Putting water and sanitation back at the heart of strategies for cholera elimination and control of other diarrheal diseases

While the world keeps its eyes on the Covid-19 pandemic, old public health scourges are still silently ravaging thousands of people, mainly in developing countries. This is the case of cholera and other diarrheal diseases in Africa.

Several actors involved in the fight against these diseases are calling for a multisectoral strategy led by African leaders and based on access to water and sanitation to sustainably eliminate cholera and better control all waterborne diseases.

Africa has experienced successive waves of cholera over the past five decades without achieving elimination.

While cholera has been eliminated in many parts of the world as a result of major sanitation projects and improved access to safe drinking water, this infectious disease transmitted by ingestion of water or food contaminated with Vibrio Cholerae remains one of the most important public health scourges in Africa, despite national and international efforts to respond to successive outbreaks.

The first outbreak of cholera in Africa coincided with the oil, socio-economic and climate crises of the 1970s, socio-economic and climatic crises of the 1970s. These were also the years of serious politico-military crises, such as the Biafra crisis. By the end of 1971, 25 African countries had reported a total of 72,415 cases and 11,389 deaths to the World Health Organization (WHO).

Each year, cholera affects 1.3 to 4 million people worldwide, causing between 21,000 and 143,000 reported deaths in nearly 70 countries, most of which are in sub-Saharan Africa. These seemingly high numbers are, however, vastly underestimated. According to the WHO, officially reported cases of cholera represent only 5 to 10% of actual cases.

Over the last 30 years, favored by the consequences of climate change, accelerated urbanization, population explosion, socio-political unrest and the consequences of successive socio-economic crises, cholera has become a re-emerging disease in Africa.

In addition to countries heavily affected by cholera such as the Democratic Republic of Congo (DRC), Nigeria, Ethiopia, Somalia, Mozambique according to the latest WHO reports, other countries are also facing a worrying situation. These are Kenya, Cameroon, Burundi, Zambia, Uganda, Sudan, Chad, Zimbabwe, Benin, Ghana, Togo, Malawi and Niger.

However, cholera is not a fatality. Cholera must, in Africa as in other parts of the world, become a disease of the past.

Cholera is not a reflection of poverty. If it is a corollary of socio-economic crises, it is also the consequence of impeded access to essential services. Its persistence in resource-limited countries is the result of inadequate response strategies that have pushed water and sanitation into the background.

Only a multisectoral strategy, driven by strengthened local leadership, can eliminate cholera sustainably. Cholera is not just a medical issue: it is through the concerted mobilization of public authorities, donors and field actors that a sustainable response can be provided. Contrary to an exclusively medical approach, better access to drinking water and sanitation allows us to fight not only against cholera but also against all waterborne diseases.

This is the approach advocated and implemented in the Democratic Republic of Congo since 2007,
Based on epidemiological research on the factors that contribute to the persistence of cholera in the Great Lakes region, the DRC has adopted a Multisectoral Strategic Plan for the Elimination of Cholera (PMSEC), involving the public authorities in several sectors (Ministries of Planning, Hydraulics, and Health), the national water distribution company, academics, foundations, NGOs, multilateral cooperation agencies, companies, and professional experts. The approach emphasizes the need for national leadership and enshrines the partnership approach. Consistent with the World Health Organization’s proposed roadmap for the elimination of cholera by 2030, this strategy includes a component on the rehabilitation and implementation of drinking water infrastructure, which is essential for the sustainable elimination of waterborne diseases.

Hence the consideration of the opportunity to generalize the elimination approach in other countries and the establishment of an international coalition for its implementation.

An international coalition under the aegis of the African Union would be the most appropriate to bring to the continent the multisectoral approach to cholera elimination as experienced in the DRC.

To definitively eliminate cholera in Africa and achieve better control of other diarrheal diseases, we call, on the occasion of the 9th World Water Forum in Dakar, for a paradigm shift.

Indeed, we collectively have the scientific evidence and technical resources to go beyond
necessary to go beyond the mere control of cholera epidemics.

We refuse to conceive of this disease as an inevitability for certain African countries that
be condemned to respond indefinitely to cholera epidemics. On the contrary, we believe that cholera can be eliminated in Africa through access to water and hygiene, as it has been elsewhere in the world.

