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C O N F I D E N T I A L SECTION 01 OF 15 HARARE 001039 
 
SIPDIS 
 
AF/S FOR B. WALCH 
MED/EX FOR T. YUN AND G. PENNER 
CA/OCS FOR E. GRACON 
DRL FOR N. WILETT 
OGAC FOR M. DYBUL, J. TIMBERLAKE, T. HIMMELFARB, C. HOLMES 
JOHANNESBURG FOR M. VEASY 
PRETORIA FOR H. HALE, P. DISKIN, AND S. MCNIVEN 
GABARONE FOR A. WOODS 
ADDIS ABABA FOR USAU 
ADDIS ABABA FOR ACSS 
STATE PASS TO USAID FOR E. LOKEN, L. DOBBINS, K. LUU, A. 
CONVERY, L.M. THOMAS, T. DENYSENKO, J. BORNS, A. SINK, L. 
PETERSEN 
STATE PASS TO NSC FOR SENIOR AFRICA DIRECTOR B. PITTMAN 
STATE PASS TO HHS FOR W.STEIGER, S. BLOUNT, AND D. BIRX 
 
E.O. 12958: DECL: 11/20/2018 
TAGS: SOCI EAID AMED PGOV CACS PHUM ZI
SUBJECT: COLLAPSE: ZIMBABWE'S HEALTH CARE SYSTEM 
 
REF: HARARE 1007 
 
Classified By: Ambassador James McGee for reason 1.4 (b) and (d). 
 
------ 
SUMMARY 
------- 
 
¶1. (SBU) Zimbabwe's health system has collapsed.  Most of 
Zimbabwe's public hospitals, including the three main medical 
centers in Harare, are closed. Many clinics lack basics 
including staff, water, electricity, and medical supplies. 
Despite protests by medical professionals and outcry over the 
cholera outbreaks that are quickly spreading across the 
country, the Zimbabwean government is unable to provide basic 
health care services or maintain public service 
infrastructure (e.g. water, sewers, power) and increasingly 
relies on donors and NGOs for help.  Even NGOs, however, are 
finding they cannot provide medical care to their own staff, 
as medical insurance is now defunct and the only way to 
access care in Harare is through private practitioners who 
universally demand U.S. dollars, in cash, up front for 
payment.  Ambulance services that typically rely on medical 
insurance as their primary source of income are also 
struggling to stay afloat.  As the economy continues to 
collapse, there is no end in sight to the woes facing the 
health sector.  Given the rapidly deteriorating environment, 
we must reconsider how we do business both in terms of our 
humanitarian assistance and our plans to provide medical care 
to our own mission staff.  END SUMMARY. 
 
------------------------------------------- 
Harare's Public Hospitals: Officially Open, 
but Functionally Closed 
------------------------------------------- 
 
¶2. (SBU)  Harare province is home to three major public 
hospitals: Harare Central Hospital, Parirenyatwa Hospital, 
and Chitungwiza Hospital.  In a meeting with donors on 
November 18, CEOs of all three hospitals described the 
overwhelming difficulties they face. All three described a 
serious crisis including staffing issues, infrastructure 
problems, shortages of linen and medical supplies, hungry 
staff, and a host of other problems that remain unaddressed 
by the Zimbabwean government (GOZ). 
 
¶3. (SBU) Up until about 2000, all three of these hospitals 
provided some of the best care in sub-Saharan Africa; people 
traveled to Zimbabwe from neighboring countries for 
complicated procedures, including pediatric heart surgery. 
One British-trained Zimbabwean doctor still working at 
Parirenyatwa took poloff on an unauthorized tour of the 
hospital and adjacent medical school facilities in September. 
 At that time, the hospital still had some patients, but 
staff complained that the facilities had been badly neglected 
for years.  While this deterioration has occurred across all 
health facilities for many years, in recent months the 
Zimbabwean government has proven unable to maintain stocks of 
even basic supplies such as bandages, gloves, medications, 
test tubes and reagents to run simple tests, and x-ray film. 
Mr. Thomas Zigora, CEO of Parirenyatwa Hospital, explained 
 
HARARE 00001039  002 OF 015 
 
 
that hyperinflation and minimal budgets have left him unable 
to repair infrastructure and medical equipment.  Whereas in 
years past hospitals could reasonably plan expenditures with 
their annual budgets, hyperinflation now strips their budget 
of meaning so quickly that hospitals no longer have any real 
operational funds.  Compounding the budgetary woes, vendors 
increasingly demand foreign currency for everything from 
laundry soap to surgical tools.  In addition, hospital staff 
- including doctors, nurses, cleaning crews, cooks, and other 
support personnel - cannot afford transport fees to come to 
work, as inflation has overtaken their meager salaries. 
While emigration has steadily eroded staffing in Zimbabwean 
medical facilities over recent years, in the last few months 
the absentee rate in medical facilities has been on the rise, 
magnifying the problem.  In nursing, especially, hospitals 
are operating with minimum staff.  Parirenyatwa, for example, 
should have 88 midwives but now has just 12; even these 12, 
however, are generally no longer reporting for duty. The GOZ 
has attempted to compensate for these shortages over the 
years by bringing in foreign doctors, including Cubans and 
Congolese, but these efforts have not resolved the staffing 
crisis.  Many doctors now say that after years of steady 
decline, the health system has finally collapsed. 
 
