A Death in Zimbabwe

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.

1.

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?

2.

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.

They turned next to Avenues Clinic for information, but its administrators refused to provide details about the incident or to order its own investigation. The chief executive officer explained that the clinic was not legally responsible for the physicians’ medical practices. “All patients are admitted in the care of their own medical practitioner,” he said. “The facilities, equipment and nursing care only are provided by the Clinic.” If anything went awry, the doctor and patient had to resolve it between themselves.⁶

This policy of limited responsibility reflected Avenues’ determination to return profits to its investors. Its exclusive concern was to get local doctors to use the hospital—the more of them who sent their patients to Avenues, the larger would be its revenues. Since some of them would not like the idea of committees to monitor medical practice and the quality of care, the clinic did not provide for any supervision. There were no departmental divisions at Avenues, no chief of medicine or of surgery who might take note of a colleague who consistently made errors. Since the clinic was not affiliated with Harare’s medical school, there were no interns or residents to provide emergency treatment, or to observe the quality of care by senior physicians. Since correcting these glaring deficiencies would cost money and limit the physicians’ discretion, neither the administrators nor the staff at Avenues were willing to do anything about them.

The Khaminwas managed, after considerable wrangling, to obtain Lavender’s hospital chart and to have three doctors of their own choosing present, including one from Kenya and one from South Africa, when the autopsy was performed. From the autopsy they learned two critical facts: that the anesthesia she was given was, to say the least, unorthodox, and that the care that she received in the first hours after the surgery grossly deficient.

The mix of anesthesia used to put Lavender to sleep and to keep her asleep during the surgery was standard (nitrous oxide and halothane). But between putting her to sleep and the start of the surgery, the anesthesiologist administered, through a spinal injection, four milligrams of morphine. Why he did so remains something of a mystery, for it was wholly unnecessary. The most likely explanation is that a number of anesthesiologists in Europe and in South Africa are using morphine in this way to reduce the stress of surgery in very elderly or high-risk patients, such as those with significant cardiac disease. (The morphine serves as a bridge between the anesthesia during surgery and the painkillers given to the patient later on.)

Apparently the Zimbabwean anesthesiologist had heard about the new technique, was eager to try it, and then did so altogether inappropriately on a healthy ten-year-old. Worse yet, this combination of morphine and anesthesia can suppress both the heart rate and respiration rate, and the condition of anyone receiving it should be checked every fifteen minutes for the first several hours after surgery. But the clinic staff only checked Lavender’s condition every hour. Thus, she apparently died from respiratory arrest brought on by faulty anesthetic technique and inadequate nursing supervision.

To make a formal complaint, Charles and Mary Khaminwa went to the Health Professions Council, which was set up originally under Rhodesian law to establish the qualifications for doctors and license those who meet them; it also investigates cases of “improper or disgraceful conduct” and “grossly incompetent medical practice,” and is empowered to reprimand, fine, and in the most serious cases, remove from practice those it finds guilty. In October 1990, the Khaminwas asked the council to review Lavender’s case and to allow them to present evidence of wrongdoing. The council agreed to investigate but never asked them to testify or to submit evidence (such as the devastating autopsy reports of their experts); it never even permitted them to hear or review the evidence that others submitted. In January 1991, when the Khaminwas asked for a progress report, the council issued the following terse reply: “It is not Council policy to apprise a complainant of the procedures adopted and to issue progress reports. When the investigation is completed you will be advised.”

After the Khaminwas made several more inquiries, the head of the council finally agreed to a meeting, which he opened by handing them a letter:

The Council has now completed its investigation…and determined there was no negligence or incompetence on the part of the surgeon, the anaesthetist or the nursing staff at the Avenues Clinic…. The anaesthetist followed recognized procedures and the nursing staff carried out their duties in accordance with the doctor’s (written) instructions.

As far as the council was concerned, the matter seemed to be closed. If Lavender’s parents disagreed with the findings, they were free to bring a malpractice suit in civil court or hope that a police investigation and indictment would lead to prosecution.

