VZCZCXRO8088
OO RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHSB #0744/01 2601455
ZNR UUUUU ZZH
O 171455Z SEP 09
FM AMEMBASSY HARARE
TO RUEHC/SECSTATE WASHDC IMMEDIATE 4911
RUEHSA/AMEMBASSY PRETORIA IMMEDIATE 5735
INFO RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEHGV/USMISSION GENEVA 2322
RUCNDT/USMISSION USUN NEW YORK 2001
RUEHRN/USMISSION UN ROME
RUEHBS/USEU BRUSSELS
RHEHAAA/NSC WASHINGTON DC
RUEKJCS/SECDEF WASHINGTON DC
RHMFISS/JOINT STAFF WASHINGTON DC

UNCLAS SECTION 01 OF 04 HARARE 000744 
 
SIPDIS 
AIDAC 
 
AFR/SA FOR LDOBBINS, BHIRSCH, JHARMON 
OFDA/W FOR ACONVERY, CCHAN, LPOWERS, TDENYSENKO 
FFP/W FOR JBORNS, ASINK, LPETERSEN 
PRETORIA FOR HHALE, PDISKIN, SMCNIVEN 
GENEVA FOR NKYLOH 
ROME FOR USUN FODAG FOR RNEWBERG 
BRUSSELS FOR USAID PBROWN 
NEW YORK FOR DMERCADO 
NSC FOR CPRATT 
 
E.O.  12958: N/A 
TAGS: EAID EAGR PREL PHUM ZI
SUBJECT:  USAID/OFDA FIELD TRIP REPORT: MITIGATING CHOLERA IN 
BULAWAYO THROUGH COMMUNITY WASH PROGRAMS 
 
REF:  HARARE 486 
 
HARARE 00000744  001.2 OF 004 
 
 
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SUMMARY 
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¶1.  SUMMARY:  In mid-August, staff from USAID's Office of U.S. 
Foreign Disaster Assistance (OFDA) met with implementing partners, 
beneficiaries, city officials, and United Nations (UN) personnel in 
Bulawayo, Zimbabwe's second-largest city, to assess current water, 
sanitation, and hygiene (WASH) conditions and evaluate USAID/OFDA 
contributions to Bulawayo's relatively low cholera rates during the 
nationwide 2008/2009 outbreak.  City officials noted that without 
the assistance of USAID/OFDA and other donors, Bulawayo would likely 
have suffered much higher cholera rates during the 2008/2009 
outbreak.  USAID/OFDA staff visited a number of ongoing, 
well-implemented, USAID/OFDA-funded projects to provide water 
storage and continue support for community mobilization and hygiene 
awareness efforts.  Although the underlying factors that could 
contribute to another cholera outbreak in Bulawayo remain unchanged, 
city officials, implementing partners, and UN staff predict lower 
cholera rates in the event of a 2009/2010 outbreak due to better 
preparation by the city and implementing partners and heightened 
cholera and hygiene awareness in communities.  USAID/OFDA continues 
to support WASH activities in Bulawayo and throughout Zimbabwe 
designed to mitigate the risk of cholera and other waterborne 
diseases.  END SUMMARY. 
 
------------------------------------ 
CONTEXT AND USAID/OFDA WASH STRATEGY 
------------------------------------ 
 
¶2.  From August 2008 to July 2009, Africa's largest cholera outbreak 
in 15 years struck Zimbabwe, resulting in nearly 4,300 deaths and 
nearly 98,600 cases nationwide.  Poorly maintained water and 
sanitation infrastructure contributed to the scope of the outbreak, 
and Zimbabwe's fragile health system was unable to treat patients 
adequately.  In response, USAID/OFDA committed more than USD 7.3 
million in emergency assistance to support the provision of 
emergency relief supplies, WASH and health interventions, hygiene 
promotion and social mobilization activities, and humanitarian 
coordination and information management to improve epidemiological 
reporting and analysis. 
 
 
¶3.  USAID/OFDA has supported WASH activities throughout Zimbabwe 
since fiscal year (FY) 2007, as the increasingly irregular provision 
of water and sanitation services heightened the potential for the 
spread of waterborne diseases such as cholera.  The case of Bulawayo 
demonstrates the merits of community-based WASH interventions, the 
focus of USAID/OFDA's WASH strategy for Zimbabwe.  For the past 
several years, Bulawayo has suffered inconsistent water supply and 
has a sewage system that functions poorly, like those in most 
Zimbabwean cities.  In 2007, the city suffered a diarrheal disease 
outbreak as a result of a severe water shortage that prompted relief 
agencies, including USAID/OFDA, to increase WASH intervention 
activities.  Since 2007, USAID/OFDA-supported programs in Bulawayo 
Qactivities.  Since 2007, USAID/OFDA-supported programs in Bulawayo 
have included: hygiene promotion activities to raise awareness; 
social mobilization to increase community reporting of cholera cases 
and sewage system breaks; distribution of soap and other hygiene 
supplies; provision of water storage tanks and water containers to 
schools and houses; and provision of water purification materials 
for community and household use. 
 
