What lessons can we learn for today from the 2008-09 cholera outbreak in Zimbabwe?
Like any other disease, the coronavirus COVID-19 has in itself no meaning: it is only a micro-organism. It acquires meaning and significance from its human contexts, from the ways it infiltrates the lives of the people, from the reactions it provokes, and from the manner in which it gives expression to cultural and political values. The danger of the coronavirus and its attendant illness, coronavirus disease, is best understood as the product of a particularly pathological intersection of political, economic, social and biological processes. Scientists primarily dwell on the latter of these. They are right to point out the novelty of the virus and the peculiar challenges its molecular biology presents for predicting the epidemiological spread of COVID-19, for grasping its immunological properties, and for developing efficacious treatments such as a vaccine. The former—i.e. the political, economic and social processes that will shape the trajectory of the epidemic—might be understood by looking carefully at other epidemics for valuable lessons. In this light, my new book, The Political Life of an Epidemic: Cholera, Crisis and Citizenship, offers some insights that might be helpful for making sense of the current pandemic and its potential impact on Africa.
My book tells the story of the Zimbabwe’s catastrophic 2008-09 cholera outbreak. It does so by tracing the historical origins of the outbreak, examining the social pattern of its unfolding and impact, analyzing the institutional and communal responses to the disease, and marking the effects of its aftermath.
The epidemic began in August 2008. It first appeared in the impoverished high-density townships of Harare’s metropolitan area. The epidemic quickly spread into peri-urban and rural areas in Zimbabwe before crossing the country’s borders into South Africa, Botswana, Zambia and Mozambique. Over the course of 10 months, the disease infected over 98,000 people, claimed over 4,000 lives, and, with an exceptionally high case-fatality rate at the peak of the epidemic, Zimbabwe’s 2008 cholera outbreak has been deemed the largest and most extensive in recorded African history.
Cholera—one of the most feared infectious diseases in public health—is an acute bacterial infection of the intestine caused by the ingestion of food or water contaminated by certain strains of the organism, vibrio cholerae. The disease is characterized by acute watery diarrhoea and vomiting. In the most severe cases, it can be fatal due to rapid dehydration or water loss. When left untreated, mortality from “classical” cholera can be as high as 50 percent. However, with effective replacement of fluids and electrolytes, through simple oral rehydration therapy, mortality can be reduced to less than one percent. How then did a simple bacterial infection—one that is easy to prevent, difficult to spread, and simple to treat—become such a massive calamity in Zimbabwe?
The long-term factors that led to the cholera outbreak can be traced as far back as the late 19th century when Salisbury was founded as the administrative and political capital of Southern Rhodesia. The new colonial state rapidly produced, extended, and renovated infrastructures—including the city’s water reticulation systems—from the late 1800s through much of the early 20th century. Reflecting the racist and authoritarian character of the Rhodesian state, water infrastructures as well as housing facilities, were provided unequally on the basis of race. Since the colonial period, the “native locations” (later the high-density townships of Harare’s metropolitan area) have suffered from overcrowding; and they have received public amenities—such as housing, water and sanitation, and healthcare—on an inconsistent and inadequate basis. They have also been subjected to periodic, at times violent, state-led “slum clearances.” The logics of segregationist rule, social control, and appeals to orderliness account for the heavy-handed management of the townships by successive governments.
After independence, Harare urbanized at a rapid rate. High-density townships expanded as formal segregation ended and both national and local government sought to improve the delivery of housing stock and supplies of water and sanitation facilities. Such tasks proved more formidable in implementation than in policy resulting in an ongoing mismatch between supply and need. Moreover, despite gestures toward transforming high-density areas, little changed with respect to the policies that were applied to them. Colonial era by-laws, plans, and statutes largely remained in place indicating the apparent tension between overturning the racial and socio-economic segregation of Rhodesian city planning and maintaining an inherited sense of modernity and orderliness in urban space. As high-density neighborhoods expanded with few new suburbs developed, the shortage of housing compelled impoverished urban arrivals to construct “illegal” shelters in the townships. In response, the government launched a longstanding battle against informal housing from the 1980s onwards through forced evictions, arrests, clearances, and demolition exercises.
In the 1990s, owing to a debt crisis, the government adopted a controversial economic structural adjustment package to manage the economy at large. The economic reforms of the 1990s led to a deterioration of urban living conditions. Because of unemployment and retrenchment, Harare’s townships accommodated increasing numbers of people, within limited space, who had turned to informal trade to stave off livelihood poverty. Worsening public health standards in terms of overcrowded housing and limited access to clean water and sanitation facilities bedevilled the townships.
