Choléra, Choléra!

Today Dennis is awake and sitting up. Gogo is happy to see me, while Dennis can not take his eyes off the notebook and pen I brought him together with some crayons. I do not understand until later why these are so important to him.

Photo: J Stavropoulou, MSF. | Grandmother

Juliette, the MSF head nurse is here as well. She is the kind of nurse you would want if you are sick. Kind eyes, beautiful face and always with a smile. Dennis is obviously feeling much better today. He had been quite a severely dehydrated case when he came in and had to be put on a drip, which he was still on today but which Juliette hoped they could stop later on. “He’s finally drinking his ORS,” says Juliette with a smile.

Dennis is small for a 10-year old and now he is so thin it makes him look even smaller. He is quiet and polite. I ask him what it feels like to have cholera. “I had a burning in my stomach,” he says rubbing his abdomen just at the memory. “How do you think you got it?” I ask and Juliette helps me with the translation. He is thoughtful for a moment, then says that he thinks it wasn’t anything he ate, but, “because I was playing outside in the rain in muddy water.” I am surprised at his perceptiveness and think that he is probably right – sewage runs openly through the neighborhood and rain would be a great disseminator of the bacteria. “When I go back, I will tell the other kids not to dig through the rubbish,” says Dennis quietly.

Dennis tells me he wants to be a doctor when he grows up so that if his mother gets sick he can take care of her. It was his mother who brought him to the hospital. Even though she had recently given birth, she carried Dennis on her back all the way; they don’t have the money for transport.

I ask him what he would wish for if he had the chance. He looks down at his thin hands resting on the red hospital blanket and says almost in a whisper, “I want to go to school.” When Juliette questions him further he says he can’t go to school because he doesn’t have books, notebooks or pens.

I say goodbye and hope that Dennis recovers fully soon. Maybe next week, once they are back at home, I will try and visit them at their flat in Mbare. For now, I turn and cup my hands in the Zimbabwe indication of gratitude and say, “Mashvita, Gogo, mashvita Dennis.” They both laugh and repeat the same for me.

My assignment today is to find a cholera kid – that is find a child above five that has cholera and whose guardian would allow me to talk to them in order to get a child’s perspective on this disease that has hit Zimbabwe.

My task may seem straightforward, since even today there are a hundreds of cholera cases around the country – over 93,000 total since the epidemic started. And, indeed, only shortly after my inquiry, Juliette, our MSF Head Nurse in Harare’s main Cholera Treatment Center, calls me to tell me that yes, there is a 10-year old kid that was admitted two days ago and I could see him since his guardian agreed.

When I arrive, Dennis refuses to open his eyes when Juliette addresses him. His grandmother, a handsome elderly lady with a crucifix hanging from her front gently shakes his shoulder. “He is pretending,” she says to us with a smile. “He thinks you will make him drink the ORS (Oral Rehydration Salts necessary for recovery).” Gogo (grandmother in Zimbabwean dialect) is about to try and rouse Dennis again, but I confer with Juliette and decide just to come back tomorrow.

Photo: J Stavropoulou, MSF. | 10-year old cholera patient, Denis.

Before I leave, I sit and talk with Gogo a bit, with the help of Juliette translating. Gogo lives in Mbare. This is one of the poorest high-density areas of the capital. It is dusty and dirty; it is where the bus terminal arrives from southern Zimbabwe and where also the whole-sale fruit and vegetable market is located. There are a number of three-storey overcrowded and derelict flats there which our watsan experts have already identified as highly unsanitary. I have already heard stories of sewage pipes burst and flowing into people’s apartments, while toilets are backed-up and completely infested.

Gogo, 69, lives in a small two-bedroom apartment with her two remaining children and nine grandchildren. I stumble on the word remaining and turn to Juliette. “How many children did she have?” I ask. Gogo answers the question matter-of-factly. “She had nine children in total; now only two are alive,” translates Juliette. I ask about their conditions of life. Gogo says there is no one with an income in the house so they rely on Catholic Relief for a monthly supply of basic food commodities.

Gogo’s daughter – Dennis’ mother – just two weeks ago gave birth to another child. That is why Gogo is at the hospital caring for Dennis; the mother is still at home with the newborn. I thank Gogo for chatting and she smiles and graciously inclines her head telling me “mazvita” – thank you.

