A woman fetching water form a river for domestic use

No Funds, No Water, Poor Sanitation; Why Kano’s Cholera Epidemic Remains Perennial

By Shahida Salihu

When 32 year old Muazu Ibrahim, resident of Kundila area of Kano state scooped water from a nearby public well for his family’s domestic use, little did he reckon that the consequence will be very devastating. Six members of his family contracted Cholera resulting in one fetal death.

“The well was already dry, we practically had to dig water out of it and we did not treat it by way of boiling or chemical before consuming,” Ibrahim, a 2019 Cholera survivor recalled.

According to him, soon after, several family members start to experience symptoms of diarrhea and vomiting, which quickly spread to others.

“The symptoms kept persisting and worsening and we had to go to the hospital when several traditional remedies failed. Unfortunately, one of our family members eventually succumbed to the disease due to lack of proper healthcare and delayed response,” he narrated

The story of Mr Ibrahim who confirmed he was not given any Cholera vaccine before, during of after the incidence is no different from that of Mariya Rabiu 19 a resident of Unguwar Wawure, in Gwale Local Government Area of Kano State who also has not been given Cholera vaccine at any point in her life even after she visited the hospital for Cholera treatment.

“I saw hell for days that I thought I was going to die, fortunately I survived but my sister could not survive it because of lack of money to buy drugs,” Ms Rabiu who contracted Cholera from consuming unwashed mangoes revealed.

For Alawiya Hassan, a resident of Zage, a small settlement behind Murtala Muhammed Hospital in Kano, she contracted Cholera after visiting a sick neighbour who also had the virulent disease.

“I began to experience stomach upset, watery diarrhoea with severe dehydration. I was rushed to the Muratala, I was given fluid and injections but no vaccine was administered before, during or after treatment,” she said.

Cholera, according to the World Health Organisation (WHO), is an extremely virulent disease that can cause severe acute watery diarrhoea and it takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water. Cholera which affects both children and adults and can kill within hours if untreated.

“Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people,” say WHO

Cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Typical at-risk areas include peri-urban slums, and camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation are not met.

“You see when you put this human factor together coupled with the sanitation and water situation we are grappling with in Kano, you will understand why this outbreak is almost perennial in the state and why no matter the effort being pumped into health infrastructure, the situation will continue to reoccur if there’s no multifaceted collaborative approach to regulation, surveillance and prevention,” explained Abdulwahab Ahmad, a Kano based development photojournalist.

A Long History of Outbreaks

Just recently, a total of 1, 336 suspected cases of cholera, including 79 deaths, have been recorded in 12 states this year, the Nigerian Centre for Disease Control and Prevention (NCDC) has said.

The states are Abia, Bauchi, Bayelsa, Cross River, Ebonyi, Kano, Katsina, Niger, Ondo, Osun, Sokoto and Zamfara.

The NCDC, in its situation report mid April, said of the suspected cases since the beginning of the year, age groups 15-24 and >45 years were the most affected age groups for males and females respectively.

It said, “Of all suspected cases, 53% are males and 47% are females,”

In late 2020, Kano State experienced a sudden increase in cholera cases, with reports indicating that over 1,000 people had been affected by the disease within a short period of time. The outbreak was largely attributed to poor sanitation practices, including open defecation and the contamination of water sources.

By early 2021, the number of cases had continued to rise, with the Kano State Ministry of Health reporting a total of 2,900 cases and 28 deaths in January alone. Health officials and organizations such as UNICEF quickly mobilized to provide support and aid to those affected by the outbreak, including the provision of clean water and sanitation facilities.

Despite these efforts, the outbreak continued to worsen, with the number of cases rising to over 6,000 by April 2021. The Kano State Government declared a state of emergency in response to the outbreak, calling for urgent action to be taken to control its spread.

The government also launched a cholera vaccination campaign, targeting high-risk areas and populations, including children under the age of five and pregnant women. The campaign was supported by international organizations such as the World Health Organisation (WHO) and UNICEF.

As of September 2021, the cholera outbreak in Kano was still ongoing, with over 22,000 cases and 392 deaths reported since the beginning of the outbreak. The government and health officials continue to work towards controlling the spread of the disease, including through measures such as improved sanitation practices and the provision of clean water sources.

By the year 2022, Nigeria recorded 23,550 suspected cases of cholera with Kano registering 1,131 cases joining one of the six states that accounted for 84 percent of all cases of Cholera in the country.

Mapping the Hotspots

Nigeria is endemic for cholera since 1970, and Kano State reports outbreaks annually with high case fatality ratios ranging from 4.98% as at 2010 to 5.10% as at 2018 over the last decade.

