An Emergency Report by Physicians for Human Rights January 2009
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, U.S. 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 U.N. 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.
Richard J. Goldstone, Former U.N. Chief Prosecutor, International Criminal Tribunals for the former Yugoslavia and Rwanda (ICTY and ICTR); Current PHR Board Member
Mary Robinson Chair, Realizing Rights: The Ethical Globalization Initiative; Former President of Ireland; Former U.N. High Commissioner for Human Rights Chair,
The Most Reverend Desmond M. Tutu, OMSG, DD, FKC, Anglican Archbishop Emeritus of Cape Town; Chair – The Elders
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 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 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 (1320 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.
» 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 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 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: 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.
» 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 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.
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 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.
© Physicians for Human Rights http://physiciansforhumanrights.org
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