¶4. (SBU) Around October 24, staff at Harare Central Hospital, 
Parirenyatwa Hospital, and Chitungwiza Hospital discharged 
all patients that "could receive adequate care at home" and 
stopped coming to work in support of an unofficial strike. 
Before the stay-away, Harare Central Hospital had about 700 
patients; as of November 18, only about 40 remain.  Doctors 
insisted that the reason for the strike was not just their 
inadequate wages (less than USD 2 in September - for a 
surgeon), but also their inability to provide effective care 
to patients.  Dr. Douglas Gwatidzo, the head of Zimbabwe 
Association of Doctors for Human Rights, told us that since 
August doctors have become increasingly vocal in their 
complaints to administrators and the Ministry of Health that 
the health system had deteriorated to a point where doctors 
could no longer work.  Without adequate supplies or 
infrastructure, doctors were often left to watch patients 
die.  These doctors and nurses decided to walk away, telling 
administrators that if the government wanted to believe 
hospitals were functioning, they could figure out a way to 
care for the patients themselves.  Doctors familiar with the 
hospitals told us that Harare Central Hospital discharged all 
of its chronic psychiatric patients (30-50), and that in the 
children's ward only two abandoned children remain, including 
one with cerebral palsy.  Some nurses have returned to check 
on the children and the handful of others, but they are 
largely unattended.  The result of the "strike" and lack of 
supplies has been catastrophic, as hospitals can no longer 
provide medical care, forcing Zimbabweans to search for 
alternatives: private care, rural hospitals, or no care at 
all.  The very wealthy fly to South Africa for care, a 
possibility for only a tiny group of elites.  Unfortunately, 
Dr. Gwatidzo and other doctors tell us, most patients simply 
go home and hope for the best. 
 
----------------- ---------------------------------- 
Operation of Hope Shocked by Harare Central Hospital 
----------------- ---------------------------------- 
 
HARARE 00001039  003 OF 015 
 
 
 
¶5. (SBU) Operation of Hope, a team of philanthropic American 
doctors and nurses, arrived in Zimbabwe on October 31 with 
the intention of performing about 85 free cleft lip and cleft 
palate surgeries at Harare Central Hospital during a two week 
visit.  The team has come every six months for the last 
couple of years, and this was their fourth visit to Zimbabwe. 
 Despite warnings that the hospital infrastructure had 
crumbled since their last visit in May, they were shocked by 
what they saw.  During their last visit the hospital was 
bustling and "normal"; this time, in contrast, it was empty 
and the only health professionals to be found were student 
nurses who live on-site and come to work just often enough to 
avoid losing their free housing. 
 
¶6. (SBU) Some of Harare Central's dedicated nurses crossed 
the unofficial picket line to work with Operation of Hope, 
and the American staff noted they were significantly more 
demoralized than ever before.  The Zimbabwean nurses told the 
Americans they knew Operation of Hope was coming because the 
hospital turned the water on.  Operation of Hope only stayed 
at Harare Central for one week because they were unable to 
work.  Jennifer Trubenbach, the executive director of the 
Washington-state-based charity, said that during their time 
at Harare Central they only performed 16 surgeries.  They 
spent most of the time negotiating with administrators, who 
were under pressure to address other pressing issues to 
provide care for all patients.  Hospital staff were 
discouraged that the American team would only perform the 
cleft lip and palate surgeries, which the Zimbabwean staff 
consider cosmetic, while other patients with critical care 
needs went untreated.  While they were at Harare Central, the 
Operation of Hope surgeons were often the only doctors in the 
entire building.  On at least three occasions they signed 
death certificates for Zimbabweans who brought in their 
recently deceased loved ones for the certificates that are a 
legal requirement for burial. 
 
¶7. (SBU) The team left Harare Central on November 11 and 
spent its last four days at the privately funded St. Anne's 
Hospital, where they found significantly more motivated 
nurses and better infrastructure.  When the team returns in 
May 2009 for another round of surgeries, it will go directly 
to St. Anne's.  By the time the team left, it was only able 
to perform 42 surgeries, mostly because of the time lost 
working through the delicate logistics at the public 
hospital. 
 
----------------------------------------- 
Public Hospitals and Clinics All Struggle 
----------------------------------------- 
 
¶8. (SBU) There is almost no end to the frightening anecdotes 
of inadequate medical care and crumbling infrastructure 
across Zimbabwe.  Member of Parliament Thabitha Khumalo from 
Bulawayo East witnessed nurses using their cell phones as 
lights to deliver a baby and stitch up the mother.  Doctors 
at the district hospital in Chivu are now adept in performing 
cesarean sections without any electronic monitoring, as they 
are without power about 20 hours per day.  The two major 
referral hospitals in Mashonaland West, in Chinhoyi and 
 
HARARE 00001039  004 OF 015 
 
 
Karoi, have functionally closed, citing water shortages. 
Ominously, cholera has been reported in both cities within 
the last two weeks.  For many months, medical waste has only 
been incinerated sporadically at Harare's hospitals because 
of a lack of coal to fire up the incinerators. 
 
¶9. (C) We spoke with Dr. Michael Simoyi, the medical director 
for the city of Chitungwiza, a populous high-density area 
near Harare.  Dr. Simoyi obtained his master's degree at the 
University of Michigan and all four of his children are 
currently at universities in the U.S.  He frankly told us of 
the serious woes facing Chitungwiza, where a cholera outbreak 
recently killed at least 17 people and afflicted 150.  A 2002 
census put Chitungwiza's population at 320,000; many estimate 
it is now home to about a million people.  Residents rely for 
primary care on four public health clinics that are 
(normally) staffed by a total of 80 nurses on 24 hour shifts. 
 Dr. Simoyi is the only physician and admits that high 
absentee rates mean that on any given day, each clinic is 
only staffed by about five nurses.  Attempts to recruit 
another doctor have been unsuccessful.  In the 1980s the 
government devoted significant attention to the primary 
health care system and purchased much of the equipment that 
the clinics still use.  Now, however, the government simply 
doesn't care, he said. 
 
