March 11, 2009

Zimbabwe 2008 © Jane Hannon

Donkey carts deliver water to a cholera treatment center in Manicaland Province.

Jane Hannon, a 39-year-old nurse from Baltimore, was in Manicaland Province in eastern Zimbabwe during November and December 2008. Originally sent to Manicaland to conduct assessments of certain areas that cholera might be reaching, Hannon and her team of two national staff nurses and an Italian logistician were finished and on their way back to the capital Harare when their assignment was extended. Here, she talks about trying to help people with cholera in the middle of a large-scale, rapidly spreading outbreak, in a country that has fallen into extreme disrepair.

We spent Thanksgiving night in Mutare district, in eastern Manicaland Province and the next day conducted an assessment of the cholera situation in Mutare City. We were headed back towards Harare when we got the call: “There’s a project in the south that needs your help.” And then the assessment mission turned into a set-up mission.

We ended up going to support several small clinics and rural hospitals, but the first one we went to was in Nyanyadzi, to the south of Mutare City, where we had been a few days earlier. There is a very basic rural hospital there. They had previously received only four cholera patients and the team was coping. There was a men’s ward with seven beds—all full—and a women’s ward with 12 beds; those were all full, too. They had a maternity ward that we ended up moving to another building to free up more space for cholera patients, and, importantly, to protect women in labor and their newborns from infection. And there was a treatment room where we squeezed four additional beds. At one point, the hospital was completely full, and on average there were about 30 patients being treated every day while I was there.

We worked with the humanitarian organization Action Against Hunger and together we got the hospital better equipped. We gave them buckets, which are critical to treating the disease, as cholera provokes massive quantities of diarrhea and vomit. We also provided the hospital with large water containers, chlorine for disinfection, medical supplies, and the training and support to manage patients and contain spread of the cholera. Treatment for cholera is pretty straightforward—replace the fluids the patient has lost, either through oral rehydration salts (ORS) or an intravenous solution of Ringer’s lactate. In some severe cases, we might administer antibiotics along with fluids. The challenge was treating these patients in Zimbabwe where the system is pretty well broken. Like much of the country now, the hospital did not have running water, so we brought them large water containers that a donkey cart took back and forth to a safe water source. We got them cholera beds, which are basically fold-up cots with a hole in the center where people empty their bowels into the buckets. Before we had the cholera beds in there, it was more difficult for patients to defecate into the buckets. There weren’t enough hospital beds initially, so there were even people on the floor. It was really an awful thing for these patients.

Angola 2006 © MSF

This is a photo of a well-organized MSF CTC in Angola. Hannon says initially in Zimbabwe the lack of supplies and the large numbers of new patients did not allow for this level of organization.

There’s a photo I’ve seen of an MSF cholera treatment center (CTC) in Angola and it’s so nice, just sort of the model of how a CTC should be set up. We were just not there. It was like trial by fire just trying to get the beds, get the water, get the buckets, and patients are coming while you’re trying to do it. We were trying to get the patients stabilized and doing everything at once. The electricity was on and off. And when there was electricity, there were no light bulbs. We had to improvise with candles and lanterns.

The Ministry of Health had given the clinics cholera kits but they couldn’t treat many people with them; the kits were lacking a lot of items. I think everything was in such short supply in Zimbabwe, the kits, which had probably been on stand-by for a while, probably had supplies pilfered to treat other patients prior to the cholera outbreak, understandably so. As soon as MSF was able to get them to us, we received MSF cholera kits with everything you need to set up a cholera unit—all the liters and liters of IV fluids, ORS, and other medical and logistic supplies to treat cholera and prevent its spread. Treating cholera is very logistics-intensive.

One of the things that made a big impression on me was that the workers, all of the staff in every clinic we went to, all needed food. The patients were all hungry. There were children who were obviously malnourished, and once they had recovered from cholera, I got them connected with an MSF nutrition program in the area. MSF ended up paying incentives to the nurses and other staff to ensure they could at least feed themselves and would therefore be better able to treat patients and manage the situation. With the inflation in Zimbabwe, salaries are worth very little in a short amount of time.

The assignment was very challenging, and you can feel very ineffectual when you have deaths, when you’re struggling to get water, when everyone is hungry. And at the end of the day, I get to come home to my country, turn on the tap, and drink a glass of water. But for them, it’s ongoing.

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