YAOUNDÈ, Cameroon – As bad as the UN says a severe cholera outbreak in Southern Africa may be, estimating more than 3,000 deaths in the past year and almost 200,000 people affected, one Catholic expert says the reality may be even worse.

“These figures might not always be up-to-date or paint the complete picture of the gravity of the situation on the ground,” said Pierre Burgos, an official with Catholic Relief Services (CRS), the overseas humanitarian and development arm of the U.S. bishops’ conference.

“The reality could be even more grim, as many cases go unreported or untreated,” he said.

Burgos is the Humanitarian Response Technical Advisor for a CRS program called Water, Sanitation and Hygiene, or “WASH.”

Cholera is a bacterial infection of the small intestine, usually caused by unsafe water or food, and in extreme cases is fatal, causing somewhere between 30,000 to 130,000 deaths each year. The new epidemic in Southern Africa has been exacerbated by a variety of factors, including poor hygiene and broken health systems, and experts say it’s hit children in the region especially hard.

Catholic Relief Services has been partnering with governments in the region to tackle the epidemic.

“We’re focusing on providing clean water, sanitation facilities, and hygiene essentials to prevent the spread of cholera,” Burgos said in an exclusive interview with Crux.

“The disease is spreading fast and hitting communities hard, especially vulnerable groups such as women, children, people living with disabilities, and the elderly,” he said. “We need to act now to prevent the increasing deaths and loss of livelihoods for affected families and communities.”

Following are excerpts of the Crux interview with Pierre Burgos.

Crux: How serious is the situation in Southern Africa, particularly in Zambia and Zimbabwe?

Burgos: The situation in Southern Africa, especially in Zambia and Zimbabwe, is dire and deeply concerning. This crisis has spread across six countries including Mozambique, Malawi, the Democratic Republic of the Congo, and Tanzania. Communities have been grappling with cholera for the past year, but the past two months have seen an alarming significant spike in cases since the onset of the rainy season.

Over the past year, the UN Office for the Coordination of Humanitarian Affairs (OCHA) has reported 188,000 cases in eight countries and, tragically, 3,000 deaths. However, it’s important to note that these figures might not always be up-to-date or paint the complete picture of the gravity of the situation on the ground. The reality could be even more grim as many cases go unreported or untreated.

The case fatality rates are alarmingly high, which underscores ongoing challenges in treatment capacities despite efforts from national governments and humanitarian health actors. And let’s not forget that we’re facing this crisis amidst ongoing conflicts, a global food crisis, and a climatic El Niño phenomenon. These added issues further stretch resources thin, and complicate response efforts.

What are the factors driving the current surge in cholera in the various Southern African countries?

It is a complex issue, and quite a few factors are at play here. The health systems in several of the affected countries are stretched thin. These systems face challenges with staffing, capacity, and access to communities in need.

A significant part of this outbreak traces back to inadequate sanitation and limited access to clean water, particularly in rapidly growing, often unplanned, peri-urban areas of Lilongwe, Harare, and Lusaka. Cholera prevention and response is also further complicated by the need for multi-sectoral collaboration between, for example, ministries of health, water and sanitation, human settlement, and finance.

With the onset of the rainy season, things have escalated. The rains exacerbate flood risks and sewer runoff and seepages contaminate water. We’re also seeing cross-border migration playing a role and complicating monitoring and containment efforts.

It is essential to recognize that because there are so many contributing factors, our approach to solutions must be equally diverse. We’re looking at comprehensive strategies that address not just healthcare delivery but also infrastructure improvements, community education, and regional cooperation to really get a handle on this situation.

Can you speak to the continued upward surge in infectious diseases post COVID-19? 

We’re seeing a concerning rise in cases of infectious diseases after the COVID-19 pandemic. Cholera is one of those diseases reported in various regions, and it’s particularly alarming because of how widespread it is. However, it’s not just cholera – there have been reports of other diseases such as measles, polio (WPV1), anthrax, and even suspected Rift Valley fever in different countries of the region.

There are a couple of reasons for this surge.

At the height of the COVID-19 pandemic, a lot of resources were diverted to manage and contain it. This meant other health issues, including vaccination programs for other diseases, took a back seat. It is important to note that while cases have dropped significantly and the World Health Organization (WHO) has downgraded COVID-19 from a pandemic-level threat, there are still COVID-19 cases and even a recent spike in cases in the region.

