Cholera has devastated Zambia at the current moment and one wonders why year in and year out we have to face this menace. From experience, I have seen that we do not do enough to prevent its occurrence and the reasons may not be that straightforward and apparent to many.
In my time as the National Health Programme Coordinator at the Zambia Red Cross around the mid 2000s, I represented the organisation on the National Epidemic Preparedness, Prevention, Control and Management committee of the Ministry of Health. One of the ongoing cries of the Red Cross and many donors at the time was that we needed to focus more on prevention rather than waiting for outbreaks of cholera to occur and for this reason a national cholera contingency plan was proposed by many government partners.
However, at the time there was never any traction from government to come up with such a plan, much to the frustration of many of the partners. As Red Cross, we thus set out to develop a “Zambia Red Cross Cholera Contingency Plan” that would have allowed us to raise funds for cholera prevention activities from our donors, who had expressed interest in funding such a plan. It would also have enabled us to meaningfully engage the various in-country partners and donors that were necessary to successfully pull off such a plan. We did not call it a national cholera contingency plan in order to avoid stepping on the governments toes and emphasised that our plan could be a small part of the national contingency plan once that was worked on.
I set out to write to various partners to call for a meeting to discuss such a plan. Rather naively, I was so focused on results and getting things done that I forgot about the very fragile ground of government and partner politics that is always at play in the health sector.
Shortly after the invitations were sent out, the Secretary General of Zambia Red Cross, Mr Charles Mushitu, called me to inform me that the Director of Public Health (I cannot remember if that was the exact title at the time with the ever-changing nomenclature at MOH), was rather displeased about our proposed meeting and wanted to see me immediately.
For obvious reasons I will not state his name but I recall it was a very brief and rather hostile meeting. I was asked what year I graduated and what my credentials were and what gave me the right to call such a meeting. I was told in no uncertain terms that that was his role and I had no right to do so. My confidence was not faded and I explained the intention of the plan, stating that it was a small Red Cross plan and not a national one and that it would be far cheaper to prevent the disease than to wait for an outbreak and tackle it then.
Needless to say, MOH discouraged all partners from attending our meeting and it never happened. Such an idea upset too many norms and it appeared even the partners were weary of upsetting MOH by being part of such an effort. So political expediency won at the end of the day, despite the overwhelming need for such a plan.
But I learnt some lessons from that, one of which is that cholera is “big business” and, at least at that time, was a big factor in not having the political will to prevent it. Outbreaks bring money. Big money. Emergency money. Money that does not need to be accounted for so strictly. During such emergencies financial rules are relaxed in order to tackle the situation quickly and, so is the intention at least, effectively. So why stop an outbreak that benefits some who may be involved in tackling it? It is all too easy and tempting during such times to take a few dollars or kwacha here and there for personal gain. Of-course there are the additional legal ways money is made, such as more allowances for personnel and so on. Even some donors at such times utilise such emergencies to lobby for more funding for the response that also beefs up their organisation’s coffers and assists in meeting other costs generally. I would hope that is not the situation we still find ourselves in.
Preventing cholera, from a public health perspective is simple: promote hygiene, clean up the environment, disinfect known highly vulnerable areas, provide safe water and better sanitation facilities and so on. I oversimplify as the logistics of this could be quite daunting, but in essence that is what it is.
The current things that are being done now by the army and other players are commendable but what stops us from doing such things before outbreaks occur? Complacency on the part of key players such as the council to keep the city clean has to be considered. An overstretched health system, political pressure to please and appease street vendors and so on also contribute. Though one has to be careful about blaming cholera on street vendors as the evidence for this is rather weak, though one cannot argue against cleanliness generally.
But largely, we suffer from a lack of any long term plan to tackle the problem. Every year we have an outbreak, run around like headless chickens and when the outbreak ends we go back to business as usual. We wait for the next outbreak.
No one seems to ask; how do we continue with the efforts we have made now to prevent the next possible outbreak? It will be a shame, but am sure it will happen, to let the city of Lusaka go back to the filth and crowded streets we had before the current clean up. Instead we should be looking to keep it this way. Why can’t food outlets be tested all the time and not just during outbreaks? Why can’t people be encouraged to practice good hygiene all the time? It is all possible and can be sustained. That is the only way to end cholera outbreaks.
So, a simple matter such as cholera turns out to be a little more complex, thanks to a little greed, politics, complacency, inadequacy of infrastructure and other factors.
How long will we wait before we demand “no cholera” rather than “stopping the spread of cholera”? I would like to see this be a campaign matter, I would like to see donors add more pressure on the government to prevent it.
But mostly power lies within us the people, every one of us, to demand decency and what is right: a clean and cholera free country is our right! We should hold those responsible accountable to deliver on this.