Zimbabwean cholera outbreak

The Zimbabwean cholera outbreak is an ongoing cholera epidemic in Zimbabwe that began in August 2008, swept across the country^[6] and spread to Botswana, Mozambique, South Africa and Zambia.^[7][8] By 10 January 2010 there had been 98,741 reported cases and 4,293 deaths making it the deadliest African cholera outbreak in the last 15 years.^[9][10] The Zimbabwean government declared the outbreak a national emergency and requested international aid.^[11]

Causes

The principal cause of the outbreak is lack of access to safe water in urban areas and communities. A unique feature of Zimbabwe is that its two main cities are located on watershed divides, which means that the water draining out of the city flows into the drinking water sources, all of which are physically located downstream of these return flows.^[12] This is exacerbated by the collapse of the urban water supply,^[13] sanitation^[14] and garbage collection systems,^[15] along with the onset of the rainy season leading to faeces with cholera bacteria being washed into water sources, in particular public drains,^[16] as well as providing readily available but contaminated water.^[17] Due to a shortage of purification chemicals, such as chlorine, the capital city of Harare stopped receiving piped water on 1 December 2008.^[18] By that date, many suburbs had not had any water supply for much longer.^[19] On 4 December 2008, the Zimbabwe deputy minister for water and infrastructural development stated that there were only sufficient treatment chemicals in stock nationally for twelve weeks supply.^[20] The collapse of these systems has frequently been blamed on the current economic crisis.^[21][22] Attempts have also been made to attribute the blame to colonial rule, although Zimbabwe had become a fully independent nation 28 years earlier, in 1980.^[23] Many households cannot even afford sufficient fuel to boil all of their water.^[24] According to Médecins Sans Frontières, the spread of cholera from urban to rural areas from December 2008 onwards was due to infected city-dwellers visiting their families' rural homes for Christmas and the burial of infected city-dwellers in rural areas.^[25]

The cholera epidemic in Zimbabwe has had an unusually high fatality rate. According to Oxfam, "this is due to the fact Zimbabweans are seriously weakened by hunger, HIV and AIDS".^[24]

A major contributing factor to the severity of the outbreak is the collapse of Zimbabwe's public health system, declared a national emergency on 4 December 2008.^[26] By the end of November 2008, three of Zimbabwe's four major hospitals had shut down, along with the Zimbabwe Medical School, and the fourth major hospital had two wards and no operating theatres working.^[27][28] Zimbabwean hospitals still open by December 2008 lacked medicines and staff. Due to hyperinflation, hospitals were not able to buy basic drugs and medicines, and the resources of even internationally-funded emergency clinics are stretched.^[17] The ongoing political and economic crisis also contributed to the emigration of the doctors and people with medical knowledge.^[29] Some victims were travelling to Botswana and other neighbouring countries for treatment.^[21]

Impact

The outbreak began in Chitungwiza on 27 August 2008, with the first case in Harare reported four days later. The next district to report cholera was Kariba on 21 September 2008, with Makonde following on 3 October 2008.^[1] Thereafter, the disease spread to reach all of Zimbabwe's ten provinces.^[1][15] The attack rate was highest in Beitbridge, Chegutu, Mudzi and Zvimba Districts (above 1,000 cases per 100,000 people or 1.0%).^[5]

The number of infected cases reported by the United Nations Office for the Coordination of Humanitarian Affairs escalated from 30 on 1 September 2008^[35] to 15,572 by 10 December.^[32] It was argued by some agencies that the reported number of cases probably under-estimated the extent of the outbreak, since many people were unlikely to have reached the clinics or treatment where the numbers were recorded. According to the Red Cross, around 46% of reported deaths occur en route to clinics and hospitals.^[36] The head of the British Department for International Development in Harare said that "there are probably twice as many people with cholera as turn up for treatment."^[37]

The case fatality rate for the outbreak was higher than expected for such outbreaks, although it began declining by January 2009.^[5] Official estimates of fatalities have run from 484 to 800, since the outbreak in August 2008,^[38] with an upper estimate of 3,000 from an anonymous senior official in the Ministry of Health and Child Welfare.^[19] Fatality rates varied from 2.5% in Harare to 18% in Chitungwiza.^[39] In Harare, the crisis reached the extent that the city council offered free graves to cholera victims.^[16] On 4 December, Oxfam estimated that by the end of March 2009, some 60,000 would be infected.^[22] By 7 December, Oxfam had revised their estimate to 60,000 cases by the end of January 2009 and a 10% fatality rate,^[24] with UNICEF giving a similar estimate.^[40] On 4 December 2008, the Zimbabwe government declared the outbreak to be a national emergency.^[26]

Politicisation

As the outbreak and health crisis grew worse, American and British leaders cited the crisis as further proof that it was, in their view, "well past time for (President) Robert Mugabe to leave"^[41] and that Zimbabwe had become a failed state.^[42] The Zimbabwe government and state media responded by blaming the outbreak on European and American sanctions^[43] and accused Britain of plotting an invasion under the cover of the outbreak.^[44] Information minister Sikhanyiso Ndlovu blamed the cholera deaths on Western sanctions, saying "the cholera issue has been used to drive a wedge among us".^[45] On December 12, Ndlovu repeated his accusation, and claimed that the cholera outbreak was actually a "serious biological-chemical weapon" attack by the United Kingdom, which Ndlovu asserted was trying to commit genocide.^[46] Said Ndlovu:

