Waterborne diseases in Mogadishu: are current public health interventions failing?

¹Faculty of Health Science, University of Somalia, Mogadishu, Somalia, ²Directorate of Health and Human Services, Banaadir Regional Administration, Mogadishu, Somalia, ³Faculty of Health Science, Al Hayat Medical University, Mogadishu, Somalia, ⁴Department of Environmental Health and Climate, IPC Section, Federal Ministry of Health and Human Services, Mogadishu, Somalia

^&Corresponding author
Abdirahman Mohamed Jimale, Faculty of Health Science, University of Somalia, Mogadishu, Somalia

Commentary    

Introduction

Somalia remains among the countries with persistent cholera transmission, with Mogadishu at its epicentre. Since 2017, the city has reported continuous acute watery diarrhoea/cholera cases [1]. In 2024, renewed flooding, inadequate water and sanitation infrastructure, and ongoing displacement triggered another large outbreak [2]. Despite interventions including OCV campaigns, improved surveillance, and case management, cholera continues to re-emerge annually. This persistent pattern raises a critical question: Are current public health interventions in Mogadishu failing?

The current epidemiological situation in Mogadishu underscores the persistence of cholera as a major public health threat, reflecting deep-seated structural vulnerabilities and recurring environmental pressures. According to 2024 reports from WHO and UNICEF, over 17,000 cholera cases were recorded across 30 districts, with Dayniile, Dharkaynley, Wadajir, Kahda, and Hamar Jajab consistently emerging as high-transmission hotspots [1,3]. These districts, characterised by dense populations, inadequate sanitation infrastructure, and limited access to safe water, have become epicentres of recurrent outbreaks. Alarmingly, nearly half of all reported cases occurred among children under five, highlighting both the disproportionate impact on vulnerable groups and the ongoing gaps in preventive health coverage and household hygiene practices [4].

Seasonal flooding, particularly following heavy rains, has further aggravated the situation by contaminating shallow wells and open water sources, which serve as primary water supplies for many urban and displaced communities. The resulting increase in waterborne transmission risk is compounded by rapid and continuous population displacement, as new arrivals settle in overcrowded informal settlements where access to sanitation, clean water, and healthcare is minimal. These conditions have severely strained Mogadishu's fragile health and WASH systems, limiting their ability to mount effective outbreak responses.

By early 2025, Save the Children reported a doubling in the incidence of infectious diseases, including cholera, within just three months, underscoring the escalating health crisis in the city [5]. This local trend reflects a broader regional pattern; the Africa Centres for Disease Control and Prevention (Africa CDC) has described the ongoing crisis as the continent's worst cholera outbreak in 25 years [6]. Collectively, these indicators reveal a persistent cycle of vulnerability driven by environmental hazards, infrastructural gaps, and socio-economic instability, signalling limited progress toward achieving the national and global targets for cholera elimination.

Assessment of Current Interventions

Surveillance and early warning: Somalia's Integrated Disease Surveillance and Response (IDSR) system has strengthened, with reporting timeliness exceeding 80%. However, operational gaps persist, particularly at the district level, where coordination challenges and limited response capacity delay containment actions. Rapid, community-based surveillance remains underdeveloped in Mogadishu's dense urban environment.

Oral Cholera Vaccination (OCV): OCV campaigns in 2024 targeted several high-risk districts and achieved short-term reductions in transmission. Yet without parallel improvements in water safety, sanitation, and hygiene, vaccine-derived protection remains temporary. Sustained prevention requires integrating OCV with long-term WASH interventions.

Case management: cholera treatment centres and oral rehydration points are routinely established during outbreaks, but prolonged aid cuts and funding gaps have weakened health system readiness. Hospitals face shortages of trained staff, supplies, and maintenance resources, hindering preparedness between epidemic waves. While case fatality rates remain low, recurrent outbreaks reflect systemic fragility.

WASH and behaviour change: in internally displaced persons (IDP) settlements, households continue to rely on unsafe water sources, inadequate storage, and minimal treatment. Sanitation coverage remains poor, and hygiene promotion efforts have not achieved lasting behaviour change. Studies indicate that fewer than one-third of households treat water before use, perpetuating transmission cycles.

Are current interventions failing? While ongoing interventions save lives and reduce mortality, they have not interrupted transmission. Mogadishu's situation reflects chronic underperformance rather than total failure. Persistent annual outbreaks, particularly among young children, reveal a dependence on reactive emergency measures instead of preventive systems strengthening. Progress is constrained by short-term humanitarian funding and fragmented coordination among implementing agencies.

Challenges: endemic cholera in Mogadishu persists due to a complex interplay of structural and contextual factors that create a conducive environment for continuous transmission. Inadequate water, sanitation, and hygiene (WASH) infrastructure remains a central driver, as many residents specially in rapidly expanding internally displaced persons (IDP) settlements such as Kahda and Dayniile, lack access to safe drinking water and proper sanitation facilities [7]. The city's rapid urbanisation and large-scale population displacement have further strained existing systems, with population growth far exceeding the expansion of basic infrastructure. As a result, many communities rely on unsafe water trucking and informal water vendors, often leading to contamination and recurrent cholera outbreaks. Financial instability also compounds the problem; unpredictable donor funding disrupts essential health services, weakens the supply chains for cholera response commodities such as oral rehydration salts and IV fluids, and undermines the readiness of health facilities to manage cases effectively [7]. Coordination challenges exacerbate these issues, as fragmented interventions among government agencies, municipal authorities, and humanitarian partners lead to inconsistent strategies and limited sustainability at the community level. Moreover, behavioural and social barriers such as low risk perception, limited health literacy, and inconsistent hygiene practices sustain transmission within households and communities, even where infrastructure improvements have been made [8]. Together, these interlinked factors create a persistent cycle that makes cholera control and eventual elimination in Mogadishu particularly challenging.

Recommendations: to effectively prevent and control endemic cholera and strengthen public health resilience in Mogadishu, a coordinated set of policy and programmatic actions is required in the next years. The following recommendations focus on sustainable, district-led interventions that integrate WASH improvements, health system strengthening, and community engagement to achieve lasting cholera control. Prioritise district-based, climate-resilient water and sanitation projects in high-risk Banadir districts, integrating OCV with hygiene promotion; develop municipal contracts and surveillance-linked disposal systems for safe waste management; distribute chlorine tablets and safe storage containers, supported by follow-up visits from community health workers; establish pooled donor and government funding mechanisms to maintain essential cholera prevention capacity year-round and strengthen district-level incident management teams and conduct post-epidemic performance audits to ensure continuity between outbreak cycles.

Conclusion     

Mogadishu's persistent cholera transmission illustrates the limitations of short-term, emergency-oriented interventions in fragile urban contexts. Although surveillance, OCV campaigns, and case management have reduced mortality, they have not lowered baseline transmission risk. Achieving sustainable control requires a transition toward multi-year, area-based WASH investments, continuous community engagement, and predictable financing. Without this strategic shift, Mogadishu will remain trapped in a cycle of recurrent outbreaks and emergency responses.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Abdirahman Mohamed Jimale conceptualised and designed the study and conducted the literature review. Nor Haji Osman and Mohamed Ahmed Ali contributed to the manuscript, wrote the first draft, and Abdikarim Abdi Adam and Abdiweli Mohamed Abdi revised the manuscript. All authors have read and approved the final version of the manuscript.

References