FIGHTING CHOLERA FROM THE FRONTLINES

In southern DRC, UNICEF works with local organisations to help sustain community-led solutions in the fight against cholera.
Cholera is a bacterium that lives naturally in water. When a person becomes infected, usually through the consumption of contaminated water or food or through dirty hands, the bacteria can trigger a reaction of the body to release fluids through violent vomiting and diarrhoea, leading to severe dehydration, which can lead to death if not treated properly. According to a 2010 study, less than half (47 per cent) the population of the Democratic Republic of the Congo has access to an improved water source. The disparity between rural and urban areas is large: in rural areas only 31 per cent of households use an improved water source, while in urban areas the corresponding figure is 87 per cent. Furthermore, only 14 per cent of the overall population have access to improved sanitation: 36 per cent in urban areas and only 4 per cent in rural zones. These factors make populations in the DRC, particularly in rural areas, extremely vulnerable to water-borne diseases such as cholera. The Democratic Republic of the Congo is one of the few

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places in the world where cholera has become endemic as well as epidemic that is to say, the illness is present all year. In Katanga province, in southern DRC, this unique context has necessitated a shift away from traditional, reactive humanitarian responses in search of a more longterm solution. Kalmie, a rapidly-growing town on the edge of lake Tanganyika in southern DRC and the epicentre of cholera outbreaks in Tanganyika district, has been a pivotal centre for the evolution of new approaches. Since 2010, UNICEF and other local and international WASH actors in Kalmie have developed a strategy that hinges

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on prevention, rather than response. This approach has had a real impact on managing the epidemic: for instance, between 2009 and 2010, the maximum number of reported cases in Kalmie was reduced by more than half. Despite this success, the preventative strategy still depends on international support. Therefore in recent years, WASH actors in Kalmie have also been working to develop a variety of community-led approaches that may eventually provide an exit strategy for humanitarian assistance.

Design: How it works

Community volunteers form the backbone of the preventative strategy by operating approximately 40 chlorination points around Lake Tanganyika and its rivers. Between 5 am and 6:30pm they provide chlorine to everyone who collects water there, forming a protective barrier that helps to prevent the spread of cholera from water sources to households and communities. Up to 75% of people who are infected with cholera never manifest any symptoms, but can still spread the disease. This makes household and individual hygienic practices, like hand washing with soap, using latrines and chlorinating drinking water, critical to preventing the spread of the illness. UNICEF works with local partners to build the capacity of local volunteer networks. Volunteers are provided with the knowledge, skills and tools that empower them to increase awareness on the disease and to promote improved hygiene practices to help individuals help themselves and their families to block the spread of cholera, (See box on Mothers Clubs) As a step towards reducing dependency on external assistance, UNICEF and other partners have supported capacity building for local chlorine production. Currently, chlorine is being produced by local organisations in Kalmie and 6 other areas in Katanga province. (See box on chlorine production). The chlorine produced is for sale locally and is promoted 2

A Red Cross volunteer uses chlorine to treat water collected from lake Tanganika. UNICEF/DRC/Ridsdel

through radio and by the volunteer networks, allowing people to treat their own water. UNICEF has also supported the capacity building of national and community radio stations, and provided them with equipment and training. The radio networks play a critical role in disseminating information about how cholera is transmitted and in promoting important hygiene behaviours such as hand washing at critical times. UNICEF has also supported folk media such as performances and music to help spread messages about cholera prevention.

Discover: What is working well

High levels of community ownership and engagement: In Kalmie, the fight against cholera has become everyones fight. Through communityled initiatives like the Mothers Clubs, community engagement is extremely high and volunteers are committed for the long-term, whether there is funding or not. This grassroots base provides a critical first line of defence against the spread of the disease. Local capacity building: When cholera first arrived in Kalmie, people thought it was caused by witchcraft. Today, support from UNICEF and other partners has helped to educate the population and create a high level

Deliver: What has been achieved

Between 2009 and 2010, the maximum number of reported cases in Kalmie was reduced by more than half. In Kalmie, the network of Red Cross Mothers Clubs has grown from 40 women in 2008 to over 300 women in 2012, and continues to grow. Local organisations are currently producing and selling their own chlorine in 7 areas of Katanga district.

Justine Kyezo, a volunteer with the Red Cross Mothers Club, promotes locallyproduced chlorine to her neighbours. UNICEF/DRC/Ridsdel

Red Cross Mothers Clubs

In 2008, the Congolese Red Cross Society, with support from UNICEF, approached Justine Kyezo and asked her to bring a few friends to a meeting. She and a few other women from four different neighbourhoods in Kalmie went home with a mission: to form Mothers Clubs, bringing women onto the frontlines of the fight against cholera. We noticed that up until that point, at all the meetings and the trainings we were offering, there were only men, says Kalmies Red Cross President, Augustin Amani. But we know that in the household, women and children are more involved with water than men are. Justine and nine other women from her neighbourhood were given training on how to prevent the spread of cholera through key household and community behaviours. Armed with illustrated booklets and pamphlets, they set out into their community to motivate and educate their neighbours, connecting to other women as mothers, grandmothers, sisters and daughters. Today Justines club has grown to more than 90 members, who gather on a weekly basis to sing songs, exchange recipes, and organise the fight
Women from the Mothers Club help to maintain a hygienic environment in their neighbourhood by volunteering for community clean-ups. UNICEF/DRC/Ridsdel