Between 2010 and 2019, the most severe cholera exacerbations occurred in 2014 and 2018 with annual incidence rates of 58.01 and 21.52 cases per 100 000 inhabitants, respectively.

Cholera hotspot clustered around water bodied areas both in urban and rural settings according to a 2021 study by Moise Ngwa of the University of Florida, Tochi Joy Okwor of the National Centre for Disease Control, Sebastian Yennan also of the Nigeria Centre for Disease Control among other authors.

Some of the hotspot identified with yearly recurrence are Gwarzo, Wudil, Dawakin Kudu, Minjibr, Fagge, Gaya, Rimin Gado, Kunchi and Rano.

Others are Kano Municipal, Kabo, Doguwa, Bagwai, Gaya, Madobi, Garum Mallam, Kumbotso, Tudun Wada and Karaye to mention a few.

Human Factors Undermining Cholera Surveillance and Response Systems in Kano

In Kano, Nigeria, health officials are struggling to control the spread of cholera outbreaks, as surveillance systems put in place to detect and respond to these outbreaks are being undermined by human behaviors.

Indiscriminate consumption of roadside foods, refuse dumps, and water is proving to be a major challenge in the fight against cholera. Residents in Kano, particularly those in the lower-income areas, are still relying on street vendors for their meals, despite warnings from health officials about the potential risks of consuming contaminated food and water.

The lack of proper sanitation and waste management in these areas has also contributed to the spread of cholera. Refuse dumps are often located close to water sources, which can lead to contamination of the water supply. This, coupled with the high demand for water in these areas, means that many residents are forced to consume contaminated water.

According to Dr. Ibrahim Abubakar, the Director-General of the Kano State Ministry of Health, the surveillance system put in place to detect and respond to cholera outbreaks is struggling to keep up with the situation. “We have put in place measures to detect and respond to cholera outbreaks, but human behaviors are making it difficult for us to contain the situation,” he said.

Dr. Abubakar urged residents to take responsibility for their health and avoid consuming contaminated food and water. He also emphasized the importance of proper sanitation and waste management in the fight against cholera.

According to Mr Ahmed, the effectiveness of the surveillance system lies on awareness and proper hygiene management.

“This is the season of mangoes, you see children consuming mangoes and flies perching on it, but they wave it off and continue consuming. Also, oftentimes you find septic tank cleaners disposing human waste in salad gardens. The bacteria infects the leaves which is in turn consumed without properly washing,” the development photojournalist explained.

He further explained that food vendors in areas without proper toilet facilities usually ease themselves and without sanitizing use the hands in serving customers.

“The vendor comes out from the toilet, clean her left hand which she uses in washing herself on her wrapper and uses the same hand to hold vegetables while she slices with her right hand and serves customers food. These are certainly transmission conduits for Cholera,” he further explained.

Poor Waste Management Also Puts Residents at Risk

Waste, trash and garbage, have continued to become hallmarks of poor sanitation and hygiene conditions that have exacerbated the Cholera situation in the ancient city of Kano.

For instance Kantin Kwari Market, the Largest Textile Market in Africa – along IBB way in Kano Metropolis reeks of environmental pollution and an obnoxious odor over unhealthy waste disposal which exposes the environment to the danger of Cholera bacteria.

This may hinder the achievement of Goal 6 of the Sustainable Development Goals Agenda 2030 in Kano state that emphasizes Clean Water and Sanitation.

The shop owners in the axis mark certain sections of the road as dumpsites, while remaining there for a long time before evacuation.

Some of the major roads and high-ways in Kano are not exempted from the menace of dumping refuse exposing the culpable negligence of the relevant authorities to properly evacuate the waste to prevent outbreak of diseases in the affected areas.

According to the Centre for Disease Control and Prevention (CDCP), the Cholera is most likely to occur and spread in places with poor sanitation, and inadequate hygiene”, among others.

During torrential downpour, the waste disposals are often washed into houses which poses a significant threat to community health and may lead to outbreak of diseases like Cholera.

However in 2021, the Kano State Government made moves to concession waste management in the state. It said that its concessioning of waste management and hand over of operational plant and equipment to a private firm, Messrs Capegate Investment Limited Company, for better refuse control and sanitation in the state will generate over N31Billion in revenue to the state.

The Honorable Commissioner for Environment, Dr. Kabiru I. Getso revealed this, in September 2021, while playing host to a joint advocacy visit by the Community Health and Research Initiative (CHR), Youth Society for the Prevention of Infectious Diseases and Social Vices (YOSPIS) and the Accountability Mechanism for Maternal and Child Health in Kano State (AMMKaS) at his ministry.

