By Rebecca Phwitiko, UNICEF Malawi
It’s only September, but the heat is already becoming unbearable. At the peak of summer, temperatures rise to a scorching 42°C in Nsanje, southern Malawi. The main road which traverses Malawi from Karonga in the north, becomes an earth road in the southern district. About 56km of bumpy earth road leads to Ndamera. There is not much to see on the way, just a few cows and some kiosks. The heat and the dust make the journey seem even longer.
Ndamera is just 3km from Malawi’s southern border with Mozambique. The locals speak Chichewa, the main indigenous language of Malawi, plus Sena, spoken by tribes in Nsanje and Chikwawa Districts, and a bit of Portuguese due to the proximity to Mozambique. Sometimes a single sentence will carry elements of all three languages.
Malawi’s first cholera case was recorded here in 1973. In the 44 years since, Ndamera has carried a cholera burden, worsened by flooding. The country’s biggest river, the Shire, runs along Nsanje’s eastern boundary. Annual flooding causes great devastation, including destruction of crops, houses and human life. It also contaminates water sources, compromising the quality of water in the district.
The face of cholera
Joyce Binda, 28, lives in Ndamera. She is a mother of two children: 7-year-old James and 2-year-old Ethel. Joyce buys fish from fishermen at a nearby marsh and resells them at her local market. Her husband Steven is a welder. Two months before, both she and her husband suffered from cholera. Joyce spent three days in the cholera treatment camp at Ndamera Health Centre.
There are no euphemisms among the Sena tribe. They speak freely, saying exactly what they mean. Joyce says that cholera hit her quickly. “It is not like other kinds of diarrhoea where you decide you need to go to the toilet and then go. With cholera, you don’t even decide you want to go to the toilet, cholera decides for you and you just find out after it has happened.”
Another cholera victim is 10-year-old Mary Mankhamba. Hers was the last cholera case recorded in 2017 in Nsanje. She was in hospital for two days but went straight to school the day she was discharged because she didn’t want to miss her end of term exams. When she grows up, Mary wants to be a doctor.
Mary’s mother Patricia says it was very scary when her daughter got sick. She now insists that Mary and her brother Moses wash their hands with soap, and ensures the water they get from the borehole is well covered. “We have learnt to be extra careful these days,” she says. Our village health worker, Mr Chagwa, gives us water guard every two weeks to treat the water.”
District environmental health officer for Nsanje Fred Minyiliwa says that cholera figures spike in years of heavy flooding. He adds that proximity to Mozambique means that some, if not most, of the cholera comes from across the border. “Out of the 19 cases registered in Nsanje between July 2016 and June 2017, five were Mozambicans,” Minyiliwa explains. “Further investigations also revealed that some of the other patients had had contact with friends or relatives from across the border.”
A key difference with 1973 is that thanks to a cholera preparedness and response strategy, developed jointly by the Ministry of Health (MOH), WHO and UNICEF and funded by UK Aid, the Nsanje District Health Office is now well equipped to deal with any cholera outbreaks.
The response unfolds like a well-rehearsed play. When a cholera case is suspected and eventually confirmed, a number of activities are set in motion. Everyone knows what needs to be done at each step. The district mobilises a team of clinicians, nurses, environmental health and water experts to investigate the origin of the infection. They visit the patient, record their history, interview family members and trace the patient’s movements for five days before the onset of cholera. The village health worker, or Health Surveillance Assistant, responsible for the area disinfects the patient’s home with chlorine.
The team also assesses the sanitation situation in the home, checking the water source, availability and state of latrine, handwashing facilities, garbage disposal, and drying racks for cooking and eating utensils. They disinfect the surrounding area, support safe water for households by distributing water filters and chlorine, and train local communities in good hygiene.
Preparation, early warning and planning
While there is a frenzy of activity to respond to a cholera case, there is also systematic planning behind the scenes to prevent an outbreak and prepare for any cases that may come up. Routine surveillance is ongoing in the village. Village health workers track and monitor the prevalence of diarrhoea in their catchment areas. They are a key part of the social mobilisation effort to ensure communities are aware of the danger of cholera and know how to prevent its transmission.
Fanuel Gonya has been a Health Surveillance Assistant in Nsanje since 1995. He teaches communities to keep their homes cholera free through good hygiene practices. A major part of his job is to remind families of the importance of basic hygiene practices like using latrines, washing hands with soap after visiting the latrine and before eating or feeding children, keeping the surroundings clean, and their water source well covered. He believes that fishing and farming around the marshes exposes the people to the risk of cholera.
“Cholera is like a sudden attack,” Fanuel says. “If untreated one can die within four hours after the diarrhoea starts. It is that dangerous. Preventing cholera is very dependent on the behaviour of the people so we try to make them understand that and get them to change.”
In 2015, UNICEF supported a water quality assessment which revealed high levels of contaminated water in homes in Nsanje. Environmental health officer Minyaliwa says this indicates that the risk of water contamination is highest at the household level. “People in Nsanje are generally getting safe water from the various water sources available,” he explains. “The contamination is taking place in the home, because of the manner in which they store and handle water.”
In the past, cholera was a seasonal occurrence, hitting mainly during the rainy season from November to March. “Things have changed,” Minyaliwa adds. “Now cholera can hit on any day.”
As cholera spreads very quickly, it is essential to have the right treatment available at all times. UK Aid, through UNICEF, has funded cholera preparedness, prevention and control activities in the affected districts. The UK provided £1.75 million from November 2016 to October 2017 to support preparedness, prepositioning of supplies, case management, training of health staff, surveillance, monitoring, supervision, and purchase of medical and water, sanitation and hygiene supplies.
“This direct support to cholera-prone districts really is saving lives,” UNICEF Chief of Health Rumishael Shoo says. “We are protecting thousands of people from having to suffer cholera by empowering communities with prevention messages and interventions, while also ensuring that those affected are treated quickly to prevent further spread of the disease.”
In Ndamera, more than 20,000 people who live in cholera hotspot villages around the border crossings received two rounds of oral cholera vaccine (OCV) immunization in July 2017. This campaign was organized by the Malawi Ministry of Health and WHO, while UNICEF provided technical support, monitoring and supervision of campaign activities, with funding from UK Aid.
These resources enabled UNICEF to procure cholera treatment supplies for prepositioning in six sites across the country, along with logistical support to transport these critical supplies all the way to the sites where they are needed. UNICEF teams regularly visit the affected areas to ensure that supplies are used for the intended purpose.
The programme also aims to build resilience, within both communities and institutions. Over 2,000 health staff in cholera prone districts have been trained to recognize the signs and symptoms of cholera, and treat and manage the disease in a way that saves lives and prevents the disease from spreading. They are also able to undertake regular surveillance in the community and flag any trends of diarrhea in the communities they serve.
“The communities are more empowered than before,” UNICEF’s Rumishael Shoo adds. “They know about the disease and are taking better care of their latrines, water storage units and other facilities in the home.”
For Malawian mothers and children like Joyce Binda and Mary Mankhamba, the support provided by the UK is transforming their lives. It is keeping them alive, healthy and able to work and study at school.
It is a making Nsanje District a better and safer place to live.