We finally get to the number we had looked for, but find out that Maria doesn’t live there; it is her brother’s house. He says where she lives there are no numbers that is why Maria uses his address. He offers to show us the way.

Photo: J Stavropoulou.

We drive along the dirt roads between the houses until the road can go no longer. Then we walk along a small footpath through tall bright green grass and maize crops rising up around us. It is hard to believe we are still in Harare. We come to a small settlement of houses, with various children around, some ladies, some chickens, a well.

And then, there is Maria walking towards us, shyly smiling, quite obviously not pregnant anymore. I am so happy to see her, I feared the worst, yet had fervently hoped for the best.

Photo: J Stavropoulou. | Maria's home.

Liliosa explains to Maria that we have come to check up on her and she is clearly astonished. She leads us back to her small home, a one-bedroom wooden structure with a corrugated-iron roof. There on the bed lies a small miracle. Her week-old daughter who Maria proudly says she has named Takudzwa, which means “We have been honored” in the local language. The child is perfect, she is even trying to open her eyes and I swear she smiled when I cooed at her.

Photo: J Stavropoulou. | Maria and baby Takudzwa.

Maria delivered her right there on the bed. Two days after she got back from our cholera camp. She not only didn’t have the money for the hospital fees, she didn’t even have the money (2 USD$) for transport to get to a clinic.

But somehow she only had one hour of labor pains and then Takudzwa arrived. It was a clean birth, no complications.

Photo: J Stavropoulou. | Maria and baby Takudzwa.

The future, though, still lies uncertain. Maria has three other children. The only income she and her sister have is buying fish wholesale and selling it to individuals. But she has no money to go to the clinic for a check-up after the birth, nor has she been able to take the child for its immunization shots.

But still, a small miracle is before us and we all smile down on the baby. Maria says despite it all she is very happy with her daughter.

Remember the pregnant lady I met at the Oral Rehydration Point? A week and a half later, I went to look for her and find out what had become of her and the baby.

“Hey Heidi!” It is always great meeting up with Heidi, our MSF nurse who works at the MSF cholera camps in Harare. Blond hair, big blue eyes, she looks like an angel and has a personality to match. She is never too tired, too stressed, or too busy to dedicate time to patients and their care.

I haven’t seen Heidi for a couple of days and am anxious to find out what happened to Maria, a nine-month old pregnant cholera patient I had met about a week and a half ago.

I had first come across Maria when I accompanied the cholera patient transfer bus on its rounds. She was quite ill when we came to her, lying in a cholera bed in one of the MSF Oral Rehydration Points we have established around in the far-flung townships of Harare. We quickly transferred her to Budiriro Clinic where MSF has set up a Cholera Treatment Center (CTC). Heidi had made sure she got two IV lines right away.

I had asked Maria then if she had the money to pay to register for Anti-Natal Care at any Clinic near her home. She had simply stared at me as if I was delusional – where would she get $50 for the maternity fees charged nowadays by Zimbabwean clinics and hospitals?

When I now asked Heidi what happened with Maria, she just shook her head sadly. “I was praying for her to get into labor while in Budiriro, but it was not happening. And then I begged the [Zim] doctor for two days more after she got over cholera to let her stay. But after then he discharged her. There was nothing I could do against that,” she says and sighs and we both look at each taking a deep breath.

Once patients in cholera camps are cured from cholera they are discharged, even if they have something else. Unfortunately, in almost all instances these patients then have nowhere else to go and no money to afford any other option.

“I’m going to go find Maria,” I decide right there and then and Heidi’s eyes light up. We both agree it would be wonderful to find out what has happened to her. But Heidi cautions me not to be too optimistic.

I arrange for transport and take with me Liliosa, one of our MSF Zimbabwean nurses. She is herself quite pregnant, but extremely active nevertheless and when I explain to her our mission she becomes as enthusiastic as I am to find Maria.

We drive through the neighborhood of Kwadzana. Here, like almost all other townships of Harare, what never ceases to amaze me is its contrast between nice small houses with their carefully tended gardens and fences and the open sewer running freely through the streets. It’s sunny and there are many people walking around, unsurprising with such high unemployment in the country. There are a lot of home-based barber shops, a chair and a mirror with signs like “New Beginnings Hair Saloon” or “Golden Hair Barber”.

