Wednesday, June 7, 2023 | ANALYSIS | Cholera outbreak a symptom of failing water and... | ANALYSIS | Cholera outbreak a symptom of failing water and sanitation systems – and it will get worse




There have been 22 confirmed cases of Cholera and one death since February.

There have been 22 confirmed cases of Cholera and one death since February.

Getty Images/ Roman Novitskii

The water and sanitation systems in the country are failing and the outbreak of cholera – which has been warned of for almost a decade – will remain a major concern if they are not remedied soon, writes Dr Jo Barnes

South Africa is now facing yet another health threat – one that has been warned about for more than a decade, namely cholera. 

Cholera is an acute diarrhoeal infection that can be transmitted by contaminated food or water, or by direct contact with faecal matter or vomit of infected persons. 

Sewage from cholera-affected areas carries high numbers of infectious organisms. Cholera is, therefore, as much a disease of poorly handled sewage as it is of drinking water quality.

READ | Health experts raise concerns about ongoing cholera outbreak in southern Africa

Cholera can cause severe diarrhoea and vomiting, which can rapidly turn fatal. Severely affected patients can lose as much as 25 litres of water over a short time, leading to serious or life-threatening dehydration.

Cholera cases have been diagnosed in three provinces at the time of writing: Gauteng, Free State and Limpopo. So far, 15 people have officially died from the disease, while about a hundred have been infected. That figure will most likely be an underestimation since not all cases come to the attention of the health authorities.

The site of the biggest present spread of cholera is Hammanskraal, north of the City of Pretoria. Hammanskraal is a case study of the sustained failure of responsible authorities over more than a decade to improve the water and sanitation of that area.

WATCH | How does cholera spread?

The water supply to Hammanskraal has been unreliable and not fit for human consumption over a long time. The water and sanitation department has issued several directives to the City of Pretoria regarding the water situation, while the Human Rights Commission recommended in 2021 that the department should take over the water supply to Hammanskraal from the City in terms of the Constitution, the Water Services Act and the National Water Act.

The National Treasury confirmed that funding has been supplied to the City of Pretoria to the wastewater treatment works (Rooiwal) in the area, but that seemed to have no effect. 

Rooiwal is in a failed state and responsible for serious sewage contamination of the area.

None of these official actions resulted in any improvement. The City is at present supplying the area with water by means of 52 water tankers servicing the area three times a week. Therein lies a really big weak link. Even though the water in these tankers may be safe, inhabitants have to carry it home in buckets and use the water from there. 

A bucket with a jug or mug next to it will only remain clean until the first-hand scooping out some water pollutes it. Then the rest of the water in the bucket is not clean or safe anymore. It then becomes a focus for the spread of waterborne disease, regardless of its clean state at the beginning.

Official response has been inadequate

Predictably, politicians descended on Hammanskraal and lofty promises were made. This was met with angry responses from the inhabitants. The department is now vowing to investigate the source of the cholera infection and has appointed a team to do so. That is close to futile at present, since the disease is already spreading in the community, and determining the original source may be well-nigh impossible. Chances are that the original infection came “walking” into the community anyway.

Cholera infection can take up to five days for the symptoms to develop, so it was likely carried into the community by an already infected person.

READ | Cholera in Hammanskraal: ‘Our leaders saw this coming, but nothing was done’

There is no mention in any of the official communications that have been reported in the media of urgently addressing the failing sewage system and poor solid waste management in the area. Those systems are the biggest carriers of risk and need attention without delay.

Sewage trickling down the street, contaminating the surfaces and the waste lying around forms a perfect source for flies, rats and cockroaches to carry the organisms around every dwelling. The soles of bare feet and shoes carry the infection home, while children play in the contaminated areas and become carriers too.

This is not just a problem for the unfortunate inhabitants of Hammanskraal. Poor water and sewage treatment and poor solid waste removal plague the whole of South Africa, with few exceptions.

That means the whole of the country can be seen as a potential risk zone.

The 2022 Blue Drop Progress Report found that 34% of water treatment systems in the country are in the high or critical risk categories for delivering unsafe water. That amounts to one in every three municipal treatment systems in the country.

Such widespread failure not only raises the risk of outbreaks of waterborne disease. It impacts the general economy, not least of all through the impact of a chronically unhealthy workforce.

READ | Gift of the Givers delivers thousands of litres of drinking water to cholera-stricken Hammanskraal

The general advice to boil water before drinking and cooking is almost laughable, given the state of our electricity supply.

To date, there have not been any widespread education campaigns aimed at the general public from the national or local health departments regarding safe prevention steps. This is another omission that is hard to explain.

Unless the various sectors of the government overseeing water and sanitation, municipal services, health and disaster management across the country start removing the walls that insulate them, and start cooperating with goodwill and great speed, the cholera outbreak will remain a source of great concern.

– Dr Jo Barnes is a senior lecturer emeritus at Stellenbosch University’s department of global health, health systems & public health

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