Cholera: A Persistent Health Risk

Nepal is struggling with the recurring threat of cholera, a waterborne disease that claims lives every year. At first glance, cholera seems to be related to healthcare services, but it is deeply connected to clean drinking water. The persistent outbreaks of cholera highlight drinking water service providers' capacity to supply quality drinking water, and it raises important questions about why the country has not been able to control this preventable disease.

Cholera has plagued Nepal for over two centuries, with outbreaks dating back to 1823. In 2024, the situation remains dire, with new cases emerging in various parts of the country, including the capital, Kathmandu. The 2009 cholera outbreak in Jajarkot was particularly devastating, resulting in 111 deaths and around 6,000 infections in just two weeks. Such incidents underscore the need for a comprehensive approach to tackling cholera, beyond the immediate response of healthcare workers.

Nepal's constitution

Nepal's constitution, endorsed nine years ago, clearly mentions water and sanitation as fundamental human rights. It declares that "every person has the right to sufficient, clean, safe, and accessible water and sanitation facilities for their personal and household needs without any discrimination." However, the reality on the ground tells a different story. The focus has often been on the quantity of drinking water, with the critical issue of water quality receiving less attention. According to a recent WASH Report by the Ministry of Water Supply, only 19 per cent of the population has access to safe drinking water, leaving the majority vulnerable to waterborne diseases like cholera.

The prevention of cholera heavily depends on the capacity of drinking water service providers. Key players in this sector include Kathmandu Valley Water Supply Limited, the Nepal Water Supply Corporation, and the Urban Water Supply Board, along with approximately 43,000 Water and Sanitation Users' Committees (WSUCs) across the country. These providers, along with private sector involvement such as tanker associations and bottled water companies, are responsible for ensuring that the water supplied to the public meets national drinking water quality standards as mandated by the Water Supply and Sanitation Act, 2079, and the Water Supply, Sanitation, and Hygiene Policy, 2080. 

However, recent tests have shown that the water supplied by many of these providers is found to have harmful microbiological contamination. This is a significant concern, as water service providers are legally obligated to deliver safe drinking water, yet the public often remains unaware of drinking water service providers' responsibilities. The focus of these providers tends to be on the quantity of drinking water rather than its quality, a situation exacerbated by the lack of regular monitoring of supplied water from government.  

Nepal's declaration as Open Defecation Free (ODF) in 2019 marked a significant milestone in reducing waterborne diseases, especially among children under five. Before 2006, approximately 10,500 children in this age group died annually from such diseases. The proper use of toilet supported for reducing child mortality rates. However, the challenge now lies in managing the fecal sludge from these toilets, most of which are full and pose a new risk of spreading waterborne diseases if not properly managed.

Water quality is often neglected by both service providers and consumers in Nepal. During the rainy season, it is common for water service providers to distribute turbid and contaminated water, which consumers have come to accept as the normal practice. Instead of addressing these issues, drinking water services providers have neglected the issues.  

The Drinking Water Quality Standard, first implemented in 2062 BS, was revised, and endorsed in 2079 BS. All water service providers are required to distribute water that complies with this standard, but this has not been fully achieved. As a result, stakeholders are promoting households level treatment options. However, there is often confusion about these methods, such as the lifespan of filters, the correct way to boil water, and the practice of consuming lukewarm water instead of properly boiled water. Additionally, not regularly cleaning filters further hinders access to clean water.

Fecal sludge management 

Poor hygiene practices among the public further exacerbate the risk of cholera. The greater danger lies in using untreated water for other purposes, such as washing vegetables, cleaning fruits, or preparing street foods like pani puri, chatpate, which can easily lead to the spread of waterborne diseases. 

Cholera remains a recurring threat in Nepal, driven by issues in water quality, inadequate management of sanitation facilities, and poor public hygiene practices. To control cholera and other waterborne diseases, it is crucial to improve the performance of water supply systems and focus on fecal sludge management. The government must develop a clear framework for assessing the service quality of water providers, with regular monitoring and evaluations that include rewards for improvements and penalties for failure. 

Addressing these challenges requires a concerted effort from water service providers, both the government and public. By enforcing water quality standards and raising awareness about proper hygiene practices, Nepal can make significant strides in reducing the incidence of cholera and other waterborne diseases. Without such measures, the country will continue to face the devastating consequences of cholera outbreaks year after year. 

(Gautam has been actively involved in various national and international organisations related to water, sanitation, and water resource management sector.)