HEALTH IN RUINS: A Man-Made Disaster in Zimbabwe, An
Emergency Report by Physicians for Human Rights, January 2009
Physicians for Human Rights (PHR) mobilises health
professionals and concerned citizens to advance the health and dignity of all
people, through actions that promote respect for, protection of, and fulfillment
of, human rights.
PHR is an independent, non-profit organisation and
has a track record of over 22 years documenting health rights violations around
the world, including in Afghanistan, Chad, Chile, Chechnya, former Yugoslavia,
Kosovo, India, Israel and Palestine, Mexico, Peru, Rwanda, Sudan, and the United
States.
Since 1986, PHR members have worked to stop torture,
disappearances, political killings, and denial of the right to health by
governments and opposition groups, and to investigate and expose violations,
including deaths, injuries, and trauma inflicted on civilians in armed conflict;
suffering and deprivation, including denial of access to health care caused by
political differences as well as ethnic and racial discrimination; mental and
physical anguish inflicted on women by abuse; loss of life or limb from
landmines and other indiscriminate weapons; harsh methods of incarceration and
interrogation and torture in prisons and detention centers, and poor health
stemming from vast inequalities in societies.
As one of the original steering committee members of
the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace
Prize.
PREFACE
What happens when a government presides over the
dramatic reversal of its population’s access to food, clean water, basic
sanitation, and healthcare? When government policies lead directly to the
shuttering of hospitals and clinics, the closing of its medical school, and the
beatings of health workers, are we to consider the attendant deaths and injuries
as any different from those resulting from a massacre of similar proportions?
Physicians for Human Rights (PHR) witnesses the
utter collapse of Zimbabwe’s health system, once a model in southern Africa.
These shocking findings should compel the international community to respond as
it should to other human rights emergencies. PHR rightly calls into question the
legitimacy of a regime that, in the report’s words, has abrogated the most basic
state functions in protecting the health of the population. As the report
documents, the Mugabe regime has used any means at its disposal, including
politicizing the health sector, to maintain its hold on power. Instead of
fulfilling its obligation to progressively realize the right to health for the
people of Zimbabwe, the Government has taken the country backwards, which has
enabled the destruction of health, water, and sanitation – all with fatal
consequences.
Heedless of concern for the population of Zimbabwe
from world leaders and groups such as PHR, the Government has denied access to
the country, detained journalists, tortured human rights activists, and even
refused visas to former U.N. Secretary-General Kofi Annan, US President Jimmy
Carter, and Graça Machel.
PHR’s team members legally entered the country and
were transparent about the purpose of conducting a health assessment.
Nevertheless, the Government apparently planned and then falsely reported their
arrest at the end of the investigation. Such actions are a desperate attempt by
Robert Mugabe to conceal the appalling situation of his country’s people and to
prevent the world from knowing how his Government’s malignant policies have led
to the destruction of infrastructure, widespread disease, torture, and death.
This report is yet another wake-up call to
Zimbabwe’s neighbors and all UN member states for urgent intervention to save
lives and prevent more deaths.
These findings add to the growing evidence that
Robert Mugabe and his regime may well be guilty of crimes against humanity.
Mary
Robinson, Chair,
Realizing Rights: The Ethical Globalization Initiative, Former President of
Ireland Former UN High Commissioner for Human Rights
Richard J.
Goldstone, Former
UN Chief Prosecutor, International Criminal Tribunals for the former Yugoslavia
and Rwanda (ICTY and ICTR), Current PHR Board Member
The Most Reverend Desmond M. Tutu, OMSG, DD, FKC, Anglican Archbishop Emeritus of
Cape Town Chair, The Elders
ACKNOWLEDGMENTS
The lead author of this report is Richard Sollom,
MA, MPH, PHR researcher, one of the principal investigators who planned and
participated in PHR’s assessment in Zimbabwe in December 2008.
Other field investigators of the PHR delegation and
co-authors of the report are Chris Beyrer, MD, MPH, PHR Consultant and Director,
Johns Hopkins Center for Public Health and Human Rights; David Sanders, MBChB,
MRCP, DCH, DTPH, PHR Consultant, and Professor of Public Health, University of
the Western Cape, Cape Town, South Africa; and A. Frank Donaghue, MA, MS, Chief
Executive Officer of PHR. Helen Potts, LLB, MTH, PhD, PHR Chief Program Officer
for Health, is author of the legal sections, with contributions from John
Bradshaw, JD, Chief Policy Officer and Director of PHR’s Washington office.
Susannah M. Sirkin, MEd, Deputy Director of PHR served as lead editor and
contributed to analysis of the findings. Paul Caruso, MD, Instructor at Harvard
Medical School, contributed to charts and graphs. Gurukarm Khalsa, PHR Web
Editor/Producer, prepared the report for publication.
The report has benefited from review by Frank
Davidoff, MD, Editor Emeritus of Annals of Internal Medicine and PHR Board
member; Justice Richard J. Goldstone, PHR Board member and former United Nations
Chief Prosecutor, International Criminal Tribunals for Yugoslavia and Rwanda
(ICTY and ICTR); Jennifer Leaning, MD, SMH, PHR Board member and Professor at
Harvard School of Public Health; and Leonard S. Rubenstein, JD, PHR President.
PHR is deeply indebted to its courageous colleagues
and many dozens of ordinary citizens and government officials in Zimbabwe who
shared their observations and experiences with our team, assisted our field
researchers with logistics in a most challenging environment, and who care
deeply for the lives and well being of their fellow Zimbabweans. For their own
protection, they shall remain nameless. This report is dedicated to them.
ACRONYMS
ARV Antiretroviral
BRIDH Beatrice Road Infectious Diseases Hospital
CDC United States Centers for Disease Control and
Prevention
CEDAW Convention on the Elimination of
Discrimination against Women
CFR Case fatality rate
CIDA Canadian International Development Agency
C-SAFE Consortium for Southern Africa Food Security
Emergency
DFID United Kingdom Department for International
Development
ECHO European Commission’s Humanitarian Aid Office
FAO Food and Agriculture Organization of the United
Nations
FOLIWARS Foreign Exchange Warehouse and Retail Shops
GFATM Global Fund to Fight AIDS, TB and Malaria
HDI United Nations Development Program Human
Development Index
HIV/AIDS Human Immunodeficiency Virus / Acquired
Immunodeficiency Syndrome
HRC United Nations Human Rights Committee
ICC International Criminal Court
ICCPR International Covenant on Civil and Political
Rights
ICESCR International Covenant on Economic, Social
and Cultural Rights
MDC Movement for Democratic Change
MDR-TB Multi-drug resistant tuberculosis
MSF Médecins Sans Frontières
NGO Nongovernmental organization
OCHA United Nations Office for the Coordination of
Humanitarian Affairs
ORS Oral rehydration salts
ORT Oral rehydration therapy
PEM Protein-energy malnutrition
PEPFAR United States President’s Emergency Plan for
AIDS Relief
PHR Physicians for Human Rights
RBZ Reserve Bank of Zimbabwe
SADC Southern African Development Community
TB Tuberculosis
UFW Unaccounted for water
UN United Nations
USAID United States Agency for International
Development
USD United States dollar
WFP United Nations World Food Program
WHO United Nations World Health Organization
XDR-TB Extremely drug resistant tuberculosis
ZADHR Zimbabwe Association of Doctors for Human
Rights
ZANU-PF Zimbabwe African National Union – Patriotic
Front
ZINWA Zimbabwe National Water
Authority
EXECUTIVE SUMMARY
INTRODUCTION AND
OVERVIEW
Physicians for Human Rights sent an emergency
delegation to Zimbabwe in December 2008 to investigate the collapse of
healthcare. The health and nutritional status of Zimbabwe’s people has acutely
worsened this past year due to a cholera epidemic, high maternal mortality,
malnutrition, HIV/AIDS, tuberculosis, and anthrax. The 2008 cholera epidemic
that continues in 2009 is an outcome of the health systems collapse, and of the
failure of the state to maintain safe water and sanitation. This disaster is
man-made, was likely preventable, and has become a regional issue since the
spread of cholera to neighbor states.
The health crisis in Zimbabwe is a direct outcome of
the violation of a number of human rights, including the right to participate in
government and in free elections and the right to a standard of living adequate
for one’s health and well being, including food, medical care, and necessary
social services. Robert Mugabe’s ZANU-PF regime continues to violate
Zimbabweans’ civil, political, economic, social, and cultural rights.
The collapse of Zimbabwe’s health system in 2008 is
unprecedented in scale and scope. Public-sector hospitals have been shuttered
since November 2008.
While some facilities remain open in the private
sector, these are operating on a US-dollar system and are charging fees ranging
from $200 USD in cash for a consultation, $500 USD for an in-patient bed, and
$3,000 USD for a Cesarean section. With fees in reach for only the wealthy, the
majority are being denied access to health care.
International human
rights framework
Zimbabwe is a party to the International Covenant on
Economic, Social and Cultural Rights (ICESCR or the Covenant), the Convention on
the Rights of the Child (CRC), the Convention on the Elimination of All Forms of
Discrimination against Women (CEDAW), and the African Charter on Human and
Peoples’ Rights. The Government has a legally binding obligation to respect,
protect, and fulfill these rights for all people within its jurisdiction.
The right to health imposes core obligations, which
require access to health facilities on a non-discriminatory basis, the provision
of a minimum essential package of health-related services and facilities,
including essential food, basic sanitation and adequate water, essential
medicines, and sexual and reproductive health services, including obstetric
care. Even with limited resources, the Government is required to give first
priority to the most basic health needs of the population and to the most
vulnerable sections of the population.
Methods for this
investigation
During a seven-day investigation to Zimbabwe (13-20
December 2008) conducted by four human rights investigators, including two
physicians with expertise in public health and epidemiology, PHR interviewed and
met with 92 participants, including healthcare workers in private and public
hospitals and clinics, medical students from both of the medical schools in
Zimbabwe, representatives from local and international NGOs, representatives
from UN agencies, Zimbabwean government health officials, members of parliament,
water and sanitation engineers, farmers, and school teachers. The PHR team
visited four of the ten provinces in Zimbabwe, in both urban and rural areas.
Provinces visited included Harare, Mashonaland Central, Mashonaland West, and
Mashonaland East.
FINDINGS
The economic
collapse
A causal chain runs from Mugabe’s economic policies,
to Zimbabwe’s economic collapse, food insecurity and malnutrition, and the
current outbreaks of infectious disease. These policies include the land
seizures of 2000, a failed monetary policy and currency devaluations, and a cap
on bank withdrawals.
Mugabe’s land seizures destroyed Zimbabwe’s
agricultural sector, which provided 45% of the country’s foreign exchange
revenue and livelihood for more than 70% of the population. Hyperinflation has
ensued while salary levels have not kept pace. A government physician in Harare
showed PHR her official pay stub; her monthly gross income in November 2008 was
worth 32 US cents ($0.32 USD). The unemployment rate is over 80%. Low-income
households have had to reduce the quantity and quality of food. The Mugabe
ZANU-PF government must be held accountable for the violation of the right to be
free from hunger.
Public health system
collapse
The Government of Zimbabwe has abrogated the most
basic state functions in protecting the health of the population – including the
maintenance of public hospitals and clinics and the support for the health
workers required to maintain the public health system.
These services have been in decline since 2006, but
the deterioration of both public health and clinical care has dramatically
accelerated since August 2008.
Healthcare and
healthcare delivery
As of December 2008, there were no functioning
critical care beds in the public sector in Zimbabwe. The director of a mission
hospital told PHR: “We see women with eclampsia who have been seizing for 12
hours. There is no intensive care unit here, and now there is no intensive care
in Harare. If we had intensive care, we know it would be immediately full of
critically ill patients. As it is, they just die.”
Life expectancy at birth has fallen dramatically
from 62 years for both sexes in 1990 to 36 years in 2006 – 34 years for males
and 37 years for females, the world’s lowest.
Limits to access:
affordability, transportation, closures
Since the dollarisation of the economy in November
2008, only a tiny elite with substantial foreign currency holdings have any real
access to healthcare. Transport costs, even within Harare, have made getting to
work impossible for many healthcare employees.
A rural clinic staff nurse reported that since he
lived at the clinic, he had no difficulties in getting to work; however, since
bus fare to get to the nearest town to collect his monthly salary cost more than
the entire salary, it made no sense to collect it. He had not done so since
April 2008. A senior government official said: Government salaries are simply
rotting in the bank. When asked about how the absence of healthcare workers was
affecting HIV treatment, the official said: This is not a strike. The problem is
the staff and the patients cannot come due to travel costs.
Between September and November 2008 most wards in
the public hospitals gradually closed. The most abrupt halt in healthcare access
occurred on 17 November 2008, when the premier teaching and referral hospital in
Harare, Parirenyatwa, closed along with the medical school.
Essential medicines
and supplies
Access to essential medications was raised by nearly
all providers interviewed. In addition to drug shortages, medical supplies
(including cleaning agents, soap, surgical gloves, and bandages) were also in
critically short supply or absent altogether. A rural clinic nurse reported:
“Right now I have no anti-hypertensives, no anti-asthmatics, no analgesics,
nothing for pain. I have a woman in labor right now, and I have no way to
monitor blood pressure ... and I have no suture material to do a repair if she
tears.”
Health information
and suppression
The Mugabe regime intentionally suppressed initial
reports of the cholera epidemic and has since denied or underplayed its gravity.
The Minister of Information and Publicity, Sikhanyiso Ndlovu, reportedly ordered
government-controlled media to downplay the cholera epidemic, which he said had
given the country’s enemies a chance to exert more pressure on President Robert
Mugabe to leave office. The Minister instructed the media to turn a blind eye to
the number of people who have died or [have become] infected with cholera, and
instead focus on what the Government and NGOs are doing to contain the epidemic.
PHR heard from several sources in Zimbabwe that the
Government has intentionally suppressed information regarding increasing
malnutrition. PHR asked a nurse staffing a public-sector clinic in a rural
district if there had been cases of malnutrition. The nurse became visibly
anxious and then replied: “Malnutrition is very political. We are not supposed
to have hunger in Zimbabwe. So even though we do see it, we cannot report it.”
DETERMINANTS OF
HEALTH
Failed sewerage and
sanitation systems
Before the ZANU-PF government nationalized municipal
water authorities in 2006, water treatment and delivery systems worked, although
suboptimally.
The Mugabe regime, however, politicized water for
political gain and profit, policies that proved disastrous, and which have
clearly contributed to the ongoing cholera epidemic.
All Harare residents PHR interviewed reported that
trash collection has effectively ceased. Throughout Harare, and especially in
the poor high-density areas outside the capital, PHR investigators saw detritus
littering streets and clogging intersections. Steady streams of raw sewage flow
through the refuse and merge with septic waste. A current Ministry of Health
official reported to PHR: There is no decontamination of waste in the country.
Nutrition and food
security
The UN Food and Agricultural Organization (FAO)
predicts that some 5.1 million (45% of the population) who will require food aid
by early 2009 in order to survive. Agricultural output has dropped 50-70% over
the past seven years. The ZANU-PF government has exacerbated food insecurity for
Zimbabweans in 2008 by blocking international humanitarian organizations from
delivering food aid and humanitarian aid to populations in the worst-affected
rural areas. Patients with HIV/AIDS and TB are especially vulnerable to food
insecurity.
In the months following the March 2008 elections,
the Mugabe regime used food as a weapon of war against MDC supporters and the
rural poor. On 31 December 2008, a government official in Chivhu prevented WFP
from distributing food aid: “The villagers accused the chief of being corrupt
and diverting donor aid and distributing it along party lines. They indicated
that ... the chief and his ZANU-PF supporters used to source maize from the
nearby Grain Marketing Board and then sell it to the poor villagers.”
A leader of a health NGO reported that: “There is no
food in many of the hospitals and there is starvation in the prisons.”
Current health
crisis: Cholera
The current cholera epidemic in Zimbabwe appears to
have begun in August 2008. As of this writing, more than 1,700 Zimbabweans have
died from the disease and another 35,000 people have been infected. The UN
reports that cholera has spread to all of Zimbabwe’s ten provinces, and to 55 of
the 62 districts (89%) and that the cumulative case fatality rate (CFR) across
the country has risen to 5.0% - five times greater than what is typical in
cholera outbreaks. Control has not been reached: There has been a doubling of
both cases and deaths during the last three weeks of December, 2008.
Cholera infectivity,
epidemiology, and treatment
The origin of the current cholera epidemic appears
to stem from the failure of the Mugabe regime to maintain water purification
measures and manage sewerage systems. Civic organizations in Harare warned of a
cholera time-bomb in 2006, but the Mugabe regime ignored the warning signs. Not
until 4 December 2008 did Zimbabwe’s Ministry of Health and Child Welfare
finally request aid to respond to the cholera outbreak by declaring a national
emergency. This negligence represents a four-month delay since the start of the
cholera outbreak, but at least a three-year delay in responding to the water and
sanitation breakdowns, which have allowed cholera to flourish.
Death rates from cholera are usually under 1%;
however, in the current Zimbabwe epidemic, the cumulative death rate for the
country is around 5%, and more than 40% of all districts have case fatality
rates above 10%. PHR asked a senior government official responsible for cholera
surveillance why Zimbabwe’s case fatality rate was more than five times greater.
She attributed the high death rate to three causes.
First, in the initial phase there simply were no
supplies, such as ORS and IV fluids. Second, few clinic or hospital staff were
sufficiently experienced or trained to respond to cholera, and many patients
died even in facilities that had adequate supplies.
