Day zero, when the 4 million people living in Cape Town run out of water, is becoming a real possibility. The city has informed residents that water supplies will be turned off on the day and only retained for high risk areas and essential services. Citizens will have to queue for water at key points of distribution.
This scenario will affect businesses, the economy, education, recreation and social life. It will also have significant implications for the health of people living in Cape Town. The city therefore needs to put plans in place to reduce the risks.
The immediate health effects can be categorised into three main areas. Pressure on the sanitation system which raises the prospect of the spread of life threatening diseases such as dysentery; loss of hygiene because people can’t wash their hands; dehydration and heat strokes. In addition, there could be other consequences such as stress levels spiking and people becoming violent as they try and access water or over stretched health facilities.
Not being able to flush
Firstly, the city depends on a waterborne sewage system and the inability to flush toilets may lead to a breakdown in sanitation. People may be unable to dispose of faecal waste easily and may resort to disposing of their faeces outside. Many viral, bacterial and protozoal diseases are spread in the faeces and the risk of environmental contamination will significantly increase. Infectious diseases that cause diarrhoea, vomiting or dysentery, such as enteroviruses, salmonella, shigella, or E Coli, will be more likely.
In addition, viral hepatitis may also be transmitted in faeces. In other parts of Africa, a breakdown in sanitation has led to outbreaks of infectious diseases. Recently, the City has faced a number of disease outbreaks such as diphtheria and typhoid –- it is important to present early to health facilities if an infectious disease is suspected, especially in children.
Not being able to wash
Secondly, the absence of water in taps, wash basins and showers may lead to a loss of hygiene. Skin infections such as impetigo and infestations such as scabies may increase as well as conjunctivitis. A reduction in effective hand washing may also increase the spread of acute respiratory viruses that cause coughs, colds, ‘flu like illnesses, bronchitis and pneumonia.
A loss of sanitation and hygiene may also lead to an increase in hand-to-mouth transmission of infectious diseases that cause diarrhoea, vomiting and dysentery as outlined above. A lack of hand hygiene and water to clean food may also lead to an increase in food-borne diarrheal diseases.
People with immune deficiencies, such as those with HIV or who are malnourished, may be particularly at risk as well as small babies and the elderly. An increased incidence of diarrhoeal diseases will have a negative impact on childhood nutrition in vulnerable communities.
Not enough to drink, and other consequences
Thirdly, the absence of a readily available water supply may predispose people to dehydration and heat stroke. Children are particularly vulnerable especially if they contract diarrhoea. This would also be a particular risk on very hot days and to those performing manual labour without an adequate supply of fluids. In addition people may be tempted to drink contaminated or non-potable water if they cannot afford to buy water or cannot easily access points of distribution.
Lastly, there may be conflict over water as a scarce resource and an increase in unrest, violence and injuries. And some businesses may be unable to function without a water supply and people may lose their income or jobs. This may place increased psycho-social stress on communities and have consequences for mental health as well as harmful alcohol use.
Conflict could also break out at health facilities as waiting times and staff workload increase because of a spike in illnesses.
What are the authorities planning
To deal with these challenges, various bodies in the City of Cape Town are working together to respond appropriately.
For example, the city is working with the police and the National Defence Force to ensure that order is maintained when day zero arrives.
From an environmental health perspective, there are routine systems in place to monitor and respond to outbreaks in the city. Surveillance for outbreaks will be enhanced over this period.
But the water supply to most health facilities will be maintained to enable them to manage ill patients, outbreaks and cases of dehydration.
Water will also be supplied through designated distribution points to limit the risk of dehydration, maintain hygiene standards and enable the flushing of toilets through the use of grey water. Areas that are at a high risk of outbreaks such as informal settlements will have their water supply maintained. This will assist with these areas to dispose faeces.
Residents are still being encouraged to wash or sanitise their hands to reduce the risk of infectious diseases spreading.
Bob Mash, Division of Family Medicine and Primary Care, Stellenbosch University; Hassan Mahomed, Public Health Specialist in the Division of Health Systems and Public Health,, Stellenbosch University, and Shrikant Peters, Public Health Registrar in the Division of Public Health Medicine, University of Cape Town