Zimbabwe: Declaring a health emergency is not enough!

Introduction

The outbreak of cholera in epidemic proportions has brought Zimbabwe back to the attention of the region and the world. Zimbabwe’s complex emergency, which is now causing so much suffering, taking lives and breaking the society apart at its seams, has been several years in the making. A key factor in creating a perfect environment for the breeding and spread of the cholera bacterium has been the neglect of essential services by the ZANU PF government over the years. But this has only been one effect of complete mismanagement and deliberate disregard for the lives of ordinary Zimbabweans. ZANU PF rule has brought a decline in basic standards of living for many years now; but in the months while Robert Mugabe has clung to power in the face of rejection by the people at the polls in March this year, the downward spiral has changed into a precipitous plunge.

In August this year, just when the first cases of cholera were being reported in Harare and Chitungwiza, WOZA undertook research designed to present a picture of the living standards of our members in Harare-Chitungwiza and Bulawayo. Some of the results of that study are now available, and present a stark demonstration of the circumstances, which have provided the backdrop for the cholera epidemic.

Water and Sanitation

Cholera thrives where there is inadequate provision for sanitation and inadequate supplies of pure water for household use such as drinking, cooking and bathing. The germs breed in human faeces and are spread through ingestion, when contaminated water or foods are used. Thus, it spreads easily where a sewage system is not functioning and raw sewage is present, or people are forced to defecate on the ground when toilets are blocked. The absence of purified water has also become a critical factor in the spread of cholera in the urban areas of Zimbabwe.

The results of WOZA’s survey highlight all of these problems in relation to water and sewage. The survey sampled just over 1,000 of WOZA’s members from Bulawayo, Harare and Chitungwiza. Of these, virtually all depend on their city council for water. 31% stated that they usually get their water from a council tap inside their house, while 62% use a council tap outside their house; 5% use a public tap, and 1% a borehole. 50% use a borehole sometimes (mainly in Bulawayo where many boreholes were drilled in response to recurring drought conditions in previous years) – suggesting that half are forced to use a borehole when the water is not flowing in the tap. 97% stated that they have experienced water cuts, with 60% having gone for a week or more without water. This masks some who have gone for much longer, many for weeks and months.

Of those surveyed, only 6% said they usually had access to clean water, while 77% sometimes had such access, and 16% never did. Obviously, during the time of water cuts residents are at serious risk as they seek water from sources other than their taps. However, what is not clear from the statistics, because residents cannot know the facts from day to day, is that even when water is present, it has rarely been treated with all the chemicals required to make it safe.

The other serious implication of failing water supplies is the dysfunction of the sanitation and sewage system. 88% of the respondents stated that they depend on flush toilets with, on average, 9.8 people using each toilet. 5% use a pit latrine and 4% a Blair toilet. When the water is cut off for days or weeks at a time, toilets do not function. Even when the water is on, the frequency of cuts means that the pipes have become clogged, resulting in many leaks and breaks, with sewage flowing all over. 11% of the respondents indicated that they had experienced burst sewers, which took more than six months to repair, while 23% had waited more than a month for repairs. When toilets are not working, people begin to use the bushy areas between residential suburbs as a toilet, with all that implies for attraction of flies and spread of any germs, including cholera. Such practices also have security implications as a teenage WOZA member was recently raped in Bulawayo whilst using the bush as a toilet.

In August, when the survey was conducted, 20% already reported cholera or some other form or diarrhoeal infection had affected their families during sewer bursts. Heavy rain, which began only in November, takes the human waste both over the ground and down to the underground water table while many people are looking for useable water in shallow wells; it then becomes clear that contaminated water is the norm.

At a recent meeting, WOZA members painted a graphic picture of daily realities in some areas. Recent heavy rains have carried faeces and waste matter from overflowing sewers right into houses. Women then have to remove maggots, which live in the sewage, along with solid faecal stools. They try to block the flow of sewage into their homes but because the rains were heavy this has been unsuccessful. Sometimes if someone upstream is trying to unblock their drain, the sewage backs up into the toilets and the bowls overflow into the houses. To stop the raw sewage flow, members have had to adopt the strategy of putting rocks and sand on top of the sewer covers to prevent the flow of solid matter. But even if they succeed, they still have to cope with the stinking water, which seeps out.