¶10. (C) While the situation in Chitungwiza's clinics is 
bleak, they benefit significantly from donor funding because 
they are also a study site for USG-funded research grants 
through the University of California, San Francisco on 
mother-to-child-transmission of HIV and they are stocked with 
the associated supplies that accompany that funding.  One 
doctor affiliated with the grant, local pediatrician Linda 
Stranix-Chibanda, runs a weekly well-baby clinic to provide 
assistance to the children of HIV-negative mothers who don't 
benefit from some of the donor-funded projects.  She told us 
that at the end of October, she saw 16 babies, three of whom 
had kwashiorkor (protein deficiency), and three mothers with 
pellagra (niacin deficiency).  Dr. Stranix-Chibanda, who has 
worked in Chitungwiza for years, said that while her sample 
was not scientific, she believed urban malnutrition was on 
the rise, even among those who historically had adequate 
resources and access to food. 
 
¶11. (C) During the cholera outbreak, Dr. Simoyi relied 
heavily on donor-funded partners including Oxfam, Medecins 
Sans Frontiers, Red Cross, and UNICEF.  They turned one of 
the clinics, Seke North, into a specialized center 
exclusively for cholera cases.  However, Seke North, like 
clinics elsewhere in Zimbabwe, has no water.  Dr. Simoyi told 
us that the problems of broken sewage pipes and constant 
water shortages continued six weeks later.  Just outside the 
Chitungwiza municipal offices, adjacent to a high density 
neighborhood, we witnessed raw sewage running in the mud. 
None of the conditions that led to the initial outbreak have 
been addressed, and the current situation is a "ticking time 
bomb" according to Dr. Simoyi.  Furthermore, the rains in 
Harare province only began this week and will significantly 
exacerbate the seasonal cholera rates as the rainy season 
continues.  German Agro Action is now funding boreholes for 
clinics in Chitungwiza, which will at least provide the 
 
HARARE 00001039  005 OF 015 
 
 
clinics with clean water. (NOTE: Oxfam and Agro Action are 
USAID-funded.  END NOTE.) 
 
--------------------------------------------- ---- 
One Public Hospital Administrator ToQrty Line 
--------------------------------------------- ---- 
 
¶12. (C) We also spoke with Mr. Obadiah Moyo, the CEO of 
Chitungwiza Hospital, whose overly rosy description of his 
hospital provided a glimpse at the political sensitivities of 
the health system.  On October 28, Moyo - who asked us 
several times to keep his visit to the Embassy secret - told 
us that his hospital was still open and that while his stQ 
was tired, until mid-October, nearly 100 percent of staff at 
Chitungwiza Hospital were consistently coming to work.  He 
further told us that his staff had successfully provided 
treatment to everyone that appeared at the hospital. 
 
¶13. (SBU) However, a locally engaged staff (LES) member who 
lives in Chitungwiza painted a substantially different 
picture.  She told us that a family friend's mother-in-law 
needed an x-ray to follow up on tuberculosis and was turned 
away.  In addition, in late October the LES's daughter 
urgently needed an intravenous antibiotic and was turned away 
from both Chitungwiza and Parirenyatwa Hospitals before 
resorting to the expensive and private Avenues Clinic in 
Harare.  Those with financil means have turned to private 
clinics while othrs have resorted to long bus rides to rural 
publc and church-sponsored mission hospitals for care. 
 
¶14. (C) Mr. Moyo told us that drug supplies and 
infrastructure have declined in recent years, and foreign 
currency is needed to replenish stocks.  In the meeting with 
donors and other CEOs on November 18, Mr. Moyo began his 
remarks by first explaining that the problem is a lack of 
cash because the RBZ cannot print enough, and he asked donors 
to support the hospitals and health infrastructure in a "big 
way".  (NOTE: Moyo's business card indicates he has both a 
PhD and a medical degree.  After our initial meeting, we 
learned that he earned neither.  Rather, he was Sally 
Mugabe's dialysis technician at Parirenyatwa throughout her 
long struggle with a kidney disease.  After Sally's death, 
Mr. Moyo suddenly became Dr. Moyo, and in 2004 he became CEO 
of Chitungwiza Hospital.  END NOTE.) 
 
------------------------------- 
Private Hospitals Struggle Too 
------------------------------- 
 
¶15. (SBU) We spoke with numerous doctors that work in both 
the public and private system, including Harare's two biggest 
private hospitals, St. Anne's Hospital and Avenues Clinic. 
Dr. Douglas Gwatidzo, director of the emergency room at the 
privately run Avenues Clinic (now the only functioning 
emergency room in the Harare area), told us on October 29 
that the situation was "terrible."  He described the health 
care collapse as the result of more than two decades of 
neglect by the government.  Even in 1989 as a young doctor, 
he and others carried basic supplies like sutures between 
hospitals to compensate for sporadic supply shortages. 
Gwatidzo further blamed the decline in health care on 
 
HARARE 00001039  006 OF 015 
 
 
ZANU-PF's inability to "figure out a way to make money from" 
the health sector.  Even at Avenues Clinic, supply shortages 
are routine and, on the day we met, the Clinic did not have 
intravenous fluids, critical in stabilizing patients. 
Medical staff at Avenues Clinic are also underpaid, city 
water is inconsistent, and patients' families often have to 
visit private pharmacies to purchase basic supplies such as 
bandages, antiseptics, and drugs. 
 
