A cholera outbreak could certainly compromise post- COVID-19 recovery efforts in informal settlements

The worst cholera outbreak to affect Malawi in two decades has now claimed 750 lives, a government minister said, while the World Health Organization chief described the southeast African country as among the hardest-hit amid ongoing global epidemics that are “more widespread and deadly than normal

– APNEWS, January 12, 2023

Since March 2022, Malawi has been experiencing the largest cholera outbreak reported in the last decade. As of 12 February, 42,427 cholera cases and 13, 841 deaths had been registered in Malawi. A total of 11,500 children’s cases and 188 deaths were reported as of the last update on February 5, 2023. (UNICEF Malawi, 2023). The outbreak was declared a public health emergency by the government in December 2022. This led to the incorporation of cholera into its Presidential Taskforce on Covid-19, to be responsible for coordination of the outbreak response.

In urban areas, the outbreak has affected a majority of the population living in informal or peri urban settlements. In Malawi, informal settlements are home to over 70% of the urban population.  These are settlements where households regularly face chronic water and sanitation insecurities. For example, in informal settlements the traditional pit latrine has remained the dominant method of faecal disposal among households. The community generated data (community profiles) shows that about 27.3% of households have exclusive use of one toile and more than 70% of households share toilets with others on the same plot. A sizable amount of the population lacks any form of toilets. When full, these toilets are supposed to be emptied but there is lack of equipment for that function. In situations where equipment is available, high fees deter these low-income families. Thus, it is common for pit latrines to be abandoned and another toilet is constructed. This process is proving to be a challenge as the land holding size decreases

The provision of safe water in informal settlements is dominated by the kiosk system that are managed by water users associations (WUA). The community profiles shows that around 53% of households purchase their water from kiosks while around 26% had individual water connections. There is evidence that communal water kiosks are insufficient in number, have high non-functional rate, are prone to vandalism, and provide water intermittently. Through an FGD we also leant that the cost of is a barrier to accessing potable water as explained by one informant

“Some families buy just one pail of 20 liters water a week from kiosks, getting the rest of their water from other (unprotected) sources such as shallow wells and rivers for washing clothes and bathing”

Other challenges mentioned by the communities include frequent breakdowns and delays in restoring supply after reported breakdowns. The inadequate sanitation and insufficient access to safe drinking water is contributing to the increased cholera cases in informal settlements in Malawian cities. And the cholera outbreak has come at a difficult time when informal settlements are just recovering from the COVID-19 pandemic and there are fears that this could could certainly compromise post-covid recovery efforts in several ways.

Firstly, the cholera outbreak has overwhelmed an already overburdened healthcare system: Cholera requires prompt medical attention, and an outbreak can quickly overwhelm healthcare systems that were already stretched by the Covid-19 pandemic. Medical facilities that are already struggling have no capacity to deal with a sudden influx of cholera cases. The outbreak is competing for resources with the Covid 19 recovery efforts.  Currently, the large geographic spread and the high number of reported cases in the country are stretching all capacity to respond to the outbreak, increasing the risk of serious public health impact.

Secondly, the cholera outbreak has increased fear and mistrust of healthcare workers and the public health system: The Covid 19 pandemic (and its vaccines) has already caused some people to lose trust in healthcare workers and public health measures. A cholera outbreak has exacerbated this problem, as people are being afraid to seek medical help thinking that the two crises are connected.  In February 2023, a public health centre in Area 25 was vandalized by the people from informal settlement of Mgona accusing health personnel of being responsible for the death of a community member who was diagnosed with cholera. 

Finally, the outbreak is also having a negative economic impact on people: Cholera outbreaks can also have significant economic impacts on the lives of people as many are too sick to work. Others are afraid to leave their homes for fear of contracting the disease. The government has introduced measures aimed at containing the spread of the disease which include closure of business places (markets) that have no proper sanitation facilities (potable water and sanitation) and selling of ready cooked foot items is also prohibited. All this is slowing down the economic recovery efforts that are already fragile due to the Covid-19 pandemic.

To prevent the cholera outbreak from compromising post-covid recovery efforts, it is important to prioritise the provision of public health measures such as sanitation, hygiene, and access to clean water in informal settlements. Healthcare systems must be capacitated to prepare and respond to cholera outbreaks and provide prompt medical attention to those in need. Finally, public health messaging must be clear and consistent to encourage people to seek medical help and follow public health guidelines to prevent the spread of both diseases. Properly packaged messages can also help residents learn about the importance of handwashing and proper food preparation techniques to reduce their risk of exposure to cholera.

In Malawi, a local NGO, the Centre for Community Organization and Development (CCODE), with its alliance partner the Federation of the Rural and Urban Poor (the Federation) are supporting informal settlements to respond to the cholera crisis.

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