Lives or Livelihoods

Zimbabwe’s hospitals are woefully unequipped for the pandemic, but the nation’s citizens can’t afford to stay inside.

Khameer Kidia
Image of COVID-19 virus. Graphic by Bianca Ibarlucea.
Graphic by Bianca Ibarlucea

Mazoe cordial is an elixir named for the region of Zimbabwe with the sweetest oranges. Originally a luxury created by British colonists on the backs of locals, the orange concentrate has been reclaimed by Zimbabweans for ourselves. Mazoe now conjures childhood memories: birthday parties, soccer practice, or the reward dispensed by our school matron after a cross-country run. Those of us living in the diaspora risk spilling it in our suitcases for a few sips of home.

So, during fieldwork at a rural health clinic earlier this year, I was confused that the staff seemed disappointed when I offered this token of appreciation. “We must mix it with water,” said Agnes, a village health worker. Of course we must mix it with water, I thought; it’s Mazoe. It took me a bit longer to realize that the issue was not the cordial, but the lack of running water.

After troubleshooting with Agnes, we gathered an assortment of plastic vessels from around the clinic, loaded them into our truck, and drove the potholed dirt road to the nearest community well. “This well was donated by a local politician,” Samuel, our driver, said. “He hoped to gain more votes in the next election.” In 2008, four thousand Zimbabweans died of cholera from untreated drinking water, yet millions still lack access to clean water. My mother in Harare has her own well, which could supply an entire village. I tried to imagine a life dependent on the wealthy and corrupt for such a basic human right.

When I opened the truck door, empty Coke bottles fell out in an acoustic chord progression of hollow, plastic thuds. A breeze from the grasslands carried the smell of imminent rain and reminded me how Zimbabwean summers fuse the ingredients of photosynthesis: thunderstorms and blinding sun. The metal pump handle was shiny—worn smooth from frequent use. Each morning, women congregate around the handle and wait their turn to fill their families’ receptacles before a long walk home. They chat and laugh, clustered closely. With Agnes, I filled each container to the brim, moistening the surrounding red soil until it was mud, chatting and laughing too.

Back at the clinic, I marveled at the building’s design, an open-air layout that was standardized for clinics across the country after independence. The clinic architects knew that confined spaces could spread tuberculosis, so some walls are porous—built of concrete blocks with flower-shaped empty spaces that allow breeze and light to fill the waiting area. On a grassy patch far from the tree bearing the sign “Coughing Zone,” Agnes mixed the white man’s Mazoe with the black women’s well water and poured the cold, golden liquid for everyone. For a split second, we forgot about cholera. We did not yet know a novel coronavirus would be arriving next month.

On our drive back through the lush bush, the skies burst open. The clinic blurred behind us as sheets of rain pressed through the concrete sieve walls, bathing the open waiting area. Samuel navigated the road’s rapidly filling craters, barely able to see inches ahead. “There is plenty water,” he explained, “just no plumbing.”

It’s March back in Boston, and my hospital prepares for coronavirus. Heading into work, I ensure my green N95 mask is snug. I want it to hurt my face. I want to be safe. The ICU where I work is windowless, without breeze or sunlight, but when I open the tap, water flows. I scrub my hands until they sting raw. We keep the tap running to wash the virus out of our scrubs and wipe it off the surfaces. I don and doff semi-transparent gowns, throwing them away each time I exit a patient’s room. The nurses at the clinic in Zimbabwe pray for such luxuries.

Over the course of two weeks, we create 200 new ICU beds with ventilators from the operating rooms and some older vents stored in the basement. By comparison, Zimbabwe has at most a hundred ventilators for its population of fourteen million. Our bioethics committee deliberates ventilator rationing in the unlikely event that we run out of all 200. Should we give them to the young, the old, the sick, the healthy, the wealthy, the heroes?