¶4.  During the 2008/09 cholera outbreak, the metropolitan Bulawayo 
area recorded 445 cases and only 18 deaths, rates significantly 
lower than other urban centers.  By comparison, Harare, the capital, 
and Harare's high-density suburbs and dormitory towns recorded 
nearly 19,600 cases and more than 650 deaths.  Several factors 
played a part in keeping Bulawayo's rates comparatively low; among 
them were ongoing USAID/OFDA support for WASH activities in the 
city. 
 
HARARE 00000744  002.2 OF 004 
 
 
 
--------------------------------------------- --- 
COOPERATION BETWEEN THE CITY AND RELIEF AGENCIES 
--------------------------------------------- --- 
 
¶5.  During meetings with USAID/OFDA staff, city officials noted that 
without the assistance of USAID/OFDA, other donors, and relief 
agencies, Bulawayo would likely have suffered much higher cholera 
rates during the 2008/2009 outbreak.  On August 13, 2009, Bulawayo 
Mayor Thaba Moyo stated that "our partners came to our rescue.  We 
managed to keep the figures down -- a big achievement as compared to 
other regions."  According to the city's Director of Health 
Services, Dr. Zanele Hwalina, "a combined effort" helped protect 
Bulawayo.  City councilor James Sithole, representing Makokoba, a 
high-density suburb, noted that "government cannot win the war 
against cholera on its own; the war was won because of relief agency 
involvement." 
 
¶6.  In general, USAID/OFDA staff noted exceptional cooperation 
between USAID/OFDA-funded non-governmental organizations (NGOs) and 
the Bulawayo city government -- a notable difference from the 
anti-NGO rhetoric and harassment typical of the national government 
in 2008.  Mayor Moyo stated to USAID/OFDA staff that "the residents 
of Bulawayo appreciate your assistance" and noted that the city 
government had made office space available to USAID/OFDA partners. 
In addition, the Mayor noted that USAID/OFDA partners provided tools 
and protective clothing to assist the city in collecting refuse, 
thus improving sanitation.  Dr. Hwalina expressed the hope for 
further cooperation between the city and NGOs, not only in the WASH 
sector, but also in the health sector, in which health NGOs 
organized and seconded staff to cholera treatment centers and 
assisted with epidemiological analysis and reporting.  Staff from 
Lead Trust, the local partner of USAID/OFDA partner Oxfam-Great 
Britain (Oxfam-GB), provided an illustrative example f the city 
government's commitment to working with NGOs to improve WASH 
conditions: in schools with USAID/OFDA-funded water tanks, the city 
provides the water free of charge, not wanting to limit the schools' 
ability to store water for students' and faculty members' use. 
 
--------------------------------------------- - 
SOCIAL MOBILIZATION TO RAISE HYGIENE AWARENESS 
--------------------------------------------- - 
 
 
¶7.  According to Dr. Hwalina, "the reason we managed to control 
cholera was the very high level of awareness."  Shadreck Khuphe, the 
UN Children's Fund (UNICEF) WASH coordinator in Bulawayo, noted that 
social mobilization programs and hygiene awareness programs funded 
by USAID/OFDA and other relief agencies in 2007 and 2008 meant that 
residents' associations "already had the best network for 
distribution of hygiene promotion materials" once cholera struck. 
Before and during the cholera outbreak, Oxfam-GB and Lead Trust 
reached approximately 127,000 people through social mobilization 
trainings, distribution of hygiene promotion materials, and 
Qtrainings, distribution of hygiene promotion materials, and 
distribution of hygiene supplies and other emergency relief 
commodities. 
 
¶8.  In Mzilikazi, one of the oldest high-density suburbs of 
Bulawayo, USAID/OFDA staff met with community sanitation committee 
members organized by USAID/OFDA partners.  The committee discussed 
the importance of mobilizing neighborhoods.  Committee member 
Cynthia Shirto noted that "we visit schools, asking about problems 
of burst pipes, which we report to the local councilor, and we 
conduct hygiene awareness presentations for students, who in turn 
teach parents."  Ms. Shirto also noted that once the cholera 
outbreak began, "we learned that we must not just sit around, but be 
active for the benefit of the whole community."  In addition, 
community sanitation committees and residents' associations help 
distribute soap and other hygiene supplies, including cotton wool, 
supplied by USAID/OFDA and implementing partners.  According to Ms. 
Shirto and others, committee members volunteer up to two hours per 
day in service of the community. 
 
HARARE 00000744  003.2 OF 004 
 
 
 
--------------------------------------------- ----- 
ONGOING ACTIVITIES TO PROVIDE BACKUP WATER STORAGE 
--------------------------------------------- ----- 
 
¶9.  The inconsistent water supply in Bulawayo, due both to general 
water shortages in the drought-prone region and to leaks and burst 
pipes, necessitates community water storage.  USAID/OFDA has 
provided ongoing funding for provision of large water tanks to 
schools, community centers, and the homes of particularly vulnerable 
inhabitants.  On days when water flows in the municipal system, 
schools and households fill the tanks, providing backup water 
storage for days when the city taps run dry. 
 