¶16. (C) St. Anne's Hospital, like Avenues Clinic, struggles 
to keep pace with rampant inflation and to maintain staff and 
supplies.  St. Anne's Hospital administrator Munatsi Shumba 
told poloff that patients pay approximately USD 2-3,000 for a 
standard surgery, and that all payments must be made (usually 
in U.S. dollars) up front.  St. Anne's Hospital primarily 
operates as a private surgical facility, with six operating 
theaters and 163 beds.  Despite the functional closure of the 
public hospitals, neither St. Anne's nor Avenues Clinic has 
seen an increase in admitted patients, simply because 
prospective patients cannot afford private care.  Despite the 
relatively large facility, Shumba said that only about 35 
beds were occupied, half the number of a year ago.  Since 
May, he said, Zimbabwean medical aid societies (medical 
insurance companies) had became worthless, meaning that now 
all patients must have access to enough cash to cover an 
entire hospital stay. 
 
¶17. (SBU) Recently, an American citizen (ref) and an LES's 
adolescent daughter received inadequate care at Avenues 
Clinic, although it is still regarded as superior to St. 
Anne's Hospital.  The LES, attending to her daughter after an 
operation, bathed her daughter every day (the nurses refused) 
and bought bandages in local pharmacies since they were 
unavailable in the hospital.  In addition, the LES had to beg 
the nurses to change her surgical dressings.  As with the 
Amcit, the teenage Zimbabwean girl had bed sores after just 
five days in the hospital because nurses did not turn her 
enough. 
 
¶18. (C) Dr. Athan Dube, a urologist trained in the UK and the 
U.S. who has a private practice and directs the Urology 
Department at the University of Zimbabwe Medical School, told 
us that he usually sets aside five percent of his surgical 
charges to pay nurses extra to attend to his patients at both 
private and public (when open) hospitals.  Dr. Dube also told 
us the quality of care a patient receives in a private 
facility depends almost entirely on the surgeon's attention 
to the patient.  Harare's private hospitals do not have 
doctors on-staff in the wards, and both St. Anne's Hospital 
and Avenues Clinic rely on nurses to provide round-the-clock 
care.  Increasingly, nurses are leaving the private health 
facilities for better opportunities outside Zimbabwe.  Those 
who remain are less and less motivated to provide high-level 
care. 
 
------------------ --------------------------- 
Mission Hospitals Flooded With Harare Patients 
------------------ --------------------------- 
 
¶19. (C) We visited Howard Hospital, about an hour north of 
Harare in Mashonaland West, on November 17.  Howard is 
 
HARARE 00001039  007 OF 015 
 
 
supported by the Salvation Army and is part of the Zimbabwe 
Association of Church-Related Hospitals (ZACH), which has 
about 125 hospitals across the country and provide 
approximately 65 percent of all rural health care in 
Zimbabwe.  ZACH institutions are all officially part of the 
national health care system.  The director, Canadian Dr. Paul 
Thistle, has worked at Howard Hospital since 1995 and is one 
of three doctors at the hospital.  On a Monday morning, every 
ward in the hospital was already overflowing, and some 
patients were on mattresses on the floor.  In 2007 Howard 
Hospital treated 140,000 patients, triple their historical 
population of 30-40,000 in the late 1990s.  While Dr. Thistle 
has not yet tabulated statistics for 2008, he believes their 
patient load continued to increase during the year.  Some of 
this increase is attributable to their large (USG-supported) 
HIV/AIDS clinic, but they have seen increases in patients 
demanding all kinds of services.  Howard Hospital provides 
this additional care with the same staff they have counted on 
for many years - three doctors and 45 nurses - and 
increasingly limited resources. 
 
¶20. (C) Even in the best of times, about 20 percent of Howard 
Hospital's clientele came from Harare (over an hour and a 
half away by public transportation), but now about half of 
Howard Hospital's patients come from Harare.  Patients had 
been drawn to Howard because user fees were low and the wait 
time for elective surgeries was often months less than at 
Harare's public hospitals.  Now, however, Thistle notices the 
increase in patients from Harare is mostly lower-middle and 
middle class patients who used to get care from public 
facilities in Harare.  Only those with funds to afford the 
bus fee to Howard Hospital or who have a friend or relative 
with a car to transport them can access Howard.  Because of 
the significant costs and delays in traveling from Harare to 
Howard Hospital, Dr. Thistle says many who arrive there are - 
often literally - on their "last gasp."  Dr. Thistle repeated 
Dr. Gwatidzo's belief that Harare's poorest are likely dying 
at home. 
 
¶21. (C) Howard Hospital relies heavily on private donations 
from NGOs and others.  However, these programs are now 
struggling with hyperinflation and the growing crises of 
malnutrition, cholera, and infrastructure collapse.  Howard 
Hospital is a site of a UNICEF-sponsored therapeutic feeding 
program for malnourished children.  However, Howard Hospital 
has been without the "plumpy nut" peanut-based food that is 
vital to this program for about a month because they have not 
been able to coordinate a large enough truck to transport the 
food from Harare to the Hospital.  Mothers bring their babies 
in for feeding and are told to come back in a week or two, 
hoping they will have received the food.  UNICEF announced in 
a November 18 meeting that they are in "emergency" mode for 
at least a 120 day period.  UNICEF is bringing in additional 
expert staff to help manage the organization's response to 
the growing humanitarian crisis. UNICEF has also ordered more 
trucks to ramp up its operations, which should improve food 
distribution. 
 