We call on all actors involved in the fight against infectious diseases, access to water and health, and the reduction of inequalities to share this ambition.

We call on all countries involved in the fight against cholera and waterborne diseases, as well as technical and financial partners to take part in this initiative.

We call on the African Union and its health arm, CDC-Africa, whose leadership has been highlighted in the fight against the coronavirus, to take on the governance of this coalition. The African Union has, on this occasion, successfully given itself the means to mobilize technical and financial partners and to accompany the countries. It is this capacity to mobilize partners and support countries that is hoped for in other public health causes such as the elimination of cholera and the control of diarrheal diseases.

Finally, we draw the attention of the international community to the need to adopt a greater ambition than that of limiting cholera epidemics. If we are to sustainably eliminate this disease and truly control waterborne diseases, significant investments in a long-term strategy are required. We call on the mobilization of international donors.

Promoters of the Appeal

Ibrahim Assane Mayaki, former Prime Minister of Niger, President of the Global Alliance for Cholera Control (GAAC), Executive Secretary of NEPAD, Niger

Pierre Lokadi Otete Opetha, Secretary General for Public Health, Ministry of Health, Democratic Republic of Congo

Amadou Bocoum, Ambassador, Senegal

Jean-Marie Kayembe Ntumba, Rector of the University of Kinshasa, Democratic Republic of Congo

Rita Colwell, Professor Emeritus, University of Maryland College Park, Johns Hopkins Bloomberg School of Public Health, USA

Jean-Jacques Muyembe, Director of the National Institute of Biomedical Research, Ministry of Health, Democratic Republic of Congo

Didier Bompangue Nkoko, Head of the Department of Ecology and Infectious Disease Control, Faculty of Medicine, University of Kinshasa, Democratic Republic of Congo

Thierry Vandevelde, General Delegate of the Veolia Foundation, France

Amadou Sall, Director of the Pasteur Institute of Dakar, Senegal (tbc.)

Signatories

Macky Sall, President of the Republic of Senegal, Chairman of the Assembly of Heads of State and Government of the African Union

Paul Kagame, President of the Republic of Rwanda

Félix Tshisekedi, President of the Democratic Republic of Congo

Amadou Diallo, Ambassador, Senegal

Alain Boinet, Founding President of Solidarités International, France

Dominique Franco, Special Advisor for Education, Institut Pasteur, France

Dennis B. Warner, WASH and Environmental Health Advisor, Millennium Water Alliance, Washington, DC, USA

Sy Rotter, President, Washington Liaison Office, USA

John Oldfield, President and CEO, Accelerate Global, USA

Pierre-Marie Grondin, Director, Programme Solidarité Eau, France

Antarpreet S. Jutla, Associate Professor, University of Florida (tbc.)

 

With this “special edition” we are pleased to offer eight articles instead of the usual four. It shows how much better we could do with your support (doundon) and that of partners like the Humanitarian Challenge Foundations. Thank you to those of you who are already supporting us or will be doing so today.

This “alerting” editorial discusses four emergency situations as well as Turkey and Syria after the earthquake. After the search for victims, there is the phase of humanitarian aid (shelter, heating, food, drinking water, sanitation, care). Then comes the time for reconstruction. Beyond the emotion, our solidarity must be sustainable.

There is Ukraine, one year after the Russian invasion, which is entering its 10th year of war since it began in 2014. In the months that followed the Russian attack of February 24, 2022, it was legitimate to ask the question of the causes of this war between the will of Empire of Vladimir Putin and the risks taken by NATO in its extension to the borders of Russia.

This questioning has since been replaced by the terrible human toll of this war on Ukraine. The figures are known, refugees and displaced persons, high number of dead and wounded, war crimes which are repeated and which are not accidents, methodical destruction of essential infrastructures, Ukraine is in the process of progressive destruction. This will continue until the peace that will conclude the war. With the Ukrainians, we are on the side of the victims.

Experience shows that peace results either from the total victory of one side or from the balance of forces through mutual exhaustion. We are still a long way from this and this war of attrition will continue its macabre work.

For the humanitarian community, the mission is clear: to relentlessly pursue relief efforts, to become more efficient, to adapt to a wide variety of situations and, for some funders, to stop the bureaucratic overzealousness that delays and complicates access to aid.

