With Health System in Tatters, Zimbabwe Stands Defenseless

February 5, 2004
By MICHAEL WINES

BINGA, Zimbabwe - Three days after getting word that
cholera was again killing villagers outside this district
capital, Binga's political and medical leaders gathered at
the town's disheveled hospital to take stock of their
arsenal against a potential epidemic.

It did not take long.

They had no intravenous solution
for rehydrating patients, a principal weapon against
cholera. Water purification chemicals were in short supply.
The generator was broken. Of the tents needed to isolate
cholera cases, one was missing its tie-down ropes, the
other was "in tatters," one man said. The doctors needed
large amounts of salt, sugar, bleach, soap and candles;
none were on hand. Of 330 gallons of gasoline sought, 44
were available - not that it mattered, as two of three cars
were in the shop. The truck was, too.

The needs might be even greater, as might the outbreak's
toll - two reported deaths, seven more illnesses. But no
one knew for sure: the two-way radio carried by the first
doctors who drove to the scene was not working, either. Nor
was the radio in the village's medical clinic.

Only a decade ago, Zimbabwe's public health system was,
with South Africa's, head and shoulders above those of most
of the 40-odd other nations of sub-Saharan Africa. But in a
weeklong trip through eastern and central Zimbabwe, both to
cities and to remote towns like Binga, it was apparent that
health care - like the rest of Zimbabwe's economic and
social fabric - is dissolving.

Three years of economic free fall and inflation, now
averaging 620 percent a year, have left Zimbabwe
desperately short of even basic drugs and medical
equipment, pushing a once robust network of hospitals and
hundreds of rural clinics close to ruin.

Experts say the decay portends potentially far more serious
problems - outbreaks of diseases like cholera and anthrax
that spread when preventive measures are poor, and deadly
childhood epidemics like measles, which exist only when
public health defenses are down.

Zimbabwe's government does not discuss details of its
public health problems, and Western journalists, derided as
tools of the nation's critics, are officially barred from
reporting here. With rare exceptions, local medical experts
and others interviewed for this article spoke only on
condition of anonymity for fear of retaliation, either
against them or their organizations.

Nevertheless, the national medical association stated
publicly in January that 4 in 10 doctors had already left
Harare, and 6 in 10 had left Bulawayo, usually for Britain,
Australia or neighboring African states like Botswana.

By one United Nations-financed study, fewer than 900
doctors remain in a nation of 11.6 million people - one
doctor for every 13,500 people.

"Basically, the health care system is collapsing on itself
right now," said one Harare medical professional with long
experience in several parts of Zimbabwe. "There's an exodus
of health care professionals from this country. And most of
the rural health structures have been left under the
supervision of nurses' aides who have nothing to treat
patients with."

The human toll of such breakdowns is difficult to measure
precisely, but the anecdotal evidence is chilling.

Nurses at Harare's Parirenyatwa public hospital, the city's
biggest, say that since November there have been no H.I.V.
test kits - in a nation where one in four people is
H.I.V.-positive. Two physicians said in separate interviews
recently that in the space of six months last year, half of
Harare's kidney-dialysis patients died, all because the
government did not spend its scarce foreign currency to buy
catheters for blood-cleansing equipment.

In Bulawayo, Zimbabwe's second largest city, a shortage of
sutures and other equipment has closed operating rooms and
forced obstetricians to curtail Caesarean-section births.
Some women have died in labor as a result, said one medical
professional who often works in Bulawayo.

The public health system that remains here, experts say,
persists on the astonishing dedication of those health
workers who have stayed. Despite President Robert G.
Mugabe's withering attacks on what he calls the racist
West, it also depends even more on the kindness of Western
strangers - many of them relentless critics of his
authoritarian government.

Foreign aid, largely from global charities and the United
States, Britain and Europe, has saved Zimbabwe from running
entirely out of drugs and medical supplies. Days ago, the
European Union pledged $30 million in aid to buy medicine
and equipment for clinics.

Only in December, the United States made a last-minute
donation that enabled the government to buy the chemicals
that keep the municipal drinking water used by more than
two million people in Harare and Bulawayo pathogen-free.

Zimbabwe, of course, is hardly alone in its misery. Public
health in much of this region is abysmal, and some other
African nations - neighboring Zambia and nearby Malawi, to
cite two - face even worse problems. What distinguishes
Zimbabwe, however, is the depth and rapidity of its fall
from the top rank of healthy nations to near basket case.