Finally, the issue of transport costs for patients
and staff, exacerbated by the closure of the public hospitals, meant that many
patients either could not reach care, or reached care in advanced dehydration,
and could not be saved.
Current health
crisis: Anthrax
WHO has reported some 200 human cases of anthrax
since November 2008 with eight confirmed deaths. These cases were attributed to
the ingestion of animals (cattle and goats) that had died of anthrax.
Zimbabweans avoid eating animals that have died of
disease – but these cases appear to occurred in starving rural people scavenging
carrion.
PHR was told that veterinary anthrax control
programmes in Zimbabwe, which had included regular monthly control programs,
have been dramatically curtailed in the economic collapse. The surviving herds
are now much more vulnerable to infectious diseases.
Current Health
Crisis: HIV/AIDS
UNAIDS figures show that Zimbabwe has a severe
generalized epidemic of HIV-1, with an overall adult (ages 15-49) HIV prevalence
rate of 15.3%. An estimated 1.3 million adults and children in Zimbabwe are
living with HIV infection in 2008. Of these, some 680,000 were women of
childbearing age. In 2007, some 140,000 Zimbabweans died of AIDS, and the
current toll is estimated at 400 AIDS deaths per day. Access to HIV/AIDS care
and treatment is threatened by the current collapse and HIV programs are
currently capped: some 205,000 people are thought to be taking Anti-Retrovirals
(ARVs), but no major program is currently able to enroll new patients. Some
800,000 Zimbabweans are thought to require therapy, or will require it in the
coming months-years.
PHR investigators received corroborating reports
from donors and HIV/AIDS patients in Zimbabwe that ZANU-PF government officials
had plundered $7.3 million USD in humanitarian aid for HIV/AIDS treatment – part
of $12.3 million USD from the Global Fund for AIDS, Tuberculosis and Malaria.
Following public outrage over the scandal months later in November 2008, the
ZANU-PF-controlled reserve bank returned the stolen funds to the Global Fund.
For HIV/AIDS the most severe threat has been the
interruption of regular supplies of antiretroviral drugs. Multiple key
informants, patients, and providers told PHR that ARV supplies had become
irregular due to breakdowns in drug delivery, distribution, provision, and theft
of ARV drugs by ZANU-PF operatives. Most troubling were reports that some
physicians were switching patients on established ARV regimens to other regimens
based not on clinical need, but on drug availability. This can lead to drug
resistant HIV strains.
These dangerous practices constitute a significant
threat to public health since the development and transmission of multi-drug
resistant variants of HIV in Zimbabwe could undermine not only Zimbabwe’s
HIV/AIDS program, but regional programs as well.
Current health
crisis: Tuberculosis
PHR asked an expert working with the national
program to describe the status of the program in December 2008: “There is no
politically correct way to say this – the TB program in Zimbabwe is a joke. The
national TB lab has one staff person. There is no one trained in drug
sensitivity testing. The TB reference lab is just not functioning. This is a
brain drain problem.
The lab was working well until 2006 and has since
fallen apart. The DOTS program in 2000 was highly effective, but that has broken
down now too. There is no real data collection system for TB. This stopped in
2006 as well.”
Both MDR-TB and possible XDR-TB (a largely fatal and
often untreatable form) have emerged in Zimbabwe, but the critical capacity to
diagnose and manage these infections has collapsed.
Current health
crisis: Maternal morbidity and mortality
Maternal health in Zimbabwe has deteriorated greatly
over the past decade. The maternal mortality rate has risen from 168 (per
100,000) in 1990 to 1,100 (per 100,000) in 2005. The major contributors are
HIV/AIDS and a significant decline in availability and quality of maternal
health services. PHR interviewed several Harare mothers at a distant Mission
Hospital who had sought obstetric care. One went to Mbuya Nehanda Government
Maternity Hospital for a cesarean section on 14 November 2008. She was told that
the operation could not be performed because there were no nurses, doctors, or
anesthesiologists at work. Another woman said: “I wanted to have my baby in
Harare but Parirenyatwa hospital was closed. I was having my prenatal care with
my own doctor at [a private clinic] but they wanted so much money. They wanted
only US dollars, in cash. $3,000 for the surgeon, $140 for the nurse, and $700
for the doctor who puts you to sleep.“
CONCLUSIONS
The health and healthcare crisis in Zimbabwe is a
direct outcome of the malfeasance of the Mugabe regime and the systematic
violation of a wide range of human rights, including the right to participate in
government and in free elections and egregious failure to respect, protect and
fulfill the right to health.
The findings contained in this report show, at a
minimum, violations of the rights to life, health, food, water, and work. When
examined in the context of 28 years of massive and egregious human rights
violations against the people of Zimbabwe under the rule of Robert Mugabe, they
constitute added proof of the commission by the Mugabe regime of crimes against
humanity.
RECOMMENDATIONS
1. Resolve the
political impasse
The UN Security Council and the South African
Development Community should call on the Mugabe regime to accept the result of
the 29 March election and allow the MDC to assume its place. Governments should
end their support of Mugabe’s regime, engaging in intensive diplomacy to assure
a democratic political transition. They should maintain and strengthen targeted
bilateral sanctions until Mugabe cedes power and a stable government is
established.
2. Launch an
emergency health response
The government of Zimbabwe should yield control of
its health services, water supply, sanitation, disease surveillance, Ministry of
Health operations, and other public health functions to a United
Nations-designated agency or consortium. Such a mechanism would be equivalent to
putting the health system into a receivership pursuant to the existence of a
circumstance that meets the criteria for the Responsibility to Protect.
If the government of Zimbabwe refuses to yield such
control, the UN Security Council, acting pursuant to its authority under Article
39 of the Charter, should enact a resolution compelling the Government of
Zimbabwe to do so.
3. Refer the
situation in Zimbabwe to the International Criminal Court for crimes against
humanity
The UN Security Council, acting pursuant to its
authority under Article 41 of the U.N. Charter, should enact a resolution
referring the crisis in Zimbabwe to the International Criminal Court for
investigation and to begin the process of compiling documentary and other
evidence that would support the charge of crimes against humanity.
4. Convene an
emergency summit on HIV/AIDS, tuberculosis and other infectious diseases
Donor governments and the Global Fund should
consider this crisis as a first test-case of the collapse of a health system in
a country that is a recipient of emergency AIDS and TB prevention and treatment
programmes. The Obama Administration, together with the Global Fund and other
donors, should convene an emergency summit to coordinate action to address the
current acute shortfalls in AIDS and Tuberculosis treatment and care.
5. Prevent further
nutritional deterioration and ensure household food
security
To prevent further deterioration of nutritional
status, especially among the most vulnerable (young children, mothers, HIV/AIDS,
and TB sufferers), the international community needs urgently to fully fund the
2009 Consolidated Appeal (CAP) for Zimbabwe of $550 million USD. Importantly,
donor governments must ensure non-interference by the current regime in
obstructing, diverting, politicizing, or looting such humanitarian aid.
The US as well as other donor governments and
private voluntary organizations should increase donations of appropriate foods
to the responsible multilateral agencies, such as WFP, to meet the impending
shortfall in the coming 3-6 months.
INTRODUCTION
Physicians for Human Rights sent an emergency
delegation to Zimbabwe in December 2008 to investigate the collapse of
healthcare in the country.
The health and nutritional status of Zimbabwe’s
people has acutely worsened this past year due to a raging cholera epidemic,
high maternal mortality, malnutrition, HIV/AIDS, tuberculosis, and now anthrax.
The cholera epidemic is an outcome of the health
system collapse and of the failure of the Government to maintain previously
operative safe water and sanitation and provide prompt infection control and
patient care.
The cholera epidemic, now a humanitarian emergency,
is a man-made disaster, was likely preventable, and has become a regional health
and security issue because of the failure of the state to respond to the health
and basic living needs of its people.
Viewed through a human rights lens, the health and
healthcare crisis in Zimbabwe is a direct outcome of the abrogation of a number
of human rights, including the right to participate in government and in free
elections and the right to a standard of living adequate for one’s health and
well being, including food, medical care, and necessary social services. The
ZANU-PF regime and its security forces continue to violate Zimbabweans’ civil
and political rights as well as economic, social, and cultural rights.
The collapse of Zimbabwe’s health system in 2008 is
unprecedented in scale and scope. Public-sector hospitals have been shuttered
since November 2008.
The basic infrastructure for the maintenance of
public health, particularly water and sanitation services, have abruptly
deteriorated in the worsening political and economic climate. Hospitals,
clinics, schools, and even key border crossings have no water, no functioning
toilets or sewerage systems, and limited medical supplies. Still open facilities
lack everything from running water and electricity to sterile gloves and suture
materials, essential medicines, and communication capacity.
In addition to such inadequate supplies, healthcare
staff are unable to work. Salaries are fixed in the virtually worthless currency
and can be withdrawn from local banks only in quantities sufficient to pay for
one-way travel to work. Staff willing to work for free often cannot afford
transport to their posts and cannot adequately feed their own families. The
healthcare facilities that remain open are critically understaffed and
overwhelmed by patients sent from closed facilities. Howard Mission Hospital, an
80-kilometer drive from the capital – the last 12 kilometers over rugged dirt
roads – is one of few hospitals open for the people of Harare. And the vast
majority of people, making less than $2 USD a day, cannot afford the cost of
transportation to this rural hospital.
While clinics and even a few hospitals remain open
in the private sector, these facilities are operating on a US-dollar system and
are charging fees that are substantially higher than would be seen even in
developed-world settings: $200 USD in cash for a consultation, $500 USD to
secure an in-patient bed, and $3,000 USD for a Cesarean section. These fees are
within reach of only the wealthy elite in Zimbabwe.
Consequently, the civilian population is denied
access to public health and medical care.
This report describes key aspects of the current
health and healthcare crisis in Zimbabwe; it also analyzes what data are
available, shares the stories of physicians, nurses, medical students,
healthcare officials, patients, as well as representatives of NGOs and other
health and humanitarian organizations as they have struggled to survive in a
collapsing system.
Finally, this report presents recommendations for
ways forward out of the collapse. An emergency is upon us. The people of
Zimbabwe are needlessly dying due to violations of human rights including the
right to health.
International human
rights framework
Zimbabwe is a party to a wide range of international
and regional human rights treaties (also known as covenants or conventions),
which contain important provisions related to the right to health,1 and the
rights to food, water and work, including the International Covenant on
Economic, Social and Cultural Rights ICESCR or the Covenant), the Convention on
the Rights of the Child (CRC), the Convention on the Elimination of All Forms of
Discrimination against Women (CEDAW), and the African Charter on Human and
Peoples’ Rights.
These treaties highlight the particular importance
1 The full formulation is: the right of everyone to
the enjoyment of the highest attainable standard of physical and mental health.
In this report, the right to health and the right to the highest attainable
standard of health are used synonymously.
2 The Government of Zimbabwe acceded to the ICESCR
and CEDAW on 31 May 1991 with no declarations or reservations. The Government
ratified the CRC on 9 November 1990, again with no reservations or declarations.
There is no ICESCR report submitted by Zimbabwe listed on the Committee web
site. The last report that human rights have for disadvantaged people and
populations, including those living in poverty.
Although a state party to the ICESCR, the Government
of Zimbabwe has not incorporated economic, social and cultural rights into its
Constitution. Nevertheless, as a party to the ICESCR and other international
human rights treaties, the Government has a legally binding obligation to
respect, protect, and fulfill these rights for all people within its
jurisdiction.
Human rights are interdependent. For example, the
right to health is closely related to realization of other human rights such as
life, food, work, water, the prohibition against torture, and the freedoms of
association, assembly and movement. Although these and other human rights
address integral components of the right to health,3 it is beyond the scope of
the current report to provide a legal framework and analysis of them. This
report focuses on the right to health, per se, the content of which is addressed
below.
Right to
health
Though first formulated in the World Health
Organization (WHO) Constitution (1946), the central formulation of the right to
health is contained in Article 12 of the ICESCR.4 Article 12 provides:
The States Parties to the present Covenant recognize
the right of everyone to the enjoyment of the highest attainable standard of
health.
The steps to be taken by the States Parties to the
present Covenant to achieve the full realization of this right shall include
those necessary for:
The provision for the reduction of the a.
stillbirth-rate and of infant mortality and for the healthy development of the
child; The improvement of all aspects of b. environmental and industrial
hygiene; The prevention, treatment and control c. of epidemic, endemic,
occupational and other diseases; under the ICCPR was submitted in 1998. The last
report under the CRC was submitted in 1996.
Committee on Economic, Social and Cultural Rights,
The right to the highest attainable standard of health: 11/08/2000.
International Covenant on Economic, Social and
Cultural Rights, opened for signature 19 December 1966, 993 UNTS 3 (entered into
force 3 Jan. 1976); Constitution of the World Health Organisation, opened for
signature 22 July 1946, 14 UNTS 185, (entered into force 7 Apr. 1948).
The creation of conditions which would d. assure to
all medical service and medical attention in the event of sickness.
In 2000, the U.N. Committee on Economic, Social and
Cultural Rights released General Comment No. 14, which provides an authoritative
understanding of the content and the right to health. The General Comment sets
out a way to analyze the right to health, thereby making it easier to identify
government obligations.
The right to health is an inclusive right extending
to both medical care and the underlying determinants of health, such as adequate
sanitation, safe water, adequate food, and access to health-related information.
It encompasses both freedoms and entitlements. The freedoms include, for
example, the right to make decisions about one’s health, including sexual and
reproductive freedom.
The entitlements include, for example, the right to
emergency medical services, and to the underlying determinants of health such as
access to safe water, adequate sanitation and adequate food. In all its forms
and at all levels, the right contains the interrelated and essential elements of
available, accessible, acceptable health facilities, goods and services that are
appropriate and of good quality. For example, good quality health facilities
require skilled health workers who receive domestically competitive salaries and
whose own human rights are protected (e.g., safe working environment and
freedoms of association, assembly and expression).
Participation by individuals and groups in all
health-related decision-making at the national and international levels is also
essential. Equality and non-discrimination are fundamental elements of the right
to health. Governments have a legal obligation to ensure that a health system is
accessible to all without discrimination, including those living in poverty. If
health facilities are accessible to the wealthy, but inaccessible to the rest of
the population, the Government can be held accountable and be required to take
remedial action.
The right to health is subject to both progressive
realization and resource availability. Put simply, progressive realization means
that a country must improve its right to health performance steadily, while
resource availability means that what is required of a developed country is of a
higher standard than what is required of a developing
country.
The corollary to the obligation to progressively
realize the right to health is that there is a strong presumption that
retrogressive measures taken in relation to the right to health are not
permissible. If any deliberately retrogressive measures are taken, the
Government has to provide an objective and rational explanation. These
retrogressive acts can occur though acts of omission as well as acts of
commission.
The right to health also imposes obligations of
immediate effect. These core obligations require, at the very least, access to
health facilities on a non-discriminatory basis, the provision of a minimum
essential package of health-related services and facilities, including essential
food, basic sanitation and adequate water, essential medicines, sexual and
reproductive health services including prenatal and post-natal services,
emergency obstetric care, and the development and adoption of a comprehensive
national health plan.
Even in the presence of limited resources, the
government is required to give first priority to the most basic health needs of
the population and to pay particular attention to protecting the most vulnerable
sections of the population.
To monitor progressive realization and to provide
health information, the right to health requires indicators and benchmarks.
These indicators and benchmarks should be disaggregated, at a minimum, on the
basis of sex, socioeconomic status, rural-urban divide, and age, so that a
government can monitor whether or not its health programs for disadvantaged
individuals and communities are working. The right to health imposes a legal
obligation. Accordingly, accountability on the part of the government for
implementation of the right to health is essential.
The accountability process requires a government to
show, explain, and justify how it has discharged its obligations regarding the
right to the highest attainable standard of health.
The process also provides individuals and
communities with an opportunity to understand how government has discharged its
right to health obligations. If it is revealed that there has been a failure on
the part of government to fulfill the obligations contained in the right to
health, rights-holders are entitled to effective remedies to redress this
failure.
Right to life and
the prohibition against torture or cruel, inhuman or degrading treatment or
punishment
Zimbabwe is also state party to the International
Covenant on Civil and Political Rights (ICCPR). The Constitution of Zimbabwe
incorporates some civil and political rights, such as protection of the right to
life (section 12), protection from inhuman treatment (section 15), as well as
freedom of expression (section 20), assembly and association (section 21), and
protection from discrimination on the grounds of race, etc. (section 23).
Zimbabwe’s accession to the ICCPR and its incorporation of some of these rights
into the Constitution is particularly relevant to this report in view of the
U.N. Human Rights Committee’s interpretation of the right to life.
The Human Rights Committee (HRC) has consistently
opined that the right to life cannot be interpreted in a narrow sense.27 In
General Comment No. 6 the HRC noted that the right to life requires the adoption
of positive measures on the part of the State. Significantly, the examples
provided include the adoption of measures to eliminate malnutrition and
epidemics and the reduction of infant mortality:
“Moreover, the Committee has noted that the right to
life has been too often narrowly interpreted. The expression inherent right to
life cannot properly be understood in a restrictive manner, and the protection
of this right requires that States adopt positive measures. In this connection,
the Committee considers that it would be desirable for States parties to take
all possible measures to reduce infant mortality and to increase life
expectancy, especially in adopting measures to eliminate malnutrition and
epidemics.”
