How to prevent a cholera catastrophe: invest in water, sanitation and hygiene

Last January, Catherine Mwale, 36, lost her four-year-old son, Gilbert, to cholera.

"He was my only child," says Catherine who lives in Lusaka, Zambia. "He was on a drip for six days. He started vomiting green stuff and around 24 hours later, he passed away."

Catherine and her family used to collect water from shallow wells, where the water was often contaminated and would make people sick. One day, Gilbert began to complain of a stomach ache and had to be taken to hospital by bus – but it was too late.

Gilbert was one of more than 700 people who died in Zambia’s latest cholera outbreak; it started in 2023 and has affected more than 23,000 people. The situation was even worse in Malawi where, in the wake of Cyclone Freddy, 59,000 cholera cases were recorded and 1,700 people died between 2022 and 2023.

Cholera is a diarrhoeal illness caused by eating or drinking contaminated food and water. It spreads easily in places without access to clean water and is made worse by poor sanitation and hygiene practices. It’s an extremely dangerous disease, causing severe dehydration, diarrhoea and vomiting, which can kill within hours if left untreated.  

But cholera is also entirely preventable. Our latest research shows that thousands of lives could have been saved across Malawi and Zambia if people living in cholera hotspots had access to clean water, sanitation and hygiene (WASH).  

Cases across Malawi and Zambia’s cholera hotspots could be eliminated, and other diarrhoeal diseases reduced by 50%, if communities had access to clean water, decent toilets and good hygiene, saving up to 4,000 lives each year. 

Chifuniro, 19, and her sister Christina, 22, lost their grandmother and adoptive parent, Modestar, to cholera in December 2023. Now, as a single mother to two-year-old Ernest, Chifuniro worries about keeping him safe. 

"I’m worried about cholera returning because if it does, we’ll be left with literally no water to use. In my opinion, it’s not possible to protect myself from this disease. I can’t tell whether the water I’m stepping in is contaminated or will make me sick."

The economic cost

As well as the tragic human cost, there is a steep economic cost associated with every cholera outbreak.  

Estimated as the costs of responding to cholera outbreaks and other household impacts, like the loss of productive time of adults who are sick, the total damages from poor WASH in cholera hotspots average US$678 million per year in Malawi and $1.42 billion per year in Zambia. That equates to 4.8% and 5.5% of national GDP respectively. 

However, our research also shows that investing in the basics of WASH in cholera hotspots could deliver combined savings of almost $1.6 billion for the Malawian and Zambian governments. This means more money would be available to invest in infrastructure, healthcare and education, helping to eradicate poverty and protect more lives.  

With access to water, sanitation and hygiene in cholera hotspots:  

• Zambia could save approximately $1 billion every year, preventing 1,850 deaths.
• Malawi could save $594 million per year, saving 1,741 lives.  

There is a cost to this investment, but it is far outweighed by the benefits. In fact, it is estimated that for every $1 invested in water and sanitation in cholera hotspots, $10 is gained in averted costs.  

The evidence is clear that an investment in WASH facilities can have huge knock-on effects on public health. In response, Zambia’s government has allocated approximately $350 million to end cholera by 2030. In Malawi, the government has increased its budget allocation for WASH from $28m to $116m since 2022’s cholera outbreak. These are promising figures, but there is more to be done.  

Looking ahead  

In the 21st century, every cholera death should be preventable, and action has never been more urgent. As extreme weather events caused by climate change destroy water and sanitation facilities, causing sewage to leak into water sources, communities who already struggle to access clean water are even more vulnerable to diseases like cholera.

But there is a solution: ensuring everyone, everywhere has access to safe, sustainable and climate-resilient WASH services. Public health programmes that educate people about transmission routes and the importance of handwashing at key moments – like before preparing food – can also be highly effective at stopping the spread of diseases when provided alongside access to facilities.  

With early intervention, thousands of deaths could be prevented. Investing in WASH is a way to protect communities both now and in the future, as the effects of climate change become worse. And as the research has shown, the costs of not doing so is more than we can afford.  

Today, Catherine Mwale is being supported by community awareness projects. "People came to visit us door-to-door. They taught us how to keep our toilets clean, the surroundings, and how to throw our garbage in the designated areas," she says.

Catherine also has access to clean water from a kiosk. "There is a huge difference in the water," she says. "The water from the kiosk is clean and doesn’t make us sick." 

Amira Aleem is Digital Editor – Policy, Practice and Advocacy, WaterAid. 

Top image: Catherine Mwale, 36, who lost her son to cholera in Zambia.