The Sudanese proverb raises the question: Does the fool drown in his search for water or is he saved by it? And who is, in fact, this fool? Given the wasteful and unfair dealings of mankind with this dwindling resource – aren’t we all? While doing research on water, The Niles correspondents in South Sudan and Sudan met fishermen who deal carefully with the water that nourishes them and business people who exploit the resource without restraint. They report on conflicts around water but also on exemplary projects where water is shared peacefully. In short, the fool is still swimming, but for how long?
14 The Niles H2O WHO* The cholera threat returns South Sudan is in the grip of a Cholera epidemic, its second after a lull of about eight years. A number of simple steps can avert the spread of the potentially fatal disease. Juliana Bol | Juba W ater is vital for life but it can kill. South Sudan’s rainy season ushers in flooding and a rising incidence of malaria and acute diarrhoea, killing people and compounding pressures on the health sector. This year, a cholera epidemic is also underway. According to the World Health Organisation (WHO), more than 1,600 South Sudanese have been diagnosed with cholera since mid-August and 45 people have died. The highly infectious disease has spread from Juba across Central Equatoria and Jonglei State, affecting populations already hard hit by the country’s protracted war. In May 2014, South Sudan suffered its first cholera epidemic after about eight years. The fast-spreading emergency continued for seven months until the dry season, affecting more than 6,421 people and killing 167, just under three percent of those affected. Is it a pandemic? A pandemic is defined as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people”. There have been seven cholera pandemics in the world to date, with the current, seventh pandemic originating in Indonesia in 1961. Contrary to speculation, last year’s South Sudanese epidemic was not caused by the presence of United Nations peacekeepers, which was how the disease arrived in Haiti in 2010. The seventh pandemic reached Africa in the 1970s and cholera has since become endemic in West, Central and East Africa (including the Sudan) with repeated outbreaks occurring almost every year. The epidemics in South Sudan are not imported, but are repeated cycles due to poor water and sanitation practices. How is it caused? Cholera is an infection caused by the Vibrio Cholera bacteria and related strains. The vibrios attach themselves to intestine walls, producing a toxin which causes a watery diarrhoea. It removes salts needed by the body (sodium, chloride, potassium and bicarbonate). The vibrios are also secreted in the diarrhoea and, due to poor sanitation practices, may contaminate water sources and food. In other words, to get infected by cholera, one must have ingested water, raw or undercooked foods, vegetables, partly dried fish and fruits contaminated with infected faeces. This is referred to as the oral-faecal route. Risk factors are contaminated water sources (shallow wells, river water, unprotected water sources), lack of adequate latrines and open defecation. Dead bodies are also highly infectious therefore some burial practices increase the risk. These risk factors are common across South Sudan and are aggravated by the rainy season. The majority of cholera infections are mild, resulting in no visible symptoms and with only about one in 20 people becoming critically ill. However, infected persons can carry and transmit the bacteria one to four weeks after first becoming infected, and a few carry the bacteria for several months. How should we care for cholera patients? The classic symptom of cholera is an acute, watery diarrhoea that looks like rice, or maize-meal water, sometimes accompanied with frequent vomiting. Some communities believe that diarrhoea is caused by an excess of water in the body and therefore deny water to anyone suffering from diarrhoea. Contrary to this, managing cholera (and diarrhoea in general) requires the patient to continuously drink a water solution containing oral rehydration salts or a salt and sugar mix to replace what is lost in the body, until all the bacteria is washed out of the body and the diarrhoea stops. In the case of frequent vomiting (more than three times per hour), intravenous therapy with Ringer’s lactate solution is recommended, but normal or half normal saline solution can also be used as an alternative. Most health facilities in South Sudan have an excess of rehydration solution in the health facility kits distributed by the Ministry of Health. Ten to twenty milligrams of zinc given per day can also reduce the severity and duration of cholera (and diarrhoea) in children under five years old. It is recommended that this is given to children for as long as the diarrhoea lasts, in addition to rehydration. Antibiotics should only be given to manage severe cases with the supervision of a health worker, but the main treatment for cholera is rehydration. How to avoid the disease? Although cholera is highly infectious, it is also highly preventable and manageable. Here are the basic guidelines: 1. Wash hands regularly with clean water and soap (or ash). 2. Boil all drinking water for at least 30 minutes or use chlorine or chlorine-based tablets to disinfect. 3. Thoroughly cook all foods and re-heat before eating. 4. Ensure that latrines are not near water sources. 5. Construct latrines where these are not available or adequate. 6. All contaminated surfaces should be disinfected with a chlorine-based solution (1 cup of chlorine to six parts of water is adequate). While the spectre of a cholera epidemic looms large with every rainy season, it is important to remember that it can be prevented. “The risk factors are aggravated by the rainy season.” The Vibrio Cholera bacteria which causes the cholera infection. Photo: Dartmouth College How to halt Guinea-worm disease? South Sudan is the country worst affected by Guineaworm disease, a parasite which can trigger temporary disability while the worm emerges from under the skin. In the 1980s there were millions of cases across around 20 African countries, but now it is only found in South Sudan and three other African countries. The Niles | Berlin T he disease, also known as Dracunculiasis, is generally spread when people drink water containing water fleas, which have been infected by guinea worm larvae. For a year, there are no symptoms but then the affected person develops a painful swelling as the female worm forms a blister in the skin, often on a leg. It takes a few weeks for the worm to emerge. The disease spreads due to people using open, stagnant water sources, often man-made, such as ponds and sometimes shallow or step wells. As the larvae inside water fleas survive only for up to four months, the disease can only carry on in an area if it affects humans. The World Health Organisation (WHO) says the painful condition could be wiped out if villages adopted the following measures: 1. Effective surveillance to detect all cases within 24 hours of worm emergence and containment of all cases; 2. Ensuring access to safe drinking water and converting unsafe sources to safe ones; 3. The construction of copings around well heads or the installation of boreholes with hand pumps, which would prevent not only Dracunculiasis but also diarrhoeal diseases; 4. Regular and systematic filtering of drinking water from ponds and shallow unprotected wells or from surface water with finely meshed cloth or, better still, a filter made from a 0.15 mm nylon mesh, which is all that is needed to filter out the cyclops from the drinking water; 5. Treatment of unsafe water sources to kill the cyclops; 6. Health education and social mobilisation to encourage affected communities to adopt healthy drinking water behaviour. (With information from The World Health Organisation (WHO) * and The Carter Center) How water is filtered, transported and consumed in Sudan and South Sudan. Photos: Anthony Kamba & Mohamed Hilali theniles6_20151123.indd 14 2015/11/23 2:13 PM
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