"The silent cries of the little ones" : Zimbabwe's under-fives cry out for justice

Malnourished child

Of all the millions of Zimbabweans who have fallen victim to ZANU PF mis-rule the malnourished children under the age of five must surely rank as the most pathetic. They cry from hunger and deprivation, and the cries rend the hearts of their mothers, or if already orphaned, the hearts of their stand-in mothers, who have little or no food to give them. But because they are the most vulnerable group of all and have no means of collectively giving voice to the deep anguish they feel, their individual cries go unheard by those who could make a difference - the ruling politicians and their apparatchiks.

Be silent Zimbabweans, and listen - with care !
Can you not hear the cries of the little ones
condemned by your inhumanity to die of starvation,
or, at the least, never to reach their God-given potential -
rather to live stunted half-lives ?
Can you not hear the cries of the little ones -
for mercy ?
Not to mention justice.

One group of professionals who are alert to the tragedy is the country's paediatricians and health care workers who have the daily task of tending the severely malnourished and often dying little ones. At a recent workshop in Harare organized by Doctors for Human Rights a number of papers were presented by practitioners who are deeply troubled by current trends resulting from the crisis levels of poverty and food deprivation and the regime's refusal to engage seriously with the issue. One paper was entitled "Severe child malnutrition: an unnecessary and avoidable crisis".

The problem is not a new one, but it is growing. A study carried out at a Harare hospital in 2003-4 showed that 55 per cent of children admitted then were suffering from malnutrition. Since that time the regime has significantly reduced the amount of feeding the international community is permitted to do through the World Food Programme and its local agencies, and in May 2005 it embarked on the notorious Operation Murambatsvina, dubbed "a catastrophic injustice ... to Zimbabwe's poorest citizens" by none other than Kofi Annan, Secretary-General of the United Nations. At the same time, as agricultural production within the country has plummeted to all-time lows, the regime has failed conspicuously to import anything like the quantity of maize required to compensate for the deficit and feed the population. The result has been a predictable intensification of the suffering, especially of vulnerable groups like the under-fives.

One experienced nutritionist has put it this way:

"I contend that towards its citizens under the age of five, the Zimbabwe government is showing no lesser degree of disregard, considering their basic needs, than towards the victims of Operation Murambatsvina".

For a number of reasons it is difficult to chart the increase in the phenomenon of severe child malnutrition, or indeed child deaths due to this cause, across the nation. ZANU PF politicians are in denial. They have no wish for the truth to be known and have therefore deliberately obstructed health officials who have sought to record the relevant statistics. One has only to recall how Jonathan Moyo when Minister of Information fulminated against the officials of the Bulawayo City Council's Health Department for daring to record in a professional manner the basic data on deaths related to malnutrition, and one realizes just how sensitive the issue is to the ruling party. And apart from political interference there are other factors making any scientific assessment practically impossible. There are the number of child deaths in remote rural areas which go unrecorded. The majority of victims are not even taken to the country's hospitals and clinics because the mothers or mother substitutes are often too poor to afford the transport fares. Add to this the masking effect of the AIDS epidemic, with about a quarter of the population HIV-positive, and the difficulty in accurately charting the national increase in child deaths due to malnutrition can be seen to be almost insurmountable. As one Bulawayo surgeon quoted in the Sunday Times observed:

"Put simply, people are dying of AIDS before they can starve to death."

Of necessity therefore and for the time being, the evidence is somewhat patchy and incomplete. Much of it is anecdotal. This is no reason however to dismiss the harrowing accounts of suffering and such provisional assessments as those who are in the front line of the battle to save lives, have so far been able to provide. After all the children concerned are dying now, and it may take many years and the removal of the present regime, before the full extent of the tragedy becomes apparent to all. We cannot wait that long to sound the alarm. If we did we might well find ourselves in the sort of deep crisis the people in Rwanda or Darfur found themselves in before the international community began to respond.

Much of the following information was provided at the Doctors for Human Rights' workshop referred to above. The balance was given anecdotally by busy medical practitioners whom our reporters were able to consult.

On a snap one day survey at one of Zimbabwe's largest hospitals 7 out of 8 children admitted were severely malnourished.
Over 60 per cent of children under the age of 12 admitted to the same hospital are now there because of severe malnutrition.
In a ward of 102 children 67 were found to be suffering with some form of malnutrition. Paediatric wards have been turned into malnutrition wards.
Records of major hospitals in both Bulawayo and Harare confirm that malnutrition is now the prime cause of deaths among children.
Among the under-fives admitted for treatment for severe malnutrition the mortality rate is 46 per cent in Harare. The corresponding figure in Bulawayo is 25 per cent.
Of those malnourished child patients who die 46 per cent die within seven days of admission. In other words they were admitted too late to be saved.
Of the children admitted to the malnutrition unit at Mpilo Hospital, Bulawayo, between April and July 2005, 62 per cent were HIV-positive.
Deaths of malnourished children in the HIV-positive category (76 per cent) far exceeds those in the HIV-negative category (8 per cent)