against cholera in their neighbourhood. There are more than 300 Mothers Club members in four different clubs in Kalmie. Justine works with the Community Liaison officer of her local health post, and attends a weekly briefing by the Ministry of Public Health where the number and locations of cholera cases are reported. When there is a flare-up nearby, she mobilises her Mothers Club to take action. The members of the club volunteer to run chlorination points around their neighbourhood, conduct door-todoor awareness raising, and organise community clean-ups at key places including water sources and schools. They teach the households in their neighbourhood how to safely dispose of rubbish, maintain a sanitary and hygienic environment, use chlorine to treat their water, and to wash their hands regularly at critical moments. The women who are members of the Mothers Clubs have found more than company and solidarity in the group. Since joining the club and learning more about sanitation and hygiene, they have noticed real improvements in their lives. Since I joined the mothers club and learned about the dangers of unsafe water, my children no longer get diarrhoea, says one woman. They are healthier and happier, and since I dont have to take them to the clinic all the time, I have more money in the household, too.
Justine Kyezo gives an information session on household health and hygiene to women in her community.

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of public awareness about how cholera is transmitted and how it can be prevented. In addition, initiatives like the Red Cross Mothers Clubs have helped to create a base of volunteers with the skills, knowledge and tools to undertake WASH and hygiene promotion activities on their own. Local chlorine production: Currently, the fight against cholera in Kalmie is still dependent on UNICEFs donation of chlorine. However, a small organisation, the Mamans Uzima (see box), has been producing chlorine locally. The Mamans Uzimas chlorine is for sale for around 500 Congolese francs (0.60 cents) and can treat a familys water supply for around a week. Community volunteer networks such as the Red Cross Mothers Clubs help to market the chlorine amongst their friends and neighbours, encouraging people to take their health into their own hands. Door-to-door peer education:In the early days, organisations relied on traditional tools such as radio, posters and pamphlets to educate people about cholera. However, with these methods it was hard to guarantee that people were getting the message. Door-to-door peer education is direct, personal communication. Community educators reinforce health messages that may be heard on the radio and their proximity provides an element of social marketing for people to adopt health and sanitation behaviours. Synergy of community volunteers with government and humanitarian efforts: In Kalmie, communityled initiatives are not treated as a separate part of the fight against cholera. Community volunteers attend

government health briefings and are a key part of the humanitarian strategy to combat the spread of cholera, while government health services provide treatment for those infected by the disease.

Dream: Vision for the future

UNICEFs vision is that communities with the capacity, initiative, knowledge and skills will drive and maintain the fight against cholera themselves. In the long-term, UNICEFs vision is for every community affected by endemic cholera to have sustainable access to clean drinking water. UNICEF is advocating for water infrastructure in Kalmie Town to be extended to meet the needs of its growing population and to increase complementarity with the Healthy Villages and Schools programme in cholera-affected peri-urban and rural areas. UNICEF and the government are also engaging in national cholera mapping and cross-border cooperation with neighbouring countries to better understand the propagation routes and improve response efficiency and effectiveness.

Partners
Partnerships are crucial for UNICEFs work. UNICEF thanks its partners, the Red Cross, the communities as well as the Pooled Fund and CERF for the successful collaboration.

Local chlorine production

Formed on December 30th 2008, the Mamans Uzima, or Mothers for Life, are a local NGO that are engaged in the fight against cholera. In November 2008, a group of women heard that a local chlorine producing NGO was about to close, and they organised themselves to take over the production. Today the cooperative has production workshops in five different areas, and over 60 members. Using a simple electrolysis process, the Mamans Uzima produce cholorine from sea salt and water. They put the chlorine into small bottles (250 ml) that they sell locally for about 500 Congolese francs (0.60 cents). This quantity can treat a familys water supply for around a week. Generally, they produce between 200 and 300 bottles a week, although they could produce much more if the demand were higher. The Mamans Uzima hope that creating a local supply of chlorine will empower households to take the fight against cholera into their own hands. However, its not a straightforward business venture: for many households living close to the poverty line, the product

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remains expensive. Its difficult to convince people to buy chlorine because during cholera epidemics, people receive chlorine distributions for free, explains Hlne Afua, the coordinator. We sell our chlorine as cheaply as we can while still covering the production costs, but it is a lot of money for poor households, and people might be tempted to use an insufficient dose to make it last longer. The Mamans Uzima have teamed up with local pharmacies and train community-based vendors to try to market their product. They have also partnered with the Red Cross Mothers Clubs, a network of women volunteers. The Mothers Clubs help to promote the local chlorine amongst their members and in their neighbourhoods. They explain benefits for treating water and disinfecting toilets.

In the Ndungu area of Kalmie, Justine Kyezo, the vice-president of the Ndungu Mothers Club, believes that the Mamans Uzimas chlorine holds the key to the future. With this, we can be in charge of our own health, she says. We dont have to wait anymore for someone to come and give us something for free. We can treat our own water and make sure ourselves that our families wont become sick. Other women in her neighbourhood agree. The price is a bit high, but its worth it for peace of mind, comments one grandmother, who lives with her daughter and grandchildren nearby. The Mamans Uzima have a vision that one day their chlorine production will be completely self-sustainable: for the moment they still rely on support from UNICEF, which donates the bottles and labels. These are imported from the region, as there is no reliable local production facility. UNICEF believes that building both the supply and demand for local chlorine can be part of a long-term, community-driven solution to manage the endemic presence of cholera in Kalmie and the surrounding area.

Previous page: Bottling chlorine at the Uzima production workshop in Kalmie. Left: A man purchases chlorine at a smallscale local pharmacy. UNICEF/DRC/Ridsdel