MSF has seen more than 11,000 patients since August in Zimbabwe's worst cholera outbreak in years and has opened dozens of cholera treatment centres throughout the country. Cases have been found in nearly all the country's provinces. More than 500 national and international MSF staff members are working to identify new cases and to treat patients in need of care. Harare, the capital city, has been the center of the outbreak. MSF has treated more than 6,000 people in the densely populated city. A second location, Beitbridge, a town on the border with South Africa, has also been hard hit. MSF has provided care to more than 3,000 people with suspected cases of cholera. "The scale and the sheer numbers of infection especially in Harare is unprecedented," said an epidemiologist for MSF who has worked periodically in Zimbabwe for the past seven years. He explained that the key reasons for the outbreak are the lack of access to clean water, burst and blocked sewage systems and uncollected garbage overflowing in the streets. "The fact that the outbreak has become so large is an indication that the country's health system can't cope," he said. A town on the border with Mozambique, Nyamapanda, also has been affected. When MSF arrived in early November the team found about 150 cholera patients and helped set up one cholera treatment center in the town, as well as four others with the Ministry of Health in the surrounding areas. In total, 1,600 patients have been seen in Mudzi District. Zimbabwe has had major outbreaks of cholera before - it is endemic in certain rural areas - but until the last few years it has been relatively rare in urban areas. The outbreak is particularly worrying as it began well before the rainy season. A major concern is that once the heavy rains start, unprotected water sources will become contaminated, causing the further spread of cholera. The rainy season normally starts in November and continues through March, although the heavy rains have yet to be seen in some areas. Because MSF has been in the country since 2000 running HIV programs, it has been able to react from the ground and quickly bring in emergency cholera response units. MSF is working in two cholera treatment centers (CTCs) which are located in existing health facilities in Harare. In total, the two main CTCs saw more than 2,000 people with cases of suspected cholera in the first week of December. An MSF emergency coordinator in Harare described the situation: "Imagine a cholera ward with dozens of people under the most basic conditions. For instance, there is only a little electricity so there is hardly any light. It is difficult for the doctors and nurses to even see the patients they are treating. The nurses have to monitor multitudes of IV bags to make sure they don't run dry which is also difficult to do in the dark and when there are so many patients." In Beitbridge, MSF has set up CTCs run mainly by MSF staff using supplies shipped in from all over the world. The peak of the emergency was unusually early in Beitbridge, which resulted in a high mortality rate within the first couple of days of the severe outbreak in the town. By the fourth day, however, MSF had established a CTC and the mortality rate eventually dropped from 15 percent to less than one percent. An additional challenge has been that government health workers in certain areas, particularly in Harare, are on strike. This has required MSF to rapidly recruit hundreds of nurses and other staff to handle the influx of cholera cases. Significant time and energy is needed to train the new staff, adding considerably to the workload of the existing staff. MSF has also conducted exploratory missions in rural communities and responded to scattered reports of cholera cases. Low numbers of cases have been found in a number of small villages; MSF established small cholera treatment units (CTUs) where necessary. MSF has eight CTUs in five districts spread over the Manicaland and Mashvingo provinces in the eastern part of Zimbabwe and treated more than 770 patients. MSF will continue to monitor the situation and treat people in the most affected areas, as well as send emergency staff and supplies to various locations in Zimbabwe where new cases arise. "A cholera outbreak of this proportion usually continues for several months," the MSF epidemiologist says. "MSF expects to be caring for cholera patients in Zimbabwe for some time to come."