¶22. (C) These narrowly targeted programs (e.g. therapeutic 
feeding, ARV provision, MTCT prevention) that used to 
supplement the government infrastructure now leave 
 
HARARE 00001039  008 OF 015 
 
 
significant gaps as they usually do not cover basic, but 
vital supplies that the government now routinely fails to 
provide.  For instance, Howard draws its water from a nearby 
reservoir, and must use expensive chemicals to treat the 
water.  Last week they ran out of chlorine and had to boil 
water, when power was available.  Cleaning supplies, soap, 
toilet paper, antibiotics, and other supplies are not 
provided by donors and are now only available with foreign 
currency.  None of these supplies are attainable with the 
meager government budgets hospitals receive.  Even Howard 
Hospital's phone has fallen victim; the copper wire has been 
stolen twice and now cannot be replaced, at least locally. 
With cholera case rates rising on a daily basis across the 
country and public hospitals closing, a lack of cleaning 
supplies and toilet papers at the best of Zimbabwe's rural 
medical facilities is ominous. 
 
¶23. (C) Dr. Thistle likened his hospital to a "MASH unit," 
saying they are in constant crisis mode.  On the surface, 
Howard Hospital looks like many rural African hospitals: 
crowded, chipped paint, but fortunate to have drugs and 
trained staff.  However, as elsewhere in Zimbabwe the nurses 
at Howard Hospital are seriously underpaid and burned out. 
Last month their government salaries paid just Z$100,000 
(about 10 cents at today's exchange rate).  Howard Hospital 
uses its private funds to supplement staff salaries with 
privately-funded food packs that cost about USD 10 per month, 
but Dr. Thistle conceded the nurses often go hungry and 
struggle to feed their families.  He attributed his staff's 
dedication in holding out to their commitment to caring for 
the patients who have nowhere else to go.  However, as the 
political stalemate draws out and skepticism rises about a 
political solution, "everyone" is rethinking if they should 
stay or leave Zimbabwe. 
 
--------------------- -------------------- 
Emergency Facilities - Nearly Non-Existent 
--------------------- -------------------- 
 
¶24. (SBU) Even before Parirenyatwa Hospital unofficially 
closed, its emergency room had become largely dysfunctional. 
A CNN report in October showed that the emergency room was 
staffed entirely by student nurses and no doctors were on 
duty.  One LES attempted to take her ill daughter to the 
emergency room two consecutive days in September, but no 
doctors were on duty.  In effect, Harare no longer has any 
public emergency facility. 
 
¶25. (C) The only emergency room in Harare is now at Avenues 
Clinic where prospective patients must now pay cash up front- 
USD 140 - just to be seen by a doctor.  An immediate cash 
payment of USD 1,000 is required for admittance at Avenues. 
Emergency Medical Rescue Ambulance Services (EMRAS), is one 
of two private ambulance services in Zimbabwe, with offices 
in Harare, Bulawayo, Gweru, Masvingo, and Mutare.  EMRAS 
general manager Craig Turner told us that calls have dropped 
by more than half, since people know they cannot afford to 
pay for care at Avenues and no other care is available.  At 
the height of their busy season in June, they received 25-30 
calls per day.  The day before we visited, EMRAS had received 
just three calls.  He told us that taking patients to 
 
HARARE 00001039  009 OF 015 
 
 
Parirenyatwa and Harare Central is a "waste of time" because 
even if the hospitals accept the patients, they are unable to 
treat them.  EMRAS repeated Dr. Gwatidzo's supposition that 
people who would normally seek medical care are likely 
staying at home, becoming sicker, and dying.  EMRAS now 
worries about its own bottom line.  With the precipitous drop 
in calls and two of their senior staff leaving in October, it 
will be difficult for them to remain in the black through the 
end of 2008. 
 
¶26. (C) Medical Air Rescue Service (MARS) is the other 
private ambulance service and also manages the only 
Zimbabwe-based air medical evacuation company.  Zimbabweans 
who can afford to become members of MARS are guaranteed 
access to an ambulance and a flight to medically evacuate 
them to South Africa; it is the company the U.S. and other 
embassies use to ensure medical evacuation.  MARS General 
Manager Shingi Chibvongodze explained their staffing, 
airplane, and ambulance availability to poloff, post medical 
officer, and conoff, after a recent complicated medical 
evacuation of an American citizen to Johannesburg.  Like 
EMRAS, MARS relies largely on members and medical insurance 
subscribers for funding.  However, MARS membership has more 
than halved from 1 million members to 400,000 in recent 
years.  Chibvongodze told us that MARS is moving away from 
relying on medical insurance because it does not pay enough 
to them as a service provider, and private facilities demand 
cash on arrival.  MARS estimates six of ten clients with 
medical insurance cannot afford the co-pay upon arrival at 
Avenues Clinic.  When they are turned away from Avenues 
Clinic, MARS takes the patient to one of the public 
hospitals.  Initially, Chibvongodze told us that MARS hadn't 
been turned away from a public hospital.  After significant 
prodding, he admitted that adequate care is no longer 
available in the public health system, although sometimes 
MARS has no choice but to leave clients with whatever medical 
staff is available in the public hospital.  During the course 
of our meeting it became increasingly clear that MARS is 
struggling to procure supplies including fuel for aircraft 
and ambulances.  Chibvongodze told us that the government 
"raids" his office two to three times a month to "ensure 
MARS's licenses are up to date."  (COMMENT: It appears that 
MARS considers their continued ability to keep fuel in their 
tanks and supplies in their ambulances a tremendous success. 
Given the current operating environment, it is a success. 
However, we are concerned about their ability to continue to 
provide a high level of service.  END COMMENT.) 
 
