RESUMEN
Cholera has been endemic in Douala, Cameroon since 1971. A number of environmental factors favourize the survival of the Vibrio in Douala including location at the mouth of Wouri delta on the Atlantic Ocean, sandy clay soil, shallow dirty polluted foul-smelling groundwater, presence of vast expanses of swamp, streams/drainage ditches infested with algae, and high temperatures with low rainfall and drought during certain periods of the year. Most outbreaks have started in Bepanda, a slum area built on a garbage dump in a swampy zone fed by drainage ditches carrying the faecal pollution from neighbouring upstream districts. It is a densely overcrowded area of uncontrolled urbanization generated by the influx of poor city new-comers who live without adequate access to clean water or basic sanitary facilities. The most affected areas are those resulting from recent unregulated urban sprawl in polluted swamp zones or garbage dumps. Since access to the public water system is inadequate with only 65000 persons connected for 3 million inhabitants, dwellers in most areas must take water from the 70000 urban wells (estimated in 2004) that are often not more than 1.5 m deep. Sewage facilities are insufficient to provide complete evacuation of solid and liquid waste. The network of rivers, streams and man-made ditches waste are poorly maintained and often overflow during the rainy season. The contents of latrines are often discharged directly into the environment. Social factors such as the reformation of urban tribes and persistence of traditional attitudes toward waste disposal and water use have not only led to high-risk behaviour but also created barriers to sanitation and hygiene education. With an inadequate sanitation inspection system, a large but purely accessible public health system and a highly disorganized private health sector exists, effective preventive measures are difficult to implement. The combination of these factors probably account for the endemicity of cholera in Douala.