Poor Investment in Social Infrastructure Exacerbates Repeated Outbreaks of Epidemic

Ethiopia is in the midst of an infectious disease outbreak. Known locally as acute watery diarrhoea (AWD), it’s now spreading throughout the capital and some regional states. While there are no official figures that document the extent of the epidemic, some organisations estimate that more than 2,000 people have been infected, resulting in nearly 20 deaths. Central to the problem of infectious disease epidemics is public health infrastructure and proper sanitation. EBR adjunct staff writer Meseret Mamo spoke with government officials and public health specialists to learn more about the extent of the outbreak and the nation’s response mechanics to halt the epidemic.

Globally, infectious disease outbreaks have shaped the course of human history by causing devastating misery and death. Although advancements in science, technology and medicine have helped thwart the effects of certain infectious diseases, even in the twenty-first century some continue to emerge at a rapid pace.
Many pandemics have been instigated by wars and natural disasters – when public health infrastructure and outbreak defence mechanisms are likely to be weakest. Under these conditions any contagious disease may lead to an epidemic outbreak that affects many people in a short period of time.
Ethiopia, a country that has been relatively free from internal conflict and big natural disasters in the past two decades, however, is currently experiencing an epidemic outbreak.
Five months ago, the government announced signs of watery diarrhoea (AWD) in a few areas. Currently, however, the disease affects many parts of the country, including the capital.
While the outbreak is referred to as AWD within Ethiopia, foreign institutions and health organisations typically call it cholera. An email message dated June 16, 2016 that was sent to United States citizens living in Ethiopia said the government was “responding to suspected cholera outbreaks in 29 [woredas] in Oromia, SNNP, and [Ethiopia] Somali Regions in 2016.” The email also provided links to information regarding cholera.
The ‘AWD’ moniker has even garnered coverage from foreign media outlets that state it’s merely a euphemism. An article in The Washington Post states that “…international humanitarian organi[s]ations privately admit that they are only allowed to call [the epidemic] AWD and are not permitted to publish the number of people affected. The government is apparently concerned about the international impact if news of a significant cholera outbreak were to get out, even though the disease is not unusual in East Africa.”
Despite the issues around naming, the outbreak is ubiquitous. According to information from the Addis Ababa Health Bureau, AWD is present in all districts of the capital, some more prevalent than others. The Kolfe Keranyo District is the leading area in Addis Ababa in this regard. Of 15 woredas in the district, the government considers six of them ‘high risk’ areas.
The outbreak has also affected the Bole, Gulele and Nifasilk Lafto districts, due to the lifestyle of people in those areas. “In the Kolfe Keranyo and Nifasilk Lafto districts there are people who use river water for cleaning purposes and rivers are contaminated with the bacteria that cause AWD,” says Mulugeta Admasu, an expert at the Addis Ababa Health Bureau. “In the case of the Bole District, there are a lot of construction sites and most of them have inadequate facilities for sanitation, so daily labourers are at risk.”
According to city officials, the Administration is working hard to prevent the disease from spreading and a task force has been assembled, which is headed by the mayor of the city and comprised of different municipal bureaus and the Ministry of Health. There is also a technical committee that is made up of nine sub-committees working to prevent and treat the outbreak.
Additionally, 29 treatment centres and nine government hospitals are equipped to treat complicated cases. The aforementioned US Embassy email also states that the federal government is working with a number of international organisations to quell the spread of the disease.
According to Ahmed Emanu, Director of the Public Relations and Communications Directorate at the Ministry of Health, who gave a press briefing to the media last month, the water and sewerage, food and medicine bureaus of the city have also joined the campaign against the disease. “Since February, infectious diseases caused by contaminated food and water have engulfed most parts of the country,” he said.
Despite a lack of official figures regarding the number of deaths caused by the acute diarrhoea, different organisations report an increasing number of infections in many parts of Addis Ababa and various regional states. For instance, in June the Ethiopian Public Health Institute reported that 2,150 suspected cases were recorded across the country. During that time, 25 cases were reported in the capital. That same month, the United Nations indicated that at least 1,884 cases and 19 deaths were reported in 26 woredas across the Oromia, Somali and Southern regions since December 2015.
Globally, acute watery diarrhoea is one of the most commonly reported conditions. It is a leading cause of mortality in children younger than four years old, especially in developing nations, according to the American College of Gastroenterology. Viruses cause most cases of AWD and the most common ones in children are rotavirus and norovirus in adults. Acute watery diarrhoea may be caused by many different infections and may also occur by ingesting contaminated food or water.
AWD often leads to severe dehydration, which makes it especially dangerous in drought-prone and afflicted areas. The incubation period – the period from when the person ingests contaminated water or food to when he or she demonstrate symptoms of illness – ranges from a few hours to five days. Most persons infected with AWD will have a mild illness or not feel ill at all. In its severest form, AWD typically manifests itself in the sudden onset of diarrhoea, which is profuse, painless and watery, with flecks of mucus in the stool. Vomiting may occur early in the illness and children may also develop fever. Dehydration is also likely to occur rapidly because up to one litre of diarrhoea may be produced within an hour.
