How Outbreaks shaped Africa, Before & After: Ethiopia

By Tumi Sotire, a Health Economist, 5th May 2020

This article is going to focus on the effect of Cholera on Ethiopia and discusses the government’s response.

Ethiopia, a growing economy

With a population of 110 million, Ethiopia has the second-highest population in Africa (1). Commonly known as the “horn of Africa “, Ethiopia is one of the fastest-growing economies in the world (1,2). The nation has the lowest form of income inequality in Africa, with a Gini coefficient of 35.0%( 2,3).The Gini coefficient is a measure of income distribution, and it ranges between 0% (perfect equality) and 100% (perfect inequality) (4). These facts suggest that as the country continues to grow economically, the wealth is likely to spread evenly across the population, including those who need it the most (with all things being equal).

As well as making significant growth in its economy, the government of Ethiopia also made substantial improvements in the health outcomes of its citizens. The life expectancy for both men and women increased by 16 years and 13 years respectively between 1990 to 2013(5) . Ethiopia’s maternal mortality ratio per 100,000 live births fell from 1,030 in 2000 to 401 in 2017 (6) . Infant mortality has also seen a significant decline; it has fallen by 83 % from 1990–2015 (7) . Even with the improvements in Ethiopia’s economy and healthcare system, cholera is still responsible for a number of deaths in the country.

Outbreak — An overview of Cholera

Cholera is a lethal infectious disease that can lead to severe watery diarrhoea (a loss of fluids and electrolytes) which can lead to extreme dehydration (8). These symptoms can present between 12 hours and five days after a person has ingested contaminated food or water. Usually, contamination is caused by faecal transmission (9). Cholera can kill individuals within hours if untreated, irrespective of age. (8).

Cholera Ethiopia’s endemic

Cholera outbreaks are often endemic in nature. An endemic describes a disease that is present permanently in a region or population. In cholera endemic countries, an outbreak can be seasonal or sporadic and represents a higher than expected number of cases (10). Ethiopia has the highest number of people estimated to be at risk of cholera in Africa (11). In 2017, there were 48,617 cases of cholera and 880 deaths (12). This could be due the size of Ethiopia’s population and thus the number of people who do not have access to clean water and basic sanitation will also be high.

Photo by Jouni Rajala on Unsplash

Cholera transmission

Cholera outbreaks and deaths are entirely preventable, given the tools and technology available to humanity. Thus, cholera outbreaks are a sensitive and reliable indicator of extreme poverty (8). It is prevalent in places where there is an absence of clean water and basic sanitation (13). Therefore, for governments to reduce or nullify the transmission of Cholera, it is important for governments to be aware of the drivers of cholera transmission. The main drivers being inadequate access to clean water and sanitation.

A third of Ethiopia’s population has access to a water supply that is below the national standard (14).Ethiopia’s national sanitation coverage is 57%. This means approximately 45 million people inadequate water supplies(15). The consequences of a humanitarian crisis, climate change, population growth and urbanisation are also drivers that increase the transmission of cholera (9). Thus, interventions that aim to reduce cholera transmission should be multisectoral as well as multifactorial. The intervention will probably include provision of vaccines; educating population on hygiene; improving water and sanitation infrastructure of the nation; providing robust infrastructure to effectively deal and respond to impact of a natural disaster. A significant amount of money must be spent on the nation’s sanitation and water facilities to eradicate this preventable disease.

Response — Government interventions

Government interventions to eradicate Cholera have been promising in recent years. Ethiopia has played a role in the global fight to eliminate Cholera (16). Last year, Ethiopia’s Minister of Health launched a multisectoral cholera elimination plan for 2030(15,16). The ‘World Health Organisation’s Global Task Force on Cholera Control’ and ‘Dr Ebba Abba Global Roadmap to 2030’ aim to decrease global deaths of cholera by 90 % by 2030(16).

The roadmap focuses on three main areas:

1. Early detection combined with rapid response
2. Multisectoral strategies to prevent Cholera from occurring in hotspots.
3. Coordination of technical support and resource mobilisation on the local regional and national level

The government’s policies should make achieving the goals marked out in the roadmap easier to implement. In 2015, Ethiopia launched an ambitious Health Sector Transformation plan. Part of this strategy was to see the deployment of 38, 000 community health care workers nationwide, focusing on advising household hygiene and prevention of infectious diseases (17,18).

