cholera, this investment yields numerous additional advantages, including improved health, resulting in more time and opportunities for education, as well as more productive livelihoods.

The World Bank highlights that for every $1 invested in water and sanitation, there is an average return of at least $4 in increased productivity, as individuals experience improved health as people are less sick and have more time for work.

Cholera prevention strategies also frequently include use of two World Health Organisation (WHO) approved oral cholera vaccines, which are safe, inexpensive, easy to deliver, and effective. A person can be fully vaccinated for $6. However, use of the vaccine alone is not as effective as addressing the root causes of cholera. As the cholera vaccine is rolled out globally, it is also critical to use this opportunity to improve people’s access to clean water, decent sanitation and hygiene, especially in cholera hotspots. Only in this way will there be a lasting approach to ending cholera.

Cholera and Political Dynamics

The cholera situation extends beyond health concerns and is intricately connected with politics. Kanyama functions as a stronghold for the ruling United Party for National Development (UPND). For instance, in the 2021 elections, UPND secured 61,892 votes in Kanyama, surpassing the closest competitor, Patriotic Front, which garnered 39,994 votes.

This prompts the question: can the UPND spearhead the relocation of Kanyama’s residents to another settlement, as it seems to be the sole viable solution for the inhabitants of this unplanned settlement?

Photo credit | Ministry of Health Facebook page