In addition to the gap in vaccinations, we’re dealing with communities that have had poor access to healthcare, as well as a backlog of routine childhood immunizations. Add to this water quality and sanitation challenges in some areas, and it’s almost like a petri dish for these diseases to spread.

It is not just a challenge for the health systems. Imagine being in a community where getting to a nurse or doctor is tough on any given day. The situation becomes dire when an outbreak occurs. As we move forward, there is an urgent need to refocus on these vaccine-preventable diseases – ramping up immunization efforts and improving access to clean water and sanitation facilities.

What have been the impacts on families? I understand children have particularly been the worst hit.

 It is really heartbreaking to see how much the children are suffering in this outbreak.

UNICEF has reported that Eastern and Southern Africa has seen the number of acutely malnourished children increase by up to 24 percent in the last year. If healthy people contract cholera, with early detection and treatment, chances of survival are high. For acutely malnourished children with weakened immune systems, they are at least three times more likely to die if they contract cholera.

Children less than 15 years old are being hit the hardest. In Zambia, nearly half of those affected are under 15 and a third are even under five. Cholera is fast-acting and can kill a person in 12 hours.

However, it’s not just about the physical toll; there is a mental and emotional aspect too. People affected by cholera often face stigmatization because the disease is associated with poor hygiene conditions. It can really break down social bonds in communities.

Affected families face an uphill battle. Many lose their income because they’re either too sick to work or are caring for sick family members. And remember, this is happening in areas where malnutrition is already a big issue, so you can imagine how cholera just compounds those problems.

It’s coming at a time when schools have to resume. What is the risk that this could lead to a further spread of the disease?

 As one measure to slow the spread, the government of Zambia has delayed reopening schools as cholera cases have surged. Children are particularly vulnerable to this disease and schools can sometimes lack the clean water, sanitation, and increased hygiene structures and processes needed to keep it at bay. Increased contact in schools could lead to a surge in case numbers and rapid spreading of the disease.

However, we also believe schools can provide opportunities to spread awareness about how to prevent cholera. By working with children, teachers, and families in schools to bring clear information on the disease and preventive measures, we can help tackle the ongoing situation.

How has it affected the health delivery system?

The cholera outbreak is widespread and affects many provinces across multiple countries.

The scale of the outbreak puts a lot of pressure on health systems already stretched thin. We are seeing the most pinch in referral systems, quality case management, and vaccination campaigns. Unfortunately, resources are still extremely limited, and providing the necessary care and support to everyone who needs it has been challenging.

CRS is supporting governments in the countries affected in different ways. In Zambia for instance, we are providing oral rehydration points linked to public health teams. These rehydration points are critical for early detection and dissemination of both information and hygiene commodities.

To manage the caseload as numbers increase, CRS also provides surge human resource staffing, including nurses, to high-volume sites. This includes enhancing the capacity of community health workers who are the frontline response within the affected countries.

What has the response from the government looked like, and how has the CRS been responding?

 It has been a tough situation. Governments are doing their best, but resources are stretched thin, especially with ongoing issues such as the conflict in northern Mozambique and the aftermath of Cyclone Freddy in 2023 which affected Zambia, Mozambique, Malawi, and Zimbabwe. The outbreaks also occur in challenging, often hard-to-reach, locations.

Despite these challenges, we see Health ministries, UN agencies like WHO and UNICEF, and humanitarian organizations pulling together to scale the response. All actors are working together to step up vaccinations, strengthen health systems, and deliver clean water.

Catholic Relief Services has ongoing emergency response systems in all affected countries. We are leveraging our unique regional reach to coordinate across borders and make our response even stronger. We’re focusing on providing clean water, sanitation facilities, and hygiene essentials to prevent the spread of cholera. We also work with governments to strengthen local health systems to manage crises like this better.

The disease is spreading fast and hitting communities hard, especially vulnerable groups such as women, children, people living with disabilities, and the elderly. Mental health issues are rising; livelihoods are being lost; malnutrition is a growing concern. Sustained funding and support is critical today to bring the response to scale.

If cholera continues to spread, it will have a grave impact on communities. We need to act now to prevent the increasing deaths and loss of livelihoods for affected families and communities.