Globally, the cholera situation is the worst it’s been in 20 years. Currently at least 24 countries are dealing with cholera outbreaks, some for the first time in decades. African countries are particularly badly affected.
The cholera pandemic began in mid-2021 but continues to intensify. In the first two months of 2023 alone, as many cholera cases have been reported worldwide as for all of 2022. The global risk is very high, according to the latest cholera situation report issued by the World Health Organization on March 22.
Cases are not only increasing, they’re also getting deadlier, with mortality rates reaching 3% and higher. Conflict, displacement, floods, and other climate-related disasters have contributed in various places.
This has been exacerbated by an ongoing shortage of cholera vaccines that has led to rationing around the world, as health workers switch from giving the usual two doses to a single dose. The one-dose emergency regimen provides less immunity.
More generally, poverty, under-resourced health systems, and inadequate infrastructure are mainstays of cholera epidemics. Cholera, a waterborne bacterial disease that leads to diarrhoea, primarily affects low-income communities without reliable access to clean water and sanitation. Malnutrition also puts children more at risk of dying of cholera.
However, when treated swiftly, serious illness is preventable – and relatively simple. Oral rehydration solutions can prevent life-threatening dehydration.
In the long term, cholera can only be averted by ensuring that everyone can obtain clean water and sanitation. But in the short term, community power is keeping the crisis from being even worse than it already is.
For example, in Malawi – where many people can’t afford or otherwise can’t access piped water – Cyclone Freddy has contributed to the country’s worst-ever cholera outbreak, which has spread to all of Malawi’s districts. Among other activities, volunteers with the Malawi Red Cross Society (MRCS) are checking up on water supplies and sanitation facilities.
One of these volunteers is Rex Lemani, from the city of Blantyre. Lemani started volunteering all the way back in 1987, while still in elementary school. He reports,
“We are distributing chlorine to households to treat the water and provide oral rehydration therapy to people who have been contaminated with cholera. We also disseminate cholera prevention messages in communities. As volunteers, our main need now is transportation to villages that are far apart, booklets with cholera prevention messages and visibility materials.”
Meanwhile, volunteers at a different Red Cross society, the one in Lebanon, have vaccinated hundreds of thousands of people, including through door-to-door visits.
Community mobilizers have been important in dealing with cholera in the past, explained Nadine Saba, director of the Akaa Network for Development, in a cholera webinar hosted by the World Health Organization Risk Communication and Community Engagement (RCCE) Team on March 21. The community mobilizers in Lebanon, who received small stipends, were able to spread information, for instance on how to prepare oral rehydration solution. They also referred affected people to services, such as sites of clean water and points for medical assistance.
Such assistance has to take into account any existing obstacles to cholera prevention and treatment, such as a lack of basic hygiene supplies. “You cannot just tell the people you need to wash if you need to have access to soap,” Saba pointed out.
Thus, as important as transmitting information is listening to people about their needs, which extend beyond a single disease. “The good thing about having community mobilizers is that they are in the shops, they are in the public places, they are where the informal gatherings are done,” Saba said. They can acknowledge people’s concerns and explain that unaddressed cholera will add to such problems. And they can customize the message for different audiences, for instance by staging puppet shows for children.
This kind of community mobilization tamps down on conspiracy theories about outsiders, Saba reported. “It’s not somebody outside that was coming to tell them some new information, especially after Covid.” But sensitivity around this is needed in, for instance, Lebanese communities where Syrian refugees are living, to avoid further exclusion of a minority group.
Amuza Dankaine, of the Malaria and Childhood Illness NGO Network Secretariat, has also witnessed the power, as well as the challenges, of community volunteers responding to cholera. A relative of his, who was pregnant at the time, was among the five people who died in a cholera outbreak in the Budaka district of eastern Uganda in 2016. And Dankaine volunteered in the cholera relief effort himself.
Speaking at the same WHO RCCE webinar, Dankaine said of the village health teams (VHTs) selected by the Red Cross to support local communities, “They belong to the communities. They touch the ground.”
Dankaine elaborated, “Community members have a very key role in ensuring that they monitor to ensure that they report any other case that happens in the community, so information flows from the community members to their VHTs [village health teams] to the health facilities.”
Of course, community volunteers won’t be able to end the cholera emergency on their own. There’s an urgent need for stronger health systems and improvements in water and sanitation to stop the cycle of cholera outbreaks. But the good news is that with sustained effort, according to the Global Task Force for Cholera Control, “the cholera emergency is avoidable.”
Eva Turro, who’s currently deployed in Malawi as the International Federation of Red Cross and Red Crescent Societies (IFRC) delegate for community case management of cholera, provides another reason for turning crisis into hope.
“Cholera is a very silent disease, and it is also associated with stigma. You really need to spend time in communities to understand how much suffering this disease can cause,” Turro acknowledges.
“But when you see a community recovering, as a volunteer, that’s when you realize why you are here and the impact of your mission. It’s an extreme moment of happiness.”
The IFRC is running an emergency appeal for donations to support the Malawi Red Cross Society’s cholera control and prevention work, which is aiming to reach over 2.1 million people in Malawi.
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