I remember a time during one of my (Messiah) college Bio classes helmed by Dr. Jon Makowski. I believe we had gotten to learning about faecal coliforms - indicator organisms that basically indicate faecal contamination of water sources - and he posed a basic question at the end of one lesson which would be addressed at the start of the next lesson:
"What is the acceptable amount of coliform bacteria (Colony forming units, CFUs) in water meant for drinking?"
I remember having to scour my books looking for the answer. My internet searches were similarly difficult; this was in Pre-Google days, so I was mostly checking for my answers on Ask.com. I remember glimpsing an article that listed the answer summarily as "zero" without much explanation, but I also came across something that gave some leeway for CFUs in recreational water sources.
True to form, Dr. Makowski started the next lesson with the same question. Varied answers were given, but none of them was right. Without much trust in my answer, I told him "Zero."
"Correct," he answered. He then proceeded to give us a very simple analogy:
"If I took a speck of stool and mixed it into a glass of water, would you drink it?"
"Of course not!" came the general class answer.
"What if I dilute one drop from that glass into another glass of clean water?"
"Still No!" the class answered.
Despite the promise of even more serial dilution, no one would accept the challenge of drinking the water. His point was clearly made. It didn't matter how much water was used to dilute that water containing the coliform bacteria; no one in their right mind would consciously consume such water. And thus go the standards for our drinkable water. None of the intestinal bacteria (indicative of the presence of possibly more dastardly organisms in our water) is meant to be detected in our drinking water.
My mind alluded back to this memory in light of the current cholera shenanigans we are facing in Kenya. A work colleague doesn't mince his words when talking about cholera when he's talking to patients about it:
"you've basically got to let them know that they've come into intimate contact with shit!" (pardon the expression)
I am a bit more diplomatic about it and I'll talk about (faecal) contamination of consumed food or water.
Cholera always used to be thought of as a disease for the poor and disadvantaged, living in their hovel abodes with poor sanitation. However, 2017 appears to be the year that things changed: first, came the cholera outbreak at a posh wedding ceremony in the upmarket Karen area; then there was the outbreak at Weston Hotel which ironically affected a medical practitioners' conference, and saw many a doctor (both domestic and international) hospitalized due to the disease; and last, but not least, there was the outbreak at a trade fair at the Kenyatta International Conference Centre (KICC), which saw two Cabinet Secretaries and one Permanent Secretary affected by the infection. A lot of people forget that our very own President opened the fair and was potentially meant to have dined on the food at the same area. The food vendor for the occasion is a prominently known hotel, but it is only discussed in hushed tones lest anyone experience any blowback.
I have dealt with my fair share of Gastroenteritis (GE) at the clinic lately; that's the technical term for conditions that affect the stomach and the intestines, which ultimately yield vomiting and diarrhoea. (technically clinicians may sometimes refer to conditions causing diarrhoea as GE). Gastritis (stomach inflammation) and Enteritis (intestinal inflammation) also exist as different entities, and yes, my colleagues and I have had to treat that too. The strange thing is that it is now very common for me to request an accompanying cholera antigen stool test. As is the norm now, a lot of my patients are middle to upper class individuals, and the reality is that their status will not confer upon them any sort of special favours when it comes to cholera.
People seem to think that it is strange for me to test them for Cholera, especially if they were able to walk themselves into the clinic; the image of a person laid out by the disease and knocking at death's door is what they seem to cling to; however, as with many disease conditions, there are grades to this condition. I have had many a patient walk into the clinic with a mild case of food poisoning, sometimes so mild that they wouldn't even mind returning to their offices afterwards. When the Cholera antigen test comes back POSITIVE, they seem to think that I'm messing with them. That becomes a good teaching point for the fact that a cholera infection is actually
dose-dependent: the more of the bacteria that you ingest, the worse your infection is likely to be. Also deserving of special mention is the people who are using antacids; lowering your stomach acidity, while making you feel comfortable will also reduce your stomach's ability to deactivate certain types of harmful bacteria. Thus you can have all levels of cholera sufferers ranging from the mildly inconvenienced to the dastardly ill requiring intensive care.
