ethics

case study

 

Due to crumbling infrastructure, sewage plants in Zimbabwe begin leaking raw sewage into rivers. Within weeks, thousands of people who rely on the rivers contract cholera. The Zimbabwean government denies that the country is experiencing a cholera pandemic, despite thousands of deaths and sick refugees presenting in bordering countries, and refuses to act on the emergency. Can the international community legally intervene in instances when a state is unwilling or unable to control an epidemic?

The above scenario mirrors what occurred in Zimbabwe in 2008, and raises the question of what recourse populations have in the event of a disaster if their host state is incapable or unwilling to provide basic aid and is reluctant to request international assistance. Currently there is no general convention that governs all aspects of disaster relief, in stark contrast to international humanitarian law, which protects civilians during armed conflicts (Davies 2010). On the question of humanitarian access, international law tends to favour the protection of sovereignty and territorial integrity over the protection of populations (United Nations 2007). However, while international law does not currently govern humanitarian disasters, the WHO’s revised IHR (2005) lists cholera as one of the diseases about which states are required to notify WHO, due to its potential serious public health impact and its ability to spread internationally. The IHR requires that states request international assistance if they have insufficient antidotes, drugs, vaccine, protection equipment and financial, human and material resources to contain the disease. The breakdown of the public health system in Zimbabwe, the case fatality rate of cholera victims, and the speed at which the disease spread in 2008 all pointed to the state being unable to effectively contain the disease outbreak (Davies 2010). In terms of the IHR 2005, Zimbabwe’s 2008 cholera outbreak constituted an emergency and the Zimbabwean government had a duty to accept the assistance offered by WHO and various NGOs. In instances where a state still refuses to accept international intervention in the face of a major disease outbreak, the UN Security Council could become involved. The UN High-level Panel on Threats, Challenges, and Change (United Nations 2004) noted that in certain instances:

[T]he Security Council should be prepared to support the work of WHO investigators or to deploy experts reporting directly to the Council, and if existing International Health Regulations do not provide adequate access for WHO investigations and response coordination, the Security Council should be prepared to mandate greater compliance. In the event that a State is unable to adequately quarantine large numbers of potential carriers, the Security Council should be prepared to support international action to assist in cordon operations. The Security Council should consult with the WHO Director- General to establish the necessary procedures for working together in the event.

Due to the possibility of being classified as a failed state (which would have opened the door to possible UN Security Council intervention), the Zimbabwe government eventually declared the cholera outbreak a national emergency in December 2008, and invited WHO to coordinate a Health Cluster response effort with the cooperation of the Zimbabwe health ministry and other nongovernmental agencies.

 

n this assignment, you will examine the international legal entities dealing with global health law incidents. Read “Cholera Outbreak in Zimbabwe” (5.2) on pages 68-69 in An Introduction to Global Health Ethics. In this case study, you explore options available for dealing with this health crisis. Write a four- to five-page paper evaluating the steps Zimbabwe should take in dealing with this situation and provide your recommendation on how to remedy a future situation.

Your report should address the following substantive requirements:

• Examine the purpose of laws.
• Describe and assess each agency that would be involved in the situation. Include pros and cons for international involvement in state affairs.
• Develop a law that would prevent such a breakdown from occurring in the future and use reasoning to illustrate why such a law would not be considered intrusive.

Your well-written report should meet the following requirements:

• Be four to five pages in length, not including the cover or reference pages.
• Formatted according to Saudi Electronic University and APA writing guidelines.
• Provide support for your statements with in-text citations from a minimum of four scholarly articles. Two of these sources may be from the class readings, textbook, or lectures, but two must be external.  
• Utilize the following headings to organize the content in your work:

  Introduction
  Description and Assessment
  Recommendation
  Conclusion 

please include citation in the body of the paragraph please please 

International

Journal of Humanities and Social Science Vol. 2 No. 24 [Special Issue – December 2012]

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Prioritizing Political Banditry than Good Governance: Rethinking Urban

Governance in Zimbabwe

Wellington Jonga

Ethiopian Civil Service University

P.O. Box 5648, Addis Ababa, Ethiopia

Abstract

Zimbabwe local government system between 1980 and the late 1990’s was robust and envied by many in Africa.

However, the birth of multiparty democracy and the fight to remain dominant changed the political landscape and

result in the recentralization of administrative authority and political power. Political banditry was still borne

and was nurtured in various types of incubators until the year 2000 when the Zimbabwean urban communities
begun to be victims of a system they failed to condemn at its adoption. The aim of the research is to describe the

concept of political banditry, how it is experienced and its effects on the application of democratic good

governance in Zimbabwe. Content review was complimented with primary data in this qualitative research. It was
found out that political banditry is there and it is perpetrated through, political appointments, restructuring of

local institutions, violence, political parties also are supporting informal violent interests groups and

recentralization of administrative and political authority and power. The agony is that the urban communities
have been marooned or raped by these political violence and administrative aptitudes. Urban communities now

cannot tame the beast they helped to create over the years (political banditry). It was indicated that

representative democracy seems to be a failure in Zimbabwe. The structures are there but they have been

captured by political bandits to serve their individualistic interests. Representative democracy needs to be
complimented by deliberation so that the people who own government and the ensuing democratic processes

could be involved in determining and reviving the institutions, the will, the commitment and the application of

democratic good governance in Zimbabwean urban areas.

Introduction

Zimbabwean urban areas are governed by one law, that is, the Urban Council Act and this legislation has bee

changed continuously since independence from the Urban councils Act (Chapter 214), Urban Council Act

(Chapter 29:15) and finally to the Local Government Laws Amendment Act, 2008. There is currently effort to

change again this Act because the stakeholders believe that the existing piece of legislation gives unlimited
powers to the Minister of Local Government. It can also be pointed out that the new constitution under design will

attempt to describe the type of local government system good for and applicable in Zimbabwe. The definition of

Zimbabwean local government system in the constitution may help to control the authority of the minister
concerned. An example is that the Minister responsible for local governments may not be conferred the power or

authority to change the Local Government Act without a referendum or approval of parliament. This system of

control will greatly bring sanity to the area of local government administration which has become illusive for
many years. The changes that were effected so far were dictated by both administrative and political pressures.

However, politics has played a considerably big role in changing the dynamics of urban good governance in

Zimbabwe. From the 1980 to about 1995 the Zimbabwe African National Union (Patriotic Front) (ZANU-PF)

dominated the politics of Zimbabwe. I mean Zimbabwe was basically a defacto one party state and not a de jure
not by because the citizens wanted the approach but because of fear of the political system or environment and

also because of the previous brutality of the colonial regimes. ZANU (PF) was a better devil politically and

administratively than political occupation and colonial racial discriminations that were ultimately portrayed in
non-development, segregation in provision of health, education, residential areas in urban areas and the division

of the areas outside urban areas into Tribal Trust Lands for Africans and larger Commercial areas for whites

colonialists.

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The urban areas and commercial farming areas because they were demarcated for profitable commercial

activities, were under direct white colonial administrations and the poor Tribal Trust Lands (later renamed District

Councils) had poor soils, rainfall and were tsetse fly infested and these areas were allocated to the blacks. It was
this political and administrative segregation that provoke the war of liberation that ultimately end up with the

creation of the state of Zimbabwe. Thus from the beginning the majority of Zimbabweans supported the war of

liberation with the intension of getting freedom – freedom from all oppression from the political systems and
institutions that had enslaved them for many years. Freedom was the binding alternative to say the least.

However, it seems as if after independence freedom has become evasive as ever. The ZANU-PF Government has

changed colours by replacing freedom and development with political banditry, centralization of power, murder,

concentration of land and economic privileges in the hands of few ZANU-PF Party cronies and eradication of
freedom of speech and association. To sum the political situation it is befitting to say that Zimbabwe has a

dictatorship government. This dictatorial approach to governance has left many institutions in limbo either

because of financial bankruptcy or administrative incapacity because of too much interference from central
government. This research is focusing on how the interventions of the Ministry of Local Government in the local

affairs of urban councils has influenced or affect the implementation of good governance in such institutions.

What seem eminent is that the Ministry of Local Government has left the decentralization approach in favour of
recentralization and political banditry in the administration of local authorities.

Democratic decentralization has been preferred for reasons that include administrative, fiscal, and political
decision-making. Decentralization is justified if it promotes democratic good governance and furthermore

participatory approaches to development. It is also argued by experts that decentralization depending on the

specific type adopted can bring government closer to the people and can also enhance communities‟ participation
and interaction with local government officers in the affairs of the locality, (Mawhood, 1983, Sharma, 1995,

Matlosa, 1998, Olowu, D, and Wunch, 2004, Cheema, 2005). Moyo (2010) expresses that decentralizing

governance should not be seen as an end in itself; it can be a means for creating more open, responsive, and
effective local government and for enhancing representational systems of community-level decision making. By

allowing local communities and regional entities to manage their own affairs and through facilitating closer

contact between central and local authorities, effective systems of local governance enable responses to people‟s

needs and priorities to be heard, thereby ensuring that government interventions meet a variety of local social
needs. Zimbabwe‟s local government system was considered worldwide as one of the best systems in Africa,

(Government of Zimbabwe, 2004). It was an immaculate and robust local government system cherished by many

in the sub-region before disaster form ZANU-PF political machinations struck.

In many developing countries, for example, Uganda, Ethiopia, Zambia, South Africa, Brazil, Mexico, Indonesia,

the Philippines and Mozambique and including Zimbabwe, the ends of local government are often unclear and
multidimensional including the promotion of local democracy and participation in national politics and

development; providing structural framework for the provision of local services, promoting local administrative

efficiency and in rather few cases, providing a framework for local economic development, (Rambanapasi

, 1992).

Fundamentally therefore, local authorities (and their lower tier structures) are a creation of the Government of

Zimbabwe (GoZ), created to execute its efforts in terms of reaching out to the people at the ver y grassroots of

society.

The performance of these sub-national institutions has continued to deteriorate over the past years as the country

continued to witness signals of administrative ineptitude on the part of councils, (Institute for Democratic
Alternative for Zimbabwe, 2010). The daily complains or criticisms of the performance of urban councils by

communities, local and national politicians and civil society organizations especially in the media could be an

indication of stakeholders‟ reservations with the current governance performance of these institutions. The need to

improve good governance in urban councils has continuously irked both the Zimbabwe African National Union
(Patriotic Front) (ZANU – PF) and the Movement for Democratic Change dominated local governments between

the years 1980 and 2010, (Institute for Democratic Alternative for Zimbabwe, 2010). Continued political banditry

from the Ministry of Local Government has left opposition politicians, the lay man, civil society and civil
organizations and scholars worried but with a deem view of what will happen to the local government system of

Zimbabwe.

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Dialoguing political banditry in urban areas of Zimbabwe

The concept is born from two words, that is, politics and bandit. However, politics is a normal and acceptable way

of life throughout the world. Politics generally indicates competition for political space. It is also competition for
control of a constituent through use of propaganda and truthful information. Thus politics could be viewed as

platform provided by the government to allow politicians competing to communicate their policies, programmes

and projects to society so that ultimately society or communities can choose the political structure that will more

likely their perceptions and interests. It is like showcasing some thing good that will come in future or that has
been done and that will be improved on. A bandit on the other hand is an unwanted individual. He/she is someone

who is against a legal system that is existing even if that system does not necessarily mean is wrong. The idea is

that the bandit will use violence like murders, destroying communities‟ shelter and livelihoods and community
structures to cause mayhem.

The issue of political banditry is special for Zimbabwe because the bandit is not an outside force but a political
party, government and the politicians the urban communities were supporting yesterday. They have become

political bandits because the aspirations now contradict normal country or Zimbabwean communities‟ aspirations.

They party or parties are now murdering or killing the innocent individuals to force these communities to support
them. If readers could be taken back to “Murambatsvina” WHEN even the United Nations felt remorse to the

extent of deliberating the issue and sending a representative to Zimbabwe despite the fact that that representative

was received with utter animosity. The Zimbabweans know and understand democracy. They vote every four

years for their representatives. They problem is that these representatives, political structures, government and
certain interest group are no longer accountable to the people, transparent in their political dealings, do not respect

the rule of law or political and social freedoms and some of them no longer represent people‟s interests.

This is a fiasco where the institutions that are tasked with supporting and defending people‟s rights are the very

institutions now oppressing the greatest majority of the Zimbabwean society. The people now do not now what to
do. They are afraid of the state repressive security department, the intelligence, the army and the police who are

openly compromising the country laws for the benefit of specific interests that include political parties,

individuals and political interests groups. The perpetrators are not hiding anything but they are using political

structures and system that are available to them. They are political bandits because they are manipulating these
structures corruptly to advantage the selfish interests. Society has been maroon by government for the benefit of

individuals in government. Political banditry like this is dangerous because even if it is easy to see to deal with it

needs cautiousness, international support and meticulous system that collect information and train communities to
regain control of their rights and freedoms. The research was thus motivated to write this paper because he had

viewed the situation in urban Zimbabwe and concluded that what is happening is not democracy at all but

political banditry that is humiliating the citizens in a parochial form and political machinations portrayed by
ZANU-PF Party and other political groupings as democracy at work. Thus in this cases political banditry is a

situation whereby the politicians could do certain wrong things knowingly bout they do it for their personal

objectives or gains. It includes, corruption, stealing, fraud, violence, murders and killings, manipulation of laws,

disrespect of rule of laws, non accountability to the constituencies, lack of transparency and so on. These
mentioned aspects are generally against the establishment of good governance at the local and national sphere of

Zimbabwe.

Research problem and objectives

The current situation of highly charged political tense and a situation were central government intervenes willy-

nilly is tantamount to a fiasco situation that deserves immediate salvaging from the neutral, affected and infected

Zimbabweans and related civil organizations. The focus of the research is to unveil the different strategies

employed by central government to intervene into local affairs and in addition to analyze how this intervention is
hampering local good governance implementation. The current public management of urban councils is like a

satire in the book “Animal Farm” were George Owel portray the powerful individuals in a society like the pigs

specifically like Napoleon (in the Zimbabwean Situation those in ZANU PF Party) could urinate on other
people‟s plans (Movement for Democratic Change (MDC) and the impoverished). The question is „How is this

theatre unveiling?”

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Research methodology

The analytical research data was derived from four Provinces‟ biggest cities of Harare, Bulawayo, Mutare and

municipality of Bindura. Primary data gather through a questionnaire and secondary data from content reviews
was used to deveop the research article. Content reviews included reading and analyzing data from internal urban

councils‟ documents and media reports. A target population of 98 was used from which a sample of 48

respondents was drawn using simple random sampling technique.

Reflections on the definition of democratic good governance

Citing the United Nations (UN, 1996), Dool (2005) articulates the definition of urban good governance as the sum
of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city.

It is a continuous process through which conflicting or diverse interests may be accommodated and cooperative

action can be taken. It includes formal institutions as well as informal arrangements and the social capital of
citizens. Ferlie, at al (2007) summarized the different definitions of governance in an attempt to show diversity

and divergence of views. Governance is the structure of political institutions. Governance is the shift from

bureaucratic state to the hollow state or to third-party government (Milward and Provan 2000; Salamon 2002,

Rhodes 1997). Governance is market-based approaches to government (Kettle 1993, Nye and Donahue 2000).
Governance is the development of social capital, civil society and high levels of citizen participation (Hirst 2000,

Kooiman 2001; Sorensen 2004). Governance is the work of empowered, muscular, risk-taking public

entrepreneurs (Osborne and Gaebler 1992). Governance is Tony Blair‟s “third way”, a political packaging of the
latest ideas in new public management, expanded forms of political participation and attempts to renew civil

society (Newman 2001). Governance is the new public management or managerialism (Kernaghan, Marson and

Borins 2000). Governance is public sector performance (Heinrich and Lynn 2000).

Governance is inter-jurisdictional cooperation and network management (Frederickson 1999; O‟Toole 2003;

Peters and Pierre 1998). Governance is globalization and rationalization (Pierre 2000). Governance is corporate
oversight, transparency and accounting standards (Monks and Minow 2004; Jensen 2000; Blair and MacLaury

1995). Kigongo-Bukenya (2011) on the other hand states that good governance generally connotes how public

institutions conducts public affairs and manage public resources in order to guarantee human rights,

accountability, transparency and public participation in decision-making. Good governance emphasizes
interaction among people, structures, processes and traditions in providing sound leadership, direction, oversight

and control of an entity in order to ensure that its purpose is achieved and that there is proper accounting of the

conduct of affairs, the use of resources and the results of the activities. Good governance is the corner stone of
transparency, integrity, honesty, loyalty, commitment to genuine profit of humanity. Good governance is ethical

behaviour in public and private life, (Ibid).

Khandakar Qudrat-I Elahi (2009) explains that while governance is understood as the exercise of economic,

political and administrative authorities to manage a country‟s affairs, good governance are the processes and
structures that guide political and socio-economic relationships. The absence or extent of good governance is

implied by several characteristics, for example, participation means all men and women have voices in decision-

making, either directly or through legitimate intermediate institutions. Rule of law refers to fair and impartially

enforced legal frameworks. Transparency indicates the processes, institutions and information accessible directly
to those concerned. Responsiveness means the reactions of institutions and processes to the demands and the

concerns of stakeholders. Good governance is consensus-oriented meaning it creates broad consensus through

mediations among different stakeholders. Equity means all men and women have opportunities to improve or
maintain their well-being. Effectiveness and efficiency indicates that processes and institutions produce results

that meet needs while making the best use of resources.

Accountability means decision makers in government, the private sector and civil society organizations are

accountable to the public, as well as to institutional stakeholders. Strategic vision expresses that leaders and the

public have a broad and long-term perspective on good governance and human development, along with a sense
of what is needed for such development. There is also an understanding of the historical, cultural and social

complexities in which that perspective is grounded. Interrelated, these core characteristics are mutually

reinforcing and cannot stand-alone.

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The UNDP (2000) posits that one survey in Zimbabwe discussed good governance in terms of attaining a good
society characterized by, positive relationships at all levels based on equity, understanding, cooperation and

mutual respect, respect for the citizens‟ political, economic and social rights, fair distribution of resources,

maximum development of individuals and communities, a strong and committed leadership as well as peace and
democracy. It is further stated that good governance ensures that political, social and economic priorities are

based on a broad consensus in society and that the voices of the poorest and the most vulnerable are heard in

decision-making over the allocation of development resources. In urban development and management, the future

is not some place the nation is going to, but one the nation is creating. Therefore, good vision, planning and
capacity building on the part of city fathers and managers are necessary. Political bickering and destruction by

ministers and political parties at the detriment of forward planning and good governance is an unfortunate

tolerance on the part of the residents.

