Sunday, September 23, 2012

Cholera in West Africa


Kanké, age 10. Donka Cholera Treatment Center in Conakry, Guinea.

The biggest change in my work since I moved to West Africa is the decreased number of assignments from news outlets. Part of it probably has to do with the fact that I am new to this region, but it's also undeniably a region with less mainstream-media interest, compared to the Middle East/Afghanistan. It's also not news that freelance photojournalists often supplement their journalism assignments with whatever will the pay the bills--weddings, corporate, advertising. This is the current reality. However, I've been lucky to be able to make a living strictly doing journalism. That is, up until now.

So, I've started doing a bit of photography for humanitarian organizations. I count myself lucky again, because the agencies I have worked with so far have allowed me to approach the work like a photojournalist. In particular, I found an assignment I recently did for Médecins Sans Frontières (Doctors without Borders) particularly fulfilling. I traveled to Sierra Leone and Guinea in August to photograph a growing cholera epidemic. It was a quick trip, only 3 days in the capital of each country, but I learned a lot and I was able to shoot it like any reportage assignment, which felt really good.


Cholera is a preventable and treatable disease, and yet people die from it every year. It is most often caused by a bacteria that finds its way from the feces of an infected person to the water and food supply. It is found in places with poor sanitation, hygiene, and water treatment. It can cause rapid fluid loss in the form of severe diarrhea and vomiting, leading to death in just 3-6 hours. According to the Centers for Disease Control (CDC), an estimated 3-5 million cholera cases and more than 100,000 cholera deaths occur each year, worldwide.

























Cholera is a miserable illness. It causes days of diarrhea, vomiting and painful cramps.


In Freetown, the capital of Sierra Leone, at a Médecins Sans Frontières (MSF) emergency cholera treatment center located in the impoverished quarter of Mabella, nurses treated patients like 12-year-old Mohamed, above, with oral and intravenous fluids. More than 13,000 people suffering from cholera had been admitted to hospitals in Sierra Leone and Guinea by the end of August.

To understand why people get cholera, it is necessary to understand the conditions in which they live.


In Mabella, sewage and trash flow untreated into the ocean. There is no trash collection. There is no system to carry sewage safely away from this overcrowded neighborhood where some of Sierra Leone's poorest residents live. People don't have running water in their homes, and there are few toilets. Because of this lack of toilets, it is not uncommon for people to go to the bathroom out in the open.


In West Africa, it is also the rainy season. From April to the end of October, especially in low-lying coastal areas, rainfall brings humans closer to the waste water and raw sewage that isn't properly drained to begin with.


Young people bathed in the runoff from a sawmill, one of the few water access points in Mabella. Residents use this water for washing, laundry, drinking, and cooking.


People in Sierra Leone speak a language called Krio, a mixture of English, French, Portuguese, and Yoruba, brought to Sierra Leone by freed African slaves. The majority of people I encountered in Sierra Leone were incredibly warm and welcoming, despite living under difficult circumstances, and the language had this musical, slangy quality. I felt like I could almost understand, but I still needed an interpreter. When explaining to people who I was and why I was "snappin' " (taking photographs), the interpreter told them it was about "dis cholera business" (this cholera business). Boy is "bobo" and girl is "titi". Occasionally I could hear someone say "orpotoe," white person, as I passed by. Meeting people and listening to the language were by far my favorite parts of this assignment--besides the actual photography of course.


 A girl ate lunch outside, next to foraging livestock.


Residents crossed a bridge in Mabella.


During Sierra Leone's civil war from 1991 to 2002, 4.5 million people (more than half of Sierra Leone's total population) fled brutal violence in the countryside for the (relative) safety of Liberia, Guinea, and Freetown. I think the conflict had a tangible impact on how people in Freetown are living today, 10 years later. Simply put, Freetown is on a narrow piece of land wedged between the mountains and the ocean. (This is also why Freetown has some of the worst traffic congestion I have ever seen--and I have seen plenty, believe me.) There was only so much room for the city to expand; so as refugees flooded in, they packed into slums like Mabella, places with little to zero infrastructure to handle such an influx of people. I've seen reports stating that most refugees returned to their areas of origin after the end of the war, but I think the corresponding economic and infrastructure devastation that comes with civil conflict forced many people either to stay in Freetown or to come back to it.




