In 2000/01 South Africa endured a cholera epidemic that spread throughout the eastern coastal region and to other provinces. It resulted in 265 deaths in five provinces and 117 147 people, mostly in KwaZulu-Natal, were infected. The epidemic was, according to the World Health Organisation, the biggest such outbreak in Africa for the reporting period.
According to rural development researchers and the South African government, the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre, those who could not afford new charges implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease. The cholera epidemic was declared an emergency and the government promised to provide six kilolitres of water free to every household every month.
The Municipal Services Project report, Still Paying the Price: Revisiting the Cholera Epidemic of 2000‒2001 in South Africa, which was released this month, examined the extent to which the response to the epidemic has led to sustained provision of safe water and improved sanitation to the poor. The report also suggests there is a clear relationship between cost recovery, indifferent management leading to interruptions in supply, and vandalism.
The research drew on studies at two sites: one at Nqutshini, a small settlement near the town of Empangeni on the banks of the Mhlatuzi river; and the other at Nkobongo, a developing low-cost housing area with continued informal settlements near Ballito, 40km north of Durban. It was found that there was some concealment and denial of the disease because of the stigma it carries.
In a number of cases where people fell ill, family members were uncertain how to respond. Often the cholera victim tried to conceal and deny the disease, and this led to significant delays in seeking treatment. In one instance, a young girl died after hiding her symptoms for some time; in another, an older man had to be heavily persuaded before going to the hospital. The stigma associated with cholera complicated the acceptance of the need to avoid using river water, to treat this water and, if sick, to seek medical assistance.
Research revealed that there were varying responses to the messages put out by the authorities on radio and television and carried by the community health workers. Many in Nqutshini found it difficult to acknowledge that the river from which they had always collected water should be the carrier of disease. Some accepted that the water they were collecting from the river may be contaminated and need treatment, others did not. Some saw the warnings against using river water as a way of forcing people to pay the monthly charges. It appears that for a period water was treated with Jik (bleach) by many, but this dropped off rapidly when the bleach was no longer available for free.
Scepticism about the official view was also associated with ideas reflecting a view of hostile external forces aiming to undermine the community, for example, the belief by some that whites were spreading the disease by low-flying aeroplanes. In all cases, the report presents the vivid personal recollections of those who were afflicted, the dread it evoked and the speed at which people’s health declined.
A survey that followed the ethno-graphic research allowed a comparison between conditions during the epidemic in 2000/01 and at the time of fieldwork. There were improvements evident insofar as most people now access piped water closer to their residences or through yard connections and use ventilated improved privies (VIPs). Most people now feel their water is safe to drink and don’t treat the water.
However, there are ongoing complaints of frequent interruptions in the water supply owing to vandalism and burst pipes and because of non-payment. In the two communities studied and at the epicentre of the cholera outbreak, the state was not providing free basic water as promised, although the communities are both poor and thus generally vulnerable to cholera. At Nqutshini, piped water was not flowing at all. Partly because of the dysfunctional water supplies, there was increased water storage by community members — an additional factor associated with cholera.
The incidence of diarrhoea among children in the household is also associated with extreme poverty, as are problems accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors — in particular the continued cycle of water-related disease in households over time — point to poor health conditions and continued vulnerability to disease among those living in extreme poverty.
The government’s policy of free basic water has been unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities, who would most benefit from its provision. Poor communities need a reliable water service, which requires better municipal management. Interruptions lead to long storage of water, which poses a health risk to those who consume this water. Communities and households with a prior experience of water-related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water-related disease to end the cycle of disease.
David Hemson is research director of the Human Sciences Research Council. For a copy of the report, contact Debbie Bruinders at the Municipal Services Project, ISSA, Rhodes University