Receiving the team along with various other directors at the Ministry, the commissioner stated that, “the waste will also be used to produce organic and inorganic fertiliser so as to improve agricultural output in the state, while generating electricity. According to the agreement, in the first year the company will start remitting to the state government, it will be N50m per month, the next year it will be N100m per months, the third N200m that’s how it will continue till the duration of the agreement,” he explained.

“Also, there will be provision of additional waste collection centres, refuse dumping centres and walls/bunkers will be built along routes for wastes to be dumped across,” he stressed further.

He tasked the three organization to work towards actualization of the Kano Environmental Pollution Bill which according to him includes penalties to defaulters on pollution.

But in April 2022, Daily Trust reported that the streets of Kano have again witnessed what many had thought was a thing of the past. They were littered with dirt at a proportion quite alarming.

With Kano City the city generating several thousands of metric tonnes of waste on daily basis, the state government had entered into a Private Public Partnership with Capegate Investment Limited to handle its wastes. The firm had replaced the now-defunct government agency —Refuse Management and Sanitation Board (REMASAB).

But since the firm took over some 10 months ago, several hiccups have limited its plan of making Kano the cleanest city in the country as these hiccups have ensured the city occasionally moved to the top of the log of dirtiest cities in the country.

The Group Chief Operating Officer (COO) of Capegate, Bello Abba Yakasai, told Daily Trust that the firm remains committed to its goal of making Kano State not only one of the cleanest in the country but also to generate revenue from waste for the state.

He explained that the recent setback was as a result of three major factors. The first according to him is the recent hike in the price of diesel, which now sells for over N700 per litre from N200-300 per litre it was sold when the firm took over.

“There is no subsidy on that for us who are working for the welfare of the people. We have to buy from the open market. So, our ability is currently being reduced. We were unable to provide the services as they should be and I think it is not just Capegate, almost all organizations that are affected by this hike in prices. And up till now, the prices have not gone back to normal,” he said.

Kano, according to him, has 52 major dumpsites apart from the refuses dumped on the streets and it takes at least one payloader and 15 tippers to clear one dumpsite in a day and this equipment use a combined diesel of 820 litres to operate in a day, which at current price goes for over N500,000.

He also admitted that because of Kano’s population, the city generates waste at a very high level, saying each of the dumpsites gets filled up just two days after clearing it.

As such, while the firm is still grappling with clearing the dump sites with its now reduced workforce (because of the high cost of the diesel), it also has to make provision for the clearing of refuse that is dumped on the streets by the residents.

Responding to the myriad of challenges confronting the waste management sector in the city, the state’s commissioner for environment, Dr Kabir Getso, told Daily Trust that the state government is doing its part to ensure all issues are resolved.

He said before, the government used to shoulder the responsibility for everything but now with this partnership, it is designed in such a way that people will be paying for the waste that they are generating.

The ministry, according to him, has concluded the drafting of four bills specifically targeting waste management in the state and they are currently being vetted by the state’s ministry of justice after which they will be presented to the state governor, who will, in turn, submit it as an executive bill to the state assembly.

Not Just Waste Management, But Water Matters too

According to WHO, Provision of safe water and sanitation is critical to prevent and control the transmission of cholera and other waterborne diseases. However, due to increasing population and power supply challenges, many residents in rural areas, and even urban centres in Kano – like other densely-populated cities in Nigeria – continue to experience water scarcity.

An investigation conducted, revealed that the problem affects residents in the eight metropolitan local governments – Dala, Fagge, Gwale, Kano Municipal, Kumbotso, Tarauni, Nassarawa and Ungogo.

The Kano State Water Board explained that various measures are being taking to enhance water supply to the residents.

Kofar-Wambai disclosed the measures recently, when he spoke to the media, through the Director of Commercials, Alhaji Umar Bala.

He explained that the treatment plants in Kano were established some decades ago, to feed about 2 million people, revealing that the population has now increased by over 7 million, leading to the increase in the demand for potable water.

He noted that the water they treat and supply to the residents is now inadequate, due to the rehabilitation and expansion work going on at Galo river by the Federal Government.

Stretching Health Centers

According to the World Health Organisation (WHO), severe cases of Cholera will need rapid treatment with intravenous fluids and antibiotics. Oral cholera vaccines should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in areas known to be high risk for cholera

Most of those infected will have no or mild symptoms and can be successfully treated with oral rehydration solution. A global strategy on cholera control, Ending Cholera: a global roadmap to 2030, with a target to reduce cholera deaths by 90% was launched in 2017.

