Cholera in the city: A sad tale of science and politics

Nairobi sits smack in the middle of a long Cholera Belt that stretches from the Indian Ocean to Lake Victoria. Faced with a disease that is defying medicine and science, the city had better rethink its public health systems.

Thirty-year-old Rasoa Lutenyi had always snaked her way around the pools and mountains of waste outside the tin houses of Kawangware with ease, borrowing from the same attitude with which she navigated through life as an unemployed mother of two who still bore the duty of looking after her siblings.

She had no choice. As a first born, it was upon her to look for casual jobs to support her mother and siblings in Kakamega as well as the two children she was raising alone.

On Thursday last week, a bout of vomiting and diarrhoea weakened her so much she could no longer hip and hop her way around the trash in her neighbourhood to seek medical care. By the time her sister, Faith Lutenyi, rushed her to Kenyatta National Hospital, all the goodwill and attention could not save her. She died three days later, on Sunday, July 9, 2017; the latest victim of a cholera outbreak in Nairobi that has defied medicine and science.

PUBLIC HEALTH

Her mother, Florence Museti, said her daughter’s descent to the grave was too fast. “I do not even know the second name of her youngest child,” said the distraught mother. “I haven’t even met the baby’s father.”

The circumstances of Rasoa’s life and cause of death are everything that is wrong with Nairobi’s public health management, and give all the answers to why the current cholera outbreak has become hard to contain. In Kawangware, like in other parts of the city, including the central business district, sanitation is a foreign concept.

So far six people have died and more than 300 others are hospitalised. Many more others have been affected since December last year, when cases of cholera started being reported in the country.

But it was not until more than 40 doctors attending an international medical conference at Weston Hotel in Nairobi contracted the disease that the authorities stepped up their surveillance. It was too late, because the disease had run out of control as technocrats argued in boardrooms, sneaking politics into a public health management debate.
The question that has escaped that debate is why cholera, a disease that, for all intents and purposes, is regarded in medical circles as outdated, has come back to ravage a modern metropolis.

The answer lies in that casual, dismissive attitude towards a rather dangerous yet preventable disease that can kill in hours. Medical history shows that the world is now battling the seventh wave of a cholera outbreak since 1817, when it was first discovered in the Ganges Delta of the Indian sub-continent.
In Africa in the Time of Cholera: A History of Pandemics from 1817 to the Present, Myron Echenberg, a retired professor of African History at Canada’s McGill University, reports that the bacterium vibrio cholera was first recorded in Kenya around 1865, hot on the heels of a deadly outbreak in Zanzibar.

INTELLIGENT PATHOGEN

The pathogen is so intelligent that once it gets to the stomach, usually through ingestion, it releases a virulent poison to the linings of the intestines. The body reacts by channeling all its water and fluids to the stomach to flush the invader out, leading to rapid dehydration and death of the victim. Patients often lose up to eight per cent of their body weight in hours

Dr. John Kiiru, an infectious disease expert at Kenya Medical Research Institute (KEMRI), says that the classical sign that one is dealing with cholera — rice-coloured water in the diarrhoea — is as a result of the peeling of the inner linings of the stomach as the body fights off the infection.
The shame that cholera carries has interfered with the manner in which public health authorities respond to it, as well as how people seek medical attention when they suspect they have it.

Rasoa, the fiercely independent woman killed by the disease in Kawangware last week, experienced her first stomach rumblings on Thursday, and her brother-in-law, Patrick Amkoa, says she insisted on going to hospital alone.

Her reaction is hardly surprising — the shame that the disease carries is deeply embedded in the values of many cultures. The violent and uncontrolled ejection of stool and vomit evokes revulsion as an act so private becomes a public spectacle.

The inability to control bowels in young adults reminds them of infancy. At Kenyatta National Hospital (KNH), nurses dress patients with adult diapers. In the elderly, it speaks of senility.

If victims do not make it to hospital on time, their blood gets so thick because of the dehydration that it cannot be transported in the body. Without electrolytes, their hearts lose their rhythmic beat and their organs fail, after which they slip into a coma. Death follows soon after.

Researchers at Kemri fear that the strain responsible for Nairobi’s newest outbreak, following in the footsteps of cholera’s usual intelligence, has “decorated itself to become resistant”.

The strain, vibrio cholerae inaba, has acquired a resistant characteristic called extended-spectrum beta-lactamases, or just ESBL. It is suspected to have hatched in the Indian sub-continent and was first detected in Kenya in 2015 at the Daadab refugee camp.

MASS CASUALTIES

It has been responsible for mass casualties in Haiti, Rwanda, and the Democratic Republic of Congo, riding the wave of the common serotypes of cholera inaba and cholera ogawa.
To get to Nairobi it followed the Cholera Belt — Malindi, Mombasa, and the Nairobi-Kisumu highway— causing smaller outbreaks along the path and moving to other towns, like Thika.

Prof Samuel Kariuki, a lecturer of tropical microbiology who has studied enteric pathogens long enough to label them as “sly and cunning”, is sure we have a long fight in our hands.

