Cholera in Africa: More crappy news

It really (really) pisses me off when cholera is in the news - again. Cholera should not exist. It angers me even more when it is featured so prominently in so much of the reporting reaching my desk from many parts of the developing world, particularly in Africa. Cholera is preventable. If cholera kills someone, the world is doing something wrong.

The latest piece of shitty news is this disturbing piece from Kenya, where cholera is hitting a little too close to home:

Obama Brother May Have Cholera


and from the Associated Press:


Official: Obama's half-brother falls ill in Kenya


We hope that it is just a nasty case of diarrhea. We hope that this will be treated (as it can be quite easily) and that Malik Obama will be back at work soon. We hope that it is not cholera, and if it is, we hope even more that it doesn't kill him like it does many other Africans, preventably.

Keys to cholera:

- It is dangerous (viz. fatal all too often).
- It is easily spread through lack of simple safe drinking water and sanitation facilities.
- It is treatable.
- Most importantly, it is preventable, and both the international donor community and every government throughout the developing world can do something about it.

Sources:

• My other recent blog post on the issue. There will likely and distressingly be more such posts.


• An insightful piece from the Centers for Disease Control and Prevention.


• Cholera at the World Health Organization

This steady stream of cholera in the news has to stop. Cholera mortality and morbidity must stop. The White House is in an extraordinarily strong position to contribute to the elimination of fatal cholera and other diarrheal disease. For an interesting and related take on unnecessary and preventable childhood mortality please see Nicholas Kristof's piece Good News: Karlo Will Live. And call the White House.

Cholera BAD: A Lion in Our Village

If you read one journal article this year, make it this one, from the New England Journal of Medicine:

A Lion in Our Village — The Unconscionable Tragedy of Cholera in Africa

A lion in our village indeed. This is the under-recognized story of cholera in Africa powerfully told by Drs. Eric Mintz and Richard Guerrant.

We know that cholera is caused by unsafe water and inadequate sanitation, and solved by safe water and improved sanitation. This is not an intractable problem.

From their first handful of words "inexcusable,...completely preventable" to even more potent language later on "Epidemic cholera represents a fundamental failure of governance, and bold and visionary leadership is required if we are to attack its root causes," the authors do justice both to the gravity of the problem and to its solvability in Africa as elsewhere in the developed and developing world.

What's missing is the governance and the political and financial capital to get to solutions - both prevention and treatment - this is fixable and unnecessary.

The Time of Cholera

By now we have all read of the cholera situation in Zimbabwe (or should have). It sucks - and has been caused by any number of mostly if not entirely preventable factors far beyond simply the gnarly water and sanitation situation there.

Although it is difficult to step back and look at the cholera outbreak more broadly right now, let me add a couple of thoughts:

- this crisis highlights the need for a holistic approach to water for people: safe drinking water supplies, sanitation facilities and hygiene (handwashing) interventions are all required. Cholera is not spread simply by water, but by water contaminated by human feces which has not been adequately treated, and by dirty fingers, food, etc.

- this cholera outbreak also highlights the need for tight language in appropriations for the Water for the Poor Act, the Water for the Poor Enhancement Act, and other related legislation, e.g. on child survival. That language needs to focus on people and poor. Period.

- safe drinking water and good sanitation facilities are both the prevention of and the cure for cholera. It is much more efficient to prevent cholera and other diarrheal diseases than to treat them. Ask Peru about the economic/financial costs of prevention vs. cure when a cholera outbreak cost their economy $1b+ a few years ago.

- cholera is now a regional health and economic issue, and could become a regional (southern Africa) security issue quite easily with the xenophobia prevalent in the region.

- Zim is not alone. Cholera outbreaks are occurring or have recently occurred in Kenya, Peru, the Philippines, Malawi, Zambia, DR Congo, Angola, Nigeria, Burundi, Guinea-Bissau, South Africa and others.