As is now well known, Zimbabwe was plunged into a political and economic crisis, especially from 2000 onwards. As a newly formed opposition party, the Movement for Democratic Change (MDC) launched a major challenge against ZANU(PF), and the ruling party deployed an array of legal, coercive and patronage strategies to retain power in key sectors of the economy and in public services. An example of such changes with central importance to the cholera outbreak was the creation of ZINWA—the Zimbabwe National Water Authority. ZINWA mismanaged and sabotaged the water reticulation systems in Harare and elsewhere. It did so by taking away responsibility for water management from the municipalities, thereby cutting off many opposition-run councils from a crucial aspect of public service delivery. Additionally, ZINWA fired technical staff who had been working in water delivery and replaced them with party loyalists. This allowed the water authority to redirect funds from water bills to the security sector and to the ruling party. Consequently, when Harare was afflicted by severe water shortages, ZINWA had already deposed of the technical, human and financial resources necessary to supply water, to fix waterworks when pipes burst, and to dispose of sewage safely.
On top of the collapse of water supply was a collapse of the healthcare delivery system, itself a consequence of Zimbabwe’s political-economic meltdown. Lacking staff, stuff, space and systems, the healthcare delivery system became a crucial factor in the perpetuation of the cholera outbreak. These health system failures were compounded by dramatic changes in livelihoods for much of the population including and especially those changes caused by Operation Murambatsvina—a large-scale Zimbabwean government campaign in 2005 to forcibly clear slum areas across the country. Homelessness, squalor and infrastructural damage in the townships in combination with fuel and currency shortages engendered and augmented widespread, critical food shortages that triggered a sharp rise in acute malnutrition. Acute malnutrition and hunger induced greater susceptibility to cholera in the population, especially among the poor and the vulnerable, and exacerbated its pathological effects in those affected. By 2008/09, the overlapping crises of the collapsed health system, the multi-level failure of the water reticulation system, and the political economy of daily life converged to create a “perfect storm” for a ruinous cholera outbreak.
The dramatic scale and devastating impact of the cholera epidemic precipitated a political outcry that echoed loudly across a spectrum of institutions. The disease reinforced an image of Zimbabwe as “pathological,” a “pariah,” and “failed” state, as portrayed by the country’s opposition political parties, a host of foreign governments, multiple agencies in the mainstream international media, key organizations in the humanitarian sector, and several influential global security and development think tanks. For instance, the Council on Foreign Relations, asserted that Zimbabwe’s health crisis, epitomized by the cholera epidemic, could be “attributed to the decay of state institutions and infrastructure” under the “brutal regime” of the “despot Robert Mugabe.” Prominent reports by the International Crisis Group (2008) and Physicians for Human Rights (2009) characterized the Zimbabwean situation, and specifically the cholera outbreak, in terms of ‘state failure’ and thus as a potential target for military intervention motivated by the Responsibility to Protect (R2P) doctrine.
On December 4, 2008, under considerable political and bureaucratic pressure following three months of denial and inaction, the Minister of Health at the time, Dr David Parirenyatwa, proclaimed that the cholera epidemic was a national disaster. Parirenyatwa pleaded for international relief and medical humanitarian assistance. What appeared to be a positive development in the cholera saga was upended only a week later. On December 11, in a televised address to the nation from Heroes’ Acre, President Mugabe shocked many involved in the cholera response when he stated, “I am happy we are being assisted by others and we have arrested cholera.” Turning his attention to the suggestion of military intervention, via R2P, in the country on humanitarian grounds, he added: “So now that there is no cholera, there is no cause for war anymore.”
The controversy did not stop there. The following day the former and now deceased Minister of Information, Dr Sikhanyiso Ndlovu, seized upon the outbreak to launch a daring vitriolic attack on the West, accusing it of being the source of the cholera. In charges harking back to the liberation struggle during which the Rhodesian army used biological warfare, by spreading anthrax pathogens in weaponized form among guerrilla fighters and rural civilians, Ndlovu accused the West of deploying similar tactics in 2008:
Cholera is a calculated racist terrorist attack on Zimbabwe by the unrepentant former colonial power [Britain] which has enlisted support from its American and Western allies so that they can invade the country, install their stooge who will allow them to repossess our resources . . . British operatives are in the country now under disguise and have increased cholera and anthrax seeding. There has been a replanting of cholera and anthrax . . . This is a serious biological and genocidal warfare on our people by the British, still fighting to recolonize Zimbabwe.
Opposition politicians insisted that their counterparts in the ruling party were too afraid to acknowledge the disease publicly because, they argued, it would be an admission that ZANU(PF) had “failed” as a government and lacked legitimacy to continue governing the country. In the context of unprecedented electoral violence, economic meltdown and fraught political negotiations to form a coalition government, the cholera outbreak was one crisis too many.
Amidst all the recriminations for the cholera outbreak and the deaths left in its wake, the declaration of a national disaster allowed the Ministry of Health to partner with international donor agencies and NGOs to stitch together a humanitarian response to the disease albeit after considerable delay. In almost every part of the country, cholera treatment centers were set up as teams of healthcare workers channeled patients through different stages of clinical treatment. Large groups of volunteers did outreach work in surrounding communities to promote safe hygiene practices while also distributing water-treatment tablets and, in some cases, drilling boreholes and erecting water tanks in lieu of piped water supplies. Undoubtedly, tens of thousands of people were saved from cholera and the disease was likely prevented among hundreds of thousands more.