-------------------------------- 
Blood Availability Unpredictable 
-------------------------------- 
 
¶27. (C) On November 7, poloff and post medical officer 
visited the National Blood Service of Zimbabwe (NBSZ), a 
private facility that is the only source of blood in 
Zimbabwe.  We were concerned about the availability of blood 
after an American citizen was unable to get blood for a 
needed transfusion (ref) and rumors of other similar 
incidents in recent weeks.  Emmanuel Masvikeni, Public 
Relations Manager, explained that under ideal circumstances 
they should draw 80,000 units annually.  In 2007, they only 
 
HARARE 00001039  010 OF 015 
 
 
drew 52,000 units and failed to meet hospital requests by 22 
percent.  Despite these struggles, NBSZ maintains high 
standards and an extremely safe (0.33 percent of donors in 
2007 were HIV positive, despite a national prevalence of 16 
percent among adults), 100 percent voluntary donor system. 
He told us that ideally, they should have 3,000 units on 
hand, and now they have about 2,000.  Masvikeni explained 
that the NBSZ is unable to recoup its costs.  First, it 
cannot charge hospitals more for each unit of blood 
(currently USD 70 per unit, or the equivalent in Zimbabwe 
dollars) without permission of the Ministry of Health and 
Child Welfare, which has refused to raise the price. 
Approximately 75 percent of blood is sold to government-run 
hospitals, which often don't pay or pay late when the 
Zimbabwe dollar equivalent has deteriorated.  As a result, 
the NBSZ has operated at a severe financial deficit since 
¶2006.  The NBSZ, which was once a model within southern 
Africa, now relies heavily on foreign donors to help defray 
costs. 
 
¶28. (C) The blood bank also faces the pervasive challenges of 
staffing and purchase of consumables.  Nationally, it should 
have 40 nurses.  Within the last year, 12 have left.  Among 
its 18 nurses in Harare, five have left so far this year. 
This constant exodus of trained staff leaves a serious 
deficit as new staff are difficult to find and train. 
Masvikeni cited payment and retention of staff as the NBSZ's 
biggest challenge. 
 
¶29. (C) In addition, purchase of consumables from office 
supplies to test tubes, blood bags, and reagents to test 
blood pose serious challenges.  The blood bank relies heavily 
on USD 1.5 million from UNICEF's Expanded Support Program 
(ESP) to procure reagents to test blood for HIV, hepatitis, 
and other infectious diseases.  Masvikeni gave us a tour of 
the blood bank and showed us a freezer full of donated blood 
that had not yet been tested.  The freezer that should hold 
tested blood was completely empty, as the NBSZ had been out 
of buffer to test the blood for at least two weeks. 
According to the UNICEF procurement officer who works with 
the NBSZ, the ESP program provides test kits and blood bags, 
but not enough to fulfill all of the NBSZ's demands. 
Additional funding was expected in April, but had only become 
available in November.  Consequently, the NBSZ has 
significantly reduced collection and testing has been delayed 
while waiting for the supplies to come through from South 
Africa.  While the blood bank may have 2,000 units on hand, 
very few of those are ready for use.  We have heard numerous 
cases in recent weeks of patients in public, private, and 
mission hospitals unsuccessfully requesting blood from the 
NBSZ. 
 
-------------------------------------- ------------ 
HIV/AIDS Clinics Have Drugs and Nurses -- Sometimes 
-------------------------------------- ------------ 
 
¶30. (SBU) The doctors we spoke with all agree that the 
distribution of HIV/AIDS drugs is one of the only bright 
spots in the current health care crisis.  We visited the 
district hospital in Chivu, about an hour south of Harare, in 
September and found it well stocked with ARVs and anti-TB 
 
HARARE 00001039  011 OF 015 
 
 
drugs, but little else.  Other hospitals and clinics tell the 
same tale.  The international community's support for 
providing ARVs for Zimbabwe's large HIV-positive population 
and for the mother-to-child-transmission prevention program 
make these activities success stories.  However, the closure 
of hospitals, increasing problems with distribution schemes, 
and absenteeism pose serious threats to these gains. 
 
¶31. (SBU) Dr. Greg Powell, an Australian pediatrician who has 
practiced medicine in Zimbabwe since 1977, told us that 
Zimbabwe continues to have some of the highest ARV compliance 
rates in Africa. He credits Zimbabwe's strong history of 
paying attention to community health workers and primary care 
with the continued provision of health care in rural areas. 
Indeed, nurses at rural hospitals appear to have lower rates 
of absenteeism.  Most live on the hospital grounds in free 
housing and have their own vegetable gardens on-site.  Urban 
health workers struggle to pay for transportation and usually 
do not have enough land to support a large garden. 
 
