JOHANNESBURG, 19 December 2008 (IRIN) - The alarm was first raised about a fresh cholera outbreak in Chegutu, about 100km southwest of the Zimbabwean capital, Harare, on 10 December. Help did not arrive until three days later.

"When we got to the site it was horrific – 50 people had died within two days, there were only two nurses, and there were dead bodies everywhere," said an exasperated Georges Tadonki, head of the UN Office for the Coordination Humanitarian Affairs (OCHA) in Zimbabwe.

Custodia Mandhlate, representative of the World Health Organisation (WHO) and chair of the Zimbabwe Health Cluster responding to the cholera epidemic, said her team was struggling with failing communciation networks, and the incapacity of government agencies to stem an outbreak that was "out of control" and has claimed more than 1,000 lives.

The country's health system has collapsed, the government is broke, and the inflation rate is unofficially in the trillions of percent. It is a "very complex problem", said Tadonki.

Nurses and doctors have been on strike for months, so "there are hardly any medical personnel at work – they refuse to come to work for a salary which cannot even buy them a loaf of bread."

The scale of the crisis was also overwhelming, said Mandhlate. "Cholera cases have been reported in 9 out of 10 provinces," which also made it difficult to anticipate the next outbreak.

Cholera epidemics have been occurring annually in Zimbabwe for the past decade.

"Since 2003, at least two outbreaks have been recorded every year," said Mandhlate. The recent outbreaks have been attributed to the failing water and sanitation systems, left unmaintained as a result of the country's economic meltdown.

Urban residents, who are forced to rely on the dilapidated water systems, are more at risk of large outbreaks; on the other hand, rural Zimbabweans living in isolated districts may be more at risk of dying from cholera because of their distance from medical help, according to the WHO.

Besides a lack of capacity, the emergency response is being hampered by insufficient emergency stocks of drugs, materials and supplies, a lack of vehicles and fuel, and lack of food for staff and patients, the health cluster said.

What has to be done

"There is of course the humanitarian response to the current emergency, but it has to be a mixture of responses which would provide for the transition to whatever recovery is needed," said Mandhlate.

On 18 December the Zimbabwe Health Cluster released a US$19 million Cholera Outbreaks Co-ordinated Preparedness and Operation Plan to help it respond to the crisis.

The plan includes giving medical personnel incentives to resume work, such as "topping-up" their salaries; a functional early-warning system, and helping to capacitate district and provincial laboratories. "We are also looking at providing food to medical personnel to get them into work," said Tadonki.

Zimbabwe's Ministry of Health and Child Welfare, UN agencies, and international NGOs such as World Vision, the International Organisation for Migration, Doctors Without Borders from Spain, Holland and Luxembourg, and other local NGOs form the cluster.

According to the plan, the country hopes to build up national and provincial stocks of water, sanitation and hygiene supplies and medicines to allow a quicker response, as well as an emergency reserve fund to facilitate the deployment of personnel.

Tsitsi Singizi, a spokeswoman for the UN children's fund, UNICEF, said the agency was providing safe, clean drinking water to affected communities.

"We have been providing 360,000 litres of safe water every day, now we have managed to procure enough water-treatment chemicals to take care of the entire country's need and have started distributing it," she said.

The first of seven planned Red Cross emergency response units (ERUs) have arrived in Zimbabwe. The ERU is a team trained and equipped to handle emergency humanitarian scenarios, and can be mobilised and dispatched with optimum speed and is fully self-sufficient.

Typically, ERUs are only deployed in the most critical humanitarian situations, such as the Indian Ocean tsunami in 2004 and the Pakistan earthquake in 2005.

The first team to arrive on a charter flight into Harare, sent by the German and Austrian Red Cross, specialises in providing improved access to clean water, and is tasked with improving sanitation and hygiene. The remaining six ERUs are expected to arrive in the next few days to provide basic health care, mass sanitation, and water and sanitation.

But getting it altogether

Yet the biggest challenge is that "it is extremely difficult to plan ahead," said Tadonki. "The level of [donor] confidence in the country is very low, so it is extremely difficult to negotiate with donors to try to convince them."

The uncertain political situation was also aggravating the situation. "There is an urgent need to resolve the political crisis - it is making it very difficult for us," he added.

Zimbabwe has been "hit by so many crises" in 2008 that the humanitarian agencies have not had much time to breathe. "We had political violence at the beginning of the year, then the numbers of people who were displaced as a result, and it just continued," Tadonki commented.

Bringing humanitarian staff into Zimbabwe to build capacity has also been problematic, and a team of French specialists was recently denied access. "The government has a say on who comes in and who doesn't," Tadonki said.

UN Secretary-General Ban Ki-moon told journalists on 17 December that the Zimbabwean government had indicated "the timing is not right" for him to dispatch a special envoy to assess conditions in the country, including the cholera epidemic.

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