They don’t mention Zimbabweans. This week a man I went to high school with is the first Zimbabwean to die of coronavirus. He was a prominent local TV show host. Rumor has it his family searched in vain for a ventilator during his last hours. My mother lives in Zimbabwe; she is in her sixties with high-risk medical conditions. If she needed a ventilator, she would die too. I wish they could send just a few to Zimbabwe. Even the older vents from the basement.

Because of the time difference, my cellphone bleeps at odd hours as a deluge of WhatsApp messages arrives from family and healthcare colleagues back home. “How do we reuse our masks?” “Do we need running water?” “Can we use garbage bags instead of medical gowns?” I feel useless and embarrassed that my Boston hospital spent millions on a mask-decontamination machine. I suggest rubbing alcohol, if available. We share experiences from the front lines. I recommend testing patients twice, in case of false negatives. They tell me there aren’t enough kits to test most patients once. Triage according to oxygen levels, I say. But rural Zimbabwe doesn’t have the ten-dollar pulse oximeters we use to measure those levels. Nevertheless, we all agree that the most effective strategy requires no additional resources: lie patients on their bellies; they will breathe more comfortably.

The Zimbabwean Ministry of Health releases its daily update. April 29th: forty cases and four deaths—still early days. But if Zimbabwe reaches its predicted peak in July—winter and flu season—they won’t have ventilators or clinical trials or heart-lung machines. In some hospitals, they won’t even have running water.

By early May, there is an explosion of public health messaging in Zimbabwe, and people’s lives have begun to change. Blue and yellow flyers with stick figures mime prevention strategies in Shona—geza maoko (hand washing), vhara muromo (cover your mouth), and usaenda kana kugara pedyo nevamwe vanhu (practice social distancing). None of the flyers explain what to do if you don’t have running water or if you can’t socially distance.

The Zimbabwean government—well-versed in controlling its people—enforces a strict lockdown. My mother tells me that businesses use an infrared thermometer to measure the temperatures of those entering. A relative is turned away at a police roadblock and told she must shop at the store closer to home. A colleague texts me a photo of a fine he received for maskless driving. The police are emboldened; the consequences of violating quarantine become severe.

“People are starving to death,” my mother argues over Skype when I praise the stringent lockdown. I feel a pang of guilt as I stare at my stimulus check. The cost of isolation is far greater in Zimbabwe. At the end of 2019—after Cyclone Idai killed more than a thousand people and left many more homeless—the country was facing the threat of a terrible famine; more than seven million people—over half the population—had been forced into food insecurity. Most are street vendors, food stall owners, airtime salesmen. Without savings or refrigeration, they rely on short-term pay and daily visits to the market. Now their earnings have stopped and the markets are closed. There is no working from home, no stimulus check.

I picture Mbare, the open-air market closest to my home in Harare. Raw peanuts and spinach pile high. The aroma of roasting corn fills the air as men cluster around fires to scorch chibage—the white maize staple—until it is blackened on the outside and the kernels are tender enough to pluck. There is a racket of haggling and chatter and chickens. Women exchange banknotes from their blouses for purple sweet potatoes and handfuls of mopane worms. At this beloved crossroads, coronavirus will flourish. Yet the market is a lifeline. “The tension,” a global health mentor writes via email, “is finding the right balance between lives and livelihoods.”

As I click away from his email, wondering where this balance might lie, I stumble across a recent video on the Human Rights Watch website. Mothers and daughters gather at a well in Harare near my family home. It has a shiny pump handle like Agnes’s. The women walk five kilometers for two chigubus (plastic containers) of water—barely enough to quench their husbands’ thirst, clean their homes, and bathe their babies. They wait ten hours, sometimes overnight, in crowded queues. They cannot socially distance. They share the pump handle, but the ritual is different from the one I learned from Agnes. There is no chatting or laughing. For their families’ only hope of sanitation, the women brave unsanitary conditions. They are trying to strike the same balance as the food vendors and market goers: death now versus death deferred.

Khameer Kidia is a Zimbabwean physician at Brigham & Women’s Hospital in Boston. His writing has appeared in The New England Journal of Medicine and Annals of Internal Medicine.
Originally published:
May 20, 2020


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