The professor of surgery hears a knock on his office door. A surgeon enters gingerly to apologise for missing an important student seminar they were running. “I was pushing the truck”, he says. His colleague smiles sympathetically and shows no surprise. With fuel shortages and national strikes, pushing one’s vehicle in a fuel queue is a weekly part of Zimbabwean’s life these days.

These are tough times for Zimbabwe. The food and fuel shortages are placing huge stress on a population that is already facing inflation of 270% a year, 70% unemployment and widespread political repression by President Robert Mugabe’s regime. Indeed, about half the doctors I spoke to did not wish their names to be mentioned in this article.

The country’s health statistics reveal a nation going backwards. According to UNICEF, between 1960 and 1990 child mortality fell from 159 per 1000 to 80. But in the next 10 years it rose to 123 of every 1000. And now, 3 years on it can only have worsened further. Hunger is widespread, 34% of adults are HIV positive—the second highest prevalence of HIV in the world after Botswana, shortages of gas mean that the previously efficient immunisation programmes are being neglected and government health spending has fallen in line with the economy’s nosedive.

“Have you heard of Harare North?”, a surgeon working at one of the capital’s private clinics asks. “That’s London.” He says. “They tell me that in some parts of London you hear more Shona spoken than English.” Shona is the main African language spoken in Zimbabwe. In conversations I had during visits to clinics and hospitals, sooner or later a Zimbabwean doctor would always bring up the “brain drain”, an exodus of skilled medical staff, particularly nurses and anaesthetists, who flee Zimbabwe for the UK, New Zealand, and South Africa. A survey of medical students at the University of Zimbabwe conducted a few years ago found that two thirds intended to leave the country after graduating. At one of the country’s major 1000 bed hospitals there is no qualified pharmacist, and, as a result, pharmacy technicians are now running the department. If HIV/AIDS is the deadly cancer gnawing away at the population, then the brain drain is the medical profession’s own wasting disease—with particular specialists like pharmacists in very short supply, and an average vacancy rate of 24% across the medical spectrum.

It is not hard to see why retaining staff is such a problem. Pay is so low that doctors feel they are being given no incentive to stay in the country. A typical senior house officer earns a monthly salary of $Z280 000 after tax—about US$187—working a 70–80 h week. Most doctors rely on private work to survive despite recent salary increases. According to Jonathan Matenga at the University of Zimbabwe this has seriously undermined the manpower of the government hospitals: “Ideally these people would work 08:00h till 17:00h in the state hospitals but if they did that they wouldn’t be able to survive. This explains the exodus. Doctors are demoralised, there are fewer and fewer on the ground and they feel they are overwhelmed.” Doctors in many hospitals are no longer able to treat patients. In the rural areas district hospitals are short of drugs and basic supplies of needles. A patient who needs antibiotics is often lucky to get paracetemol.

Hospitals in Harare, however, still seem clean and relatively well run and patient care is for the most part surprisingly good considering the circumstances, but it is unclear how much longer medical staff can keep this going. In a bizarre parallel with a junkie needing to do the rounds of the dealers, doctors working in the capital have a daily battle to “score” the drugs and basic equipment they need.

Tendai, a junior registrar who asked that his surname not be used, says that because the standard suture materials have run out, wounds have to be sewn up with an absorbable suture material, which is not always strong enough to keep an abdomen together. Recently at Harare Central there was no halothane, which meant no operations could be carried out under general anaesthetic for 2 weeks, he says. And the third generation antibiotic ceftriaxone was being used when a more basic one would do, because there was no “ordinary” penicillin left due to foreign currency shortages. Consequently the ceftriaxone has been finished with no prospect of getting anymore—a “terrible waste” in Tendai’s opinion. Tendai says he will wait until he becomes a registrar before deciding on his future. But if Mugabe is still in power he will have little choice but to leave, he says.

Most frightening of all for medical staff is the day-by-day, hour-by-hour risk of being infected with HIV through an accident, for even double gloving and plastic aprons are not always protection enough. Two doctors at the University medical school are thought to have become infected with the virus in recent years by accidentally sticking themselves with instruments contaminated with blood from infected patients.

Back in the 1990s the government had promised ‘free health care for all by 2000’ but today, because of the lack of funds, the patients may be forced to pay out of their own pocket for such basics as needles and syringes. Doctors and nurses are forced to withhold treatment until payment or a deposit is provided. In some cases that means that relatives who have brought patients into hospital must race to a bank to collect the necessary funds before the medical procedure can go ahead.

Politics and health are inextricably linked in Zimbabwe. The programme of land reform that President Mugabe launched in 2000 has meant that a period of drought has become a humanitarian disaster with half the population now dependent on international food aid. Landless peasants with no resources and little agricultural expertise have been expected to take over from commercial farmers who had some of the highest yield-rates in the world. Without the necessary experience or financial backing many have abandoned the land allocated to them and huge swathes of the countryside that once supported the staples of maize and wheat are now overrun with weeds or simply lying idle. Thanks to the relief efforts of the World Food Programme people are only hungry, not dying of starvation. But with 34% of adults HIV positive, Zimbabwe is having to cope with the lethal combination of weak immune systems being further undermined by hunger.

To cope with the medical staff shortages the Ministry of Health has ordered the University of Zimbabwe’s medical school to train over two hundred doctors a year, three times as many as they used to, which the school must do with less staff than they had previously. Professors worry that such numbers will mean that only the most assertive students get the instruction they need. Matenga says the medical school—which used to be “as good as any in the developing world”, is now being affected. The government’s insistence on quantity has compromised the quality of teaching and the greater intake numbers has seen the calibre of individual students fall, Matenga says. But, Matenga adds, “I don’t want to entirely blame the government despite the fact they have made a mess of things. The impact of HIV on health economics cannot be underestimated. 60·70% of admissions to the wards are the result of HIV/AIDS, so a massive proportion of the health budget is going on AIDS. Even a first world country would struggle to cope with that.”

The government, for its part, claims that although problems exist, they are being exaggerated. David Parirenyatwa, a general practitioner and the son of the country’s first black doctor, has been minister of health since last August. He says that the manpower issue is being tackled effectively by introducing a new nurse grade—the state enrolled nurse, who has 2 years training rather than the 3 years of the state registered nurse. “We have also considerably improved the working conditions and salaries of nurses and doctors. The result is that a lot of nurses have now withdrawn their resignations.” The biggest problem he says is acquiring new equipment since this almost always involves buying from abroad and hence sourcing non-existent foreign currency. He says he has encouraged international organisations to view health as a humanitarian issue “so that people don’t see health running parallel with politics”.

He is grateful to WHO for helping the country with vaccines and the European Union for giving €26 million to buy drugs with. His ministry, like all others, has suffered from the economic crisis since Zimbabwe’s land reform programme started. But Parirenyatwa insists land reform was essential and bemoans the attitude of nongovernmental organisations and donor countries—he cites Belgium and Sweden, who have pulled out of Zimbabwe.

For Mugabe, considered by many as the chief villain in Zimbabwe’s political drama, Parirenyatwa is full of praise: “He is amazing. He is always asking me questions about health—what is happening with HIV, vaccines, and child supplementary feeding programmes.” Parirenyatwa says the government’s three current priorities are food, fuel, and importing medical drugs, in that order, a vivid illustration of how day-to-day survival has replaced any long-term agenda.

This piece appeared in the The Lancet on 5 July 2003

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