In spite of massive failures in provision of clean water and functioning sewerage, residents continue to be billed for the “service.” Many council workers are asking for payment in rand currency. Some who have left employment because council could not pay them decent salaries are said to have helped themselves to the long rods used to clear blockages, leading to long delays in carrying out repairs.

As if the problems of water and sewage were not enough, garbage also becomes another breeding ground for disease. 93% of the respondents stated that they lived in areas where the council was expected to collect rubbish; in fact the payment for rubbish collection is normally included in the rates bill. But over the past six months very few had experienced any rubbish collection, and have had to find a way of disposing of it themselves. 43% stated that they dumped their rubbish, only 11% created a rubbish pit, while 45% burned their rubbish, leaving of course the residue, which cannot be burned. It is thus hardly surprising that mounds of garbage are found throughout the high-density areas, breeding grounds for all sorts of disease carriers including rats and mosquitoes. The acrid smoke from burning garbage hangs over the streets, causing breathing difficulties for the many inhabitants suffering from asthma and other respiratory illnesses.

Access to Food

What type of diet do Zimbabweans in these circumstances manage to access? The women answering the questionnaire were asked to indicate what foodstuffs they had purchased within the preceding two weeks. 93% responded that they had purchased vegetables (generally leafy green vegetables – rape or choumoullier, spinach or sometimes cabbage) demonstrating the important role that vegetables play in providing nutrition. Only 67% had purchased mealie (maize) meal, while the others had doubtless a supply of mealie meal from before the two weeks. Only 8% had purchased rice, an alternative staple to mealie meal, but clearly now an unattainable luxury for most households. Only 13% had purchased milk or amasi (sour milk eaten with sadza), 12% meat or chicken, 5% eggs, 19% beans, 27% kapenta and 22% soya chunks (a protein-rich meat substitute). The last three items, then, provide the majority of the protein input to diets, but clearly many households are going without. 65% managed to buy soap, but only 9% bought toilet paper (presumably using newspaper which further clogs pipes) and only 8% bought pads or cotton wool used for sanitary needs. The absence of anything except the bare necessities is reflected in the purchases of drinks or mazoe orange (5%), beer or chibuku (opaque beer) (1%) cigarettes or snuff, a form of tobacco, which is inhaled (2%).

In all areas of the country, food, if available, is now sold in foreign currency. Those without access to it rely on barter trade. Some WOZA members have resorted to bartering firewood for essential items – one bundle of firewood fetching a single plate of mealie meal or a quarter of bar of soap.

Recently two young children (siblings), aged eight and nine-years old, from Robert Sinyoka, a peri-urban area on the outskirts of Bulawayo, starved to death after trying to survive on a form of maize gruel (created by boiling the husks and sweepings of ground maize). It is not nutritious and much of the husk is not digestible. Other members in Robert Sinyoka testified to trying to survive on wild fruits.

Despite the evident starvation, WOZA members, along with members of the opposition parties, cannot access food aid being distributed by humanitarian organisations because ZANU PF civil servants have a stranglehold on distribution points. Only 13% of the respondents had received any food aid since the year 2000. WOZA has thus found that humanitarian organisations have not been able to assist our members – and so despite their courageous defiance, they are starving. Even purchase can be problematic if one does not belong to the ruling party. A massive 49% said they had been prevented from buying food at some time because they were not members of ZANU PF, as youth militia or war veterans often man queues at shops selling scarce commodities.

Health Services

This is the context in which Zimbabwe’s health system has experienced a virtual total collapse. The conditions are ripe for the spread of diseases, most of which are treatable, but the government and local council health services are not available. While private medical services still function for those who can afford to pay, very few of the women surveyed ever use private doctors.

