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Why is cholera killing thousands in southern Africa?

‘If we were doing enough, we would not have seen such a massive cholera outbreak.’

Southern Africa’s informal settlements often lack adequate water, sanitation, and hygiene infrastructure, like this informal settlement in Windhoek, Namibia Margaret Courtney Clarke
Southern Africa’s informal settlements often lack adequate water, sanitation, and hygiene infrastructure, like this informal settlement in Windhoek, Namibia.

Climate change is fuelling a sanitation crisis in southern Africa’s informal settlements as drought pushes more people into cities, creating perfect conditions for the spread of disease and overwhelming government attempts to provide services and support.

Since 2022, at least 188,000 people across southern Africa have been infected in a series of cholera outbreaks that have killed more than 4,100. Zambia has experienced its worst epidemic in 20 years, with 705 people reported dead and more than 21,000 infected since the beginning of seasonal rains in October. 

Febby Banda’s seven-year-old son contracted the disease in January. He was admitted to the Heroes National Stadium in the capital, Lusaka, usually home to the national football team but transformed into a massive treatment centre during the outbreak.

“I worried for my son because deaths were being recorded on a daily basis,” Banda, 45, told The New Humanitarian. “I couldn’t eat, I just kept praying to God for his recovery.”

She suspects her son was infected after eating food or drinking water contaminated with human excrement while out playing with his friends.

This sounds alarming, but could very well be the case.

Banda and her son live in the Chazanga compound, an informal settlement north of Lusaka with no running water or sewerage. Residents share pit latrines that don’t safely separate waste from human contact. When it rains, the water level rises and faeces pour into the neighbourhood, contaminating the shallow wells where drinking water is drawn from: A perfect breeding ground for cholera.

From drought-hit farm to city

In January, President Hakainde Hichilema urged citizens to relocate from densely populated urban areas like the Chazanga compound and into rural villages to prevent the spread of cholera. But Zambia is also suffering crippling impacts from an El Niño climate event that has triggered drought across southern Africa and caused devastating crop failure in the country’s rural areas. Instead of seeing people moving out, the urban population is growing.

“The shortage of food from this year’s drought will only see more people coming to the city,” said Banda, whose son has fortunately recovered from his cholera bout. “They are searching for a better life, but Lusaka is under pressure to contain the influx of people.” 

Southern Africa is highly vulnerable to climate change. Across the region, from Angola to Mozambique, an estimated 24 million people are likely to go hungry in the wake of an El Niño that has led to the driest spells in more than 40 years.

According to the Intergovernmental Panel on Climate Change (IPCC) – a body of experts convened by the UN – droughts, floods, storms, and extreme heat are the biggest causes of climate migration, and 70% of climate migrants settle in cities. 

“Sanitation infrastructure is already lacking, and the burden is too much to provide more.”

The same report says an additional 2.5 billion people will be residing in cities by 2050, with informal settlements most at risk as populations outpace the ability of governments to provide basic services. In Zambia, the percentage of people using at least basic sanitation facilities is already in decline. 

The same is true in Namibia, which recently suffered a deadly four-year outbreak of hepatitis E caused by widespread open defecation, with informal settlements counting for 62% of confirmed cases

Gotlieb Sheyavari Timo of Development Workshop Namibia, an NGO dedicated to helping residents in neglected areas access proper sanitation facilities, said its efforts have been outpaced by new arrivals as drought hits rural Namibia.

“Most of the people that used to depend on rainfed agriculture are looking for other ways to improve their livelihood, so they move to urban areas looking for jobs,” he told The New Humanitarian. “Sanitation infrastructure is already lacking, and the burden is too much to provide more.”

Planning can’t keep pace

Sebastian Husselmann has tried to manage this influx in his role as chief engineer for bulk and wastewater in the Namibian capital, Windhoek, where an estimated 45 tons of faeces are deposited each day through open defecation alone. 

“There’s no structure, no town planning, no streets; at random, people come and put up their shacks,” he told The New Humanitarian. “That makes it almost impossible for the municipality to provide structured services like water, sanitation, and waste removal.” 

In Zimbabwe, informal settlements are growing at a rate of 14% each year, alongside a sharp decline in the number of people using basic sanitation in urban areas. The country reported 569 cholera deaths and 26,708 cases at the end of February. 

Elias Hwenga, Zimbabwe’s Red Cross Society secretary-general, told The New Humanitarian that drought this year would only see more arrivals to urban areas, leading to an increase in waterborne diseases, malnutrition, and respiratory infections.

“There must be no more unplanned settlements.”

“The rural populace always perceives urban areas as having huge economic opportunities,” he said. “Climate change is likely to amplify these perceptions.”

Mambo Hamaundu, permanent secretary in Zambia’s Ministry of Local Government and Rural Development, said his officials were focused on adapting to rapid urbanisation to prevent further outbreaks of cholera and other diseases, and had prioritised putting an end to the expansion of informal settlements. 

“We’ve seen a number of people move from rural to urban areas because of climate change,” he said. “In as much as we may not stop the rural-urban drift, it is important that when people come, they come to areas that are properly planned with crucial amenities. There must be no more unplanned settlements.”

Oliver Kaoma, secretary-general of the Zambia Medical Association, agreed that informal settlements must become a thing of the past to prevent future outbreaks, but he implored the government to also launch a behavioural change campaign.

“We need to work with schools, traditional leaders, and community leaders to ensure that people are adhering to hygiene standards; that if you are defecating in a place not designated, it has the potential to cause disease,” he told The New Humanitarian. “Are these things happening? The answer is no. If we were doing enough, we would not have seen such a massive cholera outbreak.”

Finding solutions 

Malawi, Namibia, Zambia, and Zimbabwe have each had past success with Community-Led Total Sanitation (CLTS), a collaborative approach aimed at igniting a change in sanitation behaviour through community participation. 

Facilitators help community members understand the impact of poor hygiene, which they hope will incentivise residents to build their own toilets and prevent open defecation. When a community shows ongoing adoption of good hygiene practices with at least 80% of residents using sanitation facilities, they are awarded Open Defecation Free (ODF) status.

But solutions like these are not yet happening on a large enough scale to prevent the spread of disease. Two years after the introduction of CLTS, Namibia still only has 16 ODF areas, while ODF communities in Zambia and Zimbabwe have struggled to maintain their status without subsidies or continued support.

“People still get sick even if you have a toilet because there is no water”

And even when there are toilets and the will to use them, people need running water to keep clean. 

Mamakie !auxas, 48, lives in the Democratic Resettlement Community, one of Namibia’s largest informal settlements. She was tired of getting infections, so she built her own toilet in front of her shack. “People still get sick even if you have a toilet because there is no water,” she explained. “Where am I supposed to wash my hands?” 

As climate change and population growth drive the expansion of southern Africa’s informal settlements, providing both incentive and infrastructure will be vital in preventing outbreaks of faecal-oral disease. 

“No time is too soon,” said Kaoma of the Zambia Medical Association. “As long as things remain the same, then we can expect another outbreak.”

Edited by Obi Anyadike.

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