Cholera: A Wake-Up Call For South Africa's Development Strategy
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Dear Colleagues,
You may be interested in an article on cholera written by Mickey Cho-
pra and myself. An abbreviated version was printed in Business Day on
Wednesday, February 7 2001. Any comments would be welcomed.
David Sanders
mailto:lmartin@uwc.ac.za
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Cholera: A Wake-Up Call For South Africa's Development Strategy
South Africa's cholera outbreak of the past five months has accounted
for almost 30,000 cases and approximately 80 deaths, including at
least one urban death in Gauteng. This situation is a stark microcosm
of S.A.'s "dualism", reflected in its health system (and indeed its
approach to development more generally). The very low case fatality
rates (0.3%) attained so far through sophisticated and costly medical
interventions (health facility-based intravenous rehydration, as op-
posed to rehydration by mouth, shown to be very effective in Bangla-
desh's large-scale epidemics) equal the best statistics of the modern
world. Yet the rapid and uncontrolled spread, is due to social condi-
tions equivalent to those seen in the world's most underdeveloped
countries.
In the 19th Century cholera epidemics punctuated the squalid urbani-
zation of Britain's industrial revolution and catalysed social action
around environmental hygiene. Currently cholera is endemic in South
Asia and for the past two decades in Latin America; it thrives in
situations of squalor and deprivation, often in slum settlements on
the fringes of cities. That this situation is an indictment of a
country as wealthy as S.A. was noted and its impact meticulously re-
corded during the 1980's cholera outbreak in a number of former home-
lands.
Should South Africans, almost seven years after the advent of democ-
racy, be surprised at this, the latest and worst cholera epidemic?
Through its partnership with the private sector (as exemplified by
the Build, Operate, Train and Transfer (BoTT) programme) the Depart-
ment of Water Affairs and Forestry (DWAF) has invested in water pro-
jects. However, as a recent DWAF sponsored conference concluded:
"(there is) a growing perception of the failure of the BoTT programme
to deliver sustainable services, it would not be an understatement to
say that the sector is in crisis". It goes on to commend the delivery
of services but warns that "there have also been many problems which
result in serious concerns regarding sustainability, including at
least: lack of genuine engagement of local government and communities
in the services provision process; lack of understanding of community
dynamics, perspectives, processes etc. on the part of consultants and
contractors; lack of adequate discussions and agreement being reached
regarding levels of service, tariffs etc. at the commencement of pro-
jects; and inappropriate implementation of service standards, inap-
propriate designs and inflated costs." (Rural and Peri-Urban Water
Supply and Sanitation in South Africa: Appropriate Practices Confer-
ence DWAF 2000).
This lack of attention to community processes and appropriate levels
of service has had even more serious consequences in the sanitation
sector. In a letter in the Cape Times of January 10, 2001 Mike Mul-
ler, Director General, DWAF asserts: "we have been the first to state
that providing water will not contain cholera on its own. We also
need to provide hygienic sanitation facilities and critically, to
change behaviour, to reduce the risks that people face from infec-
tious disease like cholera." He instances this commitment by refer-
ence to the Northern Cape Household Sanitation Programme an "award-
winning pilot project of the department which addresses poverty by
implementing affordable sanitation measures that can be maintained by
the household".
While DWAF is to be congratulated for piloting innovation, at a na-
tional level its efforts in this regard are generally perceived to be
minimal. For example, the National Sanitation Task Team (an inter-
departmental committee set up in 1995 to draft national sanitation
policy and co-ordinate its implementation) has been poorly resourced,
and supported. The acknowledgement of sanitation as a priority area
is undermined by the low status it is given both within DWAF, where
the national head of sanitation occupies only a deputy director posi-
tion, and also by Health, Education and Provincial and Local Govern-
ment which have not given sanitation the attention it has long de-
served. Financial allocations for sanitation activities are small and
even these have not fully been spent by provinces. It is disingenuous
for Muller to assert that ". people do not always give sanitation a
high priority. Indeed, while funds for water supply are oversub-
scribed many times, funds available for improved sanitation have not
been spent in some areas not because we expect to receive application
forms but because we depend on communities' buy-in." While it may be
true that sanitation is not high amongst the numerous pressing pri-
orities of the poor, it is nonetheless both a felt need and an essen-
tial component of a comprehensive strategy to reduce the heavy burden
water-related disease imposes on the majority of South Africans. In-
deed, authoritative research has suggested that sanitation provision
may be the most critical element in the water-sanitation-hygiene
awareness triad necessary to combat diarrhoeal disease (of which
cholera is but the most dramatic). And without adequate sanitation,
huge expenditure on new water schemes is badly compromised, as faecal
contamination of communal water sources, which are still used for
high volume activities such as washing and bathing, continues un-
abated.
To anyone familiar with other countries in the region, South Africa's
rural areas are strikingly devoid of safe and hygienic sanitation
structures. Our team of public health and nutrition personnel which
has been working for the past 3 years in the barren but densely popu-
lated hills of the former Transkei have been struck by the absence of
good latrines. That local residents resort to using the eroded moun-
tain valleys as toilets has been confirmed by our research in Mt.
Frere, as is the fact that water is frequently drawn from the streams
that run through these ravines. Unsurprisingly, diarrhoeal disease
ranks as the top reason for attendance at health facilities, and re-
search strongly implicates it as a major cause of young childhood
malnutrition which remains depressingly common in this area.
The lack of latrines and the dysfunctionality of many borehole-
supplied piped water supplies ultimately reflect not only the empha-
sis on cost recovery for water but also South Africa's technocratic
approach to development, where the focus is on (often inappropriate)
hardware (large plant as opposed to protection of small water
sources) at the expense of "software" - the crucial social processes
necessary for implementing and sustaining development projects. The
laborious but indispensable processes of engaging communities around
the various options for water and sanitation, and developing their
capacity to assist in the construction and maintenance of facilities,
have, for the most part, been eschewed in South Africa.
In most other Southern and Eastern African countries environmental
health technicians (sometimes called health assistants) are numerous
and predominantly rurally-based, and play both a community develop-
ment role as well as possessing technical skills to correctly site
and construct latrines and wells. But such a "low-tech" approach is
not for South Africa. Here, instead, we contract private engineering
firms, and in the public sector employ fully-fledged environmental
health officers (formerly called health inspectors) trained in Tech-
nikons, where a standard national curriculum and the culture of prac-
tice have hitherto emphasized health "inspection", rather than social
and community development. Unlike neighbouring countries' health as-
sistants, our environmental health officers are predominantly urban
in their location, and tend to be distributed in inverse relation to
the need for environmental services: Khayelitsha, for example, pos-
sesses far fewer environmental health officers than Wynberg.
The dominance of a technocratic approach which proactively engages
the private sector is in line with the current policies governing
transformation of the public sector. Indeed, DWAF has been more ag-
gressive than most sectors in pursuing this model. This has replaced
the intended focus of the RDP, which advocated the development of a
public sector responsive to communities, whose capacity to actively
participate in the social process would be deliberately promoted.
While the currently dominant approach may be able to effect "deliv-
ery" more quickly, the cost is high of not pursuing the more labori-
ous and complex (but more sustainable) route of a participatory proc-
ess, combining capacity development and support with appropriate and
affordable technologies. And this cost is currently expressed as
cholera cases. These are, on a daily basis, vastly outnumbered by
cases of childhood diarrhoea, which, although less dramatic, impose a
far greater burden and cost on our services and result in many more
deaths.
By David Sanders and Mickey Chopra
Respectively Professor and Lecturer in the
Public Health Programme at the University of Western Cape
mailto:lmartin@uwc.ac.za
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