How municipalities fail SA’s poor in the time of cholera

Few would have imagined that the dreaded disease cholera would ever ravage communities in SA as it did Caribbean countries in the late 19th century, providing the setting for Gabriel Garcia Marquez’s famous novel, Love in the Time of Cholera. But it has, and the tragedy is no less profound.

Adding fuel to the fire of xenophobia, many fingers point north to Zimbabwe, where dire poverty provided the ground for the cholera disease after the collapse of the embattled country’s water and sanitation systems late last year, with more than 50000 infections recorded. But with latest press reports on the growing crisis in the north of SA confirming the disease’s toll of 44 lives and 6200 sick, what blame should be laid at the door of our own water and sanitation systems, and by implication, the municipalities entrusted with delivering these services?

While recent media reports have speculated that infected Zimbabweans in SA may have sparked the epidemic, it is the lack of service delivery by municipalities in Mpumalanga and Limpopo that has facilitated the deadly spread of cholera in this country.

The health department’s head of communicable diseases, Frew Benson, has confirmed that most cholera cases have been registered in Limpopo and Mpumalanga, although cases have also been identified in the seven other provinces, and at least 50 new cases a day are expected to be identified in Limpopo and Mpumalanga in the short term before the crisis is brought under control. This situation prompted a site visit by Health Minister Barbara Hogan and African National Congress president Jacob Zuma, whose presence was wholly appropriate given that there is far more than a health issue emerging. The spread of the epidemic is underpinned by poverty and a lack of infrastructure, which severely compromises the residents of rural areas.

Advice to avoid contaminated water and ensure good hygiene has been issued, but is shockingly naive in light of the conditions facing those who live in the worst- affected areas. To be sure, cholera can be prevented by boiling water or sterilising it using chlorine tablets or household bleach, and by washing hands thoroughly with soap and clean water. But this assumes an abundance of clean water (boiled or sterilised) to cook and wash with, as well as a low dependence on ground or surface water — all ground or surface water in cholera areas is considered potentially contaminated — and indeed adequate information about cholera among those at risk. Is this a fair assumption?

Those involved in development planning or poverty alleviation recognise that there is a strong correlation between the different determinants of poverty that keep poor people marginalised and trapped in a cycle of poverty. To mention a few of these traps: poor access to services, low income levels, as well as high levels of unemployment. Confirming this, Municipal IQ research on productivity levels demonstrates how residents of rural or previous homeland municipalities in SA are far more likely to be poor than residents of other municipalities. Municipal IQ reasons that reasonable access to tap water (assuming tap water is not affected by the cholera virus) and minimum sanitation (Municipal IQ excludes the bucket system) would ensure that residents of the average South African municipality are reasonably well protected from the cholera virus. Hence, where there is inadequate provision of basic municipal services, cholera is likely to surface.

Municipal IQ data, combined with the latest Statistics SA data, suggests that most residents of Mpumalanga have reasonable access to services, but are not that well off — about 9% of residents lack access to either clean water or minimum levels of sanitation (far better than the average access to basic services in KwaZulu-Natal or Eastern Cape), but unemployment is at almost 34%, and 55% of households earn less than R800 a month. Considering that a quarter of municipalities in the province are classified as being either rural or former homeland municipalities, it is easy to identify systemic disadvantage and those most at risk of infection from cholera.

These municipalities, with worse than average levels of water access, such as the Dr JS Moroka local municipality (at 27,7%), are at particular risk. In addition, those residents residing in municipalities with low levels of access to clean water will also be more likely to be reliant on ground or surface water and, given their likely geographical isolation, are likely to be least well informed about the risks of cholera and ways of treating it.

The situation in Limpopo is significantly worse — 17,5% of residents do not have adequate access to water, relying instead on contaminated natural water sources. Access to adequate sanitation levels is somewhat better at 11,9%, but with provincial unemployment of 38,5% and almost two thirds of households living on less than R800 a month, it can be assumed that poverty is endemic. Even more so in marginalised areas; with almost half of Limpopo’s municipalities classified as either former homeland or rural, many municipalities present fertile territory for cholera, where high HIV/AIDS infection rates and inadequate nutrition and healthcare compound the negative consequence of a legacy of deprivation and inadequate basic service infrastructure.

In those Limpopo municipalities containing former homeland or rural areas, more than 22% of residents do not have adequate access to water, while unemployment is at almost 50% — with 71,3% of households living on less than R800 a month. Hardly the profile then of households with access to information, income for buying soap, cleaning products and bleach as preventative measures, never mind flushing toilets and tapped water.

The incidence of cholera throughout the country suggests that no one is completely safe from contracting the disease, but least of all those in poor households where, typically, access to water and sanitation is limited and spread between many household members and standards of sanitation are compromised by squalid living conditions associated with poverty.

The nuances of provincial variation point to the importance of data disaggregation — while access to water and sanitation in Mpumalanga, at 91%, is reasonable in terms of staving off the threat of cholera in most municipalities and households, special attention must be paid to specific rural or former homeland municipalities which may contain higher levels of poor households with lower than average access to clean water and adequate sanitation.

In Limpopo, with almost a fifth of all households not accessing clean water adequately, more urgent attention is required to address the epidemic and to ensure clean water is available to residents of all municipalities.

And it should be asserted that disaster management should be more than just helping the victims, but should include providing health information to remote areas, accompanied by water purification products, soap and, if necessary, water tankers.

More systemically, ensuring early warning systems monitor water quality and address failures (at local and national levels), as well as the long-term roll-out of basic services, are crucial.