Cholera in South Africa: a symptom of two decades of continued sewage pollution and neglect

South Africans have expressed outrage at the deaths of at least 15 residents of Hammanskraal, in the city of Tshwane. The deaths were caused by cholera – a diarrhoeal disease caused by Vibrio cholerae bacteria. The disease can be fatal if left untreated. The bacteria produces a toxin in the small intestine. This causes the secretion of enormous amounts of water, leading to diarrhoea and a rapid loss of fluids and salts (electrolytes).

The bacteria are shed in the stools of people who are infected. People get infected when they come into contact with or consume water that has been contaminated with the bacteria. Cholera is closely linked to inadequate access to clean water and sanitation facilities. Preventing it requires more than practising individual hygiene. Areas typically at risk include peri-urban slums and rural areas where the minimum requirements of clean water and sanitation have not been met.

The cholera outbreak in Hammanskraal is not limited to that area: the reported cases are part of a wider outbreak in South Africa as well as the wider southern African region. Prof Anja du Plessis, a research specialist in water resource management, believes that the crisis could have been averted. She explains to The Conversation Africa’s Ina Skosana.

What is behind this crisis?

The current cholera outbreak is not necessarily an issue of potable water. It’s the result of a combination of factors. These include dysfunctional and non-compliant wastewater treatment works, mismanagement, under-investment and misappropriation of funds. Along with the lack of political will and action over the past two decades, these factors have formed a perfect storm. It is a legacy issue which has been emphasised by myself and other researchers since as far back as 2002.

The health crisis we are seeing can be attributed to the legacy of sewage pollution across the country because wastewater treatment works are in poor or critical condition due to under-investment and mismanagement.

More than 80% (105 of 115) of wastewater treatment systems have been identified to be in a critical state. These water treatment plants require urgent intervention and rehabilitation. The partial or the complete lack of functioning wastewater treatment works is accompanied by significant negative implications for public health, the environment as well as socio-economic development and growth. It should be managed in a proactive way to ensure that people receive potable water in line with the South African National Standard 241 for drinking water.

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South Africa has made progress in expanding access to water infrastructure on a national level. However, access to water has declined in five of its nine provinces between 2002 and 2019. Only 64% of households are estimated to have a reliable and safe water supply service.

And having access to water supply infrastructure does not guarantee reliable and safely managed water supply. The water might not be of suitable quality for drinking and/or cooking.

What is needed for water to be potable?

Drinking water is considered to be potable when it has been filtered and treated in various processes. The water must be free from contaminants and harmful bacteria or pathogens. Water is suitable when it is safe for both drinking and cooking.

Non-potable water can taste normal (like potable water) but can cause serious health problems – in this case, cholera.

What other issues are at play?

The country’s continued sewage crisis, which has now led to a cholera outbreak, is largely due to non-functional municipal sewage systems. More than 90% of the total 824 treatment plants across the country release raw or partially treated sewage directly into the country’s already scarce water resources.

The Vaal River is a good example. It has been reported to be “polluted beyond acceptable levels” by the South African Human Rights Commission, significantly affecting the environment, socio-economic growth and endangering people’s health.

Additionally, a total of 151 municipalities are close to collapse. And 43 municipalities have already collapsed and require immediate intervention. Major issues include weak governance, alleged corruption, and poor management of assets, operations and maintenance. There aren’t enough experienced individuals with suitable qualifications. There has also been a lack of accountability and political will over the past two decades. These issues within municipalities have led to the failure of wastewater treatment works. Some have reached crisis levels.

The combination of dysfunctional or non-functional municipalities and dilapidated wastewater treatment works has significantly affected the most vulnerable populations. Most of these people live in informal settlements and urban slums, and are defenceless against water-related illnesses.

The main factors behind the country’s sewage crisis and cholera outbreak are:

lack of maintenance of basic infrastructure at local government level

lack of capacity and suitable skills

lack of implementation and enforcement of existing legislation and policy

lack of accountability.

What must be done now?

South Africa’s water quality scores as “tolerable” in terms of microbiology standards and “unacceptable” by operational standards. This shows poor wastewater treatment works performance.

The microbiological score indicates the possibility and presence of immediate unacceptable health risks. On a national scale the bacterial and/or pathogen concentration values exceed the numerical limits specified in SANS 241. In other words the total Coliforms count per 100ml is above the set standard of 10 counts per 100ml.

The unacceptable level for operations indicates that the operation of treatment systems and risk to infrastructure is of concern and not efficient. The data emphasises the non-functioning and overall neglect of wastewater treatment works.

To improve prevention and response to health crises, such as the current cholera outbreak, the government needs to test supplied drinking water, from all sources, on a frequent basis to establish compliance and be clear about the results as well as the amount and extent of cholera cases across the country.

The current state of drinking water supplied across the country also needs a critical evaluation. The country can simply not afford the continued dysfunction of municipalities and wastewater treatment works.

Reactive management, lack of political will, transparency and unaccountability over the past two decades have contributed to the current state of affairs. The cholera outbreak in Hammanskraal could have been avoided and prevented if necessary actions had been taken.