The women were asked what they do when they or a member of their family falls ill. 77% reported that they never see a private doctor, 18% sometimes do, and only 5% usually do. 46% usually rely on their own treatment, and 36% use a council clinic. The rest usually see a religious healer (14%) or a traditional healer (3%). Considering the fact that the majority of council clinics are at the time of writing (December) either closed or functioning only with skeletal staff and no medicines or equipment, it can be clearly seen how vulnerable the population is. For example, Budiriro Clinic in Harare is the only clinic still open in the area and therefore has to service seven large suburbs, each of which previously had its own clinic. In fact only that 5% who usually consult a private doctor would be likely to receive adequate treatment. But in the early stages of the epidemic, those not recognizing the seriousness of the disease and relying on their own treatment or even the nearest clinic, religious healer or traditional healer, were at high risk of losing their lives. The fact is that the figures show that even when the clinics were still open in August, only just over a third of residents went to them as their first port of call – either because they could not get treatment there or because they could not afford to pay the fee charged.

Corruption in the health sector is also commonplace. Many areas in Harare and Bulawayo report that their local clinic dispensaries are refusing to give medication and Anti-Retroviral (ARV) tablets even to those who are long term customers. Clinic staff are said to whisper to people to go ‘outside’ to purchase from an appointed person in foreign currency. A member from Matshobana in Bulawayo testified that she was directed to the private home of a doctor to buy ARVs after a tip-off from a nurse at a clinic. Water purification tablets are also being sold at inflated prices ‘outside’. Even the plastic packets that tablets are put in are sold ‘outside’.

Another member in Bulawayo whose relative is seriously ill and survives on drip infusions described her problems in getting drips fitted. Her relative was recently admitted to hospital and four drips were needed. After the drips were bought in foreign currency and the family had paid to have her attended to, nothing happened until someone whispered that if they wanted to be attended they had to go and pay again ‘outside’ in forex, which they did, and were given another receipt with a stamp but no amount reflected. Despite paying for four drips, every time a new drip was fitted they had to pay again because a different nurse was on duty.

The collapse of essential services is a direct result of the deliberate manipulation of the economy by the ZANU PF government, the attempt to claim control of local government services in spite of the incompetence and unwillingness of central government to handle them, and corruption inspired by greed. Resources needed for these services were diverted through various criminal activities for the benefit of cronies. Local councils in the hands of the opposition were deliberately starved of funds by refusing to allow them to raise tariffs sufficiently to meet requirements in a time of hyperinflation. The level of corruption and incompetence goes beyond simple neglect on the part of government - it reflects at a minimum criminal negligence and at worst planned genocide.

Conclusion

In recent weeks, two WOZA leaders have passed away – victims of a humanitarian crisis that could have been avoided. Julia Chipeyama (44) died from cholera in Harare whilst another life cut short was that of Bulawayo leader Thembelani Lunga, a 32-year-old mother of two who was the breadwinner of an extended family. She was HIV positive and constantly had problems accessing a regular supply of ARVs. She was also denied these during a four-day incarceration at Bulawayo Central Police Station in August 2008.

WOZA women form a cross-section of the dwellers of Zimbabwe’s high-density residential areas. Their experiences are those of average Zimbabweans. The attention of the world is focused on the spread of cholera, which results from these conditions. What has not been adequately described is the daily struggle to find water, to deal with sewage and garbage, to buy sufficient food, and to handle illness when it strikes. The deaths from cholera are just those from one very dangerous and rapidly spreading infection. To them must be added the pregnant women turned away from hospitals who go home to deliver, and die from want of a simple caesarian section operation, those whose insulin has run out, the appendicitis cases, the asthma attacks, bleeding ulcers, septicemia, - all treatable conditions from which thousands of deaths are now occurring. And this does not include those with kidney failure, who cannot be dialysed, those needing chemotherapy, even a simple plaster cast on a limb, or treatment for a wound. In September an eight-year old boy in Bulawayo fell in his schoolyard and twisted his knee; a week later he was dead. The death certificate cited cause of death as “swollen knee”. The family could not afford to pay for an autopsy, so no one knows the medical cause of death. But the real cause of death is clear – criminal negligence of the worst kind on the part of the ZANU PF government. If the life expectancy of Zimbabwean women was 34, as reported by the World Health Organisation three years ago, what must it be today, when our situation is so much worse?

