Keeping cholera at bay

6 World Health • 46th Year, No. 3, Moy-June 1993 Keeping cholera at bay Luis A. Loyola & Patrido Hevia ' he cholera epidemic which broke out in Peru in January 1991 was part of the seventh pandemic of this disease that started in Indonesia in 1961. From Peru it has gradually spread to almost all the countries of Latin America, highlighting the lack of safe drinking- water and basic sanitation services, malnutrition, poverty and overcrowding in slum areas. It has cost Peru dearly in economic terms through the loss of foreign trade and tourism, but also through the cost of medical care and disputes between different sectors. In order to cope with this situation, action was needed in many different fields - the environment, organization of health services, epidemiological surveillance, education, social communication, the economy, housing and building, and even fishing. In this effort the government authorities and the community succeeded in joining forces, since it was essential for their strategy to be intersectoral in its approach and to involve the participation of ordinary people. There have been many positive examples of intersectoral activities carried out with active community participation. Invariably the people's initiatives proved to be the central factor in achieving effective and rational use of resources and successful protection of health. The communal oral rehydration centres, where health promoters and locally trained members of the community offer health care are obvious examples of this vital process of working together. Slum settlements A typical experience of intersectoral and organized community involvement can be seen in the district Peru in 1991: cholera broke aut and came to stay. A victim receives intravenous rehydration. A slum settlement in Peru - at high risk from the recent cholera epidemic - involved all sectors in the community in a defensive plan which succeeded in keeping fatal cases to a minimum. of Chorrillos, in the health subregion of Lima South. Once a quiet fishing creek and beach resort for the wealthy, Chorrillos was completely changed by the continual influx of migrants heading towards the capital from the mountainous and poverty-stricken countryside. They gradually occupied the area, creating more than 60 urban slum settlements known in Peru as "pueblos j6venes" (young towns). More than 70% of the population of roughly 250 000 live today in these fringe areas - thousands of families with scanty economic resources and a variety of cultural backgrounds. Competition for land, the need for health care, and the struggle to improve their lot, indeed just to survive, have led to their setting up grass-roots organizations, such as soup kitchens, committees for free distribution of milk, mothers' clubs, social welfare associations, youth groups and fishermen's associations, and these in turn have provided opportunities to discuss how to put social and political matters into practice. In August 1990, what was known in Peru as the "economic shock" caused much hardship. In Chorrillos it led to the formation of a district committee on social emergencies, including representatives of local government, the health and education authorities, the Catholic Church, grass-roots social organizations and nongovemmental organizations. Four successive area meetings on health took place, culminating at the end of 1990 in a workshop entitled "Towards a District Health Plan for Chorrillos", World Health • 46th Year, No. 3, May-June 1993 at which the community itself identified its health needs and ranked them in order of importance. Thus the scene was set and the actors were in place when the cholera epidemic broke out at the end of January 1991. As soon as the scale of the danger threatening everyone, but especially the poorest, was realized, a Cholera Control Command was established, involving all the various intersectoral organizations committed to carrying out the district health plan. This Command never lost touch with its community base or with the multisectoral organizations active in the district. In fact, it spurred the community to move even faster towards a district health system. October 1991 saw the start of an intersectoral project with community participation, supported by the Ministry of Health of Peru and with technical cooperation from the Pan American Health Organization as well as financial cooperation from the government of Italy. Known as the Project on Health, Environment and the Fight Against Poverty (SMALP), it was launched through the combined efforts of all these parties and, although it reflects their own interests and conflicts, it nevertheless has great potential for success against a background of instability and uncertainty. Health for those at risk The general objective was to help to improve the health status, environment, and welfare of high-risk groups through the development and consolidation of the Chorrillos district health system. By agreement, responsibilities were shared among the different social and health partners, and overall leadership was assumed by the Ministry of Health at the district level. Chorrillos now has a network of health services comprising seven health centres and 11 health posts under the authority of the Territorial Health Unit of the Ministry of Health. These provide coverage at the local level through community health workers who include traditional birth attendants, health promoters, faci1itators and communicators. Before the expected flare-up of cholera in the summer months (December 1991 to March 1992), the SMALP project helped to organize four events at the local level (each in