Researchers have estimated that each year there are 1.3 to 4.0 million cases of cholera, and 21 000 to 143 000 deaths worldwide due to cholera (1) Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.

However, factors such as human behaviors, poor sanitation and hygiene have stretched the State’s health security infrastructure and exposed its suboptimal capacity to cope in the face of epidemics such as Cholera.

“But that is not just the problem, the problem is that there is no health registration at the Medical Out-Patient Department (MOPD) of most of our hospitals. Nobody will tell you releases of epidemiology cost,” says Ibraham Garba Maryam, a Kano based accountability crusader and activist.

He also argues that the state Primary Healthcare Centers (PHCs) are not functional enough to address causes of death by Cholera patients in Kano due to inadequate research findings.

“The Government is not sincere, besides the tog of war between the state and the PHC management, as the Commissioner controls a supposedly independent Board like his private entity, there is nothing like global best practice since capital budget release for the sector is less than 7% but with crazy overhead cost of more than 200%!” Mr Maryam explained.

However, Musa Sufi a development Journalist and Director General of the Adamu Abubakar Gwarzo Foundation (AAGF), believes that the state governments response and tracking compared to other states with the same challenge is commendable, but he thinks a more technology driven approach needs to be deployed.

Sufi who is also a member of the Social Mobilisation and Advocacy unit of the Kano State Cholera Response Committee argued that while the state has done its best in adapting to global best practice in Cholera management, the global stage needs to as well learn from Kano especially in terms of using traditional and religious leaders, town criers, singers radio programmes for awareness creation.

“We see the impact and result of our approach most times for example communities like Minjibr and Gaya constructed boreholes and stopped consuming contaminated waters, we have also seen decline in mortality and infection rated in the last two years,” he said

He however admitted that vaccines are not enough because of high demand due to Kano’s population.

Perspective of a Healthworkers

In an interview with Sani Ibrahim, a health worker in Murtala Muhammad Specialist Hospital he explained some measures hospitals, PHCs are putting in place to avoid a recurrence of the cholera outbreak that occurred last year?

He said, “During the CHOLERA outbreak in kano in the year 2021 people suffered alot, as it affected almost all parts of the kano both Northern, Southern and Central part of it. At such time a lot of people were admitted in various health facilities, and some numbers of mortality were recorded.

“One of the measures put in place as the rainy season approaches is a surveillance system to watch societies and detect and respond immediately to any cholera outbreak.

This surveillance system includes feedback at the local level and information-sharing at the global level.

He added that another measure is the implementation of water and sanitation interventions.

“The long-term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation.

“We are implementing adapted long-term sustainable WASH solutions to ensure the use of safe water, basic sanitation, and good hygiene practices in cholera hotspots.

“These interventions not only prevent cholera but also a wide range of other water-borne illnesses. Furthermore, they contribute to achieving goals related to poverty, malnutrition, and education.

” I would also like to emphasize that prevention of cholera is dependent on access to safe water, adequate sanitation, and basic hygiene needs. Therefore, it is important for communities to prioritize these basic needs to prevent the spread of cholera and other diarrheal diseases.”

Hanging Epidemiology Funds

Investigations conducted by this reporter reveals that while paltry allocations are usually made for capital expenditure, overhead costs are usually very excessive yet the budget is trailed with little or no releases at all.

Findings reveal that the sum N300,000,000 was allocated to epidemic preparedness and response in 2021; however, no disbursement had been made as at September 30, 2021.

Similarly, N210,000,000 was earmarked for upgrading health laboratories in 2021, but zero funds had been disbursed as at September 30, 2021.

Also, for epidemiology and control of outbreaks such as Cholera, a provision of N20,000,000 was made in the 2021 budget for the Ministry of Health. However as at September 30,2021, no disbursement had been made towards this particular line item. The allocation to this has been increased to N40,000,000 in the 2022 budget.

For the Basic Healthcare Provision Fund (BHPF), a provision of N1 billion was made in the 2021 budget. However as at September 30,2021, only N183.83 million had been recorded as actual. The allocation to this has been reduced to N688.48 million in the 2022 budget.

As the State continue to battle cases of Cholera and associated concerns, thousands of victims like Muazu Ibrahim, Alawiyya Hassan, and Mariya Rabiu remain out there with the apprehension that unless the issue of funding, water, sanitation and waste management is squarely addressed, the case of Cholera will continue to be a perennial epidemic.

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