Zimbabwe, Mutare Town

Cholera Mitigation in Urban Areas

Background:  

One of the worst outbreaks of Cholera occurred in Zimbabwe between August 2008 and May 2009. To appreciate the seriousness of this epidemic it is salutary to compare a regular cholera outbreaks where it is usually estimated that 0.2’1% of the local population will contract the disease and die, compared to Zimbabwe where it was estimated that 4.5% of the population of around 11 million had contracted cholera by the time it peaked in February.

After eight years of mismanagement, the principle cause of the cholera outbreak in Zimbabwe was the collapse of the urban water supply, sanitation and garbage collection. Municipal water supplies were often cut off for days on end and there were no chemicals in the country to treat urban water supply. Urban populations were reverting to collecting surface water, but with the onset of the rains in November 2008, raw sewerage was washed into water sources, used for drinking water. When the epidemic started, there was a shortage of emergency purification tablets for household water treatment. In the high density suburbs, few households could afford fuel (wood or charcoal) to boil their water.

Ignorance as to how to prevent cholera was a further factor and when city dwellers visited their rural homes at Christmas, cholera spread to the rural areas, fanning out to every one of the 57 districts in the country. At this point the economy collapsed with hyper inflation at 231 million %. This further aggravated the MoH ability to respond as hospitals could not buy medicines, and three of the four major hospitals had shut down. On top of the cholera outbreak, the burden of disease in Zimbabwe is one of the worst in Africa, with 24.60/o of active adults infected with HIV/AIDS and 300,000 children under 14 infected.

• Country: Zimbabwe
• Period: 2009
• Donor: USAID – OFDA
• Partner: OXFAM
• Province: Manicaland
• District: Mutare Urban
• Number of households: 5,400

• Number of CHCs: 36
• Number of Members: 5,400
• Percentage CHC coverage: 99%
• Number of EHTs: 
• Number of CHC facilitators: 10
• Number of beneficiaries: 23,600
• Cost of Project: US$
• Cost per beneficiary: 

Project Area:

By March 2009, a total of 89,018 Zimbabweans out of 11 million had contracted cholera and 4,011  had already died. In Manicaland, a Province with a population of 1.6 million, there were 12,704 cases with 420 deaths.

However it was notable at of this number Mutare with a population of  195,300 (2009)  recorded ‘only’ 198 reported cholera cases and 8 deaths from December to April 2009. Why were there proportionately so few cases?  We attribute this to the effectiveness of community mobilisation through CHCs.

Mutare, the provincial Capital and third largest city in Zimbabwe,  is only 10 kms from the Mozambique border, where cholera is endemic. The high density suburb of  Sakubva (pop. 23,600) is the oldest and most dilapidated area of Mutare, and is where the commuter bus stop from Mozambique stop at the sprawling open market. In March, 2009, there had been no collection of garbage for four months, and some roads in Sakubva, were literally sealed off with metre high piles of rotting garbage. Old sewerage systems from the 1940’s were unrepaired and were overflowing in the rains and mixing with broken water mains.

The standard  response by international aid agencies in Cholera mitigation is to distribute emergency NFI (Non Food Item) kits containing aquatabs and a plastic container to’vulnerable households, to chlorinate drinking water. Zimbabwe AHEAD, was contracted by OXFAM to distribute kits operated in Mutare.

Above: A highly visible indicator of the changes that had taken place in Sakubva was the disappearance of the vast mounds of rotting garbage that were blocking entire streets. Rubbish in the streets was separated, burnt and recycled and within days Sakubva was unrecognisably free from solid waste.

Incredulous City Council

The City Council estimated that the clean up done by the CHC members would have cost US$ 20,000 if they had used their dump trucks and six months of manpower. The point was however, that they had no dumptrucks to deploy and civic support had saved the day. The Council now give contracts for solid waste disposal to the health clubs.

Project Activities:

Adapting the CHC methodology to the cholera emergency, Zimbabwe AHEAD mobilized communities in Sakubva and 10 trainers were deployed. They in turn trained local facilitators who rapidly formed up 36 Community Health Clubs, each with an average of 150 members. Within weeks 5,400 committed members, mainly women, were mobilized to rapidly take control of potential health hazards providing health education to the population as fast as possible. They attended weekly health sessions which focused on all the high risk practices responsible for the transmission of cholera and diarrhoea.  With the reality of cholera, members were focused on the seriousness of the threat and responding above expectation, following all recommended hygiene practices. Hand washing with soap, clean kitchens and safe sanitation were all part of the homework.

Outcomes:

As it was an emergency there had been no time to do a base line survey, so as to monitor the changes as a result of the CHCs. However the very fact that cholera was contained in one of the projected high risk areas, was an indicator that the CHCs had had an impact. The majority of households in Sakubva were practicing the recommended hygiene known to prevent the transmission of Cholera. It had been expected that of all the suburbs in Mutare,  Sakubva would be black spot for cholera. But there only 4 reported cholera cases and no deaths in Sakubva.

ln June the emergency programme was completed with 2,400 people receiving certificates for full attendance of the 20 health sessions. The empowerment of women through this method is ensured, as a critical mass of people have endorsed public health standards to ensure that cholera does not re-emerge in each  rainy season, when cholera is expected to reappear in Zimbabwe, usually from across the border in Mozambique where it is endemic.

Above: The CHC members, mainly women, divided up the settlement, with each household taking responsibility for clearing the debris and ensuring the storm drains along the road were maintained, which kept rain water flowing