In a later General Comment the HRC again established
that the right to life required positive acts on the part of the State including
the provision of data on pregnancy and childbirth-related deaths of women, the
provision of information on the impact of deprivation and poverty on women, and
the provision of sexual and reproductive health services, including access to
safe abortions among other services. Sepúlveda notes that the HRC maintains the
same line of argument when examining State Party reports.
The HRC has confirmed that, as with the right to
life, the prohibition against torture is non-derogable even during declared
public emergencies. It is insufficient simply to prohibit this conduct; States
must ensure effective protection. Complaints are to be effectively investigated,
those found guilty held accountable, and the alleged victims must have effective
remedies.
Torture is a clear example of how human rights
violations impact health. Reciprocally, damaged health furthers the destruction
of human rights – by destroying human capital and by consuming scarce financial
and material resources; hence, the interaction between health and human rights
contributes importantly to the downward spiral of an entire society.
Torture or cruel, inhuman or degrading treatment or
punishment is understood in a broad sense as it may extend to persons kept in
solitary confinement, especially when the person is kept incommunicado.
Additionally, when people are deprived of their
liberty, the prohibition against torture or cruel, inhuman or degrading
treatment or punishment is augmented by the positive requirements of article 10
(1) of the ICCPR: All persons deprived of their liberty shall be treated with
humanity and with respect for the inherent dignity of the human persons.
METHODS
This report is based on the findings of a health and
human rights assessment conducted in Zimbabwe by a PHR team, comprising four
human rights investigators, including two physicians with expertise in public
health and epidemiology. The team conducted a series of key informant interviews
and several focus group discussions, and interviewed a wide range of
stakeholders. The qualitative domains of the interview instrument were developed
by adapting health and rights instruments used by PHR, the Center for Public
Health and Human Rights at Johns Hopkins University, and the School of Public
Health at the University of the Western Cape, South Africa in similar settings
where violations of the right to health occurred. An Expert Review Board
convened by PHR reviewed the instruments, which the team adapted to the field
while in Zimbabwe. For protection of key informants, all interviews were
anonymous by removing identifying information from the interview record.
PHR investigators asked participants for their
verbal informed consent after hearing an explanation of PHR, the investigation,
and the intent to conduct advocacy based on the assessment findings. All
participants were adults aged 18 or older, and all interviews were conducted in
English, which is commonly spoken in Zimbabwe.
During the seven-day investigation to Zimbabwe
(13-20 December 2008), PHR interviewed and met with 92 participants, including
healthcare workers in private and public hospitals and clinics, medical students
from both of the medical schools in Zimbabwe, representatives from local and
international NGOs, representatives from U.N. agencies, Zimbabwean government
health officials, members of Parliament, water and sanitation engineers,
farmers, and school teachers. The assessment team visited four of the 10
provinces in Zimbabwe, in both urban and rural areas, and in some of the
affected border areas. Provinces visited included Harare, Mashonaland Central,
Mashonaland West, and Mashonaland East.
Interview data were analyzed using qualitative
methods and were augmented with a literature and lay media review. The security
conditions in the country precluded doing a quantitative study.
LIMITATIONS
PHR conducted an emergency investigation, which, by
its nature, is subject to limitations in duration, scope, and access. The field
investigation took place during a short time frame of seven days in country.
The scope of the current investigation did not
permit a full analysis of the health system. Restricted access to health
facilities, participants, and regions precluded a complete account of all human
rights violations occurring. This investigative study should be construed as a
snapshot in time, partial rather than complete accounts or prevalence reports of
human rights violations. Notwithstanding these limitations, the study has
produced sufficient firm data to make informed recommendations.
BACKGROUND
When Robert Mugabe came to power in 1980 he
implemented several policies that benefited the majority of the people such as
extending education and health care to the black majority and increasing minimum
wages. The lives of most Zimbabweans improved dramatically in the first years of
independence. Dramatic improvements were seen in key health indicators such as
life expectancy, maternal mortality and infant mortality.
We’re going to kill
you
PHR investigators interviewed three Zimbabweans as
they lay in separate hospital beds.1 On 13 December 2008, 15 police and military
personnel stopped a car carrying a 32-year-old MDC counselor from Chitungwiza,
his 29-year-old wife, and their friend, a 26-year-old male, who was driving the
vehicle. The three were traveling to attend a funeral service for a young
relative who had died from cholera.
After a group of 15 armed police and military
stopped them at a makeshift roadblock outside Rusape in eastern Zimbabwe, they
searched the vehicle and found work-related documents showing that the husband
was an MDC city councilor. One of the police yelled at them: “You’re coming here
to mobilize MDC support against Mugabe, so we’re going to kill you!”
The group of police and AK-47-toting military drove
them to a nearby vacant elementary school building that served as their
barracks. There, several of the 15 police and military took turns beating each
of the three individually while the other two were forced to watch. After taking
$25 USD out of her bra, the attackers forcibly ripped the wife’s clothes off and
lashed her back and arms with a leather whip. They then pummeled her buttocks
with a wooden baton stick. The police and military beat the two men similarly
and forced them to spread ash and water all over their bodies. The police then
made them roll on the ground back and forth as fast as possible. Two of the
police took turns jumping on the stomachs of the two men, forcing them to vomit.
When the husband began to have diarrhea, the police and military left them alone
in apparent fear of cholera.
Before leaving, one of the military officers
threatened the MDC councilor: “We’re coming to your house to finish the job.” On
examination, both the husband and wife had visible signs of having been whipped
and beaten, with lacerations on their backs and shoulders and severe
intramuscular hematomas of the buttocks.
PHR investigators also interviewed staff from the
local NGO that arranged and paid for their medical treatment at a private
clinic.
Tragically these early improvements have all been
eroded by Mugabe’s policies. In the nearly 29 years that Mugabe and his ruling
party, the Zimbabwe African National Union-Patriotic Front (ZANU-PF), have been
in power, the Government has established a record of gross human rights abuses
that is well documented.
Human rights organizations have shown that the
Mugabe government has carried out policies designed and calculated to cause
suffering and loss of life to specific groups of people, specifically the
Ndebele ethnic minority concentrated in the Matabeleland North and South
provinces as well as urban and rural groups who support the opposition Movement
for Democratic Change (MDC).
Matabeleland
massacres
Mugabe is from the Shona ethnic group, which makes
up more than 70% of Zimbabwe’s population of 12 million, and throughout his rule
he has consistently disadvantaged the minority Ndebele, who constitute 20% of
the population and whom he saw as supporters of opposition parties. In February
1982, Mugabe accused opposition leader Joshua Nkomo, who was Ndebele, of
plotting to overthrow the government. Nkomo was fired from cabinet, and several
of his supporters in the army were jailed. Violent anti-Mugabe protests erupted
across Matabeleland, where Nkomo’s Ndebele supporters were concentrated.
The largest number of human rights atrocities
occurred between 1983 and 1987, when Mugabe ordered a brutal campaign in which
the army killed an estimated 20,000 rural Ndebele people in Zimbabwe’s two
southern provinces, Matabeleland North and Matabeleland South. These killings
highlighted Mugabe’s ongoing abuse of Zimbabwe’s ethnic minority, the Ndebele
people.
Mugabe ordered a special army brigade into
Matabeleland to stamp out the anti-government violence. The Fifth Brigade was
made up of virtually all Shona troops, and it had received special training from
North Korean advisers. The Fifth Brigade swept across Matabeleland throughout
1983 and 1984 carrying out a series of mass beatings, torture, and killings,
according to numerous witnesses. The army also set up road blocks, which
prevented food supplies from going into the Matabeleland region where there was
drought and where widespread hunger was reported.
In 1987, Mugabe succeeded in getting Nkomo to merge
his smaller party, PF-ZAPU, into Mugabe’s ZANU-PF. The army’s violence in
Matabeleland halted; but the government continued to restrict spending on
health, education and infrastructure in the region.
Operation
Murambatsvina
In June 2005, Mugabe’s government destroyed the
homes and businesses of urban populations suspected of supporting the opposition
MDC. The urban townships in Harare, Bulawayo and other major cities had voted
overwhelmingly against Mugabe and for the MDC. In retaliation, Mugabe launched
Operation Murambatsvina – Shona for “clean out the filth” – in which the army
and police destroyed thousands of MDC-supporter homes in the urban townships.
The destruction was on such a massive scale that the United Nations sent a
delegation to Zimbabwe to investigate. The UN Special Envoy reported that
700,000 homes and small businesses were destroyed, affecting an estimated 2.4
million people.
Thousands of these newly homeless people were
trucked into rural areas by the Government and told to settle there, without
benefit of food or supplies.
Once again large groups of people huddled alongside
roads. Public health experts expressed concern that the newly homeless
population suffered high levels of malnutrition, disease and, as a result, lower
life expectancy.
Election violence
Mugabe’s ruling political party, ZANU-PF, lost power
in the House of Assembly on 29 March 2008 for the first time since the country’s
independence in 1980. On that date, Morgan Tsvangirai’s opposition party, MDC,
won a majority of seats in the Assembly. During the first round of presidential
elections that took place on the same day, Tsvangirai won out over Mugabe, but
since neither won a simple majority, run-off elections were scheduled for June
2008. Citing massive and targeted violence against MDC supporters throughout the
country, Tsvangirai withdrew from the second round. The election proceeded with
Mugabe standing unopposed – despite widespread international criticism – leading
to Mugabe’s victory.
To address the political impasse, negotiations
between the two parties began in July 2008; former South African President Thabo
Mbeki has mediated these talks on behalf of the Southern African Development
Community (SADC). All parties signed a power-sharing Memorandum of Understanding
in September 2008 allowing Mugabe to remain as president while Tsvangirai would
become prime minister. Negotiations have since faltered over the composition and
political control of key ministerial posts. During these ongoing negotiations,
widespread human rights violations continue within a culture of impunity.
Ongoing human rights
violations
A political environment marked by partisan violence,
arbitrary arrest, incommunicado detention, torture, and extrajudicial killings
have continued unabated since the March 2008 parliamentary and presidential
elections.
The Zimbabwe Peace Project, a human rights coalition
of local NGOs and faith-based organizations, recorded 20,143 incidents of human
rights violations between January and September 2008 including: 202 murders, 13
attempted murders, 41 rapes, 21 attempted rapes, 411 cases of torture, 463
kidnappings and abductions, 3,942 assaults, 444 cases of unlawful detention,
10,795 cases of harassment or intimidation, 2,290 forced displacements, 195
cases of discrimination (e.g., being denied access to government-subsidized
food), 419 cases of looting or theft, and 907 cases of malicious damage to
property.
The majority of these human rights violations were
politically motivated: 73% of victims are said to be supporters of the
opposition MDC, and 80% of the perpetrators of violence are alleged to be
ZANU-PF supporters.
Torture
Human rights groups have documented a pattern of
torture inflicted by state agents on those suspected of supporting the
opposition.45 Army, police, the Central Intelligence Organization (CIO), the war
veterans and youth militia have all perpetrated torture, according to testimony
from survivors.46 Cases of falanga, where the soles of feet are beaten until
they are swollen, have been widespread. Another common torture is the beating of
a person’s buttocks until the flesh comes off. Electric shock, often with
electrodes applied to the genitals, has been inflicted to provoke convulsions
and unconsciousness and has been carried out in police stations. Doctors have
documented thousands of cases of injuries consistent with victims’ claims of
torture.
The erosion of civil and political rights under the
Mugabe regime parallels an equally severe economic collapse in Zimbabwe.
Economic collapse
A causal chain runs from Mugabe’s disastrous
economic policies, to Zimbabwe’s economic collapse, to food insecurity and
malnutrition, to the destruction of public healthcare, and finally to the
current outbreaks of infectious diseases. These policies include the land
seizure of 2000,48 a failed monetary policy and currency devaluations, and a cap
on bank withdrawals.
These policies have led to displaced farmers, low
salaries and unemployment, hyperinflation, dollarization of the economy – all of
which have led to food insecurity and malnutrition that have aggravated the
recent outbreaks in disease and drastic declines in leading health indicators.
Failed monetary
policy and currency devaluations
The significant loss in foreign exchange revenue
from agricultural exports in tandem with failed monetary policies in turn
undermined all economic activity.
In May 2008, the state-controlled Reserve Bank of
Zimbabwe (RBZ) allowed the dollar to float, but did not maintain its commitment
in the face of the currency’s continuous fall. The RBZ next carried out a second
redenomination scheme in August 2008 by removing ten zeros from the currency;
this monetary policy failed to rein in hyperinflation.
Cap on bank
withdrawals
In addition, the RBZ capped the monthly amount that
an account holder can withdraw from one’s bank in December 2008 to 10 billion
Zimbabwean dollars per month,52 which would purchase one loaf of bread or two
bus fares at December prices. Zimbabwe’s hyperinflationary environment,
moreover, renders any withdrawal limit irrelevant within days as prices soar.
Displacement of farm
workers
During the land seizures which began in March, 2000,
more than 4,000 white-owned farms were taken over by Mugabe’s supporters. Twelve
white farmers were killed during the land seizures. The workers on those farms
were also targeted for abuse because they were identified as supporting the
opposition. There were more than 300,000 farm laborers on the white-owned farms,
comprising the largest group of employees in the country. With their families
the farm-workers were more than one million people. The vast majority of these
farm-workers were thrown out of their homes and off the farms. Many suffered
violence and loss of property. For months large groups of these displaced
workers were seen camping alongside roads. Public
health experts estimated that this large group of people suffered serious health
problems.
Low salaries and
unemployment
More significantly, salary levels have not kept
apace with inflation. A government physician in Harare showed PHR investigators
her official pay stub; her monthly gross income amounted to the equivalent of 32
US cents ($0.32 USD). The Zimbabwean currency is literally not worth the paper
on which it is printed and is commonly seen strewn on the pavement. Moreover,
Zimbabwe’s unemployment rate is estimated to be over 80%. Low-income households
have been most adversely affected forcing them to reduce the quantity and
quality of purchased food.
Hyperinflation
Inflation has sky-rocketed from 231 million percent
in July 2008 to an unfathomable 79.6 billion percent each month, according to
the Cato Institute, equating to an annual inflation rate of 89.7 sextillion
(1021) percent as of November 2008. RBZ Governor Dr Gideon Gono continues to
issue new higher denomination notes while the Mugabe regime fails to address the
fundamental problem of the lack of foreign revenues, investment inflows, and
domestic production.
Dollarization
Hyperinflation has led in part to the unofficial
dollarization of the Zimbabwean economy as residents there have extensively
begun to use foreign currency alongside (and often in place of) the Zimbabwean
dollar.
The US dollar has become the de facto currency along
with the South African rand, and most goods are only available in foreign
currency stores. Until late 2008 it was illegal to buy or sell goods or services
in any currency other than the Zimbabwean dollar; however, the government
gradually loosened these restrictions, and in November 2008, dollarization
became legal when the RBZ licensed selected businesses to sell goods in foreign
currency.
Today nearly every business accepts (if not prefers)
foreign currency for payment, whether licensed or not. Dollarization has led to
two main adverse effects.
Switching to foreign currency has caused the
domestic currency to depreciate further, fueling the inflationary spiral.
Although prices of goods and services in foreign exchange remain relatively
stable, the dollarized economy in Zimbabwe discriminates against those who do
not have access to foreign currency – specifically, vulnerable populations, the
rural poor, and those without relatives abroad.
Those Zimbabweans who have access to foreign
currency include relatives of the growing diaspora (currently numbering more
than three million) who have largely emigrated to neighboring countries, the
United States, Australia, and the United Kingdom.
Zimbabweans began sending remittances to their
relatives back home on a large scale as the collapse of the economy escalated in
the early 2000s. The Global Poverty Research Group estimates that in 2006, 50%
of all households surveyed in Harare and Bulawayo were regular recipients of
money, food, and other goods from relatives who had fled Zimbabwe – an
exceptionally high density of receipt.
Several key informants told PHR investigators how
they receive such remittances through text messaging (SMS). Entrepreneurial
expatriates living in the United Kingdom launched Mukuru in 2007 – an SMS-based
coupon remittance program that allows Zimbabweans living in the UK to remit
value to friends or relatives in Zimbabwe through their mobile
phone.
Coupons are sent via text message, which people in
Zimbabwe can redeem for actual goods across an expanding network of local
stores, banks, and gas stations. A University of Zimbabwe professor of political
science estimates, however, that 80% of Zimbabweans do not have access to
foreign currency or remittance payments.
Zimbabwe’s shortage of foreign exchange and domestic
currency has even led to what may become known as petrolization: the bartering
of goods and services for fuel coupons. Although exchanging such fuel coupons is
legal, the coupons themselves are not legal tender and are only redeemable at
gasoline stations.
Some businesses and even public institutions are now
demanding fuel coupons as a means of payment. In a 31 December 2008 statement,
the Mugabe-appointed RBZ Governor warned Zimbabweans of counterfeit coupons and
urged members of the public to resort to the official currency for day-to-day
payments and to use foreign currency for special cases covered by the RBZ
dispensations (e.g., Foreign Exchange Licensed Warehouses and Retail Shops,
Foreign Exchange Licensed Oil Companies, and Foreign Exchange Licensed Outlets
for Petrol and Diesel).
Showing that he too has lost confidence in the
Zimbabwean dollar, RBZ Governor Gono established these government-sanctioned
foreign currency shops and businesses in September 2008 as a means of capturing
some of the foreign currency circulating in the country. The creation of Foreign
Exchange Licensed Warehouses and Retail Shops (FOLIWARS), however, negatively
impacts not only Zimbabwe’s economy, but also the rural poor and vulnerable
populations who have no access to foreign currency. Goods purchased at FOLIWARS
are imported from South Africa and Botswana, thus accelerating neighboring
countries’ economies and suppressing local industry. FOLIWARS also fuels
inflation by creating demand for foreign currency and further devaluing the
Zimbabwean dollar.
