Responding to a Public Health Crisis

Max Perel-Slater, Maji Safi Group Co-founder and Tanzanian Executive Director, grew up in Berkeley, California, and graduated from Berkeley High School. He received his BA in Environmental Studies & Earth and Environmental Science from Wesleyan University. He also studied abroad with the School for International Training in Arusha, Tanzania, where he did an independent research project about the water situation in Shirati, Tanzania. He continued this research the following summer as part of his Senior Capstone Project at the Wesleyan College of the Environment. Max has worked on water projects in Shirati since 2009. He was selected as a World Learning Advancing Leaders Fellow in 2013 for his work with Maji Safi Group.

In early April, Maji Safi Group began hearing rumors of cases of cholera in the Rorya District. As a public health and disease prevention organization, we took these stories very seriously and started to contact the district health authorities, including local government officials, health officers, officials from the district hospital, and the district medical officer. Unfortunately, at this point there were no clear answers regarding the situation.

What is Cholera?
Cholera is a type of acute, watery diarrhea and vomiting caused by a bacterial infection. In its most severe form, cholera is one of the swiftest lethal infectious diseases known – characterized by an explosive outpouring of fluid and electrolytes that, if not treated appropriately, can lead to death within hours. In places where drinking water is unprotected from fecal contamination, cholera can spread with stunning speed through entire populations. These two characteristics of cholera have yielded a reputation that evokes fear and often panic. However, with prompt and appropriate treatment, mortality can be kept low. Furthermore, cholera outbreaks can be prevented or controlled through a combination of public health interventions, predominately through disease surveillance and early warning, safe water, adequate sanitation, health and hygiene promotion, and education campaigns on the use of oral rehydration solutions. (UNICEF Cholera Toolkit 2013)

Due to the severity of a potential cholera outbreak, we readied our team for a large-scale response, if needed. Although cholera awareness, prevention, and treatment are part of the MSG Community Health Workers’ standard training, we felt it was important to conduct a short refresher workshop with our staff to discuss the specific characteristics of the disease, methods of prevention, and home-based rehydration and care for people already suffering from cholera infections. We also found that there was a serious need for learning tools and handouts about cholera in Swahili. Consequently, MSG’s Community Art Coordinator, Jacky Lucas, and the team began developing a pamphlet on cholera prevention and rehydration of patients.

On April 15, we received word from the District Health Officer that there were 30 confirmed cases of cholera in the Rorya District. Cases had been reported in seven villages, which led to markets and public gatherings being prohibited as a precautionary measure. MSG had not previously been active in the villages affected by the cholera outbreak. These villages are about 30 km from our office and center of operations.

Cholera in Tanzania
While cholera has been eradicated in many areas of the globe, countries with poor sanitation and hygiene conditions are still devastated by the disease. In fact, cholera is known as the sanitation disease. Tanzania is an endemic country, meaning that over the last five years, one or more cholera outbreaks have occurred each year. Official numbers report that there have been over 9,000 cases of cholera in Tanzania in the last 4 years, with over 160 deaths. However, some community organizations suggest that these government figures may be significantly underestimated.

Due to understaffing, the Rorya District government did not have the capacity to operate a cholera education campaign without external help, so Maji Safi Group was asked to mobilize our Community Health Workers and step in. Rorya District Head Health Officer, Mr. Maimbo, commented, “Maji Safi Group has a very important role in teaching the community how to protect their families and neighbors and how to get treatment for sick people. People need to know to treat their water, wash their hands, and use a toilet.”

In cooperation with local government officials, MSG developed a plan for providing communities with crucial information about the outbreak, teaching students at primary and secondary schools, visiting families, and making public announcements in the affected villages. Our CHWs were also available at the MSG Disease Prevention Center at the KMT District Hospital to provide information and teach families of patients. Additionally, our hotline and radio program supported our on-the-ground initiatives with updates, allowing community members to ask questions and discuss the outbreak.

Local government officials in the affected villages were very supportive of MSG’s work and frequently wanted to walk with the CHWs to direct them to the families in the greatest need. After spending the day visiting families with the CHWs, Utegi village leader, Mr. Odhiambo, said, “It went well. It is helping us prevent the spread of the cholera disease. The community said these lessons had not been available before. They want you to come back and teach them and their neighbors more.”


