March 09, 2009

Luis Maria Tello, MSF emergency coordinator in Zimbabwe, encountered a devastating scene when he arrived in the town of Chegutu, 100 miles south of the capital Harare, on December 12, 2008. “The situation was absolute chaos. There were no beds and patients everywhere,” said Tello. “People were dying of thirst because there was no water. Dead people were lying everywhere."

Zimbabwe 2008 © MSF

An MSF doctor treats a young cholera patient in Mudzi, near the border with Mozambique.

Luis Maria Tello, Doctors Without Borders/Médecins Sans Frontières’ (MSF) emergency coordinator in Zimbabwe, encountered a devastating scene when he arrived in the town of Chegutu, 100 miles south of the capital Harare, on December 12, 2008. “The situation was absolute chaos. There were no beds and patients everywhere,” said Tello. “People were dying of thirst because there was no water. Dead people were lying everywhere.

Just that morning, he had been alerted by government officials that cholera had hit Chegutu, and he and several MSF field staff had set off immediately from Harare with a truck containing 3,500 liters of Ringer’s lactate, a solution used to treat cholera. Already, 74 people were said to have died in the government’s rapidly created cholera treatment center (CTC) on the grounds of a local clinic, and 650 cases of cholera had been registered.

The team’s first job was to remove bodies scattered on the ground among the living, then to disinfect and bury them. They erected six tents, set up more than 150 beds, and got to work registering and rehydrating patients. Meanwhile, patients had been without food or water for days. An elderly man attempted to remove his IV drip so he could leave in search of food—unwilling to wear his IV in public for fear of stigmatization. MSF also learned that many people suffering from cholera had stayed at home, having heard of the desperate conditions at the CTC, making it likely that many more people may well have died without seeking treatment. To remedy this situation, MSF logisticians identified a local bore hole and began to supply the center with water, while also providing logistical support for food supplies being brought in by the UN World Food Program and Catholic Relief Services, a New York–based nongovernmental organization.

The World Health Organization’s (WHO) worst-case prediction of 60,000 cholera cases was exceeded in the beginning of 2009. By the first week of March, 88,000 cases had been reported; MSF had treated 56,000 of them. Cholera had appeared in almost every province of Zimbabwe, which has a population of more than 13 million. And with the rainy season continuing, the prognosis remained grim, as heavy rains helped spread the bacteria by flushing standing sewage into unprotected wells.

At the root of these and many other problems is Zimbabwe’s political and economic meltdown. The country had been known as the “breadbasket” of Africa. For years, health professionals have been fleeing the country along with countless others, unable to afford the most basic things, such as transportation to work. With shortages in personnel, supplies, and services, hospitals and clinics have closed, leaving critical holes in the public health system. Zimbabwe’s average life expectancy is 34 years, due mainly to the massive spread of HIV, which affects one out of every five people. People living with HIV face major challenges in getting to the remaining health facilities and receiving treatment, and many have fled the country. Despite a critical shortage of personnel, government rules make it very difficult for international organizations to send health professionals into the country; a work permit can take three months to obtain, and foreign doctors are required to perform an additional three-month internship at a government hospital, many of which are now closed.

MSF Responds to the Crisis

MSF has been working in Zimbabwe since 2000, primarily treating people with HIV/AIDS; MSF currently cares for 40,000 patients, 27,000 of whom receive antiretroviral drugs. This outbreak of cholera erupted on the heels of violence involving politically motivated attacks. This violence reached unprecedented levels last June during the lead-up to controversial elections. Meanwhile, the country was in the midst of an ongoing, devastating economic crisis with inflation reaching an astounding 231 million percent, breakdowns in infrastructure, and shortages in essential goods. People fled the country in large numbers while others were afraid to leave their homes for fear of violence. And many skipped meals as food prices skyrocketed.

Zimbabwe 2008 © Joanna Stavropoulou/MSF

Top: Patients are rehydrated at an MSF cholera treatment center in Kadoma.
Bottom: MSF staff conduct community outreach around Harare, including distributing chlorine tabs to disinfect water.

MSF teams in Zimbabwe have had to adapt quickly as crisis followed crisis. In June, they opened programs to treat people injured in the violence, as well as those who were fleeing and had no access to health care. In August, when cholera broke out, MSF immediately flew in cholera kits from Europe and additional staff with expertise in cholera response, who got to work setting up two CTCs at medical facilities in Harare.