While the government is making positive steps to eradicate Cholera, it is essential to remember that implementing policies are more complicated than creating them. Given we are only in the second year of an 11-year plan, it would be unfair to make a judgment on progress Ethiopia has made. Especially considering the world is in the middle of a pandemic due to another infectious disease.

There are certain factors, such as climate change, that increase the prevalence of Cholera which is beyond the control of the Ethiopian government. I believe that with the recent growth in the economy, the government of Ethiopia is in a strong position to make significant strides towards eradicating Cholera. There have been improvements in Ethiopia’s infrastructure but, cholera — which is preventable — is still responsible for a significant number of deaths in the country.

References:

1. Population, Development, and Environment in Ethiopia | Wilson Center [Internet]. [cited 2020 Jun 5]. Available from: https://www.wilsoncenter.org/event/population-delopment-and-environment-ethiopia
2. Ethiopia Economy 2020, CIA World Factbook [Internet]. [cited 2020 Jun 5]. Available from: https://theodora.com/wfbcurrent/ethiopia/ethiopia_economy.html
3. https://www.indexmundi.com/facts/indicators/SI.POV.GINI/rankings/africa
4. https://data.oecd.org/inequality/income-inequality.htm
5. Ethiopians have increased their life expectancy by 16 years while South Africans have shortened theirs — Quartz Africa [Internet]. [cited 2020 Jun 5]. Available from: https://qz.com/africa/491374/ethiopians-have-increased-their-life-expectancy-by-16-years-while-south-africans-have-shortened-theirs/.
6. https://data.worldbank.org/indicator/SH.STA.MMRT?locations=ET
7. Mehretie Adinew Y, Feleke SA, Mengesha ZB, Workie SB. Childhood mortality: trends and determinants in Ethiopia from 1990 to 2015 — A systematic review. Advances in Public Health. 2017;2017.
8. https://www.who.int/news-room/fact-sheets/detail/cholera
9. What’s the difference between a pandemic, an epidemic, endemic, and an outbreak? [Internet]. intermountainhealthcare.org. [cited 2020 Jun 5]. Available from: https://intermountainhealthcare.org/blogs/topics/live-well/2020/04/whats-the-difference-between-a-pandemic-an-epidemic-endemic-and-an-outbreak/
10. https://www.who.int/topics/cholera/faq/en/
11. Ali M, Nelson AR, Lopez AL, Sack DA. Updated Global Burden of Cholera in Endemic Countries. PLOS Neglected Tropical Diseases [Internet]. 2015 Jun 4 [cited 2020 Jun 5];9(6):e0003832. Available from: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003832
12. Legros D. Global cholera epidemiology: opportunities to reduce the burden of cholera by 2030. The Journal of infectious diseases. 2018 Oct 15;218(suppl_3):S137–40.
13. Olago D, Marshall M, Wandiga SO, Opondo M, Yanda PZ, Kangalawe R, Githeko A, Downs T, Opere A, Kabumbuli R, Kirumira E. Climatic, socio-economic, and health factors affecting human vulnerability to cholera in the Lake Victoria basin, East Africa. AMBIO: A Journal of the Human Environment. 2007 Jun;36(4):350–8.
14. Ethiopia joins global efforts to end cholera by 2030 [Internet]. WHO | Regional Office for Africa. [cited 2020 Jun 5]. Available from: https://www.afro.who.int/news/ethiopia-joins-global-efforts-end-cholera-2030-0
15. admin. Ethiopia launch of Ending Cholera: A Global Roadmap to 2030, [Internet]. Satenaw Ethiopian News/Breaking News. 2019 [cited 2020 Jun 5]. Available from: https://www.satenaw.com/ethiopia-launch-of-ending-cholera-a-global-roadmap-to-2030/
16. https://reliefweb.int/report/ethiopia/ethiopia-cholera-outbreak-response-emergency-plan-action-epoa-dref-n-mdret021-pet053
17. https://www.who.int/cholera/publications/global-roadmap-summary.pdf?ua=1
18. Ethiopia-health-system-transformation-plan.pdf [Internet]. [cited 2020 Jun 5]. Available from: https://www.globalfinancingfacility.org/sites/gff_new/files/Ethiopia-health-system-transformation-plan.pdf