When the affected state causes the crisis: the case of Zimbabwe
by Christophe Fournier and Jonathan Whittall, MSF July 2009

Zimbabweis facing an extraordinary and multidimensional crisis. An estimated three million Zimbabweans have crossed the Limpopo river into South Africa as a matter of survival; more than three-quarters of the remaining population of nine million face serious food shortages; maternal mortality has tripled since the mid-1990s; a cholera epidemic has infected over 90,000 people, killing over 4,000; one in five adults are HIV positive, and one person dies every four minutes from AIDS; 94% of the population is officially unemployed; and thousands were beaten and intimidated by government security and paramilitary forces during last year’s elections.

Political instability and mismanagement have led to economic crisis, with inflation exceeding a staggering 89 sextillion percent; in mid-November 2008, prices were doubling on average every 24 hours. The economic collapse has brought industrial and agricultural production to a virtual standstill; there are severe shortages of essential goods, and basic infrastructure and public services have all but collapsed.

Médecins Sans Frontières (MSF) has been working in Zimbabwe since 2000 and has witnessed a continuous deterioration of the humanitarian situation. The responsibility for this man-made crisis lies in the handsof the state.

A health system unable to cope

Zimbabwe once boasted one of the best health systems in Africa. Now, this system has collapsed. In a country where more than 500,000 people need antiretroviral therapy (ART) and more than 3,000 people die of AIDS-related diseases every week, the collapse of the healthcare system puts people living with HIV at huge risk. More than 100,000 patients were put on ART in 2008, just as health facilities were closing. Most of these patients are now on their own without proper follow-up and access to the drugs they need.

Meanwhile, the recent cholera epidemic, which started before the rainy season in August 2008, was unprecedented in scale for Zimbabwe. Cholera is endemic in some rural parts of Zimbabwe, but has been relatively rare in urban areas where most homes have – or used to have – treated, piped water and flush toilets. The recent outbreak hit Harare’s high-density suburbs, rapidly spread to key border areas and subsequently travelled along major transport routes into rural areas. In all, 90% of Zimbabwe’s districtswere affected.

The reasons for the scale of the outbreak are clear: lack of access to clean water, burst and blocked sewage systems and uncollected refuse overflowing in the streets, all symptoms of the breakdown in infrastructure resulting from Zimbabwe’s political and economic collapse.

The scale of the cholera epidemic and the health system’s inability to cope compelled MSF to launch a massive response. Between August 2008 and March 2009, MSF has treated more than 55,000 cholera patients. We have provided care by using government health structures and drawing on the support of government health personnel; by paying the salaries of Ministry of Health staff so that they can continue working; and through our own staff. At the peak of the cholera outbreak, more than 500 MSF staff members were working to identify new cholera cases and to treat patients. The focus of the outbreak shifted from cities to rural areas, where access to health care is particularly limited. However, cases in Harare are on the rise again and the epidemic was far from under control.

Zimbabwe’s inability to cope with the health crisis is evident in the loss of key health staff, especially nurses. Astronomical inflation means that a nurse’s salary is simply not sufficient for survival. Many health workers have turned to the informal sector or have fled to South Africa and other countries. There is also a widespread shortage of basic medical materials and drugs. Health facilities now accept only foreign currency fee payments – an impossible hurdle for the majority of Zimbabweans.

The international humanitarian response

The World Health Organisation (WHO) has focused on providing technical support to the Ministry of Health. However, given that the health system has collapsed, more proactive measures are needed to ensure that basic systems are in place. WHO acknowledged the need to change gear and respond to the cholera crisis in rural areas, but this realisation came months after MSF had already followed the cholera epidemic into rural areas – making it clear that reactivity has not been a strong point in the international response to date.

More broadly, the UN system in Zimbabwe has been slow to acknowledge and respond to the crisis in all its manifestations, not just cholera. Contingency planning has focused prematurely on early recovery – with very little attention on emergency response, at least until recently. The majority of NGOs in Zimbabwe have historically operated within a development-oriented framework. Although this may have been appropriate previously, this is clearly no longer the case.

Political and aid actors – including the UN and donors – need to shift their approach and strategy if they are to address the humanitarian issues facing Zimbabwe effectively and efficiently. Increased humanitarian aid is necessary, but so too is a move to a more proactive emergency approach based on a recognition of the severity of the crisis – in all its manifestations. Donor governments and UN agencies must ensure that the provision of humanitarian aid remains distinct from political processes. Their policies towards Zimbabwe must not be implemented at the expense of the humanitarian imperative to ensure that Zimbabweans have unhindered access to the assistance they need to survive.

