The death of one child from possible medical malpractice at a private hospital in Harare, the capital of Zimbabwe, might not seem a case of a human rights abuse on a continent where literally millions of people are dying from starvation and AIDS, and continue to suffer from such preventable diseases as cholera, dysentery, polio, and tetanus. But the difficulties encountered in Harare by Charles and Mary Khaminwa as they tried to make the medical profession accountable for the death of their daughter Lavender in August 1990 raise fundamental questions not only about the relation between professional responsibility and a respect for human rights, but also about the increasingly repressive policies of the Mugabe government. What are the consequences when medicine—or for that matter, law, journalism, the academy, or the clergy—fails to uphold basic ethical standards against the self-interest of its members? And if the profession places no restraints on their greed and health care is left unregulated in a free-market economy, who will protect citizens from the arbitrary use of authority, whether in hospitals or in prisons, by doctors or by guards?
On February 12, 1991, Charles and Mary Khaminwa wrote to the Washington office of Africa Watch requesting help that would “enable us to continue our legal struggle to bring to book those responsible for the death of our child, the late Miss Lavender Muhonja Precious Khaminwa.” As their letter explained, the Khaminwas were a Kenyan couple who had moved to Harare in 1984 so that Charles, a lawyer with several years’ training in the US, could direct a community development project. Ten-year-old Lavender, their eldest child, had been attending a private boarding school on the outskirts of Harare. During the first week of August 1990, she came home complaining of stomach pains; when the Khaminwas took her to the family pediatrician, he recommended that she see a surgeon. “On 9 August 1990,” the Khaminwas recounted, “Lavender was admitted to a local private hospital, the Avenues Clinic in Harare…. On 10th August 1990, she was subjected to an appendectomy and died suddenly a few hours later.”
On the basis of autopsy reports, statements made by the physicians and nurses, and reports of other cases in Harare of death or disability from anesthesia, the Khaminwas were convinced that “Lavender was the victim of wrong, unorthodox, hazardous and seemingly experimental treatment, and of poor or non-existent post-operative and post-anesthetic surveillance and care.” For six months they had tried to persuade the Zimbabwean medical societies and public officials to investigate the circumstances of her death, but had been so far unsuccessful. “We have been shocked to discover the extent to which medicine…seems to be operating in an ethical vacuum. A deficit of control exists in the monitoring apparatus.” The politicians “leave their medical communities to more or less administer themselves”; physicians inevitably cover up for each other, and average patients, whose “fear of authority, any kind of authority, had become so ingrained,” cannot even imagine mounting a protest. The Khaminwas’ extraordinary struggle appeared to embody a concern for health care as a basic right, and so, on behalf of Africa Watch, we went to Zimbabwe to meet them and learn more about the case.
Zimbabwe is one of the handful of African countries that left the existing economic establishment intact after it became independent. When Robert Mugabe took power in 1980, overturning the Rhodesian regime of Ian Smith after a decade of insurgency, he chose to placate the whites, hoping to avoid a flight that would deprive Zimbabwe not only of capital but also of people with managerial and technical skills. His principle of reconciliation was expressed in his motto, “I have drawn a line through the past.”1 It seemed that Zimbabwe, at least, was trying to establish a new model for the transfer of power from whites to blacks, without a reign of terror or corruption or economic decline.
Thus most Rhodesian officials who had violated human rights, Ian Smith included, were never prosecuted, and in spite of staggering differences in wealth between whites and blacks, Mugabe, during his first decade as prime minister, did not confiscate white-owned land, including the rich and profitable tobacco farms. (In March of this year, he pushed through legislation allowing the state to forcibly acquire white-owned land at less than market value; it is still not clear whether he will exercise this authority in the face of possible challenges from the Zimbabwe Supreme Court as well as from foreign sources of aid like the IMF and the World Bank.)
In matters of health and welfare, Mugabe’s socialist regime has permitted many private services such as health and education to exist along with public ones, so that wealth has replaced race as the decisive factor in a segregated society. Expensive private schools educate mainly white children, apart from all but a few privileged blacks, and costly private physicians and private hospitals treat white patients, apart from all but the most well-off blacks.
From the government’s perspective, this two-track system has many advantages. In medicine, it keeps white discontent to a minimum, while shifting the entire financial burden for obtaining modern medical care to the white community. At the same time, public medical funds are free to be used to underwrite preventive health care programs, which have brought some genuine gains to the rural poor. During the 1980s, state expenditures for child and maternal health doubled (from 7 to 14 percent). Infant mortality declined (from 97 per 1,000 births in 1970 to 68 per 1,000 in 1990), and the number of babies fully vaccinated against whooping cough, tetanus, polio, and measles more than doubled (from 25 to between 50 and 80 percent).2
But in spite of these advances, blacks in Zimbabwe still receive only the most rudimentary medical services. They depend almost exclusively on village health workers who know little about and can do almost nothing for most of the common diseases that affect adults, including hypertension, diabetes, and cancer. Most of those who suffer from these diseases go untreated, and the few who do eventually get medical attention arrive at clinics in so advanced a stage that interventions are usually futile. In effect, whites have access to the latest technologies while blacks get little more than inoculations.