The foreign currency shops also allow the wealthy
elite, including ZANU-PF ministers and government officials, to circumvent
shortages of commodities in the local economy by frequenting FOLIWARS and
loading up on food stocks and luxury goods available in these stores. The vast
majority of Zimbabweans who barely survive on less than $1 USD per day has no
access to these stores.
In sum, the Mugabe ZANU-PF government must be held
accountable for the violation of the fundamental right to be free from hunger
for its citizens, not only for those with access to hard currency. More
specifically, as a result of Mugabe’s farm seizure and failed monetary and
fiscal policies, Zimbabwe has experienced severe shortage of foreign exchange,
hyperinflation, a paucity of basic commodities, and a sharp rise in unemployment
– all of which result in the inability of Zimbabweans to purchase food, hence
the occurrence of widespread malnutrition, and a population rendered extremely
vulnerable to the current outbreaks in disease that are now occurring. This
causal chain is an economic indictment of the ZANU-PF government, which has
employed macro-economic strategies that have demonstrably and disastrously
failed and have undermined people’s health and well-being.
PUBLIC HEALTH SYSTEM
COLLAPSE
The Government of Zimbabwe has abrogated the most
basic state functions in protecting the health of the population – including the
maintenance of public hospitals and clinics and the support for the health
workers required to maintain the public health system.
The result is that people whose health has been
undermined by the collapse of public services, who lack access to clean drinking
water, adequate nutrition, and primary prevention services have become unable to
obtain care in the public sector when they fall sick. These services have been
in sharp decline since 2006, but the deterioration of both public health and
clinical care has dramatically accelerated since August 2008.
PHR examines the collapse of Zimbabwe’s public
health system by assessing access to healthcare and healthcare delivery
(affordability, transportation, closing of hospitals, health workforce, access
to medicine and medical supplies, public versus private healthcare,
private-sector user fees, the role of NGOs in healthcare delivery, and access to
health information) as well as several key determinants of health (water,
sanitation, nutrition and food security).
HEALTHCARE AND
HEALTHCARE DELIVERY
The current status of healthcare in Zimbabwe is best
understood as an overall health system collapse: both public health functions,
including water and sanitation services, and the clinical care delivery system,
from hospital-based care to community clinic primary healthcare, have markedly
decreased in both amount and quality or ceased to function altogether in 2008. A
senior Ministry of Health official whom PHR interviewed stated: The healthcare
system has Discarded Zimbabwean 500,000,000 dollar
bills.
virtually stopped despite the fact that in the
1990s, Zimbabwe’s healthcare system was so good that 85% of the population lived
within 10 kilometers of a health facility, according to another health official.
Nowhere has the collapse of healthcare in Zimbabwe
been more striking than in critical care. As of December 2008, there were no
functioning critical care beds in the public sector in Zimbabwe. Patients
needing intensive care who do not have the $500 USD (in cash) for an admission
are literally dying. For instance, in obstetrical critical care, the director of
a still functioning but markedly over-burdened mission hospital told PHR:
“A major problem is the loss of life and fetal
wastage we are seeing with obstetric patients. They come so late the fetuses are
already dead. We see women with eclampsia who have been seizing for 12 hours.
There is no intensive care unit here, and now there is no intensive care in
Harare. If we had intensive care, we know it would be immediately full of
critically ill patients. As it is, they just die.“
The collapse of Zimbabwe’s healthcare and healthcare
delivery is reflected in the country’s deteriorating health indicators in such a
short timeframe:
The Human Development Index (HDI) for Zimbabwe has
fallen from a rank of 130th in 1999 to 151st out of 177 countries in 2007.
(HDI offers a broad measure of well-being by
examining a country’s life expectancy, adult literacy, educational enrollment,
and purchasing power parity.)
The maternal mortality ratio has increased at an
alarming rate from 283 per 100,000 in 1994 to 1,100 per 100,000 in 2005.68 The
infant mortality rate (the probability of a child born in a specific year or
period dying before reaching the age of one) rose from 52 per 1,000 live births
in 1990 to 68 per 1,000 in 2006.69
The adult mortality rate (the probability that a
15-year-old person will die before reaching her 60th birthday) in Zimbabwe
sky-rocketed from 286 per 1,000 in 1990 to 751 per 1,000 in 2006.70 Most
distressing is that life expectancy at birth fell dramatically from 62 years for
both sexes in 1990 to 36 years in 2006 – 34 years for males and 37 years for
females.71 This drastic fall in vital health statistics results in part from
diminished access to care, public hospital closings, and inadequate or
unaffordable medical supplies, which this report discusses below.
Access to
healthcare
There are two components relevant to access to
healthcare: first, financial access or the affordability of healthcare and
second, physical access or transportation, both detailed below.
Affordability
The dollarization of the economy since November 2008
has led to an economic apartheid in healthcare access. Since then, only a tiny
elite with substantial foreign currency holdings can be said to have any real
access to healthcare. This amounts to marked discrimination against the poor
generally – but also more specifically against those working in the public
sector, including healthcare staff at clinics and hospitals, who are still being
paid in Zimbabwe dollars. Only those with access to foreign currency can
purchase life-saving medical treatment.
The private healthcare sector, much like the rest of
Zimbabwe’s economy, has been increasingly dollarized since the last currency
devaluations in the third and fourth quarter of 2008. Virtually all economic
activity is in US dollars. PHR was told repeatedly by patients and providers of
the very alarming and increasing high cost of healthcare.
Transportation
The cost of transportation has become prohibitive
for both providers and would-be patients. Providers cannot afford to get to
work. Patients can no longer afford to travel to healthcare facilities.
Transport costs, even within Harare proper, have made the simple act of getting
to work impossible for many healthcare employees. The Director of a national
healthcare NGO reported to PHR that the public clinics are staffed by government
salaried nurses, pharmacists, aides and other staff. These staff are no longer
reporting to work because they cannot afford the transport costs, many have not
been paid in months, and their pay is no longer a living wage. Several nurses
interviewed by PHR reported that their monthly wages for the past month
(November 2008) were less than their daily round-trip transportation costs to
work.
Hence, nursing staff are currently losing money by
reporting to work. A rural clinic staff nurse reported that since he lived at
the clinic, he had no difficulties in getting to work; however, since bus fare
to get to the nearest town to collect his monthly salary cost more than the
entire salary, it made no sense to collect it. He had not done so since April
2008. A senior government official put it this way: “Government salaries are
simply rotting in the bank.”
When asked about how the absence of healthcare
workers was affecting HIV treatment, the official stated that: “This is not a
strike. The problem is the staff and the patients cannot come due to travel
costs.”
Transport costs have also made accessing healthcare
facilities an enormous challenge for would-be patients. One of the few hospitals
open to the public near Harare is a mission hospital with three physicians, an
hour’s drive from the capital. On the day PHR visited the hospital all the beds
were full, patients were sleeping on the floors of the wards between the beds,
and the corridors too, were lined with patients.
PHR physicians asked the director if the hospital
was always so crowded, and he reported that it was actually less busy and less
over-crowded than in previous weeks when Harare patients were less numerous and
most patients came from the surrounding communal area. The reason, he stated,
was transport costs.
People simply could not afford the cost of getting
to the hospital. This facility was some 80 kilometers outside Harare, the last
12 kilometers requiring travel over a rough dirt track. Buses and other
transport dropped off patients at the road head and those too poor to hire a
taxi were using ox-drawn carts for the long ride to the hospital. For those
unable to afford even the ox carts, some local people were willing to transport
patients in wheelbarrows.
Closing of public
hospitals and medical school
Between September and November 2008 most wards in
the large public hospitals gradually closed. The most abrupt halt in healthcare
access occurred on 17 November 2008, when the premier teaching and public
referral hospital in Harare, Parirenyatwa Hospital, closed its doors along with
the medical school. Parirenyatwa Hospital and Harare Central Hospital (also
closed in November 2008) are Harare’s largest. The Hospital had no running water
since August of 2008. Toilets were overflowing, and patients and staff had
nowhere to void—soon making the hospital uninhabitable. Parirenyatwa Hospital
was closed four months into the cholera epidemic – arguably the worst of all
possible times to have shut down public hospital access. Successful cholera
care, treatment, and control are impossible, however, in a facility without
clean water and functioning toilets.
Parirenyatwa Hospital’s surgical suites were closed
in September 2008. Pediatric surgeries also ceased in the same month. A surgeon
PHR interviewed reported having children in his care who he knew would die
without needed surgeries, but said: “I have no pain medication, some
antibiotics, but no nurses . . . . If I don’t operate the patient will die, but
if I do the surgery the child will die also.”
The closure of hospitals has led to the
deterioration of clinical instruction for medical students. Following these
closings, the Vice-Chancellor of the University of Zimbabwe declared the medical
school closed for an early vacation. PHR interviewed members of the Zimbabwe
Health Students Network on the closure of the hospital and the medical school.
The students reported that lectures had been canceled from two to three months
before the official closure on 17 November 2008, since the teaching faculty had
gradually stopped coming to work. Lecturers told the students they could no
longer afford the transport to come to work. A fourth-year medical student in
Harare told PHR that
“...school exams were cancelled because there was no
paper and no ink to print them.”
Students did not go on their required rural clinical
rotations since there was now no teaching or mentoring available in the rural
areas. One faculty member told them he had ceased trying to teach his course
since he did not want to take part in a charade. One medical student stated:
“Truth be told, the closing of the medical school was just collateral damage of
the collapse of the health system.”
PHR investigators also visited the medical school
library. A handful of students were studying near windows in order to have
enough light to read, given there was no electricity. Although the textbook
collection appeared adequate – albeit most titles are relatively old – most
journals on display were significantly out-of-date.
Health
workforce
The exponential and continuing drop in the value of
Zimbabwe’s currency has resulted in a spiraling decline in working conditions
and remuneration for public sector health personnel.73 The near collapse of
public sector healthcare provision is dated by most as having commenced in
mid-November 2008. Although certain categories of health workers (e.g., junior
physicians and nurses) have in the past withdrawn their labor for limited
periods, on this occasion, a broad spectrum of personnel – professionals and
support staff – either ceased coming to work or began working minimal hours per
week due to insufficient wages.
The response has been a continuing and large
migration out of the public health service and into the private sector, and,
increasingly, to other countries. Precise numbers are difficult to obtain since
many health professionals maintain their registration (licensure) with their
respective medical boards. Many have increased their time in the private sector
or entered it for the first time. Those health professionals interviewed by PHR
indicated that their main reason for taking such action was their insufficient
and declining salaries. Indeed, a group of senior medical students told PHR
investigators that some of their colleagues are undertaking private medical
work. One example given was of fourth- and fifth-year medical students
performing illegal and unsupervised abortions in exchange for payment in foreign
currency.
Access to
medications and medical supplies
The decline of the public health sector dating back
to the late 1990s frames the current collapse. Long-standing under-investment in
infrastructure by the Mugabe regime and recurrent under-expenditure, including
in medicines, supplies, equipment and, most importantly, human resources,
underlies the healthcare crisis. Lack of access to essential medications was
raised as a concern by nearly all providers interviewed. In addition to drug
shortages, medical supplies (including the most basic clinical supplies such as
cleaning agents, soap, surgical gloves, and bandages) were also in critically
short supply—or absent altogether. A rural clinic nurse reported:
“Right now I have no anti-hypertensives, no
anti-asthmatics, no analgesics, nothing for pain. The worst is I have patients
with epilepsy and no anti-epileptics. I have a woman in labor right now, and I
have no way to monitor blood pressure, no oxytocin for post-partum hemorrhage,
and I have no suture material to do a repair if she tears.”
This same nurse, when asked if he had sufficient
supplies reported that he had a few pairs of latex gloves, but that he stored
these at his home, not at the clinic, to save them for emergencies.
Another nurse in a public sector clinic, which had
been heavily burdened with cholera cases, reported that: “Our situation is
really bad. We have no running water in the clinic. The toilets are not
functioning and we have no proper chemicals to clean them, so the smell is very
bad. It is demoralizing to the cleaners to have no proper chemicals to clean the
toilets. We nurses have no protection, no gloves, to protect ourselves. The
clinic is not clean. We have no way to get rid of our trash. Now that the
cholera has started the Red Cross has given us some gloves and some
disinfectants, but it is not enough.”
This nurse reported her fear of treating cholera
patients without proper materials for precautions like gloves and protective
garments.
These financial problems for those working in the
government health sector are the direct result of the marked under-funding of
health by the Mugabe regime.
One senior official reported to PHR that: “The
Ministry of Health budget was approved in January 2008. It is supposed to last
the year, but was spent in the first month. This has been true for the past five
years—it [the annual health budget] only lasts about a month.”
Health officials also cited the deteriorating
working conditions, with care being compromised by lack of essential supplies
and equipment. In addition, the breakdown of physical infrastructure, such as
water and sewerage systems and blockage of patient and staff toilets, has made
it increasingly impossible for health personnel to render a service. One
informant indicated that some personnel working at Harare Central Hospital would
even travel to their homes to use the toilet.
The Heads of States meeting in Abuja (Nigeria, 2001)
recommended that a country’s health budget should constitute at least 15 percent
of the total government allocations. From 2005 to 2008, Zimbabwe’s percentage
allocation for health has averaged 9.5%.
Doctors treated like
dogs at peaceful protest
According to several key informants who were
participants, a group of local physicians, nurses, pharmacists, medical and
dental students organized a non-violent demonstration on 18 November 2008 to
protest poor working conditions and wages.
The group, numbering several hundred, intended to
march peacefully from Parirenyatwa Hospital in Harare to the office of
Zimbabwe’s Minister of Health to deliver a petition. Soon after the march began,
approximately 50 police exited armored personnel carriers and prevented the
healthcare professionals, many of whom were wearing white coats, from marching.
Many in the march then continued protesting within the confines of the hospital
itself. Two truck-loads of armed police arrived on hospital grounds and began
beating them using wooden baton sticks.
One medical student interviewed reported not being
able to walk for a week. He stated: “Doctors with high esteem were treated like
dogs.” As many protesters were wearing their white coats, once the marchers
began to flee, they were readily identifiable in the crowds by the police who
were chasing them.
Public versus
private healthcare
There are marked urban-rural disparities in
healthcare access in Zimbabwe, and these have worsened in the healthcare crisis.
Most of the private-sector healthcare is urban, and primarily in Harare and
Bulawayo. In rural areas healthcare is provided through both the public and
private sectors.
According to the head of a local health NGO, private
mission hospitals account for 68% of healthcare delivery in rural areas. There
are 126 mission hospitals and clinics throughout Zimbabwe’s ten provinces. Some
mission hospital staff are paid by grants from the national health budget;
mission hospitals supplement staff salaries with funds raised from the
faith-based and donor community. As the Harare hospitals have closed down since
November 2008, the proportion of patients from Harare presenting at rural
mission hospitals has increased. A mission hospital director reported:
“We are now getting 50-60% of our admissions from
Harare, and this is an increase since the Harare hospitals have closed. In the
past, about 25% of our admissions were from Harare 80 kilometers Some of the
private, non-profit mission hospitals also officially serve as district- and
provincial-level hospitals in the public healthcare system.
Mission hospitals in Zimbabwe are supported mainly
by the Catholic and Anglican churches as well as the Salvation Army.
A health administrator at the same mission hospital
noted that the steep recent increase in (predominantly middle-class) patients
coming from outside the district has been counterbalanced by a decrease in
utilization by patients from within the district – particularly those living far
from the hospital for whom transport costs are unaffordable.”
Private-sector user
fees
Exorbitant user-fees preclude access to
private-sector healthcare for most people in Zimbabwe.
According to several physicians working in urban
private hospitals whom PHR interviewed, user fees for medical services are far
beyond what is affordable for the vast majority of Zimbabweans: $200 USD in cash
for an initial medical consultation, $500 USD to secure an in-patient bed,
$3,000 USD for a Cesarean section
Such user fees are within reach of only very few
wealthy Zimbabweans. Consequently, the vast majority of the population is
effectively denied access to medical care. A member of Parliament reported to
PHR investigators that even the Minister of Health is not immune to the high
cost of medical care, relating how he was recently unable to produce the $3,000
USD Police chasing health professionals at a non-violent
demonstration.
cash required by Avenues private hospital in Harare
in order for his wife to be admitted for emergency care.
Referring to physicians who are not treating
patients due to their inability to pay, a rural mission hospital physician
reported:
“It’s a healthcare delivery war. ... The ethical
underpinnings of healthcare in Zimbabwe have broken down.”
Ambulance
fees
The severe shortage of ambulances in Zimbabwe and
the high cost for this emergency service are barriers to accessing affordable
healthcare throughout the country.
According to a senior Ministry of Health official
whom PHR interviewed, there are almost no ambulances in the rural districts.
Patients are put in an oxcart and loaded onto the nearest bus. Private
ambulances currently accept only U.S. dollars, starting at $100 USD even for
short trips. Furthermore, ambulances have little relevance in Harare for those
without the dollars for private care as the public sector hospitals have been
closed since November 2008. There is nowhere in the city for an ambulance to
take a patient unless he or she has a $200 USD in cash for a medical
consultation.
