Relighting the candle - MSF's emergency cholera response in DRC
“I had no choice. My youngest son Eliezer was going out like a candle.” In a roughly constructed building with walls, floor and roof made from lengths of plastic sheeting, a worried father sits by his son’s side on a low bed. The main ward of MSF’s Cholera Treatment Centre (CTC) in Mbandaka, the capital of Equateur Province in the Democratic Republic of Congo, has a partition dividing it in two. Eliezer Wetchi and his father are in the second ‘ward’, for recovering or less severely-ill patients.
“To get to the MSF treatment centre, we spent all night travelling down the Congo River,” Mr. Wetchi continued. “At first I thought my son had malaria, but after a week of treatment in our village he was still throwing up and having diarrhoea. I heard about the cholera epidemic on the radio and then I knew the only option was to get to the treatment centre as quickly as possible. That evening I held Eliezer in my arms and we got a place on the last motor-powered boat going to Mbandaka. All night I watched over him; I didn’t dare close my eyes for a second.”
Spreading down the Congo
The cholera epidemic, which has so far caused more than 250 deaths, started in March in Kisangani, the capital of Oriental Province and the last stop on the Congo River for the cargo barges that are the main form of transport in this largely roadless area. An MSF team treated more than 1,000 cholera patients in Kisangani, and, by mid-April, the situation there was under control. But with thousands of people travelling up and down the Congo River every day, sporadic cases started appearing in towns and villages along the river.
“It was early June when the epidemic started exploding again,” said Félix Tran, Project Coordinator of MSF’s mobile emergency team in Congo. “The town of Bolobo in Bandundu Province started reporting three, then five, then 20 cases a day. We sent a small team of experienced emergency experts who built a treatment centre and have treated nearly 1,000 patients so far.
“Then it was Makanza, Lisala, Mbandaka and a string of other port towns along the river that started notifying cases. We do not have enough staff to mount a response in every town, so we monitor the epidemiological situation, we send a small evaluation team to the places that are reporting increasing numbers of cases and we go for a full medical response where we fear the highest potential for a major epidemic. That was why we chose Mbandaka, a big town with serious water and sanitation problems and a rising number of cases.”
The emergency team in Mbandaka
“We landed at 11 o’clock on a Friday and by midday I was here at the site of the CTC, opposite the big public hospital,” said Vale Eye, MSF emergency team logistician. “We hired a lot of manual labour and got to work immediately. When I left at one-o-clock in the morning, the CTC had taken form. By Sunday, we had a treatment centre that was ready to receive patients. That’s how we work; we get a lot done in a short time. We’ve met the minimum MSF standards and now there are just some details to finish off to bring it closer to the maximum standards. Given the gravity of the situation here, we had to just get going and produce a functioning CTC fast.”
A steep learning curve
Although the eastern parts of DRC have frequent cholera outbreaks, it is more than ten years since the western provinces have had an epidemic. Joel NyimiNyimi is an MSF emergency team nurse, and in charge of all medical aspects of the treatment centre in Mbandaka.
“One of my main roles is to train the Ministry of Health doctors and nurses in how to treat cholera patients. Ideally they will do most of the treatment and I will have a supervising role. So far we have treated more than 350 cases so it is busy, and I have a lot of supervision to do, particularly at night. In other cholera emergencies I have done, if patients die it is usually at night. The patients don’t stop being ill if the staff are tired and are paying less attention. I am here during the day and I also visit at 11pm, 1am and 3am to check that each patient is being properly cared for.”
Fear of cholera
It’s not just the medical staff who need to be told about cholera. The local people know enough about cholera to be very concerned, but not enough to know how to protect themselves, recognise the symptoms and take the appropriate course of action. Victorine is sitting with her seven-year-old son Ebengo in the recovery ward of MSF’s CTC, waiting patiently to be given the all-clear to return home.
“When I got back from the market I was surprised to find Ebengo already in bed at five pm. Just as I approached the bed he started violently throwing up. Three times that night he had bad liquid diarrhoea. His eyes were sunken and he was pale and weak. I got very frightened and I started crying and praying. I started thinking he might die. I had lost control of the situation. Then I remembered the radio announcements they had been playing about the cholera epidemic.”
Spreading the word
Dieudonné Bokwala is the emergency team’s health promotion specialist. One of his first actions was to produce a radio message in the local Lingala language and to schedule for it to be broadcast several times a day on the three main local radio stations. Many of the patients say that they came to the CTC because they had heard about it on the radio. Dieudonné has also been training a network of local volunteers, one or two in each neighbourhood, to actively spread information about cholera and the free service offered at the CTC as widely as possible.
Moving to Kinshasa
Since June 20, 92 suspect cholera cases have been registered in Kinshasa, the capital of DRC.
“The port of Kinshasa on the Congo River sees thousands of people embarking and disembarking every day. If the epidemic takes root in Kinshasa the consequences could be disastrous,” said Luis Encinas, Operations Coordinator for MSF. “This is why it is absolutely essential to immediately take major preventative measures: reinforce the epidemiological surveillance; limit the spread of the disease; and treat each end every patient who falls sick from cholera.”
The three major factors that have promoted the spread of cholera in other towns along the Congo River are all currently present in Kinshasa: dense urban population; a lack of hygiene and little access to clean water; and the confirmed presence of the disease in several locations. MSF is building a CTC in the crowded suburb of Kingabwa that will be used to treat patients and also to provide a training centre for all medical and non-medical personnel involved in the capital’s outbreak response.
Preparing to go home
While more patients arrive daily in Mbandaka and the preparations are under way in Kinshasa, back in Ward ‘B’ of the Mbandaka CTC Eliezer’s father is preparing to return home.
“I have mixed emotions; I am so relieved for my son, but at the same time I'm worried for the other people with the same symptoms in my village. There are many people with the same illness but they don't know it's cholera and they may not have the same instinct as me, to come to Mbandaka for treatment. But the important thing for me is that Eliezer's much better - they say that soon he'll be able to go home."
The Democratic Republic of Congo is a vast country with urgent medical needs that stem from a lengthy and brutal conflict and from the run-down nature of the health system. Alongside the more fixed MSF project locations, the PUC (Pool d’Urgence Congo, or Congo Emergency Team) is a highly mobile and reactive team of logisticians and medics, able to respond to sudden-onset medical crises wherever they occur.
With bases in Kinshasa, Kisangani and Mbandaka, PUC staff monitor the epidemiological situation throughout central and western DRC, areas that are now relatively peaceful but where epidemics can run riot if there is no effective medical response. While the medics are equipped to provide treatment, mass-vaccination campaigns and emergency surgery, in practice the logisticians are often the key to a successful PUC response. Motorbike, dugout canoe and walking are often the only means of transport when operating in remote areas and electricity is usually a dreamed-of luxury.
Over the past year MSF’s PUC teams have vaccinated more than 650,000 children against measles, responded to a major yellow fever outbreak, set up a treatment centre for a deadly strain of polio and treated, so far, more than 1,500 cholera patients.
What is cholera?
Cholera is an acute intestinal infection caused by a bacteria – Vibrio cholerae – found in unsanitary environments. The diarrhoea and vomiting brought on by the disease quickly lead to severe dehydration and can result in death. Cholera can be simply and effectively treated provided the treatment is started early enough. Treatment involves replacing the lost water and electrolytes such as potassium and sodium by rehydrating the patient with oral rehydration solution or, for the more serious cases, intravenously.