Cholera is a calculated, racist, terrorist attack on Zimbabwe by the unrepentant former colonial power, which has enlisted support from its American and Western allies so that they can invade the country.^[47][48]

In the meantime, a senior ZANU-PF official argued that the government and party leadership was more focussed on the forthcoming ZANU-PF conference than on the current crisis.^[49] On 11 December 2008, President Robert Mugabe made a speech screened on national television in which he said:

I am happy to say our doctors have been assisted by others and WHO (the World Health Organization)... so now that there is no cholera... Because of cholera, Mr Brown wants a military intervention... Bush wants military intervention because of cholera... There is no cause for war any more. The cholera cause doesn’t exist any more.^[50][51]

Reports from the WHO contradicted Mugabe’s view and indicated a growing death toll. According to the WHO, as of 8 December nearly 800 people had died of cholera and more than 16,000 cases were being treated.^[50] Later that same day, Zimbabwean visas were denied to six French aid workers, including three crisis management specialists, two epidemiologists and a water treatment expert.^[52] Britain's Africa minister, Mark Malloch-Brown, dismissed Mugabe's claim that the Zimbabwe cholera crisis is over, commenting as follows:

I don't know what world he [Mugabe] is living in. There is a raging humanitarian crisis in Zimbabwe as well as an economic crisis and still there is no representative government able to lead the country out of this disaster.^[53]

The French foreign ministry and USAID also contradicted Mugabe's statements and called on him to allow aid to reach the people in need.^[42][53]

Response

Assistance has been made available by numerous international agencies,^[17] and funding for water, sanitation and hygiene programmes, epidemic response and the provision of essential drugs has come through from several governments and trans-governmental organisations:

By 7 December, UNICEF had secured sufficient international donor funding to provide sufficient water treatment chemicals for three weeks water supply for Harare and had arranged a shipment of chemical sufficient for four months supply.^[24] UNICEF distributed 360,000 litres of water per day in Harare, as well as handing out soap and buckets.^[37] Notwithstanding the contributions received, UNICEF indicated on 9 December 2008 that US$17,500,000 was needed to respond properly to the outbreak.^[69] As of 15 December, following agreement with the Zimbabwe government, the World Health Organization was procuring medical supplies to roll out a response plan to run health centres.^[70]

Spread beyond Zimbabwe

The cholera outbreak spread during 2008 to districts in Botswana, Mozambique, South Africa and Zambia bordering Zimbabwe.^[8][14]

South Africa

The outbreak spread to the Zimbabwean migrant worker community in Limpopo and Mpumalanga provinces of South Africa^[71] and cholera bacteria were detected in the Limpopo River on 3 December 2008.^[69] By 12 December 2008 11 deaths and 859 infections had been recorded in South Africa.^[39] This rose to 2,100 cases and 15 deaths by 14 January 2009^[72] and to 12,000 cases and 59 deaths by March 10.^[73]

The South African government set up medical facilities and drinking water supplies at the Beitbridge border post^[74] and deployed the National Outbreak Response Team and additional medical personnel to Musina.^[75] Anthony Turton, a political scientist and Unit Fellow with the Council for Scientific and Industrial Research (CSIR) in South Africa, who had earlier warned of the risk of cholera in South Africa and wrote a report that recommended that the South African government increase its spending on water treatments lest a cholera outbreak occur in the country,^[12] was suspended for having made "inappropriate statements to the media".^[76] On 10 December 2008, the Limpopo Provincial Government declared Vhembe District Municipality, which borders Zimbabwe at Beitbridge, Matabeleland South province, a disaster area.^[51] On a 28 January 2009 visit to Musina with high-ranking government and ruling party officials, Health Minister Barbara Hogan said

Cholera is spreading... We are beginning to see a shift from Zimbabwe to South Africa. The situation is scary... I am concerned about the impact this is having on our provinces.^[77]

Other countries

The spread of the outbreak to Zimbabwe's other neighbouring countries was initially slower than in South Africa, with one death recorded in Kafue District in Zambia and none in Botswana or Namibia by 9 December 2008.^[34] However as 2009 came, cases have increased, with 4,354 cases and 55 deaths reported by 10 February 2009 in Zambia and 1,596 cases and 14 deaths in Katanga, the southernmost province of the DR Congo.^[78] In Mozambique, cholera has spread to 10 out of 11 provinces,^[78] with a total of 9,533 cases by 1 Jan to 1 Mar 2009 and 119 deaths by March 17 ^[79] – as well as the deaths of four health workers in a mob attack, blamed on "misinformation and misunderstanding in efforts to combat cholera".^[80] with 12 of the prisoners from the incident having died in jail.^[79] In Malawi 104 deaths were recorded since January, making it the worst outbreak since 2001-2002 where 960 people died.^[81] Southern Africa is not the only outbreak of cholera in Africa, Kenya, Somalia, Tanzania, DRC, and Ghana have had unrelated cholera outbreaks with between 10-100 deaths in 2009 as of February.^[78]

References

External links

• Cholera situation in Zimbabwe - UN OCHA
• UN Office for the Coordination of Humanitarian Affairs, Zimbabwe
• World Health Organization Alert: Cholera in Zimbabwe
• World Health Organization: Daily Cholera Updates
• US Centre for Disease Control and Prevention Notice: Cholera in Zimbabwe and Neighboring Countries
• Zimbabwe cholera crisis (Oxfam)
• Zimbabwe cholera crisis (Red Cross)