2.3 Dialoguing the philosophy of good governance

Saltzstein, Copus, Sonenshein and Skelche (2008) indicate that Woodrow Wilson (1887) looked favourably
upon governance in England and Germany, where he found greater efficiency and professionalism. He

argued that the superior techniques of management found in Europe could be applied directly in the United

States by separating policy and administration and by employing professional, non-partisan administrators rather
than individuals appointed through the spoils system. The intentions of Wilson‟s reform movement were

epitomized in the council-manager plan. This was intended to increase the efficiency and economy of the internal

operations of the city administration and promote decision -making in the overall public interest of the city
rather than the partisan agendas of particular groups. When a researcher views Wilson‟s ideas in the 1880‟s and

then compare with Zimbabwe‟s leaders in the 2000‟s the issue of nation building and perceptions on development

comes into play. In Zimbabwe, the politicians have openly supported bureaucrats who are political by supporting

the Zimbabwe African National Union-Patriotic Front (ZANU-PF). To these leaders or politicians, a good
bureaucrat is a ZANU- PF supporter meaning that there is no distinction between politics and administration. In

addition, ZANU-PF Government because of this stance has appointed only ZANU-PF supporters or politicians to

positions of power at national and local levels. They despise the ideas of Max Weber, Herbert Simon and Chester
Barnard and many other scholars who treasured the neutrality of bureaucrats in performing public business.

The politicization of the public offices that include urban councils has incited controversy and acrimony and
ultimately resulted in the dysfunctioning of the local governments. In Zimbabwe urban councils, „full council‟

debates and the conduct of councils‟ business in general have been politicized. Policy making and management of

councils‟ public goods and services have a political party connotation or ingredient in their outlook. It is
unfortunate that when urban council business is divided on party lines the local politicians (councillors) adopt an

individual goal as opposed to community or constituents goals and objectives. This is the major reason why the

councillors become selfish and corrupt because they become accidentally bigger than the constituents that elected

them. They trade ethical behaviour for selfish and immoral individual desires of becoming permanent councillors
or national politicians even if it means murdering or supporting murders within communities they represent. The

collusion of such politicians and those who are supposed to be bureaucrats has left many urban councils in

Zimbabwe bankruptcy financially, policy and good governance wise. The bureaucrats in this situation cannot
advise the politicians in council chambers because their tenure or survival as council employees is dependent on

rubber stamping or ordinarily supporting Zanu-PF or Movement for Democratic Change (MDC) councillors‟

policies or political machinations.

Mugabe (UNDP, 2000:86) defined local governance as a process of involving people in the making of decisions,

which affect their livelihood in a transparent and accountable manner. It entails the devolution of power and
responsibilities upon lower levels of society, encouraging participation, recognizing the diversity of communities

and societies, and the promotion of openness and elimination of corruption in managing public resources. It is

further reiterated in this report (Ibid), that the issues related to training of elected and permanent officers of urban

councils relate very well to the subject of good governance. It is assumed that an informed councillor or executive
officers will implement and support the principles of good governance than otherwise. Despite the above

definition by the Zimbabwean President he has adopted a dictatorial governance system both at national and local

levels.

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This only indicates that good governance is not a monopoly of democratic governments but that even dictators

can achieve efficiency and effectiveness (sometimes referred to as good public administration) through

application of ruthless means. Many Zimbabweans have traded their lives for democracy. Despite death of many
democracy activists many have also sort asylum in many countries worldwide. However, despite these

observations Zimbabwean leaders particularly those from the ZANU-PF Party still use good governance as a

word for and an instrument of propaganda. They portray themselves as champions of democracy and good
governance even if their policies and political environment portray otherwise.

Transparency is a major characteristic of good governance. Hyden in Mehde, (2006) argues that governance is the

conscious management of regime structures with a view to enhancing the legitimacy of the public realm. An

aspect, which is always linked to good governance, is transparency. Transparency is strongly equated with the

philosophy of openness. Wright in Mehde (2006) points out that improved transparency and effective mechanisms
of evaluation could reveal disparities in the outcomes of benefit of certain groups of people, so that an upgrading

of previously relatively badly-treated people is a possible consequence. It therefore, implies; participation in

decision-making; involvement of citizens; accountability; answerability and political responsibility, (Du Toit, et al
1998:146). In Zimbabwe transparency has been replaced by autocracy and political banditry. Central Government

through the Ministry of Local Government has intervened in local affairs attacking politicians and decisions that

contradict ZANU-PF policies and specifically national politicians to the detriment of local democracy and

development. In many cases, transparency and participation freedoms have been curtailed by Central
Government that has unleashing terror or violence on local politicians through local thugs like Changano in

Mbare Suburb of Harare.

Many urban councils have been condemned and dismissed and/or replaced by Management Commissions

appointed by the Minister of Local Government. Except the council led by a ZANU-PF Mayor Solomon

Tavengwa, many of the councils that were dissolved were led by MDC Mayors or were dominated by MDC
Councillors for example, the cases of Mutare, Harare, Victoria Falls and Chitungwiza were under Commission

administration by June 2006. In June 2006 all the technocrats in the Commission managing the City of Harare

were dismissed but the politicians were not touched or harassed by the Minister of Local Government. This is
political banditry because the ZANU-PF Government using its Minister of Local Government is manipulating the

status quo at local level to advantage a losing party. These kinds of politics or public administration do not

treasure good governance. It does not mean that when one is a MDC Party councillor his/her decisions are

retrogressive. The punishing, persecutions, retributions or terrorizing of urban councils dominated by MDC
councillors is a complete misnomer because good governance ethics of openness, freedom of communication and

participation in decision making are being violated. Another indication of political banditry in the administration

of urban councils are the many cases were legally elected councils are destabilized through the appointment of
individuals who represent what is called “special interests”.

The idea of “special interests group” has been even institutionalized by being included in the urban councils‟
legislations since the 1990‟s the time ZANU-PF Party started losing control of the urban constituents to

opposition parties like now the ruling Party MDC. The banditry is in the fact that at an election all interests are

represented through their political affiliations. Thus individuals are free to chose and elect a candidate from the
political parties that represent their interests. The idea of remembering special interests after an election is theft,

corruption, dishonesty or fraud that is only bent on benefiting regimes or politicians whose political traits include

monocracy, autocracy, violence, thuggery, treachery and inconsistence. Many of the individuals who are being
appointed to represent special interests are known ZANU-PF supporters and this can be interpreted to mean that

the “special interests” covered by the piece of legislations are ZANU-PF – Party interests. This further contradicts

the role of elections in a society or country. The question is “Why should urban councils in Zimbabwe have

elections every four years if ZANU-PF Party can manipulate the process and appoint its supporters through back
door?”

The majority of the respondents (90%) also argued that when councils are in session valuable time is spent on

arguments based on political differences rather than on harmonizing useful and progressive ideas that could be

nurtured to bring about development of these municipalities.

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Walti, Kubler and Papadopoulos in Mehde (2006) state that it is no coincidence that the governance concept is
closely related to the analysis of network structures and that it might even be defined as „a shorthand for efforts

aimed at creating networks and partnerships to enhance both interagency and public-private coordination. Laduer

further indicates that the network theory above all indicates the rise of a new logic which accepts the potential of
heterarchical inter-relationships to generate emergent patterns of coordination which may replace universal rules

imposed from above, (Mehde, 2006).

The constant Central Government intervention into the affairs of urban councils has a centralizing effect. The

space available to local politicians, administrators and individual community members becomes limited. Only the

realization that opposition parties‟ supporters are being murdered or violently engaged curtails the space available
for freedoms especially the freedom of speech and communications. Good governance in urban areas of

Zimbabwe can never be achieved when torture and violence are not condoned. Respect of human rights is

barometer to measure the level of civilization in a country. Civilization is an out come of tolerance, respect of

human rights, freedoms and a desire to want development in general as opposed to destruction and killing.
Networking of individuals and organizations is possible in a situation were freedoms are respected and

communities desires are generally the same , that is, the desire for development meaning change from poor living

conditions to a qualitatively better living style or situation. In a militarized situation like that of Zimbabwe were
even investment meetings that are not initiated or sanctioned by the ZANU-PF Government need to be cleared by

police institutions around the country, network is close to impossible. Networking for development is possible

were a government creates an enabling environment and it becomes a facilitator of the process. Zimbabwe has lost

all the gains it had accrued from decentralizing power and authority to lower level structures of government.
Recentralization of power and authority because of fear of opposition political parties‟ political gains is a typical

treachery to openness transparency and freedom of association.

To promote clean good governance, Goel, (2007) maintains that clearly defined ethical standards would also need

to be adopted by the civil servants as well as politicians. Moral and ethical behaviour is essential for sustainability

of dynamic relationships formed during the conduct of the governance, (Ibid). As a replacement of ethical
behaviour Swami Budhananda talks of „men of character‟. The argument is that both those in governments and

the public must be men of character. They should respect the laws and the laws they make must be created for the

public good and not for the benefit of a few individuals who cherish corruption and individual gains against

majority interests or public goals. Ethics are defined by the constitution and subsequent legislations that are
designed from it. Too many changes to specific legislations may disadvantage the citizens who may fail to control

the political structures that influence such changes. A good example of legislation that has continuously been

changed but evaluations show negative advantages to communities and institutional development is the Urban
Councils Act. The Act has been changed in 1980 bringing the Urban Councils Act (Chapter 214), again it was

changed in 1997 bringing about the Urban Councils Act (Chapter 29:15) and it was changed again in 2008

bringing about the Local Government Laws. Currently there is initiative to change again this law. This only

indicates that changes to any legislation is not enough but society, civic organizations and various levels of
governments need t commit themselves to implementing in full elements of specific legislations. These changes

facilitated within short periods did not give enough space to allow for implementation and evaluations of the

implications of such legislative changes. The changes in addition, influenced organizational structures, leadership
systems and public management. An evaluation of the effects of changes of legislation shows that 80% of the

respondents were not happy or did not perceive any direct advantages accruing from the processes.

Budhananda in Goel (2007) argues that when we do not have enough character, in society there will be more
quarrel and fight, agitation and unrest, corruption and nepotism than peace and harmony, control and happiness,

honesty and uprightness. Budhananda further reposes that lack of enough character will corrupt the taste of the

people, nay, of our own children in order to make money by selling goods which would pamper their low and
vulgar tastes. This argument is true for Zimbabwe urban areas where the youth and other groups in society are

using violence and murders to get money or certain properties. The youths are no longer industrious or

hardworking like the previous groups. They now want easy wealth through dubious and unethical means. In
situations where good character is lacking religion will be reduced to soulless ritualism, ethical code will be

perverted into sophistry, altruism will become self-aggrandizing social work, and spirituality will be reduced to

secularity to hedonism, hedonism to ruination, surer than death, (Ibid).

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Dhaliwal (2004) further articulated that the establishment of good urban governance in the world‟s towns and

cities is for only providing people with access to basic social services, promoting decentralized decision-making,

improving city environment quality, but at the same time assuring economic growth, job creation, social cohesion,
poverty alleviation and equity

Local democratic good governance entails the existence of ethics or laws that facilitate collective action that
manage a locality‟s public affairs and are accountable to local residents. Local governance starts with some

expansion of authority for local governments. Without local authority there is no local government nor is it

rational for people with serious needs and limited resources to invest in formal local governments (Owulo and
Wunch 2004). Ostrom (1997), E. Ostrom (1990), Hyden (1992) and Hyden, Oluwo and Okoth-Ogendo (2000)

affirm that governance is developing and operating the “regimes” or the fundamental (constitutive) rules that

structure and regulate the relationships among the populace in the management of the public affairs (Ibid).

Respondents (78%) contacted on the same issue in urban areas of Zimbabwe indicated that the current laws are
biased against certain groups or political parties. Respondents‟ perceptions were that local government laws lack

coherence and are designed to protect short term political gains of certain political parties. Legislations should be

crafted to support a certain vision or generally a long term strategic plan to develop a given community. On the
other hand Berman (1998) elucidate that the very ethnic fragmentation typical of Africa seems to engender “big

man” based patronage that sustains local fragmentation (Ibid).

They (Ibid) additionally reveal that when looked at comprehensively, rules create a structure of permissible and

forbidden actions and a set of incentives and disincentives that structure the pattern of governance that occurs

among people at the grassroots. It is then important to note that each level at which governance is intended to
occur must be understood as a set of rules that do or do not sustain the behaviours and relationships necessary for

it to be effective and sustained. Councillors and mayors must in this case be agents of those people (residents),

but they remain accountable (and removable) by the people included in the local regime through procedures
specified by laws. Oluwo and Wunch (2004) advance the opinion that intergovernmental relations are a key factor

affecting the nature of any governance regime. Making rational choice is essential in a democracy and for a

democracy to survive. Rationality is critical in discussing good governance because absolute freedom of choice

may encourage mobocracy in a state or sub-national structure. Monocracy is eliminated by providing citizens with
choice to make decisions currently and in the future and thereby determining their future destines.

Wilson (2011) reflecting on the British system of local governance specified that whereas local government is
concerned with the formal institutions of government at the local level, local governance focuses upon the wider

processes through which public policy is shaped in localities. It refers to the development and implementation of

public policy through a broader range of public and private agencies than those traditionally associated with
elected local government. He explains that partnerships, networks and contracts, along with quangos and task

forces in Britain have become increasingly important parts of the local political scene during the last decade. This

opinion supports respondents‟ (80%) views that participatory decision-making, networking and freedom of speech
is only possible where a regime or a government promotes human rights and rule of law. As already been

indicated, a major principle enhancing democracy is decentralization of power and authority. It seems there is a

contradiction in Zimbabwe where formal institutions have been abandoned in favour of informal political and

administrative organizations. This is done not to increase communications but the government uses the informal
structures to evade responsibilities and to usurp power and authority from certain organizations or groups in

society. Contrary to much of the prevailing wisdom, Stanyer (1996) reminds social scientists that problems of

fragmentation and complexity are not new. Local governance, he argues, has always been a messy business. Local
public functions in Britain and other Western countries have always been carried out by local quangos, field

administration, local trusts, co-operatives and local firms and these have been noticeable elements in society,

economy and political system since industrialization began. The use of organizational forms which are not local

government and are narrowly defined has always been a feature of the British system of government, (Ibid).

2.5 The link between good governance and institutions

The World Bank (2000a) in Kjaer (2004) and in agreement with UNDP (2000), Hyden in Mehde (2006), Du Toit

(1998) and Matlosa (1998) maintains that governance is the institutional capacity of public organizations to

provide the public and other goods demanded by a country‟s citizens or their representatives in an effective,

transparent, impartial and accountable manner, subject to resource constraints.

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Despite too much party politicking, changes of legislations and dismissals of elected councils and replacing
them with Commissions, about 90% of the respondents in this study indicate that stakeholders in Zimbabwe urban

areas are not satisfied with public goods and service delivery. The urban councils since t he year 2000 have run

bankrupt and thereby becoming seriously incapacitated to provide pertinent services for the urbanites. It is
significant to mention that the Habitat Agenda advocates transparent, responsible, accountable, just, effective and

efficient governance of towns, cities and metropolitan areas. It is doing so by enabling local leaders hip, the

promotion of democratic rule and stressing the urgency for public authorities to use public resources in all public

institutions to further these objectives, (World Bank, 2000a). North (1990) and Hall and Taylor in Kjaer (2004)
illuminate the debate on governance by affirming that governance theory has a broad institutional grounding. It is

significant then to note that good governance theory is mainly occupied with institutional change and it involves

human agency. Thus Kjaer (2004) assumes that after having identified governance as broadly referring to the
setting and management of political rules of the game and more substantially with a search of control, steering

and accountability, some core concepts in governance theory should be clarified and as noted by other scholars

already referred to, these are legitimacy, efficiency, democracy and accountability.

Tewdor-Jones and Mc Neill (2000) commenting on Britain‟s institutional and political restructurings of the

1990‟s quoted Jones, (1998) and Marks et al., (1996), who indicated that local processes of governance have
assumed enhanced importance within emerging systems of multilevel governance, while Jessop (1997b) is of the

opinion that unique forms of sub-national governance are a by-product of the decomposition of and devolution of

powers and responsibilities from central government. In Zimbabwe, decomposition and recentralization of power

and authority have introduced anarchy and mal-administration in local governments because of partisan conflicts
that are violent. The institutions that monitor and regulate the implementation of laws have been compromised to

the extent that the application of law has become selective and dependent on how the senior security agency

chiefs feelings that are based on political views. Respondents (100%) involved in this research explained that
there are cases of violence and murders that were reported as from 2000 and up to date despite overwhelming

evidence the culprits are evading the courts because they are supporters of ZANU-PF Party. Thus good

governance in urban areas has been compromised by thugs, corrupt politicians, lack of respect of human rights,
rule of law and violence on opposition politicians and their supporters.

This is also a sign of political banditry at work in urban areas. The citizens cannot get protection from the
government they elected against law breakers. It is important to note that Hood (1991) in Olowu and Wunch

(2004) articulated certain core values in the management of public organizations like urban councils. The focus

here is on transparency because no arbitrary procedures, no abuse of office and no bias are important. Success in

good governance can be measured by the degree of trust or confidence and the ability to exercise citizenship
effectively. Olowu and Wunch (2004) advance an argument that accountability through an open and broadly

based political process is needed to steer decisions and actions as well as to legitimize local governance

institutions. Thus effective institutions are needed to organize and structure the official and public actions needed
and to assure that decision-making process are effective, reliable and legitimate. Wunch (1999) promotes the idea

under discussion when he stipulate that there must be an effective and supportive set of rules that regulate local

affairs in general in order to rule out actions destructive to local governance (fraud, corruption, intimidation,
violence) by partisans and others and to settle disputes that might otherwise paralyze or disrupt it (Ibid). It has

already been indicated that fraud, violence, intimidation and corruption are increasingly becoming common in

Zimbabwe since the year 2000. Party politics has compromised objectivity in policy decisions, application of law

and managing public goods and services. Political banditry is clearly portrayed in situations were , for example,
supporters of the two MDC Parties are not given food handouts (even if they may be coming from a donor) or

maize seed because the individuals overseeing the distribution have ZANU-PF Party links. Another example is

where certain individuals are not allowed to vend in certain areas because they do not support a given party. Many
individuals have lost houses, housing stands, flee markets space or stalk and so on because they belong to the

wrong political party.

A further argument is that it is not rational to invest resources in governance processes and institutions that lack

authority in making decisions in key areas of citizens‟ concern or in ones that lack the fiscal and human resources

to implement their own decisions. Fung and Wright in Tambulasi, (2010) point out that participation and
representation are critical outcomes of local governance as they „increase accountability and reduce length of the

chain of agency that accompanies political parties and their bureaucratic apparatus.

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Four factors that are crucial ingredients for effective local governance in Africa are: (1) a supportive national

political context, (2) effective systems of intergovernmental relations that support the allocation and utilization of

fiscal and human resources, (3) a strong local demand for public goods along with substantial levels of local
social capital and (4) successful resolution of a number of local-level institutional design questions, (Olowu and

Wunch (2004). Local councils that have representatives of more than one party are able to debate budgets and

project priorities and compete for local power. A relatively stable political framework (Ibid) in Botswana has
encouraged the development of a cadre of professionals skilled in managing local governments and in navigating

its intergovernmental relations. Botswana stability affords local officials to be able to plan and complete projects,

attract, employs and retains able personnel and responds to local needs.

