Top line summary
Current trends suggest that Zimbabwe will, in the coming week or two, record its 100,000th case of cholera.
Almost 4,300 people have died of this illness since the outbreak began in mid 2008.
The threat of cholera remains very real for Zimbabwe. The outbreak was born largely as a result of the country's almost entirely collapsed water, sanitation and health systems. These issues have not been addressed.
Reluctant support from donors has undermined the Red Cross Red Crescent cholera operation - forcing a premature down-scaling of emergency operations. The Red Cross Red Crescent is now calling for support for mid to long-term recovery and rehabilitation efforts.
Introduction
In the coming days Zimbabwe will record its 100,000th cholera case. The epidemic has entrenched itself as Africa's worst outbreak in more than 15 years. Almost 4,300 people have now died, and the case fatality rate stands at 4.4 per cent - unacceptably high given that a controlled cholera outbreak is defined by a rate of one per cent or less.
Rates of infection and death have declined markedly over the past one or two months. The reasons for this are varied: the impact of the humanitarian response; the establishment in some areas of interim social services, and; the natural life of any public health crisis.
However, the eradication of cholera in Zimbabwe or the complete conclusion to this current epidemic is unlikely unless the underlying causes of the health crises are addressed. Central to this outbreak remains the almost complete collapse of Zimbabwe's basic water, sanitation and health infrastructure. Communities across the country are still without access to potable water and basic sanitation, and health facilities continue to be understaffed and under resourced.
In January 2009, the International Federation of Red Cross and Red Crescent Societies (IFRC) warned that its cholera operation was at risk as a result of a surprisingly slow donor response. Despite this warning, the operation's original budget of 10.17 million Swiss francs has only been 45 per cent covered.
The IFRC operation - estimated at one stage to have constituted 60 per cent of the country's
entire cholera caseload - has since been downgraded prematurely. The seven Emergency Response Units deployed across the country have been demobilized, with responsibilities assumed by the Zimbabwe Red Cross.
The focus now is on medium to long-term recovery and rehabilitation activities -measures to alleviate the impact of severely degraded civil society infrastructure, such as providing communities with semi-permanent access to clean water and basic sanitation.
The threat of cholera remains very real.
Retreated, not defeated
In December 2008, the World Health Organization (WHO) released a worst case scenario for Zimbabwe's cholera outbreak of 60,000 cases. This figure was quickly passed in February 2009, and the organization soon released new analysis with an upper estimate of above 100,000.
In February of this year, the meteoric rates of infection of December 2008/January 2009 had already begun to slow. Red Cross Red Crescent field assessments from this time highlighted a ruralisation of the outbreak. Where once the crisis had been focused in urban areas - particularly the high density suburbs around the capital Harare - the illness had now taken a foothold in villages and communities across the countryside.
To an extent, this shift explained the slowing rate of infection: fewer people lived in these communities than in the semi-formal settlements surrounding the large cities, for example. But this new trend also brought with it new challenges.
During the urbanized phase of the outbreak, treatment and prevention efforts could be centralized. Cleaned and chlorinated water could be provided to large numbers of people, large treatment centres could service high density areas, and community education efforts could reach whole communities relatively rapidly.
With a ruralised crisis, comparatively more resources, that were more flexible, were needed. The endemic frustrations of operating in Zimbabwe - inadequate transport and communications - also played out more acutely. Aid organizations were often only made aware of community-level outbreaks when their treatment centres were inundated with cases.
In the months since, new cases across the country have declined, though some new flare ups were reported again in and around Harare and other cities. The humanitarian response no doubt contributed to this welcome trend, with cholera treatment centres being established across the country, and millions of litres of clean water being produced. Thousands of community based volunteers have disseminated potentially life-saving public health messages, arming families and communities with the information that they needed to reduce their risk of exposure to cho
But again, the fundamental drivers of this public health crisis remained largely unchecked. The treatment centres and water purification units were only ever interim measures. The steady decline in the spread of the illness should not be seen as a complete victory. Unless significant efforts are made to rehabilitate at least some components of the country's degraded water and sanitation infrastructure, communities remain vulnerable to further and severe outbreaks.