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Rapid assessment of protection issues within Zimbabwe's cholera epidemic and response
Save the Children
April 2009

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Executive Summary

As of January 15, 2009 the cholera epidemic in Zimbabwe had escalated into a major humanitarian disaster, with a total number of 42,675 cases registered and 2,225 deaths, 56.4% of which had occurred within communities.

The rapid onset and escalation of the cholera epidemic resulted in a response focused on provision of life saving interventions to those infected, and interventions to prevent the further spread of the epidemic. Given the rapid spread of the epidemic and its high morbidity and mortality rates, the Protection Sector Working Group was concerned about the most vulnerable groups within the population, their ability to access prevention / response interventions, and any particular risks they might face. In mid-January the group produced a document giving practical guidance on how to mainstream protection into the cholera response, particularly to high risk groups including children, women, displaced and refugee populations, disabled and PLWHA. To complement this intervention, Save the Children Alliance undertook rapid assessments in two operational areas: Beitbridge and Binga.

These two districts are characterised by their remoteness, absence of water and medical services, and high proportion of cholera-related cases and deaths. The main aims of the assessments were to evaluate the degree to which protection issues (with a focus on child protection) had been incorporated into the cholera response and to better understand the psychosocial impact of the epidemic.

Assessment methodology included focus group discussions, key informant interviews, participation in meetings, and observation. A total number of 150 people participated in the assessment: 42 community members, 61 children, 21 health care staff, and 26 additional stakeholders.

Although the assessment took place in only two geographic areas, it is likely that the issues emerging are reflective of the country wide cholera response, although further data gathering in other cholera affected areas of the country would strengthen the findings.

Key findings:

• Key stakeholders generally felt unprepared, and unable to effectively co-ordinate the response in the initial weeks of the epidemic;
• Although a range of global guidelines exist that promote and support the incorporation of a psychosocial component into emergency health preparedness and response, this issue is being addressed largely through the good will of a few agencies and individuals rather than through a co-ordinated and integrated rights-based framework of action. Impact identified in this assessment has included:
  • The cholera epidemic is further exacerbating the already devastating psychosocial impact of HIV and AIDS in communities and families. The renewed erosion of family livelihoods may result in families adopting coping mechanisms that put their children at risk of abuse, exploitation and other harm
  • The rapid and severe nature of the illness and rules about funeral ceremonies don't give family members including children time to prepare for death or mourn in a culturally acceptable way. The long-term impact on children is enormous.
  • The care and protection of children left at home during their caregiver(s)' hospitalization, or after parental/ caregiver death is not being systematically monitored or addressed
• The high level awareness-raising around cholera has had a positive impact on knowledge levels and hygiene practices although some negative practices continue.
• Children are not being specifically targeted for awareness raising which puts them at risk of a range of protection concerns
• IEC materials are primarily written, making them inaccessible to illiterate adults and children.
• A range of preventive strategies are in place, the approach and intensiveness influenced by available resources, remoteness of locations, and medical opinion about best practice. There are concerns around Doxycyline being used as a prophylaxis
• A range of treatment, care and access challenges exist, which are especially affecting children, the elderly and people living with HIV and AIDs and other chronic illnesses
• Locally collected disaggregated statistics are not being analysed, discussed or used to rapidly inform/modify local-level responses, which puts the most vulnerable and marginalized populations (PLWHA, chronically ill, children, disabled, elderly, etc) at risk of not benefiting as fully as they could from cholera interventions.
• A range of factors exist that may be contributing to ongoing cholera including absence of women and young people in community and district level decision-making structures, absence of children's and adolescents' involvement in prevention and response activities, persistent beliefs that witchcraft is at the root of the epidemic, long distances that sick people must travel to get treatment, "dragging their diarrhea and vomitus from village to village, ongoing migration of people,".

In conclusion, the cholera epidemic has taken in place in the context of a complete breakdown in essential services including water, sanitation and health care. Responses to curtail the epidemic have focused on addressing the water and sanitation situation, raising awareness about prevention and treatment, and undertaking life-saving interventions, all of which have been undertaken in the most challenging of environments. Although these interventions will address the epidemic itself, the psychosocial impact especially on the most vulnerable populations, will be much longer lasting. This has yet to be addressed, as have a number of specific age and vulnerability-related issues.

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