Role of NGOs in
healthcare delivery
The above serious under-provision of services has
had a demonstrable major negative impact on the health and well-being of many
Zimbabweans, especially the poor majority. The energetic and focused efforts of
a number of local non-governmental organizations (NGOs), international NGOs,
bilateral organizations, and donors have played a critical role, however, in
providing healthcare to Zimbabweans, bolstering the country’s healthcare system,
and addressing the current humanitarian crisis.77 For example, UNICEF has
coordinated a number of critical interventions and sourced key inputs.
International donors by mid-December had contributed over $8 million USD for the
cholera response.
This has included the trucking of over 500,000
liters of water per day to Budiriro high-density suburb, the sourcing of
borehole drilling equipment and technical personnel, the importation of
intravenous and oral rehydration supplies, and the provision of over 70% of
Zimbabwe’s vital medicines.
Médecins Sans Frontières (MSF) is largely
responsible for staffing the major cholera treatment centers (including Beatrice
Road Infectious Diseases Hospital, Chegutu Hospital, and Beitbridge Hospital) as
well as coordinating antiretroviral treatment for more than 30,000 HIV/AIDS
patients. The World Food Program and the Consortium for Southern African Famine
Emergency (C-SAFE) are coordinating the supply of relief food aid, which is
being distributed mainly by local NGOs. Finally, the largest contribution to
health service provision continues to be made by mission health facilities. In
short, the government’s withdrawal from healthcare delivery has been
counter-balanced by increasing involvement of the donor and voluntary sector.
It is widely acknowledged, however, that these
efforts, while crucial, cannot replace a functioning public sector. So for
example, when PHR visited urban and rural clinics to assess cholera
preparedness, several clinics did have oral rehydration supplies, intravenous
fluids, and IV infusion sets that staff felt were adequate to their cholera case
burdens. These commodities were virtually all supplied by UNICEF, with funding
reportedly from the British Government through the Department for International
Development (DFID), the European Commission Humanitarian Aid Office (ECHO), the
Canadian International Development Agency (CIDA), and other members of the donor
community. These same clinics however, lack running water and functioning
toilets, adequate (and paid) staff to provide cholera care, and other essential
medicines.
PHR found a similar situation with regard to US
bilateral assistance for Zimbabwe’s HIV/AIDS program. The US Embassy in Harare
supports the large President’s Emergency Plan for AIDS Relief (PEPFAR) program
in Zimbabwe, which is currently providing antiretroviral (ARV) medication for
some 40,000 patients across the country – about 20% of all patients in the
country receiving these AIDS drugs.
But the PEPFAR program is dependent on the overall
healthcare system to function. Since the closure of the public hospitals in
November 2008, access to free HIV testing and counseling services has declined.
Members of an HIV/AIDS support group told PHR that the cost for an HIV test at
the private clinics now offering the service was $200 USD (in December 2008).
Hence access to testing for the majority of Zimbabweans, the first step in
seeking HIV treatment, has declined.
Hospitalization for AIDS patients who require it has
also dramatically declined—so even those patients on PEPFAR supported ARVs may
be unable to access in-patient care if they need it and do not have U. dollars
to pay the $500 USD admission charges that PHR was told are being demanded by
the private hospitals.
Access to health
information
Actions and omissions by the ZANU-PF government have
markedly worsened the healthcare system collapse. PHR identified a number of
instances, including the cholera epidemic and the reporting of malnutrition,
where government denial and suppression of health data have contributed to this
collapse.
The Mugabe regime intentionally suppressed initial
reports of the cholera epidemic and has since denied or underplayed the gravity
of the epidemic with fatal consequences.80 The Minister of Information and
Publicity, Sikhanyiso Ndlovu, reportedly ordered government-controlled media to
downplay the cholera epidemic, which he said had given “... the country’s
enemies a chance to exert more pressure on President Robert Mugabe to leave
office. The Minister instructed the media to turn a blind eye to the number of
people who have died or [have become] infected with cholera, and instead focus
on what the Government and NGOs are doing to contain the epidemic.”
Zimbabwe Association of Doctors for Human Rights
(ZADHR) informed PHR that when their physicians had offered to the Harare City
Council to volunteer to respond to the cholera epidemic in October 2008, the
Council declined their offer and responded: “We have the situation under
control.”
A nurse felt strongly that the Government’s denial
of the cholera epidemic was part of the problem: “What the Government is saying
about cholera is lies, lies, lies.”
We asked her to explain this statement and she
replied: “We have had many cases of gastro[enteritis] and cholera cases since
August. The Government says that cholera is under control – I saw this yesterday
on the TV. But how can this be true when people are still dying?“
PHR also received reports from several sources in
Zimbabwe that the Government has intentionally tried to suppress information
regarding a burgeoning caseload of malnutrition. PHR asked a nurse staffing a
public-sector clinic in a rural district outside Harare if there had been cases
of malnutrition and diseases like kwashiorkor presenting in children. The nurse
became visibly anxious and then replied: “Malnutrition is very political. We are
not supposed to have hunger in Zimbabwe. So even though we do see it, we cannot
report it.”
DETERMINANTS OF
HEALTH
The health of Zimbabweans and of all people requires
a great deal more than medical care. PHR assessed key underlying determinants of
health that have contributed to the collapse of healthcare and healthcare
delivery in Zimbabwe. As part of its emergency assessment mission, PHR examined
access to safe water, adequate sanitation, sewerage, and food security.
Water and sanitation
The basic infrastructure for the maintenance of
public health, particularly water and sanitation services, has deteriorated in
the worsening political and economic climate. According to several public health
specialists whom PHR investigators interviewed, water treatment and delivery
systems were better managed before the ZANU-PF government nationalized municipal
water authorities in 2006-2007. The Mugabe regime, however, politicized water
for political gain and profit, policies that proved disastrous for sanitation
and water delivery systems, and which have clearly contributed to the ongoing
cholera epidemic.
The government established the Zimbabwe National
Water Authority (ZINWA) with the promulgation of the Water Act in 1997. The
functions of ZINWA include advising the government on policy, standards, and
conservation of national water supplies as well as promot[ing] an equitable,
efficient, and sustainable allocation and distribution of water resources while
assist[ing] local authorities in the discharge of their functions . . . with
regard to the development and management of water resources under their
jurisdiction and in particular, the provision of potable water. A government
official reported to PHR that the ZANU-PF government nationalized
well-functioning municipal water authorities to provide additional revenue
streams for the cash-strapped government.
Usurping this function also deprived MDC-backed
municipal councils of an important source of revenue.
A health professional from Bulawayo informed PHR
investigators that ZINWA suspended plans to take over Bulawayo’s city water
council in 2008 believing that residents there would vote against ZANU-PF during
the parliamentary elections as backlash to the unpopular move. Bulawayo,
Zimbabwe’s second largest city, has not experienced the same water shortages as
in Harare and has a markedly lower incidence of cholera with most cases being
imported into Bulawayo, according to a government epidemiologist.
ZINWA has presided over the collapse of water
sanitation and delivery across Zimbabwe. According to two members of parliament
whom PHR interviewed, the ZANU-PF government has since willfully allowed
outdated and damaged water systems to go unrepaired and water supplies to go
untreated. A water systems engineer in Harare stated that ZINWA had not improved
water service delivery; instead the parastatal agency had caused its ruin.
Residents in Harare informed PHR that on 29 November 2008, without warning,
ZINWA cut off water to the capital for several days.
Zimbabwe’s own government-controlled press later
reported that ZINWA had failed to procure enough aluminum sulfate – one of four
chemicals used to treat the water supply – so it stopped pumping water from the
Morton Jaffray Water Treatment Plant in Norton outside Harare. According to
several sources, instead of ensuring an adequate stockpile of water treatment
chemicals or quickly importing them from South Africa, the ZANU-PF Minister of
Health, David Parirenyatwa, flippantly responded by urging the population to
stop shaking hands.
The November cut-off was not the first instance of
water shortage in Harare; numerous Harare residents informed PHR that water
delivery has been sporadic for years – sometimes absent for more than six
months.
Failed Sewerage and
Sanitation Systems
Surface water, which seeps into porous ground and
into shallow wells, has become contaminated with fecal waste because of leaking
sewerage pipes.
A key informant with an NGO that provides technical
assistance to the Government on reticulated water systems informed PHR that
Zimbabwe has one of the highest levels of unaccounted for water (UFW) at
45%.
(Reticulated water systems are piped water networks
as opposed to well water.) In other words, the country loses nearly half its
water supply through leakage from broken water pipes. These leakages and the
intermittent supply of water lead to inadequate pressure in the reticulated
system. When water is not pumped through the pipes at a continuous rate, the
pipes do not completely fill with water, leading to negative pressure. This
pressure draws in the effluent from parallel-running sewerage pipes.
The economic collapse occasioned under Mugabe’s
government has had further indirect but important negative effects on water and
sanitation: clogged sewerage pipes leading to inoperative toilets in households
and the cessation of public trash collection.
City council public works department employees
usually unclog pipes and sewerages, but because they are not working (due to
insufficient wages), this crucial task is not performed. PHR received reports
that these municipal employees are moonlighting in the private sector. To
augment their meager salaries, some are using available municipal supplies, such
as sewerage rods, and offering their services to the public for cash payment.
Another cause of contaminated surface water is broken sewerage pipes. Effluent
with human waste leaks from burst pipes allowing seepage into the reticulated
water system. The clogged pipes have also led to inoperative household toilets.
People are then forced to urinate and defecate outside their homes. All Harare
residents PHR interviewed spoke of the city’s sanitation system collapsing
during the past several years.
All Harare residents PHR interviewed reported that
trash collection has effectively ceased. Throughout Harare, and especially in
the poor high-density areas outside the capital, PHR investigators saw detritus
littering streets and clogging intersections. Steady streams of raw sewage flow
through the refuse and merge with septic waste. A current Ministry of Health
official reported to PHR: “There is no decontamination of waste in the country.”
ZINWA mismanagement coupled with the economic
collapse has led to the current cholera epidemic. A water systems engineer
informed the PHR team that a severe shortage of potable water has forced people
to dig shallow wells (10-12 meters), which are not deep enough to extend below
the protective bedrock.
Bedrock, which may lie more than 20 meters below the
surface, is a natural barrier that protects the water below it from
contaminants. Boreholes, which are mechanically dug to a depth of 30-40 meters,
usually ensure a source of uncontaminated drinking water. The engineer explained
that when shallow wells are dug, seepage from run-off water enters these wells
from which the residents are drinking. Much of this run-off water, however, has
recently been contaminated with fecal waste containing the cholera bacteria.
Further, these shallow wells are essentially linked because they are not
protectively lined with cement. He warned that the rainy season commencing in
December is going to exacerbate the crisis because when the ground and soil
becomes saturated with water, it is easier and faster for the (contaminated)
run-off water to travel from well to well. Residents of the high-density areas
near Harare, Budiriro and Chitungwiza, where incidence of cholera is highest,
filed a class-action lawsuit against ZINWA in November 2008 for failing to
provide safe and clean drinking water, thus leading to more than 300 deaths from
cholera in their districts alone.
Nutrition and food
security
Another keydeterminant of health concerns nutrition
and access to an adequate supply of safe food (i.e., food security). Until 2000,
Zimbabwe was one of Africa’s leading agricultural breadbaskets. As recently as
2000, agriculture constituted the base of Zimbabwe’s economy contributing to 45%
of export earnings and providing livelihood to more than 70% of the population.
Today, more than two million Zimbabweans rely on
food assistance. The UN Food and Agricultural Organization (FAO) predicts that
this figure will rise to 5.1 million (45% of the population) who will require
food aid by early 2009 in order to survive.
Many sources suggest that these stark figures result
from the policies of the ZANU-PF regime, which has rendered nearly half its
population vulnerable to food insecurity. These policies include the land
seizure and the blockage and politicization of food. Drought has further
exacerbated food insecurity. PHR investigators examined the impact of this
insecurity in the HIV/AIDS population and in children.
Land seizure
In April 2000, the ZANU-PF-controlled parliament
approved amending the Zimbabwe Constitution to establish the legal framework for
land acquisition.
Mugabe quickly mobilized some 35,000 war veterans
and unemployed youth militia and ordered them to begin expropriating white-owned
farms while brutally assaulting and sometimes murdering the commercial farmers
and farm workers. Under the guise of land redistribution to benefit landless
black Zimbabweans, Mugabe instead awarded many of these once productive farms to
government ministers and other ZANU-PF supporters for their
patronage.
Many of these farmlands now remain fallow and serve
as nothing more than second homes to these non-farming government officials.
Indeed, agricultural output has dropped 50-70% over the past seven years. The
land seizure led to sharp falls in agricultural production, precipitated the
collapse of the economy in turn impacting negatively on small-scale farmers
unable to afford agricultural inputs such as small grain seeds, top-dressing
fertilizer, pesticides, and fuel, and increased food insecurity for
millions.
Government
politicization and obstruction of food aid
The Mugabe regime has also been accused of using
donor food aid as a tool to manipulate elections by providing food to
communities that supported his ZANU-PF political party and denying food aid to
communities that did not.
After the Matabeleland massacres, the Mugabe
government established a pattern of restricting the transport of food into that
region during election periods so that only supporters of Mugabe’s ZANU-PF party
would receive food. This policy became severe around the parliamentary elections
in June 2000 and again around the presidential election in March 2002.
The Army prevented supplies of maize meal, the
staple food, from being delivered to many Matabeleland and other rural areas,
such as Binga and other parts of the Midlands, that had voted against Mugabe. It
also restricted the operations of aid organizations, such as Save the Children
and Oxfam, and prevented large quantities of food from being distributed. In one
incident, in June 2002, Mugabe’s supporters in Binga prevented the distribution
of nutrition packs to schoolchildren.
The state-owned Grain Marketing Board (GMB) sold
inexpensive maize, but officials would sell the grain only to card-carrying
members of Mugabe’s ZANU-PF party. People suspected of supporting the opposition
were refused food.
This policy of restricting food aid to areas that
support the opposition party, the Movement for Democratic Change (MDC) has
persisted and was used during the recent 2008 elections. In addition, the
Government restricted seed and fertilizer in areas which voted for the
opposition. This restriction of food became most blatant in June through August
2008, when the Mugabe government banned all charitable organizations from
distributing food or from operating in Zimbabwe’s rural areas.
This politicization of food aid has continued. On 31
December 2008, a government official in Chivhu prevented WFP from distributing
food aid: “The villagers accused the chief of being corrupt and diverting donor
aid and distributing it along party lines. They indicated that ... the chief and
his ZANU-PF supporters used to source maize from the nearby Grain Marketing
Board and then sell it to the poor villagers.”
Hunger is a special problem in institutional
settings as well. A leader of a health NGO reported that: “There is no food in
many of the hospitals and there is starvation in the prisons.”
PHR did not visit any of Zimbabwe’s prisons or
detention facilities, but is deeply concerned that violations of the rights of
prisoners to adequate food, water, sanitation, and healthcare may be occurring.
A senior Ministry of Health official confirmed that “...malnutrition is
pronounced in prisons.”
The ZANU-PF government has exacerbated food
insecurity for Zimbabweans in 2008 by blocking international humanitarian
organizations from delivering food aid and other succor to populations in the
worst-affected rural areas. Since the start of the March 2008 election period,
government officials increasingly constrained the humanitarian community’s
access to vulnerable populations, according to several international NGO staff
in Zimbabwe whom PHR interviewed. On 4 June 2008, the ZANU-PF government
formally requested full cessation of field operations for humanitarian
organizations providing relief in Zimbabwe.
The Mugabe regime prevented the UN World Food
Program (WFP) and other UN partner organizations from delivering food assistance
to the rural poor.108 It is difficult to assess how many thousands have died as
a result. Only in October 2008 were these humanitarian organizations allowed to
resume distribution of monthly emergency food rations. Almost certainly this
resumption of life-saving food aid is mitigating nutritional decline.
Drought
Poor harvests during the past three years due to
droughts and erratic rainfall – especially in marginal agro-ecological zones –
exacerbate the government-induced unavailability of basic agricultural inputs
(or farmers unable to afford such inputs).
PHR investigators interviewed several rural
subsistence farmers who reported that over the past three years they have
experienced severe food shortages. On random inspection of a few grain silos in
one area that is prone to food insecurity in times of drought, PHR confirmed
that they had exhausted their meager stocks of maize, which would normally
supply them during the lean months of the growing season (December through
March) before the next 2009 spring harvest. Most families whom PHR interviewed
survive on less than one meal per day, and a senior Ministry of Health official
confirmed this deplorable statistic adding that the food situation is very
pathetic and quite bad in Zimbabwe. In fact the United Nations estimates that
two-thirds of Zimbabweans currently subsist on one meal a day and that 56% of
all Zimbabweans live on less than $1 USD per day.112 The World Food Program
additionally warns:
“The crisis is going to get much worse in the coming
months” due to this extreme lack of food stocks following an especially poor
2008 harvest; thus, food insecurity and extreme nutritional vulnerability are
likely to persist.
Impact of food
insecurity on HIV/AIDS
PHR also conducted a focus group of 15 HIV-positive
urban women who all reported experiencing food insecurity. In addition to drug
therapy, food and nutrition are essential for treatment. More than half the
women interviewed reported having no food to eat that day. They said they lived
each day, and for that day alone. More than half of the women ate a small amount
of the lunch provided by the hosting NGO (or none at all) because they wanted to
take the food home to feed their children. One woman broke down crying when she
was offered an extra sandwich; she noted that she would take it home to her
young son who is also HIV-positive and who had not had food in two days.