Take infant mortality, one key indicator of public health:
between 1999 and 2002, Malawi's rate dipped by about five
percent while South Africa's held essentially steady.
Zimbabwe's jumped at least 15 percent, and is believed to
have risen further last year.

That is no isolated trend. Overall mortality rates, as well
as childbirth-related deaths, also worsened over the decade
in Zimbabwe in comparison with its neighbors.

Yet no one outside Zimbabwe's government knows with
certainty how deeply the crisis in public health runs here.
Mr. Mugabe's government, increasingly wary of bad
publicity, has stymied the public release of United Nations
assessments of major social indicators. The network of
clinics and doctors has frayed so badly that experts
suspect the data once routinely dispatched to statisticians
are no longer reliable.

On a personal level, the evidence of decay in health care
is overwhelming. A recent stroll through the Parirenyatwa
public hospital in Harare showed that staff shortages had
shuttered whole corridors. At a second major hospital,
Harare Central, the laundry has stopped working. In the
pediatric wards, blood work-ups are no longer performed
in-house because of equipment and staffing problems.
Refrigerators in the overstuffed morgue, where corpses can
remain for up to six months, are not working.

In an interview in late January, a Harare resident who gave
his name only as Thomas told how his father-in-law was
rushed to a city hospital in November with high blood
pressure and breathing problems, only to discover there
were no doctors to see him. Shortly after Christmas, a
stroke left him paralyzed on one side.

"We took him to Suburban Hospital," a private institution,
Thomas said. "They wanted 900,000 Zimbabwe dollars as a
deposit for admission" - about $300, a sum laughably beyond
average people here.

"So we took him to a clinic, and they wrote a prescription
and said to bring him to the clinic every day for an
injection."

Thomas paid 250,000 Zimbabwe dollars for medicine, needles
and syringes, and ferried his paralyzed father-in-law to
the clinic daily for a 10,000-dollar-a-day injection.
Within days, he was dead.

But Zimbabwe's crisis is most painfully apparent not in the
cities, but in rural areas. There, doctors and patients
alike say many of the hundreds of local government clinics
now have no working radios, refrigerators or trained
medical workers, and often few medicines beyond basic
antibiotics and a pain reliever. One person told of seeing
a broken leg set solely with the help of acetaminophen,
commonly known as Tylenol.

In a remote corner of eastern Zimbabwe, an official of one
private charitable clinic said in a recent interview that
none of the four closest government clinics currently
employed either a doctor or nurse. The charity's case loads
have more than doubled in the last year, she said.

"They come here for malaria pills," she said, referring to
a standard preventive tablet in high-risk malarial areas
like Zimbabwe. "We tell them that they should check at the
clinics. And they say, `Uh-uh; we know you have it here.' "


Zimbabwe's economic crisis has made gasoline so costly that
vaccines and other drugs can no longer be reliably ferried
to faraway villages. "Zimbabwe used to run its own
immunization program. In fact, it was the only country in
sub-Saharan Africa which could buy all its own vaccines,"
one global aid official said in a recent interview. "But by
2000, it couldn't afford it."

So Zimbabwe's immunization programs, once exemplary, now
provide coverage below 70 percent for some major childhood
diseases. Indeed, the official of the charitable clinic
said it was expanding its own free immunization program to
head off an expected flood of sick children from areas
where government immunization programs have stalled.

Some of the same shortcomings were evident in the Binga
district, the northwestern region that was the scene of
cholera outbreaks in January and late last year. Binga,
hard against vast, man-made Lake Kariba, has always been a
region of impoverished peasants, with poor services and
sanitation, so cholera was not unexpected. The area
affected this time, around the remote village of Lunga, is
said to have almost no latrines and little access to
treated water.

Yet when the disease first struck late last year here and
in neighboring Mashonaland West, medical experts said in
January, district health clinics had neither the qualified
staff nor the radio communications to identify cholera and
spread the alarm.

Chris McIvor, the mission head in the region for the
charity Save the Children, said in a telephone interview in
late January that Zimbabwean health workers responded
heroically to last year's three-month outbreak, which
sickened 900 people and eventually killed 40 before being
brought under control in December.

"Having said that, there's no doubt that there is a
shortage of facilities, supplies, fuel, adequate numbers of
staff and adequate drugs," he said. "And we're very
concerned that in the current environment, further
outbreaks of cholera - not just in Binga, but in other
places - could be much more serious.

"With the state of health services currently," he said, "I
think that the response in 1990 would have been speedier
than it is now."