Zimbabwe: a crossroads for the health professions

EDITORIALS Zimbabwe: A crossroads for the health professions Some 21 years ago, Mary Rayner, an Amnesty International researcher, penned a searing indictment of apartheid medicine entitled Turning a Blind Eye: Medical Accountability and the Prevention of Torture in South Africa.1 Today, more than two decades later, health professionals in southern Africa face similar challenges as evidence accumulates of both systematic state torture of political opponents and hesitance of doctors to speak out against human rights abuses that they see daily. The country concerned, however, is not South Africa but its northern neighbour Zimbabwe – once the breadbasket of southern Africa but now in a deep political crisis following a disputed presidential election in March 2008 and a flawed runoff poll. Following the results of the general election, won by the opposition, a rapid and carefully orchestrated escalation of has violence targeted opposition leaders and their supporters, in the form of widespread mass beatings, intimidation, extrajudicial executions and torture.2-4 Yet, notwithstanding the singular dedication of the Zimbabwe Association of Doctors for Human Rights (ZADHR) and individual health care workers,2-7 the organised health profession in Zimbabwe remained largely invisible as regards active protest against the health and human rights abuses seen daily in consulting rooms and health care facilities across the country. Such behaviour is reminiscent of the silence during the 1983 - 1984 assault at Robert Mugabe’s behest by Zimbabwe’s Fifth Brigade on the people of Matabeleland, which led to around 20 000 deaths.8 Why is it, then, that the vast majority of doctors working in Zimbabwe have not spoken out against the current violence and its cause in their country? was the assertion by the then chair of the Medical and Dental Practitioners Council of Zimbabwe (MDPCZ) at a 2006 human rights conference in Cape Town that ‘… issues of human rights have been mainstreamed into the core business of the medical and dental professions’.13 However, both ZiMA and the MDPCZ have a duty more directly and explicitly to call on the State to refrain from fomenting violence and from intimidating their members against treating victims of the violence. ZiMA should be mindful of the lessons to be learnt from the failure of the former Medical Association of South Africa (MASA) to speak out in defence of human rights activists during the apartheid era, which contributed in large measure to the ‘narrowing of space’ for health professional action to limit state abuses.14 For example, rather than supporting Dr Wendy Orr in her action to publicly expose state-sponsored violence in a Port Elizabeth prison in 1985, MASA refused to assist her on the flimsy excuse that she was not a member, and then reluctantly acknowledged her cause when she joined.15 Indeed, MASA’s track record of attacking antiapartheid activists and defending government interests is well documented.14 One explanation must be the high levels of intimidation in Zimbabwe, which affect health professionals, other professionals such as teachers, and ordinary citizens alike.9 As the BMA has previously argued, fear of reprisals is often an underlying reason for the complicity of health professionals in human rights abuses such as torture.10 In addition, however, there are disturbing reports of medical professionals actively colluding with security and vigilante forces in covering up the consequences of torture, or of actively assisting in actions designed to swing the election in Mugabe’s favour.11,12 Although there is no evidence of parallel conduct by ZiMA, the lessons of history should be clear. Professional organisations have obligations16 to ensure that their members are protected from state coercion and are able to act ethically and in compliance with human rights standards set out in numerous World Medical Association (WMA) declarations – even if this involves criticising government actions.17 In this matter, the South African health professions should ‘loudly and clearly condemn the abuse of human rights in Zimbabwe, support in every possible way those Zimbabwean colleagues and organisations courageously promoting ethical and human rights, defend colleagues in Zimbabwe who are threatened or intimidated by the regime’,18 and urge ZiMA to be bolder in its adherence to the calls made in the WMA resolution of October 2007 to take a stronger stand on matters of human rights.19 The challenge for health professionals globally is to ensure stronger accountability and implementation of these ambitious statements. There is no doubt that the vast majority of health professionals in Zimbabwe believe in their mission to be healers and carers and would like to practise medicine in an ethical manner, but find themselves unable to act independently of state control.4 Even if they seek to be ethical, they face insurmountable obstacles if they try to treat victims of the violence impartially and with respect, or to act as advocates for their patients. The public statement of the Zimbabwe Medical Association (ZiMA), condemning violence from all parties to the conflict,5 has been a welcome development, as Part of the problem in Zimbabwe is that of dual loyalty20 which, while frequently encountered in different contexts in medicine, becomes a life-and-death dilemma when conditions of severe political repression threaten the lives of ordinary citizens who hold different political beliefs from those in power or, indeed, of