So: try to keep as many Zimbabweans alive in the short term, keep cholera from spreading beyond its current borders in the medium term, and let's do what we can to prevent it from happening again by addressing water, sanitation and hygiene in the long term.

Sanitation Hits It Big

Sanitation has a few things going for it:

There is a realization that the ROI of an investment in basic sanitation infrastructure in the developing world is high: $1 gets you $9, to be more precise - good return. (WaterAid and WHO)

There is also a growing recognition that, like it or not, meeting the water Millennium Development Goal will not have the impact on public health we all want it to unless there is significant progress on the sanitation MDG as well. (Lancet)

But today, sanitation takes one more step toward being recognized as the marquee player we all know it is by getting prime billing at the World Business Council on Sustainable Development:

The Sanitation Challenge: What Does it Mean for Business?

The article itself doesn't come up with any groundbreaking answers to the question it poses, likely because those answers aren't readily apparent. But inadequate sanitation and water-related illnesses fill 50% of the world's hospital beds, with an obvious and significant impact on corporate activity. A healthy employee is a happy, productive employee. If that employee's family and community are healthy, so much the better.

I look forward to what the WBCSD's newly-launched Sanitation Workstream can produce...

And would one of you please attend what's being billed as the "sanitation session" at Davos this year and report back?

Sat 26th January 2008: 14.00 - 15.15 Interactive session "Death, Disease and Dirty Water"

Vaccinations vs. safe drinking water and sanitation

An interesting article in The Lancet late last year didn’t receive the attention that it – or at least one sentence in it – merits.

I’d like to change that with the help of my now six readers:In Vol. 368, Issue 9543 (Oct 7 – 13, 2006) The Lancet published an editorial to coincide approximately with the release of the UNDP 2006 Human Development Report “Beyond scarcity: Power, poverty and the global water crisis”.

The Lancet piece dealt with the primacy of water and sanitation in global development, and drew attention to the likelihood that the world will fail to meet the MDG on sanitation. It also highlighted the regional disparities which are masked by global progress on the water MDG (viz. progress in India and China masking a lack of such progress in subSaharan Africa). Also of note in the one page editorial was the continued/continuing lack of prioritization of water and sanitation in budgets throughout the developing world.

The sentence at the heart of the argument I want to make on this blog is:

"It is dangerously short sighted to pour immense time and resources into vaccinating children only for them to die a few years later from diarrhoeal illnesses."

I don’t care if the solution to the global safe drinking water and sanitation problem is not a “traditional” health intervention like passing out antiretrovirals or vaccinations. There is clearly not a silver bullet, or even a silver shotgun solution to the water challenge – each situation (unfortunately) requires its own unique solution. Those solutions involve fewer traditional health interventions, and more engineering and infrastructure projects, more behavioral change and education programs (think massive handwashing campaigns for women and kids like this one).

Public health officials in any country, state, province or elsewhere should support and lobby for these non-health initiatives to provide safe water and sanitation, as should the international donor community:

a) they save lives and livelihoods, and

b) less water-related mortality and morbidity frees up hospital beds, staff and other health care resources for those more traditional health interventions. A person sick from preventable waterborne diarrheal disease is occupying a hospital bed whose purpose would be better served by hosting an HIV or TB or malaria patient (plus that girl suffering from diarrhea would be better off in school thank you very much).

Health systems are burdened beyond capacity in many areas already – advocates for public health, water and sanitation throughout the developing and developed world should focus more cogently on preventing preventable illness.

World Dunny Day! Cheers!

I imagine that all six of my readers already know that it is World Toilet Day today, but just in case one of you out there just woke up, Happy World Toilet Day! Or as the Aussies say World Dunny Day.


To the 2.6 billion without such amenities, hold on, I'll be right out.

Clinton Global Initiative Part 1: Water, water, nowhere

Sorry for the gap in posts – have been on the road a lot lately, including a couple of very interesting visits to water development groups in Guatemala – check out Agua del Pueblo here or google them to find out more about their work for those of you interested in Guatemala. They are primarily funded by a bilateral relationship with the Spanish government now, but looking to diversify and expand their work with water, sanitation and hygiene promotion.