Literature written on the subject reveals that apart from war and natural disasters, the frequent and rapid spread of infectious epidemics like AWD in a given society is an indicator of inadequate public investment in social infrastructure. Even though Ethiopia is lauded globally for its health delivery system, several AWD outbreaks have taken place in the last decade.
According to a World Economic Forum report entitled ‘Managing the Risk and Impact of Future Epidemics’, public health outbreaks and epidemics are likely to become ever more complex and challenging because of the continued failure to develop health-related infrastructure, especially in developing countries.
Social infrastructure refers to programmes, facilities, policies and agencies that aim to foster the overall well-being of the populace, including hospitals, emergency protocol, clean water provisions and sanitation. According to the World Health Organisation, a number of environmental factors influence the spread of communicable diseases that lead to epidemics. The most important of these include the water supply, sanitation facilities, food and climate.
According to Stephen S. Morse (PhD), an American epidemiologist, human population movements or upheavals caused by migration, natural disasters or war are often important factors in disease emergence. He stresses that classical public health and sanitation measures have long served to minimise dissemination and human exposure to many pathogens that spread through traditional routes such as water and food. Morse adds that some diseases are also preventable by immunisation and vector control.
Although access to safe water and sanitation are a prerequisite for the realisation of many human rights, including those relating to people’s survival, Ethiopia is far from ensuring the provision of these services for its population.
Despite claims by officials that access to drinking water in urban areas has substantially improved, residents in cities like Addis Ababa, especially on the outskirts, suffer from constant water shortages that leave them with no other option than using unsafe water for drinking, cooking and cleaning. Areas now affected by AWD are ones where water shortages have been severe. In rural areas, women and girls still spend hours fetching water by traveling long distances, which often isn’t clean or safe, compromising their health and welfare. According to data from the Ministry of Health, 12Pct of households in the capital don’t have the means to keep water safely. This is in addition to the fact that only 55Pct of urban dwellers have improved access to modern sanitation facilities.
Many infectious diseases are transmitted through water. They often spread easily from person to person, and when clean water is not available for drinking and hand washing, caretakers of the sick may also get infected, becoming vectors of transmission themselves. If the sources of drinking water are subject to contamination it requires appropriate treatment to remove disease-causing contaminants.
Officials stress improper sanitation is another factor that exacerbates infectious disease outbreaks, and that they’re likely to re-emerge unless basic water and sanitation deficiencies are properly addressed. “The fact that the epidemic has occurred during the rainy seasons makes the spreading easier due to sanitation-related problems; therefore, there is a chance to contaminate more places,” says Mulugeta.
A lack of access to improved sanitation facilities can cause bacteria to leak into the water supply, potentially infecting those who drink the water. With hundreds of thousands of people without access to potable water or sanitary toilet facilities, many have no choice other than to defecate and urinate in the open, which further complicates the ability to keep the epidemic under control.
However, Mulugeta says toilets are built in areas where there are none, even in places where illegal settlers live, and attempts are being made to distribute clean water to places where there are supply interruptions and no pipelines for clean water. However, the outbreak is still prevalent in many parts of the country.
Under such circumstances, experts say any awareness creation activities are likely to prove futile because people are unable to follow certain measures, like hand washing. Rather, they stress the need to invest more in comprehensive behavioural change programmes.
Since the announcement of the outbreak of AWD, different radio and television messages have been disseminated. Even phone texts were sent, reminding the public of basic sanitation measures like hand washing after using the bathroom, before preparing foods and before eating. “Many mock the messages because they seem so elementary,” says Mulugeta. “[They] may be elementary but are also very vital.”
Now that the rainy season is almost over, many hope that the outbreak will end. However, public health officials have another fear in connection with the impending dry season. A public health officer who spoke to EBR on the condition of anonymity says that flies are one vector for infectious disease. “The dry season enables flies to reproduce and become active,” he argues. “Though the risk will be determined by the amount of bacterium on the flies, the condition is still a risk if the outbreak is not under control soon.”
The coming months also bring about another situation in which diseases are likely to spread: the beginning of the school year. Students who spend hours together in confined spaces without adequate sanitation may be at risk for certain diseases. Wubeshet Abera, Team Leader of the Infrastructure Provision at the Addis Ababa Educational Bureau told EBR that they are working to make schools safe from this risk. “All government school directors are now in trainings and one of the agenda items is how to make the school environment healthy and free from the risk of the epidemic,” he says.
Presently the MoH is using some schools for treatment, like in the Ethiopian Somali Region. In an email response to EBR, UNICEF’s Ethiopia country office said that schools should be disinfected and not used as treatment centres once they re-open for students.
Stakeholders agree the areas that are most prone to epidemics are ones in which the poorest people reside. In order to control epidemics like AWD, they say it is imperative that people have access to clean, safe drinking water and improved sanitation. Building wells and latrines before a disaster or an epidemic emerges would provide a more formidable defence against future outbreaks. EBR