Politics, Health, and People

At the height of Zimbabwe’s ongoing health crisis in December 2008, President Mugabe proclaimed, “There is no more cholera!” The aging despot’s fantastic declaration belies the stark reality that Zimbabwe has collapsed under the weight of a man-made disaster. Robert Gabriel Mugabe, who has ruled this country of 12 million people since 1980, may be delusional, but remains defiantly in power. Only a few months ago he swore: “I will never, never, never surrender. Zimbabwe is mine.”

Certainly there can be no lasting solution to Zimbabwe’s health crisis without a satisfactory resolution to the political crisis. But will Zimbabwe resurrect itself only after the octogenarian leader dies, as Spain did after Francisco Franco or Cambodia after Pol Pot? Or can the fledgling coalition government of Robert Mugabe’s Zimbabwe African National Union Patriotic Front (ZANU-PF) and Morgan Tsvangirai’s Movement for Democratic Change (MDC) succeed – against seemingly insurmountable odds – in restoring hope and prosperity to Africa’s once-thriving breadbasket?

They have their work cut out. The collapse of Zimbabwe’s economy and health system is unprecedented in scale and scope. Zimbabwe has over 90% unemployment as well as the world’s highest inflation – an unfathomable ninety sextillion percent. All public-sector hospitals have been shuttered since November 2008. The nutritional and health status of Zimbabwe’s people has acutely worsened this past year due to epidemics of cholera, HIV/AIDS, and tuberculosis. Zimbabwe now has one of the world’s lowest life expectancies at 36 years. High maternal mortality and severe malnutrition augment the daily death toll.

Heedless of the concern world leaders have expressed for the people of Zimbabwe, the Mugabe regime has derailed international efforts to assist: he has politicized humanitarian aid, detained journalists, tortured human rights activists, and even blocked Kofi Annan, Jimmy Carter, and Graça Machel from their humanitarian mission.

As part of a Physicians for Human Rights investigation, I led a team that managed to enter the country and transparently conducted an emergency health assessment in December 2008. Nevertheless, the Government planned and falsely reported our arrest after we had escaped. These actions are a desperate attempt to conceal how Mugabe’s malignant policies have led to the destruction of infrastructure, widespread disease, torture, death and the abysmal state of his people.

This article traces the antecedents to the current health crisis and the unprecedented national regression that occurs when a government reverses its population’s access to food, clean water, sanitation and healthcare. It concludes with a prescription for redress.

Mugabe’s rise to power

Cecil Rhodes, the eponymous colonizer of Rhodesia, obtained mining rights in 1888 from King Lobengula of the Ndebele people indigenous to present Zimbabwe. With this concession, Rhodes convinced the British government to grant him a royal charter over Matabeleland, home of the Ndebele, which precipitated an influx of European settlers to the region. The settlers eventually displaced the Ndebele onto less favorable lands. In 1923 Southern Rhodesia (now Zimbabwe) became a self-governing British colony, only to be consolidated with Northern Rhodesia (Zambia), and Nyasaland (Malawi) thirty years later. Growing African nationalism and dissent compelled Britain to dissolve the union in 1963, thus forming three separate colonies.

Ian Smith, the leader of the white-minority government of Southern Rhodesia, promulgated a Unilateral Declaration of Independence from the United Kingdom in 1965 and declared Rhodesia a republic in 1970; only the neighboring apartheid government of South Africa recognized Smith’s regime. Civil war ensued over the next decade. With his regime in near ruin, Smith signed an accord with Robert Mugabe and other revolutionary leaders ending civil war in 1978. The following year Great Britain convened a constitutional conference with the Smith government and with Mugabe and the other opposition leaders. The delegates signed the resultant Lancaster House Agreement in December 1979 paving the way to independence. The British subsequently oversaw the disarming of revolutionary forces and Zimbabwe’s first democratic elections in 1980. Zimbabwe African National Union (ZANU) won a landslide victory, and its leader, Robert Mugabe, became the country’s first Prime Minister.

