Beyond reproach: Are Zimbabwe’s doctors accountable to anyone?

Some of Zimbabwe’s private doctors could be getting away with “murder” because no one polices them. Even in cases where malpractice is proven it is very difficult to prosecute them because the medical fraternity is so solidly behind each other that it is difficult to get witnesses. Worse still, the government seems to have reneged on its responsibility to monitor their activities because it is afraid they will leave the country. Another reason is that they are allegedly providing “high quality health care at no cost to the taxpayer”.

These are some of the findings by two American researchers, David and Sheila Rothman, who visited Zimbabwe last year at the request of Charles and Mary Khaminwa, following the death of their daughter, Lavender at the Avenues Clinic in August 1990.

The Rothmans’ reports was recently published in the New York Review of Books.

The Khaminwas were a Kenyan couple who came to Zimbabwe in 1984 so that Charles, a lawyer, could direct a community development project. They wrote to the human rights organisation, Africa Watch, requesting to bring to book those responsible for the death of their daughter.

Lavender, who was only 10 years old and was attending a boarding school in Harare, came home in the first week of August complaining about stomach pains. She was taken to a family paediatrician who recommended that she see a surgeon. On August 9, she was admitted to Avenues Clinic. She underwent an appendectomy the following day and died a few hours later.

Following the autopsy the Khaminwas were convinced that their daughter was a victim of “wrong, unorthodox , hazardous and seemingly experimental treatment, and of poor or non-existent post operative and post anaesthetics surveillance and care”.

The Khaminwas tried for six months to persuade medical societies and public officials to investigate the circumstances surrounding their daughter’s death, but they were unsuccessful. In fact, to them, it appeared there was a “conspiracy of silence” within the medical fraternity.

“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,” they said in their letter. The politicians, they said, “leave their medical communities to more or less administer themselves”. As a result physicians inevitably covered up for each other, and the average patients whose “fear of authority, any kind of authority, had become so ingrained” cannot even imagine mounting a protest.

The Khaminwas frustrating campaign began on the day of Lavender’s death. They were at the clinic during her surgery, spoke with her briefly in the recovery room and returned home. They received a call at 9 pm saying that Lavender had collapsed. They rushed to the hospital but she was dead by the time they arrived. They went to see the anaesthetist and all he had to say was that Lavender had suddenly stopped breathing.

The surgeon had nothing to add. The administrators of the clinic refused to provide any details saying the clinic was not legally responsible for the physicians’ medical practices. The chief executive of the clinic said all patients were admitted in the care of their doctors. The clinic provided facilities and equipment . If anything went wrong the doctor and the patient had to resolve it between themselves.

“This policy of limited responsibility shows the Avenues’ determination to return profits to its investors,” the Rothmans say. “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 committees to monitor medical practice and equality of care, the clinic did not provide for any supervision. There were no departmental divisions, no chief of medicine or of surgery who might take note of a colleague who consistently made errors. Since the clinic was not affiliated to the 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.”

After failing to make any headway with authorities at Avenues Clinic, the Khaminwas managed to secure three doctors including one from Kenya and another from South Africa to be present at the autopsy. The autopsy revealed that the anaesthesia that Lavender was given was, to say the least, unorthodox and the care she received in the first hours after surgery was grossly inefficient. The mix of anaesthesia was standard (nitrous oxide and halothane) but between putting her to sleep and the start of the surgery the anaesthetist administered four milligrams of morphine.

“Why he did so remains something of a mystery, for it was wholly unnecessary, ” the Rothmans say. “The most likely explanation is that a number anaesthetists in Europe and 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 anaesthesia 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 anaesthesia 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 a faulty anaesthetics technique and inadequate nursing supervision.”

The Khaminwas made a formal complaint to the Health Professions Council which is supposed to investigate cases of improper or disgraceful conduct, or grossly incompetent medical practice. The council is also empowered to reprimand, fine and in the most serious cases, remove those it finds guilty from practice. Although the council agreed to investigate, it never sought evidence from the Khaminwas including the autopsy reports they had. It did not also permit them to hear or review evidence given by others.

When the Khaminwas asked for a progress report on the council’s investigations, they received the following 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 several inquiries they were informed: “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 recognised procedures and the nursing staff carried out their duties in accordance with the doctor’s instructions.”

