Prevention fails to halt South Africa's well-treated cholera epidemic

WHO officials have lauded South African health workers for achieving perhaps the lowest ever case-fatality rate in a cholera epidemic. But the praise is hollow comfort for many thousands of people now at risk from the disease in Johannesburg, after the first urban river tested positive for cholera last week.

The country's largest cholera outbreak for almost 2 decades has has caused at least 25 500 infections and 73 deaths since August, 2000, mostly in AIDS-stricken KwaZulu-Natal province. The WHO team that reviewed epidemic management there reported on Jan 15 that "successful case management" accounted for the "exceptionally low" death rate, estimated at 0·29%. However, the opposition Democratic Alliance counters that people are dying in remote areas before cholera is diagnosed. And cases have steadily increased since the end of 2000, with KwaZulu-Natal still recording at least 500 new infections a day. Five of nine provinces are now affected, including Gauteng, where authorities are on full alert since cholera was detected in the Jukskei River on Jan 18.

Cholera now threatens many thousands of informal settlers along the river, because, despite emergency education, some residents continue to use the contaminated river as their only source of water. This situation is familiar to the majority of residents living below the poverty line in affected areas throughout the country. The government claims it has provided 6·4 million people with clean water, but the epidemic has demonstrated shameful inadequacies in rural development in South Africa: at least 8 million people are still without tap water and inadequate roads are hampering water delivery. WHO has also encountered shortages of health-promotion workers, ineffectiveness of education program, lack of community involvement in education efforts, and over-pressurized hospitals.

But water and sanitation remain the key issues. In the Sunday Independent on Jan 21, Ebrahim Asmal of the South African Human Rights' Commission noted that about 60% of households in affected areas had inadequate sanitation and, in one province studied, up to 90% of new water connections were not fully functional. He also alluded to last year's assertion that the epidemic started after water supplies were cut because users could not pay newly introduced water fees. Community cost-recovery programs, promoted by the International Monetary Fund, are a key component of the government's much-criticized macroeconomic policy. Yet, Asmal notes that the country spends approximately R4 billion (US$ 500 million) treating diarrhea and dysentery a year, whereas only about R750 million was spent on water in the past financial year.

Source: Morris K. The Lancet, Vol. 357 (9252), Jan. 27, 2001.