From breadbasket to basket case

After Mugabe came to power, he extended healthcare to the black majority and increased minimum wages, which led in part to the dramatic improvement in life expectancy, maternal mortality, and infant mortality (key health indicators). Unfortunately, his subsequent policies such as a draconian land-reform campaign eroded these early advances and led to the displacement of farmers, unemployment, hyperinflation, and a dollarized economy. 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.

Mugabe’s land reform crippled the economy. To rectify historical injustices as well as consolidate political power, Mugabe had his ZANU-PF-controlled parliament amend the Constitution in 2000 to establish a legal framework for land acquisition. He quickly mobilized some 35,000 civil war veterans and unemployed youth militia and ordered them to expropriate some 4,000 white-owned farms. Security forces killed 12 white farmers during the land seizures and targeted 300,000 farm laborers whom the Mugabe regime identified as supporting the MDC opposition. Numbering more than one million, the vast majority of these farm-workers and their families was thrown out of their homes and off the farms.

The Government claims “that restoring land to the landless majority was right and necessary.” But 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 political supporters for their patronage. Many of these farmlands now remain fallow and serve as nothing more than second homes to Mugabe’s cronies, including Zimbabwe’s First Shopper, Grace Mugabe.

The land seizures have led to a 70% fall in agricultural production since 2000 and have undermined all economic activity. The significant loss in foreign exchange revenue from agricultural exports coupled with recent currency devaluations have led to the world’s highest rate of inflation in Zimbabwe. This hyperinflationary environment in turn produced a dollarized economy as the U.S. dollar has become the de facto currency along with the South African rand. 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 diaspora relatives who send remittances back home.

Lack of access to foreign exchange, a paucity of basic commodities, steep unemployment, and successive years of poor harvests all contribute to severe food insecurity for more than seven million Zimbabweans who rely on food aid. We are now witnessing the occurrence of widespread malnutrition and a population rendered extremely vulnerable to the current outbreaks in disease. This dire situation represents an economic indictment of the ZANU-PF government, which has employed macro-economic strategies that have demonstrably undermined people’s health and well-being.

Health forsaken

A knee-jerk response to such calamity might be to shrug it off as just another tale of woe in Africa. But the crucial difference, setting Zimbabwe apart from other failed states, is that the country is not at war – nor has it been for over three decades. Moreover, Zimbabwe once boasted the best education and medical care in Africa. According to UNESCO, the country enjoys the highest literacy rate (91%) on the continent from years of investing in its youth. The country’s healthcare system in the 1990s was so successful that 85% of the population lived within ten kilometers of a functioning health facility staffed by well-trained Zimbabwean health professionals.

But today these same government-run rural health clinics are shuttered for lack of essential drugs and the most basic clinical supplies such as cleaning agents, surgical gloves, and bandages. Abysmal salaries complicate further the healthcare crisis. When a doctor’s monthly wages do not cover even a one-way bus ticket to work, hospitals close. A brain drain has occurred; it is no wonder that physicians and nurses left the public health service in droves into the private sector or abroad.

The most abrupt halt in healthcare access occurred in November 2008, when the premier teaching and referral hospital in Harare, Parirenyatwa, closed along with the medical school. At the same time, a group of local health professionals organized a non-violent demonstration to protest poor working conditions and wages. Two truck-loads of armed police arrived on hospital grounds and began beating the physicians and nurses using baton sticks. 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. “Doctors with high esteem were treated like dogs,” reported one participant.

Although the public health system has collapsed, private-sector health facilities – including for-profit health clinics and non-profit mission hospitals – continue to provide care. But only the wealthy elite with substantial foreign currency holdings can afford private care, and lack of transportation precludes access to the rural mission-run hospitals for most Zimbabweans. Consequently, the vast majority of the population is effectively denied access to medical care.

The energetic and focused efforts of a number of non-governmental organizations have played a critical role, however, in providing healthcare to Zimbabweans, bolstering the country’s healthcare system, and addressing the current humanitarian crisis. Doctors Without Borders is largely responsible for staffing the major cholera treatment centers, and the World Food Program is coordinating the supply of food aid. These crucial efforts, however, cannot replace a functioning public sector.