¶32. (C) Dr. Powell directs the J.F. Kapnek Trust, which 
administers two USAID-funded projects.  The first involves 
prevention of mother-to-child-transmission of HIV/AIDS 
(PMTCT) in 26 districts that covered 100,000 mothers in 2007. 
 The second supports Zimbabwe's growing population of over 
one million orphans and vulnerable children (OVC).  Powell 
and other doctors that work with HIV programs told us that 
HIV-prevention and treatment programs are increasingly 
vulnerable to the systemic decline in both the health sector 
and the economy: absenteeism of nurses, closure of 
facilities, skyrocketing costs of drugs like antibiotics, and 
hunger.  Despite NGO and donor efforts to ensure ARVs are 
available, the on-the-ground reality is that those systems 
are weakening.  For instance, at Mount Selinda mission 
hospital in rural Manicaland ARVs are available, but the 
hospital is now devoid of nurses.  In urban settings, over 
4,000 patients who rely on Harare Central and Parirenyatwa 
hospitals for their supply of ARVs may or may not know that 
officials have made extraordinary efforts to ensure ARVs and 
nurses to administer them remain, despite widespread reports 
that the hospitals are closed.  At a Chitungwiza clinic, one 
breastfeeding HIV-positive mother went to get her ARVs at the 
beginning of November, but was turned away because no one was 
there to give her the drugs.  MPs from Manicaland told us 
about several clinics where one ARV has been unavailable for 
two months, because of distribution problems.  We have also 
heard some rumors of people selling ARVs on the black market. 
 Throughout the country, those who do not get enough to eat 
stop taking their ARVs.  These disruptions to ARV compliance 
pose serious threats to Zimbabwe's success in battling the 
AIDS epidemic. 
 
--------------------------------- 
Privately Funded HIV/AIDS Clinic 
Transformed Into Full-Service NGO 
--------------------------------- 
 
¶33. (C) Swiss Doctor Ruedi Luthy came to Zimbabwe in 2002, 
leaving behind a position as the director of infectious 
diseases at a Zurich hospital, to establish a clinic to use 
his first-world HIV/AIDS treatment background to benefit poor 
 
HARARE 00001039  012 OF 015 
 
 
Zimbabweans who are HIV-positive.  On November 11 we visited 
his clinic that now helps care for 1,900 patients, about 
one-third of whom are children, who meet strict inclusion 
criteria: people who are very poor, raising children, and 
have a job that is important to society (e.g. nurse, teacher, 
pastor).  He describes his clinic as an orphan prevention 
program, as he seeks to provide care to key members of the 
community who can help provide for their families.  While he 
initially planned to provide just ARVs and TB drugs, he has 
steadily ramped up services over the years to now include a 
full-service clinic, laboratory, and pharmacy, food and 
clothing distribution, and a preschool.  Like Dr. Thistle at 
Howard Hospital, Dr. Luthy relies on a wide array of donors 
to obtain drugs and funding to pay his 14 nurses and two 
doctors and other operational costs.  He reported that in 
recent weeks he had seen many children with severe diarrhea. 
He said that because public clinics lack laboratory 
resources, they will often simply prescribe an antibiotic and 
send the child away.  He fears haphazard antibiotic use in 
the public sector will lead to increased drug resistance. 
 
------------------------- 
No More Medical Insurance 
------------------------- 
 
¶34. (SBU) The collapse of medical insurance also affects our 
partners who implement U.S.-funded humanitarian aid programs. 
 International NGOs including CARE and MercyCorps now tell us 
they can no longer provide medical coverage for their 
Zimbabwean staff and are struggling to cope.  In one week, 
CARE spent USD 6,800 cash to cover medical expenses for three 
staff members who were desperately ill and did not have cash 
to obtain medical care on their own since their health 
insurance was not accepted at private facilities.  With the 
closure of Parirenyatwa Hospital, the only dialysis facility 
in the country is one private clinic that no longer accepts 
medical insurance.  Patients requiring two dialysis sessions 
per week are now forced to come up with about USD 400 per 
week.  Dr. Gwatidzo told the press that "as a result of the 
hyperinflationary environment most medical aid insurance 
schemes have become meaningless and they have stopped 
covering any specialist care. If we go by what the general 
services withdrawal in state hospitals has been like, it's 
not surprising at all that the units were closed.  Actually, 
it would have been a miracle if under this economic and 
political crisis these units had remained functional." 
 
------------------------------------- 
GOZ Bureaucracy Pushes Up Drug Prices 
------------------------------------- 
 
¶35. (C) We spoke with Dr. Seku Naik, a Zimbabwean of Indian 
origin whose company works throughout SADC countries in 
pharmaceutical and medical supply production and 
distribution.  In 2007 he finally moved his main office to 
South Africa, as stifling business conditions in Zimbabwe no 
longer allowed him to run regional operations out of Harare. 
Naik remains in Harare as the Zimbabwe representative; he is 
the largest distributor of pharmaceuticals to both public and 
private sectors.  Ten years ago, he had 11 pharmacies across 
Zimbabwe, but he now has just three in Harare.  Despite this 
 
HARARE 00001039  013 OF 015 
 
 
decline, he still retains 10 percent of the national retail 
market.  He has also learned to diversify his businesses. 
For instance, his pharmacy in the upmarket Sam Levy Village 
does about USD 15,000 per month, USD 10,000 of which is 
designer, imported perfume.  He described the Medical Control 
Authority of Zimbabwe (MCZ) as the most expensive 
pharmaceutical registration system in the world.  To register 
a new drug for use in Zimbabwe, he pays USD 2,100 for the 
initial registration and USD 600 annually to maintain the 
registration.  Currently, Naik maintains these registrations 
for 200 drugs, a significant expenditure, which forces him to 
keep prices relatively high.  He told us that Zimbabwe's 
requirements are the most stringent within the SADC region, 
and other SADC countries are slated to harmonize their 
requirements with Zimbabwe's in 2011. 
 