Hoe (2005) has argued that, for good governance to prevail there must be effective institutional mechanisms that

ensure accountability through the capacity to monitor and enforce rules and to regulate economic activities in the

public interest, (Mgonja, 2010). Salapmeh (2009) quoted Clarke and Stewart, (1998) state that governance was a
major factor in local government and that private and civil society organizations played major roles in local

politics “shifting and sharing responsibilities among public, private and civil society organizations. Galison,

(1994) states that alliances between central government bureaucrats and local leaders/local elites also have been
used, revealing that democratic rule does not assure more responsive and accountable government (Ibid).

Autocratic regimes can simply use force to command or intimidate citizens to support certain policies or laws.

Acuity on the Ministry of Local Government, Public Works and Urban Development’s relations with

urban councils

The objective of the Ministry of Local Government, Public Works and Urban Development in Zimbabwe is to
supervise or monitor the activities of local governments and also to monitor the services offered to the public by

such public institutions. Questions evaluating the level of democracy and good governance in urban councils

indicated that 86% of the respondents felt that there was too much external interference, 60% felt that debates on
policy issues were stifled or low, that 60% of the respondents indicated that consultations with stakeholders was

very low and that 72% felt that motivation to initiate constituents programmes was also low. The result just

demonstrates that good governance was lacking in these institutions and therefore basic foundation work to

introduce the principles of good governance was supposed to be engineered or re-engineered now. The Manica
Post (6-12 January 2006:9) reveals a situation where the mayor and councillors of the City of Mutare resigned

because of too much intervention by the Minister of Local government in the affairs of the city council. A

Movement for Democratic Change (MDC) provincial secretary for information and publicity explained; “ The
decision was taken after realising that our elected councillors and mayor couldn‟t work under the newly appointed

commissioners. It was the councillors themselves who pointed out that they were no longer able to effectively

exercise their duties after Dr Chombo (Minister of Local Government) ordered them to consult with the
Governor‟s office on all matters relating to finances and human resources.” The conflicts were inevitable

because the Governor of Manicaland were the City of Mutare is located was a ZANU-PF Party card holder.

The researcher also noted that despite „firing of councillors‟ and „hiring of Commissioners‟ in many towns and

cities of Zimbabwe between 1995 and 2008, public management of urban councils did not improve. Stakeholders

continued to complain about garbage collection, poor roads maintenance, electricity break – outs, inadequate
clean water, and sewerage bursts and blockages, inadequate transport provision and slams developments because

of inadequate housing projects developments. In the City of Harare mal-administration by the Commission

surfaced through the conflicts between the chairperson of the Commission and the Town Clerk. On 27 June, The
Herald (2006:1) reported that Sekesayi Makwavarara had fired the Town Clerk (Nomutsa Chideya) because of

mismanagement of the City Council. Also the Minister of Local Government supported Sekesayi Makwavarara

when she sacked the City of Harare Commission. Respondents interviewed also argued that Zimbabwe should

amend its constitution and the Urban Councils Act so that the powers of the Minister of Local Government are
reduced. This reduction could be done by inserting a close that requires the Minister of Local Government to

carry out a referendum before making changes to any law or to consult stakeholders before dismissing a

legitimate council. “The Revitalisation of Local Authorities” (2004:14) document explains; “The local
government system in Zimbabwe is not entrenched in the constitution as in other countries like South Africa. This

entails that Treasury cannot directly apportion a certain quota in the national budget to the councils. Year–in year–

out, Treasury disburses funding for programmes in local authorities areas via sector ministries.

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The bureaucratic entanglements attendant to the disbursement modus operandi prejudice councils in terms of
project implementation. It is regrettable to note that the “rejected” draft constitution (2000) had made a vivid

attempt to constitutionalise local government. The point is if the opportunity arises the government must seek to

entrench local government into the constitution; as the arrangement will ensure that a certain percentage of the
funds raised by the central fiscus are deployed directly to the local government institutions.” Currently the

minister‟s powers are excessive because he can fire any council without reference to any other body that may

represent the citizens. The respondents felt that the current firing of the councils has unraveled many since those

appointed by him have performed even worse in managing these councils.

The continuous firing of councils and changes to legislations show the levels of mistrust and political interference
in the administration of urban councils. A respondent from the Urban Councils Association of Zimbabwe (UCAZ)

alleges “— This animal called mismanagement has always been used against the firings of local governments”.

He further stated that it is difficult to defend oneself against allegations of mismanagement because the term can

mean anything and there are no written rules used to dismiss councils. What we have in the Act are powers
conferred on the minister when dealing with such institutions. Two respondents from UCAZ who were

interviewed argued that the Commissions appointed by the Minister are nonsense and were a symbol of political

gimmick by central government. They are meant to divert ratepayers‟ attention from poor service provision to
empty political issues. The respondents from UCAZ felt the Commissions have brought no new thinking and one

respondent expressed, “How can the Harare City Council Commission create twenty five business units from ten

previous ones. I cannot or I don‟t have interest to read or keep the Commissions Strategic Plan or the so-called

„Turn Around Plan‟ because it does not make sense.” The respondents felt that the Strategic Plan has the effect of
creating more vacancies and forces council to raise more revenue to implement strategic decisions but on the

contrary the current revenue base cannot sustain the operations of the council. Therefore the respondent felt that

the Commission was abusing public funds because it was not feasible during that time to achieve the stated goals.
Currently under the MDC councillors‟ control, Harare City Council revenue base has not improved. Most of its

functions have been manipulated and stifled by ZANU-PF Party and Government ministers‟ shenanigans. The

interviewees accused the government of misusing power and taxpayers‟ money because the majority of the
members appointed to the Commissions had no better experience of managing councils compared to the sacked

councillors.

Political banditry can be depicted from the manner in which the approval of the Turn Around Plan of the City of

Harare (2006) was approved. All (100%) informants from the City of Harare stated that the Minister of Local

Government did not follow proper procedures for the endorsement of the Turn Around Plan by the council

because members were given ten minutes to read, digest the contents and to approve it. The informants felt that
the document was thick and key to the effective and efficient administration of Harare City Council and therefore

needed a longer time for consideration. An aggravating reason for demand of more time was that a sizeable

number of councillors did not even have five O- Level subjects. They were semi-literate and therefore it was
unfeasible that they could read and understand the contents of the document within that extremely short duration.

The implication is therefore that at times improper decisions are taken as a result of the limit ed debate on critical

items.

Implications of political banditry on good governance

The previous sections have tried to elucidate on the different methods the national government and politicians
have used and are continuously using to commit political banditry in local governments of Zimbabwe. Too much

interference of central government in local affairs replaces decentralization with recentralization, autocracy and in

certain circumstances tyranny of the majority against the few democrats. In the urban councils of Zimbabwe the
nature of central governments interference through the Minister of Local Government demonstrates clearly a

process of structural transformations that are bent on preparing these structures and local communities to support

an establishing dictatorship. Dictatorships survive first by cultivating grassroots support through propaganda and

restructuring local institutions to align them for the inevitable task of changing local communities and institutions
into appendages of the national elite. The research agrees with Amoako (2000) who argues that before setting

forth a clear vision of the future role of governance in Africa, one need to reflect on the past. Post-independence

African states have tended to fit into one of the four categories and Zimbabwe seems to have acquired all the
characteristics to be outlined. It means that governance in the country is generally pathetic.

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The four categories are; the patrimonial state in which government officials treat the state and its assets as their

own personal property; the predatory state, which sees its citizens only as prey for its greed; the shadow state, in

which informal political networks run a shadow economy and engaged in many illegal activities and collapsed
state, in which citizens are left to their own devices. The existence of these four kinds of states has burdened

Africa and particularly Zimbabwe with post-independence history of repression and dispossession, far from the

rhetoric of our constitutions and the promises of our countries‟ founders. However, a fifth type of state can be
described as a state in which leaders impose sufficient repression to maintain power and keep their opponents

weak while adhering to formalities that give the appearance of democracy. The characteristics of the states

outlined before are rampant in Zimbabwe and they fit into characteristics the researcher is referring to as political

banditry. Thus in Zimbabwe, the civic organizations and political actors and leadership should not be deceptive
ingenious to the extent that they can afford to carry on like a piano player in a brothel who pretends not to notice

what is going on upstairs.

The central government has usurped the power and authority of local institutions whose continued existence is

being guaranteed by the Parliamentary legislation in the form of the Urban Councils‟ Act but in reality they have

been reduced to mere organs of state power. They are supposed to unquestionably implement central government
directives.

Political banditry has negatively affected governance. The principles of good governance that include,
transparency, rule of law, freedom of speech, participatory decision-making, accountability and respect of human

rights all have being ignored deliberately to benefit political „destituteness‟ or political criminals that are being

used to force the citizens to support the ZANU-PF Party. Legally appointed or elected local leaders lose political

space to violent youths and ex-combatants (now commonly referred to War Vets and Green Bombers) who are
supported by the main opposition party. A number of local leaders or activists were murdered in the process of

trying to win control of urban constituents or public offices. Respondents indicated that despite overwhelming

evidence against certain perpetrators of political crimes ZANU-PF Party supporters are never arrested or
prosecuted. Exposing major ingredients of political intolerance to transparency, freedom of choice and speech and

democracy or political pluralism, many supporters of the MDC Party are constantly harassed and imprisoned for

providing an alternative to democracy. Data collected from respondents signify that public administration has

seriously been undermined and therefore deteriorated because laws have been violated intentionally to acquire or
promote political gains.

The discussions also exposed the possible political and administrative weakening of local political structure or
institutions and individuals like the „full council‟, mayors, councillors and even employee like the Town Clerks.

The weakening comes as a result of constant changes to the laws governing the activities of such individuals or

institutions or because of hostile environment or clients like the rate payers and because of political interference
especially through the Ministry of Local Government. The Ministry of Local Government has been accused of

deliberately delaying the approvals of urban councils budgets or appointments of certain senior council personnel,

it has forcibly appointed committee/commissions to investigate issues considered to be within the urban councils

domain, it has demanded that the urban councils pay the committee members even if in the first place the Urban
councils would have rejected the manner in which the committee (s) were appointed, it has corruptly interfered in

the awards of certain tenders like the tender for the construction of the road from the city centre to the Harare

Airport, the Minister has been implicated in the corruption involving awarding of housing stands and the fact that
most of the MDC Party supporters are in urban areas, in 2004 the Central Government through the Ministry of

Local Government destroyed many houses considered to be informal under an infamous policy called

„Murambatsvina‟. This scandalous destruction of shelter led the United Nations to send a representative Tybijuka

to investigate the circumstances and impact of the policy on the homelessness. The “Murambatsitsvina
Programme” is a clear sign of political banditry of those involved because construction of informal shelter is a

result of the failure of legal political and administrative institutions like urban councils to provided houses or even

serviced stands that could be developed by individuals. The implications resulting from lack of respect the rule of
law are many and seriously disadvantaging the urban councils.

In Harare, a group of thugs calling itself „Chipanagno‟ has taken over control of council business like awarding
flea market stands at Mupedzamhamo, and Magaba and stands for selling vegetable and products at Mbare

Musika.

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The council authorities have failed to control this illegal activity because they are threatened with murder and the
media has written stories or murdered especially of member of parties other than ZANU-PF in the area. This

deterioration of public management is a serious threat to the service provision in the urban areas because the

municipal administrations are illegally deprived of their sources of revenue.

The political conflicts and administrative ineptness in the management of urban councils could be an indicator of

the limitations of representative democracy. In many instances in a representative democracy the candidates for an
elections use propaganda and they promise to provide goods and services that may be even beyond their

capability or legal right. After they have been elected into office, for example, as councillors many of these

politicians never make an effort to collaborate with their constituencies. There are councillors who complete their
terms of office without at any point bringing problems of their constituencies on council agendas. Some of them

do not know how communities‟ opinions are turned into policy agendas and thus such calibre of politicians may

be ignorant of procedures followed in deliberating agenda items in a full council. The point is that political

banditry may be a result of illiteracy of many councillors who do not know their rights and the privileges allotted
to the council institutions by the laws. Some councillors and employees join and survive their working career in

urban councils because of patronage and boot licking.

This paper encourages public administrators and political scientists to look beyond representative democracy in

policy formulation and management of local governments. Representative democracy is inadequate to facilitate

good governance in urban councils of Zimbabwe. Sunstein citing Arrow in Dryzeck and Christian (2003) argues

that it is doubtful that private desires or even aspirations can be well-aggregated through the process of majority
rule and thus proving the necessity for deliberation across those holding initially different preferences. I see

political bandits hiding behind their political parties and illegal political structures in urban areas of Zimbabwe.

The local political and administrative structures have been hijacked form providing public goods and services to
providing covert support for ZANU-PF Party cadres to remain in power infinitely. An alternative strategy to

establishing democratic good governance is the adoption of deliberative democracy. I do not view representative

and deliberative democracies and their principles as antagonistic but I want to project them as complimentary. My
opinion is that deliberative democracy could be used as a graft to strengthen representative democracy. It can be a

tool in the development or institutionalization of representative democracy. Deliberative democracy in Zimbabwe

can be a good strategy to bring awareness in the citizens to involve themselves in the activities of urban councils.

Deliberative democratic theory is a normative theory that suggests ways in which we can enhance democracy and

criticize institutions that do not live up to the normative standard, (Chambers, S, 2003). It is a talk-centric

democratic theory that can replace voting-centric democratic theory (representative democratic theory). Voting-
centric theorists and practitioners view democracy as the arena in which fixed preferences and interests compete

via fair mechanisms of aggregation. In contrast, deliberative democracy focuses on the communicative processes

of opinion and will formations that precede voting (Ibid). In Zimbabwe, the urban council does not need
aggregation of views from communities but what is critically missing is coordination of individual opinions

through democratic forums provided and supported by local and national institutions free of violence and

intimidations. The individuals and then community wills are important because they determine the future of
council resolutions and ultimately urban councils‟ programmes and projects irrespective of whether the

individuals or communities are pro- or anti- Zanu-PF Party or any other political establishment. The will

formation and realizations creates a bond for the possible support of councils‟ resolutions. This is a critical

element that is currently lacking in the operations of urban councils because certain political parties and groups
including informal and illegal interests groups try to force communities or individuals to adopt their ideas without

providing deliberative communication. The principle of democracy realizes that individuals are different and they

appreciate and desires difference needs. Therefore leaders and politicians should not view individual urbanites as
their duplicates. They are stakeholders in the organizations and customers of urban councils.

In democratic urban good governance accountability replaces consent as the conceptual core of legitimacy. A

legitimate political order is one that could be justified to all those living under its laws (Chambers, 2003). In

Zimbabwe there is lawlessness, murders and violence. Local government institutions are dissolved willy-nilly by

the Minister of Local Government and urban councils‟ legislations are also continuously changed to suit the
wisdom and aspirations of specific political establishments rather than facilitating legislative and institutional

changes to reflect communities‟ development and desires.

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Thus, in deliberative democracy and more important with respect to the theory of good governance, accountability

is primarily understood in terms of “giving an account” of something that is, publicly articulating, explaining, and

most importantly justifying public policy. As far as I am concerned, deliberative democracy and good governance
are opposite sides of the same coin. They have similar attributes and use almost the same characteristics when

applied urban councils‟ management. della Porta (2005) in Tompson, (2008) states that but that would not over-

come this persistent problem: the elements of deliberation are often run together, as in this definition: “…we have
deliberative democracy when, under conditions of equality, inclusiveness and transparency, a communicative

process based on reason…is able to transform individual preferences and reach decisions oriented to the public

good”. Habermas in Chambers (2003) correctly noted that consent (and, of course, voting) does not disappear in

performing local government activities. Consent is giving the political leadership permission to lead. Consent is
given a more complex and richer interpretation in the deliberative model than in the aggregative model. It means

that citizens need to deliberate about and decide when and where bargaining is a fair and appropriate method of

dispute resolution. The critical element that is missing in the administration of urban councils of Zimbabwe is
availability of the space to bargain for preferences. This space is shrinking continually because of political

banditry. The political play field is uneven and certain political parties like ZANU-PF have procrastinated and

demand that there views are society‟s views basically just because the party was the revolutionary party during
the war of liberation. It is a fixation approach to the disadvantage of changing and changed society.

The question of political banditry recurs because political parties and interest groups that view social policy,
national politics and development from a parochial point of who led the war of liberation have failed the

Zimbabwean nation to go beyond colonialism. Though not the focus of this debate but such kind of thinking has

inevitably led to creation of regressive policy and laws and even groups in society that contributed to the

economic meltdown that begun around the mid-1990s and become vivid in the year 2000 when the fast-track land
redistribution allocated commercial farm to school children and peasants who could not acquire the capacity to

economically and commercially utilize the pieces of land they got free. The point is Central Government had to

mobilize national sources to support the incapacitated new farmer to the detriment of other development
programmes. If one remembers that in 1982 the same government had amalgamated Rural and District Councils

with a noble view of creating viable local authorities that were anchored by resources coming from the

commercial farms. What happened is that the fast-track land redistribution brought the very poor peasants from
communal areas into commercial farms. The programme ruralized certain commercial farming areas.

This policy thus impoverished the former wealthy commercial farming areas and the Rural District Councils that

have become bankrupt to the extent that they are unable to provide needed public goods and services like schools,
clinics, dip tanks and roads. Instead of using old men‟s wisdom, deliberation is debate and discussion aimed at

producing reasonable, well-informed opinions in which participants are willing to revise preferences in light of

discussion, new information, and claims made by fellow participants. Councillors in this case become facilitators
of policy and development programmes. However, the councilors must attend all deliberative meetings to gather

correct views of the citizens since they are also citizens. By being elected to certain political positions it does not

mean that an individual is more intelligent than those who elected him/her. Citizens elect individuals through

competition so that that they get a leader because everyone to lead is total impossible. Chambers (2003) further
explains that although consensus need not be the ultimate aim of deliberation, and participants are expected to

pursue their interests, an overarching interest in the legitimacy of outcomes (understood as justification to all

affected) ideally characterizes deliberation.

Instead of the use of violence, force and any other clandestine methods of whipping citizens into accepting pre-

determined goals as what is the norm now in Zimbabwean, urban councils Chambers (Ibid) argues that theorists
of deliberative democracy are interested in such questions as: „How does or might deliberation shape preferences,

moderate self-interest, empower the marginalized, mediate difference, further integration and solidarity, enhance

recognition, produce reasonable opinion and policy, and possibly lead to consensus? Deliberative democratic
theory critically investigates the quality, substance, and rationality of the arguments and reasons brought to defend

policy and law. It studies and evaluates the institutions, forums, venues, and public spaces available for

deliberative justification and accountability. It looks at the social, economic, political, and historic conditions

necessary for healthy deliberation as well as the attitudes, behaviors, and beliefs required of participants.‟ Where
deliberation has been accepted as the norm of doing things by an urban council, there the beginning point is

equality of all and the suggestions proffered by different individuals.