Neither course offered much prospect for success. The chief justice of the Supreme Court in Zimbabwe, Anthony Gubbay, told us that he could not recall a single malpractice case in the past twenty years. The international Medical Defense Union, the private group that provides low-cost malpractice insurance world-wide, has observed in a report that Zimbabweans hardly ever consider such an action: “Patients are grateful for the medical attention received and in any case are not litigious.”⁷

One reason malpractice suits are rare is that it is illegal for lawyers in Zimbabwe (as in England) to accept a case on a contingency fee. (In the United States, malpractice lawyers sue at their own expense, and take a percentage of the award—generally one third—should they win.) And costs are all the more prohibitive in Zimbabwe, where plaintiffs who win their lawsuit are awarded damages only for lost income and out-of-pocket expenses, not for “pain and suffering.” In the case of a child’s death, damages are limited to medical and funeral costs, which would amount to much less than attorneys’ fees.

The Khaminwas did everything they could to bring the police into the case. Since Lavender died during surgery, the police were required to perform an autopsy and they allowed the Khaminwas to bring in their own experts. The autopsy findings persuaded the police that the case should be treated as a “matter of urgency,” but their inquiry, like that of the Health Professions Council, dragged on for months. When Charles and Mary repeatedly asked about the delays, the attorney general reprimanded them for a lack of “restraint.” To this date, no public report has been issued and no indictments have been handed down.

The reasons for the police inaction became apparent when the Khaminwas asked the government itself to launch an investigation. To strengthen their case, they documented other instances of medical incompetence by the same anesthesiologist who had treated Lavender. Mr. A.’s daughter died during surgery to remove a gall stone; Mrs. Z.’s son suffered irreversible brain damage after surgery for circumcision; and Mrs. C. died after having a tooth extracted. But the Khaminwas could not prove that these were cases of malpractice. Anesthesia, after all, carries a real, if low risk, and without documented findings from autopsies and morbidity and mortality inquiries by other doctors, it is almost impossible to distinguish between a chance event and the work of an incompetent. A lack of oversight makes it almost impossible to document the need for oversight, which is why the clinic so doggedly resisted impartial inquiries.

To ask for a government inquiry put the Khaminwas at some personal risk since Mugabe has repeatedly demonstrated he will not tolerate even mild challenges to his rule. Although he has never officially proclaimed Zimbabwe to be a one-party state, this appears to be his ultimate goal. He controls the major daily newspapers and radio stations and the Central Intelligence Organization, whose agents are everywhere.⁸ During our visit, we were told both by human rights activists as well as prominent doctors that one is well-advised to keep silent in Zimbabwe. We had an exceptionally candid interview with one distinguished Harare physician, but he took us out of his comfortable office and talked with us for nearly an hour in a hallway by an open window, away from wiretaps and hidden microphones.

Mugabe made clear his general disdain for political rights the week before we arrived, when the Commonwealth nations met in Harare. Human rights were prominent on the agenda, and Mugabe’s opening remarks paid lip service to the Commonwealth’s basic principles. But when students at the University of Zimbabwe in Harare were planning to demonstrate at the conference on behalf of free speech, Mugabe sent riot police who stormed the campus and fired tear gas to break up the meeting.⁹

Notwithstanding the repressive atmosphere, the Khaminwas told a group of politically active students at the university about the death of Lavender, and on November 10, 1990, some two hundred of them (including many members of Zimbabwe’s most notable human rights organization, the Catholic Commission for Justice and Peace) marched on Avenues Clinic and the Health Professions Council. Linking Lavender’s case to their longstanding campaign for free speech and government accountability, they distributed leaflets protesting the “conspiracy of silence” that surrounded Lavender’s death. Ten days later they petitioned the attorney general to expedite the police inquiry, only to be told that an investigation was underway and results would be forthcoming.

The demonstration got the attention of some members of Parliament, and one of them introduced a resolution to conduct “a public inquiry into the activities of some doctors at certain private clinics with the aim of bringing the same to book for any malpractice.” In the debate, Mugabe’s minister of health, Dr. Timothy Stamps, successfully opposed the motion, saying it was not in Zimbabwe’s national interests to have an inquiry. Dr. Stamps himself is a very popular figure in Zimbabwe, mostly because he helped to persuade Mugabe to lift the censorship that his government had earlier imposed on all matters relating to AIDS.

Stamps took the opposite approach with the death of Lavender. He praised Avenues for providing high-quality health care at no cost to the taxpayer and insisted that the combination of anesthesia and morphine administered to Lavender was “conventional, safe, and time honoured…widely used world-wide in many tertiary units.” (He disingenuously said that “open heart surgery would be impossible without…this procedure,” ignoring that this case involved routine surgery on a healthy child.) Stamps also sought to stifle the press; he criticized one newspaper’s coverage of the case as “inappropriate and unacceptable” because it was “not consistent with good public order,” and appealed to national pride, noting that Lavender’s doctors and anesthesiologist were “respected specialists whose loyalty to Zimbabwe is unquestionable.”

