Focusing on health in the crisis in Zimbabwe

Abstract

Zimbabwe is—and is in—a precarious state. This once-thriving nation known as the bread basket of southern Africa received its first famine-relief shipment from the World Food Program at the end of last month. In recent years unemployment, inflation, and HIV-infection rates have soared. But it is the sharp rise in political violence and fears of a slide towards dictatorship that has made Zimbabwe a focus of international concern. On March 9 and 10, presidential elections will take place, the results of which will have a profound impact not only on that country but also on her neighbours in southern Africa. Robert Mugabe, who has led the nation since independence in 1980, faces the stiffest challenge yet to his hold on power. Mugabe's party, Zanu-PF, has used its parliamentary majority to pass four pieces of legislation designed to rig the election results. The laws include provisions banning independent election monitors, criminalising any public criticism of Mugabe, strengthening government security powers, outlawing trades-union activity, and silencing the media. Official demands for free and fair elections from outside Zimbabwe have been largely inconsistent and ineffectual. The European Union decided on Feb 3 to suspend a decision on imposing “smart” sanctions. These sanctions would have included the freezing of assets and foreign bank accounts held by Mugabe and his inner circle, who are widely believed to have transferred large sums overseas. The EU put sanctions on hold pending safe entry of observers. It is worth remembering that EU observers were in place for the parliamentary elections in Zimbabwe in 2000—and subsequently reported: “The scale of violence and intimidation in the run-up to the campaign and during the election period marred the final result. The government failed to uphold the rule of law and compromised law enforcement agencies.” Health care was not excluded from this violence and intimidation. There were reports of nurses being physically assaulted and raped. Hospital staff encountered demands to not treat or admit victims of political violence, usually after or around election rallies. Health professionals were put in the invidiousposition of having to choose between bowing to the pressure to discriminate against often seriously injured patients and risking personal harm. The Lancet has learned that some rural district hospitals closed temporarily, since their staff were too frightened to report for duty. Concerned professional organisations, such as the Zimbabwe Medical Association and the Zimbabwe Nurses Association, felt they had no avenues of appeal in circumstances where the rule of law was being disregarded by the very agencies of law enforcement. There is every indication that the violence of the 2000 election campaign is being repeated in the current presidential election campaigns. A mission to Zimbabwe last month by Physicians for Human Rights, Denmark, reported: “All evidence, including our observations, clearly indicates that politically motivated violence in Zimbabwe is widespread and increasing on a daily basis.” The group also recorded “unequivocal evidence of torture”. The Lancet has received reports of health professionals being attacked for treating members of the opposition parties. If the current situation continues, the threat to health reaches beyond provision of care in Zimbabwe to a wider impact on public health in southern Africa. Zimbabwe's crisis is sending waves of instability to neighbouring nations. Zimbabwe's imploding economy is already one reason for the deterioration in foreign investment in southern Africa. Further destabilisation would be felt even more keenly were a humanitarian crisis to ensue. South Africa is reportedly making quiet preparations for an influx of refugees from Zimbabwe. Add to such a situation the very high prevalence of HIV and tuberculosis in those who would be displaced and the potential publichealth challenge becomes only too clear. The crisis in Zimbabwe is not only that international agreements on democracy and press freedom are being bypassed. International understandings on physicians' professional autonomy and governments' responsibilities to protect public health are also being ignored. While diplomatic activities continue, medical organisations worldwide have a duty to highlight these abuses.