'"If I had enough to eat I could take the adult dose", claims Lucy who is one of the "lucky" Zimbabweans receiving treatment for HIV. Fragile, just able to lift her arm, I was apparently seeing her at her best in her small shabby house she shares with too many others in the unbearably poor outskirts of Zimbabwe's second city, Bulawayo.
Everything is falling to pieces in Bulawayo and especially the health care system. But while the regional African Presidents see refugees pushing up their burden of malaria and HIV, they shy from breaking ranks with a fellow African leader and refuse to condemn Zimbabwe's patent contempt for democracy. It's time to ask whether aid to the region should be stopped until these spineless leaders decide to act on the only leader Zimbabwe has ever known -- his excellency, comrade President Robert Mugabe.
Zimbabwe's rapidly escalating and politically-induced humanitarian disaster, which has manifested itself in chronic shortages of food, medicine, fuel, electricity and hard cash, has driven over three million Zimbabweans into South Africa, Botswana and other neighboring states. In a chilling echo of what the Khmer Rouge did in Cambodia in the 1970s, Didymus Mutasa, Secretary of President Mugabe's Zanu-PF government, said: "We would be better off with only six million people". Prior to the crisis, Zimbabwe's population estimate was 12 million; today 60 to 70 percent of the country's productive population is now living elsewhere. * What food remains is often allocated along political lines, leaving over 5 million malnourished: Secretary Mutasa may get his wish.
Zimbabwean Health Collapse -- Probably the Worst in the World
According to Amnesty International many refugees are assaulted or raped on arrival and destitute young women frequently end up as prostitutes. The refugees know it's going to be very hard, but leaving is still preferable to staying.
Twenty years ago, life expectancy in Zimbabwe was 58; in 2002 it was 33 and dropping. The official HIV/AIDS rate in 2002 was about 25 percent (the highest in the world for any sizeable country), but the real rate is probably much higher. With no hope for treatment, and little for long term survival, behavior rapidly worsens. According to one survey, over a third of Zimbabwean men who are aware they are HIV positive do not tell their partners they have the disease. And astonishingly 79% of women surveyed said they would not tell their partner if they had HIV. As one put it to me - "life is too short here to worry about HIV."
Dr. Mark Dixon from Mpilo Hospital in Bulawayo says that 70 percent of the patients he treats for any reason carry the HIV virus. A possible explanation for this extraordinary number is the high incidence of unprotected sex (usually rape) in Mugabe's youth camps, where sexual power is used to suppress dissent against the ruling party.
Over 250,000 Zimbabweans now die from AIDS annually. Many sufferers have no drugs and no future, as they are too sick to travel and seek treatment abroad. The only good thing about this is that they won't carry the virus elsewhere. Younger Zimbabweans, who are generally healthy though malnourished, leave if they possibly can. This is exactly the age group that carries the highest HIV burden -- estimated by local doctors to be over 40 percent -- and they take the virus with them wherever they go.
To make matters worse, some of the Zimbabwean strains of HIV are probably resistant to drugs that were used in frequently interrupted trials in Zimbabwe. In Bulawayo, Lucy's drug regimen has been changed twice in the past six months, once due to drug shortages, the second due to lack of food, without which she was unable to take the correct dosage of drugs.
South Africa Takes the Strain, Can Others?
South Africa, with its 42 million people, is perhaps big enough and rich enough to accommodate the Zimbabwean influx. Other countries are not so well placed. According to figures from nongovernmental organizations working in the region, Botswana, with just over a million people, now probably hosts more than 200,000 illegal Zimbabwean immigrants. And that allows for the thousands who are unofficially deported from Botswana back to Zimbabwe every week (official figures talk of only 2,500 per month, but NGOs say it's far higher).The permanent and temporary influx has caused terrible strains, leading to conflict, rape, and the possibility of increasing the HIV rate from an already staggering 38 percent.
The HIV infection rate in Zambia and Mozambique is worsening. Official figures say it's 16.5% and 12.2% respectively, but neither country has the level of border control enjoyed by Botswana and hundreds of thousands of HIV-positive Zimbabweans may well be entering both countries.
According to Michael Biemba, the Livingstone council AIDS coordinator, HIV rates are 55% in Livingstone (the closest Zambian town to Zimbabwe) and this is partly due to the influx of prostitutes from Zimbabwe. There are fights breaking out between local sex workers and the influx of desperate Zimbabweans who are undercutting their prices. AIDS rates in close by Katima Mulilo in Namibia and Kasane in Botswana are also high and rising, and Zimbabwean sex workers are largely to blame there, too. One Zambian doctor monitoring AIDS in this border region said that rates of over 60% were not unusual. Given the lag for HIV to take its fatal toll, the Zimbabwean influx into the entirety of its neighboring states will take time to really show its worst effects, but the worst is what we should expect.
An Old Foe Returns -- Malaria Again
Although HIV is the main concern, malaria rates in the region are set to rise as well. In 2004 Zimbabwe's underfunded health department managed to cover just 3.4% of buildings designated to be sprayed with insecticides. Exact malaria rates are unknown but likely to be soaring; the child death rate is extremely high, due to the shortages of drugs. Meanwhile at a malaria rally my colleague Richard Tren attended in November, the health minister was more interested in attacking the opposition MDC party than in combating malaria. His chant "Down with the MDC; Down with Mosquitoes" was half-heartedly taken up by a shocked audience expecting a health speech.
The Limpopo Province in South Africa forms the Southern border of Zimbabwe. Its health department has excellent data, and Dr. Philip Kruger says that January's malaria rate in the Province was five times higher than last year, and "Zimbabweans are a likely cause."
Despite the impact on the region, few non-Zimbabweans, especially political leaders, will openly criticize Mugabe. This leaves a vacuum the international community is loathe to fill. Tom Woods of the State Department told me that the "US would not hold the region hostage over Zimbabwe." But he agrees that an African solution is required, such as occurred recently in Togo, and only South African president Thabo Mbeki has the clout to provide it.
While Mbeki continues with his strategy of "quiet diplomacy", the corpses of those who die of AIDS related diseases and kwashiorkor -- caused by acute malnutrition -- continue to pile up in Zimbabwe's mortuaries. Also piling up are the bodies of murder victims since there are no longer any qualified personnel left in the country to conduct forensic post mortem examinations. Until the pathology tests are done, relatives of the victims cannot bury their dead.
With Western help, an exit strategy for Mugabe could be devised and the rule of law returned to Zimbabwe. But to achieve this aim the international community must speak with one voice.
Carole Bellamy, head of UNICEF, last week asked for more aid for Zimbabwe. This is the wrong signal to be sending regional leaders who will use any sign of Northern weakness to vacillate over Mugabe. Bellamy must know that the aid will not be used to save lives of the poor but will be used politically. Mugabe only knows about power and protecting it, aid and soft words have not worked, tough talk from the Sate Department, backed up by action from the region, is what is required. Lucy's life and that of millions of fellow Africans hinges on political will to push change in this outpost of tyranny.
Roger Bate, a health economist, is a fellow at AEI and a director of Africa Fighting Malaria. His co-authored paper on the Zimbabwean and regional health crisis 'Despotism and Disease' can be found at http://www.fightingmalaria.org/research.php?ID=32
* Editor's note: an earlier version of this article claimed that the World Food Programme (WFP) was thrown out of the country in December. It was incorrect to say that WFP has stopped operating in Zimbabwe. But WFP has had to reduce distribution by over 50% in recent years. TCS regrets the error.