the catchment area of one of the health centres), and a meeting at district level attended by representatives of the community, at which new plans and proposals were discussed and finalized. These sought to transform conventional health services programming into a catalytic process for encouraging new ideas and involving local social groups in joint decisions on the management of the health services, with a view to improving specific health conditions. The four preferred lines of action were: strengthening the health services' capacity for response; environmental sanitation; training; and social mobilization. With respect to cholera, the following activities were regarded as priorities: • establishment of surveillance committees; • starting a community fund for cholera prevention; • imposing fines for dumping garbage; • training in environmental sanitation and food handling; • organization of mass campaigns of social communication; • making an approach to Petro-Peru to obtain fuel to boil water. Do's and don'ts 7 Insistent messages in the mass media have informed families what they should and should not do. They have forcefully recommended boiling water, taking care with food, hand- washing and the proper disposal of waste and excreta. The use of the caserito, or plastic water container with a tap at the bottom, has become popular in families and among street- vendors of food. The Ministry of Health has sent the district enough chlorination tablets to purify two million litres of water. Certain other districts have tried to ban street- vendors of food, but this proved impossible as it is difficult to find alternative work for these people, who have no skills and depend on their sales for survival. Training workshops on cholera prevention have been arranged for people who handle food and for teachers . There are now 134 communal oral rehydration centres, staffed by trained volunteers. The soup kitchens and community education centres have received guidance about cholera control , such 8 World Health • 46th Year, No. 3, May-June 1993 as monitoring and improving water quality, controlling insects, rodents and bacteria, disposal of excreta, and health education, with joint participation from the education sector, the churches, the municipality and the health authorities. Instructions on the management of clinical cases were quickly passed on to medical and paramedical personnel, with courses for laboratory technicians, nursing auxiliaries, social workers, nurses and doctors on how to manage patients admitted to hospital and the use of appropriate solutions and oral rehydration salts. These courses proved amazingly popular. health of Chorrillos. The Chorrillos district health unit reported 711 cases in 1991 and 7 53 in 1992, very low totals which illustrate the effectiveness of all the measures taken. Community involvement and the intersectoral approach were vital factors in keeping case fatalities at an extremely low level in this chronically poor district. The project proved to be a novel experience which is still evolving as more progress is made. It brought together people who often worked against each other in the past, but who have now found common ground for working together for the The trial-and-error nature of this process, without ever losing sight of its goal, shows the way forward where no ready-made solutions exist. Strategic surveillance is therefore essential, since permanent monitoring and evaluation are the only way to keep on course and at the same time to reap the benefits of experience. • Or Luis A Loyola is the PAHO/WHO Representative in Peru, Oficino Sanitoria Ponomericono, Cosillo 2 I 17, Lima I 00. Or Potricio Hevio is Adviser in Development of Health SeNices, Los Cedros 269, Son lsidro, Lima, Peru. Cholera in Peru On 23 January 1991 the first case of cholera in Peru w as reported in the province of C hancay, in the district of Chancaillo, 80 km from Lima . The epidemic spread rapidly, especially in the rural and urban slum areas, challenging the people's capacity for response even as they faced the starkest social and economic crisis in their history. The hard~hit health services could count only on the legendary dedication of their human resources, who nobly rallied to cope w ith the w orst epidemic ever to hit the country. The health sector w as aware that it could not handle the epidemic unaided , so it decided to set up multisectoral committees for cholera control w ith representation from all sectors (education , agriculture, the armed forces, local government and grass-roots organizations). Each commit- tee was charged w ith reaching consensus decisions appropriate to each region and helping to put them into Fish con be a source of contamination when eaten row effect, trying to ensure that cases were treated and the epidemiological cycle of infection was interrupted as quickly as possible to prevent further cases. This experience has taught Peruvians that responsibility for health does not lie with one sector alone but with the entire population. Today, two years after the epidemic, the concept of health and the involvement of society as a whole is more important than ever, and there is real participation in preventive activities . In fact, cholera has awakened the country to the enormous potential of the community and has succeeded in involving the whole population in health- related tasks. Community health w orkers are the unsung heroes who have show n the world how Peru attained the low est case-fatality rate in the country's w orst epidemic . Dr Carlos M oreno C hacon Directo r-General of Health Services, M inistry of Health, Avenida Salaverry, Lima , Peru.