In Khayelitsha, diarrhoea and gastro-enteritis have overtaken HIV/Aids as the biggest killer of children under five years with the deaths doubling over the last four years.

By mid- 2004, 60 Khayelitsha toddlers had died of diarrhoeal disease, a preventable and treatable illness.

‘€œLack of access to basic services does impact on the health of a community, especially children,’€ said Dr Ivan Toms, head of Cape Town’€™s health services.

‘€œWater is easier to get to communities, but sanitation is a tough one,’€ he acknowledges, adding that Khayelitsha is ‘€œby far the most challenging’€ of all the districts under his management.

‘€œThe real issue is that it is an informal settlement with a massively burgeoning population. There are 48 000 people arriving in Cape Town every year. The question is how to plan and deal with it,’€ said Toms.

Khayelitsha is widely acknowledged as an area of multiple problems.

‘€œRegardless of the measures used, it has among the worst social and economic problems in Cape Town, and indeed, in the country as a whole,’€ writes Nomvuyo Dayile and Ruth Stern of the University of the Western Cape’€™s (UWC) School of Public Health.

Stern and Dayile are part of the Cape Town Equity Gauge, established to try and address the inequities so clearly defined in Khayelitsha.

At least 55 percent of people in Khayelitsha, said to be home to around half a million residents, live below the poverty line. Half of all adults are unemployed while one in three people have no access to on site water (in their homes).

There are an average of 105 people per toilet in Sites B and C in Khayelitsha, or one toilet per seven households where toilets have been provided.

The storm water system, where all run-off rain and household water is channeled, has become highly contaminated by overflowing sewers, buckets of faeces being emptied in the street and people being left with no option but to use the veld as toilets. Storm water ends up in rivers and streams.

‘€œThese factors are inevitably associated with a high level of disease, particularly among children,’€ according to Stern and Dayile.

Several toilet systems have been tried in Khayelitsha but most are a huge failure as the systems are unable to cope with the massive demand.

The Infant Mortality Rate in 2003 (deaths of babies under a year old), a useful indicator of the health of a population, was 43 per 1000 live births in Khayelitsha.

In, Cape Town, the Infant Mortality Rate is around 25, with diarrhoeal disease found to be one of the highest causes of death in children.

In 2004, the Infant Mortality Rate in Khayelitsha was reduced to 36, an effect Toms believes of getting basic services to some communities.

In an attempt to address the poor access to sanitation and the resultant high levels of worm infestation (96%) among children from informal settlement schools, the Khayelitsha Task Team (KTT) was launched in 1998.

Under the KTT umbrella, a programme that included the regular deworming of children was launched together with the development of teaching materials for school, an attempt to improve the water and sanitation infrastructure in the schools and the inclusion of health and hygiene in the school curriculum.

Team co-ordinator Benita Mayosi, is employed by the Medical Research Council (MRC): ‘€œIt is a challenge as we may teach the children all the good things, but they need clean water and toilets at the schools and at home to apply it,’€ says Mayosi, who has been battling for years to improve the sanitation situation at some of the schools.

‘€œNobody takes responsibility for the problem. If the sewerage pipes are blocked it’€™s an engineering problem. The fact that it is about 40 children to one toilet is a public works problem. So, you have a scenario where the schools don’€™t know who to refer their problems to,’€ explains Mayosi.

Professors David Saunders of the UWC School of Public Health and Mickey Chopra of the MRC’€™s Health System Research Unit, believe the health inequalities in South Africa are rapidly worsening.

In a paper published this year in the American Journal of Public Health, they point out that the Cape Town Equity Gauge has found that districts in Cape Town with the highest burden of disease, such as Khayelitsha and Nyanga, received far fewer health care resources than wealthier districts.

Saunders and Chopra said that, despite the large inequities, ‘€œlocal government policymakers and officials have found it extremely difficult to shift resources away from the wealthier districts’€.

With the local government elections looming and President Thabo Mbeki stating that the country needed to strive towards a society free of shacks and bucket toilets, ministers have followed his cue.

Health minister Dr Manto Tshabalala-Msimang earlier this month committed government to ensuring that everyone in South Africa had access to a functioning basic water supply services and a basic sanitation facility by 2010.

In his budget speech Finance minister Trevor Manuel also committed government to ensuring that ‘€œno household is denied the simple dignity associated with basic water, sanitation and energy supplies.’€

Health and hygiene facilitator in Khayelitsha Patricia Thunzi believes things need to change sooner rather than later.

‘€œOur small children always have skin eczema, we have high levels of stunted growth. Our children are not healthy like other children.’€

Her observations are shared by health promoter Vivienne Budaza, who works in the local government clinics in Khayelitsha: ‘€œHow do I talk to the mother about health and hygiene when food is a problem. When the poverty is so stark you can smell it in the waiting room? Very few people believe there is a better life waiting for them. They have given up the will to live.’€

Statistics for Khayelitsha

Almost 30% of residents do not have easy access to water and 80% of Khayelitsha residents live in shacks. A total of 14 521 households do not have access to water while the sanitation backlog is around 29 811 households.

280 of every 7 805 children born, died at birth in 2004.

Infant Mortality Rate (2004): 36 per 1000, compared to an IMR of 24 for the city.

Top 5 causes of death among the under 1 year olds (2004)

1 ‘€“ Ill defined and unknown causes including natural ‘€“ 55 deaths (19,2%)

2 ‘€“ Diarrhoea and gastro-enteritis ‘€“ 52 deaths (18,8%)

3 ‘€“ Short gestation and low birthweight ‘€“ 39 deaths (13,5%)

4 ‘€“ HIV/AIDS ‘€“ 37 deaths (11,7%)

5 ‘€“ Pneumonia ‘€“ 27 deaths (9,2%)

Diarrhoeal disease did not even feature as causes of death in districts such as Mitchells Plain and the South Peninsula.

Gastro-enteritis and diarrhoea is now also the biggest killer of under five year olds in Khayelitsa ‘€“ up from 35 deaths in 2001 to 60 in 2004.

Tuberculosis

26 794 cases of TB were treated in 2005. This is a 9,7% increase.

Khayelitsha carried 23% of the Cape Town burden, with 1 612 of every 100 000 people infected.

One clinic in Khayelitsha has the same number of TB cases as the three entire districts in Cape Town. In 2005 over 2000 cases of TB were registered at the Site B Clinic alone.

Epidemiologists believe the Aids epidemic is fuelling the TB epidemic with 74% of TB patients in Khayelitsha also HIV positive. At Site B, nine out of ten TB patients are HIV positive.