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Representative democracy has failed to provide bargaining space because the councillors who are elected are
elected on party tickets and the beginning is carrying to council chambers strong and undiluted party agendas.

Usually discussions at constituencies‟ level divide communities on party lines and therefore when these

councillors come to council meetings the discussions become a zero-sum or winner take all game.

Decisions need to be taken and fair decision rules need to be in place, but a deliberative approach focuses on
qualitative aspects of the conversation that precedes decisions rather than on a mathematical decision rule.

Gutmann & Thompson (1997) in Chambers (2003) correctly argue that in designing and proposing deliberative

forums, scholars generally have four goals in mind: to augment legitimacy through accountability and

participation; to encourage a public-spirited perspective on policy issues through cooperation; to promote mutual
respect between parties through inclusion and civility; and to enhance the quality of decisions (and opinions)

through informed and substantive debate.

Deliberative democracy should not be confused with direct democracy. For example, it might be suggested that

citizen participation in local policy issues should not be encouraged because it will be dominated by parochial

attitudes exemplified by NIMBY (“not in my back yard”). A deliberative model involves citizens at every stage of
policy formation, including research and discovery stages. Thus, a deliberative model offers a way to overcome

NIMBY by getting citizens to cooperatively solve policy dilemmas rather than simply vote on policy options.

NIMBY seems to have corrupted and ruined management of urban councils in Zimbabwe. It has been indicated
that almost all urban councils are currently dominated by the Movement for Democratic Change (MDC) Party

councilors. However, ZANU-PF Party evokes NIMBY because it feels it is the revolutionary party and the MDC

Party is taking orders from America and Britain so it has a „regime change‟ agenda. Considering the fact that all

government ministries are located in Harare and that Harare is controlled by the MDC Party then the implication
is that ZANU-PF Party and the current unity government are housed by MDC Party urban council. This is a

source of political banditry where then the ZANU-PF Party and Minister of Local Government tries illegally and

unethically to change this situation by firing councils, mayors and councillors and appointing special interest
representatives. Estlund (1990) and List and Goodin (2001) in Chambers (2003) further argue that regarding

political decisions, deliberative democrats assume that decisions taken through deliberation will be superior to

ones taken by a mere aggregation of votes. This superiority can imply instrumental rationality (decisions better
suited to reach agreed-upon goals), moral justification or mutual tolerance and respect.

Administration ineptitude in the urban councils of Zimbabwe appears to be exacerbated by selfishness on the part
of politicians and uninformed members of the communities. The councillors, for example, elected to urban

councils tend to focus on accumulating wealthy in the form of houses or housing stands, business and returning

their positions after expiry period. Landwehr and Bächtiger (2011) argue that regarding actors, deliberative theory
lets us expect a set of attitudinal transformations, that is, after deliberation, actors are expected to be better

informed, less selfish and more willing to cooperate than pre-deliberation. Empirical evidence is mixed, however.

It is important to mention that deliberation is not a panacea for all the ills of representative democracy. In
politically charged environments like that of Zimbabwe, deliberation if mishandled may result with negative

results. Deliberation works very well in situations were other principles of democracy are respected. This is why

the researcher believes that representative democracy could be a first step towards deliberative democracy.

Hansen (2004) in Landwehr and Bächtiger (2011) expounds that while deliberation increases opinion consistency,
it neither leads to landslide transformations nor increases stability of opinions. This sentiment is consistent with

the view that deliberation is function or requires institutional preconditions to be successful. This insinuate the

idea that institutions need to put in place clear rules and regulations that will define the space available to the
institution in terms of policy developments, provision of goods and services and coordination with central

government policies and programmes.

Tompson (2008) convincingly articulated that at the core of all theories of deliberative democracy is what may be

called a reason-giving requirement. Citizens and their representatives are expected to justify the laws they would

impose on one another by giving reasons for their political claims and responding to others‟ reasons in return. If
citizens or communities were honouring this, justifying the laws and behaviours expressed against other members

in society then conflicts may be lessoned. In Zimbabwe, it seems powerful personalities manage to impose

forcibly their will against the will of the poor and powerless. The powerful can murder and get away with it even
if reports are made to police.

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The laws or courts of law in urban areas of Zimbabwe are close to protecting these powerful individuals from

being arrested and impartially prosecuted. The implications of the results are that the urban areas of Zimbabwe are

nearer to anarchy or state of nature (Hobes) and were democracy has been traded for authoritarian rule. At the
national level the country politicians have disagreed to the extent that they took these problems to the Southern

African Development Community (SADC) amelioration. It is this unprecedented hostility at the national level that

has been duplicated at local levels. A discussion does not count as deliberation at all if one person completely
dominates; the discussion is better deliberation to the extent that the participation is equally distributed; and the

discussion is more likely to be more egalitarian if the background conditions are more nearly equal. As citizens

engage in deliberation, they learn more about the issues, gain respect for opposing views, employ more public-

spirited arguments, and so on (Ibid).

Manson (1999) in Zwart (2009) states that while this concept has became a highly contested arena within

democratic thought, it is clear that deliberative democracy began as a critique of representative democracy‟s
emphasis on the formal procedures through which representatives, who translate voting preferences into policy,

are elected. The engineering of representative government is such that it tries to protect popular government

against tendencies to degenerate into populism or majoritarianism. Bohman and Rehg (1997) in Zwart (Ibid) thus
concluded that the central institutions of governance exist to provide equitable opportunities for citizens to shape

the exercise of power, with that influence assisted by a plurality of competing parties. A limitation of

opportunities for citizens‟ participation is favoured and consequently a relatively passive role for citizens is
advocated in the form of voting in the case of representative democracy. Deliberative democratic theory

encourages open and free debate among and between citizens. It contradicts views of representative democrats

like Schumpeter who suggest that the participation of an uninformed, apathetic and manipulable public could be

downright dangerous. Sunstein (1997) (Ibid) further acknowledges that representative democracy does not
sufficiently challenge the views of individuals and groups and fails to do what democracy should do, that is, to

offer a system in which reasons are exchanged and evaluated. A well-functioning system of democracy rests not

on preferences but on reasons (Jonga, 2011). In addition, Jonga (2011) also argues that a system of democratic
decentralization has to be so organized such that a balance between centralization and decentralization of

authority and functions characterizes the relations between the central and local government organizations. While

the central government has to delegate some of its authority and encourage autonomy of local authorities, it has to
retain some responsibilities relating to control, direction supervision and guidance particularly during the infant

stage of development of local authorities. Central government has to retain the functions, which the local

government may not be able to undertake due to the magnitude of resources or expertise required.

Adhikari (2000) in Jonga (2011) adequately and convincingly argues that the more equal the conditions of men

become and the less strong men individually are, the more easily they give away to the current of the multitude

and the more difficult it is for them to adhere by themselves to the opinion which the multitude discard. In Jonga
(2011), Dryzek (1987) and Zwart (2009) quoting Harbermas argue that democratic legitimacy is thoroughly

unconstrained; there are no restrictions on who may participate or on what kinds of arguments may be advanced,

or on the length of deliberations. The only resource available to participants is argument, and the only authority is
that of the better argument. Unlike representative democracy, deliberative democracy encourages the public

thorough debate that brings products that are beyond individual interests. Zwart, (2009), Miller, (1993) and

Dobson, (1996) quoted by Jonga (2011) confirm this idea when they state that „It is good for me‟ is not an
argument that many other participants could potentially accept. However, „what is good for me‟ is not good for

everyone. Citizens‟ visions, goals or interests differ in many ways and this divergence of opinions and interests

must be respected. Therefore, while deliberative (or discursive or communicative) democracy stresses fair and

legitimate procedures over particular outcomes, it is possible to conceive of the procedure as always giving rise to
a special type of product, being a general interest or the common good which representative democracy could

failing to achieve.

Conclusion

The discussion has tried to portray that political banditry exists and in Zimbabwe it is happening without control.
The culprits and especially politicians who also support informal interest groupings that are perpetrating violence

and intimidations seem to be above the law. Deductions from the arguments presented in this paper seem to

indicate that the scenario of political banditry has reduced the urban councils to mere organ of state power.

International Journal of Humanities and Social Science Vol. 2 No. 24 [Special Issue – December 2012]

133

The administration of these urban areas has deteriorated continuously and it appears solutions are far from coming
by. The major focus of many politicians is get control of the institutions by hook and crook. Conflicts and

thuggery has become the order of the day and politicians have turned a blind on them so that their parties could

gain control through political banditry. It has contributed to the deterioration of the good governance in these
institutions. Political banditry is venting itself through the institutions of central government like the Ministry of

Local Government, councillors and political administrative structures. However, the reason identified to be

creating and enhancing the circumstances is political hatred or differences and the need for the former ruling party

ZANU-PF to want to remain in power. The researcher concluded that this political conflict and administrative
incompetence could be blamed squarely on the inadequacy of representative democracy. Thus to strengthen

representative democracy in the administrative and political performance of urban councils, deliberation could be

adopted as an additional tool for communication and creating adequate political space for individuals with
divergent views to debate their options and come to a consensus on the best option to deal with local community

problems. In this case deliberative democracy could be grafted at the end of representative democracy to enhance

efficiency and effectiveness in the operations of urban councils in Zimbabwe. Jonga (2011) argues that the
thinking is that representative democracy is rigid; a bit old fashioned and takes citizens as secondary stakeholders

in policy-making and other governance processes. It is then my assumption that deliberative democracy

encourages participatory decision-making and thus appears more superior to the other. Berg and Rao (2005)

perfectly indicate that the essence of democratic rule is that authority emanates from the people; from the citizens
of a polity. The implication is that everyone by definition is competent, no particular skill, expertise or education

is required in order to participate.

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http://dx.doi.org/10.4314/wsa.v37i4.15
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ISSN 0378-4738 (Print) = Water SA Vol. 37 No. 4 October 2011
ISSN 1816-7950 (On-line) = Water SA Vol. 37 No. 4 October 2011 559

* To whom all correspondence should be addressed.
 +27 12 841-2024; fax: +27 12 841-3954;
e-mail: nfunke@csir.co.za
Received 27 September 2010; accepted in revised form 7 October 2011.

The case of cholera preparedness, response and
prevention in the SADC region: A need for proactive

and multi-level communication and co-ordination

MD Said1, N Funke2*, I Jacobs2, M Steyn2 and S Nienaber2
1Euroconsult Mott MacDonald –Technical Assistance Support Team (TAST), Ministry of Water Resources & Irrigation,

PO Box 476, Juba, South Sudan
2Council for Scientific and Industrial Research, Natural Resources and the Environment Unit, PO Box 395, Pretoria 0002,

South Africa

Abstract

In this paper the authors seek to identify the most appropriate model for a regional co-ordination mechanism for cholera pre-
paredness, response and prevention. The qualitative mixed-method data collection approach that was followed revealed the
need for alternative solutions, including a socio-political understanding of cholera responses at different levels of scale and at
different stages of an outbreak. Important areas that need to be understood include the multiplicity of actors and the complex-
ity of their interaction, the importance of building local capacity, the need for varying responses at different levels of scale,
the need for improved inter- and intra-country co-ordination and information exchange, the importance of cultural belief
systems and the impact of the media on the response to cholera outbreaks. Ultimately, despite the proposed co-ordinating role
that the Southern African Development Community (SADC) can play in a regional cholera response effort, the onus remains
on states to build capacity at the local level and to capacitate local communities to drive response efforts semi-autonomously.

Keywords: Cholera prevention, preparedness and response, socio-political understanding of cholera, socio-cultural
understanding of cholera, transboundary disease, Southern African Development Community (SADC), cholera

Introduction

Africa accounts for over 90% of all cholera cases reported to the
World Health Organisation (WHO, 2007). Gaffga et al. (2007)
refer to Africa as the new homeland for cholera, as cholera out-
breaks have been reported on an annual basis since 1990. The
SADC region is therefore a prime case study area for observing
regional responses to cholera, particularly due to the trans-
boundary nature of the disease, which poses a health security
risk to almost all of the SADC member states. Cholera epidem-
ics are cyclical, seasonal, and have been reported annually in
several Southern African states since 2000 (WHO, 2006). The
recent outbreak that originated in Zimbabwe in August 2008
resulted in 98 424 suspected cases and 4 276 deaths in the coun-
try, as reported on 30 May 2009 by the Ministry of Health and
Child Welfare in Zimbabwe (WHO, 2009). Nine other countries
in Southern Africa were also affected by cholera, either as a
result of the Zimbabwean outbreak or independently of it. These
countries were Angola, Botswana, Malawi, Namibia, South
Africa, Swaziland, Zambia, Zimbabwe and the Democratic
Republic of the Congo (DRC) (Kiem, 2009).

The fragile socio-political and environmental situation of
many Southern African states makes the region particularly
susceptible to cholera outbreaks. In addition to weather pat-
terns conducive to the outbreak of cholera, a history of labour
migration, lack of adequate sanitation in informal settlements
and rural areas, failed or failing health care systems, inadequate
community involvement, poor domestic and personal hygiene,
lack of capacity at the local government level, lack of logistical

co-ordination of relief aid, cultural stigmas regarding treatment
of cholera and political instability in several states are all fac-
tors that have contributed to the increase in outbreaks (United
Nations Office for the Co-ordination of Humanitarian Affairs,
2008; Mintz and Guerrant, 2009). This has raised concerns
about regional security as well as the role and preparedness of
the SADC states in addressing health emergencies of a trans-
boundary nature.

This paper reviews the presence of epidemic cholera in the
SADC region and is based on research conducted to identify the
most appropriate model for a regional co-ordination mechanism
for cholera preparedness, response and prevention. At the outset,
the research team hypothesised (based on a preliminary litera-
ture review) that the responsibility for establishing and running
such a mechanism would likely be situated at the regional (i.e.
SADC) level.

This hypothesis was, however, challenged by the qualitative
mixed-method data collection approach that was adopted during
the project. The research results revealed the need for alternative
solutions that include a socio-political understanding of cholera
response at different levels of scale and at different stages of an
outbreak. Priority areas include: understanding the multiplicity
of actors and the complexity of their interaction, the importance
of building local capacity, the need for varying responses at
different levels of scale, the need for improved inter- and intra-
country co-ordination and information exchange, the impor-
tance of cultural belief systems, and the impact of the media on
the response to cholera outbreaks.

The authors summarise these findings and further argue
that, despite the proposed co-ordinating role that SADC can
play in a regional cholera response, the onus is still on states to
build capacity at the local level, develop appropriate prepared-
ness plans, review them periodically, and share this information
with other states in the region. Here it is important to recog-
nise that while state action is required to provide systems for

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inter-state co-ordination, local communities need to be capaci-
tated to drive response efforts semi-autonomously.

Methodological framework

The authors adopted a qualitative, descriptive analysis of
regional responses to cholera. This approach was adopted for
several reasons. Firstly, the body of literature on cholera in
SADC is voluminous; however, it has been conducted from a
largely scientific point of view. More specifically, cholera out-
break response research has focused on medical aspects that are
important for decreasing mortality (WHO, 2004a). Due to the
fact that outbreak response is often led by medical professionals,
other aspects, such as environmental and communication issues,
have often been neglected (WHO, 2004a). This has largely
resulted in the omission of socio-political and socio-cultural
perspectives. The lack of publicly-documented and accessible
research on multi-actor response and multi-level co-ordination
strategies provides critically important gaps in scientific
research and policy, and subsequently the need for more inte-
grated analyses. A more comprehensive response is needed to
limit the spread of the disease, and a trans-disciplinary descrip-
tive analysis of the nature of the problem is therefore essential
to highlight the linkages between scientific, socio-political and
socio-cultural dynamics and policy.

Secondly, it is apparent that a vast treasury of experiential
knowledge exists in the minds of key individuals working in the
field of cholera response strategies in the region. However, this
knowledge is seldom captured. Participatory engagement was
therefore identified as an appropriate research method to retain
the experiential knowledge of these individuals.

The method employed was divided into 2 phases: a lit-
erature review and qualitative participatory engagement. The
literature review included an analysis of primary and secondary
sources including policy documents, popular articles and aca-
demic articles. Qualitative participatory engagement comprised
of a multi-stakeholder workshop, observation of governmental
committee meetings in South Africa, qualitative interviews and
several other consultative processes.

The chosen methodological framework brings to the fore the
socio-political and socio-cultural issues that are often forgotten,
ignored or undermined, but that play a critically important role
in determining the success or failure of technical and science-
based interventions.

The context in which cholera occurs

Cholera the disease

Cholera is an acute dehydrating diarrhoeal disease caused
by ingestion and colonisation of the pathogenic strains of the
gram-negative bacterium, Vibrio cholerae. Although more
than 180 serogroups of V. cholerae exist, only 2 serovars – O1,
and less commonly O139 – have been linked with epidemic
disease (Wachsmuth et al., 1994; Lin et al., 1999; Du Preez et
al., 2010). A serovar refers to distinct variations within a subspe-
cies of bacteria or viruses. A group of serovars with common
antigens is called a serogroup (The American Heritage Medical
Dictionary, 2007).

Vibrio cholerae non-O1 serogroups were until fairly
recently only associated with sporadic diarrhoea cases and
not known to cause diarrhoea epidemics. In 1992, however,
toxigenic strains of the O139 serovar appeared in India and
Bangladesh as the first non-O1 serovar to cause epidemic

cholera (Albert et al., 1993; Ramamurthy et al., 1993; Lin et al.,
1999). While the possibility of a Cholera O139 outbreak has not
been associated with Africa, the recently-published Du Preez
et al. (2010) study found both strains in estuarine waters and
sediments of Mozambique, now also linking the O139 strain to
African waters and indicating a possible human health risk.

While V. cholerae is a natural inhabitant of estuarine envi-
ronments (Colwell and Huq, 1994), humans are the only known
natural host for V. cholerae, and the disease is spread mainly by
faecal contamination of water and food. Direct person-to-person
spread of the disease is uncommon (Hensyl, 2000). The incuba-
tion period varies between 6 hours and 5 days. Oral rehydra-
tion therapy (ORT) is the treatment of choice as it is effective,
economical, easy to administer and capable of reducing the
case fatality rate (CFR) to less than 1% (WHO, 1993). However,
despite the existence of basic treatment solutions, cholera is
still not being prevented or controlled, especially in developing
countries.

Cholera and water quality

Cholera is associated with several socio-economic factors, such
as population density and poverty, and is closely linked to poor
sanitation and hygiene, and a lack of a safe, clean water supply
(WHO, 2010). In addition, basic measures to improve water
quality such as boiling, chlorination, and filtration are not eco-
nomically feasible for many rural or peri-urban communities,
and sanitation targets are still lagging behind in sub-Saharan
Africa countries (United Nations, 2009). Waterborne transmis-
sion has been quoted as being the most important route of trans-
mission in Africa, with several researchers linking cholera to
untreated drinking water from contaminated water sources such
as lakes, rivers, springs and shallow wells (Bradley et al., 1996;
Shapiro et al., 1999). In rural environments, contaminated water
sources transmit the disease to the communities through which
they flow, while in urban and peri-urban communities, cholera
outbreaks are usually caused by breakdowns in water treatment
systems and/or contaminated public water supplies.

