Cholera, commonly known as a "disease of poverty," continues to claim 115 lives deaths per hour among marginalized communities in Africa that lack access to clean water, sanitation, and healthcare.

Unsafe sanitation practices and behaviours are resulting in greater water pollution, disease outbreaks, and rising mortality rates across Africa, the 2024 State of Africa’s Environment report on water said.

The report released by the Indian-Based Centre for Science and Environment highlights that death rates from unsafe water sources in Africa are alarmingly high, reaching 50 deaths per 100,000 people—1,000 times higher than in developed countries.

Nigeria experienced one of the largest cholera outbreaks, affecting 32 of its 36 states, with around 90,000 people falling ill and over 3,000 deaths reported by the end of 2021. In 2023, Zimbabwe faced one of its most severe cholera outbreaks in recent years, spreading to all 10 provinces. By May 2024, the country had recorded more than 30,000 cholera cases and 600 deaths in the first four months of the year.

In Ethiopia, limited access to safe water and sanitation has contributed to cholera becoming endemic. Since the outbreak began in August 2022, the country reported 44,044 cases and 571 deaths by May 2024. Additionally, between 2019 and 2021, Ethiopia documented a total of 15,515 suspected cholera cases.

“Three-fourths of the cases were reported from the drought-affected regions of Oromia, Somali and Southern Nations, Nationalities and Peoples Region.”

According to the Ethiopia Public Health Institute, as mentioned in the report, over 15.9 million Ethiopians, about 15 percent of the total population, reside in areas with a history of recurring cholera outbreaks. National cholera surveillance data from the past nine years (2015-2023) indicate that the country has experienced cholera outbreaks annually.

In Malawi, the cholera outbreak began in early 2022 and persisted into 2023-2024, with over 36,000 cases and 600 deaths recorded by early May 2024.

The report notes that Malawi has not been cholera-free since 1973. According to a CSE report, in the last 11 months of 2022, more than 950 Malawians died, and approximately 29,000 cholera cases were reported during that time.

“For Africa, it has been a scourge for the last 53 years. For the second driest continent of the world with high level of inequality in access to safe water and sanitation, the disease burden is too high. Various studies estimate that at least 40 million people live in cholera-endemic areas in Africa with a risk of frequent outbreaks,” the report said.

The report indicated that in January 2023, the WHO categorized the global increase in cholera as a Grade 3 Emergency, the highest classification for a health crisis necessitating a thorough response. One year later, over 30 countries reported cholera cases, with the African region ranking second after the Eastern Mediterranean Region.

“From January 1 to May 16, 2024, some 194,897 cholera cases and 1,932 deaths were reported worldwide. The region with the highest reported case count was the Eastern Mediterranean Region, followed by the African Region, the Region of the Americas, the Southeast Asia Region, and the European Region.”

According to the WHO Africa Region’s Monthly Regional Cholera Bulletin dated June 30, 2024, cholera outbreaks were reported in 14 countries across the continent. It was classified as a “crisis” in Comoros, the Democratic Republic of the Congo, and Ethiopia.

“Since the beginning of the year 2024, the number of cholera cases and deaths reported to the WHO Regional Office for Africa (afro) as of 30 June was 104, 038 and 1, 732 respectively, with a case fatality ratio of 1.7 per cent. Comoros, Ethiopia, Congo, Zambia, and Zimbabwe account for 85.7 per cent (89,208) of the total cases and 91.2 per cent (1,580) of total deaths reported till June 30, 2024,” the report quoted the afro’s monthly bulletin released in July 2024.

Unsafe water and poor sanitation

2021 figures in the report show that Africa accounted for nearly half (44%) of the global deaths attributed to unsafe water and poor sanitation, totaling 533,276.79 deaths out of 1,215,365.13.

Nigeria accounted for 28.04% representing 149,811 deaths, Ethiopia 8.28% (44,212 deaths), Chad 5.49% (29,262 deaths), and Ghana 1.55% (8,271 deaths). Sao Tome and Principe, Libya, and Tunisia recorded the lowest figures of 0.01%, 0.02%, and 0.03%, respectively.

The report highlights that the decline in groundwater quality is an emerging challenge that exacerbates the disease burden. It notes that, although much of the economy in Sub-Saharan Africa relies on groundwater, insufficient attention is given to its quality.

“Due to geological formations several African countries have higher concentrations of fluorides, arsenic and chlorides. These also make groundwater unfit for drinking without treatment.”

A 2020 study by CSE found high concentrations of iron, magnesium, and chlorides in Uganda's groundwater, attributed to natural mineralization. Fluoride levels also exceeded WHO drinking water guidelines due to volcanic deposits. These conditions, CSE says, can lead to various health issues, such as fluorosis, while high iron levels contribute to unpleasant odors and tastes, and manganese can damage plumbing fixtures and laundry.

In Tanzania, the CSE study identified that groundwater is contaminated with nitrates and sulfates. The mining of these resources, along with the hazardous dumping of waste, leads to pollution in water bodies, increasing their salt and mineral content and affecting their pH levels (acidity or basicity).

"The community should either have community-level water supply systems which treat the groundwater before supply to households or there should be mechanisms where the groundwater supplies are treated before supply to households, which again can be a costly affair for the rural households,” CSE recommended.