Blurring the lines between political goals and humanitarian response will have dire consequences in an already highly politicised context. The government of Zimbabwe must give humanitarian agencies the space they need to function independently. Food aid is the clearest example of politicised humanitarian action. Although food distributions have resumed in some locations following the government’s ban on NGO activity during the elections in 2008, patients at MSF clinics tell us that distributions are manipulated for political purposes. In Epworth clinic, MSF patients were unable to get food aid for over six months after the June election, leading HIV/AIDS patients to default from treatment as they searched for food.

The responsibility of the state

Zimbabwe’s response to the humanitarian crisis varies from one ministry to the next. MSF has had a positive working relationship with the Ministry of Health, treating many cholera patients in Ministry of Health structures alongside the ministry’s own staff. At the other end of the scale, the authorities have blocked MSF’s attempts to respond to the broader, less visible components of the health crisis. Despite glaring humanitarian needs, the government continues to exert rigid control over aid organisations.

MSF faces restrictions in implementing medical assessments and interventions. The World Food Programme (WFP) estimates that seven million Zimbabweans are in need of food aid, but, until recently, MSF had no quantitative assessment of the medical implications of this food shortage because we had been prevented from conducting nutritional assessments. Responding to the cholera epidemic has been easier, though still difficult.

MSF has also had to overcome state-imposed obstacles to bringing health staff into the country – despite the acknowledged shortage of these badly needed professionals. For example, MSF doctors are still required to undertake a three-month internship under the supervision of a senior doctor at a state hospital. This has been problematic since the major hospitals where these internships are performed have closed and have no staff. Work permits for international staff are difficult to obtain and renew. On average, it takes about three months to obtain a work permit. This obstructive approach suggests that the Zimbabwean government is unwilling to acknowledge the scale of the health crisis and facilitate the necessary humanitarian response.

The cross-border implications of Zimbabwe’s crisis

The dire situation in Zimbabwe has led to a steady flow of Zimbabweans seeking refuge not only in South Africa, but also in Mozambique, Botswana and Zambia. An estimated three million Zimbabweans have sought refuge in South Africa alone, making this Africa’s most extraordinary exodus from a country not in open conflict. Zimbabweans fleeing across the border to South Africa risk beatings, rape or robbery by bandits known as the ‘guma-guma’.

The challenges facing Zimbabweans do not end once they have crossed the border. In South Africa they are met with little sympathy from the government, which often fails to meetnot only its international responsibilities but also those enshrined in the South African constitution. Even with the current collapse in Zimbabwe, the government of South Africa has characterised Zimbabweans in the country as ‘voluntary economic migrants’. Between 2000 and March 2008, there were 66,578 new applications for asylum from Zimbabweans. Of these, 710 were granted refugee status and 4,040 were rejected. Over 62,000 cases remain pending. In the first quarter of 2008, there were more than 10,000 Zimbabwean asylum-seekers – more than had applied in the whole of 2005 – and only 19 approvals.

According to the South African History Archive (SAHA), ‘the massive increases in 2005 to 2006 and in 2008 reflect repression related to Operation Murambatsvina and more recent violence associated with ongoing repression, and support the general human rights reporting and analysis coming from Zimbabwe that show the situation deteriorating’. As a result, many Zimbabweans live in constant fear of deportation. Although the South African constitution guarantees access to healthcare and other essential services to all those who live in the country, this policy is not always respected. The risk of deportation – and more recently xenophobic violence – deters many Zimbabweans from seeking treatment.


MSF has called on the government of South Africa to stop deporting Zimbabweans and to allow for the provision of appropriate humanitarian assistance, including legal protection for Zimbabweans seeking refuge in South Africa. Although such assistance and protection in South Africa are urgently needed, it should be seen as a temporary solution. Zimbabweans’ basic needs should be met inside their country, removing the need for them to flee to neighbouring states.

To achieve this, the government of Zimbabwe will have to accept responsibility for this state-formed crisis and take action to ensure that state structures serve the needs of the people of Zimbabwe. The crisis in Zimbabwe is bigger than the visible and widely reported cholera epidemic, which is just one of many manifestations of the political and resultant economic turmoil in the country. Cholera must be addressed within the broader health crisis – a complete lack of access to health care in a context of high prevalence of HIV and food shortages.

Now more than ever, an adequate humanitarian response in Zimbabwe will require an increase in ‘humanitarian space’ for independent aid organisations such as MSF and others to carry out our work. The Zimbabwean government must lift restrictions on bringing medical supplies and personnel into the country, allow independent assessments of need and guarantee that aid agencies can work wherever needs are identified.

Dr Christophe Fournier is International Council President of Médecins Sans Frontières. Jonathan Whittall is the head of MSF’s Programmes Unit, based in Johannesburg. His email address is jonathan.whittall@joburg.msf.org.