Nevertheless, the resources and energy poured into the humanitarian response were never intended to be more than short-term. After the outbreak, no serious efforts were undertaken by humanitarian agencies to change health and hydraulic infrastructures since such fundamental, long-term development work is not the purview of disaster relief. As an officer from the Zimbabwean chapter of the Red Cross captured it, “We look at saving lives and helping people where there is a problem. But the background to what is happening, we don’t usually want to hear that.” It may well be too much to expect humanitarian organizations to do more. After all, long-term work, that attends to public health infrastructure, is typically the responsibility of the state often in conjunction with development organizations. The messy politics that led to the outbreak precluded a coherent and long-term response to its underlying determinants.
Beyond the high politics of the disease and its humanitarian response, the cholera outbreak has left its mark on everyday life in Zimbabwe. For residents of the townships that were epicenters of cholera, the outbreak became an important site of evaluating the legitimacy of the ruling government, of venting anger at its manifest failings, and of making do when the government was unable or unwilling to deliver. But this public anger and outrage at the government for its causal role in the epidemic and in the inadequacy of its relief efforts has not translated into any effective political mobilization or permanent change. In the high-density township of Glen Norah, I spoke with Chido and Gamu, two teenage girls who survived the cholera outbreak. By their own reckoning, they were born in poverty, live in poverty, and will die in poverty. Their political consciousness came into being at the nadir of Zimbabwe’s crisis. For them, the cholera outbreak, the political violence, the daily hardship, and the implacable sense of loss that defined 2008 etched itself on their minds leaving them terrified of the depths to which the country could sink.
In the years following the 2008/09 cholera outbreak, the Zimbabwean government has implemented crucial measures to manage recurrences of the disease. In particular, the Ministry of Health has formulated a comprehensive and sophisticated detection and control plan for epidemic disease through use of its Integrated Disease Surveillance and Response protocol. However, this strategy is, by its very nature, reactive; it is designed to address outbreaks when they occur not to prevent them in the first place. The latter remains difficult for structural reasons. In the last decade, the Ministry of Health, has recorded significant gains in responding to and diminishing the case fatality rates of cholera while also noting that environmental factors—specifically poor and inadequate water supplies, recurrent breakdowns in the sewer systems, inadequate sanitation in both urban and rural settings, poor waste management practices, inadequately supervised food preparation processes, and unplanned overcrowded settlements in urban areas—have rendered diarrhoeal disease endemic in Zimbabwe’s cities. It should go without saying that these same factors bode poorly for an outbreak of COVID-19.
When I was last in Zimbabwe in December, the country appeared to be entering a crisis of striking similarity to that of 2008-09. Shortages of food, fuel, water and currency have left people with few options but to procure these necessities in the informal sector. If or when the coronavirus begins to spread in Zimbabwe, how would social distancing work in such a context? How would informal businesses and the livelihoods of the poor be protected in the event of a shutdown, such as those in Europe and North America? The importance of sanitation and hygiene to prevent the transmission of the coronavirus cannot be overstated but this is largely meaningless without access to clean water. In 2008, when the government extolled the virtues of hygiene and sanitation to prevent the spread of cholera, township residents scoffed at the cynicism of these instructions. As one elderly woman in the township of Budiriro put it to me, “look at it this way: if you have the power to give me water and you give me dirty water, I would say that you are killing me.”
The healthcare system is not well placed to respond to another outbreak. Many doctors have fled the country owing to inadequate remuneration and poor working conditions in government hospitals. Late last year, the lamentable state of healthcare provision prompted doctors’ associations to accuse the government of “silent genocide.” Even if such claims are read as hyperbolic, they reveal the lack of trust between the government and its health workforce. Further still, many Zimbabweans suffer from or are at risk of malnutrition not to mention other diseases such as HIV and tuberculosis that are damaging to immune systems. It seems very likely that vast numbers in the population with be vulnerable to this respiratory infection.
We might ask whether the government is taking the pandemic seriously enough? The disturbing assertions of Oppah Muchinguri, the Minister of Defense, that COVID-19 is God’s way of punishing the West for imposing sanctions on Zimbabwe do not portend well. At a time when international cooperation is paramount in responding to the pandemic, I fear the damage that might be wrought by careless political statements and insensitivity to the collective anxieties that have gripped the world.
Most importantly, Zimbabwe faces a crisis of trust. The present moment calls for social solidarity, political leadership, and community mobilization. And yet, for the reasons I’ve laid out in this essay, this seems a tall order. Nevertheless, I will continue to hope that the unsung heroes of Zimbabwe’s cholera outbreak—doctors and healthcare practitioners, bureaucrats and aid workers, churches and volunteer groups – will once again rise to the occasion. But this will never be enough. Epidemics are tests of social and political systems. Cholera exposed the myriad weaknesses of Zimbabwe’s politics in 2008. Will the coronavirus do the same 12 years later?