Cholera Exhausts Zimbabwean Health Care System

In December, the World Health Organization's worst-case scenario for Zimbabwe's cholera outbreak was that 60,000 people might become infected before the end of March. But already, nearly 70,000 cases of cholera have been reported.

Despite the fact that cholera is relatively easy to treat and to prevent with basic hygiene and appropriate sanitation, more than 3,300 people have died of the disease since the outbreak began in August 2008, according to the WHO.

A simple treatment of oral rehydration can save most lives, but health experts who have visited Zimbabwe recently say those measures simply aren't available because the economy is in meltdown.

Under the present circumstances, it's easy to forget that Zimbabwe once had one of the best health systems in Africa. That may have contributed to current problems, according to Dominique Legros, the WHO's director of Disease Control in Emergencies.

Because the health system worked, Zimbabweans weren't familiar with the disease when the current outbreak started.

"It's a country so developed that they had very few cases of cholera," Legros says. "Over the last year, they had small outbreaks they managed to control in a few weeks."

"Contrary to some countries, the population [of Zimbabwe] as well as the health care workers were unfamiliar with the way to prevent it and the way to treat it," he says.

WHO is beginning a campaign to educate the public and distribute oral rehydration kits and tablets to decontaminate water.

Facilities Mostly Intact

Legros says he was impressed that the health facilities were still in good shape when he visited Zimbabwe in December, despite the fact that many had no electricity or running water.

"What I have seen are well-trained health-care workers and decent facilities," he says. This is something quite different from countries that have experienced long-term war, he says.

Unlike other countries where the health infrastructure is devastated, Legros says, Zimbabwe won't be starting from scratch — if and when measures are taken to improve the situation.

Simple things are most needed, he says. Things like paying the workers and getting them needed medical supplies, including masks and gloves.

More Than Cholera

A team of Americans and South Africans investigating the situation for Physicians for Human Rights found that Zimbabwe is not just facing a cholera epidemic, but a series of health crises.

Dr. Chris Beyrer of Johns Hopkins University, who was on the team, said he saw one nurse at a rural clinic who was trying to help two women in labor but didn't have needles or sutures.

"The nurse said, 'I have nothing for pain for these women. I have no antibiotics. I have nothing for post-partum hemorrhage.'"

Beyrer says that if one of the women had suffered a tear during delivery, the nurse would have had no way to repair it.

Even before this crisis, Zimbabwe had a high caseload of people infected with HIV. The rate of infection among adults is estimated at 15 percent, according to the WHO.

For every person dying of cholera, Beyrer says, another 10 people are dying of AIDS.

Beyrer was particularly concerned about people with HIV, because they were running out of anti-AIDS medications.

Worse than that, Beyrer says, HIV patients told the team of visiting doctors that the combinations of drugs they were taking were repeatedly changed.

"So, people are being switched on drug regimens, sometimes every two weeks," he says. Patients were getting "all the negative effects of being on different drugs without the benefits."

They ran the risk of generating another public health problem because swapping antiretroviral drugs causes resistance. The same thing is happening with the drugs for tuberculosis patients.

Proposing A Solution

To remedy the situation, Physicians for Human Rights recommends that Zimbabwe's sanitation system be put in receivership — and run by international health organizations — while the government is in transition. Humanitarian assistance to treat cholera has been pouring in, but has not significantly reduced the death rates.

Despite news reports of health workers abandoning health facilities, Beyrer says he found a tremendous number of doctors and nurses still trying to do their jobs, even though they hadn't been paid in months.

A physician showed Beyrer her pay stub.

"Her monthly salary came out to about 36 cents (U.S.)," he says. "Their monthly salary is now worth less than the one-way bus fare to the bank to pick it up."

Both the WHO and Physicians for Human Rights acknowledge that the political situation makes it difficult to get money to workers who need to be paid in dollars and other foreign currency, since the Zimbabwe dollar is virtually worthless.

Some nongovernmental organizations such as the Global Fund to Fight AIDS, TB and Malaria, and the World Food Program are still operating in the country. But the assistance often does not reach some provinces of the country, all of which have been affected by the catastrophe.

As for the WHO's worst-case scenario now, it is that these conditions will become endemic if the country's water supply and health care systems are not repaired. Once past the rainy season in March, the threat of a malaria outbreak looms.

Read the article by the Physicians for Human Rights or the press release from the World Health Organization.

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