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Why Malawi’s record cholera outbreak demands long-term solutions

‘There are times when countries cannot go it alone, and this is one of them.’

A health worker disinfects water at a clinic in southern Malawi, in November 2022. Eldson Chagara/Reuters
A health worker disinfects water at a clinic in southern Malawi, in November 2022. A cholera outbreak has claimed over 1,600 lives in the country over the past year.

Cholera outbreaks are exploding around the world, in places the disease has not been seen in decades. In Malawi, where we serve as members of parliament, an outbreak is currently breaking records. It is by far the worst epidemic of its kind that we have encountered.

 

The resulting suffering is tremendous, but perhaps the greatest tragedy of all is that cholera is both predictable and preventable. Nobody should suffer or die an excruciating death from this disease.

 

Pharmaceuticals – vaccines and antibiotics – are valuable if available, but the key to tackling cholera is prevention. What is needed is global investment in sustainable water, sanitation, and hygiene (WASH) to decisively quash this preventable disease and others like it.

 

Global attention on WASH is growing ahead of the UN Water Conference, the biggest water meeting in 50 years taking place later this month in New York. As the interim co-chairs of a new parliamentary water caucus in Malawi, we are calling for this focus to turn into actionable investment. Lives depend on it.

 

Record outbreak

Since Malawi’s record-breaking outbreak began in March 2022, more than 50,000 cases have been reported. Over 1,600 people have died, representing a case fatality rate of above 3%. By contrast, in an average year, around 100 people might die from the disease during the rainy season. 

 

This epidemic – which commenced well outside the rainy season here – has crippled our health system. As cholera admissions surge, hospitals have been hit with a shortage of resources, coupled with an inadequate number of health workers. 

 

Cholera is a bacterial disease which causes severe dehydration that can kill within hours if untreated. It is usually spread by eating food or drinking water that is contaminated by the faeces of an infected person. The disease tends to impact those living in extreme poverty, where there is inadequate sewage disposal and water treatment. Displacement by crises like floods, droughts, and war increases the risk of outbreaks. As weather becomes more extreme due to climate change, it brings more floods and droughts and damages already limited WASH infrastructure. 

 

Cholera epidemics are currently hitting vulnerable populations across Asia, the Middle East, the Caribbean, and Africa. The global vaccine stockpile is running low, and in December the World Health Organization said it had run out of vaccines altogether.

 

What the government is doing

Malawi’s national COVID-19 taskforce (which also spearheads cholera interventions) has taken measures to minimise spread of the disease, which has affected all of the country’s 29 districts.

 

Primary and secondary schools have been closed in hard-hit areas; crowded and unhygienic markets have been shuttered; and the sale of homemade food in public places has been banned. We are working with donors and civil society organisations on sensitisation campaigns to improve the management and disposal of waste. We want to better educate people on the importance of treating water collected from unreliable sources. 

 

These efforts are necessary, but they are clearly not long-term solutions, and some are problematic as they worsen the economic woes of small-scale business owners, especially in rural areas.

 

Vaccines work, but for just two to three years before they must be readministered. This is a difficult and resource-intensive task even when vaccine stockpiles are sufficient. These various efforts underscore the need to tackle cholera with long-term prevention.

 

We are working internally, calling for an increase in WASH budgeting and expenditure in Malawi. Our government’s long-term goal is to increase safe water access from the current 60% to around 95%. But this is a challenge for a small landlocked country on the front lines of the climate crisis.

 

There are times when countries cannot go it alone

Cholera outbreaks need to be brought under control, and we are grateful for emergency assistance. Among them, the EU just released emergency humanitarian funding of EUR 1.5 million to support Malawi in its efforts to address the current cholera epidemic. Both the US Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) are providing emergency supplies and support. 

 

But one thing is clear: The long-term intervention is WASH. It needs to be front and centre and prioritised by international public and private donor communities – from funding and technical assistance to training and support for long-term operations and maintenance. 

 

Underscoring that point, the WHO’s Global Task Force on Cholera Control coordinates more than 50 institutions, NGOs, academic institutions, and UN agencies. Its stated goal is to eliminate cholera as a public health threat by 2030. As the GTFCC steering committee recently said, “Unless we invest in systems that build preparedness and resilience among at-risk populations, the cholera burden will continue to rise.”

 

GTFCC calls for donor funding for “critical large-scale WASH infrastructure investments in cholera hotspots,” and notes: “While additional funds would be needed to realise the right of all human beings to safe water and sanitation, we can make immense progress simply by targeting cholera hotspots with existing WASH resources.” 

 

Long-term momentum is building 

For its part, the UN is holding a major water conference from 22-24 March, and has engaged a new public/private effort – the Sanitation and Hygiene Fund – to catalyse sanitation economies that will attract investors. 

 

Malawi is now among the 22 high-priority countries for the US government’s recently updated five-year Global Water Strategy; and US Vice President Kamala Harris recently announced the first-ever “White House Action Plan on Global Water Security”.

 

In February, the Inter-Parliamentary Union of 178 national parliaments hosted a hearing focused on encouraging members of parliaments around the world to prioritise WASH investment. Among the opportunities for parliamentarians is to establish country-based WASH caucuses to specifically focus on increasing WASH access, infrastructure, and training in operations and maintenance to ensure sustainability. 

 

These kinds of efforts must become investments and not only to prevent cholera: Access to safe water and sewage disposal brings solutions to a whole host of health and development issues, from building economies and healthier workforces, to keeping girls in school.

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