But how could it be that we've fallen this far where a disease like cholera is fair game for every one in the land? It should be child's play dealing with cholera because we know how it's spread and thus how we can keep it at bay. I surmise that a couple of factors are key.
- Sprawl - I pass through some areas in Nairobi, and I'm taken aback by just how much has sprung up in terms of new developments. Areas that used to consist of well built bungalows were replaced with high-rise buildings as the bungalows of yore were brought down en masse. People might see this as a mark of progress, but to me it merely spells disaster: sewer lines have not been upgraded to keep up with the pace of construction, and other people may opt to set up septic tanks that are ill-equipped to deal with the demands placed by their inhabitants. And in case anyone forgot, WATER is a finite resource that keeps getting more scarce by the day.
- Clean Water Trucks - with the water shortages suffered on a regular basis (some of them actually orchestrated by unscrupulous individuals for material gain), these trucks have been making quite the profit. However, it is a slippery slope with this vastly unregulated sector: what is the source of their water, and what is the level of cleanliness in those tanks that are used for storing and transporting the water?
- Poor surveillance and enforcement - seems to me that we have so many government bodies in charge of everything under the sun, but the typical Kenyan citizen gets burned by everything that those aforementioned bodies are meant to be protecting us from. NEMA (The National Environmental Management Authority) is probably one of the more useless ones. Despite the major cholera outbreak in 2017, they spent that time patting themselves on the back for chasing down the infinitely less important "plastics issue". They practically made Kenyans feel like criminals for walking around with plastic bags, but they dragged their feet about dealing with folks openly discharging untreated waste into water sources.
I feel that the last two might be particularly intertwined. Lately, while driving along Ngong Road - at the point after Westwood - I have been seeing a water truck parked right next to the edge of the Mbagathi River. Granted, there used to be car washing services occurring in that general vicinity, but the vehicles were never parked at the river's edge. I think that those trucks are pumping in water directly from the Mbagathi River.
This shouldn't be such a bad thing until you consider the situation upstream of Mbagathi River. A stream which eventually drains into Mbagathi starts out around the Mathare slum area of Ngong Town; by the time the stream makes its way down to the Zambia Road vicinity, it literally consists of black water. The stench is unbearable, the water is murky and turbid. It is obvious that raw effluent is making its way into the water from houses adjacent to the river (and a clinic, if rumours turn out to be true). This water is what will eventually make its way into the Mbagathi River, and even the Nairobi River downstream.
There is room for dilution of the black water as it joins the Mbagathi River; but in much the same way that my Bio teacher couldn't get us to drink water that contained a serially diluted amount of fecal matter, I don't think anyone should conscientiously consider using that water for anything.
Now, I will note that I have seen a similar looking truck (with a white tanker) being used to spread water on the Lang'ata Road expansion occurring in the Karen area. But it isn't a stretch to consider that the same truck might dabble in being used to transport potable water to people.
NEMA should be at the forefront of sorting this issue out, but I have very little hope in the people of NEMA, from personal experience. My family used to live adjacent to a compound that consisted of many houses, but all their waste drained into one septic tank. Now, the landlord was not in the habit of emptying that septic tank, and, periodically, it would overflow into our compound. My mother brought this to the attention of the relevant NEMA individual in-charge, and he came to assess the situation on the ground. Threats were issued to the offending party, but it soon became pretty clear that bribes laid the issue to rest.
The sad thing is that I'm pretty sure ours was not a one-off experience. Perhaps that man would have acted differently if he'd had to deal with a cholera sufferer. We had a patient come into the clinic some time ago who was cold to touch, had low blood pressure and was incoherent. She was bone dry and her kidneys had started to shut down from severe dehydration. That patient practically brought our well-staffed clinic to a standstill as we struggled to resuscitate her and we eventually ended up sending her straight to the ICU. I think anything less in terms of management would have been a death sentence for her. It ended up being a rough week for her, but she survived.
We cannot sit down and pretend that this issue does not exist. The solutions are simple, but they will require dogged stubbornness and resolve to make sure that they are followed to the letter. We are all at risk, and we need to prepare for the worst. Our personal vigilance needs to be bolstered by proper surveillance and enforcement by all the relevant statutory bodies otherwise our own efforts would be for naught.
Be vigilant.
God Bless
