Risky sanitation = risk of cholera in South Sudan

In May 2015, increasing numbers of cases of cholera were being reported across Juba County in South Sudan. Following the start of the rainy season, people’s access to safe drinking water and sanitation services, which was already limited, became even more challenging, especially in the crowded camps which had been set up across Juba after the eruption of violence in late 2013.

In June 2015, the Ministry of Health declared a cholera outbreak in Juba and, by July, 396 confirmed cholera cases and 26 deaths had been recorded, with children under the age of ten identified as being most vulnerable to the disease.

The IFRC released 225,368 Swiss francs from its Disaster Relief Emergency Fund (DREF) to support the South Sudan Red Cross in providing immediate assistance to people affected by the outbreak through health and hygiene promotion. The National Society reached 38,953 families across seven communities in Juba county, far exceeding their original targeted 10,000 families. In November, the Ministry of Health reported the situation under control, and commended the South Sudan Red Cross for its efforts.

To improve the quality of operations and level of accountability, the IFRC conducted a review of the South Sudan operation. For the first time, a trained member of a Regional Disaster Response Team was included. Gloria Kunyenga, from the Malawi Red Cross, specializes in cholera responses as Malawi also experiences regular outbreaks. Including Gloria in the review was intended to promote peer-to-peer learning between National Societies. She captured some of her thoughts and impressions of South Sudan, the National Society and its volunteers, and the response operation in a daily diary.  


Day 1:

Arriving in Juba for the first time is exciting. While I have had the pleasure of meeting some of the South Sudan Red Cross staff before in workshops, this will be my fist chance to work with them in a team on the massive health challenge they have been dealing with – a cholera outbreak. Earlier this year I worked with my own Malawi Red Cross Society on fighting a cholera outbreak in communities and I am excited to be able to bring some of the knowledge and skills I learned in that experience to South Sudan.

On arriving in Juba, I navigate the tricky immigration process, and am met by Michael, a cheerful driver for the International Federation of Red Cross and Red Crescent Societies (IFRC), who takes me to the National Society. On the way into town, we see a number of cars queuing at fueling stations. Michael explains that despite the country being rich in oil, the capital is experiencing  a fuel shortage. At the National Society premises, I am introduced to staff and volunteers, and am given a security briefing. Security in the city can be a problem, and I  wonder how I will take pictures, as it seems that photography is often not allowed in public places. Nonetheless, I remain excited about the opportunity to work in this new setting and begin talking to staff who have been involved in the response to the cholera outbreak.

It seems that the outbreak has been caused by poor access to safe drinking water and sanitation. Later, sitting close to the beautiful Nile river while having dinner, I learn that it has been renamed the “Cholera river”, since many of the communities that have been affected by the outbreak rely on it for their water.


Gloria day 2

Day 2:

In the morning, I’m collected from my hotel and we make our way along bumpy roads to the offices of the South Sudan Red Cross. As we approach, I am encouraged to see volunteers waiting under a tree to escape the hot sun. Despite the heat, the volunteers seem enthusiastic and ready for the day. Part of my job here will be to learn from the volunteers what worked and what didn’t work so that we can improve on our efforts in future disaster responses. I am also hoping that I can bring some of the lessons I learn here home to Malawi. After an initial briefing with staff and volunteers, we visit a community called Hai Seminary, where discussions are had with a group of men and women. I am taken around the community and can see that a lot of work has been done to keep their surroundings clean, including the toilets. A major lesson from this group is how important it is to use volunteers from the community, rather than bringing them in from the outside, as they will better understand the problems that are being experienced. It is interesting to meet Isaac, the cholera focal person, who is also a volunteer. He feels the cholera response has contributed to the capacity building of volunteers. I can see the commitment that Isaac has in working with vulnerable communities. He is key to the success of the response and gets respect from fellow volunteers.

At the end of the day, I reflect with the Secretary General of the South Sudan Red Cross on how the cholera operation went. He feels it was a success. From what I can see, part of that success has been due to the National Society’s coordination with other organizations involved in the response, to ensure there was no duplication of the activities carried out, and that gaps were filled, as well as the setting up of a dedicated health technical committee responsible for managing the operation.  


Diary day 3

Day 3:

Today, we are going to New Site which is a military settlement. Again the roads are not in good condition, and we spend some time negotiating the best route into the community. As we are taken around, it is clear that there are sanitation challenges that will put it at risk of cholera. I join a volunteer who is interviewing a household. The head of the family explains that they have no toilet, and their only source of water sometimes makes them sick. From my own experience, this is often one of the biggest challenges with fighting a cholera outbreak; while bacteria causes the disease, things that lead to an outbreak are often systemic problems that need long terms solutions like infrastructure and behaviour change.

According to the chief of the village, “This is a military place where settlement is not orderly and there are no social amenities; no toilets can be constructed due to poor soils. It is a water-logged community with no access to safe drinking water. Also, because schools are far, our children do not go.” I reflect on how important education is to understanding the importance of sanitation, and how essential the hygiene promotion carried out by the volunteers was to curbing the cholera outbreak. 

Management of cholera in this community cannot be an easy task as open defecation is the order of the day and sources of drinking water are very shallow wells. Driving back from this community is again a problem as our car gets stuck into the mud for over an hour. As we wait, I contemplate on how inaccessible this community is, and how challenging it must have been for people affected by the cholera outbreak to receive the treatment they needed. The oral rehydration solutions that were distributed by volunteers to treat suspected cases could well have saved people’s lives in this community.