In addition, the relationship between cholera and poverty is
well documented and remains a global threat, especially in the
developing world (Borroto and Martines-Piedra, 2000; Soussan,
2003). The most susceptible individuals tend to be those living in
poor communities characterised by economic and social hard-
ships. Roughly 70% of people in the SADC region, and 60% of
people residing in poor rural communities, are dependent on
groundwater for domestic water supply (Banda, 2009). However,
only a few SADC countries actively monitor groundwater use
effectively and manage it sustainably. In the absence of effective
monitoring and surveillance systems and streamlined report-
ing procedures, little can be done to curb the contamination of
groundwater that exposes millions of people living in rural areas
to waterborne diseases (Zuckerman et al., 2007; United Nations
Office for the Co-ordination of Humanitarian Affairs, 2008;
Banda, 2009; Mintz and Guerrant, 2009).

Access to clean water is not only a rural problem, however,
and also affects many urban populations across the SADC
region as governments fail to replace poor infrastructure
(Banda, 2009). On average, the provision of rural water sup-
ply has improved considerably in the last decade, with access
to improved water sources having increased from 56% in 1990
to 64% in 2006 in Africa (WHO, 2008). However, in some
countries, such as Zimbabwe and Zambia, urban water services
coverage has in fact decreased (Fig. 1). This is presumably due
to urban migration and rapidly increasing urban populations,

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61

as well as the failure to meet the increasing demand for water
supply. The deterioration of existing water services due to poor
maintenance may also contribute to the problem.

Reported statistics such as those represented in Graph 1
must be examined with a degree of caution in that they priori-
tise water access above water quality. For example, the graph
indicates that a percentage of a population has received access
to improved water sources in urban and rural areas. However,
this information does not clarify whether the service is still
functioning and when last it was monitored, whether the water
supplied is of an appropriate quality, and how often quality
standards are not met, as well as for how many hours a day
the service is rendered. In Zambia, for example, urban water
supply ranges between 5 and 20 hours a day in many towns.
Bartram and Cairncross (2010) argue that health benefits are
closely linked to the level and quality of service and that the
Millennium Development Goal (MDG) for water is inadequate
as it assumes water quality to be safe when supplied from an
improved source. Thus, the figures provided must be read care-
fully to understand the limitations on the information that they
provide, and the possible areas of poor water quality hidden
within these figures.

In summary, the link between water quality and prevention
of waterborne diseases is well documented, although the prior-
ity for many governments in developing countries to achieve
broad-based water access has often masked the challenge of pro-
viding water of a suitable quality, and of regularly monitoring
that quality. Much of the SADC region still struggles to strike
a balance between water quantity and quality with the primary
focus still being on access to water rather than its quality.

Challenges in the SADC member state

s

Despite the fact that cholera is a preventable and treatable ill-
ness, the SADC region continues to be plagued with annual
outbreaks (United Nations Office for the Co-ordination of
Humanitarian Affairs, 2009; Funke et al., 2010). Why does this
problem continue to exist?

Firstly, cholera has become an inherent part of the biophysi-
cal environment (Funke et al., 2010). This means that the bacte-
rium reoccurs on a regular basis, often appearing to be triggered

by fluctuating weather patterns involving heavy
rain or dry seasons (United Nations Office for
the Co-ordination of Humanitarian Affairs,
2008; Mintz and Guerrant, 2009). Secondly,
cholera thrives in an environment where there is
poor infrastructural development, particularly
in terms of running water, sanitation and health
services (Funke et al., 2010). This makes SADC
particularly vulnerable to cholera. Thirdly,
notwithstanding cholera cases in Africa being a
manifestation of poor infrastructure, the CFR is
also a reflection of the inadequacy and inacces-
sibility of basic health care (Mintz and Guerrant,
2009). A case in point is Zimbabwe, where the
CFR for cholera was reported at 5.4% from 15
August to 18 December 2008. This situation was
provoked and accentuated by a lack of safe drink-
ing water and sanitation, as well as inadequate
health services (United Nations Office for the
Co-ordination of Humanitarian Affairs, 2008;
Mintz and Guerrant, 2009). In terms of health
care, capacity also varies to a large degree. Lack
of resources, internal conflict and limitations of

technical expertise are some of the challenges that affect the
functioning of medical services.

Also, as a preventative measure, there has historically not
been much support for mass vaccination and chemoprophylaxis,
as these have been observed to be ineffective in preventing
and controlling cholera in populations with endemic disease.
However, more recent findings have revealed a proven efficacy
and tolerability in mass vaccination and, indeed, a resurgence
of this method’s popularity in curbing cholera spread as a result
of improved and modified vaccines (Sack et al., 2004; Longini
et al., 2007; Sur et al., 2009; Zuckerman et al. 2007). The WHO
currently recommends pre-emptive use of cholera vaccination in
certain endemic and epidemic situations, although clear guide-
lines have yet to be developed (WHO, 2004b; Zuckerman et al.,
2007).

The logistics of rolling out such campaigns are also
challenging, especially in rural areas (WHO, 1993; WHO,
2000). Challenges include the need to: recognise the outbreak;
rapidly mobilise resources to the affected area; dispense
antibiotics or vaccines to the affected population; and follow-
up with patients to confirm that the intervention has been
appropriate and effective. Administering mass vaccinations
alone, however, will not prevent and control the spread of
cholera. Policy-makers also need to be mindful of how poor
infrastructure and health services may impede the efficacy of
these vaccinations.

Fourthly, cholera affects the entire SADC region because it
has profoundly transboundary dimensions (Funke et al., 2010).
Its movement across borders in the region occurs for 2 main
reasons. In the first case, the Southern African region has experi-
enced a culture of legal, illegal and refugee migrations for more
than 150 years, a pattern which continues to grow despite official
attempts to regulate it (Gorbachev, 2002; Crush and Frayne,
2007; Swatuk, 2009). Migrant populations such as farm workers
have been among those listed to be at high risk of contracting
cholera, especially during harvest periods, as working and living
conditions are poor and their only sources of drinking water are
contaminated rivers and canals (United Nations Office for the
Co-ordination of Humanitarian Affairs, 2009). These workers
have also contributed to the spread of the disease to rural villages
when they return home on periodic visits to family.

60

99
80

97

71 77
100 95 99 92

100

80
99

87
99

38

90

28

81

29 29

99
77

88

61
0

45

78

46

72

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

P
e
rc
e
n
ta
ge

SADC Member Countries

Percentage of population with access to improved water sources, urban and rural 
(Source: www.wssinfo.org)

Proportion of Rural 
population with 
Unimproved Water 
Supply (%)

Proportion of Rural 
population served 
with Improved 
Water  Supply (%)

Proportion of Urban 
population with 
Unimproved Water 
Supply (%)

Proportion of Urban 
population served 
with Improved 
Water Supply (%)

Figure 1
Reported percentages of populations in SADC countries with access to

improved water sources, urban and rural (Source: WHO, 2008)

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Cholera epidemics in SADC member states

Since 1970, when the first cholera outbreak of the seventh global
pandemic was documented on the African continent, a number
of SADC member countries have been affected (Goodgame and
Greenough, 1975; WHO, 2001).

In 2000, 27 African countries notified the World Health
Organisation (WHO) of cholera outbreaks. According to the
WHO Weekly Epidemiological Records’ annual cholera case
summaries of 1995-2005, all SADC countries, with the excep-
tion of Botswana, Lesotho, Mauritius, Namibia and Seychelles,
reported cholera (WHO, 2006). Figure 2 shows the magnitude
of the cholera epidemics within this period.

The August 2008 outbreak of cholera in Zimbabwe rapidly
spread to the neighbouring countries of Mozambique, South
Africa and Botswana and later also affected Angola, Malawi,
Namibia, Swaziland, Zambia and the DRC. The situation was
aggravated by the influx of illegal immigrants into South Africa,
coupled with inadequate water and sanitation facilities and poor
hygiene at temporary processing centres for asylum seekers
(UNICEF, 2009). Equally concerning is that some countries
which had previously been free of the disease, such as Botswana
and Namibia, have also started reporting cases (see Table 1).

Results of qualitative participatory engagement

Although much is known about the medical and biological
dimensions of cholera in the SADC region, the social, political,

and cultural dimensions of cholera outbreaks
are less well documented. Given this reality, a
multi-stakeholder workshop and other methods of
participatory engagement were pursued to solicit
inputs on these dimensions. A number of key find-
ings emerged from this participatory process.

Interrogating who is responsible for
cholera preparedness and response

One of the key areas of consideration was the issue
of ‘who is responsible for a response to cholera
outbreaks?’ On the one hand there is the well-
established view that governments are responsible
for dealing with domestic matters that arise within
their borders. This view is backed by a power-
ful set of international norms which respects the
sovereign power of states in their own territories
and the practice of non-intervention in the domes-
tic affairs of states (Peters, 2009). To the extent
that cholera is an illness that affects people within

state boundaries, it can be argued that national governments,
and more specifically national health departments and related
emergency health response units, are responsible for provid-
ing the necessary resources, support and response to deal with
this issue. On the other hand, the issue of who is responsible for
responding to cholera outbreaks is a ‘grey area’ in an ever more
interconnected and globalised world. A few issues in particular
contribute to this complexity.

Firstly, as mentioned earlier, cholera has transboundary
dimensions (Funke et al., 2010). The illness therefore does not
necessarily remain within the borders of one specific country.
When the burden of illness falls on many countries at the same
time, critical questions arise about how best to coordinate the
distribution of resources, skills and emergency support among
different countries.

Secondly, what should happen when governments do not
or cannot respond to health crises and fail to deliver on their
responsibility to protect and provide for the needs of their
citizens? Governments face many challenges when responding
to health crises, including budget constraints, lack of healthcare
materials, poor maintenance and operation of water infrastruc-
ture and weak early warning systems in many countries in the
SADC region (Funke et al., 2010). A specific example is the
case of the 2008 Zimbabwean cholera outbreak, where one of
the aggravating factors was that the health care system had
almost completely collapsed as a result of the complex political
and economic issues in the country at the time (Balakrishnan
2008; Funke et al., 2010). Therefore hospitals and clinics were

Table 1
Cholera cases reported in SADC member states, 2008-2009

(Source: United Nations Office for the Co-ordination of Humanitarian Affairs, 2009)
Country Reported Cases Reported Deaths CFR (%) Time Period
Angola 5 478 60 1.2 01 Jan. 2008 – 05 Apr. 2009
Botswana 15 2 13.3 01 Nov. 2008 – 17 Apr. 2009
Malawi 5 170 113 2.2 15 Nov. 2008 – 17 Apr. 2009
Mozambique 15 649 133 0.8 01 Jan. 2009 – 11 Apr. 2009
Namibia (Inc. AWD) 203 9 4.4 22 Oct. 2008 – 14 Apr. 2009
South Africa 12 765 64 0.5 15 Nov. 2008 – 10 Apr. 2009
Swaziland (only AWD) 13 278 0 0 22 Dec. 2008 – 28 Mar. 2009
Zambia 7 412 151 2.0 10 Sep. 2008 – 09 Apr. 2009
Zimbabwe 95 738 4154 4.3 15 Aug. 2008 – 10 Apr. 2009

Cholera cases in SADC member states: 1995-2005

0

20000

40000

60000

80000

100000

120000

Ang ola
Bot swana

DRC Lesotho
Mada gascar

Malawi
Mauritius

Mozambique
Namibia

Seych elles
Sou th Africa

Swaziland
Tanza nia

Zambia
Zimba bwe

Member states

N
o

. o
f

ca
se

s

1995 Cases 1996 Cases 1997 Cases 1998 Cases 1999 Cases 2000 Cases

2001 Cases 2002 Cases 2003 Cases 2004 Cases 2005 Cases

Figure 2

Reported annual cases of cholera in SADC member states
between 1995 and 2005 (Source: WHO, 2006)

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understaffed, under-resourced and unable to respond to the
magnitude of the cholera outbreak.

In some cases governments refuse to acknowledge that they
have a cholera outbreak as they fear that such an admission
will result in negative repercussions such as reduced trade and
investment in the country (Funke et al., 2010). To try to avoid
specifically talking about cholera, many governments refer to
the problem as acute watery diarrhoea (AWD), which requires
a different treatment to cholera and makes the problem seem
less urgent (Cumberland, 2009). Lack of political will to take
ownership of cholera outbreaks generally leads to time wasted
and lives lost. Often when governments are unable or unwilling
to respond to cholera outbreaks the onus falls on neighbouring
governments and transnational and local non-governmental
organisations (NGOs) to step in and handle the crisis.

Thirdly, there is a growing network of transnational and
local organisations (WHO, Red Cross, Médecins sans Frontières
(MSF), etc.) that have enormous expertise, experience, knowl-
edge and resources when it comes to dealing with cholera
outbreaks (Funke et al., 2010). These actors can often provide
support that governments themselves are not able to garner
in times of cholera crisis. The presence of these transnational
actors, however, raises difficult questions. Do these organisations
need a government’s permission to become involved? What if
governments are inadequately responding to cholera outbreaks
but do not want the involvement of non-government actors?

Given these complex factors, it is clear that the issue of chol-
era preparedness and response is nested within a multi-actor,
multi-level agency context.

The problem of a reactive response to cholera

In many developing countries, the approach to cholera out-
breaks is a reactive ‘emergency response’ and directed at
controlling the outbreak and minimising mortality. In the event
of a cholera outbreak, it is assumed that the health sector in
the affected country will take the lead in notifying the relevant
national institutions as well as the resident WHO office. The
national health sector can officially ask the relevant ministries
or departments, other UN affiliates, international non-govern-
mental organisations (INGOs) and non-governmental organisa-
tions (NGOs) for financial assistance and/or technical expertise
to contain the outbreak. Otherwise, the onus will revert to the
WHO to initiate dialogue with the national government in a
combined effort to contain the outbreak.

The WHO is the UN affiliate that is responsible for global
health issues. WHO operations in UN member states address
the health needs of resident populations through collaborations
with several partners. These include other UN agencies, donors,
international and local NGOs, WHO collaborating centres, the
private sector and civil society. The WHO, therefore, takes the
lead in assisting member states to prepare and respond to chol-
era emergencies (World Health Organisation, 2007).

Some countries or regions are completely unprepared when
a cholera outbreak occurs. Inconsistency in the development
of appropriate policies and their implementation has also been
noted (WHO, 2007; 2009). Also, the burden of responding to
cholera often lies with the health emergency units in national
health departments rather than in an institutionalised section of
the department dedicated to a response to cholera in particular.
Often emergency health units have to deal with multiple health
crises at once (e.g. swine flu and measles), resulting in the units’
capacity being stretched too thin to adequately deal with any
one crisis in detail (Funke et al., 2010).

Socio-political dimensions of the cholera issue in the
SADC region

What is evident in literature (Cumberland 2009; Schaetti et al.,
2009), and has been confirmed in this study’s empirical find-
ings, is the widespread awareness that cholera preparedness,
response and prevention is a highly politicised issue in many
countries.

The International Health Regulations (IHR) provide an indi-
cation of high level political involvement in, and recognition of,
the issue of communicable diseases. Since 1969, the IHRs have
undergone many revisions to the point of their adoption into
international law in 2007. The IHRs provide the legal frame-
work for international co-operation for the control of infectious
diseases such as cholera (WHO, 2007). Amongst other things,
these standards oblige WHO member states to notify WHO
of any outbreaks of diseases in their countries that have the
potential to cross borders and threaten public health worldwide
(Funke et al., 2010). The fact that it has taken so long to award
international legal status to these regulations indicates that it is
a highly sensitive and political matter to try to convince govern-
ments to take ownership of the management of health issues
within their sovereign territories. It is an ongoing challenge to
implement the IHRs, due to weak political will to do so (Funke
et al., 2010).

Socio-cultural dimensions of cholera

Another issue that has clearly emerged from the literature
review and participatory process is the reality that there is a
powerful socio-cultural discourse that exists in relation to chol-
era. This means that it is critical to consider ‘community-held
ideas, fears and individual help-seeking behaviour regarding
the infectious disease’ in order to come up with solutions and
responses that are relevant and appropriate to specific groups
of people (Schaetti et al., 2009). In addition, it is also vital to
recognise that cultural beliefs and practice are not homogenous,
but differ across time, place and population. Such observations
stress the importance of including site-specific analyses when
doing research on the acceptance of interventions in response to
cholera (Schaetti et al., 2009).

Socio-cultural responses to illness manifest in many differ-
ent ways. Some communities, for example, see diarrhoea as a
normal part of life (Cumberland, 2009). This perception places
people at risk as they do not react quickly to the symptoms of
cholera. Others see cholera as a disease that is associated with
poverty and lack of hygiene (Cumberland, 2009). This ‘embar-
rassing’ stigma has been known to cause people to stop talking
about the illness and to resist treatment to avoid being exposed
to the community’s judgement of people who have cholera. This
behaviour is problematic because talking about the problem is
an important way of addressing it.

Another issue relates to perceptions of trust. Will a specific
community primarily turn to western medicine or traditional
healers with their health problems? Will a specific person turn
to a known community healer or an ad hoc (often foreign-run)
cholera relief camp to treat their illness? For example, studies
in relation to the viability of a cholera vaccination in Tanzania
revealed that there was a perception in some Tanzanian commu-
nities that this vaccination would result in infertility (Schaetti et
al., 2009).

Also, certain culture-specific behaviour may increase com-
munities’ vulnerability to cholera. In terms of religious beliefs,
Jehovah’s Witness followers, for example, are likely to resist

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treatment via intravenous drip, which is the standard treatment
for cholera. In households where polygamy is practiced there
is a bigger risk of cholera spreading due to multiple households
being linked to each other, either because the women and chil-
dren live together or because the men move regularly between
multiple households. The way that food is consumed and shared
is another point for consideration. Are bowls shared or sepa-
rate? Is food communally prepared by women in a community
or do families prepare food separately? It has been found, for
example, that high risk points for cholera transmission are large
gatherings, such as funerals, where food, drink and space are
shared by a crowd of people (United Nations Office for the
Co-ordination of Humanitarian Affairs, 2009).

