Let’s fight cholera as we would fight terrorism, banditry

He arrived at the hospital looking haggard, frail and supported by two men. His shirt dirty with watery vomitus despite his wife’s frantic efforts to keep him tidy and presentable. His trouser was wet and soiled with free flowing diarrhea, the same way we sometimes see drunkards by the roadside.

Looking into his sunken eyes, his lips trembling, was the anxious gaze of a man imploring for help. I knew this man, a civil servant as I was then, decent and respected.

In fact, his predicament could as well be mine, eerily reminding me that anyone can get cholera. Beside him, many more patients were streaming into the hospital, setting into motion an epic logistical and organization dilemma within the facility. At times, staff looked overwhelmed and paralysed. That was in 1997, Molo Hospital, when I was a medical officer in Nakuru.

The different scenes of my first cholera epidemic make me cringe as the memories play in my mind. As human beings, cholera demeans our dignity, sickens us wretchedly, and even kills. The cholera germs are now almost everywhere around us in Nairobi, and we all need to protect ourselves and our families.

Cholera is acquired only through ingesting water or food contaminated with cholera germs. It could be through source water, fresh or cooked food, unwashed hands by food handlers, own unwashed hands contaminated while holding toilet door knobs or greeting people, and through flies picking germs from infected vomitus and diarrhea and depositing on food.

The presence of many people with cholera either sick or just carrying the germs unknowingly, a high density of susceptible population, lack of clean drinking water, poor hygiene and poor sanitation are the hell sent milieu that feeds the cholera misery machine.

Breaking transmission (reventing a new infection to an uninfected person) requires working on all these five driving factors concurrently. From a public health viewpoint, controlling cholera requires resolute commitment, substantial resources, knowhow, quick action, and organizational skills. In this write-up, I will not deal with what public health officials ought to do, but help you understand cholera and what you can do as an individual to protect yourself and your family.

To understand the first factor on the importance of the number of people with cholera either sick or unknowingly, you need to understand that cholera affects only human beings and ridding the disease ultimately rests on eradicating the germ from the sick and those who harbour, even if unaware.

The cholera disease presents itself in only 1 of 4 infected people, while the remaining 3 are either not showing any disease symptoms or are mild and often not taken seriously. Even so, all infected people with or without disease will pass the massive quantities of germs through feaces or vomitus. It should not therefore surprise one when someone catches cholera while all the people around look healthy.

In brief, the numbers we are seeing being reported of the sick are the tip of the iceberg, it is an epidemic of vast proportions. The second factor of high density of susceptible population, means that resources such as water, sewer, waste disposal and toilets in a limited geographic area with many people, are strained and any gaps in sanitation will result in efficient transmission to a large group of people.

Both the first and second factor can be tackled by reducing the number of susceptible people through vaccination. When you get vaccinated, you develop immunity and will no longer be available for cholera to infect you. There are three oral cholera vaccines pre-qualified by WHO, Dukoral, Sanchol and Euvichol and registered in Kenya.

All are safe, and 65 per cent protective meaning that it prevents 65 per cent of all potentially new cholera infections, which is substantial, but needs to be complemented with other measures. Sanchol and Euvichol, are used from the age of one year and above, easy to use, require two doses separated by two weeks, and protective for 5 years.

A dose costs about Sh2,000 and because of the high cost required for the two doses, even a single dose can be used in the short term, although protection is reduced to only six months.

The third factor is clean drinking water. With the shortage of water in Nairobi and the high risk of contamination for both piped and that supplied by hawkers and water trucks, home chlorination, as an alternative to boiling drinking water, should be considered as it affordable and easy.

The fourth factor is hygiene through washing fresh groceries, and washing hands with soap and clean water every time before eating and after defecation. Washing hands is perhaps the most effective measure at personal level, but many people generally ignore the practice.

If we were to track the places where an individual’s hands touch while performing routine chores for only an hour, we will be amazed by the amount of dirt we gather, but seldom remember. This healthy behaviour needs to be reinforced continuously with or without cholera.

The fifth factor is sanitation at personal or family level means using the toilet and keeping it clean, appropriate disposal of domestic wastes to check fly populations, and serving food hot and covering the rest so as to prevent flies from contaminating it.

In a nutshell, get vaccinated, use chlorine for drinking water, wash fresh foods, wash hands with soap before eating and after defecation regularly, use toilet and keep it clean, dispose wastes appropriately and keep flies off your food.

Beside personal measures, it is everyone’s obligation to demand for the services we are entitled to, from both the county and national governments. The silence and activism for good public health services is deafening. Deaths from cholera, banditry, or terrorism are all the same and should be defended with equal vigour.

Cholera deaths are preventable because safe and reliable water sources, a good sewerage system as stipulated in Article 43 of our Constitution, break the chains of transmission on their own.

Dr Chesang is Public Health Society of Kenya Council Member