As evidence, the drastic fall in vital health statistics below reflects the precipitous collapse of Zimbabwe’s health system:

• The maternal mortality ratio quadrupled from 283 per 100,000 in 1994 to 1,100 per 100,000 in 2005.

• The infant mortality rate rose from 52 per 1,000 live births in 1990 to 68 per 1,000 in 2006.

• The adult mortality rate (the probability that a 15-year-old person will die before reaching 60) in Zimbabwe sky-rocketed from 286 per 1,000 in 1990 to 751 per 1,000 in 2006.

• Most distressing is that life expectancy at birth fell dramatically from 62 years for both sexes in 1990 to 36 years in 2006.

As paralytic as Mugabe’s policies have been for the healthcare system, his political machinations have also eroded key underlying determinants of health.

Foul water, foul play

Key underlying determinants of health include access to safe water, adequate sanitation, and sewerage. The Mugabe regime nationalized MDC-run municipal water services for political gain and profit in 2005 and became solely responsible for the provision and treatment of water. Within three years, under ZANU-PF control, the national water authority collapsed due to egregious malfeasance:

• Incredibly, the government dumped raw sewage into Lake Chivero, Harare’s main water supply in 2007. Public health clinics saw an explosion of cholera and diarrheal cases.

• Since then, the ZANU-PF government has willfully allowed outdated and damaged water systems to go unrepaired and water supplies to go untreated. Last year, for example, the government failed to procure enough aluminum sulfate – one of four main chemicals used to treat the water supply.

• The Government then arbitrarily cut off water to Harare residents last fall. The November cut-off was not the first time there has been a water shortage in the capital. Water delivery has been sporadic for years – sometimes absent for more than six months.

If there is any good news with the new unity government, it is that water services are now back under municipal control.

The Government has also failed to provide adequate sewerage and sanitation. Public trash collection in Harare simply no longer exists. Throughout the poor, high-density areas outside the capital, piles of waste litter streets and clog intersections. Steady streams of raw sewage flow through the refuse and merge with septic waste from broken pipes. Human waste leaks into these pipes and spreads contaminants and disease. A severe shortage of potable water has forced people to dig shallow wells; however, seepage from run-off water enters these wells from which city residents drink. Much of this run-off water is contaminated with fecal waste containing vibrio cholerae.

In the time of cholera

Cholera is an acute diarrheal disease caused by bacteria in contaminated water and leads to severe dehydration and death within several hours if not treated quickly. It spreads through water and food contaminated with human feces from people infected with the bacteria. Treatment is simply oral rehydration (fluids that contain salt and sugar). Epidemics arise almost uniquely when a government fails to maintain water, sanitation, and sewerage systems – for example, during times of war or natural disaster.

The current cholera epidemic in Zimbabwe dates back to August 2008 and has killed more than 4,000 people and infected another 100,000 – all from an entirely preventable and easily treatable disease. The cumulative case fatality rate, an important indicator of effective treatment, is five times greater in Zimbabwe than the international norm of one percent.

Civic organizations in Harare warned of a cholera time-bomb in 2006, but the Mugabe regime ignored the warning signs, suppressed health data, and ordered doctors not to report it. The Mugabe government did not acknowledge the epidemic until December 2008 when the disease had already killed 500 individuals. This long delay allowed the disease to take hold throughout all ten provinces. The disease has now spread to Zimbabwe’s five neighboring countries. This negligence represents a four-month stall since the start of the cholera outbreak and at least a three-year delay in responding to the water and sanitation breakdowns.

Rising threat of tuberculosis

While the cholera epidemic is finally coming under control, tuberculosis (TB) may soon take its place as a leading cause of death in Zimbabwe. TB is a highly contagious, potentially lethal infectious disease caused by Mycobacterium tuberculosis and spreads by air droplets (coughing, speaking, sneezing, even singing). According to the World Health Organization, the public health arm of the United Nations, Zimbabwe has the fourth highest incidence of TB in the world. When the Mugabe government finally admitted that it did indeed face a spiraling cholera epidemic, the ZANU-PF regime funneled its meager resources toward combating the disease. One of the problems with this vertical healthcare approach, however, is that it redirected resources away from other pressing health issues. Enter tuberculosis.