Role of the media in raising the political profile of
disasters and thereby attracting funding: the CNN
effect

In recent years, observers of international affairs have raised the
concern that the media have increased their ability to affect the
conduct of, particularly, United States (US) diplomacy and for-
eign policy. Dubbed the ‘CNN effect’, the impact of new global,
real-time media is typically regarded as substantial. As part of
the CNN effect, the media may function alternately or simulta-
neously as: a policy agenda-setting agent; an impediment to the
achievement of desired policy goals; and an accelerant to policy
decision-making by shortening decision-making response time
(Livingston, 1997). While the ‘CNN effect’ most commonly
refers to the effect that news media have on politics and govern-
ment during political conflict, the media also have a noteworthy
effect on decisions made during natural disasters. As videos
and images are broadcast worldwide immediately after or even
during natural disasters, these images may convince the public
to donate money or pressure governments for immediate action.
However, sensationalising cholera outbreaks in Africa provides
controversial stories for international audiences, and supports
the image of Africa as a poverty-stricken, malfunctioning and
diseased continent (WHO, 2004a). In addition, selective media
coverage means that some cholera outbreaks will attract inter-
national attention, commitment to help and resources at the
expense of others (Funke et al., 2010).

The media’s role is not only negative and can also be useful
in terms of performing an educational and knowledge-dissem-
inating function. Public health authorities are generally inter-
ested in using the media to provide information on preventative
and control measures, i.e. public service announcements. At
the same time, however, journalists will often want to focus on
spreading or even sensationalising a story. It is therefore impor-
tant to establish a balance between these 2 interests (WHO,
2004a).

Conclusion

As is evident from the discussion above, cholera epidemics have
been on the increase in Africa, and are not only a health prob-
lem but should also be understood and addressed from a social,
cultural and political point of view. Concerted efforts are there-
fore required to establish a proactive long-term strategy consist-
ing of national multi-sectoral and multi-level plans to deal with
this issue in a co-ordinated way. Supply of safe water, adequate
sanitation, and basic domestic and personal hygiene are critical
measures for the prevention and control of cholera and other
waterborne and food-borne diseases. Furthermore, governments
should prioritise the known high risk areas, as cholera generally

affects urban and peri-urban high-density areas more than rural
low-density areas. Health education is also key, and messages
regarding safe water use and storage, hand washing, safe food
handling and disposal of human excreta are important and can
be communicated through radio, television, community leaders,
schools and public loud speakers.

For these initiatives to succeed, ownership should lie with
the national governments of the individual SADC member
states. SADC (through, for example its health desk) and the
African Union (AU), as well as other governing bodies on
the continent, have an important role to play in encouraging
national member states to admit to having a problem. This
could be done by forming a regional cholera response team and
circulating a regional case definition of cholera that should be
adhered to by all SADC member states. There is also a need for
improved inter- and intra-country co-ordination and informa-
tion exchange (Funke et al., 2010).

National governments (and specifically their health min-
istries or departments) need a national response plan whereby
they commit individually, with the support of supra-national
entities, to addressing cholera outbreak situations. At the same
time they also need to communicate with each other during such
a situation. However, it is also necessary that public health care
entities at the provincial and local level are sufficiently equipped
by the national government to deal with cholera outbreaks, as
it is at these levels that much of the ‘on the ground’ response
action to cholera takes place. Cholera outbreak management
should therefore be co-ordinated at the national level, but clear
directions should be given to actors at the sub-national level on
how to respond to the outbreak with some level of autonomy and
authority (Funke et al., 2010). To this end, mechanisms must
be established for ensuring good collaboration between volun-
teers from NGOs and national health care workers in the field.
Developing or maintaining good relationships between key
actors may be facilitated by recording details of responsibilities
in embassies of United Nations (UN) representations, organis-
ing regular briefings and providing regular information on the
epidemiological situation and on the effectiveness of outbreak
responses (WHO, 2004a).

Instead of constantly reacting to cholera outbreaks, it is sug-
gested that proactive steps be taken to prevent future outbreaks
(WHO, 2009; Funke et al., 2010). The need for a proactive rather
than a reactive process would allow countries or regions to
prevent future outbreaks and pre-plan or respond rapidly dur-
ing outbreaks. This would be the best way to reduce the risk of
community-wide spread of the disease (National Department of
Health, 2006). A proactive approach saves valuable time as it
replaces the need to first complete an outbreak investigation. In
addition, such an approach allows for more rapid implementa-
tion of control measures and therefore could save many lives
(National Department of Health, 2006).

In order to successfully implement effective cholera preven-
tion and a proactive response plan, short-, medium- and long-
term objectives have to be in place to address existing gaps.
Also, a proactive response plan needs to make provision for
preparedness at local, national, regional and international scale
and should be reviewed periodically (Funke et al., 2010).

Recommendations

As alluded to above, a proactive plan needs to have short-,
medium- and long-term objectives, which should include the
following:

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Short term:
• Moving cholera out of the health crisis units of national health

departments. A space needs to be institutionalised in national
health departments for dealing with, talking about and
responding to annual cholera outbreaks. Too often cholera is
overshadowed by other, more immediate health crises, such
as the recent (2009/10) outbreak of swine flu in the SADC
region. In addition, financial resources need to be provided
for surveillance, education and additional medical supplies.

• Doing vulnerability mapping of areas that are prone to chol-
era, due to environmental or infrastructure reasons or other
unforeseen reasons (e.g., disasters such as flooding, vulner-
ability of bordering countries prone to cholera outbreaks
and conditions of disaster, political unrest and health system
break-down) (Funke et al., 2010).

• Developing an early warning system for prediction of
cholera outbreaks due to environmental change (Ford et
al., 2009) and compiling a cholera outbreak prevention
and response plan. Such a plan describes the step-by-step
process of an outbreak response, the logistical arrange-
ments, the need for and quantities of supplies and the list
of people serving on the outbreak response team (National
Department of Health, 2006).

• Appointing an outbreak response team. This team should
consist of a multi-disciplinary and multi-sectoral team con-
tracted to assist with preventing, detecting and containing
the outbreak (National Department of Health, 2006).

• Writing a communication plan. This plan should not only
structure the communication during the outbreak response
but should make provision for structured networks and
forums to discuss interim goals and objectives, as well as
provide a platform to share and develop the outbreak pre-
vention and response plan within and between different
sectors and at different scales (Funke et al., 2010).

• Continuing the implementation of the IHRs. It is important
that states are held accountable for keeping to the commit-
ments made by signing these regulations.

• Understanding community specific perceptions and behav-
iour in those communities that are vulnerable to cholera
outbreaks. Such understanding is critical to supporting the
process of determining what the most effective and appro-
priate interventions are for approaching the cholera chal-
lenge in the short-, medium- and long-term.

• Recognising that, even where an effort has been made to
understand the culture-specific perceptions and behaviour
of a community, any solutions or responses to a cholera
outbreak need to be locally accepted (rather than imposed
in a top-down manner). This entails engaging in the long-
term project of education and awareness creation in order to
prepare communities for what to expect and do, particularly
in high-risk cholera times (such as the rainy season).

Medium term:
• Tracking incidence and reporting trends for cholera over the

last decade.
• Planning for increased timelines of reporting cholera during

peak transmission season or at known vulnerable areas,
including being on high alert in border areas (National
Department of Health, 2006).

• Educating health-care providers and community partners
(food and water operators), as well as the general public,
regarding the prevention, symptoms, treatment and control
of cholera. In addition, general health and hygiene aware-
ness training should be given to vulnerable communities on

an ongoing basis. In addition, instructions on the emergency
treatment of water and how to mix oral rehydration solutions
(ORS) should be given. Education materials should also be
prepared for emergency situations (National Department of
Health, 2006).

Long term:
• Ensuring that all people in the country have provision for

safe water, sanitation, hygiene and health services. Areas
that are known to be prone to cholera outbreaks should be
given priority.

• Ongoing education of health workers as well as communi-
ties to help with the prevention and management of future
outbreaks.

• Strengthened monitoring and surveillance of environmental
data as well as disease data to help with early detection and
control of cholera outbreaks.

As is evident from the above, responding to cholera in the
SADC region is a difficult task. Extensive knowledge and
understanding of the unique social, economic and political
contexts in SADC states needs to be developed. In addition,
adequate sharing and exchange of information are needed
to address the challenges that face the successful design and
implementation of proactive cholera prevention, preparedness
and response strategies. Such strategies should capacitate all
actors at different scales and divide responsibilities amongst
them, thereby enabling them to make a combined effort to better
manage this recurring and debilitating health disaster.

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A Predictable Tragedy
Robert Mugabe and the Collapse of Zimbabwe

Daniel Compagnon

336 pages | 6 x 9
Paper 2013 | ISBN 9780812222890 |

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“Compagnon’s devastating analysis of the regime argues that the country’s collapse was in fact the predictable outcome of the methods and approach Mugabe has always followed. . . . Compagnon¹s book stands out as the best account of the crisis to date.”—Foreign Affairs
“[A] masterpiece that will have a dignified shelf life in Zimbabwean studies. The book is well researched and detailed. Its arguments are convincing without being overly polemic. It leaves readers with no doubt about the culpability of Mugabe in the collapse of Zimbabwe.”—African Studies Review
“In this passionate book, Daniel Compagnon delivers an unrelievedly withering indictment of Zimbabwe’s post-independence political regime. . . . Wide-ranging and detailed, the analysis is illuminating and provocative.”—International Journal of African Historical Studies
“Daniel Compagnon’s book succeeds in its fundamental task: it describes in great detail how Robert Mugabe destroyed Zimbabwe. Indeed, it is highly unlikely that we will see a more comprehensive description of the Mugabe regime. While the exact endpoint of that regime remains to be determined, Compagnon’s book will be seen as an authoritative account of how it wrecked a once-vibrant country.”—Jeffrey Herbst, President, Colgate University
“A Predictable Tragedy provides a comprehensive historical analysis of the nature of Robert Mugabe’s rule. This is an important contribution because it shows that post-2000 Zimbabwe politics are not ‘new’ but the product of an authoritarian political system that began in 1980. Mugabe’s regime is, and always has been, one of personal rule, Compagnon argues. Academics and domestic opponents were taken in by the regime’s rhetoric of reconciliation, democracy, and socialism, failing to understand the true character of the regime. Only after 2000 did they begin to comprehend, and then very slowly and perhaps not yet fully, the Mugabe regime’s commitment to hold power at all costs.”—Norma Kriger, author of Guerrilla Veterans in Zimbabwe: Symbolic and Violent Politics, 1980-1987
When the southern African country of Rhodesia was reborn as Zimbabwe in 1980, democracy advocates celebrated the defeat of a white supremacist regime and the end of colonial rule. Zimbabwean crowds cheered their new prime minister, freedom fighter Robert Mugabe, with little idea of the misery he would bring them. Under his leadership for the next 30 years, Zimbabwe slid from self-sufficiency into poverty and astronomical inflation. The government once praised for its magnanimity and ethnic tolerance was denounced by leaders like South African Nobel Prize-winner Desmond Tutu. Millions of refugees fled the country. How did the heroic Mugabe become a hated autocrat, and why were so many outside of Zimbabwe blind to his bloody misdeeds for so long?

In A Predictable Tragedy: Robert Mugabe and the Collapse of Zimbabwe Daniel Compagnon reveals that while the conditions and perceptions of Zimbabwe had changed, its leader had not. From the beginning of his political career, Mugabe was a cold tactician with no regard for human rights. Through eyewitness accounts and unflinching analysis, Compagnon describes how Mugabe and the Zimbabwe African National Union-Patriotic Front (ZANU-PF) built a one-party state under an ideological cloak of antiimperialism. To maintain absolute authority, Mugabe undermined one-time ally Joshua Nkomo, terrorized dissenters, stoked the fires of tribalism, covered up the massacre of thousands in Matabeleland, and siphoned off public money to his minions—all well before the late 1990s, when his attempts at radical land redistribution finally drew negative international attention.

A Predictable Tragedy vividly captures the neopatrimonial and authoritarian nature of Mugabe’s rule that shattered Zimbabwe’s early promises of democracy and offers lessons critical to understanding Africa’s predicament and its prospects for the future.

Daniel Compagnon is Professor of Political Science at the University of Bordeaux and coauthor of Behind the Smokescreen: The Politics of Zimbabwe’s 1995 General Elections.

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Critical Thinking: Case Study –

Cholera Outbreak

(90 points)

In this assignment you will examine the international legal entities dealing with global health law incidents. Read “Cholera Outbreak in Zimbabwe” (5.2) on pages 68-69 in An Introduction to Global Health Ethics. In this case study you explore options available for dealing with this health crisis. Write a four- to five-page paper evaluating the steps Zimbabwe should take in dealing with this situation and provide your recommendation on how to remedy a future situation.

Your report should address the following substantive requirements:

• Examine the purpose of laws.

• Describe and assess each agency that would be involved in the situation. Include pros and cons for international involvement in state affairs.

• Develop a law that would prevent such a breakdown from occurring in the future and use reasoning to illustrate why such a law would not be considered intrusive.

Your well-written report should meet the following requirements:

Be four to five pages in length, not including the cover or reference pages.

Formatted according to

Saudi Electronic University

and APA writing guidelines.

Provide support for your statements with in-text citations from a minimum of four scholarly articles. Two of these sources may be from the class readings, textbook, or lectures, but two must be external.  

Utilize the following headings to organize the content in your work:

Introduction

Description and Assessment

Recommendation

Conclusion

Cholera Outbreak

——-

ID —–

HCM515 – Health Ethics and Law

Saudi Electronic University

Dr. —-

——-, 2017

Cholera Outbreak

Cholera is acute infectious disease caused by ingesting of contaminated food or water (World Health Organization, 2017). It causes severe dehydration and leads to death. Primary causes are insufficient safe water and lack of appropriate sanitation. It occurs in areas where the environmental infrastructure is destroyed and damaged such as in Zimbabwe. Many cholera outbreaks were reported in Zimbabwe in past years from 1992 till 2008 (Mason, 2009). The most tragic one was in 2008 where more than 600 cases were reported and death rates were 104 in one city (Mason, 2009). In few months, cholera cases dramatically increased in all provinces of Zimbabwe (Mason, 2009). By the first week of December 2008, cholera was reported endemic as it reached other neighboring counties and emergency was declared (Fisher, 2009).

Healthcare system breakdown in Zimbabwe was due to the economic crisis. Financing problems and infrastructure failure were not solved earlier. In addition to, shortage of medical equipment, lack of health workforce, many hospitals are closed and limited health services have contributed in this tragedy (Mason, 2009). The deteriorated civil and political rights have failed to protect the people (Howard-Hassmann, 2010). Human rights were violated in which there was a severe food crisis from 2000 to 2009 that led to many deaths (Howard-Hassmann, 2010). Clearly, there are many aspects to consider in this matter which include governmental, political, financial and public health aspects. This script will provide comprehensive analysis of decision making in Zimbabwe politically as well as clinically and its influence on ethical practices among public health demonstrators.

Political and Social Aspects in Zimbabwe

Democracy in Zimbabwe was known to be role of whites. White contribution in politics was honored and respected while black contribution was criminalized (Jonga, 2012). After Independence Day in 18th April 1980, Zimbabwe became more like a dictatorship government (Jonga, 2012). Mugabe was playing a monopolizing power in Zimbabwe (Compagnon, 2011). When there was a threat to his power or opposing opinions to his politics, violence was the solution. The irresponsible politics have led Zimbabwe to crisis (Compagnon, 2011). Mugabe’s work was to rule with power and to accumulate all the wealth to his personal interest at expense of the population (Compagnon, 2011). His mind was not into the social and economic states of Zimbabwe, but only into ruling Zimbabwe with and merciless power (Compagnon, 2011).

Multi ethnic states of Zimbabwe made the political management complicated. Financial failure and organizational ineffectiveness were common because of central government’s interference. In August 1980, Mugabe gave a speech at the United Nation (UN) emphasizing on five values of Zimbabwe’s foreign policy, which are: equity, democracy, non-racialism, right of independence and peace (Patel, 1987). These values were only spoken words. Racism was common in which there were multi ethnic groups in Zimbabwe favoring black Africans and colonizing white Africans (Chan & Primorac, 2013). There was no democracy but only tragic and horrible bureaucracy (Chan & Primorac, 2013). The power of colonizing whites was dominant until he was called “the black Hitler” (Harris, 2015).

Political crimes were allowed and practiced until the year 2000 (Jonga, 2012). Zimbabweans became the victims of these political crimes. Corruption and fraud were common in which the police can change reports and destroy evidences (Compagnon, 2011). Politicians who are committing violence and crimes seem to be protected and above the law (Jonga, 2012). Corruption, fraud, crimes and threats in Zimbabwe have made the population live in fear. The political power was just to control the wealth regardless of populations’ needs and to rule with power and threats. Politics in Zimbabwe government were unstable and politicians are above the law. Human rights were violated frequently (Howard-Hassmann, 2010). Social life in Zimbabwe is tough since there is no law to protect the people and their rights.

The response to cholera outbreaks was the responsibility to be taken by Zimbabwean healthcare system and government. It is well known that the government is responsible to deal with these situations internally and try their best to control it. Cholera outbreaks rapidly spread to neighboring countries for example Mozambique, South Africa and Botswana (Said et al,2011). Cholera spread also to Angola, Malawi, Namibia, Swaziland and Zambia (Said et al, 2011). The government and national health departments didn’t take any actions to control this rapid spread of cholera. Cholera crisis in Zimbabwe was out of control that led WHO and related international agencies to help and provide support.

Description of Health and Financial Aspects in Zimbabwe

Government’s role in the health sector of Zimbabwe is to promote health, provide access to healthcare services, provide maintainable funding for health settings, prevent and control the spread of infectious diseases (Tizora, 2009). All these objectives were not met and Zimbabwean government has failed to achieve them. There was insufficient and unequal access to healthcare services, poor quality of healthcare services, no funding to healthcare sectors and the wide spread of cholera (Tizora, 2009). In 2008, cholera has killed 2024 people and infection rates were at least 40,0005 (Tizora, 2009). The lack of safe water and sanitation have led to the spread of cholera in all provinces of Zimbabwe (Tizora, 2009). Major hospitals were closed and other hospitals had been functioning without running water, no functioning toilets, no soap, no medications and no enough food for patients or healthcare workers (Tizora, 2009). Also, medical and nursing schools were closed. Exams in medical schools were cancelled because of lack of papers and ink to print the exam papers (Tizora, 2009). There was no fund to help heath sectors to function well. There was no electricity in main mortuary in which deceased are rotting (Tizora, 2009).

There were some free medications that patient but they were sold to them with unexcepted high prices. Therefore, most of Zimbabweans were not getting proper treatment and medications that they can afford to pay (Tizora, 2009). The healthcare system in Zimbabwe have failed to meet the needs of population due to the economic crisis. In addition to, shortage of medications, medical equipment and health workforce that led to the bad health status in the country (Mason, 2009). Severe dehydration caused by cholera can often be prevented using oral rehydration salts (ORS) which was not available in Zimbabwe (Mason, 2009). Many physicians left their job because of the low salaries, lack of medical tools and medications (Mason, 2009). There was no clear and complete assessment on the progress of cholera in Zimbabwe due to staffing and economic limitations which resulted in the inability to have a countrywide health profile (WHO, 2008).