Recommendations
• Zimbabwe is now a “complex emergency”, a failed state, without a functioning government and with the destruction of the economy, the infrastructure, and social capital. This requires an immediate political solution and we call on the international community, and in particular the Southern African Development Community (SADC) and the African Union (AU), to act in defense of the ordinary citizens of Zimbabwe.
• The Ministry of Health has finally declared a national health emergency but we do not trust them to administer an emergency health programme efficiently and with integrity. We call on the Ministry to step aside and allow the World Health Organisation (WHO) to take over all cholera treatment centers, including the payment of a decent wage to emergency health workers.
• We call on public health and clinic employees to honestly assist people and to put a stop to corruption in provision of medicines and bedside care and in attending to sewerage system repairs.
• We call on city councils to provide support for decent and speedy burials – Zimbabweans deserve to be buried with dignity.
• We call on the United Nations Development Programme (UNDP) to initiate plans to resuscitate the water and sewage reticulation systems, which should be handed directly to local councils and not central government for implementation.
• We ask that international humanitarian organizations alter their food distribution methods to allow easier access by all the needy to food aid.
• To Zimbabweans, we say - take your life into your own hands and help stop the spread of cholera. Clean up your areas of rubbish and try to stop the flow of sewerage. Demand an audience with local and provincial leaders and immediately report any corruption by health or council professionals.
• To ZANU PF – enough lives have been lost to your inability to govern and care for the nation - your time is up. Please leave us free to elect leaders who can address this humanitarian catastrophe you have created.

The current situation in Zimbabwe cannot be resolved by a corrupt, incompetent and illegitimate group of rulers who are responsible for creating this disaster in first place. We need urgent intervention by the international community operating on the ground independently of any ZANU PF-controlled government structures.

4th December 2008

For more information, contact Jenni Williams +263 912 898 110/112 or +263 912 362 668
Or email us at [email][email protected] / [email][email protected] or www.wozazimbabwe.org

Appendix – A tribute to Julia Chapeyama

On Saturday 15th November 2008, Julia Chapeyama (44), a leader of Women of Zimbabwe Arise (WOZA) was admitted to Budiriro Clinic, which caters for seven large suburbs of Harare. She was immediately infused with two drips, which took ten minutes, but her condition did not improve and she died two hours later. She was laid to rest at Glenville Cemetery on 20th November 2008. Cemetery officials told members that Julia was one of 34 cholera victims to be buried at that cemetery that day alone. Four female children, Tatenda, Primrose, Sandra and Cynthia, survive Julia. Sandra was writing her ‘O’ Levels when her mother died and Cynthia had just finished her Grade 7 exams.

Julia started to feel sick on the morning of 15th November with vomiting and diarrhoea. She refused to go to the clinic, insisting that her daughter, Cynthia, be taken first. Cynthia was admitted and has since recovered. When the friends who had taken Cynthia to the hospital returned, they found that Julia’s condition had worsened and they had to rush her to Budiriro Clinic, but she died two hours later.

She was laid to rest on 20th November at Glenville Cemetery. Although council officials had ordered that no large crowds were allowed at cholera funerals, Julia’s friends and fellow WOZA members paid their respects to her by attending in a steady stream of small groups that only stayed a short time.

Julia joined WOZA in 2003 and has been in the leadership structure since then. Although a quiet person, she was always ready for demonstrations and capable of mobilizing friends and neighbours. To be a WOZA member, one must complete a ‘Sisterhood Promise’ and to become a leader, one has to prove relevance to their community. Julia proved this to the last as she nursed members of her structure through their cholera bouts, only to finally succumb herself.

As we review her loss, we place her untimely death at the hands of David Parirenyatwa, Minister of Health. If he had been humble and accepted help from UNICEF when it was first offered, Julia might still be alive today. We place responsibility for her death also on ZINWA, who took over water supply from our democratically elected council without our consent. For over a year, water supply has become worse by the day. But ultimately the responsibility rests squarely with the entire ZANU PF leadership for the destruction they have wrought in Zimbabwe.

To Julia, we promise, they will be held accountable for these crimes against humanity. Her courage and commitment to demand social justice lives on in our hearts. May her soul rest in peace.