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Five deaths as child diarrhoea cases surge

  • Reported cases of diarrhoea in children under five in Cape Town rose by 146% during February
  • At least five children as a result
  • World Health Organisation cites lack of sanitation, and sewage among causes of child diarrhoea
  • Sewage flows on streets in Cape Town’s poorest areas but city not investigating any link between sewage spills and child diarrhoea

With her 18-month-old daughter suffering from acute diarrhoea in mid-February, Novangele Nyikana left the one-room shack she shares with her partner and  children, and sought help at the Khayelitsha hospital in Cape Town.

Nyikana’s daughter Thina was admitted and spent three weeks being treated for what the World Health Organisation states is the second largest cause of death among young children. At least five children have died due to diarrhoea between the beginning of summer and 25 January, according to city spokesperson Luthando Tyhalibongo, who was not able to state whether more deaths had since occurred.

As there are no beds at the hospital for mothers to sleep on, Nyikana spent her nights trying to sleep on a chair,  developing a kidney infection after a week. She says she was treated with intravenous antibiotics for seven days. After recovering, she spent another week on the hospital chairs while her partner, Sicelo Kupe, cared for their other three children back home in Taiwan informal settlement, in Khayelitsha. This meant neither Kupe or Nyikana, who are both unemployed, could look for work to supplement the two child support grants they receive.

Then on 6 April, less than a month after the 18-month old came out of hospital, Nyikana’s two-year-old was suffering her third day of diarrhoea. Having lost her appetite, the toddler was limp, displaying none of the energy expected at that age.

There is no running water in their home but sewage runs along the streets. Water is collected from a communal standpipe about 30 metres away and the family has to use a communal toilet. There are five toilets for an estimated 100 families in their section of the informal settlement. 

But arguably the largest threat to the childrens’ health is the raw running sewage in their environs. There is hardly a street in the surrounding area that does not have broken and overflowing sewer covers. Almost every journey – all taken on foot – involves stepping through or across puddles or potholes contaminated with sewage. This includes the walk Nyikana’s five-year-old daughter takes to school. Living in the close confinement of a one-room shack, it is almost impossible to prevent this contamination being traipsed into the home.

It is not surprising then, that Nyikana’s children are among the more than 4,533 children under five treated for diarrhoea in Cape Town during February, part of a 146% increase from February 2021, according to figures from Cape Town’s mayoral committee member for health, Patricia van der Ross. But these figures are from City-run day clinics alone. Cases treated at provincial health facilities, such as the Khayelitsha hospital where Nyakina’s 18-month old  was treated, and non-governmental clinics, are not included in the figures. It is not yet known how the number of cases reported this season match up against the number of cases reported is summer seasons prior to Covid-19. A request for historic data has been sent to the city.

No investigation into sewage link

The spike in cases of diarrhoea among young children in Cape Town is an annual occurrence, and as the city has stated, supported by the national Department of Water and Sanitation’s data portal, the quality of municipal drinking water supply is not a cause. But despite the World Health Organisation stating poor sanitation facilities and exposure to sewage are among the causes, van der Ross says the city’s health department is not investigating any links between sewage spills and cases of child diarrhoea.

As reported in Mother City News last month, a city media statement of 3 March drew attention to figures showing a 70% rise in cases for January 2022 compared to January 2021, with no mention of the 146% rise in cases during February. The media statement attributed the rise in cases to summer heat causing food to spoil easily, and advised frequent hand washing.

Senior lecturer emeritus at Stellenbosch University’s Department of Global Health, Dr Jo Barnes believes sewage in the environment is a direct link, and it has little to do with summer heat. Barnes points to the largest number of cases being reported in late summer and early autumn months, which are cooler.

“I’ve observed that a large number of people attribute the annual outbreak to the heat. However, by late November it is hot enough for food to spoil quickly, whereas the annual peak (in cases of child diarrhoea) is from mid February to April every year without fail.”

Barnes said years of research and consultation with paediatric specialists leads her to believe it is the first rain showers of late summer and early autumn, the harbingers of the wet winter season, which are the main drivers of diarrhoea outbreaks.

Weather records show the first late summer shower in Cape Town was on 3 February this year, about two weeks before Nyakina’s baby was admitted to hospital. 

Barnes’ theory is that during the dry summer, faecal pollution from sewage overflows and open defecation where sanitation services are inadequate, “piles up in the environment”, but remains static as it dries from the heat. It then flows along streets and streams when the autumn showers arrive. Compromised sewerage infrastructure which may have avoided overflows due to lack of storm water ingress, also starts overflowing. 

“It’s as regular as clockwork,” she said. “Within a week or two the number of diarrhoea cases pick up significantly. It only takes a few millilitres of rain to carry this mess back into circulation.”

Later, as the winter rains set in, the pollution is flushed from the streets and fields into the rivers and ocean, coinciding with a drop in reported diarrhoea cases.

Van der Ross said the City has not investigated the link between cases of diarrhoea and sewage infrastructure failure resulting in almost permanent flows of sewage along streets in areas such as Khayelitsha Site C and Dunoon.

A child walks home from school along sewage-filled streets in Site C, Khayelitsha.

City infrastructure failure and future fixes

There were an average of 323 reported sewage spills across the city in January, according to figures provided by Cape Town mayoral committee member for water and sanitation, Zahid Badroodien. However, this may not include chronic sewage spills in areas such as Khayelitsha Site C, where reporting by residents has become redundant. 

City authorities say 75% of these spills are caused by residents throwing rubbish into the sewer system and often release media statements showing dead animals, discarded car parts and household items recovered from the sewers. Informal or illegal building over sewer access points exacerbates the situation.

In response to questions on the situation in Site C specifically, Badroodien said there are contractors on site but were awaiting the relocation of structures before repairs to sewer infrastructure could proceed. However, a time period for completion of repairs could not be provided.

Badroodien states the city’s new water and sanitation infrastructure budget over the next three years will quadruple sewer pipe replacement, with “big investments” to upgrade sewers, pump stations, and wastewater treatment works. 

Partnering with communities and responding to sewage spills was also “high on the agenda”.

The big ticket items in the budget up to 2025 include R755m to increase sewer pipe replacement from 25km to 100km of piping per year, R529m to upgrade and repair sewer pump stations, and R3,3bn on upgrades to wastewater treatment works. A further R860m is to be spent on major sewer upgrades in certain parts of the city.

He said the city currently provides 57,000 toilets of various types, along with cleaning services, and 7,640 taps to 257,000 households in informal settlements such as Taiwan. Over the next three years, R2,38bn will be spent on water and sanitation services to informal settlements. 

He said the goal was to half the number of sewage spills by 2030.

Translation and fieldwork assistance by Nombulelo Damba-Hendrik

This investigation was produced in collaboration with the Center for Collaborative Investigative Journalism and OpenUp, with the support of the Open Society Foundation.