¶36. (C) Zimbabwe's National Pharmacy (Natpharm) is a 
parastatal that acts as the primary distributor of drugs to 
institutions in the public sector.  Dr. Naik told us that 
Natpharm has suffered from brain drain in recent years as 
NGOs have hired pharmacists to help with ARV and TB drug 
distribution.  Dr. Naik also described a recent incident 
where donated TB drugs were nearly completely lost to 
expiration.  He was contracted by the European Union to 
purchase 2.7 million euros worth of generic TB drugs that 
have a shelf life of just two years.  The EU signed an 
agreement with the Ministry of Finance to coordinate the 
donation to the Ministry of Health, and the drugs were 
delivered to Natpharm for distribution, pending final 
signature of the agreement by the Ministry of Finance. 
According to Dr. Naik, the official at the Finance Ministry 
who was to sign the agreement suddenly went on leave and the 
document was not signed for many months.  Dr. Naik believes 
the official may have been paid off because his competitors 
who had resourced name-brand drugs, rather than generics, 
were upset at having lost the contract.  By the time Finance 
official signed the documents, the drugs only had a few 
months' validity remaining. 
 
--------------------------- 
Medical Profession in Peril 
--------------------------- 
 
¶37. (C) Zimbabwe's medical school was once among the very 
best in Africa.  On November 17, the medical school announced 
it was sending away all third, fourth, and fifth year 
students on vacation in light of the "situation in the 
teaching venues for clinical studies."  Clinical training is 
normally conducted primarily at Harare's three main hospitals 
under the supervision of more senior doctors.  In recent 
years, however, that training has been less and less 
supervised as absenteeism and brain drain pull senior doctors 
away from the public system.  Numerous doctors told us that 
recent graduates are less confident, less qualified, have a 
weaker grasp on medical ethics, and - frighteningly - are 
often more arrogant.  Dr. Powell told us that over 80 percent 
of Zimbabwean medical graduates now work overseas.   In 2007, 
the Medical School was left with just 40 percent of its 
lecturers and an unprecedented 30 percent of students failed 
their final exams.  Ten years ago, the pass rate was much 
higher. 
 
HARARE 00001039  014 OF 015 
 
 
 
¶38. (SBU) On November 18, over 700 doctors and nurses held a 
spirited but peaceful protest on the grounds of Parirenyatwa 
Hospital.  They called for medicine in hospitals, clean 
water, fair pay, and for the government to end the cholera 
epidemic.  About 70 riot police armed with batons and tear 
gas threatened them with arrest and prevented them from 
marching into town to the Ministry of Health.  The medical 
professionals chanted "Zimbabwe has cholera" and declared "we 
know you won't beat us because you have sick mothers, too." 
After several hours, police chased the health workers and 
broke up the protest.  Some demonstrators were beaten, but 
none seriously.  No one was arrested. 
 
-------- ----------------------------------------- 
COMMENT: No Visible Light at the End of the Tunnel 
-------- ----------------------------------------- 
 
¶39. (C) Zimbabwe's public health system from the rural health 
workers up to the complex surgeries at Parirenyatwa Hospital 
was once a model for Africa.  The hospitals and clinics were 
clean and had reliable doctors, nurses, water, electricity, 
food, and medications.  International donor programs for 
ARVs, maternal health, and other programs were welcomed 
additions to that strong government-provided infrastructure. 
Now, however, the foundation these programs once relied on 
has disappeared.  Until the last few months, that downfall 
has been gradual, but now it has finally crashed.  Nearly 
everyone we spoke with was emotional, most were angry, and 
some cried, when describing their frustration with the 
collapse and their inability to perform their profession. 
Given the collapse of the health system, we see several 
implications for the U.S. Mission in Zimbabwe. 
 
¶40. (C) First, our health programs that support HIV/AIDS 
cannot achieve previous levels of success without strong 
health infrastructure.  While we can and do successfully 
provide ARVs and TB drugs, clinics also need clean water, 
electricity, staff, and antibiotics to fight secondary 
infections and laboratories to test not only CD4 counts, but 
also to ensure AIDS patients are given the right drug to 
fight other illnesses they confront.  Nurses and doctors need 
salaries they can survive on, and so do the kitchen, 
cleaning, and laundry staff.  We are concerned about the lack 
of food and its negative impact on ARV compliance.  If the 
government continues to neglect its duty to provide a basic 
health infrastructure, Zimbabwe's success in reducing its HIV 
prevalence could quickly be undone.  While we have typically 
been reluctant to provide salary support, Zimbabwe is now in 
a full blown health care crisis, and this and other staff 
retention mechanisms are being carefully re-examined by the 
donor community.  Several donors have come together to 
consider a comprehensive salary support program to improve 
retention across all hospitals and health institutions.  This 
would ensure that staff at public, mission, and private 
institutions are paid comparably and would hopefully improve 
staff retention. However, even this support would not 
compensate for the continued inadequate infrastructure and 
supplies that medical professionals need to provide patient 
care.  We continue to closely monitor access to critical HIV 
services and anti-retroviral treatment. 
 
HARARE 00001039  015 OF 015 
 
 
 
¶41. (C) Second, we need to closely monitor the health 
facilities that we depend on as a mission community.  In the 
event of an emergency, we rely heavily on MARS for medical 
evacuation and Dr. Gwatidzo and Avenues Clinic to stabilize 
us.  We are deeply troubled by their periodic lack of 
essential supplies like blood and intravenous fluids.  (NOTE: 
While MARS might still be responsible for in-country 
transport, Post would likely rely on SOS 
International/Johannesburg for an air transfer to South 
Africa.  END NOTE.)  Our post medical officer and consular 
section are working with the regional medical officer to 
monitor the situation, increase the supplies available within 
the health unit, and examine how to best keep the mission and 
American citizen populations informed of what level of care 
they can realistically expect.  END COMMENT. 
 
McGee