ordinary citizens who just happen to be in the wrong place at the wrong time. However, this problem of dual loyalty may sometimes arise from the anticipation of pressure on health professionals, rather than real evidence, and may be considerably ameliorated, particularly when health care 777 October 2008, Vol. 98, No. 10 SAMJ pg777-778.indd 777 9/29/08 10:33:29 AM EDITORIALS providers act through their professional associations to uphold ethical standards for those whom they are sworn to serve. ZiMA and MDPCZ must therefore boldly promote the right ethical choices in this dilemma so as not to be seen as complicit in the subjugation of their patients’ interests to the political directives of those in power. The onus is on ZiMA and MDPCZ to show leadership in this regard; they can be assured that the global health community will stand by their side in their actions to protect and defend the best interests of their patients. 1. Rayner M. Turning a Blind Eye? Medical Accountability and the Prevention of Torture in South Africa. Washington, DC: AAAS Science and Human Rights Program, 1987. 2. Amnesty International. Zimbabwe. A Trail of Violence After the Ballot. London: Amnesty International, 2008. AI Index: AFR 46/014/2008. 3. Zimbabwe Association of Doctors for Human Rights. Zimbabwe: Violent assault and torture continue unchecked. http://www.pambazuka.org/en/category/comment/47598 (accessed 23 June 2008). 4. Zimbabwe Association of Doctors for Human Rights. Statement concerning escalating cases of organised violence and torture, and of intimidation of medical personnel. http://www. pambazuka.org/en/category/zimbabwe/48024 (accessed 23 June 2008). 5. Zimbabwe Association of Doctors for Human Rights. Victims of organised violence and torture continue to flood the health system. http://www.ifhhro.org/main. php?op=news&id=236 (accessed 23 August 2008). 6. IRIN News. Zimbabwe: schools and teachers suffer post-election violence. http://www. irinnews.org/report.aspx?ReportId=78032 (accessed 23 August 2008). 7. Editorial. Medicine and Conflict: Zimbabwe’s unsung heroes. BMJ 2008; 337: a1303. Leslie London Professor and Director School of Public Health and Family Medicine University of Cape Town 8. Catholic Commission for Justice and Peace in Zimbabwe and the Legal Resources Foundation. Breaking the Silence; Building True Peace; A report into the disturbances in Matabeleland and the Midlands; 1980 - 1988. Harare: Catholic Commission for Justice and Peace in Zimbabwe, 1997. (Republished as Gukurahundi in Zimbabwe: A Report on the Disturbances in Matabeleland and the Midlands 1980-1988. Johannesburg: Jacana Press, 2007.) 9. IRIN. ZIMBABWE: Schools and teachers suffer post-election violence. http://www.irinnews. org/report.aspx?ReportId=78032 (accessed 23 June 2008). Dan Ncayiyana 10. British Medical Association. Medicine Betrayed. London: Zed Books, 1992. Editor, SAMJ and Director, Benguela Health 11. Thorneycroft P. Tsvangirai’s plea from the heart to end the bloodshed. Sunday Independent, 27 April 2008. David Sanders 12. Zhangazha W. EU revokes contract with Chimedza. Zimbabwe Independent. http://www. thezimbabweindependent.com/local/20551-eu-revokes-contract-with-chimedza.html (accessed 23 August 2008). Professor and Director School of Public Health University of the Western Cape, and Former Associate Professor and Chair Department of Community Medicine University of Zimbabwe Ahmed Kalebi Convener of the Human Rights Committee of the Kenya Medical Association (Nairobi Division), and BDIAP Fellow of Anatomical Pathology University of the Witwatersrand Johannesburg Josephine Kasolo Department of Physiology Makerere University Kampala Uganda 13. Makurira P. Perspectives and experiences with regards to human rights in health professional education in Zimbabwe. Presentation at conference: Core Competencies in Human Rights for Health Professionals, University of Cape Town, July 2006. http://www.hhr.uct.ac.za/ conferences/conferences.php (accessed 23 June 2008). 14. Baldwin-Ragaven L, de Gruchy J, London L. An Ambulance of the Wrong Colour. Health Professionals, Human Rights and Ethics in South Africa. Cape Town: UCT Press, 1999. 15. Medical Association of South Africa. MASA Bulletin. S Afr Med J 1985; 68: 703. 16. Baldwin-Ragavan L, London L, de Gruchy J. Learning from our apartheid past: Human rights challenges for health professionals in contemporary South Africa. Ethnicity and Health 2000; 5(3): 227-241. 17. Amnesty International. Ethical Codes and Declarations Relevant to Health Professionals: An Amnesty International Compilation of Selected Ethics and Human Rights Texts. London: Amnesty International, 2000. 18. World Medical Association. World Medical Association Resolution on Health and Human Rights Abuses in Zimbabwe. Adopted by the WMA General Assembly, Copenhagen, Denmark, October 2007. http://www.wma.net/e/policy/a29.htm (accessed 25 June 2008). 19. Ncayiyana D, London L, Sanders D, Kalebi A, Kasolo J. Zimbabwe’s humanitarian conflict. BMJ 2008; 337: a1286. 20. Rubenstein LS, London L, Baldwin-Ragaven L, Dual Loyalty Working Group. Dual Loyalty and Human Rights in Health Professional Practice. Proposed Guidelines and Institutional Mechanisms. A Project of the International Dual Loyalty Working Group. Boston: Physicians for Human Rights and University of Cape Town, 2002. http://physiciansforhumanrights.org/library/reportdualloyalty-2006.html (accessed 23 August 2008). Corresponding author: L London ([email protected]) 778 October 2008, Vol. 98, No. 10 SAMJ pg777-778.indd 778 9/29/08 10:33:30 AM