We’re looking for just a number. That’s how this works, no street names, just all the houses numbered, sometimes logically, sometimes not. We get directions from a lady that says we have to turn where the telephone booths used to be – Liliosa’s laughs; another of the many features of a deteriorating Zimbabwe.

Back in the car I stare out the window thinking about the situation. I ask Precious if she like so many of her country-people is thinking of leaving the country. “No,” she says shaking her head. “Sometimes it is not about you, it is about the next person, about the next vulnerable person. You have to think about that other person,” she explains.

We reach another section of Mabvuku where 160 households have not had water and electricity for over a year. But worse than this is that not only do their toilets not work, but the sewage blocks up and spills into their houses. “The woman that lives there,” says Precious pointing to a house to our right, “was weeping to me last week in despair because the sewage had covered all the rooms in her house. She didn’t have anything to properly clean and disinfect her home after she cleared the filth.”

“It is by the grace of God that you have found us and we are not dead from cholera,” says Moses, 45, one of the residents of the area. He has used sandbags to block the sewage pipes from backing up into his house.

Precious and I hit the road again and travel to a neighboring settlement called Caledonia Farm. This is so close to Harare, but it is a completely rural settlement, with sand-dirt roads, fields of corn, sunflowers smiling out through deep lush green. Here people were dumped when the government destroyed over 700,000 houses during 2005 in an alleged effort to clean up high-density settlements.

Hardwork Malifande, a resident shows us around. He is a teacher but now he doesn’t go to teach since the government is not giving them adequate salaries to live. He tries to get by through private lessons.

Hardwork walks over to one of the house where MSF has built one of the 200 latrines constructed for this community. Regina is very proud of her freshly-varnished wood latrine and is broadly smiling. “How many families use this latrine?” I ask her. She calculates slowly and answers, “about five families.” Five families! I think how just between my boyfriend and I we get into an argument about the use of our toilet, I can’t imagine five families!

Photo: J Stavropoulou | New latrine.

But Regina is very content, even if it means that the work of keeping the latrine clean falls to her since she is the one living closest. “I am very happy,” she says. “Before I was always travelling a long distance to go to the toilet, but now there is no problem because everything is now in my good hands.”

Hardwork takes us to another homestead where an elderly man and his wife take care of the newly constructed latrine. The man has white grizzled hair cropped short and gnarled hands. He can not speak English, though he seems to want eagerly to share something with me. But he is shy and embarrassed. Finally, as we are about to leave he looks me in the eyes and haltingly says “Thank you.”

Today the sky is turquoise blue with smiling white clouds floating around but all during last night it had been raining. I’m accompanying Georgina one of our MSF nurses. She is 32, pretty with an open smile and neat hairdo of raised cornrows and very determined. She wants to visit one of MSF’s most remote Harare ORPs (Oral Rehydration Points). We have set up 17 all over Harare; basically they are small cholera centers that help patients get access to treatment.

We have gotten to a point where the road just looks like one muddy river. Tinashe, our driver, just shakes his head good naturedly and he sets his cholera-ambulance converted minivan to splash through the mud – we are through! We all laugh relieved. We bob along the dirt road, through fields of maize and soya plantings. This is the summer season in Zimbabwe – everything is lush green, the air is crisp and warm and every other day it rains.

“There’s our ORP,” points out Georgina and in the middle of a field I distinguish a small tarpaulin-covered stand and two ladies sitting inside. When we approach they come out smiling to greet us.

Photo: Joanna Stavropoulou | Residents in high density townships set up small stands selling anything from cookies to soap. Their houses are makeshift shacks covered with tarpaulin.

Mary and Zodwa are in their late fifties and have lived in Hathcliff Extension for decades. They are very happy to see us. They are wearing the plastic aprons we have given them over their neat attire. They show Georgina their notebook where they have carefully recorded who visited their little center, what symptoms they had, how much Oral Rehydration Salts they administered. No visitor today had needed to be transfer to the cholera treatment center for more intense treatment.

Mary and Zodwa work at this little MSF cholera point from 8am to 5pm everyday. They proudly show me around their stand, point where the buckets of disinfecting water is to wash out cups, the ORS solution, where they store the satchels. The MSF stand is standing in the middle of a red-muddy field and yet the tarpaulin placed on the stand’s floor is spotless, everything orderly, clean. The ladies complain that they would like to have a mop, they use their own rags to clean every inch on their knees. They then explain the procedures they follow when a patient comes to their stand, what symptoms they check for, how many hours they keep them under observation, how they decide whether to transfer them or not.

