As a paediatrician I specialised in childhood diseases of the gastrointestinal tract. I obtained a doctorate for a study of infants presenting to the Red Cross Children’s Hospital in Cape Town with acute diarrhoea. In the introductory chapter of my thesis, I quoted the researchers Rohde and Northrup (1975) who stated that, “the incidence of diarrhoea is more closely related to socioeconomic conditions than to climate, to poverty rather than place.”
At that time (1981-1982) diarrhoea in infants was an annual summer epidemic in Cape Town located largely amongst the black and coloured communities of the Cape Flats. In recent times the frequency of the disease amongst children from these communities has decreased significantly due to an improvement in sanitary and socioeconomic conditions and the introduction of a rotavirus vaccine, an important cause of viral diarrhoea in children. Nevertheless, the disease remains more frequent in communities in the Western Cape and elsewhere challenged by poverty and inadequate living conditions.
Cholera is described on the WHO website as “an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae.” The WHO categorises cholera as “a remaining global threat to public health and an indicator of inequity and lack of social development”.
Although asymptomatic in many and resulting in mild to moderate symptoms in others, cholera can be an extremely virulent disease causing severe acute watery diarrhoea, dehydration and death. When severe the infection can kill within hours if untreated. A key fact is that even those who are asymptomatic shed the cholera bacteria in their faeces for up to ten days after the infection. This creates the potential to infect other people.
The WHO states that “cholera transmission is closely linked to inadequate access to clean water and sanitation facilities.” The epicenter of the recent outbreak of cholera in South Africa, an area known as Hammanskraal in the Gauteng province, has been challenged by failing infrastructure over years, in particular water purification and sewerage disposal. However, cases have been reported from five provinces with over 200 confirmed cases and at least 32 deaths reported to date.
The President accompanied by various ANC political heavyweights “engaged” the Hammanskraal community apologising for the failure of government and indicating that to address the deficiencies in infrastructure would require an investment of R4 billion which would take some time.
The South African Constitution in the Bill of Rights states that “everyone has the right to an environment that is not harmful to their health or well-being” A cholera outbreak of this nature in a country such as South Africa with the expertise and infrastructure at its disposal, is an indictment of the competency and effectiveness of government at all levels, but particularly of local government.
Even when the cholera outbreak had occurred, the recorded death toll to date reflects poorly on the access to and the quality of healthcare services available in these communities. The treatment of cholera is not complex and in many cases simply large volumes of rehydration fluids administered orally, will suffice. In severe cases, however, urgent intravenous rehydration and the administration of antibiotics is required to reduce the possibility of deaths. Treatment that should be easily accessible to citizens with access to a functioning healthcare system.
What the South African cholera outbreak emphasises is the importance of effective local government to ensure the provision of a reliable and safe supply of water to communities. As with effective disposal of sewerage, they are not “nice to haves” but rather an essential requirement of government, notwithstanding what is guaranteed by the South African constitution. Failures in these areas, while not as immediately visible as a lack of removal of refuse and deteriorating road infrastructure are an indication of the sorry state of many municipalities across the country.
Funds must be allocated, effectively utilised and not squandered to ensure both the creation and maintenance of bulk infrastructure particularly in those areas impacted by population growth resulting from rapid urbanisation. These are not necessarily glamorous initiatives that attract the type of publicity that politicians seek, but as emphasised by the consequences of the cholera outbreak, failure in this regard can rapidly cause political embarrassment as the President experienced in Hammanskraal.
What is also required are public servants appointed with the necessary skills and commitment to manage and maintain the water purification and sewerage treatment plants. Systems and procedures must be in place to ensure that this key infrastructure continues to function adequately. Early warning systems must be in place to identify when they are not doing so, enabling rapid interventions. In many areas across the country incidents have been reported of raw sewerage flowing into rivers which are then accessed by communities as a water source. This provides an immediate mechanism for the spread of water borne diseases, of which cholera is one.
Certainly the repeated power outages as a result of failures at Eskom do not improve the functionality of both water purification and sewerage treatment plants but aware of the critical nature of this infrastructure those in positions of authority should ensure alternative sources of electricity.
In answer to my question as to whether the occurrence of a cholera outbreak in South Africa is a market of government failure, reflecting on what I have outlined above, the answer is “yes”. Failure to provide and maintain essential infrastructure, failure to provide accessible healthcare and failure to meet the requirement of the South African Constitution as set out in Clause 24(a) of the Bill of Rights which states that “everyone has the right to an environment that is not harmful to their health or well-being.”