Among the paediatricians whom we were able to consult there was a broad consensus that the problem of child malnutrition showed a marked increase in the last quarter of 2005. A comparison of the numbers of admissions of children suffering from severe malnutrition at Mpilo Hospital for example over the period October to December 2004 and over the corresponding period the following year, reveals an increase of nearly one hundred per cent. In simple terms the numbers doubled between 2004 and 2005. The doctors themselves were of the view that the increase could be attributed in large measure to the final cessation of the general NGO feeding programmes (by order of the regime) in April 2005, it taking about six months for the full effects of that stoppage to be felt. No doubt Operation Murambatsvina which started in May 2005 also contributed to the increasing levels of food deprivation. Much of the malnutrition is now urban-based, which is a new phenomenon in Zimbabwe and supports the thesis that the so-called "clean-up" operation was a major contributor.

Interestingly one Bulawayo doctor observed that among the parents or relatives bringing the severely malnourished children to hospital for treatment in recent months many were not dressed like "the very poor". The inference drawn from this fact was that the relatives were not long-term destitute persons but rather were recently impoverished. This points to the "Murambatsvina factor".

The severe restrictions placed upon the NGOs feeding programmes also had an adverse effect upon the medical rehabilitation of under-fives. Prior to the imposition of these restrictions and while NGOs were still able to supply clinics with such nutritious foods as the corn/soya blend, hospitals could discharge patients after successful treatment with some confidence that they would continue to receive the necessary quantities of nutritious foods they required. From April 2005 this was no longer the case. Clinics were often lacking the food supplies needed to provide the after-care and to help restore the nutritional deficits previously detected in the children, and so mothers stopped taking them there. It is not known how many children brought back from the brink of death by hospital intervention have subsequently relapsed due to food deprivation attributable to this cause.

Given the gravity of the situation some might wonder why we are not yet seeing significant numbers of "skin and bone" children such as were memorably recorded by television cameras during the drought and famine in the Sahel. This raises an important point which needs to be understood by all who have a concern for the under-fives. As one senior nutritionist explained, there are basically two ways of assessing whether the amount of food available to children is nutritionally sufficient. The first enquires, is it sufficient to keep them alive ? The second, is it sufficient for them to reach their physiological potential ?

The former criterion is employed in emergency relief situations such as occurred in the Sahel, and more recently in Darfur. The latter is the criterion that Zimbabwe's Ministry of Health has employed over very many years, and obviously the one doctors concerned with children's issues would prefer to see adopted in non-emergency situations.

In the former case the standard method of measurement is body weight against height. Only those children therefore in whom height and weight are out of proportion are labeled as malnourished. A glance at such a child reveals his skinny, or wasted, condition. This is the classic mark of an acute nutritional emergency.

On the other hand if the yardstick is the child's physiological potential a different measurement is used, namely body weight for chronological age.

The Zimbabwe Ministry of Health has designed a standard weight-for-age card for under-fives, thereby signaling its intention of charting children's actual weight development against their growth potential. The internationally accepted range within which healthy development takes place is demarcated on this card by percentiles: the 3rd and 97th percentiles are set down as the outer marks which should not be exceeded. Given a healthy environment and sufficient caloric intake 94 per cent of children would develop along a percentile somewhere between these extremes, most of them clustered around the 50th percentile. By plotting weight-for-age on these cards it immediately becomes clear whether there is cause for concern about the child's health.

If children's weight is recorded in relation to their height, however, this may easily be missed. The point is that the growth rate of children for both weight and height can and does adjust to conditions of long-term food deprivation (low calorie intake) by reducing so that sufficient nutrients are available. The end result is a child who is both too light and too short for his age, but since height and weight are still proportionate the child "looks ok". To the casual observer there is no problem here, nothing to suggest a nutritional deficiency. Only by enquiring the child's age and comparing weight-for-age against an accepted norm is it possible to ascertain that he is lagging behind that norm - and this is exactly what the Zimbabwean Ministry of Health's weight-for-age card for under-fives does.

The obvious question then for those concerned with the wellbeing of our children is whether the yardstick adopted by the Ministry of Health, which measures a child's growth potential against actual growth, is the appropriate one for under-fives in Zimbabwe.

From a nutritionist's point of view, and also in consideration of every child's basic human right to adequate nutritious food, the answer must be a resounding "Yes!". Such a right has long been recognized by the international community and by Zimbabwe. To quote the International Convention on the Rights of the Child (Article 24 sub-section 2(b)),

"State parties will take appropriate measures to combat disease and malnutrition through the provision of adequate nutritious foods and clean drinking water."

Or again to quote the International Covenant on Economics, Social and Cultural Rights (Article 11(1)),

"The State parties …recognize the right of every one to an adequate standard of living for himself (herself) and his (her) family, including adequate food, clothing and housing, and to the continuous improvement of living conditions. The State parties will take appropriate steps to ensure the realization of this right …"

Zimbabwe ratified this Covenant on 13 May 1991.