He was one of the researchers who carried out a genetic analysis of DNA in over 2,000 typhoid germs from Africa and Asia, and also isolated the virulent strain of Typhoid H58 that moved from Asia to Africa in the last 30 years.

“Cholera is intelligent,” he says, “and that is expected of a creature that has lived for millions of years, longer than mankind.”

The phrase ‘antimicrobial resistance’ has become common within the medical fraternity, and in simple terms it means that drugs have lost their power to kill harmful pathogens in the human body. Cholera is one of those pathogens. Over time, it has recorded the knowledge of what is happening around it in its DNA.

“When you expose it to subtle doses of drugs, and it feels ‘this dose is not strong enough to kill me’, it learns the attacking style of that drug, and it changes itself for the next attack,” explains Prof Kariuki. “It may develop ‘pumps’ to flush the drugs out or grow a thicker layer against the drug, and the next time you take medicine, the bacteria will just scoff at the drug.”

The other way cholera has become hard to control is through genetic re-assortment, where all the bacteria sit together and ‘marry’ each other to form a newer, stronger pathogen.

Cholera has come to Nairobi at the worst possible time, barely a month after a World Bank-funded report by the East African Public Health Laboratory Networking Project (EAPHLNP) showed that none of the countries in East Africa has national or regional surveillance on antimicrobial resistance.

Patients are often initiated on antibiotics after stool culture confirmation in microbiological labs, which are even fewer in urban centres.

The report found out that there is not only resistance to third generation medicines, but also a 67 per cent successful hostility to quinolones, a stronger, more effective group of antibiotics. Public hospitals, therefore, will be forced to move to other stronger antibiotics which governments may not afford.

Prof Revathi Gunturu, a microbiologist at the Aga Khan University Hospital, told Healthy Nation that cholera, by its very nature, is not as infectious as other enteric pathogens such as shigella and salmonella, but can be quite lethal if poorly managed.

When the disease broke out, Kenyan authorities kept quiet about it, denying that there was an outbreak as the Ministry of Health said it was waiting for lab cultures. The provisional diagnosis was gastroenteritis, a mild food borne condition, despite 45 rapid tests turning positive for cholera.

HIDING TACTICS

Nairobi, however, was not acting out of step with tradition, as governments have developed the habit of hiding cholera for fear of losing tourism revenue, or for national pride. In 2009, Ethiopia refused to declare a suspected outbreak that killed 684 people and infected nearly 60,000 others in less than a year.

But this delay causes several problems. The failure to properly label the disease and its magnitude causes a less urgent response from experts in terms of funding and mobilisation.

In the silence and the politics, the bacterium lives to its name as a weapon of mass destruction. For instance, after losing his sister-in-law, Patrick Amkoa is fighting yet another battle as his wife Faith Lutenyi has been hospitalised at Kenyatta as well, in the same ward where Rasoa breathed her last.

“I am so terrified. I do not even want to eat because I am wondering whether I will lose all of them,” he says.

Cholera, in its scheming calculations, lives in the soil, toilets and the aquatic environment which nourishes it until it has the chance to strike. Genetic studies have traced its resistance to the soil, drawing the connection between environmental hygiene and how the disease moved from the lower income areas to five-star residences.

DID YOU KNOW?

Slumdog vectors: Until recently when water vending machines were introduced to Nairobi’s slums, there was no water supply. Residents have been tapping into the water pipes that pass through their neglected environments on the way to rich neighbourhoods and contaminating the water before it reaches the other end. When it rains, the water lifts the bacteria from the soil and garbage into the water systems. A source of cheap labour, slum dwellers can touch the food in five-star hotels as they serve the high and mighty.

Rapid infection: Dr. Thumbi Mwangi, an epidemiologist, says there is a number assigned to any disease to determine how contagious it is and highlight its ability to move from one person to another. The base is R0 — pronounced as ‘R Naught’ — and some diseases score as lowly as 1. And then there is cholera, whose R0 has been estimated to range between 1.95 and 6 in various studies. That means one person can cause six other infections, and then from each of those six there would be other six, ad infinitum.

False Glory: In 1827, privilege-address Britons blamed the Indian squalor for the presence of cholera, basking in the false glory that the rich are immune to the disease. That same year Sir Thomas Muro, a governor, died of cholera. Some long 190 years later, in 2017, Kenya’s Henry Rotich and Adan Mohammed, both of them Cabinet Secretaries, were rushed to hospital after contracting the disease. The disease made a dramatic comeback in Africa in 1970 and has remained a great public health threat, notes Dr. Martin Mengel, a clinical assessor at the German Federal Institute for Drugs and Medical Devices, in the book Cholera Outbreaks in Africa. The World Health Organisation (WHO) estimates that sub-Saharan Africa accounted for 86 per cent of reported cases and 99 per cent of deaths worldwide in 2011. The first cases were officially recorded in Kenya in 1974, but the worst outbreak in the country wasn’t until 1999, when 33,400 cases were recorded.