Stench of state failure in Zambia’s cholera outbreak

Cholera is caused by bacteria that infect the stomach. Only when the bacteria reach a critical level does an infected person have symptoms, which are high fever, vomiting and diarrhoea. There are about ten carriers for every patient treated with cholera, which creates a huge problem of infected excrement. Without proper sanitation, local water supplies can become contaminated by the disease causing it to spread very quickly. Outbreaks are relatively common in developing countries but in most cases would be avoidable with basic services in sanitation and water. Drinking boiled water would also prevent the spread of cholera if people could afford electricity or fuel, or could access firewood easily.   

Lusaka has roughly 2.5 million residents and is one of Africa’s fastest growing cities. 70 percent of the city’s residents live in peri-urban areas, high density informal settlements populated by the poor that rely on pit latrines, which do not provide sufficient protection from exposure to faecal waste. Without proper roads, these pit latrines cannot be accessed to be cleared. At least ten percent of Lusaka’s water supply provided by the city comes from shallow ground water, which is prone to contamination, and it is this that is again responsible for the current outbreak of cholera. In reality there is an unknown number of boreholes in the city drawing from this water source and thus the risk is even higher.  In truth, Zambia’s current cholera outbreak is not anything new and is part of an ongoing death toll as a result of diarrhoea in the country, estimated in 2012 at 87,000 annually and almost all of these deaths are attributed to poor water, sanitation and hygiene.

The Zambian government has made imperious demands that poor people in slum areas must practice better personal hygiene; yet do not provide them with the means to do so. With the death toll at 70 and over 3,000 infections since the outbreak began in October 2017, in January 2018 the Zambian government shut down churches, schools and markets in the worst affected areas in Lusaka, which resulted in social consequences and affected livelihoods.

The army was called in to enforce a quasi-state of emergency in areas where no movement was allowed after 6pm in the evening. Insulted by the government thrusting blame on underserviced communities, people began to defy the ban on public gatherings. Restrictions on public gatherings and trade make little sense as a way of containing the outbreak, as the disease was not spread by people being in contact with one another. The police forcefully dispersed Sunday church services to the point that, in one case, they even resorted to the use of teargas.  Riots broke out over cholera restrictions especially the closure of markets, leading to the arrest of 55 people. 

Cholera outbreaks have become a regular occurrence in Lusaka and point to structural problems with water and sanitation services by the Lusaka Water and Sewerage Company (LWSC) wholly owned by the Lusaka City Council. Most water connections in Lusaka are to formal households and businesses, leaving those in peri-urban areas, where the poor reside, with limited direct access to piped water. Water is sold to people using private intermediaries through water kiosks. The LWSC is also responsible for waterborne sewage connections, again limited to formal residential and commercial sites, and has poorly maintained pipes and treatment facilities. Services for the majority of Lusaka’s residents that use pit latrines are practically non-existent.

Yet in 2007, the World Bank funded the Water Sector Performance Improvement Project to improve the technical and financial sustainability of the LWSC. The project closed in 2013 with insipid results, most notably in peri-urban areas where the project only increased access to 5,000 residents through 100 new kiosks. Even though the LWSC barely services peri-urban communities, the project was unable to create technical and commercial efficiency of operations for the financial viability of independently owned and managed utilities. Gains that were made in these efficiencies by the end of the project in 2013 were lost when the project was evaluated two years later in 2015. The evaluation also found that at least ten percent of the water kiosks built during the project were not functioning.  

The project struggled and took six years instead of three to complete but still the LWSC was unable to achieve sufficient cost recovery, utility operation, maintenance, rehabilitation and expansion for the sustainable provision of water supply services to Lusaka’s growing population. This is proof of the failure of the policy shift from 1994, when Zambia sought to devolve the responsibility for water supply and sanitation to local authorities and the private sector that were to form autonomous commercial utilities for cost recovery so that they would be financially self-sufficient, resulting in entities such as the LWSC.  

The project revealed that the coordination between the government and city councils on the national water supply and sanitation planning is wholly insufficient. Decentralisation of basic services has shifted the responsibility of the state to a local level, allowing the government to shirk its responsibility for rural urban migration and inadequate housing and basic services, including clean water and sanitation, for the growing poor population in Lusaka.

Lusaka City Council will need to pay back the “soft loan” of US $33 million to the World Bank for this project. The only aspect of the project that did produce a favourable outcome was policy engagement on institutional support and investments. The results paved the way for the LWSC to be the recipient of the US $355 million Millennium Challenge Corporation (MCC) compact with Zambia, signed in 2015, investing in water supply, sanitation, and drainage infrastructure.

The compact is funding the development of a Lusaka Water Supply, Sanitation and Drainage Master Plan through to 2035 but the model has not shifted from financial viability through commercialisation and cost recovery, which failed despite consistent effort under the World Bank project. It is not surprising that the model remains intact since the MCC is a US government aid programme for countries that adopt economic and political reforms, specifically framed in neoliberal constructs of market-oriented measures designed to open economies to competition.

Despite the poor results of the World Bank project and the evaluation admitting that alternative approaches are needed when conventional sewerage may not be financially feasible, services developed under the MCC compact for poor communities to clear pit latrines, are unaffordable and therefore underutilised. The MCC compact claims to focus on social and gender inclusion, but this is limited to educational initiatives. The recent cholera outbreak is evidence that one of the main desired results of the compact, to decrease the incidence and prevalence of water-borne diseases, has still not been achieved. Several of these investment projects funded by the MCC compact focused particularly on sanitation and were to be completed by the end of 2017, but again failed to make any significant difference to the lives of Lusaka’s urban poor.

Zambia is not alone in its failure to provide basic water and sanitation services. There is a current outbreak of cholera in ten countries in Southern and Eastern Africa. Cholera is an indignation suffered by the poor for which they should not have to carry the blame. Instead, the outbreak reveals the prevalence of ineffective public services and the failure to provide sanitation, safe drinking water and basic health care. At the core of this rot is policy prescription by powerful interests outside the continent, pushing economic openness that continues to fail Africa.

*Aisha Bahadur is a consultant providing strategic support to civil society organisations including trade unions focussed on African issues.