The Cholera Epidemic in Zimbabwe, 2008–2009

The 2008–2009 Zimbabwe cholera epidemic resulted in 98,585 reported cases and caused more than 4,000 deaths. In this study, we used a mixed-methods approach that combined primary qualitative data from a 2008 Physicians for Human Rights-led investigation with a systematic review and content analysis of the scientific literature. Our initial investigation included semi-structured interviews of 92 key informants, which we supplemented with reviews of the social science and human rights literature, as well as international news reports. Our systematic review of the scientific literature retrieved 59 unique citations, of which 30 met criteria for inclusion in the content analysis: 14 of the 30 (46.7%) articles mentioned the political dimension of the epidemic, while 7 (23.3%) referenced Mugabe or his political party (ZANU-PF). Our investigation revealed that the 2008–2009 Zimbabwean cholera epidemic was exacerbated by a series of human rights abuses, including the politicization of water, health care, aid, and information. The failure of the scientific community to directly address the political determinants of the epidemic exposes challenges to maintaining scientific integrity in the setting of humanitarian responses to complex health and human rights crises. While the period of the cholera epidemic and the health care system collapse is now nearly a decade in the past, the findings of this work remain highly relevant for Zimbabwe and other countries, as complex health and rights interactions remain widespread, and governance concerns continue to limit improvements in human health. C. Nicholas Cuneo, MD, is a Doris and Howard Hiatt Global Health Equity Resident in Internal Medicine and Pediatrics at Brigham and Women’s Hospital and Boston Children’s Hospital, Boston, MA, USA. Richard Sollom, MA, MPH, is a senior fellow at the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard T.H. Chan School of Public Health, Boston, MA, USA. Chris Beyrer, MD, MPH, is Desmond M. Tutu Professor in Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Please address correspondence to C. Nicholas Cuneo. Email: [email protected]. Competing interests: None declared. Copyright: © 2017 Cuneo, Sollom, and Beyrer. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Health and Human Rights Journal HHr HHR_final_logo_alone.indd 1 10/19/15 10:53 AM c. n. cuneo, r. sollom, and c. beyrer / papers, 249-264 250 D E C E M B E R 2 0 1 7 V O L U M E 1 9 N U M B E R 2 Health and Human Rights Journal Introduction The 2008–2009 cholera epidemic in Zimbabwe resulted in 98,585 reported cases and 4,287 reported deaths, making it the largest and deadliest in the history of Zimbabwe.1 The initial outbreak was notable for its high cumulative case fatality rate (4.3%) that persisted over a protracted duration (10 months). It was then followed by a second wave of infections lasting through June 2011.2 The epidemic emerged within months of two violent rounds of presidential elections that pitted President Robert Mugabe of the Zimbabwe African National Union-Patriotic Front (ZANU-PF), in power since 1980, against the primary opposition leader, Morgan Tsvangirai, of the Movement for Democratic Change (MDC). In December 2008, in response to the epidemic, Physicians for Human Rights dispatched an emergency delegation to Zimbabwe to investigate the country’s health infrastructure and to document possible ongoing human rights abuses.3 The organization’s investigation revealed multiple such abuses as well as the true scale and scope of the epidemic. These findings have been supported by other reports.4 Most critically, ZANU-PF’s loss of municipal elections in Zimbabwe in 2005 led party leaders to refuse to fund municipal budgets for cities where it had been defeated, including in Harare, the capital.5 These retaliatory cuts led to a cessation of water purification for the city and, eventually, the redirection of raw human sewage into the city’s main reservoir.6 In this paper, we contextualize the Zimbabwean epidemic within a broader conceptual framework that outlines the role of political institutions in mediating cholera outbreaks. Using data from Physicians for Human Rights’ 2008 investigation, as well as supplementary information from the social science and human rights literature and from international news reports, we describe the human rights abuses that contributed to the epidemic in relation to a larger pattern of human rights violations by ZANU-PF leaders under the Mugabe regime, including the politicization of water and sanitation. Then, through a systematic review and content analysis of peer-reviewed scientific literature, we explore the extent to which these abuses, including ZANU-PF’s role in perpetrating them, were discussed or not discussed in scientific discourse. With regard to the scientific literature on the cholera epidemic, it is striking how few authors directly noted the political or human rights aspects of the crisis. This seeming reluctance of the scientific community to fully address the political determinants of the epidemic exposes challenges to preserving scientific integrity in the setting of humanitarian responses to complex health and human rights crises. The imperative to seek access to vulnerable populations in such settings limits many partners from discussing the political and human rights aspects of these crises, even when they are well documented by other sectors, including human rights organizations. In the case of Zimbabwe, both the Zimbabwe Association of Doctors for Human Rights and the Zimbabwe Health Students Network had reported on abuses in this period and were active participants in the research effort described here. While Zimbabwe’s cholera epidemic and health care system collapse is now nearly a decade in the past, our findings remain highly relevant for Zimbabwe and other countries in the region and beyond, as complex health and rights interactions remain all too common, and governance concerns continue to limit improvements in human health.