The terrible levels of healthcare services in Zimbabwe could be controlled if there was a strong healthcare system that applies heath laws and human rights effectively. In addition to, the presence of a strong government who attends to the populations’ needs and care about their rights. Unfortunately, the healthcare laws and ethics were absent in healthcare system of Zimbabwe. Besides, Mugabe was accumulating all the wealth to his personal interest at expense of the population who are suffering to receive their basic rights and meet their basic needs (Compagnon, 2011).

Agencies involved in Zimbabwe’s health situation. In December 2008, cholera was declared as it reached neighboring countries. Zimbabwe needed assistance and received help from external agencies such as World Health Organization (WHO), Medicines Sans Frontieres (MSF), The United Nations International Children’s Fund (UNICEF), the Centers for Disease Control and Prevention (CDC), Oxfam, Plan International and the Red Cross (Fisher, 2009). The WHO, Global Outbreak and Alert Response Network (GOARN) and its allied organizations have developed medical and healthcare services that include infection control specialists, public health professionals, epidemiologists, communications and social transport experts (Fisher, 2009). Also, they procured emergency kits and medical aids across Zimbabwe.

WHO’s objective is to promote health and build a healthy future for people all over the world. WHO have created Cholera Response Operational Plan to control cholera outbreak in Zimbabwe (WHO, 2008). It is an emergency measure for deteriorating Zimbabwean healthcare system which is consisted of many services to support Ministry of Health (WHO, 2008). This plan aimed to reduce the spread of cholera by ensuring effective isolation, mobilization, safe water and sanitation. In addition to, reduce mortality rates by ensuring efficient access to care and early detection of disease. All of these services were provided in cooperation with ministry of health in Zimbabwe and other agencies.

MSF is an international medical organization that provide emergency relief to needy countries with weak healthcare system (MSF, 2008). It has opened many Cholera Treatment Centers throughout Zimbabwe. MSF treated more than 6,000 people and was providing healthcare services in places with no electricity (MSF,2008). These services have dropped mortality rates significantly and improve the health status in Zimbabwe. UNICEF is another agency that was involved to defend rights of children in Zimbabwe. Its goal to provide a better life to children and their families. UNICEF has contributed $17 million to health emergency programs in Zimbabwe. It sent airlift of emergency supplies which included drugs, health kits and intravenous fluids to Zimbabwe (UNICEF, 2008). Also, more than half a million of safe water was sent to Zimbabwe (UNICEF, 2008).

CDC is a healthcare agency that aims to prevent and control infectious diseases. CDC had a great role in controlling spread of cholera and strengthening Zimbabwean healthcare system. It has built safe water systems across Zimbabwe. Moreover, it provided public education and required information about mobilization. Oxfam is an international agency aims to a world with no poverty. It responded to cholera outbreak with effective healthcare strategies. It has contributed to treat cholera cases by early detection, immediate treatment and effective prevention of cholera. It provided sanitation, safe water and food to thousands of people in all provinces of Zimbabwe. In addition to, proper education about early signs and symptoms of cholera was given.

Another well recognized humanitarian organization that contributed to save the lives of Zimbabweans is Plan International. It protects children rights and advocates equity to girls. Many healthcare programs were established in Zimbabwe to control spread of cholera and educate the people about it. Plan International offered education, training, safe water and sanitation that helped Zimbabwe to recover from cholera crisis (Plan International, 2016). Another independent humanitarian agency that helped to treat cholera is Red Cross. It aims to prevent human suffering in emergencies. It has produced sanitation and safe water to Zimbabweans in all provinces starting from the main affected ones. Treatment facilities were established and health awareness programs were given (International Federation of Red Cross, 2009).

Advantages and disadvantages of international involvement in cholera outbreak.
The main advantage of international involvement in Zimbabwe was control the spread of cholera. Cooperation of international agencies in Zimbabwe have helped healthcare system to overcome the tragic crisis of cholera gradually. When cholera became endemic, there was a need for immediate response by experts and health professionals to set proper plan of actions toward preventing and controlling spread of cholera. These experts and health professionals from all international agencies have made the change. Zimbabwean’s healthcare system was strengthening by the support of all international organizations. In addition to, cholera awareness and education that led the people to take actions and speak up. Another advantage was paying attention to human and children rights which include right to healthcare access, right to be safe, right of justice and peace.

Thinking about legal aspect of international agencies’ involvement to solve cholera crisis in Zimbabwe is complex (Said et al, 2011). The advantages overcame disadvantages of international involvement in Zimbabwe. In this matter the inability of population to trust their own healthcare system is the possible disadvantage. They waited long time to receive their basic needs, help and support from their country while international organizations were offering help. The image of Zimbabwean’s healthcare system is damaged. It can gain the public trust if they receive government’s support and encouragement.

Cholera Outbreak Law

Cholera outbreak law covers health, financial, governmental and social services. Health services must be supported by strong health policies that are approved by ministry of health and healthcare system. Healthcare policies should address control of disease, prevention, measurement and treatment. As well, standardized case reporting, guidance to treatment priorities and prevention awareness (WHO, 2008). Also, ensuring access to safe water and sanitation. In addition to, reduce mortality rates by standardized case management, treatment plans and prevention tools. More important is cholera prevention campaigns and proper mobilization (WHO, 2008). Availability of ORS treatment in each healthcare setting is needed. Besides, assigning emergency teams in healthcare settings can help to control the spread of cholera (Said et al, 2011). Implementation of international health regulation can create a consistent work flow that would assist the healthcare system in emergencies (Said et al, 2011). Strong healthcare system, professional healthcare workers, essential drugs and more clinics in urban and rural areas can help in cholera outbreak.

Financial support is needed to improve quality of healthcare services. Realistic pays and better work environment can retain healthcare workers (Mason, 2009). Government support of healthcare system financially is needed. Improvement of healthcare services depends on having enough healthcare funding. Providing basic public needs such as water and food is essential (Mason, 2009). Economic support of these basic needs is the government’s responsibility and obligation to do. Government should pay attention to the population’s needs. Safe water and sanitation are basic requirement that should be provided to prevent cholera. Government’s awareness of human rights and needs are highly important. Applying health ethics and law in healthcare sectors can improve the standards of healthcare delivery and strengthen the healthcare system.

Recommendations

A strong healthcare system should be ready to face the emergence of infectious diseases. Plan of prevention and disease control should be established. Clear polices and guidelines about treatment plans should be followed. Ongoing health education and awareness about infectious diseases are highly needed in outpatient and inpatient settings. Vaccination and proper documentation of disease progress is important to keep constant healthcare profiles. Health ethics and law are important to be practiced in each healthcare setting. Human rights should be protected. Zimbabwe and other countries should advocate for patients’ rights. Governmental support to healthcare system is necessary in order to provide healthcare services to the population. It is the time to take an action and recognize the need of disease prevention in its early stage (Mason, 2009). Cholera crisis is just one example of may infectious diseases that can emerge any time. Effective collaboration between Zimbabwe and international agencies is crucial for observation and action plans (Mason, 2009). Even though, there are some political and financial issues, improvements and better changes are approaching.

Conclusion

Many cholera outbreaks were reported in Zimbabwe in past years from 1992 till 2008 (Mason, 2009). Comprehensive analysis of decision making in Zimbabwe was described in details. The irresponsible politics have led Zimbabwe to crisis (Compagnon, 2011). Healthcare system breakdown in Zimbabwe was due to the economic crisis. Financing problems and infrastructure failure were not solved earlier. Mugabe was ruling with power and he was accumulating all the wealth to his personal interest at expense of the population who need safe water and food (Compagnon, 2011). There was insufficient and unequal access to healthcare services, poor quality of healthcare services, no funding to healthcare sectors (Tizora, 2009). In December 2008, cholera was declared as it reached neighboring countries. Zimbabwe needed assistance and received help from external agencies such as WHO. Effective collaboration of all international agencies with Zimbabwean ministry of health have improved healthcare status and prevented the spread of cholera. Advantages of international agencies’ involvement overcame the disadvantages. Main advantage was controlling spread of cholera and another important advantage was the big attention to human rights and ethics. The best method to control a disease is to prevent it from happening in the beginning. This is what it needs to be done by all healthcare systems all over the world.

References

Brown, P (2003). Refugees recall a different Zimbabwe. The Zimbabwe situation. Retrieved

from: http://www.zimbabwesituation.com/old/jan13a_2003.html

CDC. (2008). Cholera prevention and control. Retrieved from:

https://www.cdc.gov/cholera/prevention.html

Chan, S., & Primorac, R. (2013). Zimbabwe in crisis: The international response and the space

of silence. Routledge.

Compagnon, D. (2011). A predictable tragedy: Robert Mugabe and the collapse of Zimbabwe.

University of Pennsylvania Press.

Fisher, D. (2009). Cholera in Zimbabwe. Ann Acad Med Singapore, 38(82), 193.

Harris, A. (2015). 6 Facing/Defacing Robert Mugabe. What Postcolonial Theory Doesn’t Say, 31, 105.

Howard-Hassmann, R. (2010). Mugabe’s zimbabwe, 2000-2009: Massive human rights

violations and the failure to protect. Human Rights Quarterly, 32(4), 898-920,1080.

International Federation of Red Cross. (2009). Zimbabwe: As cholera escalates, Red Cross Red

Crescent funding falls short. Retrieved from: http://www.ifrc.org/en/news-and-

media/press-releases/africa/zimbabwe/zimbabwe-as-cholera-escalates-red-cross-red-

crescent-funding-falls-short/

Jonga, W. (2012). Prioritising Political Banditry than Good Governance: Rethinking Urban

Governance in Zimbabwe. International Journal of Humanities and Social Sciences,

2(24), 117-135.

Medicines Sans Frontieres. (2017). Zimbabwe: MSF responds to worst cholera outbreak in years.

Retrieved from: http://www.msf.ca/en/article/zimbabwe-msf-responds-worst-cholera-

outbreak-years

Oxfam. (2009). Oxfam America awarded $1 million for cholera response in Zimbabwe. retrieved from: https://www.oxfamamerica.org/press/oxfam-america-awarded-1-million-for-cholera-response-in-zimbabwe/

Patel, H. H. (1987). No master, no mortgage, no sale: the foreign policy of Zimbabwe. CREDU.

Plan International. (2016). Zimbabwe. Retrieved from: https://plan-international.org/zimbabwe

Said, M. D., Funke, N., Jacobs, I., Steyn, M., & Nienaber, S. (2011). The case of cholera

preparedness, response and prevention in the SADC region: a need for proactive and

multi-level communication and co-ordination. Water SA, 37(4), 559-566.

Tizora, R. E. (2009). Bureaucratic corruption in Zimbabwe (Master’s thesis).

UNICEF. (2008). UNICEF airlifts cholera and health supplies to Zimbabwe. retrieved form:

https://www.unicef.org/media/media_46920.html

WHO. (2008). Cholera in Zimbabwe. retrieved from:

http://www.who.int/csr/don/2008_12_02/en/

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MSF responding to worst cholera outbreak in Zimbabwe in years

15 December 2008

MSF has seen more than 11,000 patients since August in Zimbabwe’s worst cholera outbreak in years and has opened dozens of cholera treatment centres throughout the country. Cases have been found in nearly all the country’s provinces. More than 500 national and international MSF staff members are working to identify new cases and to treat patients in need of care.

Harare, the capital city, has been the center of the outbreak. MSF has treated more than 6,000 people in the densely populated city. A second location, Beitbridge, a town on the border with South Africa, has also been hard hit. MSF has provided care to more than 3,000 people with suspected cases of cholera.

“The scale and the sheer numbers of infection especially in Harare is unprecedented,” said an epidemiologist for MSF who has worked periodically in Zimbabwe for the past seven years.

He explained that the key reasons for the outbreak are the lack of access to clean water, burst and blocked sewage systems and uncollected garbage overflowing in the streets.

“The fact that the outbreak has become so large is an indication that the country’s health system can’t cope,” he said.

A town on the border with Mozambique, Nyamapanda, also has been affected. When MSF arrived in early November the team found about 150 cholera patients and helped set up one cholera treatment center in the town, as well as four others with the Ministry of Health in the surrounding areas. In total, 1,600 patients have been seen in Mudzi District.

Zimbabwe has had major outbreaks of cholera before – it is endemic in certain rural areas – but until the last few years it has been relatively rare in urban areas.

The outbreak is particularly worrying as it began well before the rainy season. A major concern is that once the heavy rains start, unprotected water sources will become contaminated, causing the further spread of cholera. The rainy season normally starts in November and continues through March, although the heavy rains have yet to be seen in some areas.

Because MSF has been in the country since 2000 running HIV programs, it has been able to react from the ground and quickly bring in emergency cholera response units.

MSF is working in two cholera treatment centers (CTCs) which are located in existing health facilities in Harare. In total, the two main CTCs saw more than 2,000 people with cases of suspected cholera in the first week of December.

An MSF emergency coordinator in Harare described the situation: “Imagine a cholera ward with dozens of people under the most basic conditions. For instance, there is only a little electricity so there is hardly any light. It is difficult for the doctors and nurses to even see the patients they are treating. The nurses have to monitor multitudes of IV bags to make sure they don’t run dry which is also difficult to do in the dark and when there are so many patients.”

In Beitbridge, MSF has set up CTCs run mainly by MSF staff using supplies shipped in from all over the world. The peak of the emergency was unusually early in Beitbridge, which resulted in a high mortality rate within the first couple of days of the severe outbreak in the town. By the fourth day, however, MSF had established a CTC and the mortality rate eventually dropped from 15 percent to less than one percent.

An additional challenge has been that government health workers in certain areas, particularly in Harare, are on strike. This has required MSF to rapidly recruit hundreds of nurses and other staff to handle the influx of cholera cases. Significant time and energy is needed to train the new staff, adding considerably to the workload of the existing staff.

MSF has also conducted exploratory missions in rural communities and responded to scattered reports of cholera cases. Low numbers of cases have been found in a number of small villages; MSF established small cholera treatment units (CTUs) where necessary. MSF has eight CTUs in five districts spread over the Manicaland and Mashvingo provinces in the eastern part of Zimbabwe and treated more than 770 patients.

MSF will continue to monitor the situation and treat people in the most affected areas, as well as send emergency staff and supplies to various locations in Zimbabwe where new cases arise.

“A cholera outbreak of this proportion usually continues for several months,” the MSF epidemiologist says. “MSF expects to be caring for cholera patients in Zimbabwe for some time to come.”

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The case of cholera preparedness, response and prevention in the SADC region: A need for proactive and multi-level communication and co-ordination

Article (PDF Available)  in Water S.A 37(4):559-566 · October 2011 with 19 ReadsDOI: 10.4314/wsa.v37i4.15
Cite this publication

• M. D. Said

• Nikki Funke

13.65
Council for Scientific and Industrial Research, South Africa

• + 1

  I. Jacobs

• S. Nienaber

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Abstract
In this paper the authors seek to identify the most appropriate model for a regional co-ordination mechanism for cholera preparedness, response and prevention. The qualitative mixed-method data collection approach that was followed revealed the need for alternative solutions, including a socio-political understanding of cholera responses at different levels of scale and at different stages of an outbreak. Important areas that need to be understood include the multiplicity of actors and the complexity of their interaction, the importance of building local capacity, the need for varying responses at different levels of scale, the need for improved inter- and intra-country co-ordination and information exchange, the importance of cultural belief systems and the impact of the media on the response to cholera outbreaks. Ultimately, despite the proposed co-ordinating role that the Southern African Development Community (SADC) can play in a regional cholera response effort, the onus remains on states to build capacity at the local level and to capacitate local communities to drive response efforts semi-autonomously.

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Maronel Steyn

, Sep 23, 2015
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htt p://dx.doi.or g/10.4314/wsa.v37i4.15
Available on website http://www.wrc.org.za
ISSN 0378-4738 (Print) = Water SA Vol. 37 No. 4 October 2011
ISSN 1816-7950 (On-line) = Water SA Vol. 37 No. 4 October 2011 559
* To whom all correspondence should be addressed.
 +27 12 841-2024; fax: +27 12 841-3954;
e-mail: nfunke@csir.co.za
Received 27 September 2010; accepted in revised form 7 October 2011.
The case of cholera preparedness, response and
prevention in the SADC region: A need for proactive
and multi-level communication and co-ordination
MD Said1, N Funke2*, I Jacobs2, M Steyn2 and S Nienaber2
1Euroconsult Mott MacDonald –Technical Assistance Support Team (TAST), Ministry of Water Resources & Irrigation,
PO Box 476, Juba, South Sudan
2Council for Scientic and Industrial Research, Natural Resources and the Environment Unit, PO Box 395, Pretoria 0002,
South Africa
Abstract
In this paper the authors seek to identify the most appropriate model for a regional co- ordination mechanism for cholera pre-
paredness, respon se and prevention. The qualitative mixed-method data collection approach that was followed revealed the
need for alternative solutions, including a socio-political understanding of cholera responses at different levels of scale a nd at
different stages of an outbreak. Important areas that need to be understood include the multiplicity of actors and the complex-
ity of their interaction, the impor tance of building local capacity, the need for var ying responses at different levels of scale,
the need for improved inter- and intra-cou ntry co-ordinat ion and infor mation exchange, the import ance of cultu ral belief
systems and the impact of the media on the response to cholera outbreaks. U ltimately, despite t he proposed co -ordinating role
that the Southern Af rican Development Community (SADC) can play in a regional cholera response effort, the onus remains
on states to build capacit y at the local level and to capacitate local commun ities to drive response effor ts semi-autonomously.
Keywords: Cholera prevention, preparedness and response, socio-political understanding of cholera, socio-cultural
understanding of cholera, transboundary disease, Southern African Development Community (SADC), cholera
Introduction
Africa accounts for over 90% of all cholera cases reported to the
World Health Organisation (WHO, 2007). Gaffga et al. (2007)
refer to Afr ica as the new homeland for cholera, as cholera out-
breaks have been reported on an annual basis since 1990. The
SADC region is therefore a prime case study area for observing
regional responses to cholera, particularly due to the trans-
boundary nature of the disease, which poses a health security
risk to almost all of the SADC member states. Cholera epidem-
ics are cyclical, seasonal, and have been reported annually in
several Southern African states since 2000 (WHO, 2006). The
recent outbreak that originated in Zimbabwe in August 2008
resulted in 98 424 suspected cases and 4 276 deaths in the coun-
try, as reported on 30 May 2009 by the Ministr y of Health and
Child Welfare in Zimbabwe (WHO, 2009). Nine other count ries
in Souther n Africa were also affected by cholera, either as a
result of the Zimbabwean outbreak or independently of it. These
countries were Angola, Botswana, Malawi, Namibia, South
Africa, Swaziland, Zambia, Zimbabwe and the Democratic
Republic of the Congo (DRC) (Kiem, 2009).
The fragile socio-political and environmental situation of
many Souther n African states makes the region particularly
susceptible to cholera outbreaks. In addition to weather pat-
terns conducive to the outbreak of cholera, a history of labour
migration, lack of adequate sanitation in informal settlements
and rural areas, failed or failing health care systems, inadequate
community involvement, poor domestic and personal hygiene,
lack of capacity at the local government level, lack of logistical
co-ordination of relief aid, cult ural stigmas regarding treatment
of cholera and political instability in several states are all fac-
tors that have contributed to the increase in outbreaks (United
Nations Ofce for the Co-ordination of Humanitarian Affairs,
2008; Mintz and Guerrant, 2009). This has raised concerns
about regional security as well as the role and preparedness of
the SADC states in addressing health emergencies of a trans-
boundary nature.
This paper reviews the presence of epidemic cholera in the
SADC region and is based on research conducted to identify the
most appropriate model for a regional co-ordination mechanism
for cholera preparedness, response and prevention. At the outset,
the research team hypothesised (based on a preliminary litera-
ture review) that the responsibility for establishing and running
such a mechanism would likely be situated at the regional (i.e.
SADC) level.
This hypothesis was, however, challenged by the qualitative
mixed-method data collection approach that was adopted during
the project. The research results revealed the need for alternative
solutions that include a socio-political understanding of cholera
response at different levels of scale and at different stages of an
outbreak. Priority areas include: understanding the multiplicity
of actors and the complexity of their interaction, the importance
of building local capacity, the need for varying responses at
different levels of scale, the need for improved inter- and intra-
countr y co-ordination and information exchange, the impor-
tance of cultural belief systems, and the impact of the media on
the response to cholera outbreaks.
The authors summarise these ndings and further argue
that, despite the proposed co-ordinating role that SADC can
play in a regional cholera response, the onus is still on states to
build capacity at the local level, develop appropriate prepared-
ness plans, review them periodically, and share this information
with other states in the region. Here it is important to recog-
nise that while state action is required to provide systems for