Another lesson to ponder is the courage of Ukrainians who give their lives for their country, the Ukrainian nation. This courage, which is unanimously praised, is the historical spring that protects both freedom and independence in the face of external aggression and vital unity in the face of the risk of internal disintegration of the every man for himself.

One more word on Ukraine. In 2006, as a recent book reveals (1), French President Jacques Chirac proposed “…to give Ukraine cross-protection by NATO and Russia. The NATO-Russia Council would monitor it. This was a way to ensure the neutrality of Ukraine, that is to say its independence and its durability…”. We know what happened next.

The war in Ukraine is a sign of a major change of era for both Europe and the world. No doubt it will be necessary to reflect, in due course, on the future security architecture in Europe, which did not make it possible to avoid this war. In the immediate future, the time has come to show solidarity with Ukraine, both to save lives and to prepare for a peace that is not a defeat.

Danger for the Armenians of Nagorno-Karabakh or Artaskh.

As we wrote in the previous edition, Nagorno-Karabakh or Artsakh, where 120,000 Armenians live, is still cut off from Armenia by a blockade imposed by Azerbaijan since December 12. The Latchine corridor is an indispensable umbilical cord to supply food, medicine, gas and electricity.

On Wednesday, February 23, the UN International Court of Justice “ordered Azerbaijan to end the blockade of the Latchine corridor” and to “ensure the unimpeded movement of persons, vehicles and goods along the Latchine corridor in both directions

I received an e-mail from Alexey, a student in Stepanakert, the capital of Artsakh, from which this is a passage: “About 120,000 people remain cut off from the world, food supplies are running out, gas is cut off quite frequently. Every day we have limited access to electricity, and when I leave the house I see only long queues, we are facing a humanitarian disaster. The stalls of the supermarkets in Stepanakert but also entire shelves are empty, there is a shortage of food products. Bread, fruits, fresh vegetables and medicines have become rare commodities”.

Many institutions have already condemned the blockade and demanded the immediate reopening of the corridor. These include the Office of the United Nations High Commissioner for Human Rights, Amnesty International, the Helsinki Commission, the French Parliament, the American Senate, the European Parliament and many other organizations and personalities. In France, the President of the Republic, Emmanuel Macron, is working to ensure that this blockade ceases and that humanitarian aid reaches the 120,000 Armenians of Nagorno-Karabakh. To date, this has not been enough!

Following the Munich Security Conference on February 18, U.S. Secretary of State Antony Blinken brought together Armenian Prime Minister Nikol Paschinian and Azeri President Ilham Aliyev, and European Council President Charles Michel offered to host the Armenian-Azeri negotiations in Brussels. This is good news if the Latchine corridor is reopened now to meet the humanitarian needs of the population.

The European Humanitarian Forum in Brussels on March 21-22.

For the record, this Forum was created in March 2021 at the initiative of the French Presidency of the European Union, in close cooperation with the European Commissioner Janez Lenarcic, on the model of the National Humanitarian Conference (CNH) born in 2011 and which will meet again in Paris for its 6th edition in September 2023.

This Forum organized by the Swedish Presidency of the EU with the European Commission and ECHO, in conjunction with the coordination of NGOs VOICE, does not lack topics for reflection and debate. Among these, two major priorities are climate change and financial means.

Climate change which causes drought, flooding, decrease of agricultural yields and water resources, modification of biodiversity and finally forced displacement of more and more people. As global warming continues inexorably, humanitarians are in the front line to support and accompany populations in adapting, innovating and building alternative solutions.

In this context, we must not only accelerate our response to the growing needs, but also extend the issue of climate change to water resources for populations, agriculture, livestock and biodiversity as a source of daily life.

The other urgent priority is the inadequacy of funding for humanitarian aid in the face of increasing needs. Ten years ago, there were 50 million refugees and displaced persons in the world, today there are 103 million, two thirds of whom come from countries in food crisis. In 2023, 339 million people will need humanitarian assistance, compared to 274 million at the beginning of 2022, according to the UNOCHA report.

