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Survival in the time of cholera
Pia Engebrigtsen
February 19, 2009

http://www.health-e.org.za/news/article.php?uid=20032191

Pia Engebrigtsen worked for 2 months as a nurse in Zimbabwe's Masvingo province during the country's cholera outbreak, in which MSF has so far treated more than 45,000 people. Here she shares her story of death, heartbreak, survival and saving lives against all odds.

A quick killer

Dealing with cholera is different than other emergencies I have worked on. It was the speed of it that made it so different. When you enter an area with many people sick from cholera or a clinic completely overloaded with cholera patients, you know lives will soon be lost. Cholera can kill within hours as a result of dehydration, so you have to make very quick decisions. Tomorrow might be too late. This was a different way of thinking from my previous emergency experience. At the same time, we had to make wise decisions. Cholera was literally all over the country and we needed to be consistent in the support we gave.

Cholera patients lie completely still on their beds, while the intravenous (IV) drips that rehydrate them are running quickly. You see they are exhausted. You can often tell just by looking at them how dehydrated they are. Their eyes are sunken and the whites of their eyes will still show even though their eyes are closed.

A day in the life

We used different strategies to help as many people as possible in the large, mostly rural province where we worked. I was part of an exploratory team that visited rural areas affected by cholera to decide whether or not MSF needed to intervene. Sometimes we also went to areas where we didn't know if cholera was present, just to see the situation for ourselves. We had to travel long distances and sometimes slept in the villages.

I really liked going out into the countryside because the people were friendly, but it was never relaxing because we were always expecting to be faced with yet another cholera-affected community. The roads in the countryside were really bad; we sometimes had to struggle even with a four-wheel drive. I would imagine how hard it was for people who only have a donkey cart to transport the sick to a health centre.

The people in the villages were very calm when we arrived. The children were different, of course. They laughed and pointed, and giggled when they touched us.

If there was no health facility in the area, we would sometimes set up our own cholera treatment unit (CTU), which was often the case in the old farm lands that covered huge areas in the bush. We carried the essential equipment in the car - set up supplies such as plastic sheeting, buckets of various sizes, chlorine, cleaning equipment and protective clothing (apron, boots), as well as medical supplies including ringer lactate, oral rehydration salts, IV sets, antibiotics, gloves and first aid kits.

If there was a health centre, we made improvements so they could properly isolate the cholera patients. We trained staff to identify cholera patients from those with another diarrheal disease and to evaluate who needed urgent attention.

We found many patients in a very severe state; many were unconscious without palpable pulses. Then, after a few hours with intravenous fluid therapy, they were able to sit up and talk. You really feel how you save lives, and there are so many patients like this you get to meet. Most patients stay in the centre for 2-3 days, then go home completely cured.

Even so, it was very sad to be there. There were many people we were not able to save as cholera was all over the provinces, many little villages were affected. Sometimes we came too late -- the cholera had already 'burnt its way through- the village by the time we got there. This was the biggest problem - the distances are huge and we were not able to reach everyone in time.

The days were long; we normally worked every day until after midnight. Every day was unpredictable so you had to get as much work out of the way as possible each day. We tended to stay up late each night to finish the days' work.

Welcomed by the community

We felt very much welcomed in the communities. The people have been suffering for a long time without receiving much help from the international community, so I think any type of support would have been welcomed. They were very open and realized the need for help to fight the disease. We drove to isolated villages where we were always met by very hospitable villagers who willingly shared information and their concerns.

The nurses who worked in the local health centres were usually very grateful for our support. Most of them lacked equipment and had not been supplied with essential drugs for a long time, so our trainings and donations made a big difference in their daily work.

Teaching people about cholera

The importance of educating people about how to prevent cholera became increasingly clear to me when I realized that people were dying just because they lacked basic information. They did not know how cholera was transmitted so they could not take preventative measures.

I used every opportunity to talk to community leaders about cholera and make them understand how they could help stop the spread of the disease in their own villages. If we had time, we would also ask the leader to gather the whole community so we could explain what cholera was, how to prevent it and what to do when a person became ill. We also asked them to agree on who would provide an 'ambulance donkey cart' for the village, since most people did not have any means of transportation.

It felt very good to teach people about how to take precautions against cholera. In the beginning, many people would die in the community without having gone to the health centre; many others would arrive at the centre in a very severe state. After health education, patients would come much earlier. People rarely died in the community. The funerals of people who died from cholera were monitored by health staff to help ensure that cholera was not spread there - cholera funerals are a main source of infection in the countryside as people touch the body and then eat together.

How working with cholera changed me

The experience has definitely changed me. Before I came to Zimbabwe, I had not imagined how cruel cholera was, for me it was just an infectious diarrheal disease. Now I know what damage it brings with it. All the suffering made a strong impression on me. So many more lives would have been spared if more international aid had been present.

I think what made the strongest impression on me was meeting parents who had lost their whole families. They could be completely silent, but their eyes spoke of their pain and their hopelessness. I think many of them felt guilty for not having brought their sick family members earlier to the health facilities. But the barriers are so many; lack of money, lack of transportation means, lack of knowledge, huge distances. It is so easy to be the judge afterwards.

I will remember all the people, they were so friendly and good humoured and wise. I cannot imagine how it is possible to keep your spirit up under such hopeless conditions, but somehow they managed. They were strong minded and were not willing to give up. Life or death for a mother and her six children - a cholera story

I was awakened in the night by a phone call from a nurse on night duty who had been told that four children were seen along the road too sick to continue their walk to the nearest CTU.

It is absolutely pitch-dark here at night; we did not know where the children were and we have night curfew, so we had to wait until sunrise to go looking for them. The hours passed slowly while I pictured the children lying sick, frightened and helpless all alone in the dark.

I prepared myself for the worst and together with a national colleague I set off at dawn with first aid equipment and body bags.

We found them in a village after searching for two hours -- six children and a mother who were more or less unconscious. Some of the children we were not able to arouse, while the others were awake but too weak to speak or move. The children were lying in the arms of the mother. Inside the house we found the father dead. We also found their neighbour unconscious.

We started intravenous fluid treatment and we had to get them all urgently to the clinic. I will assume that they all would have been dead if we had come a few hours later. There was not enough space in the car so we had to put them more or less on top of each other to make room for them all. We were about an hour's bumpy drive away from the nearest cholera treatment centre. As we drove the metal floor of the car became burning hot and I tried to gather as many children as possible in my lap while I was also securing airways for them to breathe and making sure that their IV drips were running. Two of the children vomited uncontrollably. I felt so sorry for the family and could not hold the tears back, the reality was too bad.

The neighbour passed away soon after we got to the hospital, but the mother and the children were cured after several days. The mother said that she had lost her husband the same night that she and her children fell ill. Her husband and the neighbour had participated in a funeral for a cholera victim some days earlier. She realized that the disease was deadly and tried to find a way to get to the nearest clinic, which was about 50 km away. But she had no money and her neighbours where not willing to transport her with their donkey carts as they feared contracting the disease. She said she quickly became weak and was no longer able to walk the distance by foot. She was left with no other possibility than to wait for death to come and relieve them. We came the next morning and she said she could hardly believe it when she first saw the car and realised we were coming for them.

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