¶10.  USAID/OFDA staff visited several schools benefiting from 
USAID/OFDA-funded water tanks, including Lozikevi Primary School in 
Bulawayo's high-density suburb of Nguboyenja.  According to 
headmistress Letty Mpofu, the availability of backup water means 
that children need not bring water to school.  Mrs. Mpofu also noted 
that the school no longer occasionally cancels the school day for 
lack of water.  Equally important, having a constant supply of clean 
water for hand-washing and drinking lowers the risk of cholera 
transmission.  USAID/OFDA-funded distribution of hygienic household 
water containers, such as 20-liter jerry cans, facilitates the 
storage of clean water. 
 
-------------------------------- 
OTHER FACTORS CONTRIBUTING 
TO LOW CHOLERA RATES IN BULAWAYO 
-------------------------------- 
 
¶11.  During meetings with UNICEF WASH staff, Lead Trust, and city 
officials, USAID/OFDA staff learned of other factors that 
contributed to Bulawayo's comparatively low caseload during the 
cholera outbreak.  According to UNICEF, Bulawayo's longstanding 
water shortages, dating back decades, led to strong community 
awareness of the need to conserve water.  Furthermore, during the 
2008/2009 cholera outbreak, neighborhoods never ran dry for more 
than 24 hours due to conscientious efforts by the city government to 
keep treated water flowing through the system.  According to Dr. 
Hwalina, "the availability of good, quality water, in good 
quantities, was contributory" to low cholera rates.  In addition, 
the topography of the Bulawayo metropolitan area resulted in limited 
contamination of the water system by sewage, since sewage emanating 
from depleted sanitation infrastructure tends to flow to the north, 
in the direction of the watershed, whereas the dams that supply 
Bulawayo's water are located to the south of the city.  Finally, 
both the Mayor and UNICEF WASH staff noted that Bulawayo 
successfully resisted attempts by the Zimbabwe National Water 
Authority, controlled by the national government, to assume control 
of Bulawayo's water system.  However, UNICEF, relief agencies, and 
city officials all reiterated that despite these additional factors, 
WASH activities funded by USAID/OFDA and other donors played a 
critical role in mitigating the effects of cholera in Bulawayo.  The 
Qcritical role in mitigating the effects of cholera in Bulawayo.  The 
fact that such efforts started as a result of the diarrheal disease 
outbreak in 2007, a year before the nationwide cholera outbreak, 
played a key role in helping the city and relief agencies develop 
cholera preparedness and coordination mechanisms. 
 
------------- 
LOOKING AHEAD 
------------- 
 
¶12.  UNICEF voiced concerns regarding the potential for a renewed 
cholera outbreak during the next rainy season, which is likely to 
start in November or December.  Bulawayo's sewage system remains in 
a state of collapse; of 10 treatment plants, most were operating at 
less than half capacity as of August 2009, according to UNICEF.  In 
addition, much sewage fails even to reach the treatment plants due 
to blockages in the system.  Since the sewage system is water-based, 
lack of water results in lack of pressure, leading to solidifying of 
waste.  Bursts throughout the water system result in a water loss of 
 
HARARE 00000744  004.2 OF 004 
 
 
at least 30 percent, and the city has stockpiled water treatment 
chemicals sufficient for only three months in the event that ongoing 
UNICEF funding for provision of such chemicals comes to an end. 
However, UNICEF informed USAID/OFDA that efforts are ongoing to gain 
donor support for continued provision of chemicals, and UNICEF 
expressed optimism that water treatment needs will continue to be 
met for the foreseeable future. 
 
¶13.  Bulawayo's water and sanitation infrastructure thus remains 
poorly maintained and in need of large-scale rehabilitation.  As the 
rainy season -- a period when waterborne disease incidence tends to 
increase -- approaches, relief agencies and city officials alike 
note that while the underlying risk factors for a renewed cholera 
outbreak have not changed, given the city's limited resources to 
rehabilitate aging systems, the levels of awareness and preparation 
amongst city authorities and humanitarian organizations have 
increased greatly.  As Mayor Moyo states, "prevention is the best 
cure."  Hygiene promotion and awareness-raising, social 
mobilization, soap and hygiene supply distribution, water tank 
provision, and other WASH programs funded by USAID/OFDA and other 
donors helped limit Bulawayo's rate of cholera in 2008/2009. 
Continued support for the same activities will likely help reduce 
the risk of cholera transmission in 2009/2010.  In FY 2009 to date, 
USAID/OFDA has committed more than USD 8.5 million for WASH 
programming throughout Zimbabwe to improve community resilience to 
cholera and other waterborne diseases and to help mitigate a 
potential recurrence of cholera.  The experience of the residents of 
Bulawayo bears out the wisdom of community-focused WASH programming 
as a means to limit the scope of a potentially devastating disease. 
 
 
PETTERSON