City under siege: preventing cholera in Lilongwe

On Sunday 20 May 2018, Lilongwe became cholera free, following an outbreak that lasted four months, affected 388 people, and claimed 18 lives. Nationally, over 900 people were affected with 30 deaths. The outbreak was caused by unsafe water consumption and poor hygiene and sanitation practices. Unless these underlying issues are addressed, cholera is likely to return.

Located on the outskirts of Lilongwe city, Mitengo is a typical urban township, with earth roads and mud brick houses like those you find in rural villages throughout Malawi. Children play in the open spaces between houses, while women walk home with plastic buckets balanced precariously on their heads. Vendors sit alongside the road selling clothes and food, or repairing mobile phones. There is a taxi stand, where bicycle and motorbike drivers wait in the shade for their next ride.

The main difference between Mitengo and a rural village is that the houses and people are much more densely packed together. Most houses own or share a shallow well and a latrine, situated within a few metres of each other and sharing the same water source. This creates a ready breeding ground for cholera.

Nazia Chimbenenga, 25, lives with her husband and two children in Mitengo. The family makes and sells metal pots and popcorn, earning around 50,000 kwacha ($70 USD) per month. They are doing well enough to send Vanessa, 4, and Precious, 6, to private kindergarten and school. Despite being educated and relatively well off, Nazia did not know how to prevent cholera.

“Before the cholera outbreak we used to collect water from the open well behind our neighbour’s house,” Nazia says. “We used it for drinking, washing and cleaning. We also used a latrine nearby, which is shared between four houses.”

Around 2am one morning in February, Nazia’s youngest child, Vanessa, started to vomit and have acute watery diarrhea. She immediately hired a motorbike taxi and took her to hospital. “I thought it was cholera because the outbreak was already underway,” she recalls. “I was very scared. I realised my child’s life was in danger. Vanessa had reached the point of not speaking.”

The hospital admitted Vanessa and, in the morning, transferred her to a cholera treatment centre, where she was put on a drip. The same day, Nazia’s other child, Precious, also became sick and her husband Kingsley brought him to the treatment centre. While they were there, Kingsley developed symptoms himself and was admitted. Nazia was now faced with the prospect of losing her husband and both children.

“I was beyond despair,” she says. “My whole family had cholera. I was so worried that I couldn’t eat all day.”

Luckily, Nazia’s husband and both children made a full recovery. By the following Sunday, they were able to return home. A health worker visited Nazia at home and explained to her what causes cholera (bacteria contained in the faeces of infected people) and how to prevent it.

“Before Vanessa got sick, I didn’t know how to prevent cholera,” Nazia says. “Now I know we have to stop using the open well, get safe water from the kiosk, clean our food, and wash our hands after using the latrine.”

During the cholera outbreak, Nazia was able to get water trucked in by UNICEF, with funding from UK Aid. Now, her nearest source of safe water is a private water kiosk on the other side of the river. It’s a 10-minute walk and costs 50 kwacha to fill a large bucket. The water often runs out and is only reliable during the night. But she has no second thoughts about using it.

“The water is expensive and difficult to carry back,” she says. “It would be better if there was a public water kiosk on this side of the river. But I still use it. The problems are nothing compared to the ordeal I went through when my children were sick.”

Nazia carries a bucket of safe water home for her family to drink
© UNICEF Malawi/2018/Andrew Brown

Prevention is key

UNICEF Malawi’s Chief of Water, Sanitation and Hygiene, Paulos Workneh, welcomes the end of the cholera outbreak in Lilongwe. However, he warns that the disease is likely to return if concerted action is not taken, both to change people’s behaviour and to ensure they have access to safe water.

“In Lilongwe city, the only safe water is that provided by the water board, including taps and kiosks,” he says. “Open wells and rivers are not safe for drinking under any circumstances. Families can best protect their health through regular handwashing, chlorination of water, and safe disposal of faeces. Anyone with watery diarrhoea should immediately seek treatment from public health institutions.”

With the immediate crisis over, UNICEF will begin phasing out the emergency deliveries of water by truck. However, without a more sustainable long-term solution, there is a risk that families will revert to using unsafe water.

“Lilongwe Water Board has a responsibility to provide uninterrupted safe water, particularly in cholera hotspots,” Paulos continues. “There is an urgent need for more water kiosks to serve the growing population, especially in urban townships like Mitengo. Without this, it is only a matter of time before cholera returns.”

Theatre for development

To improve community awareness of cholera and how to prevent it, UNICEF manages an ongoing communication for development, or behaviour change, campaign. This is funded by UK Aid and includes community theatre and cinema activities.

Nazia attends a community theatre performance in Mitengo, where actors perform a drama about two families who share a latrine and come into conflict during a cholera outbreak. The actors use melodramatic gestures and expressions, like characters in a TV soap opera. The crowd laughs, shouts praise and criticism of characters, and cheers when local landmarks are mentioned. Children climb trees to get a better view.

After the drama, a village health worker gives a talk on how to prevent cholera. The performers encourage the audience to discuss the issues raised by the play, and then develop an action plan to prevent cholera in their area, which is approved by the local chief. The theatre group arranges to come back in a few weeks and check on progress.

The community theatre is delivered by Story Workshop. “Theatre for development is an effective method for behaviour change because it reflects people’s real lives,” Project Officer Emanuel Nthara explains. “Before the performance, our team goes around the houses to understand what is happening. We base the plot on real events and use the names of local places so that people can relate to it.”

Another benefit of the theatre method is that it allows people to challenge their chiefs if they are not doing enough. “Normally people are afraid to do this,” Emanuel continues. “But the drama format allows them to open up. They start by commenting on the play, which is less confrontational.”

This approach is delivering results. For example, in Karonga the theatre group discovered that people were getting cholera from the relatives’ tent at the health centre. “After the discussion, the hospital and chiefs agreed to put volunteers as watchmen at the tents, to monitor who went in and out and enforce hygiene rules,” Emanuel says. “After that, the number of cases dropped substantially.”

For Nazia, the nightmare of seeing her whole family struck down with cholera is not one she plans on ever repeating. She will do whatever it takes to get safe water for her children. But for other families in Lilongwe’s townships, the risk of cholera remains in the background. Only with sustained behaviour change and universal access to safe water, will they be truly safe.

There is hope. After the theatre performance, Nazia’s young son Precious says: “We talked about cholera. It’s a sickness that you can catch. We need to wash our hands after going to the toilet. I will tell my friends.”