“Imagine a cholera ward with dozens of people being treated under the most basic conditions,” said Marcus Bachmann, MSF emergency coordinator in Harare. “For instance, there is only a little electricity so there is hardly any light. It is difficult for the doctors and nurses to even see the patients they are treating. The nurses have to monitor multitudes of IV bags to make sure they don’t run dry, which is also difficult to do in the dark and when there are so many patients.”

Within days, the centers were flooded with new patients, and MSF was already hiring and training new staff to chlorinate water sources, disinfect homes, and to assist as new outbreaks occurred in rural areas.

By the end of January 2009, MSF had treated approximately 45,000 patients— about 75 percent of the country’s cholera cases, but the epidemic was far from over. Later that month in Kadoma City, in Mashonaland West Province, the number of cases pushed the city’s CTC over capacity, and MSF relocated the center to a soccer field where it set up 250 cholera beds, a 30,000-liter water tank, 20 latrines, waste management facilities, and electricity generation capacity.

Beitbridge: 500 Cases in Two Days

Nowhere has the cycle of broken infrastructure leading to an outbreak of cholera been more clearly illustrated than in the southern town of Beitbridge, on the border with South Africa. Thousands of people have gathered there in an attempt to flee the country, and MSF had opened a program to provide basic medical assistance. With this massive influx of people, no garbage collection, open sewage running through most streets, and almost daily water and power cuts, the conditions were optimal for cholera to spread.

Zimbabwe 2008 © Joanna Stavropoulou/MSF

MSF staff treat a cholera patient outside an overwhelmed CTC in Beitbridge.

Zimbabwe 2008 © MSF

A child arrives in a wheelbarrow at the MSF CTC in Kadoma.

On November 14, 2008, local health authorities contacted MSF’s team in Beitbridge with news of five cholera cases. Within two days, that number had risen to more than 500; by the end of the week, to more than 1,500. When MSF team members arrived at the local hospital, the scene was devastating. Patients were being moved to lie on the dirt outside the hospital, so that they could empty their bowels directly into the ground. The toilets were backed up and overflowing. Patients lay in the dust in the scorching heat, asking for treatment and water. But there was no water to give them, since the water supply for the hospital, as everywhere in town, was cut on most days.

An MSF doctor, Veronica Nicola, described the scene awaiting her: “There was a man lying next to one of the trolleys under the sun. By the time I got to him, he was in shock. We tried to get a vein, like, 10 times, but then he started gasping and he died right there in front of our eyes. If I had seen him half an hour before, we might have been able to do something about it, but there were so many people lying there, calling out. It was very bad.” Within three days, MSF had shipped in enough medicines and supplies to set up a CTC with 130 beds, sent in a team of 16 doctors, nurses, logisticians, and administrators, and hired more than 100 additional health workers, cleaners, and day workers. By the fourth day, the mortality rate had dropped from 15 percent to less than one percent.

Training Community Leaders to Respond

As outbreaks in rural areas have continued, MSF began implementing a new outreach strategy-training community leaders to administer oral rehydration salts and keep track of affected people. Chlorine tabs to kill bacteria in water supplies are also being distributed. MSF teams give out health promotion posters to the CTCs they visit and carry out activities to encourage communities to talk about hygiene.

In February there were more than 500 MSF staff working to treat and prevent the further spread of cholera in Zimbabwe, but the number of cases

How MSF Treats Cholera

What is Cholera?

Cholera is a highly contagious diarrheal disease spread mainly through water or food that has been contaminated by feces. Patients show symptoms of acute diarrhea or vomiting, and must be continuously rehydrated, orally or through an IV, until symptoms disappear. They must be treated in special isolation units called cholera treatment centers (CTCs). Everyone is disinfected before entering a CTC and as they are leaving, so as not to spread the infection.

How MSF Responds to an Outbreak

Responding to cholera requires a lot of materials, and MSF purchases locally when possible, items such as buckets, beds, and blankets. In addition, MSF provides field staff with pre-assembled emergency cholera kits to use during outbreaks. Here are some examples of items in an MSF cholera kit.

Supplies and Materials

Medical

  • Oral rehydration salts (ORS)
  • Ringer’s lactate – a rehydration solution administered intravenously if a patient is too ill to drink water with ORS
  • Gastric tubes, IV catheters, syringes, and other medical materials
  • Gloves - always used during cleaning and examinations

Logistical

  • Chlorine – to disinfect water supplies
  • Soap
  • Watertight boots - to protect from contaminated water and soil
  • Graduated cups for drinking and administering ORS
  • Pool tester – to monitor chlorine levels
  • Buckets – every patient has two buckets, one for vomit and one under the bed for diarrhea

Administrative

  • Cholera control guidelines
  • Water treatment guidelines
  • Patient follow-up cards

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