Climate change could help cholera make a comeback unless a concerted effort is made to spread awareness.

Cholera is often regarded as the ‘disease of the poor man’ a thing of the past, some of the earliest accounts recorded were in 1543 in India when a Portuguese historian described an outbreak in the Ganges.

Cyclone Idai hit Mozambique and Zimbabwe in March, with reported cases of cholera on the rise within days of the disaster. International health policy was established to deal with this disease as early as 1947, yet there remains a disconnect between public education and national authorities response and the efforts of international agencies and NGOs focused on mass vaccination campaigns and clean water distribution.

The result of the cyclone has led to the deaths of over 700 people across Mozambique, Malawi and Zimbabwe with infrastructure destroyed and individuals unable to meet their basic needs. Two major river banks burst to cause damage to thousands of households across the three countries, and lives changed forever overnight.

Cholera cases have reached over 1000 within the affected areas, constituting a sudden spread of the disease. The count had been relatively low before this with 139 cases documented at the end of March.

The international response has been rapid; the UN is working with the country, and the World Health Organisation has sent over 900,000 cholera vaccine doses with a vaccination campaign to follow. The Chinese government has provided support by sending doctors to battle the cholera outbreak in Beira, a port city of 500,000, and aid workers have sprayed anti-cholera disinfectant across the city.

Though this is a rapid response in the aftermath of the disaster, there remains a disconnect between public awareness of the disease and subsequent prevention efforts and the campaigns rolled out by international agencies.

Cholera is not a new problem. It has been longstanding in Beira, Mozambique specifically, due to it being a port town with a recurring history of the disease since 1973. Cholera cases from Mozambique represented between one third and one-fifth of all cases in Africa during the 1990s. Outbreaks in Beira have previously led to over 1000 deaths, with storms acting as a trigger for the sudden spread of the disease.

The most recent outbreak before the cyclone was in in 2011 where there were 1279 cases, though it led to few deaths because the right precautions were taken. Vaccinations have been used since 2003 when the Ministry of Health in Mozambique began working with WHO, IVI and MSF, but despite these attempts the disease continues to surface, thriving in unsanitary conditions and areas with poor infrastructure.

There was a shift in the way cholera was managed through the establishment of international health policy by WHO following the 1947 epidemic in Egypt. Measures to control the spread of the disease were immensely successful because there was a move towards improving sanitary conditions in local areas initiated by civil society.

The public promoted a focus on clean water supply and sanitary conditions by emphasising hygiene and public health education so that people were equipped to deal with immediate cases of cholera.  However, this has not been rolled out extensively, and water, sanitation and hygiene work remain a focus of WHO and the United Nations Sustainable Development Goals.

In the 1960s, the focus in international policy shifted to what was known as ‘environmental sanitation’; a broader approach to long term strategies of infrastructure and behavioural change to meet standard levels of hygiene.

The WASH strategy is merely one example of this, a collaborative approach undertaken by UNICEF and the WHO in 2000. It focuses on the importance of the three pillars: water, sanitation and hygiene, to be administered in all countries that the Millennium Development Goals target and in emergency and crisis response work that the organisation undertakes.

The provisioning of clean and safe water supply and adequate sanitation still must remain an integral part of international health policy, aiming to fulfil the demands of a significant proportion of the world, which do not have access to these essential rights.

In the aftermath of the cholera outbreaks in Beira, citizens have been drinking contaminated water due to a shortage of drinking water in areas worst affected by Cyclone Idai. The UN is working with the Mozambique Health Department to stop the spread of cholera by ensuring water distribution points meet basic standards. Though this is needed immediately, public health education remains essential during an outbreak, vaccination campaigns are useful, but the key to managing outbreaks in the long term is to develop a community understanding in preventing it.

International support for national and public health campaigns could be effective, as well as mobilising young volunteers to peer educate and spread information as seen during the Ebola epidemic in Sierra Leone several years ago.

Climate change is projected to hit poorest countries the hardest, cholera is no longer a tale of the past, but instead is fast becoming a disease of the poor and displaced in the present day. Public health systems are already under pressure and under-resourced, unable to take on the burden that diseases generate in today’s world.

This is exacerbated when natural disasters strike and leave implicit devastation behind for years to come. International agencies need to work with national governments to intervene quickly and implement international health policy in a way that is conducive with national health policies.

Many national governments focus on rebuilding infrastructure amid the devastation, but there needs to be more of an active effort to spread awareness about how to prevent cholera amongst the local population to ensure it can be tackled swiftly and effectively as soon as outbreaks are reported.

