A village leader’s action
Changing the course of cholera in Zanzibar's Uroa village
From his home in Zanzibar, Uroa village sheha (chief) Ali Hassan Mambo, father of eight and husband of two, sits with his family and enjoys the beautiful blue waters meeting the white sands of the world-famous beaches of the island. While millions of tourists make their way from across the world to enjoy this scenery, for Ali it is sometimes a reminder of the two sons that he lost.
Despite the abundance, the island suffers a chronic shortage of safe water for drinking and farming. Groundwater is often contaminated by seawater and sewage due to poor infrastructure. And when mixed together by heavy seasonal rains, water delivers deadly diseases, chiefly cholera.
Cholera is a highly contagious disease that is caused by ingesting faecal bacteria through contaminated water or food. It causes severe diarrhoea and vomiting that leads to extreme and fatal dehydration. So far, Zanzibar has had 17 major cholera outbreaks since 1978, especially in areas with chronic shortage of water and poor access to adequate sanitation, such as peri-urban areas, within mobile fishing populations in small islets and other coastal areas.
In April 2016, Ali lost two sons to cholera-- Muhsin Ali Hassan, 13, and 10-month-old Hadi, the eldest and youngest of his children with his wife Safia Muhsin Amour. They died within seconds of each other one morning. “In one moment, I lost two children,” he recounts while cradling his two-year-old daughter Asha. “I was very sad but this is God’s will,” Safia says wistfully. Baby Hadi was still breastfeeding and had just begun to say ‘mama’. Nearly 70 people in Zanzibar lost their lives, while thousands more fell sick during the outbreaks between 2015 and 2016 according to the Government of Zanzibar's Comprehensive Cholera Elimination Plan.
If not treated immediately, cholera can kill within days, even hours.
The Government of Zanzibar began implementing the Zanzibar Comprehensive Cholera Elimination Plan (ZACCEP) in 2017. The ten- year programme aims to eradicate transmission of cholera by 2027 by increasing safe water and improved sanitation for households and public facilities. About 30 per cent of the population in the island has no access to piped water supply services, while less than 40 per cent of the piped water is pre-treated at the source, as the rapidly growing peri-urban areas are further straining inadequate infrastructure. The programme, through effective multi-sectoral collaborations, aims to ensure:
- Access to adequate, safe and sustainable water supply to at least 95 per cent of the population in Zanzibar by end of 2022.
- At least 90 per cent of schools and 70 per cent of households have access to private or shared latrine facilities by 2027.
- Increased collection of solid waste in urban areas to 90 per cent, and by 80 per cent in peri-urban and rural areas.
- Achieve at least 80 per cent vaccine coverage of 2 doses of Oral Cholera Vaccination (OCV) among eligible populations of Zanzibar during 2018-19 as measured by a coverage survey90.
UNICEF and its partners are providing technical support to the government’s ZACCEP by building capacity to effectively deliver Behavioural Change Communication (BCC) and community mobilization programmes that aim to ensure adequate investments are being made to fight this preventable disease. Communities are empowered to invest in household Water, Health and Sanitation (WASH) and to adopt WASH practices and behaviours. Ali is one among many who have been sensitized by UNICEF, and supports the government in achieving this objective.
"We were able to mobilize the community and control the outbreak,” Ali says. “Thanks to this programme supported by the Ministry of Health and UNICEF, we don’t have this problem anymore."
“I want people to understand that even if you appear clean and living in a safe environment, you can still get cholera if you don’t observe necessary protection measures,” says Ali, who has become a sanitation champion in his village. “I want to make people aware, especially about the precautions they can take, including using safe water for cooking.”
Uroa does not have a water source of its own, leading people to buy water from vendors who come to the village. Understanding the importance of treating water, Ali does not allow these vendors to sell the water without passing through the local health facility to treat the water with WaterGuard tablets first. The same tablets are used in the local school to treat the water in 20-liter buckets placed in classrooms, with lids and taps. Larger tablets called Aquatabs are meant for more institutional-size purification, such as the 5000-liter central water tanks that have been introduced in schools and public facilities.
UNICEF provides these WaterGuard and Aquatab chlorine tablets for free at the local health facility, which also serves as a centre for WASH education.
At the clinic, community nurse Sijui Omar Khamis explains, “the key to the health of children under five is the mothers,” which is why they focus on educating mothers about safe water and hygiene. They have placed charts with indicators monitoring diarrhoea on the walls of the facility. “The incidence of cholera is going down in the village and we’re pleased,” she says.
Thanks to the sensitization, they have also found an alternative to chlorinating or boiling water the old-fashioned way. To ensure adequate availability of safe water in the health clinic, they have placed a 10-liter jerrycan with double solar panels and a gauge that signals the water is safe for consumption or storage. When cholera struck in 2016, Ali says that the village committee adopted a whole range of programmatic interventions. They banned food vending, intervened in schools, campaigned house to house, educated people on boiling water and using safe toilets.