Sanitation over HIV fixation

With all the attention given to AIDS, Malaria and TB in Africa, are we losing sight of other basic services?

Livingston, Zambia – We are fifteen minutes late for an appointment with the Chief Macha of Choma, leader of the Tonga speaking people in southern Zambia.

Our troop of journalists arrive with some embarrassment, but are welcomed into his home with a graciousness that confirms our tardiness – which we could blame on ‘African time’ – is far surpassed by hospitality on the continent.

The Choma district, made up of 260,000 people, heaves heavily under the burden of HIV, malaria and TB. But like every other region in the country, the district has made significant gains against the triad of disease in recent years.

With 7,000 people on ARV (antiretroviral) treatment, AIDS related mortalities have been stalled. Similarly, while malaria was the cause of 1,700 hospital admissions and 64 deaths in 2001, our request to speak to a malaria patient at the mission hospital was met with a very satisfied: “There are none at the moment.”

Doctors have been able to end malaria cases by 95 percent.

It is with these developments in mind, that we had come to speak to Chief Macha, who reigns over some 30,000 people in the area.

Following the formalities, the Chief, dressed casually in a maroon and yellow printed shirt and grey trousers, quizzed us. “What is your mission here?” he asked pointedly.

We offered him our standard modus operandi: We are here to cover HIV, TB and Malaria in Zambia as topics that are under reported in the international press.

“You (want to) talk about TB, HIV, which are diseases … but first things first … we have to talk about our lives (here) first before we talk about diseases,” the Chief countered.

In a curious address, he diverted the discussion away from parasitical mosquitos, uncircumcised African men and their concurrent partners and the infectious coughs of TB carriers that we have grown accustomed to in recent days.

“It all comes down to sanitation,” he said.

And he was right.

Triad of diseases

Here we were, intent on bringing out the usual set of questions related to HIV, malaria and TB: peoples’ behaviour, the role of culture and tradition and empowerment of women.

Instead, he challenged our basic assumptions of what mattered most to him, or his people.

He seemed to ask, ‘Do you know what we really need?’

As a self-described “sanitation man”, recognised in Zambia and by the UN as a champion of sanitation in the region, after coming up with “one family, one toilet” slogan, of course, his focus on sanitation on hindsight was perhaps predictable, even biased.

The statistics however, back him up.

More than 600 million or 70 percent of people on the continent still do not have access to a clean toilet. Poor sanitation is the cause of hundreds of thousands of deaths in Africa each year.

In Zambia, a survey in 2007 estimated that 32 percent of Zambians were forced to defecate in the open, while just 52 percent of the country had sanitation coverage.

And the Chief pointed out that access to a toilet and clean water was not a trifling matter of convenience.

Instead, poor sanitation is the black hole in a systemic cycle of poverty-poor hygiene-disease. Poor sanitation lays hidden behind the big names of malaria, HIV and TB, as the primary killers on the continent.

And of course, the Chief was not alluding to a new theory that sanitation caused HIV, or facilitated the transmission of TB.

But under conditions of poor or no sanitation, millions live in constant risk of a myriad of diseases: The soiled hands feeding children medication and the contaminated water that carries typhoid and causes diarrhea, contribute to economic dysfunction, and even fatalities.

The problem is almost too obvious.

Structural violence 

There remains a fixation on HIV and to a lesser extent TB as illnesses that impose a particular violence on human beings, requiring dramatic intervention.

As metaphors, the viruses prey on the moral ambivalence of human infallibility, allowing us to forget the structural violence inflicted on hundreds of millions of people forced to live in horrific conditions that keep them marginalised.

And while toilets and clean water won’t solve the challenges related to AIDS, or TB, it certainly does illustrate a severe shortcoming of global health policy.

The Gods of global health policy appear merely intent “on keeping people alive”, but not necessarily transforming their lives.

‘Zambia has succeeded in keeping people alive, but what kind of lives are they really living?’ is the question the Chief left in our minds.

As an NGO worker, who preferred to remain anonymous, described it: “Shiny pills of ARVs can seem a little incongruous with the reality of people’s lives.”

Back in the Chief’s home, his Excellency goes on to tell us that his Chiefdom, comprising of 114 villages, now had 100 percent sanitation coverage, meaning that his area was declared an Open Defecation Free (ODF) zone since 2009.

What he does not tell us is that he was able to improve sanitation from 50 percent to 100 percent in less than two years, and that his people built their own latrines.

Even more astonishing is that his was the first Chiefdom in Africa to be recognised for the feat.

People need a good environment, and education to succeed, he said.

“I am the Chief of this place, and I have no running water and my toilet is outside my house,” he said, pointing to a brick-faced building in his garden.

“Imagine the rest of the people, if it is so for me,” he added.

Al Jazeera’s Azad Essa is currently reporting on HIV/AIDS, TB and Malaria in Zambia as part of a Global Health fellowship with the International Reporting Project. He will be focusing on the recent gains by Zambia in trying to alleviate the impact of three of the most devastating diseases to hit Sub Saharan Africa.

Follow him on twitter: @azadessa