Mary and Zodwa are volunteers; they do not even receive an allowance. I am amazed by their dedication and diligence and can only wonder at what difficulties they must have in their lives and how they are able to put that aside to come and help their fellow residents.

We stay a little bit just to talk to them, of their life, their difficulties. They tell me that now the biggest problem people face is that they can’t pay the fees that clinics and hospitals are demanding; Zimbabwe’s public health care system started charging this past month in US dollars.

“People here, they don’t even know the [US$] dollar,” says Mary with emphasis, “they don’t ever see it, don’t even know its color.”

“But, so what to the people do?” I ask.

“Aah,” she shakes her head, “they just die.”

They told me of one of their neighbors this past week who gave birth at home because she did not have the 50 US$ the clinics are charging for maternity fees. But her placenta didn’t come out and after three days she died.

“At least if they could educate some midwives,” says Mary. But the ones that are around, she explains, don’t know what they are doing. Zimbabwe had such a good health system that everybody had access to health care and local midwifery went largely disused.

We respectfully thank our ladies and Georgina and I jump back in the minivan.

Photo: J. Stavropoulou | MSF community teams inject the right amount of concentrated chlorine into water containers

“Why can’t you fix the whole urban water system,” asks a man as Dominique, MSF’s Water & Sanitation (watsan) expert and I stop at a busy market place in Dzivarasekwa; a Harare township. Our MSF mobile team of bucket chlorinators is here and Dominique wants to see how they are doing. The team goes around and injects disinfecting concentrated solution of chlorine into containers of water that people bring to make sure the water is safe to drink.

The market is busy. Small stands under umbrellas are selling anything you can imagine. From vegetables, especially mangoes and avocados, to shoes — but with only one of the pair displayed (to utilize better the space, to assure that they are not stolen?). I am standing next to a vegetable stand behind which is running a river of open sewage. The stench is so overwhelming that I am turned off from buying any fruit. I am talking to the lady who owns the vegetable stand. The man who had asked the question is standing idly nearby, like so many unemployed people in Zimbabwe.

The lady agrees. “Is it for life, is it forever this treatment you are doing?” she asks. I explain that no, that we are an emergency organization that is here to help with the cholera epidemic. She says she doesn’t want to chlorinate her water. I am a little stunned but try not to show my reaction because I want to understand. “But aren’t you afraid that you will get sick?”

“But then when you stop giving this we will be affected even more than before,” she explains. The man agrees, adding laughing, “We are resistant like wild dogs; we’ve been drinking unsafe water for a long time.”

Dominique overhears our conversation. He is passionate about clean water, about his job, about keeping people safe — he tirelessly and zealously checks water systems, problems areas, possible sources of infection, he never stops, never quits. I wonder if he will react impatiently because truth to tell I was feeling a little impatient myself with this attitude expressed by the people. But Dominique takes 20-minutes to reason with Jane. On and on he talks to her, about the importance of sanitation, about keeping her four kids safe, about clean water. I look on smiling — how long will she resist? She finally has to agree simply from the force of the argument. One more family saved?

Photo: Joanna Stavropoulou | Dzivaresekwa is a typical high-density township of Harare with open sewage running throughout its streets.

Dominique and I go off in the MSF minivan towards Dziva extension. The area is in its summer rainy season lush green has small shacks built along muddy roads and some half-built brick buildings. We stop at one of the shacks and this one, like all the others in the area has its own shallow well. Amai Trust seems to be the head of the household. Tall and proud she shows us her well. The compact dirt of her small compound is well swept, a line of clothes is hanging out to dry, a well tended vegetable garden by the side of the well. The children around are barefoot and with sparse clothing, but they are well-behaved.

Photo: Joanne Stavropoulou. | Most households in Dzivaresekwa Extension have their own wells. Because these are usually very shallow they run a high-risk of contamination.

Their well is no more than a meter or two deep, with a tire to make the opening and a make-shift tap to cover the opening. Dominique asks where the toilet is and everyone turns around to laugh between themselves; “they always laugh when I ask,” says Dominique smiling at me. The latrine is no more than ten meters away from the well. “It rains, the water flows from latrine to well, people walk around, or they leave the bucket on the ground then dip it into the well,” explains Dominique. I ask Amai Trust if she boils the water. She doesn’t understand but Revayi our driver helps to translate. “No,” he explains for her after conversing, “there is no electricity in this area and firewood is very expensive and precious. There is no way for her to boil water.”

