Hope in the Time of Cholera

Once known as the breadbasket of the world for its robust agriculture, Zimbabwe is now a nation of ruptured sewer pipes, unsanitary water and walls of garbage piled high along roadsides. “You can’t mistake the stench of sewage,” says Chris Beyrer, MD, MPH ’90, director of the Johns Hopkins Center for Public Health and Human Rights, who made a covert trip there in December.

Traveling through several of the country’s provinces with colleagues from Physicians for Human Rights (PHR), Beyrer saw firsthand the situation that has caused more than 4,300 cholera deaths since August of last year. Escorted by a group of Zimbabwean doctors who risked arrest by associating with PHR, Beyrer and the team visited boarded-up hospitals and met with health care workers who detailed the insurmountable challenges to managing the outbreak: unaffordable medical supplies, no running water, uncollected waste and the dollarization of the health care system. With 231 million percent inflation, the Zimbabwean dollar has been discontinued and replaced with the U.S. dollar and the South African rand. The country and its regime, says Beyrer, offer a classic lesson in public health: When government neglects its basic services, its citizens get sick and die, often in great numbers. “The cholera epidemic in Zimbabwe is a man-made disaster, the outcome of the collapse of the most basic water and sanitation measures.”

When municipal elections in 2006 resulted in opposition party gains, President Robert Mugabe stopped maintaining water and sanitation systems in targeted areas. His campaign of spite against supporters of political rival Morgan Tsvangirai soon led to the cholera outbreak. In September the UN arranged a power-sharing deal between Mugabe and Tsvangirai, which initially went unheeded by Mugabe, and in November the regime shut down the public hospitals.

In January, Beyrer and his PHR team published editorials and released a report calling attention to the crisis in Zimbabwe—at that time, the death toll was 1,600—and he and his team issued two press releases and attended briefings in Washington, D.C. On February 11, Tsvangirai was sworn in as prime minister as part of a power-sharing agreement with Mugabe, and U.S. President Barack Obama extended sanctions against Mugabe and his regime on March 5. The next day, Tsvangirai and his wife, driving on a notoriously dangerous road, crashed into a truck carrying U.S. aid. Refuting any foul play, Tsvangirai survived his injuries; his wife did not. “The power-sharing government has really just started. Her death is a real blow,” says Beyrer, an Epidemiology professor. “[But] we think our advocacy was useful.”

What remains to be seen is how and if Tsvangirai will be able to restore basic services and halt the outbreak, which has now reached rural Zimbabwe and neighboring Malawi, Mozambique, South Africa and Zambia.

“All of this is evidence of why good government is so central to public health,” says Beyrer. “The basic functions of public health really are state functions. When a state ceases in that, public health fails.”