Thus, as far as the council was concerned, the case was closed. But the Khaminwas decided to take it further. This time they took up the case with police but they too could not do anything. This was despite the fact that the Khaminwas documented other instances of incompetence by the same anaesthetist who treated Lavender. In one case, a boy suffered irreversible brain damage after surgery for circumcision, a lady died after having a tooth extracted and a young girl died during surgery to remove a gall stone.

Lavender’s case even got to Parliament but Health Minister Timothy Stamps successfully opposed the motion siding with his fellow doctors who were “respected specialists whose loyalty to Zimbabwe is unquestionable.” Stamps also said the attack on doctors at Avenues Clinic was a “deliberate assault on government’s attempts to attract and retain competent specialists at terms much less favourable than they could attract just across the border.” The investigation that the Khaminwas were calling for, he claimed, would accelerate the “brain drain” of doctors.

The Rothmans , say this “conspiracy of silence” by the medical fraternity is rooted in the country’s post independence history. When President Mugabe took over power, he chose to placate the whites through his policy of reconciliation hoping to avoid the flight of capital and to retain people with managerial and technical skills. The government, therefore, allowed private services to exist along public ones. This resulted in wealth replacing race as the decisive factor in a segregated society.

The Rothmans say from the government’s perspectives this two-track system, has many advantages. In medicine, it kept white discontent to a minimum, while shifting the entire financial burden of obtaining modern medical care to the white community. At the same time, they say, public medical funds could be used to underwrite preventive health programmes to the latest technologies while blacks got little more than inoculations because the government has almost completely neglected the public hospitals. This is exactly what whites in the Smith era had anticipated. And in preparation for this eventuality they had established their own private, for profit hospitals like Avenues Clinic, which was opened in 1981 to cater for the elite.

According to the Rothmans, the sponsors of Avenues Clinic looked forward to handsome returns on their investment, 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 technologies. But the medicine practised there is often frightening,” the Rothmans say. “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,” they say.

They say that while maintaining effective monitoring of medicine is never easy, at least some countries have procedures to identify negligent or incompetent physicians and to discipline or remove them from practice. These include weekly staff meetings to review the course of treatment for each patient who dies while in hospital and to compare autopsy reports with physicians’ diagnosis. Another safeguard is the tissue committee which reviews pathology reports to see whether the appendix that the surgeon removed was actually diseased, or the tumour excised malignant.

“Such procedures sometimes fail, but they do not exist at all either in Zimbabwe’s overtaxed public hospitals or in profit-making clinics such as Avenues,” they say.

Because the government is reluctant to hold doctors accountable for their actions, it has failed to set a more equitable system of health care, the Rothmans say. They point out that, for example, although three-quarters of the country’s population lives in the rural areas three quarters of all the doctors in the country, “for reasons of personal comfort, income and prestige” practise in Harare and Bulawayo.

“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,” the Rothmans say. “Government salaries and payments to doctors 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 health – through higher salaries and better equipment, for example — the government simply points to the anger of doctors leaving the country if any changes are made.”

They also say that the Zimbabwean experience shows that when free-market economics provide the only control on medicine, the quality of health care deteriorates. Both patients in public and private hospitals suffer, one from lack of care and the other from incompetent care.

“Zimbabwe’s doctors, both at Avenues Clinic or on the Health Professions Council, might have compensated for the lack of State regulation by setting up their own review committees,” the Rothmans say. “Their failure to do so shows the destructive effect that financial self-interest can have on professional standards.”

They also said they had learnt from the Zimbabwean experience how “the State can corrupt the profession through excessive indulgence, leaving medical professionals entirely to their own devices, while the State-chartered medical organisations themselves do nothing to monitor the quality of medical treatment. The result was 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.”

Another worrying aspect, according to the Rothmans, was that if people like the Khaminwas who not only had the knowledge of the law but could devote more time to their case could not bring those responsible for their daughter’s death to book, what chances did an ordinary citizen have?

The answer was, nil. Even Zimbabwe’s Chief Justice, Anthony Gubbay, was quoted as saying he could not recall a single malpractice case in the past 20 years. The International Medical Defence Union (OMDU) also said Zimbabweans hardly ever considered taking legal action against doctors.

“Patients are grateful for the medical attention received and in any case are not litigious,” the IMDU says.

The Rothmans say one of the reasons why malpractice suits are rare in Zimbabwe is that it is illegal for lawyers 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 if they win. Moreover, they argue, costs are very prohibitive in Zimbabwe. Plaintiffs are awarded damages only for lost income and out-of-pocket expenses, not for “pain and suffering.”

Lawyers here refuted this claim saying plaintiffs could be compensated for pain and suffering.

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