The head of a local AIDS organization reported that
the current economic crisis has led to a sharp increase in commercial sex, which
is helping fuel the spread of HIV. PHR was told that many sex workers are now
requesting payment in kind (sugar, soap, maize meal), and have increased the
number of clients per day to 10 to 15. More than 6,000 Zimbabweans per day cross
into South Africa at the border town of Beitbridge.
An increasing number of these economic migrants are
women who make the journey and engage in commercial sex in order to buy food to
bring back home for their families.
A former Ministry of Health official and current
mission hospital administrator reported that some HIV/AIDS patients are selling
their ARV medications to receive money to buy food. She also reported that many
AIDS patients in Harare travel to their rural homes to die; thus rural mission
hospitals are seeing an increase in the HIV/AIDS caseload. This has abruptly
accelerated since the closure of the public hospitals in Harare.
Patients living with HIV/AIDS are especially
vulnerable as a result of food insecurity. They are prone to both diarrheal
diseases and wasting, which can be exacerbated by poor nutrition. For those
fortunate enough to be on ARVs, adequate nutrition is essential for the drugs to
work. Lack of essential micronutrients is itself immunocompromising, especially
for pediatric HIV/AIDS patients. Having to choose between medication or food is
especially deadly for patients with AIDS and tuberculosis, since treatment
interruptions can lead to drug-resistant organisms – a grave complication.
Impact of food
insecurity on children
Save the Children reports that child malnutrition
has risen to 50% in some regions and has found that acute malnutrition in
children aged six months to five years has nearly doubled since 2007 in one of
the two districts in which it has been working in Zimbabwe.
The humanitarian organization also reports that in
some localities wasting rates are now over seven percent. PHR anticipates these
rates will rise during the next several months as already low food stocks become
depleted. According to one senior physician interviewed: “An unprecedented
famine in Zimbabwe’s history awaits us next year.”
CURRENT HEALTH
CRISIS
The collapse of the public health system and
corresponding key determinants of health described above have resulted in a
cholera epidemic, an anthrax outbreak, worsening HIV/AIDS, tuberculosis (TB),
maternal mortality and morbidity, and malnutrition and vitamin deficiency in
Zimbabwe.
Cholera
Cholera is an acute diarrheal disease, caused by the
bacteria Vibrio cholerae, which, if untreated or is treated too late, can result
in severe dehydration and death within hours. Cholera is water-borne and
food-borne: it spreads through fecal contamination, and ingestion of water or
food contaminated by human feces. Cholera is easily treated with oral
rehydration, if it is treated in time, and with intravenous rehydration in
severe cases.
The current cholera epidemic in Zimbabwe appears to
have begun in August 2008. As of this writing, more than 1,900 Zimbabweans have
died from the disease and another 37,000 people have been infected. A recent UN
report states that the cholera epidemic has spread to all of Zimbabwe’s ten
provinces, and 55 of the 62 districts (89%) are affected.118 The UN reports that
the cumulative case fatality rate (CFR) across the country has risen to 5.0% -
five times greater than what is normal in large cholera outbreaks. A closer
inspection of these statistics reveals that 42% of all districts have cumulative
death rates greater than 10%.
As of 6 January 2009, the highest case loads have
been in Harare, Beitbridge, Makonde, Chegutu, and Mudzi districts; a recent
surge in reported cases has occurred in Manicaland province.
These statistics are thought to be underestimates.
One government health official whom PHR interviewed estimated that the current
Ministry of Health figures (distributed through the U.N. Office for the
Coordination of Humanitarian Affairs (OCHA) and WHO) represent 80% of the true
cholera caseload. According to staff at the US Centers for Disease Control and
Prevention (CDC) in Harare whom PHR interviewed, this under-reporting is due in
part to failed public health reporting systems. OCHA also acknowledges in its
daily updates that it does not receive new cholera statistics from some
districts for up to seven days. PHR physicians spoke with a government nurse at
a small rural public clinic who reported that he sees cholera patients every
day. He related:
“Cholera is killing a lot of people. There must be a
minimum of 50 deaths from cholera every day, so there must be more [cases] than
are being reported.”
In addition, PHR is concerned that unknown numbers
of cholera deaths likely go unreported because people are forced to die at home:
public hospitals are now closed, and those mission hospitals that are
functioning are financially inaccessible to many of the rural poor.
This is likely to be particularly true in more
remote rural areas and among the many child-headed households in Zimbabwe, which
has more than a million orphaned children, largely as a consequence of the
ongoing HIV/AIDS epidemic.
The available data suggest that the epidemic is
worsening. Cholera is normally seen sporadically in Zimbabwe in the rainy
season. The current epidemic began in August, in the dry season, an unusual
situation almost certainly due to the government’s disastrous failure to treat
water and sewage and decision to turn off municipal water supplies. The epidemic
progressed through the dry season. A current Ministry of Health official whom
PHR interviewed warned that we have not seen the last of the [cholera] outbreak
and expected to see the number of cases increase in the coming months as the
rainy season begins because resultant floods will further spread contaminated
water. In support of this prediction, there has been a doubling of both cases
and deaths during the last three weeks in December.
The Zimbabwe Health Cluster (comprising a number of
NGOs in Zimbabwe working on the cholera epidemic, including the World Health
Organization, the International Committee of the Red Cross, and the
International Organization for Migration) conducted a rapid assessment and
developed an operational plan for the coming year.124 The Health Cluster
estimates an annual case load of 60,000 – a figure that the Health Cluster
itself believes to be an underestimate because of using a conservative attack
rate of 1%.
Infectivity
The origin of the current cholera epidemic appears
to stem from the failure of the Mugabe regime to maintain water purification
measures and manage sewerage systems. Vibrio cholerae usually reside in tidal
waters and bays and proliferate mostly in summer months (when water temperatures
exceed 20°C). Humans become infected incidentally, but then can act as vehicles
of spread. Research has shown that passage through the human gastrointestinal
tract imparts a hyperinfective state to cholera that plays an important role in
dissemination of the disease. Human cholera epidemics are largely preventable.
If the water supply is kept safe and sanitary disposal of feces operates, the
risk of spread of the disease is virtually nil. If, however, the public sector
fails to maintain water and sanitation, the risk of disease escalates
dramatically.
A further challenge to cholera control in Zimbabwe
is the large proportion of the general population who are immunocompromised.
With more than 15% of all adults living with HIV infection, and widespread
micronutrient deficiency and malnutrition also contributing to poor immunity,
Zimbabwe’s population is markedly more vulnerable to severe clinical cholera and
to cholera spread. Since the closure of the General Hospitals in November, 2008,
and the interruption of HIV/AIDS drug supplies, delivery systems, and clinical
care over the past 18 months, the ability of the healthcare system to provide
the added care needed to address cholera among the immunocompromised is severely
limited.
Epidemiology
Cholera has been threatening Zimbabwe for several
years. In 2004, an outbreak killed 40 people and infected 900 others.129 In
2005, 14 recorded deaths and 203 cases of cholera occurred – and these during
the low-risk months from May to June.130 In 2006, a cholera epidemic resulted in
27 deaths.131 Civic organizations in Harare warned of a cholera time-bomb in
2006, but the Mugabe regime ignored the warning signs.
In February 2007, three deaths and 19 cases were
reported. Beginning in August 2007, there were reports that ZINWA had dumped raw
sewage into Lake Chivero, Harare’s main water supply source; public clinics
reported treating some 900 cases of diarrhea daily some of which may have
represented cases of cholera. These outbreaks suggest that the preconditions for
a major outbreak of water-borne disease were present and worsening for at least
the past three years. Despite the repeated warnings from civil society groups,
healthcare providers, and donors, the Mugabe regime failed to take decisive
action over these years.
Not until 4 December 2008 did Zimbabwe’s Ministry of
Health and Child Welfare finally request aid to respond to the cholera outbreak
by declaring a national emergency. This negligence represents a four-month delay
since the beginning of the current cholera outbreak, but at least a three-year
delay in responding to the water and sanitation breakdowns, which have allowed
cholera to flourish.
According to the CDC, the Zimbabwe outbreak has
spread as of December 2008 to all its neighboring countries; there are confirmed
cholera cases in Botswana, Mozambique, Zambia, and South Africa.
This spread has been accelerated by the increased
movement of Zimbabweans across international borders. In the face of the current
economic crisis and political repression, Zimbabweans are traveling more to seek
food, supplies, healthcare, and refuge in neighboring countries and carrying the
disease with them.
The striking feature of Zimbabwe’s cholera epidemic
is that it occurred during peacetime. The recent historic trend is that cholera
epidemics are associated with large-scale humanitarian disasters resulting from
war. V. Cholerae has been responsible for at least seven global pandemics since
1817 (e.g., following the 1994 Rwandan genocide). These cholera outbreaks were
precipitated by war or natural disaster that led to a breakdown in public the
health system. The implication for Zimbabwe is that the current breakdown of
public health services and the collapsed economy is tantamount to a failed
state.
Treatment
Cholera is a temporally self-limiting disease; it
usually runs its course in a matter of days. Untreated, this short disease
course can be lethal. When recognized and treated early, cholera is easily
managed with oral or intravenous rehydration. It suffices to match diarrheal
losses with fluids and electrolytes during the several-day course of the disease
and if done, many symptoms are avoided, and patients typically make full
recovery. Although specially formulated, pre-packaged oral rehydration salts
(ORS) are ideally required for rehydration in mild and moderately severe cases,
oral rehydration therapy (ORT) in the form of any sugar-salt solution or other
liquids containing salt and a source of energy (carbohydrate or protein) are
also efficacious.
Antibiotics diminish the duration and volume of
fluid loss and hasten clearance of organisms from the stool, but are not
necessary for curing cholera.
Death rates from cholera are generally around one
percent of clinical cases. PHR asked a senior government official responsible
for cholera surveillance why Zimbabwe’s case fatality rate was more than five
times greater than this norm. She attributed the high cumulative rate to three
causes:
First, in the initial phase of the response there
simply were no supplies, such as ORS and IV fluids, to treat the many cases.
Second, few clinic or hospital staff were
sufficiently experienced or trained to respond to cholera, and many patients
died even in facilities that did have adequate supplies. Finally, the issue of
transport costs for patients and staff, exacerbated by the closure of the public
hospitals, meant that many patients either could not reach care, or reached care
in very advanced stages of dehydration, and could not be saved.
The last point was corroborated by the director of a
functioning mission hospital at some distance from Harare, who reported that
since the rise in transport costs and the dollarization of private healthcare,
he was seeing more and more patients presenting too late for clinical care.
Referring to the malignancy created by government neglect and overt action, he
further stated: “Cholera is one of the symptoms of the cancer.“
He reported that his cholera patients were all
overflow from Harare because of the severe lack of free treatment available in
the city. He said: “For every cholera patient here, there are a hundred more who
are not receiving treatment.”
Cholera treatment measures have impacted the
treatment access to patients with other diseases. The government-run Beatrice
Road Infectious Diseases Hospital (BRIDH) in Harare is the city’s main
infectious diseases hospital. BRIDH is now only admitting cholera patients, and
is under tight government security.
PHR spoke with a Zimbabwean physician who was
volunteering at BRIDH and treating these patients. This physician reported being
hidden by the nursing staff during intrusive visits by the Zimbabwean Army –
armed soldiers apparently limiting access to the hospital in an attempt to
conceal the extent of the epidemic.
PHR spoke with a government official about the other
patients who had been at BRIDH. She stated that once Beatrice was designated as
a cholera hospital all other patients, including those with TB, HIV/AIDS, and
other infectious diseases, were forcibly discharged. She put it this way: “If
you don’t have cholera, too bad.”
Additionally, a number of key informants explicitly
warned PHR not to attempt to visit Beatrice Hospital because government
authorities there would most probably not allow PHR physicians to witness the
severity of the problem, or worse would compromise or shut down the
investigation. This warning attests to how the ZANU-PF government has
politicized the cholera epidemic by trying to suppress knowledge of the extent
of the disease.
Prevention
The Minister of Health announced on 5 January 2009
plans to initiate an awareness campaign focusing on good hygiene;140 not only is
this measure insufficient to address the serious needs of the public, but the
Government waited a full five months following the initial cholera outbreak to
launch it. In addition to ensuring access to safe water, the Government needs to
implement a robust public health campaign to educate people about fecal-oral
transmission (basically that vigilant hand-washing is key), about home water
purification (such as boiling, chlorination, or filtration), and about
sterilization (for example, bleaching) of any fecally contaminated items
(clothing and bedding) with which the cholera patient has been in contact.
The Mugabe regime has also compromised the
communication and educational steps crucial to combating the disease. In
Chinhoyi, for example, the capital of Mashonaland West and provincial rural home
of Mugabe, a cholera outbreak occurred in late September 2008. Although a key
informant told PHR that local authorities initially used a megaphone to alert
people of cholera deaths and that people should wash hands, they failed to
report the outbreak to higher authorities until three weeks later. Although
notification of a cholera outbreak is required by law, this breakdown in
communication, critical for an emergency response, was compromised by a failed
communications system.
A senior Ministry of Health official reported that
they relied on a failed public health reporting system that required district
and provincial medical staff to place telephone calls to the Ministry of Health.
She opined that: “Because these physicians were no longer showing up to work
because their salaries were so small and the cost of transportation to work was
too high, these phone calls were no longer being made.”
Communication was thus compromised by the economic
collapse: workers could not pay for public transportation because their salary
was less than the cost of transportation to work.
The onus of prevention of cholera lies with the
public sector. Individuals depend on government authorities and institutions to
supply clean water, to dispose of sewage, and to warn and educate when a crisis
occurs.
The culpability of the Mugabe regime lies at the
very origin of this epidemic, which has caused more than 1,900 gratuitous deaths
from this preventable and treatable disease. Access to potable water and medical
care are fundamental rights that the Mugabe regime has abrogated with lethal
effect on its own people.
Anthrax
Zimbabwe has long been an endemic country for the
anthrax bacillus, bacillus anthracis. Primarily a disease of grazing animals,
who become infected from ingestion of long-lived spore forms in the soil,
anthrax can cause several forms of disease in humans including cutaneous, and
the more lethal and rare gastrointestinal form, an outcome of eating anthrax
contaminated meat—usually from carcasses. Zimbabwe has had several outbreaks of
cutaneous anthrax, including one with over 6,000 cases during the independence
struggles between October 1979 and March 1980.
But the most recent outbreak has not been of this
endemic form, but rather of gastrointestinal anthrax. WHO has recently reported
some 200 human cases of anthrax since November 2008 with eight confirmed deaths.
These cases were attributed to the ingestion of animals (cattle and goats) that
had died of anthrax.
Zimbabwean custom is to avoid eating animals that
have died of disease – but these cases appear to have been in starving rural
people willing to risk disease themselves in order to eat. PHR interviewed one
senior pediatrician who had just diagnosed a child suffering from anthrax with
lesions in the mouth on the day of the interview; the family reported having
recently eaten meat from a dead cow. The physician suspects this was the mode of
transmission – an outcome of resorting to eating rotting meat, which people
would otherwise not do.
PHR was also told that veterinary anthrax control
programs in Zimbabwe, which had included regular monthly dipping programs for
cattle, have been dramatically curtailed in the economic collapse. The results
in the veterinary sector are that dipping and vaccination of livestock have
largely ceased and the surviving herds are much more vulnerable to infectious
diseases.
Human
Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
Zimbabwe has had severe HIV/AIDS and tuberculosis
epidemics for more than two decades. In 1999, UNAIDS considered Zimbabwe to be
the highest prevalence country for HIV infection worldwide, with some 25% of all
adults HIV positive. HIV/AIDS treatment was largely unavailable until 2004, when
the US funded PEPFAR program began providing support for anti-retroviral
therapy. Since that time both the PEPFAR program and the Global Fund to Fight
AIDS, Tuberculosis and Malaria have been providing programmatic support.
Since 2006 however, the programs have been affected
by the same systemic issues which have affected every aspect of healthcare in
Zimbabwe: loss of professional staff, hyper-inflation, a collapsing health
infrastructure, food insecurity, and breakdowns in commodity supply,
distribution and end-user delivery systems. Access to HIV/AIDS care and
treatment is threatened by the current collapse, but in addition, the HIV
program is currently capped: some 205,000 people are thought to be on ARVs, but
no major program is currently able to enroll new patients. Some 800,000
Zimbabweans are thought to require therapy, or will require it in the coming
months-years, and access is now closed to these individuals.
Epidemiology
The most current epidemiological data available on
HIV for Zimbabwe are the estimates from the UNAIDS program, which are cited by
both in-country professionals and donor agencies. The UNAIDS figures show that
Zimbabwe has a severe generalized epidemic of HIV-1, with an overall adult (ages
15-49) HIV prevalence rate of 15.3%. An estimated 1.3 million adults and
children in Zimbabwe are living with HIV infection in 2008. Of these some
680,000 were women of childbearing age.
In 2007, some 140,000 Zimbabweans died of AIDS, and
the current toll is estimated at 400 AIDS deaths per day. More people die of
AIDS each week than have died of cholera over the past five months.
Zimbabwe has an enormous number of AIDS
orphans—children who have lost one or both parents to AIDS – which UNICEF
reports was 1.1 million children in 2005, or roughly one child in four. The
Clinton Foundation has focused on provision of ARVs for pediatric AIDS care.
The surveillance system and reporting systems have
markedly declined in Zimbabwe since 2006, and had almost entirely ceased by
mid-2008. The HIV programs have been somewhat spared since they are donor
supported, but the TB program has essentially shut down, making current TB
estimates extremely unreliable. There is no drug sensitivity testing capacity in
the National TB program, and there is only one staff member in the national lab,
who has no training in TB culture methods. If multi-drug resistant TB (MDR-TB)
were spreading in Zimbabwe, or extremely drug resistant TB (XDR-TB), there would
be no capacity to evaluate these problems or address them. It is unknown to what
extent resistant strains of TB are spreading in Zimbabwe.
