Reproductive Health in Zimbabwe

I haven't written about the content I taught while in Zimbabwe.  I guess I needed to get past teaching my courses in reproductive health (for masters' level MPH students) and family health (for undergraduates in a program training them to be administrators in small health clinics so that I could give some thought to the material I taught.

It's been a rocky road for Zimbabwe in terms of its health care in general.  Before Zimbabwe became an independent country in 1980, the quality of people's health care depended largely upon race, and also upon whether a person lived in a city.  Whites and urban dwellers got pretty decent health care, and most other people did not.  Then there was a period of about ten years in which Robert Mugabe and his government tried to rectify that situation by putting more money into rural health care and providing universal free maternity and child health care.  The result was a decline in infant mortality (often taken as a good indicator of the overall health of a country) from 70.4/1000 in 1978 to a low of 50.2/1000 in 1988. (For comparison, the US, which has been criticized for its high infant mortality in the context of developed countries, was 6.1/1000 in 2005, and has been relatively steady for decades.)  At that point policies reversed, and women began having to pay fees for prenatal care, delivery with a skilled birth attendant present, and neonatal and infant care.  As a result, earlier progress was eroded.  Throughout its history since independence, maternal mortality has been high in Zimbabwe.  In 2006 it was 555/100,000, compared to the US's 12.7/100,000.  A more graphic way of presenting this information is the lifetime risk of maternal mortality for women.  In 2008 is was 1:42 for Zimbabwean women and 1:2100 for US women.

During the period since Zimbabwe's independence, its birth rate has steadily declined from 47/1000 women of childbearing age to 29/1000 (compared to 14/1000 in the US).  Over 21% of Zimbabwean women are mothers or currently pregnant at least once as teenagers, which is very high.     In the 1980's, the HIV/AIDS epidemic hit Zimbabwe, and by 1995, more than 25% of the adult population was infected.  This put a tremendous strain on health care systems, which has continued to the present day.  Largely as a result of the HIV/AIDS epidemic, there are many orphans in Zimbabwe (980,000 estimated in 2003, out of a population of about 12,000,000), and many children being cared for by grandparents or other relatives even if not orphaned because of parental incapacity due to HIV/AIDS.  Only 52% of the population is in the age range (15-64) that usually is responsible for the financial support of everyone, compared to 67% of the population in that age range in the US.  Malnutrition in childhood is an issue: in 2006, 36% of children under 5 years of age were malnourished (height for age), compared to 3.9% in the US, and more than 7% were wasting, compared to .6% in the US.

It is challenging for a sub-Saharan African country with such devastating health statistics and such a precarious economy to make progress on health issues.  As you've seen in some photos in earlier blog posts, equipment is rudimentary at best in rural health clinics.  People often don't seek medical services.  Although there are a small proportion of Zimbabweans who won't use medical services due to religious convictions, lack of money is a far greater factor in people's decisions to postpone or avoid medical treatment. Zimbabwe is a country with a per capita income estimated at $500, compared to $21,587 in the US.  In 2009, the per capita health expenditure in Zimbabwe was $6, compared to $7410 in the US.

Teaching reproductive health in the Zimbabwean context was a challenge.  The class and I had to focus on inexpensive interventions, and to think about how to make those interventions acceptable in the cultural contexts of the countries of my students.  I learned about sexually transmitted infections I'd never learned about in graduate school because they just aren't found in developed countries.  I had to scale back my expectations about routine health care when I learned that very few women ever get Pap smears, much less mammograms.   I learned about current thinking about how to minimize parent-to-infant transmission of HIV/AIDS, again in the context of Zimbabwe (where most mothers don't even know their HIV status). It was a challenge, but one from which I learned a great deal.  My thinking is much more flexible now than it was before, and I respect the barriers in sub-Saharan Africa to providing the kind of health care that I believe all people deserve.
I have no comprehensive answers to the challenges faced in Zimbabwe and the rest of sub-Saharan Africa when it comes to reproductive health.  I'd worry about me if I thought I had the answers.  What I have is a great deal more information about the nature of the challenges, and a huge amount of respect for the health professionals who work every day to try to overcome them.  I feel blessed to have been a part of the development of a few of these professionals, and wish them well in their efforts to develop programs and health clinics that make good use of the few dollars available to them to do the most good for the most people they can.  That's all anyone can do.