Yet, according to ALNAP, funding for international humanitarian assistance has stagnated at around $30-31.4 billion each year between 2018 and 2021. However, this year, the needs are estimated by the United Nations at 51.4 billion dollars! So, in 2023, will we lack 20 billion dollars to save lives and help the victims of war, disasters and climate change! We must therefore urgently mobilize $51.4 billion. Is this impossible when the world’s Gross Domestic Product (GDP) is 96,100 billion dollars in 2021!

The solutions are known. Faced with the “inequality of the burden” underlined by Janez Lenarcic, which is in fact that of solidarity and which places the bulk of the financing on a small number of OECD member countries, it is essential that many other countries contribute to finance the 20 billion dollars that are likely to be lacking this year.

Moreover, there is a great inequality in the participation in the humanitarian effort among the 30 member countries of the OECD Development Assistance Committee (DAC), which are the countries of the European continent, Canada, the United States, South Korea and Japan. Thus, while some countries devote more than 25% of their Official Development Assistance (ODA) to humanitarian aid, others allocate only 2.6% or even 1%, with the average for all contributing countries being 13% in 2020. There is a significant reserve to raise the $51.4 billion needed.

If France committed itself in 2018 to an exercise of “catching up” on its humanitarian aid and continued with a budget of around one billion euros this year, it should do better by devoting at least 13% of its ODA to humanitarian aid, or even 20% to better adapt its role to the challenges of today’s world. This is the major challenge of the next National Humanitarian Conference in September 2023, which will follow the decision of the CICID (Interministerial Council for Cooperation and Development). This will be the litmus test!

As for humanitarian organizations, they can work with both the general public and businesses to increase private donations to $6.4 billion in 2021 out of a total of $31.4 billion in public funds. The other lever to be implemented is that of optimizing available resources, pooling costs, coordinating actors and ensuring the effectiveness of the action.

The UN Conference on Water from March 22 to 25 in New York.

9th World Water Forum in Dakar on March 22, 2022. @WWFThe previous UN meeting on freshwater dates back 46 years to Mar del Plata in Argentina in 1977. Will this conference in 2023 count for nothing or will it be a conference to achieve the Sustainable Development Goals voted unanimously by the States in 2015?

Unfortunately, this Conference will not make any declaration or political conclusion. But the participants are invited to contribute to the “Wash Action Agenda” or agenda of actions for water that they commit to achieve. But what will the States and the UN themselves commit to at the halfway point of the SDGs!

As we said in 2016, the policy and the means mobilized were already signalling the failure of the commitments made. The UN now recognizes that it is necessary to multiply by four the financial means to achieve the Goal 6 of universal access to drinking water in 2030, and multiply them by 23 in crisis situations. Not to mention the governance that is lacking!

Of course, the MDGs are ambitious, but their realization responds to the essential needs of people and nations around the world, especially in crisis situations that are often forgotten.

Now, the year 2023 offers us the exceptional opportunity of a trifecta with three successive meetings at the United Nations: the Water Conference in March, the High Level Political Forum in mid-July and, finally, the World Summit on the MDGs on September 18.

The trifecta of 2023 would consist, in short, of the appointment of a special representative for water to the UN Secretary General with a secretariat provided by UN-Water, regular follow-up meetings by a group of States, the preparation of one or more resolutions at the United Nations at the initiative of States, including, for example, the establishment of an international financial mechanism based on the GDP of each country to achieve Goal 6 for water and the MDGs, a determined fight against waterborne diseases due to unsafe water, a major cause of mortality among children. In this spirit, we invite you to support the Call to Action launched to gather 200 signatories by March 22. Is it still necessary to remind that water is life and that the earth and its inhabitants are increasingly thirsty.

Conclusion.

The earthquake in Turkey and Syria, Ukraine, Nagorno-Karabakh, the European Humanitarian Forum, the UN conference on water, so many challenges that question our conscience and measure our solidarity. Beyond the declarations of intent, we will see the reality of the decisions taken and the actions undertaken.

With this “special edition” I am very happy to offer you eight articles instead of the usual four and I am counting on your support (faireundon) to promote humanitarianism in the face of the great challenges that lie ahead. Thank you for your support.

Alain Boinet.

1. Les autres ne pensent pas comme nous. Maurice Gourdault-Montagne. Bouquins Mémoires. Novembre 2022.

 

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