A crowd has gathered around our MSF minivan and they are laughing. I ask Revayi why they are laughing. “They are afraid to touch our car,” he says smiling, “because they say if they do it will infect them with cholera.” I shake my head at the irony of this.

“Coléra, coléra!!” shout little Zimbabwean kids running after our MSF minivan as it splashes through sewage soaked muddy roads in the high density Harare township of Dzivaresekwa (or Dziva or just Dizzy as some expats have started calling it). Revayi our driver laughs and puts the music up higher. He usually works his minivan as a combi (privately owned transport for locals). “What’s your name mean Revayi?” I ask him as I try to hold on in the back seat — all Zimbabwean names mean something. He says it means bad gossip, because his mother-in-law talked bad about his mother while she was pregnant so in revenge she named her son like that. Dominique turns around and we look at each other, both rather stunned with the explanation and not really knowing how to respond.

Photo: J Stavropoulou | The collapsing water and sanitation system in Zimbabwe has been one of the prime causes of the cholera epidemic in the country. People in Dzivaresekwa Extension don't have running water or electricity.

I change the subject and ask Dominique to tell me about his field of water sanitation and the project of trying to get safe and clean water to Harare’s most vulnerable residents. Dominique, French-Canadian, young and crazy obsessed with water. Any kind of water, dirty, clean, sewage — with dark thick hair and intense brows he gets easily carried away about his favorite subject.

He tells me how in this township of Dziva that we are going through they do actually have tap water, but because the system is so damaged, with pipes burst and pumps not functioning properly, that there is no pressure. This has allowed the sewage, which is running freely everywhere from its own bust and backed up pipes, to infiltrate the water system. People are literally drinking their own excrement. “We could smell the sewage in the tap water,” he says and as we splash through another open sewer in the street and the stench fills our minivan it is not very hard to imagine.

We stop at an MSF water point where our teams use a concentrated solution of chlorine to inject into people’s water buckets and thus disinfect the water. There are a lot of people walking around, kids (school has started again in Zim but there are no teachers), men and women (80% unemployment). Many try and sell anything, small cardboard boxes under rainbow colored umbrellas; mangoes, tomatoes, avocados.

Dominique is talking to the chlorinators. He is intense but he also laughs with them and they all want to know when he will be back to check on their work. I wander into a nearby house. People are always so friendly here in Zimbabwe. The people of this house come up to greet me and I ask them if they have problems with water. One of the men of this 9-people home (children, aunts, brothers) shows me their tap. It is dripping into a bucket and he says that is how the pressure has been since last year. He says they cannot wash things like blankets anymore, it would be impossible. “What about your toilet?” I ask. “Toilett?!” he cries in frustration, “it has been backed up for more than a year” he says. “Sometimes it overflows and we have to empty it with buckets.” He shows me the latrine. I look down into a dark greenish mass and I think my eyes are playing tricks on me, or the light is funny because it is almost as if it is moving, but it can’t be. I hold my breath and squint a little closer. Then, I jerk back in shocked disgust; it is a mass of thousands of maggots seething everywhere. I quickly exit.

I ask him if they have any money to get by. He sends one of the women into the house and she comes out with a pay slip. He wants to show me. He earns 13,742,381,818.1 Zim dollars a month. It looks like a lot on paper but unfortunately 13 trillion Zim dollars is less than 1 US$ today. Tomorrow, even less.

Photo: Joanna Stavropoulou

I thank the whole family, take some photos of the kids and to their absolute delight show them the result and rejoin Dominique.

Joanna Stavropoulou

Joanna has lived in Harare for over a year now. Her work as a Field Communications Officer for MSF has taken her to different parts of Zimbabwe, where she spent a substantial amount of time in Bulawayo and Beitbridge. Her daily life and the work with MSF in Zimbabwe – ranging from HIV programs to emergency response – has instilled in her a deep appreciation for the country, its culture, and people. Previously she has worked as a free-lance journalist, writing from various countries like Ethiopia and Sri Lanka, and was a radio presenter in Athens. The 39-year old is of Greek-American heritage, used to be part of the Greek National Modern Pentathlon team, loves to explore and discover new worlds, and to share her experiences with others.