Freetown/Conakry/Accra/Dakar — Aid agencies are scrambling to treat thousands of cholera patients in Sierra Leone's capital, Freetown, where the number of infections is mounting by over 250 per day. Most patients are from the city's various urban slums, where open defecation is rife, toilets are rare, sewage is improperly disposed of, and awareness of cholera is very low. Water and sanitation specialists say unless these problems are addressed, cholera will continue to flourish both in Sierra Leone and throughout West Africa.
By 28 July, 15,126 people had contracted cholera in West Africa, the most affected countries being Sierra Leone (at least 5,369 cases, but thought to have increased dramatically since then), Ghana (5,121 cases), Niger (5,023 cases), and Guinea (802 cases), according to the UN Children's Fund (UNICEF).
"There is a massive failure to take cholera seriously in this region, and to publicize it," said a West Africa cholera specialist. "Ultimately, if you want to get rid of cholera you need to address the structural issues that cause it." The money is there, "it is a question of tapping into it and taking responsibility for your citizens."
Take cholera seriously
Most West African countries are falling far short of their Millennium Development Goal to double the proportion of citizens with access to proper sanitation facilities - just 37 percent of inhabitants can access a clean toilet, according to the World Health Organization (WHO).
As in Freetown, a high proportion of the cholera cases in Conakry, the Guinean capital, and Accra, Ghana's capital, are concentrated in urban slums, where there are few clean toilets and most people openly defecate, often dangerously close to open wells that are the source of water for most residents.
The cholera outbreak now has a caseload of 60 per week in Conakry and Accra and is thought to be past its peak, when there were 90 to 100 cases per week in each city, but Charles Gaudry, head of Médecins sans Frontières in Guinea, warned that "We must still be on our guard."
Governments tend to clean up the cholera mess once it is in full swing rather than working on prevention, said an independent water and sanitation (WASH) specialist in West Africa. "It is government's responsibility to address the very basic sanitation rights of its citizens."
Donors, too, prefer to fund reactively, hence "UNICEF's 'Sword and Shield' [response-prevention] strategy is more sword than shield," noted Patrick Laurent, West Africa WASH coordinator at UNICEF.
When aid agencies approached the African Development Bank in 2011 for cholera prevention support in the Central African Republic, the response was: "When you report a cholera case, we'll give you the money."
In Guinea, just one or two aid agencies - Action against Hunger and UNICEF - work on cholera prevention with the government, while one - MSF - is doing the bulk of the treatment and transmission containment.
Ghana: prosecution over publicity
In Greater Accra, with 77 percent of the country's cholera cases, at least 20,000 people have no toilet or use bucket latrines (a pot that is periodically dumped outside), according to Accra health department director Simpson Boateng. Those living near the sea simply defecate on the beach.
The Ghanaian government banned open defecation and bucket latrines in 2010, and arrests all perpetrators, said Boateng. "We need to continue to educate them [people], but more importantly, you will be arrested when caught," he told IRIN. "As I speak, over 1,000 landlords have been prosecuted for still using pan latrines in their houses." The city council is establishing a 'sanitation court' to try the culprits. "We are simply enforcing the by-laws which frown upon this conduct," he said.
Cholera in Niger
In Niger, the situation is different in terms of topography and humanitarian context. Some 99 percent of the cholera cases are in the Tillaberi Region in the southwest of Niger, on the Niger River. The rest are in refugee camps in Ouallam, in southwestern Tillaberi.
Cholera has broken out against a backdrop of high rates of malnutrition and food insecurity, and large numbers of refugees who fled the takeover of northern Mali. The rains and insecurity make it difficult to access some cholera-hit villages, said UNICEF's Patrick Laurent.
"If you add all of the above conditions, plus the rainy season, floods and poor sanitation, it's not surprising to see a cholera outbreak," he noted.
The government has a low capacity to respond to cholera but is willing to collaborate with the many relief and aid agencies working to alleviate the emergency there, said Laurent. "For me, this is half the battle."
Rather than crackdowns, more awareness-raising is needed, suggested Accra residents, including journalists, who had no idea there was a cholera outbreak in their city.
Unlike in neighbouring Guinea and Sierra Leone, where the governments are weak and rely on aid agencies to drive the response, the Ghanaian authorities are leading the cholera response but have "underplayed it" for political purposes, said WASH specialist Laurent.
The recent death of President John Atta Mills and the approaching parliamentary elections have drawn the attention of most government officials for weeks.
Give them an alternative
Arrests may be a temporary deterrent, but people will continue to defecate in the open as long as they have no alternative, say aid agency staff. Just 17 percent of Accra's residents, and 8 percent of rural Ghanaians, have access to an adequate toilet, according to the government's 2008 health survey.
The key is to get communities all over West Africa to want to use and maintain clean toilets. In Sierra Leone, UNICEF is pushing "community-driven total sanitation", in which communities move away from open defecation once they understand its consequences, and go on to build and maintain clean toilets themselves.
In this model, UNILEVER, which manufactures cleaning products, has worked with UNICEF and local partners in Gambia, and with Water and Sanitation for the Urban Poor, a non-profit group, in Ghana to form The Clean Team. The process is: trigger a demand for toilets through behaviour change; arrive at a price that works for everyone; and then make clean toilets available.
An ongoing project in Kumasi, south-central Ghana, targeted 100 families, most of whom were sharing dirty latrines. Each was given a free chemical toilet with a sealed waste container that was exchanged two to three times per week. A family of five pays about US$15 per month for the service, which is less than it costs to use the public toilet.
The waste is processed in the city's septic tank system, but the municipality hopes to use it to produce biofuel in the future. Thus far the scheme has improved hygiene, lowered household costs and reduced the use of plastic bags for defecation, otherwise known as "flying toilets", said Clean Team manager Asantewa Gyamfi. The plan is to expand it to 1,500 families.
Keeping toilets clean
Transferring such an intensive approach to an urban slum setting in Freetown is a challenge, said UNICEF's Sierra Leone water and sanitation specialist, Gaurav Garg. Most of Freetown's flood-prone slums are hemmed in by the ocean and/or mountains, and there is simply no room to build new toilets - public latrines are the only option.
An urban WASH consortium - made up of NGOs Oxfam, Action against Hunger, Save the Children, GOAL, and Concern - charged with helping the government improve sanitation in Freetown's slums, has decided that improving and rebuilding public toilets is the only option, but keeping them clean is the real challenge, said Marc Faux, the group coordinator.
Community committees have been set up to run the toilets. Each is given four roles: collect money for their use (usually 100-200 leones per person [2 to 4 US cents] use the money to clean and repair the toilets; communicate the community's sanitation concerns to political decision-makers; and make sure waste is dumped safely. Health officials say until each of these jobs is done well, use will continue to be low.
To date, most of the waste from public latrines has been dumped in nearby rubbish tips or into the sea. The NGO consortium is currently experimenting with a low-technology device that pumps waste into containers that can then be taken to trucks. Another method being tested is a device used to separate urine from faecal matter, which can then be turned into compost over an 18-month period.
These and other innovations are an important start to addressing the myriad challenges in unsanitary, densely populated, coastal cities such as Freetown, Conakry and Accra. But they will only make a dent in cholera prevention. The issue must be addressed, "not on a project-by-project basis, but holistically, involving education, health systems, water and sanitation infrastructure - the lot," said Mariamme Dem, West Africa head of NGO Wateraid in Senegal.
That looks a long way off. For now, NGOs like MSF are hastily setting up treatment centres to care for the cholera victims who come their way - as they have done every few years since the 1980s.
This report does not necessarily reflect the views of the United Nations