Executive Secretary, SADC: Attention Director for Social and Human Development Gaberone Botswana Dear Sir Re: SADC Ministers meeting on the cholera situation We welcome the news that South Africa is hosting a meeting of health and water affairs ministers of Southern African Development Community (SADC) to look into the cholera outbreak in Zimbabwe and in the region on Thursday 11th December. We also appreciated the news that several SADC countries have contributed resources to the response in Zimbabwe. This is an important signal of regional networking and of the functioning of the SADC Protocol on Health. We understand that a SADC team has been to Zimbabwe to assess the situation and a SADC cholera information centre established. We would be grateful to receive updates from the information centre so that we can assist in disseminating information on the epidemic and the response within the region. We are concerned, as others are in the region, both at the delay in official recognition and communication of the scale of the epidemic and that the reported numbers do not represent the full scale of the epidemic or the fatality, particularly given the rapid progression to mortality and that many people do not have the money or transport to get to services. We agree with public health personnel who project that the numbers will rise as the rains become more frequent, as people use groundwater in the absence of safe water sources. The incidence of cases has been attributed from various official sources to poor water and sanitation coverage- with urban services not functioning due to failure of treatment processes, lack of power to pump supplies, breakdown of urban supplies leading use of shallow wells that are not disinfected, people purchasing contaminated water, run down sewage facilities in high density areas and poor sanitation in rural areas. The general economic breakdown, collapse of infrastructures, shift to informal markets, including for food has left people vulnerable. We also note that poverty has also pushed people out of a water supply system that was commercialised with charges at increasingly unaffordable prices for low income residents. Residents associations and health civil society in Zimbabwe have for more than a year been raising the risks of the commercialisation of ZINWA and the breakdown of services. For this reason we express concern at a media report on Dec 8th citing the Ministry of Water Resources and Infrastructural Development that the Zimbabwe National Water Authority (ZINWA) would from January be issuing water bills in foreign currency, as this will further exacerbate the cost situation, even if supplies are improved. The rapid spread of cases and high case fatality rate (over 3.5% and some estimate higher due to unreported deaths) have been reported to be linked to poor capacity in local primary health care services – drugs, staff etc- undermining treatment and leading infected people to move for treatment, spreading cases; lack of fuel and transport leading to people not getting to treatment, and infection through home care, burials etc. We note that people are suffering from poor immune status and poor nutrition due to chronic food insecurity making them more vulnerable. While people may not have been aware of the need for early rehydration, we are concerned that sugar and salt for local rehydration fluids is not available or affordable making people very dependent on distributed ORS salts. Criticism has been raised of the delay in the official response to the epidemic, with two weeks elapsing from the break up of the health worker protest that drew attention to the emergency nature of the situation on November 19th to the Government announcement of a national emergency reported on December 4th. Advocacy on the unsafe water and sanitation situation and need to strengthen the primary health care services has however been taking place for some time, from parliament, civil society and professionals. It is not only the delay in recognising the crisis that concerns us, but the delay in responding to the determinants of the crisis that we hope the SADC meeting will also address. We recognise that the response to the immediate humanitarian situation is the most urgent focus of attention. We hope that this SADC meeting will also set action on the determinants of the epidemic, and engage the resources of the region, including ourselves, on: 1. Strengthening the ethical, capable public health leadership of the response, to ensure that information on the situation is obtained from all communities, that primary health care centres obtain communication means (mobile phones etc) to report on cases, that information is publicly reported, and that planning and organisation of the response is done with involvement of state, national civil society, health workers and international agencies. We also ask that specific commitment be given to protecting those that report or raise health problems, to protecting the security and health of health or relief workers, and to preventing any obstruction of access to health inputs or health care. 2. The measures that are being taken to secure and deliver immediate responses to the epidemic at widest level, drawing on resources within and beyond the region. We recognise the potential for invoking of the public health laws to prioritise use of national resources for this, i.e.: • To ensure at national and regional level that all public sector primary health care level centres in cholera prone areas in the region to have cholera kits, including antibiotics, rehydration fluids and protective clothing, and support for emergency transport (fuel and vehicles). • To support deployment of volunteers (including retired health workers) with training and provision of protective clothing • To support civil society roles in the distribution of information, oral re-hydration salts and solution (ORS), water purifiers • To ensure adequate reserves of water treatment chemicals for all urban local government areas, including at national and regional level • To support households affected by illness, including for safe burials, provisioning of blankets to replace those destroyed and supplementary food. 3. The measures that are being taken to avoid wider imminent problems and address determinants of the epidemic: • To ensure adequate budget resources for provision of safe domestic water (e.g. drilling boreholes, treatment chemicals) and to review the privatisation and commercialisation policies that have eroded provision and affordability of safe water. We hold that water services need to be restored to direct public sector ownership with strengthened regulation of services, provisions for resident involvement, public accountability in their management and with subsidised tariffs that provide for a basic level of free household entitlement • To secure (at national and regional level) coverage of spraying and bed net distribution for malaria and of drugs and personnel at primary health care level and close to community services to manage malaria • To address the underlying vulnerability from food insecurity, particularly to ensure that households in Zimbabwe access seed and fertiliser in the coming weeks to produce food to prevent a deepening situation of food insecurity, that primary health care centres have access to seed, fertiliser, oil and other supplies for community supplementary feeding programmes, and that measures are being taken to project needs and mobilise resources for food relief that as far as possible support local food markets. • To prioritise and report on investment in the health worker, drugs, transport and communications needs for essential primary health care and district health services in health budgets, including of environmental health, maternal health, health outreach and community health services and reverse of declining budget allocations to these areas, coupled by organisation of community level funds for investments in community health programmes, resourcing of community health workers and abolition of fees at primary health care services. We would appreciate receiving report of the outcome of the meeting. Yours faithfully, EQUINET Steering committee