Antiretroviral drug
access
The US PEPFAR program currently supports ARVs for
some 40,000 Zimbabwean AIDS patients. In 2007, the program provided ARVs to
70,900 pregnant women for prevention of mother to child transmission, and
provided testing to some 403,000 women. The PEPFAR program has detailed a number
of challenges in 2008 that reinforce PHR’s findings described above:
Zimbabwe continues to suffer a severe socioeconomic
and political crisis, including unprecedented rates of inflation and a severe
brain drain of Zimbabwe’s health professionals. Elements of a previously
well-maintained healthcare infrastructure are crumbling.
Zimbabwe’s HIV crisis is exacerbated by chronic food
insecurity. Sub-optimal nutrition increases the vulnerability of individuals
with compromised immune systems to life-threatening opportunistic infections,
such as tuberculosis.
We asked a nurse staffing a rural public sector
clinic about ARV supplies: “We are doing quite well with ARVs and we usually
have these in stock. The problem is many of the patients have no food, nothing
to eat, so the drugs don’t work so well. We have no ability to provide them with
more nutrition.”
Male and female condoms were available at this
clinic, and the nurse reported that condom supplies (largely supported by the
United States Agency for International Development - USAID) were adequate and
that demand was considerable. In other regions, however, Zimbabweans report
inaccessibility to ARVs.
Waiting times for HIV testing and immunologic
monitoring with CD4 counts are also a barrier. One HIV/AIDS patient interviewed
in peri-urban Harare reported being on a waiting list for over a year to get a
CD4 count. After the blood draw, he waited another six months to get the
results. His CD4 count at that time was 270, and he had a history of clinically
active TB and HIV co-infection, but had not yet qualified for starting ARVs.
With such a low CD4 count and an opportunistic infection (TB), this patient
should have been on ARVs.
The representative of an international humanitarian
NGO operating in Zimbabwe reported that the National AIDS Council in Zimbabwe –
a coordinating body including government and NGO representatives – had told him
and other heads of humanitarian relief organizations at the end of 2007 not to
scale up with ARV enrollment. PHR spoke with a Zimbabwean Government official
who confirmed that the HIV program has virtually stopped enrolling new patients.
He added: “And now there is a black market in ARVs.”
A donor country official corroborated the report of
a black market in ARVs. A key informant informed PHR of reports that ZANU-PF
officials had loaded up their trucks with ARV medicines from the national
pharmacy and then sold them on the black market. A local medical NGO also
confirmed these abuses were happening, but the medical staff were not certain of
its extent. A local NGO that works with HIV/AIDS patients also reported that
nurses and other healthcare professionals were selling ARVs and other drugs
obtained from public hospitals and selling them on the black market to
supplement their incomes.
PHR investigators received corroborating reports
from donors and HIV/AIDS patients in Zimbabwe that ZANU-PF government officials
had plundered $7.3 million USD in humanitarian aid for ARV drugs – part of $12.3
million USD from the Global Fund. Following public outrage over the scandal
months later in November 2008, the ZANU-PF-controlled reserve bank returned the
stolen funds to the Global Fund.
The representative of a humanitarian NGO operating
in Zimbabwe also informed PHR that the Government had frozen some of his
organizations funds intended for HIV/AIDS.
These reports underscore the importance of
accountability and quality treatment in the public sector and make the collapse
of that sector all the more life-threatening for patients with HIV/AIDS in
Zimbabwe.
Finally, we asked the women’s focus group to
prioritize the solutions they saw to the HIV/AIDS problems they were facing.
Their priority solutions in order were: Governance, healthcare, food.
Impact on HIV/AIDS
Zimbabwe’s severe HIV/AIDS epidemic is the focus of
multiple donor programs including the US PEPFAR program, the CDC, and the Global
Fund to Fight AIDS, TB and Malaria (GFATM). PHR found that the collapse of the
healthcare system has profoundly impacted IV/AIDS programs and drug-delivery
systems in Zimbabwe. The prioritization of cholera treatment over other
infectious diseases in the health care system has also been a new, acute threat
to inpatient AIDS care.
For HIV/AIDS the most severe threat has been the
interruption of regular supplies of antiretroviral drugs. Multiple key
informants, patients, and providers told PHR that ARV supplies had become
irregular due to breakdowns in drug delivery, distribution, provision, and theft
of ARV drugs by ZANU-PF operatives. Most troubling were reports that some
physicians were switching patients on established ARV regimens to other regimens
based not on clinical need, but on drug availability. These changes occurred, in
some reported cases, on a monthly basis – since supplies were too low to give
patients the usual three-month supplies.
Such changes in ARV regimens can be life-threatening
for individual patients by markedly increasing the likelihood of multi-drug
resistant variants of the HIV virus, and thus of treatment failure and death.
Changing regimens on a monthly basis increases not only the risk of HIV-drug
resistance, but also of drug complications and side-effects further endangering
AIDS patients and undermining patient adherence.
These dangerous practices constitute a significant
threat to public health since the development and transmission of multi-drug
resistant variants of HIV in Zimbabwe could undermine not only Zimbabwe’s
HIV/AIDS program, but regional programs as well. This is particularly true since
the predominant HIV strain in Zimbabwe, subtype C of HIV-1, is known to have
distinctive genetic pathways of ARV drug resistance development.152 Subtype C is
the dominant strain of HIV in South Africa, Botswana, Mozambique, Zambia, and
Malawi – all countries where resistant variants of HIV- 1 C viruses could have
devastating impacts. Given that some three to four million Zimbabweans have
already fled their homeland, and that the HIV prevalence among Zimbabwean adults
is over 15%, neighboring countries may have already acquired several hundred
No treatment without
the money first
PHR spoke with a support group of 15 HIV positive
women who detailed some of their recent problems with ARV supplies. All of the
women present were receiving free ARVs on a fairly regular basis. The drugs are
distributed monthly at government clinics for free.
However, about once every three months the supply is
not adequate. When this happens patients are given a two-week supply. More
troublesome is the fact that when they return for treatment a different drug may
be available from the regime they were on the previous month. So patients are
changed across regimes due to unavailability. Patients reported getting Trimune
one month and Stelanave or Combivir pack the following month. These practices
have been going on for one year or more.
Two women reported that on occasion they have gone
to buy their own drugs when they were not available, and that the cost is
approximately $100 USD per month. Second-line drugs are more expensive and more
often not available than first line.
Discussants also shared that private doctors often
don’t really know about HIV. Two women reported presenting themselves to private
practice doctors with symptoms for two years, being treated for a variety of
illnesses, and having been sent for expensive medicines at pharmacies owned by
the same doctors for cash.
“After two years of deteriorating health, I went to
Harare hospital and wanted to get an HIV test. I knew the doctors there were
more prepared to treat people like me and I could not afford it [private care]
anymore.”
This woman confirmed that her private physician had
never suggested she get an HIV test. Many women also reported feeling that many
private doctors knew nothing about AIDS treatment and often gave ARV without
proper dosing and instructions.
“And if you are diagnosed [HIV] positive, you get no
treatment without the money first.”
thousand additional cases of HIV/AIDS. Unless
quality ARV services can be quickly restored for Zimbabweans at home, and for
these large numbers of refugees, increased HIV-drug resistance in the region is
virtually assured resulting in increased treatment costs, treatment complexity,
and poorer clinical outcomes – and, possibly, an HIV epidemic that ultimately
gets completely out of control.
The collapse of pubic-sector HIV testing and
counseling also undermines access to treatment for HIV-positive Zimbabweans and
prevention services for those at risk of infection. HIV testing is a cornerstone
of prevention and treatment. The gains Zimbabwe has made in HIV prevention could
be swiftly reversed if free public HIV testing is not made immediately
accessible.
Tuberculosis
The public-sector TB program in Zimbabwe has been in
sharp decline since 2006. The national laboratory is down to one technician and
no longer has the capacity to test for TB drug resistance. TB treatment
interruptions are occurring for similar reasons as with the ARV program: loss of
staff, supply chain interruptions (from central stores to clinical pharmacies,
shortages of TB antibiotics), and loss of diagnostic capacity. PHR asked an
expert working with the national program to describe the status of the program
in December 2008: “There is no politically correct way to say this – the
TB program in Zimbabwe is a joke. The national TB
lab has one staff person. There is no one left trained in drug sensitivity
testing. The TB reference lab is just not functioning. This is a brain drain
problem.
The lab was working well until 2006 and has since
fallen apart. The DOTS program in 2000 was highly effective, but that has broken
down now too. There is no real data collection system for TB. That stopped in
2006 as well.” The major concern with TB treatment interruptions is the
likelihood of TB drug (in this case antibiotic) resistance, which can lead to
MDR-TB and the most severe form, XDR-TB. Extensively drug-resistant TB has
emerged as an almost incurable form of TB with very high case fatality rates –
over 90% in some South African settings.
One physician at a rural mission hospital that he
currently had one probable case of MDR-TB, but was awaiting lab results. He
acknowledged that the results might never return because of the lack of lab
facilities. He stated that TB is a significant co-morbidity in the HIV/AIDS
population, but that the symptoms of TB are often masked by the symptoms of
HIV/AIDS. He also acknowledged that XDR-TB could be an emergent problem in
Zimbabwe, but that the diagnostic capacity in the country was probably
insufficient to identify this virulent form, should it be present.
Multiple-drug-resistant and drug-resistant TB
variants (especially XDR-TB) are most commonly seen among patients who have
co-morbid HIV infection. These drug-resistant strains are more likely to spread
in populations, like Zimbabwe, where high proportions of the population are
immunocompromised. Both MDR-TB and possible XDR-TB have emerged in Zimbabwe, but
the critical capacity to diagnose and manage these infections has collapsed.
That Zimbabwe has a failing TB program in the context of HIV and TB epidemics is
a threat to the health of its own people, and a regional threat since the
further generation and spread of MDR-TB and XDR-TB would be a lasting public
health catastrophe.
Drug-resistant variants of TB and HIV are arguably
more of a threat to southern Africa than the spread of cholera from Zimbabwe.
Cholera is an acute illness that remains both treatable and curable with basic
medical services. Drug-resistant HIV and TB will pervade in the region for years
and will greatly increase the cost and complexity of treatment and care, while
decreasing the clinical benefits of treatment.
Maternal morbidity
and mortality
It is generally agreed that indicators of maternal
health in Zimbabwe have deteriorated greatly over the past decade and now are
among the world’s worst. The maternal mortality ratio has increased at an
alarming rate from 283 per 100,000 in 1994 to 1,100 per 100,000 in 2005. The
major contributors are HIV/AIDS and, particularly in the recent period, a
significant decline in availability and quality of maternal health services.
This situation has been dramatically worsened in the period since November 2008
by withdrawal of maternity services throughout the public health sector, and
especially in the major conurbations. The flight of professional health workers
and recent withdrawal of labor (strikes) by doctors, nurses, and midwives
combined with the widespread unavailability of key items of equipment and
medicines (e.g., suture materials, swabs, protective clothing and gloves,
oxytocin, etc.) have resulted in closure of most delivery units. Several
informants told US that, as a consequence, large and increasing numbers of
pregnant women expecting normal deliveries are being forced to deliver at home,
with many traveling from urban areas to their rural homes.
Additionally, women requiring assisted deliveries
are compelled to utilize private sector or mission facilities. PHR received
reports of women booked for elective Cesarean section at public-sector maternity
units being referred to private, non-mission facilities. Since the current
(mid-December) charges for Cesarean section at private facilities (e.g., Avenues
Clinic) total approximately $3,700 USD, many women travel to rural mission
hospitals for such care. (Given that two-thirds of the population earns less
than $1 USD per day, this cost is prohibitive).
Given a birth rate 31.62 births per 1,000 and a
current estimated population of 11.35 million in Zimbabwe, there are
approximately 360,000 births per year. The World Health Organization reports
that 5% of all women in Zimbabwe gave birth by Cesarean section in 2005, thus
roughly 18,000 women require this obstetric surgical procedure each year.
Because Zimbabwean hospitals are now closed, and it is no longer possible to
receive this critical emergency care in the public sector, thousands of women
are at risk of dying.
“Nearly 66% of maternal deaths in Zimbabwe are
directly caused by just five common obstetric complications. These are bleeding,
infection, complications of abortion; high blood pressure associated with
pregnancy and prolonged or obstructed labor.”
Staff from mission hospitals reported to PHR
investigators that other maternal health conditions requiring emergency hospital
care are also presenting at their facilities. Moreover, delays are often
incurred as a result of difficulties in securing or paying for transport. We
were told of a woman who had had an incomplete abortion (miscarriage) in a
distant part of the district, and who had to secure the requisite funds to
travel to All Souls’ Mission Hospital, incurring a three-day delay in having her
potentially life-threatening condition treated.
PHR did find evidence that the declines in maternal
healthcare had been suppressed by the Government. A former government physician
reported: [The Ministry of Health] “suppressed the maternal
mortality rate for the past two years.”
Protein-calorie
malnutrition
The same emergency physician stated that
Parirenyatwa hospital was filled with malnourished kids (before its closure) and
that like maternal mortality rates, the incidence of child malnutrition has been
suppressed. Malnutrition is not new to Zimbabwe; however, PHR received a number
of reports that suggest that this preventable disease is increasing
dramatically.
Several informants, including pediatricians, stated
that cases of severe protein-energy malnutrition (PEM) have become more common
in hospitals over the past several months. They attributed this to the combined
impact of HIV/AIDS and food insecurity. On a visit to a rural mission hospital,
PHR was shown several young children with severe PEM (marasmic Kwashiorkor and
marasmus). While some of these children were HIV-positive, others were not, and
inquiry revealed that their households were extremely food insecure.
A senior Ministry of Health official confirmed that
one would definitely find wasting and stunting in rural areas. A senior
physician at a mission hospital stated that the lack of transportation prevents
most children with malnutrition from coming to his rural hospital, where there
were 15 such children in the pediatric ward when PHR visited. In his district,
the number of children with malnutrition was so high he can’t even count. He
also reported that in his rural district an increasing number of relatively
healthy people in their twenties and thirties are coming to hospital and dying
because of starvation. He stated that most people in his rural district survive
on one meal a day or less and that most people only eat meat twice a year at
most. He stated: “Kwashiorkor is also present, but hidden in the community.”
The head of an international humanitarian NGO
reported that he anticipates a sharp increase in malaria and malnutrition in
March – April 2009.
Vitamin deficiency
Several informants, including local NGO personnel,
mission hospital staff, and physicians reported having each seen several cases
of pellagra (in Mudzi and Tjolotjo districts), which is caused by severe
deficiency of nicotinic acid, one of the B vitamins. In fact, a senior physician
at a mission hospital reported seeing pellagra, which had disappeared in the
previous ten years, every day now. Pellagra, as a problem of public health
significance, is characteristically seen during famines or times of nutritional
stress, particularly when diets consist predominantly of maize. This nutritional
disorder is characterized by diarrhea, dermatitis (cracking and peeling skin),
and dementia.
Although PHR investigators did not see any overt
cases of pellagra, they encountered an elderly widow, who had lost all her
children to illness, foraging for firewood who had early signs of pellagra-like
dermatitis. She reported having no food stocks and being totally reliant on
neighbors and charity. Inspection of the grain storage structures of her
immediate neighbor revealed a very small amount, enough for only a few weeks.
CONCLUSION
Physicians for Human Rights conducted an emergency
assessment of the collapse of Zimbabwe’s public health system in December 2008.
Viewed through a human rights lens, the health and
healthcare crisis in Zimbabwe is a direct outcome of the malfeasance of the
Mugabe regime and violations of human rights.
The civil and political rights referenced in the
introduction of this report are non-derogable, meaning that they cannot be
abrogated or limited in any way, not even in times of public emergency or war.
Any failure on the part of the Government of Zimbabwe to implement and protect
these rights amounts to a violation. The economic, social, and cultural rights
mentioned in this report are subject to progressive realization.
Accordingly, the Government is required to provide
an objective and rational explanation for any deliberately retrogressive
measures taken in respect of these rights. To date, this has not occurred.
Additionally, each of these rights also contains core obligations, which
Emergency Cesarean
section
A primary school teacher aged 30 who lives near
Warren Park in Harare was interviewed at Howard Mission Hospital on 16 December.
She is a primary school teacher who has taken permanent leave since August
because the pay is so poor.
Because her first pregnancy had required a Cesarean
section, she had been scheduled to deliver her second child at Mbuya Nehanda
Government Maternity Hospital by Cesarean section on 14 November 2008. She went
to the hospital on that day and was told that the operation could not be
performed because there were no nurses, doctors, or anesthesiologists at work.
She was advised to go to a private obstetrician who demanded $200 USD for
registering under his care and $500 USD for delivery. (This excludes the payment
required for hospital accommodation, use of the OR, supplies and medicines.)
Since these costs were unaffordable, she proceeded
to the Avenues Clinic where she was quoted the same charges. She then learned
through a relative of the service available at Howard Mission Hospital and was
driven there from Harare on 15 November 2008, admitted and placed on a waiting
list for operation.
The arrival of successive emergencies resulted in
her receiving her operation only on 11 December 2008 when she was already in
labor. There were no complications, and a healthy baby was delivered. She
expressed gratitude for her excellent care at Howard Hospital, but stated that
“it was painful that the nurses at Mbuya Nehanda hospital would not assist
[her]”.
