Published December 19, 2012
In a primary school on the eastern side of Sierra Leone’s capital Freetown, 204 young girls pack into a single room and sit in the dark. Their faces are illuminated by the glow of a projector, but they are not watching a movie.
A young boy’s voice speaks in the local Krio language. “You mix up the spoon salt, and six spoons sugar inside one liter of water makes the water fine for the drink.”
The students are learning how to create their own oral rehydration salts to treat cholera, the waterborne disease that spread across West Africa this past year.
I have been following Unisa Carew, the program administrator for the Sierra Leone Red Cross’ mobile cinema team, as he travels from town to town, teaching how to prevent cholera through personal and food hygiene practices. Cholera is a highly contagious infection of the small intestine, transmitted through water and food. It causes vomiting and watery diarrhea, and consequently severe dehydration. Without proper treatment, cholera can result in death in less than a day.
“The young girls are fetching water before school,” said Unisa. “So we reach out to them. Diarrhea and vomiting, and cholera, can be prevented.”
In Freetown’s slums dripping standpipes are the major source of water. During the cholera outbreak, the clinic in one poor neighborhood called Susan’s Bay worked 24 hours per day. Patients came to the clinic for cholera treatment, but health workers also went out visit the homebound; the disabled, the elderly and people with HIV/AIDS.
In these grim neighborhoods a consortium of international non-government organizations has trained local residents as "Blue Flag Volunteers." The volunteers receive kits with oral rehydration salts, alongside soap and buckets. When families’ own stocks of rehydration salts run out the volunteers show them how to create their own. Small blue flags on roofs identify them to their communities.
I was interested in seeing how gender roles and water interacted in the aftermath of the cholera outbreak. In Sierra Leone, as in many African societies, women do most of the domestic and agricultural work. Men typically do not help with chores or fetch water, though they still demand leadership roles in local communities. Pointedly, each group of Blue Flag volunteers that I met seemed to have more women than men.
“You have to be someone available at any time your community needs you,” said Binta Bah, a 23-year-old Blue Flag Volunteer in Susan’s Bay. “Our key role is to promote hygiene and minimize cholera and diarrhea.”
Many of the female volunteers I met said they could easily relate to the other women they gave their advice and supplies to. “Issues of health can best be communicated with confidentiality and privacy between women,” said Ms. Bah. She admitted though that it is still not always easy to get the message across. “We have difficulties with mothers because of their beliefs. They believe that if a child has diarrhea two or three times in a day, it is a part of the normal development due to the moon or tide. We have to tell them this is just not the case.”
“We found that people know what is good hygiene behavior,” added Marc Faux, coordinator of the NGO consortium. “When we go and measure what they actually do, we find the actual hand wash rates are really, really low. So there’s a problem with what people know and what they do. Bad hygiene is like smoking: people know it’s bad for you but you still smoke. People really need to change their behavior and that’s something quite complicated.”
The main supplier of water to Freetown is the Guma Valley Water Company. However, their pipes are crumbling and out-of-date and, despite a staggering three meters of annual rainfall, there is not enough water to go through the system. Any redirection to standpipes can cut off water from other sections. The company is entering into a 100-day plan for reform. It is unclear what the new plan will achieve.
As I investigated the parlous water supply situation in Freetown I could not help thinking too that outsiders were failing to focus on the root causes of the problem. NGOs were training local people in the slums, but when I visited the Guma reservoir and nearby water treatment plant, I found a ramshackle establishment with one disinterested guard in attendance.
In Freetown, as in other desperately poor capitals in the region, people are crammed together in cities that lack the bureaucratic wherewithal to deal with such a density of population. In Europe, cholera, which was devastating in the 19th century, was eventually defeated through urban planning and civic administration; sewers, trash disposal, functional pipe-borne water supplies and planning codes to curtail the development of slums.
Cholera will only be defeated in West Africa through the same means. However, in Sierra Leone, perhaps understandably given the difficulties of reforming sclerotic West African bureaucracy, the aid establishment seems to focus instead on relief of the symptoms. The blue flag volunteers are a laudable initiative. I felt though that alongside training them NGOs should be doing more to put them out of business in the long term.