 

Since the start of the cholera outbreak…

MSG has conducted home visits with

396 families 

and

22 cholera patients


MSG has taught

754 people

at local markets about cholera prevention


MSG has aired

8 radio shows

about cholera with

169 callers

and

24,000 estimated listeners


MSG’s Hotline has sent disease prevention text message alerts and lessons to hundreds of community members and has had

92 callers

interested in learning more about cholera prevention


MSG’s Disease Prevention Center at the Rorya District Hospital
has been visited by

136 patients, medical staff, and community members


MSG has taught

1,646 students

at primary and secondary schools in villages with cholera


MSG has learned that only

7%

of the community members taught by MSG
had previously received education on cholera


MSG has learned that only

9.6%

of the community members taught by MSG
already knew all of the symptoms of cholera


The village of Nyanduga has been devastated by the cholera outbreak. During home visits in the area, we found that in certain neighborhoods, nearly every family had someone who was currently sick or had been sick within the last two weeks. The recurring risk factors with these families are no treatment of drinking water, no access to toilets, and no knowledge of disease prevention. As MSG Director of Operations, Bruce Pelz, said, “I sat with two 80-year-old women while Community Health Worker Prisca taught them about cholera prevention. I realized that this was the first time in their lives that they had ever received education about preventing disease.”

The lack of knowledge about disease prevention in villages like Nyanduga has devastating consequences. This became abundantly clear while CHW Jacob and I visited a large family in a neighborhood devastated by the outbreak. A neighbor told us to visit this family because at least one person had been sick. The family greeted us warmly, and they all stopped pealing cassava to gather around and listen to what we had come to say. They told us that their seven-year-old son, Peter, had started to have watery diarrhea and vomit three weeks ago.For two days, he got worse and worse until he was no longer able to get out of bed. They took him to the hospital where he was diagnosed with cholera and given an IV and antibiotics.

Two days after returning home from the hospital, Peter’s four-year-old younger sister, Linda, also began to have watery diarrhea. She was still recovering from a malaria infection and quickly became very weak and dehydrated. Her parents rushed her to the hospital on her father’s bicycle. She was given an IV to rehydrate her and was sent home. Linda’s diarrhea continued, and the next day she passed away. The night before the funeral, Linda’s 17-year-old aunt, who lives with the family, began to have cholera symptoms. Linda’s parents said they felt terrified and helpless – they did not understand why people in their family kept getting sick and felt powerless in preventing cholera.

As Jacob explained the methods of preventing the spread of cholera (treating drinking water, hand washing, toilet use, etc.), the family looked relieved to have the disease demystified, but at the same time frustrated. “Why did we not receive this information before? We went to the hospital three times, but no one told us about the disease.”

One person being sick with cholera can lead to many family and community members getting infected. The spread of cholera can be stopped at the household level, but families need information on how to do it. It is clear that while sick people are getting treatment at the health centers and dispensaries, there is also a huge need for prevention information.

The next day, we visited the Utegi Health Center, where the majority of the cholera patients had been treated. The staff was very happy to see us. They talked about how understaffed the facility was, and that the cholera outbreak had stretched them to the limit. The MSG Community Health Workers began a discussion about cholera and the challenges the community had expressed. It became clear that the staff knew about the disease and how to prevent it, but did not have the tools or the training to teach people how to stop the disease from spreading. We did a role-playing exercise where staff members played both community members and health care providers. We empowered the health center with pamphlets and asked them to inform us if a new patient arrived and needed additional prevention education.

Further Need of Support

The Community Health Workers’ efforts have been truly inspiring. Early in the outbreak, it became clear that Maji Safi Group is the only organization providing disease prevention education. The CHWs have worked tirelessly to reach as many community members as possible in the affected villages. The CHWs have consistently looked for ways to improve our intervention and to target the groups with the greatest need.

MSG will continue to work in the villages affected by the outbreak to gain ground in preventing future outbreaks. The community continues to embrace our message. MSG is also working to make WASH products more accessible by making agreements with local agents to sell these items at reasonably rates. Additionally, we are creating a plan for future outbreaks, including having a network of health providers in villages, so MSG can get quick alerts about developing situations.

As Maji Safi Group and the CHWs continue the cholera education campaign and develop an early warning system for future outbreaks, we need your support! We have set a goal of raising $10,000, needed to offset the costs of this response and prevent future outbreaks of this dangerous disease. To date, we have raised $3,500. If all of our 550 e-newsletter recipients and other supporters donate $10 or more, we will be well on our way to the goal! Please consider supporting MSG’s important work, so that more than 7% of the local population will have education about a disease that takes their friends and family every year!

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