Cholera is a word that fills the world's poorest people with dread, but if asked, the average person in the west would probably know little apart from what is gleaned from foreign correspondents reporting from hellish refugee camps.
So the basics are worth taking note of. Cholera is a bacterial infection, and is contagious, particularly where people live cheek by jowl, such as in refugee camps, urban areas, and particularly in slum settlements. Critical in preventing outbreaks and tackling the disease long term is access to safe water and sanitation.
There are an estimated 3 to 5 million cholera cases and 100,000 to 120,000 deaths due to cholera every year according to the World Health Organisation. Left untreated it can kill in hours, but 80% of cases can be successfully tackled with oral rehydration salts, which are remarkably effective and just cost literally just a few pence apiece.
This link that cholera can be spread from sewage to water supplies was the critical breakthrough that the celebrated father of epidemiology John Snow recognised in the 1854 outbreak in central London's Soho area, and led to the removal of the handle from the contaminated Broad Street water pump. The pump, still without its handle, is still in place today in recognition of Snow's groundbreaking achievement.
Despite this link being understood over a century and a half ago, 783 million people today still lack access to clean water, while over 2.5 billion people lack access to sanitation. Cholera outbreaks continue to blight people across the developing world, including in Mozambique in southern Africa where I recently travelled with WaterAid.
This beautiful country in southern Africa is one of the poorest and least developed places in the world, ranking 184 out of the 187 countries ranked on the human development index by the UN. Cholera has been a persistent problem in the country, which is unsurprising considering that only 18% of the population has access to safe sanitation, and just under half to clean water.
A shiny new airport greeted us as we landed in Maputo, the capital of Mozambique. I remember this being constructed the last time I was here. Built with Chinese investment, it was a statement of Mozambique's economic growth, estimated at around 7%, fuelled in large part by coal and natural gas discoveries.
Visiting the bairro or district of Costa da Sol along Maputo's coast was going to be interesting. I had been here five years ago when the WaterAid team in Mozambique had just started a multi-year water, sanitation and hygiene programme.
I had remembered it as a settlement of about 17,000 families, inhabited largely by a fishing community, and the neighbourhood was visibly very poor. Thatched houses were a common site. Women struggled to get safe water. A powerful image that troubled me was the trek that women made to a pit, a few meters deep, a little distance from their homes to collect water, dirty water, scooped out of the sand laden pit, their only 'reliable' source of drinking water.
Estamos, a national NGO, had started working in the Costa da Sol with WaterAid support. The initial phase was on hygiene promotion with the help of locally identified and trained motivators or animators. Their role was to go from house to house and promote messages about washing hands before eating and after going to the toilet.
Messages on protecting the water used for drinking were also promoted, and more importantly, discussions were held with households on the need to stop defecating in the open and to encourage families to build improved latrines, appropriate for the area. This was especially important since cholera was one of the most common illnesses. At the start of the programme, the local authority had reported 371 cases the previous year.
Having convinced the local community of the need for a safe toilet, the next task was to encourage families to construct improved latrines, with an appropriate cement slab, that would ensure that human waste is safely collected. Where there were 'unimproved' latrines, i.e. latrines that could potentially be a health hazard, the task was to convince people to discontinue their use and replace them with the improved toilets.
Availability of water was another key challenge. This required Estamos to work closely with Agua de Mozambique (AdeM), the water utility. As part of the programme, water kiosks were constructed which were operated mostly by women identified and supported by the community. There was a pre-paid billing system based on which water was purchased by the operator, for selling it onwards to the local community. For those who could afford, AdeM were persuaded to provide household connections direct to families.
Meanwhile, the community association that was formed grew in strength. With regular hygiene promotion, family based interaction and their involvement in the latrine slab production centre, their confidence and profile grew. Responding to a call for bids by the municipality for solid waste collection, the association bid for and won the contract to collect and dispose solid waste. It is now a local enterprise that employs 15 local youth.
It was fascinating to hear this story of this work on my return back to Costa da Sol after 5 years. Many houses had moved to household water connections thus reducing the dependence on the kiosks. While that meant that the business in the kiosks shrunk, it was positive from the access point of view, as more families had water taps in their courtyards, saving time for the women in particular. It was also a matter of dignity to have a household water connection!
But the biggest change was the significant reduction in incidence of cholera. From nearly 400 in 2004-05, the rate had fallen to a mere 21 in 2008-09. There is still a challenge to eradicate it completely. There are newer families who are moving in and with each new entrant to the community; the hygiene work needs to be taken to them. But there is confidence that the killer disease is now under control - a combination of better hygiene awareness and access to water and sanitation facilities.
This has been recognised as a major success by the Maputo municipality and the local health authorities as well. Perhaps, as a result of this, the houses also look very different - better constructed houses, more sturdy and durable.
Getting access to water and sanitation is still a challenge in Mozambique. The Mayor of Maputo, David Simango, is keenly aware of the migration into Maputo and its impact on the water and sanitation services. As he said, "There are challenges for Maputo. But there is a master plan in place for providing water and sanitation services. Some things are changing. Local communities are participating more actively, people are contributing to local projects and their maintenance, people are more aware....and incidence of cholera is reducing".
It is a testament to John Snow that 150 years on his legacy is still saving lives around the world, including in Mozambique. It is only a shame that after a century and a half his work is not yet complete in the developing world, and unlike in the west, outbreaks of cholera have not yet been consigned to the history books.
Girish Menon, Director of International Programmes, WaterAid
You can read more of my personal blogs at http://yourminstrel.blogspot.co.uk/