Violations of core
obligations of the rights to health, water, food, and work
Denial of equal access to health services on a
non-discriminatory basis, especially for the most vulnerable: de facto
discrimination, directly following from the dollarization of the health sector
is the inability of people, with severely restricted access to foreign currency,
to purchase life-saving medical treatment; the costs of transportation to health
facilities resulting in these facilities being inaccessible.
Denial of access to medicines: insufficient
recurrent expenditure to ensure an adequate supply of medications (e.g.,
oxytocin for post-partum hemorrhage, depletion of ARVs resulting in the
interruption of regular supplies; and depletion of TB drugs leading to
multiple-drug-resistant strains of tuberculosis).
Denial of access to safe water and adequate
sanitation: cessation of water supply; willfully allowing outdated and damaged
water supplies to go untreated; depletion of water treatment chemicals such as
aluminum sulfate; failure to maintain the reticulated water systems; failure to
repair or replace inoperable sewerage pipes.
Denial of minimum essential food that is
nutritionally adequate and safe: State activity resulting in prevention of
access to food, such as the land seizures in 2000, which has led to sharp falls
in agricultural production and food insecurity for millions; ZANU-PF blockage of
humanitarian food aid resulting in needless deaths.
require immediate implementation and are not subject
to resource constraint. Any failure on the part of the Government, among others,
to implement these rights amounts to a violation of the respective right.
Violations of the
right to life
The Zimbabwean government is required to adopt
positive measures to reduce infant mortality, increase life expectancy
(especially in adopting measures to eliminate malnutrition and epidemics). The
following activities and omissions of the Government have resulted in deaths or
have the potential to result in deaths: Uncontrolled cholera epidemic; Cessation
and obstruction of humanitarian aid; Lack of access to emergency obstetric care;
Changes in ARV regimens due to depletion of stocks, increasing the likelihood of
multi-drug resistant variants of the HIV virus, and so of treatment failure and
death; Theft and black-marketing of ARV drugs. These deaths and potential deaths
would appear to be a clear violation of the right to life.
Violations of the prohibition against torture,
inhuman or degrading treatment or punishment The government policy of torture,
intimidation, kidnappings and other inhuman and degrading treatment or
punishment, for the past several years is a clear violation of the prohibition
against torture, inhuman or degrading treatment or punishment.
Traveling far for
obstetric care
PHR interviewed a woman from Harare who had traveled
to a distant Mission hospital for a Cesarean section.
She stated: “I wanted to have my baby in Harare but
Parirenyatwa hospital was closed. I was having my prenatal care with my own
doctor at the Avenue Clinic [a private clinic and hospital in Harare.] But they
wanted so much money. They wanted only US dollars, in cash. $3,000 for the
surgeon, $140 for the nurse, and $700 for the doctor who puts you to sleep. We
could not afford that, so four days ago we came here. This was the only hospital
helping people in Harare.”
Reporting on her entire bill for the delivery and
post-surgical care at the Mission hospital, she said: “Altogether I think it
will be about 1 billion Zimbabwe dollars [about $10 USD at the current exchange]
and this my husband and I can afford.”
Failure to adopt and implement a national health
workforce plan, which addresses issues such as: health information systems;
health worker salaries; health worker human rights of association, assembly and
expression; health worker occupational health and safety; and the skills drain.
Violations of the obligation to respect the right to
health, water, food, and work
Government actions that contravene the standards set
out in the rights to health, water, food, and work: failure to ensure
maintenance of the water and sanitation system leading to the outbreak of
cholera; failure to ensure supply of water, electricity, sanitation, medical
supplies, to hospitals, leading to shuttering of hospitals and lack of access to
health care; the deliberate misrepresentation of information vital to health
protection or treatment (e.g., the statistics of the cholera epidemic and the
levels of malnutrition).
Severely underweight
boy
A boy aged 16 months was admitted on 12 December
2008 with pneumonia. After antibiotic treatment, his chest infection had greatly
improved, but he remains severely underweight. Inspection of his weight-for-age
card revealed (the typical pattern of) growth faltering from eight months of
age. Although he continues to be breast-fed, his mother described a diet
inadequate in both quantity and quality. She reported giving him three meals a
day, consisting largely of dilute porridge with little added protein or oil.
When asked about household food stocks she reported
that the household of ten, with five children under the age of five, relies
almost wholly on humanitarian food aid (bulgur wheat) as well as maize grain
(three 50-kg sacks for most of this year) received from neighbors in exchange
for one cow.
On further inquiry, PHR established that this
household previously possessed three cattle, with only two now remaining for
essential draft power (plowing). Sale of such precious assets reflects extreme
household food insecurity.
Violations of the obligation to protect the rights
to health, water, food, and work
Follow from State failure to take all necessary
measures to safeguard persons within the jurisdiction from infringements of the
right to health by third parties: Exorbitant fees in the private health sector
denying access to the services
Failure to ensure that private medical practitioners
have sufficient skill to treat HIV/AIDS patients.
Violations of the obligation to fulfill the rights
to health, water, food, and work Follow from State failure to take all necessary
steps to ensure the realization of the rights contained in articles 6, 11 and 12
of the ICESCR:
Insufficient expenditure or misallocation of public
resources;
Failure to provide health care, including sexual and
reproductive health services; Failure to ensure non-discriminatory access to the
underlying determinants of health, such as nutritiously safe food and safe
drinking water, and basic sanitation; Failure to reduce maternal mortality
rates; Failure to provide directly food in a quantity and quality that is
sufficient to satisfy the dietary needs of people; Failure to ensure safe
working conditions for health workers; Failure to protect the rights of
association, movement and expression of health workers; Failure to provide
health workers with domestically competitive salaries; Failure to ensure the
appropriate training of health workers.
Crimes against
humanity
Crimes against humanity have been considered part of
international customary law for over half a century. The term originated in the
1907 Hague Convention preamble, which articulated the customary law of armed
conflict. Between 1907 and the 1945 Nuremberg Charter,160 the notion that
international law encompassed humanitarian principles that existed beyond
conventional law,161 gained widespread consensus. The 1945 Nuremberg Charter,
article 6 (c) articulated the first definition of crimes against humanity.
Article 6 (c) provides: “Crimes against humanity: murder, extermination,
enslavement, deportation, and other inhumane acts committed against civilian
populations, before or during the war; or persecutions on political, racial or
religious grounds in execution of or in connection with any crime within the
jurisdiction of the Tribunal, whether or not in violation of the domestic law of
the country where perpetrated.”
The International Military Tribunal for the Far
East, followed upon the Nuremberg Charter, in article 5 (c) of its Charter. The
statutes of the International Criminal Tribunal for the former Yugoslavia and
the International Criminal Tribunal for Rwanda, include this category of crimes
and contribute to developing and broadening the notion of crimes against
humanity.
It is now a settled rule of international customary
law that crimes against humanity do not need to be connected to international
armed conflict and may not need to be connected to conflict at all.164 The
definitions contained in the statutes of both ad hoc tribunals influenced the
definition of crimes against humanity contained in the statute of the
International Criminal Court (ICC).
The ICC was established by the Rome Statute of the
International Criminal Court (The Rome Treaty). The Rome Treaty is an
international treaty, binding only on those States which formally express their
consent to be bound by its provisions. Although Zimbabwe is not currently a
State party to the Rome Treaty, the UN Security Council has the authority to
address international threats to peace and security and refer such matters to
the ICC. It should be made clear that under customary international law,
individuals in the Mugabe regime may be found guilty of crimes against humanity.
Article 7 of the Rome Treaty provides:
1. For the purpose of this Statute, crime against
humanity means any of the following acts when committed as part of a widespread
or systematic attack directed against any civilian population, with knowledge of
the attack: Murder; Extermination; Enslavement; Deportation or forcible transfer
of a population; Imprisonment or other severe deprivation of physical liberty in
violation of fundamental rules of international law; Torture; Rape, sexual
slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any
other form of sexual violence of comparable gravity; Persecution against any
identifiable group or collectivity on political, racial, national, ethnic,
cultural, religious, gender as defined in paragraph 3, or other grounds that are
universally recognized as impermissible under international law, in connection
with any act referred to in this paragraph or any crime within the jurisdiction
of the Court; Enforced disappearance of persons; The crime of apartheid; Other
inhumane acts of a similar character intentionally causing great suffering, or
serious injury to body or to mental or physical health.
For the purposes of paragraph 1 of Article 7, an
attack directed against any civilian population, means a course of conduct
involving the multiple commission of acts referred to in paragraph 1 against any
civilian population, pursuant to or in furtherance of a State or organizational
policy to commit such attack.
Widespread refers to the number of victims.
Systematic refers to thoroughly organized acts following a regular pattern on
the basis of a common policy involving substantial public or private resources.
The findings of this report indicate that to
establish a crime against humanity on the part of Robert Mugabe and other member
of his government, one needs to rely on article 7(1)(k) of the Rome Treaty. The
Elements of Crimes, one of the basic legal texts of the ICC, sets out the
following five prerequisites:
1. The perpetrator inflicted great suffering, or
serious injury to body or to mental or physical health, by means of an inhumane
act.
2. Such act was of a character similar to any other
act referred to in article 7, paragraph 1, of the Statute.
3. The perpetrator was aware of the factual
circumstances that established the character of the act.
4. The conduct was committed as part of a widespread
or systematic attack directed against a civilian population.
5. The perpetrator knew that the conduct was part of
or intended the conduct to be part of a widespread or systematic attack directed
against a civilian population.
The findings in this report provide prima facie
evidence that may satisfy most, if not all, elements of crimes against humanity.
Robert Mugabe and his regime have conducted several acts: willful disregard to
an ongoing and geographically extensive cholera epidemic; systematic obstruction
of humanitarian aid at all points of entry and in-country distribution;
obstruction of access to emergency obstetric care;
The term attack can in peacetime refer to state
campaigns of aggression or assaults against civilian population degradation of
all aspects of health systems leading to widespread collapse of health care
capacity and closure of hospitals; sweeping and repeated campaigns of land
seizures leading to economic collapse and population-wide nutritional diseases
and malnutrition; and comprehensive disruption in supplies of medications
leading to significant levels of human death.
Each of these acts has been inhumane in nature and
character and has caused great suffering or serious injury to body or to mental
or to physical health. Data regarding the collapse of the health system, the
cholera epidemic, and the regression in vital heath metrics have been collected
by various U.N. agencies and are in the public domain. It is undeniable that
Robert Mugabe and members of his government have actual and abundant knowledge
of the broader context of these acts. And finally, the majority of the
Zimbabwean population has been the focus of the acts.
The findings contained in this report show, at a
minimum, violations of the rights to life, health, food, water, and work. When
examined in the context of 28 years of massive and egregious human rights
violations against the people of Zimbabwe under the rule of Robert Mugabe, they
constitute added proof of the commission by the Mugabe regime of crimes against
humanity.
RECOMMENDATIONS
Resolve the
Political Impasse
As PHR’s report clearly reveals, there can be no
adequate solution to the health crisis in Zimbabwe without a solution to the
political crisis.
The United Nations Security Council must ensure that
the current political impasse in Zimbabwe is resolved expeditiously by calling
on the Mugabe regime to accept the result of the 29 March election where MDC T
gained a majority.
Accordingly, and in the spirit of the Southern
African Development Community agreement, the MDC should be allowed to assume its
place in a government whose composition and ministerial allocations reflect the
democratic will of the people of Zimbabwe as expressed in the March elections.
The South African Government should facilitate this
process.
The US and other governments should press the
Southern African Development Community member nations and other regional actors
to end their support of Mugabe’s regime and to call for a democratic political
transition.
The US and other governments should maintain all
targeted bilateral sanctions in place for Zimbabwe until Mugabe cedes power and
a stable government is established.
Launch an Emergency
Health Response
The UN General Assembly, at its 2005 World Summit,
has affirmed the principle of the Responsibility to Protect. At this summit,
attended by over 170 member states, the member states acknowledged the necessity
of intervening against the sovereignty of a State (under the UN Charter Chapter
VII: Action with respect to threats to the peace, breaches of the peace, and
acts of aggression) in order to protect the population of that State from
state-sanctioned or state-permitted atrocities, including crimes against
humanity.
It is relevant to note that the UN Security Council
has already stated that, unchecked, the HIV/AIDS pandemic may pose a risk to
international stability and security.
The epidemics of HIV/AIDS, cholera and TB currently
raging in Zimbabwe pose threats to international peace and security in the
region and beyond.
Health services and essential aspects of public
health infrastructure in Zimbabwe are now in a state of complete collapse. The
policies and practices of the Mugabe regime precipitated the crisis, and the
regime lacks the capacity, let alone the intent, to reverse it even with the
support of the international agencies now providing emergency assistance. The
Government has failed to engage in political and economic reforms necessary to
enable health systems to recover. It has also obstructed the distribution of
humanitarian aid.
Only through the intervention of the international
community can hospitals and clinics be reopened, supplies and drugs obtained,
staff paid, and public health infrastructure be restored, so that the acute
health care needs of the people of Zimbabwe can be met.
Accordingly, the government of Zimbabwe should yield
control of its health services, water supply, sanitation, disease surveillance,
Ministry of Health operations and other public health functions to a United
Nations-designated agency or consortium.
Such a mechanism would be equivalent to putting the
health system into a receivership pursuant to the existence of a circumstance
that meets the criteria for the Responsibility to Protect. This entity, taking
full advantage of the human resources for health available in Zimbabwe
(including administrative resources at the Ministry of Health), and generously
supported by international donors, should assume all administrative
responsibility for the operation of health services, water supply, sanitation
and other public health functions until such time as a government capable of
providing these services is in place.
The entity would exercise all functions and powers
of the Ministry of Health, regulatory agencies responsible for health functions,
and agencies responsible for water supply, power and sanitation.
The UN should convene an urgent conference of donors
and relevant UN agencies to secure the resources needed to restore health
services and public health infrastructure in Zimbabwe.
UN Security Council’s Resolution 1308: Stressing
that the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and
security and [f]urther recognizing that the HIV/AIDS pandemic is also
exacerbated by conditions of violence and instability, which increase the risk
of exposure to the disease through large movements of people, widespread
uncertainty over conditions, and reduced access to medical
care.
If the government of Zimbabwe refuses to yield such
control, the UN Security Council, acting pursuant to its authority under Article
39 of the Charter, should enact a resolution compelling the Government of
Zimbabwe to do so.
The incoming Obama Administration, for its part,
should prepare a comprehensive package of humanitarian and reconstruction relief
to be implemented as soon as political stability is restored.
Refer the situation in Zimbabwe to the International
Criminal Court for Crimes Against Humanity. There is no doubt that egregious,
widespread, and systematic violations of human rights have occurred under the
Mugabe-led ZANU-PF regime and that death and serious injury to the physical and
mental health of Zimbabweans continue unabated. To date, international criminal
prosecution has not addressed crimes against humanity in the context of willful
and state-sponsored actions that lead to massive loss of life resulting from,
for example, failures to respond to epidemics, active obstruction of
humanitarian aid, or the deliberate destruction of health systems.
Although Zimbabwe is not a party to the Rome Statute
of the International Criminal Court, Article 13(b) of the Statute enables the
ICC to exercise its jurisdiction with respect to crimes against humanity where
the matter is referred to the Prosecutor by the UN Security Council acting under
Chapter VII of the UN Charter.
The UN Security Council, acting pursuant to its
authority under Article 41 of the Charter, should enact a resolution referring
the crisis in Zimbabwe to the International Criminal Court for investigation and
to begin the process of compiling documentary and other evidence that would
support the charge of crimes against humanity.
Convene an Emergency summit on HIV/AIDS,
Tuberculosis and other infectious disease
Zimbabwe’s severe HIV/AIDS epidemic is the focus of
multiple donor programs including the US PEPFAR program, the US Centers for
Disease Control, and the Global Fund to Fight AIDS, TB and Malaria. PHR found
that the collapse of the healthcare system has profoundly impacted HIV/AIDS
programs and drug-delivery systems in Zimbabwe. The acute need to prioritize
cholera treatment over other infectious diseases in the health care system has
also been a new, acute threat to inpatient AIDS care.
For HIV/AIDS the most severe threat has been the
interruption of regular supplies of antiretroviral drugs. Given the grave risk
to the infected populations, and the urgent need to prevent the generation of
multi-drug resistant strains of the virus, the Obama Administration should
consider this crisis as a first test-case of the collapse of a health system in
a country that is a recipient of emergency AIDS and TB prevention and treatment
programs.
The Obama Administration, together with the GFATM
and other donors, should convene an emergency summit to coordinate action by
PEPFAR and the Global Fund to fight AIDS, Malaria, and Tuberculosis to address
the current acute shortfalls in AIDS and Tuberculosis treatment and care.
Prevent further nutritional deterioration and ensure
household food security. To prevent further deterioration of nutritional status,
especially among the most vulnerable (young
children, mothers, HIV/AIDS, and TB sufferers), the international community
needs urgently to strengthen ongoing humanitarian efforts in Zimbabwe.
Specifically, donor governments should fully fund the 2009 Consolidated Appeal
(CAP) for Zimbabwe of $550 million USD.
Importantly, donor governments must ensure
non-interference by the current governing regime in obstructing, diverting,
politicizing, or looting such humanitarian aid. The United States as well as
other donor governments and private voluntary organizations should increase
donations of appropriate foods to the responsible multilateral agencies, such as
WFP, to meet the impending shortfall in the coming three to six months. –
ZimOnline |