PHA-Exch> Health in Ruins: PHR Reports on the Man-Made Health Crisis in Zimbabwe

[Claudio Schuftan]

Health in Ruins: PHR Reports on the Man-Made Health Crisis in Zimbabwe

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.

*EXeCUTIVe SUmmarY*

*INTrOdUCTION aNd OVerVIeW*

*P*hysicians 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 ZANUPF

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 nondiscriminatory

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 U.N. 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 U.S.

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.

vi Health in Ruins: A Man-Made Crisis in Zimbabwe

» *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 dollarization 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 antiasthmatics,

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.

vii

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 U.N. 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

» *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 U.N.

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

programs 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.

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 U.S.

dollars, in cash. $3,000 dollars for the surgeon, $140

dollars for the nurse, and $700 dollars 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.

» *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.

ix

*ReCOmmeNda TIONS*

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 U.N. 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 U.N. 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

programs. 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 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.


FOR THE FUL REPORT, GO TO www.physiciansforhumanrights.org
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