I’m blogging today from right in the middle of the 2007 Clinton Global Initiative, waiting patiently for a direct mention of water, sanitation, hygiene, diarrhea, cholera, or anything… Throw me a bone people! There has been a great deal of optimistic, inspiring discussion in the plenary and breakouts so far from 52+ current and former heads of state and probably 1000 other people, representing 600+ commitments, tens of millions of lives impacted or saved, in over 100 countries.

Five significant commitments have been made public so far, the most interesting of which is the “Global Campaign to Reduce Maternal and Child Deaths in Poor Countries” launched by Norway’s Prime Minister Jens Stoltenberg with others.

Finally, a discussion early this afternoon in the Global Health session about Prime Minister Stoltenberg’s commitment elicited an interesting remark from CARE’s President and CEO Helene Gayle. She suggested that in order to meet the goals laid out by the Prime Minister, it is necessary to take a broader approach to child and maternal health, and focus on the causes of that mortality and morbidity – and she mentioned safe water and sanitation specifically.

More to come.

PS Off to question Jane Goodall about the nexus of biodiversity conservation (viz. great apes) and homo sapiens need for safe drinking water. See earlier related post here.

PPS Best quote ever: Development is about much more than safe water, but never about less.

Faecal Attraction

So I’m reading a book about poo, and its contribution to civilization. Somehow this got left out of my undergrad class on Western Civilization at Georgetown.

The book I reference is Poop Culture: How America Is Shaped By Its Grossest National Product. I haven’t reached the end yet, but I don’t expect any real surprises – I think I know how this one ends. It’s an awfully interesting read, with insights about poo that I hadn’t considered (or wanted to). We all would benefit by paying closer attention to this issue, and Poop Culture adds some interesting blue-sky approaches to human waste treatment that we should consider – e.g. converting it to energy.

Executives from the Water Environment Federation consistently and justifiably argue that what separates developed from developing countries is not human rights, respect for the environment, or Internet access but PIPES – unglamorous infrastructure. E.g. what happens to poo once it leaves the body?

My challenge is seeing that what happens to that poo around the world doesn’t result in unnecessary mortality and morbidity such as from diarrheal diseases. Over 2.6 billion around the world lack adequate sanitation facilities, or quite literally a place to go to the bathroom. This doesn’t mean that they are NOT going to the bathroom, but rather that 2.6 billion people do so in a way that often negatively impacts their health and the health of their neighbors, kids, passersby. Many organizations are struggling with a way to make this massive public health challenge more compelling. What would make it as cool to talk about poo/defecation/shit at cocktail parties as it is to talk about HIV/AIDS?

Dave Praeger’s book gives us a hint, or at least a lesson to be learned from history:

“By the end of the nineteenth century, state and social reformers in both England and America were working hard to spread the flush toilet across society and alleviate critical sanitary threats. Much of the strategy involved the state extending and maintaining modern sewer and water infrastructures, but reformers still needed to convince skeptics that the new bathroom technology was a boon and not a power-grab by the government. To overcome resistance in people who had been pooping in privies or chamber pots all their lives and were quite content with them, they associated health, happiness, refinement, and civilization with the flush toilet. The corollary of that, of course, was that people who didn’t use flush toilets were the opposite.”

This approach hits close to that of today’s social marketing experts, primus inter pares PSI. Social marketing is defined as “the systematic application of marketing alongside other concepts and techniques to achieve specific behavioral goals for a social good.” The bottom line is that 2.6 billion people need the health benefits associated with improved toilet facilities – the best way to make that happen may well NOT be preaching about those health benefits, but rather finding clever ways to make toilets/pit latrines more cosmopolitan, hip, cool, fun, refined, or alternatively to make it embarrassing to NOT have one.

So what can we learn from PSI’s approach and late nineteenth century America and England. Hopefully a lot – precisely zero people died from cholera in these two countries in 2007.