The outbreak caught us unaware

Fight cholera in the flood prone district of Nsanje

James Chavula
Cholera survivor Yesaya Mussa applying chlorine to water to make it safe for drinking
UNICEF Malawi/2022/Elephant Media
15 May 2022

It's a scorching Thursday morning typical of the Shire Valley at the southern tip of Malawi. Yesaya Mussa, a chorister at the World Bible Church in Nsanje Town, is devotedly whistling and humming his favourite hymn while passing wet cement  to a builder at a construction site near his home in Nthukuso Village. 

In March, the 21-year-old choir member was the first cholera patient in the southernmost town along the Shire River.

Now recovered, he has to do the 'dirty work' to give his sister a decent home and show doubting neighbours that he has shaken off the disease that left him on the cusp of following his mother to the grave. 

"I'm now fully fit," he brags, ditching the day's chore. "On the day I was taken ill, you wouldn't have thought I would be alive today. Things changed fast.  I felt stomach aches and had severe diarrhea. I was weak and dehydrated. My eyes sunk in the skull. "

His peers swiftly hauled him to Nsanje District Hospital around 5pm knowing  the diarrheal disease would kill him within three hours unless treated urgently. The current  outbreak has killed three in Nsanje and Machinga districts since it erupted in early March.

Before being taken to the hospital, Yesaya made five quick trips to his neighbour's latrine located at a distance equivalent to a football field's length from his homestead, which has none.

"I wasn't surprised when laboratory tests returned positive results because the previous day, I had made a boat trip across the Shire River to attend the funeral of a child who had died of cholera in the neighbouring Mozambique," he explains.

Yesaya was in a choir of over 30 which travelled to Ngulengule in Murumbara District across the porous border. They departed around 9am and arrived at the funeral around noon. 

"Due to the disease outbreak, we agreed that no one was going to eat or drink anything during the trip–we carried our own packed meals. But thirst is unstoppable on a sunny day. Just after burial, I fetched drinking water from a family near a borehole," he recounts.

The resultant cholera outbreak did not just startle the populous Nthukuso Village where a latrine served up to 10 families before the devastating flooding caused by Tropical Storm Ana reduced some water, sanitation and hygiene facilities to rubble. Now up to 15 homesteads share one latrine.

"Even the health workers were taken unawares. They didn't know where to put me while awaiting the results from the laboratory."

Shortly after being diagnosed with the disease first detected in Malawi in 1973, Yesaya was swiftly stretchered off to a vacant TB ward currently under renovations. 

Dr Waleke Khumalo from Nsanje District Hospital has played a role in the fight against cholera
UNICEF Malawi/2022/Elephant Media
Dr Waleke Khumalo from Nsanje District Hospital has played a role in the fight against cholera

"I spent six lonely days in the ward because there was no cholera treatment centre. The health workers worked extremely hard to save me, but they didn't appear well prepared or properly equipped for more cases to come. After all, we haven't heard of any cholera outbreak in Malawi for the past five years," Yesaya narrates.

To close the gaps, UNICEF urgently supported the Ministry of Health to establish a 10-bed cholera treatment centre at Nsanje District Hospital. 

Dr Waleke Khumalo, the District Medical Officer in Nsanje, says the consignment included chlorine used for killing germs in water and contaminated surfaces as well as antibiotics that help critical patients stabilise within two or three days.

The medical doctor says the health workforce was caught off-guard by the outbreak.

For them, there was no time to  thoroughly prepare for the outbreak first detected in a Mozambican who had taken a boat across the Shire River to seek treatment at Ndamera Health Centre along the border laced with uncharted routes.

Khumalo explains: "UNICEF support proved vital because the first case illustrated that we were not as prepared as we should have been. The supplies helped us avert possible infections and treat more patients effectively and with dignity. 

"When it comes to cholera, a single case is an emergency, and we didn't foresee this coming because the district had last recorded a cholera case in 2017. We were dealing with the aftermath of  Tropical Storm Ana when the outbreak erupted, so it was one emergency after another."

The cholera treatment centre has replaced another that was pitched for Covid-19 management.

"We did our best to control the first cholera outbreak amid the Covid-19 pandemic, but our intervention wasn't as robust as it was supposed to be. There was no tent or bed at the treatment centre. The previous ones had been damaged, so we had to improvise some space for patients dropping in," Dr Khumalo explains. 

The medical doctor says even skilled health workers "weren't particularly ready for this outbreak" either.

"Two days after the first case was hospitalised at the district hospital, we got two more cases and then the numbers kept increasing. The antibiotics helped stabalise the weak patients, lessening pressure on the 10-bed treatment centre and health workers.

The outbreak struck while the district hospital had run out of essential medical supplies for cholera treatment.

"Normally, we struggle with medical supplies and UNICEF boosted our capacity to treat cholera patients. We managed to treat four and still have some supplies that can help us assist 20 more cases."

Dr Khumalo said the hospital is in dire need of giving sets that help pump vital fluids from drips into a dehydrated patient's body.

During the visit, the cholera treatment centre had spent the first week without a patient since the start of the outbreak–a rare break for the overwhelmed six nurses, two clinicians and health surveillance assistants who worked day and night to avert preventable deaths at the centre.