A girl sat on a walking path between homes.

The war aside, Sierra Leone ranks near the very bottom at 180th of the 2011 United Nations Human Development Index, the UN's attempt to measure of "quality of life" around the world. (Click here to see the full list of rankings by country. The United States came in 4th.) Cholera is just one of many challenges the people of Sierra Leone face.


Aminata and her little brother sat outside their home.





Neneh, 15, prepared roasted peanuts to sell at the market.


The peanuts were washed before roasting.


Women prepared a big batch of stew to sell at the market.


Children filled buckets with water at one of Mabella's few water points right next to a waste water canal.


What can be done? The cholera treatment centers were built to offset the emergency, and health agencies worked to educated the public on how to protect themselves, even distributing bleach for people to add to their drinking water. But as long as people live without reliable access to sanitation and clean drinking water, I doubt cholera will ever completely go away.


Kadija, 4, rested in the arms of her mother in the observation area of Mabella Cholera Treatment Center.


Wellington Community Center in west Freetown was turned into another MSF cholera treatment center. Above, a nurse tried to ease 14-year-old Aminata's cramped limbs with massage.


Sia sat with her 5-year-old son Aliou at Wellington Cholera Treatment Center.


 Sylvester, 16, at Wellington Cholera Treatment Center.


A nurse helped 7-year-old Alusine drink oral rehydration solution at Macaulay Cholera Treatment Center, yet another facility run by MSF in Freetown.


Women at Macaulay Cholera Treatment Center.


In neighboring Guinea, one of the origins, or at least a "hot zone," of Conakry's cholera epidemic appeared to be Bonfi Port, the capital's main fishing port. The MSF cholera emergency response team was called to the port late one night to take away the body of a person who died of cholera there.


The day I visited the port, fishermen gutted and cleaned fish on the ground. These fish were destined for drying in the smokehouses, which can be seen in the background of the photograph.


It was thought that fishermen could be spreading cholera when they touch contaminated fish and then ingested it or spread it to others.


Fisherman Ibrahima Cise created a new fishing net at the port.


Rain fell in an impoverished neighborhood where a little girl became ill from cholera.

Due to a few logistical difficulties, I wasn't able to spend as much time outside the cholera treatment centers in Conakry as I would have liked. I really only got to visit this one neighborhood briefly and the port.


Guinea came in just a couple steps higher than Sierra Leone on the UN Human Development Index, at 178th.


At MSF and ICRC-run Donka Cholera Treatment Center in Conakry, women received IV fluids.


Guinea's health care system faces many challenges--among them a shortage of medicines, equipment and facilities. We traveled to a government-run clinic in Coyah, an hour's drive from the capital, where cholera patients slept out in the open, behind the clinic. Outside. The reason for this? The clinic has no electricity, and it is extremely difficult to find veins for intravenous needles on dark skin without light. Actually, nurses told me that finding veins on dark-skinned people is difficult even with light.


An IV in the hand of a person suffering from cholera at the government-run health clinic in Coyah.


Back in Conakry, MSF's Koloma Cholera Treatment Center rose out of the puddles near an impoverished section of the city.


Bountouraby Camara sang to her mother Fatmata Soumah, who was battling cholera at the Koloma center.


A nurse checked Fatmata's pulse, and her daughter felt for the rise and fall of her chest.



Donka Cholera Treatment Center.


Nurses used the light from a mobile phone while inserting an IV needle in 4-year-old Saidouba's arm at Donka Cholera Treatment Center. Saidouba's father said that it took the family two and a half hours to reach the treatment center, a delay that caused the boy to become extremely dehydrated, as the cholera caused him to rapidly lose his bodily fluids.


Saidouba sat up shortly after he began to receive fluids via IV.


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