Physicians at Beatrice Infectious Diseases Hospital in Harare could no longer treat their TB patients because government authorities mandated they treat only cholera patients. A dysfunctional laboratory, a lack of diagnostic capacity, and a severe shortage of first-, second-, or third-line drugs thwart treatment. Do we hear the din of this international alarm bell? It is a clarion call sounding a new nidus for the development of multiple-drug-resistant TB. This highly lethal form of TB develops and spreads rapidly when treatment interruptions allow the bacillus to evolve mechanisms of resistance to available antibiotics.

Drug-resistant variants of TB are arguably more of a threat to southern Africa than the spread of cholera, which is an acute illness that remains both treatable and curable with basic medical services. Drug-resistant TB will pervade in the region for years and will greatly increase the cost and complexity of care.

Resistant HIV?

A threat equally menacing as TB lurks on the horizon: drug-resistant human immunodeficiency virus (HIV). In Zimbabwe, more than 15% of all adults are infected with HIV. Whereas only 4,000 people have died of cholera over the past nine months, roughly 3,000 people die of HIV-related illness each week in Zimbabwe. An estimated 1.3 million Zimbabweans live with HIV infection.

For HIV/AIDS, the gravest threat has been the interruption of regular supplies of antiretroviral (ARV) drugs. ZANU-PF operatives have disrupted drug delivery and provision and have stolen ARV drugs and funds for HIV/AIDS. Most troubling, some physicians are consequently obliged to switch patients’ drug regimens based not on clinical indications but on medication availability. This practice can lead to drug-resistant HIV strains and poses a significant threat to public health.

Prescription for redress

The Southern African Development Community (comprising 15 regional governments) brokered a power-sharing agreement between ZANU-PF and MDC following the contentious 2008 elections. As part of this agreement, ZANU-PF retained control over 16 ministries (including defense and home affairs) while MDC gained control of 15 ministries (including health). The international community nearly strong-armed Tsvangirai to accept the terms of this far-from-perfect cohabitation. As Prime Minister, Tsvangirai opted to join the unity government and accepted the formidable challenge of redressing the collapse of Zimbabwe’s economy, healthcare and attendant epidemics.

The only hope of tackling the underlying causes of the current outbreaks in disease and collapse of the health system is for Western donor governments to open their coffers. For that to happen, the Zimbabwean government must return to rule of law, respect of human rights, and sound macro-economic policies – benchmarks that potential donor countries have already articulated. The two largest donors, the American and British governments, for example, have thus adopted a wait-and-see approach before renewing substantive development aid to Zimbabwe. But this approach is a pernicious Catch-22, because each week they wait, thousands needlessly die as the West plays into Mugabe’s hands.

To retain power, Mugabe is incented to continue violating human rights. Such abuses dissuade donor countries from providing the financial support that would help ensure the success of Tsvangirai’s efforts, bolster the MDC, and weaken ZANU-PF in the next round of elections, scheduled in two years. Unfortunately, the internationally backed power-sharing agreement gave Mugabe control over the very levers of power (security forces) that commit these ongoing atrocities.

Donor countries should instead initiate targeted support now to rehabilitate Zimbabwe’s collapsed healthcare, water, and sanitation infrastructure for this struggling nation in transition. Reconstruction assistance should be channeled via transparent and accountable nongovernmental organizations. Such targeted support would obviate government corruption and most importantly save lives. Zimbabwe’s long-term prosperity requires more, however, than relying solely on external support. For sustainable development, the new unity government must address the issue of land reform in order to revive its once-productive agricultural sector.

The health crisis in Zimbabwe is a wake-up call to the Southern African Development Community and all UN member states for urgent intervention. It also adds to the growing evidence that Robert Mugabe and his regime may well be guilty of crimes against humanity.