It would be wrong therefore, not only in a moral sense but also in a legal sense, to wait until an emergency situation arises and large numbers of skeletal figures start presenting for treatment. The crisis is already upon us and requires an urgent response.

Studies undertaken on under-fives in Matabeleland in 2002 revealed that malnutrition was then below the emergency threshold. However it is important to point out two things in relation to these findings. First, they were based on the acute nutritional emergency criterion which ignores the actual-against-potential growth factor, which the Zimbabwean Ministry of Health itself, at least in the past, was committed not to leave out of account. And second, between 2002 when the studies were done and 2006 subsistence farmers in Matabeleland have had to contend with a succession of poor, and sometimes very poor, harvests due to insufficient rainfall. Food availability has declined in a corresponding way and the people have been forced to adopt all sorts of survival strategies to cope.

Moreover in 2003 NGOs were playing a vital role in providing maize, beans and cooking oil which was of general benefit to the whole community. School feeding points had been established for children and extra mealie meal and beans were being provided for pregnant women and breast-feeding mothers. The recipients were heavily dependent on these feeding programmes. Yet in mid 2004, against all the future projections of experienced relief workers from the United Nations and the donor community, the regime declared that it was expecting a "bumper harvest". On this pretext Robert Mugabe ordered international food donors out of the country and terminated a UN food survey which was then under way. The bumper harvest was of course totally illusory. On the contrary, and as firmly predicted by UN officials, Zimbabwe soon ran into a severe deficit of cereal grains, which it has only managed to offset minimally by the regime's own efforts to import from the region. We have already alluded to the devastating impact of the restrictions imposed on donor food aid. The significantly increased number of young children presenting at Zimbabwe's major hospitals towards the end of 2005 and subsequently with varying degrees of malnutrition is but one instance of this.

Malnutrition studies on under-fives based on actual-against- potential growth are few and far between. There is an urgent need for this kind of research, though finding qualified practitioners with the time to do it and then overcoming the regime's natural reluctance to allow research in such a politically sensitive field, mitigate strongly against it. Such limited and informal studies however as have been undertaken, in rural Matabeleland for instance, tend to suggest that a significant number of children are experiencing episodes of static weight or actual weight loss. One study shown to us in which weight development of a random sample of under-fives was tracked from February 2003 to February 2006 revealed that nearly a third of those monitored had experienced actual weight loss at some time during this period. And most significantly the study showed that episodes of static weight or weight loss only set in late in 2004 after NGO feeding had been declared superfluous by the regime.

In his own words the verdict of the practitioner responsible for this study was as follows: "a government that once stood for an end to colonialist and racist notions of what 'the natives' were entitled to, and a Ministry of Health that once opted to make the realization of children's growth potential the aim of its under-fives policy, have proven, when gauged by their own yardstick, not only their utter inability to deliver, but even their deliberate intent to sacrifice the well-being of their youngest citizens." This is surely as damning an indictment of the regime's track record in the medical field as one could ever expect from a professional employed in that field.

In summary we may say that while there is no general acute nutritional emergency yet evident in Zimbabwe there is good reason to be deeply concerned about the deteriorating situation. More than this, there is reason to act now, without delay, because of the regime's own "utter inability to deliver" or, worse still, "their deliberate intent to sacrifice the well-being of their youngest citizens". Few skeletal figures of the starving there may be at this point in time to shock the world into action but that is absolutely no reason for complacency. The fact is that, judged by their own yardstick, the regime and its health delivery system are already failing seriously and the suffering thereby inflicted on the nation's children is increasing steadily. The urban figures presented provide a clear message. Current food insecurity and shortages are likely to continue for an extended period of time and this will only add to the misery. One has only to speak to some of the medical personnel in the front line of the battle against famine and its terrible effects, or to some in the caring professions like pastors and social workers, to sense how urgent is the problem. We cannot, we dare not, wait for the full scientific survey which would undoubtedly help, for that will not be forthcoming under the present regime. To wait for the regime itself to respond would be naïve and foolish. No. The time has surely come for the international community to come to the rescue of Zimbabwe's most vulnerable through the intervention of the United Nations.

The report of the International Commission on Intervention and State Sovereignty states that "state sovereignty implies responsibility … for the protection of its peoples". It provides further that

"where a population is suffering serious harm, as a result of … state failure, and the state in question is unwilling or unable to halt or avert it, the principle of non-intervention yields to the international responsibility to protect."

Let not the regime of Robert Mugabe prattle on about national sovereignty. They have had the opportunity - 26 years in fact - to provide appropriate protection for all the people of Zimbabwe and they have failed lamentably. Nor is there any prospect of the suffering of the people reducing in the foreseeable future. On the contrary. The time has come therefore for the international community through the agency of the United Nations, to do for Zimbabwe's people what the regime is "unwilling or unable" to do. Let the United Nations intervene.

And until that happens let Zimbabweans who care join their protest cries to the silent cries of the little ones.