But Stamps, in covering up for his colleagues’ misdeeds, revealed that he was particularly troubled by the “deliberate assault on [the] Government’s attempts to attract and retain competent specialists at terms much less favourable than they could attract just across the border.” The kind of investigation demanded by the Khaminwas, he said, would accelerate the physician “brain drain,” causing more Zimbabwean doctors to emigrate to Botswana or, increasingly, to South Africa.

This fear was by no means groundless. Physicians have skills that enable them to choose how and where they work. When they become dissatisfied with conditions in one country they can migrate elsewhere—and often do. It is said, for example, that both the British National Health Service and American inner city hospitals would collapse were it not for the presence of Indian doctors. In Zimbabwe itself the number of doctors has declined from 1,733 in 1983 to 1,243 in 1987—the last year for which figures are available—and the drop has occurred despite the fact some sixty physicians a year graduate from Harare’s medical school.¹⁰

Because the government is reluctant to hold doctors accountable for their actions, it failed to set a more equitable system of health care in the early 1980s. Three quarters of Zimbabwe’s population live in rural areas, but for reasons of personal comfort, income, and prestige, three quarters of all the physicians practice in the two major cities, Harare and Bulawayo. When the ministry of health announced that new graduates from Harare’s medical school would have to serve for five years in rural areas, many of the graduates simply left the country rather than fulfill the obligation. When the ministry responded by cutting the service requirement to two years, that compromise only provoked a strike and failed to stop the doctors from emigrating. The plan was abandoned.

Although everyone can see that many physicians neglect public patients in order to treat paying private patients, neither the ministry of health nor the medical establishment is willing to do anything about it. Government salaries and payments to doctors, we were told, are too low to sustain the standard of living they now expect—a house, a car, and private schools for their children. Instead of trying to improve the quality of public medicine—through higher salaries and better equipment, for example—the government simply points to the danger of doctors leaving the country if any changes are made.

3.

By persevering in their case, the Khaminwas have produced a remarkably revealing account of what happens when a government coddles the medical profession and is unwilling to insist on procedures that will protect patients from harm. The record is oddly reminiscent of the situation we uncovered earlier in the inquiry we made into mistreatment of children in Romania—with a difference.¹¹

When we investigated the AIDS epidemic among Romania’s orphaned children, we learned how the state can corrupt the profession through excessive interference. Ceausescu’s “pronatalist” policies were aimed at forcing women to have children, and they imposed strict rules of censorship on the profession. Ceausescu ordered doctors to register the names of factory employees who were pregnant, and he prohibited discussion of any aspects of AIDS. When the physicians followed his orders, violating the Hippocratic oath to respect patient confidentiality and to do no harm, the result was a public health disaster. In Zimbabwe, we learned how the state can corrupt the profession through excessive indulgence, leaving medical professionals entirely to their own devices, while the state-chartered medical organizations themselves do nothing to monitor the quality of medical treatment. The result was also a public health disaster, one that affected both the most vulnerable members of society and also the more privileged citizens who use private clinics such as Avenues.

The Zimbabwean experience shows that when free-market economics provides the only controls on medicine, the quality of health care deteriorates. Both patients on the public wards and private patients will suffer, one from lack of care, the other from incompetent care. Zimbabwe’s doctors, both at Avenues or on the Health Professions Council, might have compensated for the lack of state regulation by setting up their own review committees. Their failure to do so shows the destructive effect that financial self-interest can have on professional standards.

The lessons that emerge from Zimbabwe are all the more important since several other countries, most notably South Africa, seem about to follow the same pattern. As South Africa throws off its legacy of apartheid and desegregates its health-care facilities, whites are rushing to establish their own private, for-profit clinics while government officials say they fear doctors will migrate to England and the United States. But if a policy of nonaccountability evolves as it did in Zimbabwe then who will see to it that the South African township populations have doctors to serve them? What is to prevent hospitals like Avenues from springing up in Johannesburg and Capetown? Will the appropriate government or professional bodies act to protect patients from self-interested physicians? One can only wonder how many cases like Lavender’s are required before Zimbabwe and its neighbors appreciate the need to answer these questions—if they ever will.