Moreover, the progress made in prevention is being canceled out by the spreading AIDS epidemic. Zimbabwean public health officials estimate that 500,000 people out of a population of ten million are infected with the virus, a rate equal to that of Uganda; others, including the US Agency for International Development, put the number at one million and calculate that 25 to 30 percent of those between the ages of twenty and forty years old, and 40 to 60 percent of those in the military, are HIV-positive. Although information about the AIDS epidemic is no longer censored, the problem is still not widely discussed, and, from what we could learn, most AIDS patients are simply sent home to die.3
In any case, Mugabe’s government has almost completely neglected the public hospitals. Under Rhodesian rule, there were two public hospitals in Harare. The one for whites, then called Andrew Fleming and now Parirenyatwa, was located in one of the most exclusive neighborhoods, near the university medical school; the ratios of nurses and doctors to patients and the expenditures per patient were all comparable to those of a hospital in London. The hospital for blacks, Harare Central, was nearer the black neighborhood and woefully lacking in funds. After independence, the two hospitals were racially integrated and put under the same administration, but this brought no improvement for Harare Central while the care at the former whites-only hospital declined in quality. Now the wards of both hospitals are desperately overcrowded and understaffed, and even the most basic medical equipment is lacking.4
Many in the White community had expected that public health services would become worse with independence; even before Mugabe came to power whites were arranging for the construction of their own private, for-profit hospitals, among them the Avenues Clinic, where Lavender died. In the late 1970s, a number of corporations and private investors joined together to pay for its construction costs, and in 1981, the clinic opened, with two hundred beds ready to serve Harare’s whites, and the few blacks who could afford its considerable fees.5 The sponsors looked forward to handsome returns on their investments, and the patients to first-class medical care.
The outcome, however, has been far from a success. Avenues Clinic has clean corridors, a well-stocked pharmacy, and the newest medical technologies. But the medicine practiced there is often shoddy and the incompetence among the physicians frightening. This situation has a variety of causes, but the main problem is that no one will hold the hospitals or the staff accountable for their actions—not the state, not the investors, and not the profession itself.
Maintaining effective oversight of medicine is never easy anywhere, but the US and most other developed countries have procedures to identify negligent and incompetent physicians, and to discipline or remove them from practice. These include weekly staff meetings (known as morbidity and mortality rounds) to review the course of treatment for each patient who dies while in the hospital (did the physicians miss something and how might they be aware of it next time?) and to compare autopsy reports with physicians’ diagnosis (did errors or incompetence contribute to the death?). Another safeguard in a modern hospital is the so-called tissue committee, which reviews pathology reports to see whether the appendix that the surgeon removed was actually diseased, or the tumor excised malignant. Such procedures sometimes fail, but they do not exist at all either in Zimbabwe’s over-taxed public hospitals or in profit-making clinics such as Avenues.
Just how urgent is the need for such oversight became apparent to Charles Khaminwa in the months that followed Lavender’s death. He realized from the first that it did not help that he was black while the doctors who treated Lavender were white; yet he had considerable advantages, including postgraduate training in law at Columbia and Cornell and a family income that allowed him to devote full time to the case. Still, Khaminwa and his wife were unable to bring the doctors responsible for Lavender’s death to justice—and if he failed, what chance would more ordinary Zimbabwean citizens possibly have in an effort to make medicine accountable?
The Khaminwas’ frustrating campaign began on the day of Lavender’s death. They waited at the clinic during the surgery, spoke with her briefly in the recovery room, and returned home when visiting hours were over. At 9:00 PM they received a telephone call from the clinic that Lavender had “collapsed”; they rushed back, but by the time they arrived, she was dead. In a state of shock and anger, they went to see the anesthesiologist, but all he would say was that the child had suddenly stopped breathing. They demanded to talk with the surgeon, who returned to the hospital to meet with them, but he had nothing to add.
Quoted in Richard Carver's October 1989 report for Africa Watch, "Zimbabwe: A Break with the Past?" pp. 9–10.↩
Rene Loewenson, David Sanders, and Rob Davies, "Challenges to Equity in Health and Health Care: A Zimbabwean Case Study," Social Science and Medicine, Vol. 32 (1991), p. 1,086; US Agency for International Development, Bureau for Africa, "Country Report: Zimbabwe," January 1991; see also the "Report of the [Zimbabwean] Secretary for Health for 1981, Harare, p. 19, and the World Bank, Sub-Sahara Africa: From Crisis to Sustainable Growth (Washington, DC, 1989), p. 69.↩
Jane Perlez, "Educational Effort Fights AIDS in Zimbabwe," The New York Times, April 12, 1992, p. 18; US Agency for International Development, Bureau for Africa, Country Profile, Zimbabwe, January 1991, p. 1.↩
An underground newspaper, The Insider, had as its lead story: "Inside a Hospital: Dr cries as child dies because he can't find right drug. Nurse collapses and there is no equipment to help her" (December 1991/January 1992).↩
Gerald Bloom, "Two Models for Change in the Health Services in Zimbabwe," International Journal of Health Services, Vol. 15 (1985), pp. 451–468.↩
Quoted in Richard Carver’s October 1989 report for Africa Watch, “Zimbabwe: A Break with the Past?” pp. 9–10.↩
Rene Loewenson, David Sanders, and Rob Davies, “Challenges to Equity in Health and Health Care: A Zimbabwean Case Study,” Social Science and Medicine, Vol. 32 (1991), p. 1,086; US Agency for International Development, Bureau for Africa, “Country Report: Zimbabwe,” January 1991; see also the “Report of the [Zimbabwean] Secretary for Health for 1981, Harare, p. 19, and the World Bank, Sub-Sahara Africa: From Crisis to Sustainable Growth (Washington, DC, 1989), p. 69.↩
Jane Perlez, “Educational Effort Fights AIDS in Zimbabwe,” The New York Times, April 12, 1992, p. 18; US Agency for International Development, Bureau for Africa, Country Profile, Zimbabwe, January 1991, p. 1.↩
An underground newspaper, The Insider, had as its lead story: “Inside a Hospital: Dr cries as child dies because he can’t find right drug. Nurse collapses and there is no equipment to help her” (December 1991/January 1992).↩
Gerald Bloom, “Two Models for Change in the Health Services in Zimbabwe,” International Journal of Health Services, Vol. 15 (1985), pp. 451–468.↩