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560
inter-state co-ordination, local communities need to be capaci-
tated to drive response efforts semi-autonomously.
Methodological framework
The authors adopted a qualitative, descriptive analysis of
regional responses to cholera. This approach was adopted for
several reasons. Firstly, the body of literat ure on cholera in
SADC is voluminous; however, it has been conducted from a
largely scientic point of view. More specically, cholera out-
break response research has focused on medical aspects that are
important for decreasing mortality (WHO, 2004a). Due to the
fact that outbreak response is often led by medical professionals,
other aspects, such as environmental and communication issues,
have often been neglected (WHO, 2004a). This has largely
resulted in the omission of socio-political and socio-cultural
perspectives. The lack of publicly-documented and accessible
research on multi-actor response and multi-level co-ordination
strategies provides critically important gaps in scientic
research and policy, and subsequently the need for more inte-
grated analyses. A more comprehensive response is needed to
limit the spread of the disease, and a trans-disciplinary descrip-
tive analysis of the nature of the problem is therefore essential
to highlight the linkages between scientic, socio-political and
socio-cultural dynamics and policy.
Secondly, it is apparent that a vast treasury of experiential
knowledge exists in the minds of key individuals working in the
eld of cholera response strategies in the region. However, this
knowledge is seldom captured. Participatory engagement was
therefore identied as an appropriate research method to retain
the experiential knowledge of these individuals.
The method employed was divided into 2 phases: a lit-
erature review and qualitative participatory engagement. The
literature review included an analysis of primary and secondary
sources including policy documents, popular articles and aca-
demic articles. Qualitative participatory engagement comprised
of a multi-stakeholder workshop, observation of governmental
committee meetings in South Africa, qualitative interviews and
several other consultative processes.
The chosen methodological framework brings to the fore the
socio-political and socio-cultural issues that are often forgotten,
ignored or undermined, but that play a critically important role
in deter mining the success or failure of technical and science-
based interventions.
The context in which cholera occurs
Cholera the disease
Cholera is an acute dehydrating diarrhoeal disease caused
by ingestion and colonisation of the pathogenic strains of the
gram-negative bacterium, Vibrio cholerae. Although more
than 180 serogroups of V. cholerae exist, only 2 serovars – O1,
and less commonly O139 – have been linked with epidemic
disease (Wachsmuth et al., 1994; Lin et al., 1999; Du Preez et
al., 2010). A serovar refers to distinct variations within a subspe-
cies of bacteria or viruses. A group of serovars with common
antigens is called a serogroup (The American Heritage Medical
Dictionary, 2007).
Vibrio cholerae non-O1 serogroups were until fairly
recently only associated with sporadic diar rhoea cases and
not known to cause diarrhoea epidemics. In 1992, however,
toxigenic strains of the O139 serovar appeared in India and
Bangladesh as the rst non-O1 serovar to cause epidemic
cholera (Albert et al., 1993; Ramamurthy et al., 1993; Lin et al.,
1999). While the possibility of a Cholera O139 outbreak has not
been associated with Africa, the recently-published Du Preez
et al. (2010) study found both strains in estuarine waters and
sediments of Mozambique, now also linking the O139 strain to
African waters and indicating a possible human health risk.
While V. cholerae is a natural inhabitant of estuarine envi-
ronments (Colwell and Huq, 1994), humans are the only known
natural host for V. cholerae, and the disease is spread mainly by
faecal contamination of water and food. Direct person-to-person
spread of the disease is uncommon (Hensyl, 2000). The incuba-
tion period varies between 6 hours and 5 days. Oral rehydra-
tion therapy (ORT) is the treatment of choice as it is effective,
economical, easy to administer and capable of reducing the
case fatality rate (CFR) to less than 1% (WHO, 1993). However,
despite the existence of basic treat ment solutions, cholera is
still not being prevented or controlled, especially in developing
countries.
Cholera and water quality
Cholera is associated with several socio-economic factors, such
as population density and poverty, and is closely linked to poor
sanitation and hygiene, and a lack of a safe, clean water supply
(WHO, 2010). In addition, basic measures to improve water
quality such as boiling, chlorination, and ltration are not eco-
nomically feasible for many rural or peri-urban communities,
and sanitation targets are still lagging behind in sub-Saharan
Africa countries (United Nations, 2009). Waterborne transmis-
sion has been quoted as being the most important route of trans-
mission in Af rica, with several researchers linking cholera to
untreated drin king water f rom contaminated water sources such
as lakes, rivers, springs and shallow wells (Bradley et al., 1996;
Shapiro et al., 1999). In rural environments, contaminated water
sources transmit the disease to the communities through which
they ow, while in urban and peri-urban communities, cholera
outbreaks are usually caused by breakdowns in water treat ment
systems and/or contaminated public water supplies.
In addition, the relationship between cholera and pover ty is
well documented and remains a global threat, especially in the
developing world (Borroto and Martines-Piedra, 2000; Soussan,
2003). The most susceptible individuals tend to be those living in
poor communities characterised by economic and social hard-
ships. Roughly 70% of people in the SADC region, and 60% of
people residing in poor rural communities, are dependent on
groundwater for domestic water supply (Banda, 2009). However,
only a few SADC countries actively monitor groundwater use
effectively and manage it sustainably. In the absence of effective
monitoring and surveillance systems and streamlined report-
ing procedures, little can be done to curb the contamination of
groundwater that exposes millions of people living in rural areas
to waterbor ne diseases (Zuckerman et al., 2007; United Nations
Ofce for the Co-ordination of Humanitarian Affairs, 2008;
Banda, 2009; Mintz and Guerrant, 2009).
Access to clean water is not only a rural problem, however,
and also affects many urban populations across the SADC
region as governments fail to replace poor infrastructure
(Banda, 2009). On average, the provision of rural water sup-
ply has improved considerably in the last decade, with access
to improved water sources having increased from 56% in 1990
to 64% in 2006 in Africa (WHO, 2008). However, in some
countries, such as Zimbabwe and Zambia, urban water services
coverage has in fact decreased (Fig. 1). This is presumably due
to urban migration and rapidly increasing urban populations,

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as well as the failure to meet the increasing demand for water
supply. The deterioration of existing water services due to poor
maintenance may also contr ibute to the problem.
Reported statistics such as those represented in Graph 1
must be examined with a degree of caution in that they priori-
tise water access above water quality. For example, the graph
indicates that a percentage of a population has received access
to improved water sources in urban and rural areas. However,
this information does not clarify whether the service is still
functioning and when last it was monitored, whether the water
supplied is of an appropriate quality, and how often quality
standards are not met, as well as for how many hours a day
the service is rendered. In Zambia, for example, urban water
supply ranges between 5 and 20 hours a day in many towns.
Bartram and Cair ncross (2010) argue that health benets are
closely linked to the level and quality of service and that the
Millennium Development Goal (MDG) for water is inadequate
as it assumes water quality to be safe when supplied from an
improved source. Thus, the gures provided must be read care-
fully to understand the limitations on the information that they
provide, and the possible areas of poor water quality hidden
within these gures.
In summary, the link between water quality and prevention
of waterborne diseases is well documented, although the prior-
ity for many governments in developing countries to achieve
broad-based water access has often masked the challenge of pro-
viding water of a suitable quality, and of regularly monitoring
that quality. Much of the SADC region still struggles to st rike
a balance bet ween water quantity and quality with the primary
focus still being on access to water rather than its quality.
Challenges in the SADC member states
Despite the fact that cholera is a preventable and treatable ill-
ness, the SADC region continues to be plagued with annual
outbreaks (United Nations Ofce for the Co-ordination of
Humanitarian Affairs, 2009; Funke et al., 2010). Why does this
problem continue to exist?
Firstly, cholera has become an inherent part of the biophysi-
cal environment (Funke et al., 2010). This means that the bacte-
rium reoccurs on a regular basis, often appearing to be triggered
by uctuating weather patterns involving heavy
rain or dr y seasons (United Nations Ofce for
the Co-ordination of Humanitarian Affairs,
2008; Mintz and Guerrant, 2009). Secondly,
cholera thrives in an environment where there is
poor infrastructural development, particularly
in terms of running water, sanitation and health
services (Funke et al., 2010). This makes SADC
particularly vulnerable to cholera. Thirdly,
notwithstanding cholera cases in Africa being a
manifestation of poor infrastructure, the CFR is
also a reection of the inadequacy and inacces-
sibility of basic health care (Mintz and Guerrant,
2009). A case in point is Zimbabwe, where the
CFR for cholera was reported at 5.4% from 15
August to 18 December 2008. This situation was
provoked and accentuated by a lack of safe dr ink-
ing water and sanitation, as well as inadequate
health services (United Nations Ofce for the
Co-ordination of Humanitarian Affairs, 2008;
Mintz and Guerrant, 2009). In terms of health
care, capacity also varies to a large degree. Lack
of resources, internal conict and limitations of
technical expertise are some of the challenges that affect the
functioning of medical services.
Also, as a preventative measure, there has histor ically not
been much support for mass vaccination and chemoprophylaxis,
as these have been observed to be ineffective in preventing
and controlling cholera in populations with endemic disease.
However, more recent ndings have revealed a proven efcacy
and tolerability in mass vaccination and, indeed, a resurgence
of this method’s popularity in curbing cholera spread as a result
of improved and modied vaccines (Sack et al., 2004; Longini
et al., 2007; Sur et al., 2009; Zuckerman et al. 2007). The WHO
currently recommends pre-emptive use of cholera vaccination in
certain endemic and epidemic situations, although clear guide-
lines have yet to be developed (WHO, 2004b; Zuckerman et al.,
2007).
The logistics of rolling out such campaigns are also
challenging, especially in r ural areas (WHO, 1993; WHO,
2000). Challenges include the need to: recognise the outbreak;
rapidly mobilise resources to the affected area; dispense
antibiotics or vaccines to the affected population; and follow-
up with patients to conrm that the intervention has been
appropriate and effective. Administering mass vaccinations
alone, however, will not prevent and control the spread of
cholera. Policy-makers also need to be mindful of how poor
infrastructure and health services may impede the efcacy of
these vaccinations.
Fourthly, cholera affects the entire SADC region because it
has profoundly transboundary dimensions (Funke et al., 2010).
Its movement across borders in the region occurs for 2 main
reasons. In the rst case, the Southern African region has experi-
enced a culture of legal, illegal and refugee migrations for more
than 150 years, a pattern which continues to grow despite ofcial
attempts to regulate it (Gorbachev, 2002; Crush and Frayne,
2007; Swatuk, 2009). Migrant populations such as farm workers
have been among those listed to be at high risk of contracting
cholera, especially during harvest periods, as working and living
conditions are poor and their only sources of drinking water are
contaminated rivers and canals (United Nations Ofce for the
Co-ordination of Humanitarian Affairs, 2009). These workers
have also contributed to the spread of the disease to r ural villages
when they return home on periodic visits to family.
60
99
80
97
71 77
100 95 99 92
100
80
99 87 99
38
90
28
81
29 29
99
77 88
61
0
45
78
46
72
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Per centage
SADCMem berCount ries
Percentageofpopulationwithaccesstoimprove dwatersources,urbanandrural
(Source:www.wssinfo.org)
ProportionofRural
populationwith
Unimpr ovedW ater
Supply(%)
ProportionofRural
populationserved
withImpr oved
Water Supply(%)
ProportionofUrban
populationwith
Unimpr ovedW ater
Supply(%)
ProportionofUrban
populationserved
withImpr oved
Water Supply(%)

Figure 1
Reported percentages of populations in SADC countries with access to
improved water sources, urban and rural (Source: WHO, 2008)

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562
Cholera epidemics in SADC member states
Since 1970, when the rst cholera outbreak of the seventh global
pandemic was documented on the African continent, a number
of SADC member countries have been affected (Goodgame and
Greenough, 1975; WHO, 2001).
In 2000, 27 African countries notied the World Health
Organisation (WHO) of cholera outbreaks. According to the
WHO Weekly Epidemiological Records’ annual cholera case
summaries of 1995-2005, all SADC countries, with the excep-
tion of Botswana, Lesotho, Mauritius, Namibia and Seychelles,
reported cholera (WHO, 2006). Figure 2 shows the magnitude
of the cholera epidemics within this period.
The August 2008 outbreak of cholera in Zimbabwe rapidly
spread to the neighbouring countries of Mozambique, South
Africa and Botswana and later also affected Angola, Malawi,
Namibia, Swaziland, Zambia and the DRC. The situation was
aggravated by the inux of illegal immigrants into South Africa,
coupled with inadequate water and sanitation facilities and poor
hygiene at temporary processing centres for asylum seekers
(UNICEF, 2009). Equally concerning is that some countries
which had previously been free of the disease, such as Botswana
and Namibia, have also started reporting cases (see Table 1).
Results of qualitative participatory engagement
Although much is known about the medical and biological
dimensions of cholera in the SADC region, the social, political,
and cultural dimensions of cholera outbreaks
are less well documented. Given this reality, a
multi-stakeholder workshop and other methods of
participatory engagement were pursued to solicit
inputs on these dimensions. A number of key nd-
ings emerged from this participatory process.
Interrogating who is responsible for
cholera preparedness and response
One of the key areas of consideration was the issue
of ‘who is responsible for a response to cholera
outbreaks?’ On the one hand there is the well-
established view that governments are responsible
for dealing with domestic matters that arise within
their borders. This view is backed by a power-
ful set of international norms which respects the
sovereign power of states in their own territories
and the practice of non-intervention in the domes-
tic affairs of states (Peters, 2009). To the extent
that cholera is an illness that affects people within
state boundaries, it can be argued that national governments,
and more specically national health departments and related
emergency health response units, are responsible for provid-
ing the necessary resources, suppor t and response to deal with
this issue. On the other hand, the issue of who is responsible for
responding to cholera outbreaks is a ‘grey area’ in an ever more
intercon nected and globalised world. A few issues in particular
contribute to this complexity.
Firstly, as mentioned earlier, cholera has transboundar y
dimensions (Funke et al., 2010). The illness therefore does not
necessarily remain within the borders of one specic country.
When the bu rden of illness falls on many countries at the same
time, critical questions arise about how best to coordinate the
distribution of resources, skills and emergency support among
different countries.
Secondly, what should happen when governments do not
or cannot respond to health crises and fail to deliver on their
responsibility to protect and provide for the needs of their
citizens? Governments face many challenges when responding
to health crises, including budget constraints, lack of healthcare
materials, poor maintenance and operation of water infrastruc-
ture and weak early warning systems in many countries in the
SADC region (Funke et al., 2010). A specic example is the
case of the 2008 Zimbabwean cholera outbreak, where one of
the aggravating factors was that the health care system had
almost completely collapsed as a result of the complex political
and economic issues in the country at the time (Balakrishnan
2008; Funke et al., 2010). Therefore hospitals and clinics were
Tab le 1
Cholera cases reported in SADC member states, 2008-2009
(Source: United Nations Ofce for the Co-ordination of Humanitarian Af fairs, 20 09)
Countr y Repor ted Cases Reported Deaths CFR ( %) Time Period
Angola 5 478 60 1.2 01 Jan. 2008 – 05 Apr. 2009
Botswana 15 213.3 01 Nov. 2008 – 17 Apr. 2009
Malawi 5 17 0 113 2.2 15 Nov. 2008 – 17 Apr. 2009
Mozambique 15 649 133 0.8 01 Jan. 2009 – 11 Apr. 2009
Namibia (Inc. AWD) 203 94.4 22 Oct. 2008 – 14 Apr. 2009
South Africa 12 765 64 0.5 15 Nov. 2008 – 10 Apr. 2009
Swaziland (only AWD) 13 278 0 0 22 Dec. 2008 – 28 Mar. 2009
Zambia 7 412 151 2.0 10 Sep. 2008 – 09 Apr. 2009
Zimbabwe 95 738 4154 4.3 15 Aug. 2008 – 10 Apr. 2009
Cholera cases in SADC member states: 1995-2005
0
20000
40000
60000
80000
100000
120000
Angola
Botswana
DRC
Lesotho
Madagascar
Malawi
Mauritius
Mozambique
Namibia
Seychelles
South Africa
Swaziland
Tanzania
Zambia
Zimbabwe
Member states
No. of cases
1995 Cases 1996 Cases 1997 Cases 1998 Cases 1999 Cases 2000 Cases
2001 Cases 2002 Cases 2003 Cases 2004 Cases 2005 Cases

Figure 2
Reported annual cases of cholera in SADC member states
between 1995 and 2005 (Source: WHO, 2006)

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understaffed, under-resourced and unable to respond to the
magnitude of the cholera outbreak.
In some cases governments refuse to acknowledge that they
have a cholera outbreak as they fear that such an admission
will result in negative repercussions such as reduced trade and
investment in the countr y (Funke et al., 2010). To try to avoid
specically talking about cholera, many governments refer to
the problem as acute watery diarrhoea (AWD), which requires
a different treatment to cholera and makes the problem seem
less urgent (Cumberland, 2009). Lack of political will to take
ownership of cholera outbreaks generally leads to time wasted
and lives lost. Often when governments are unable or unwilling
to respond to cholera outbreaks the onus falls on neighbouring
governments and transnational and local non-governmental
organisations (NGOs) to step in and handle the crisis.
Thirdly, there is a growing network of transnational and
local organisations (WHO, Red Cross, Médecins sans Frontières
(MSF), etc.) that have enormous expertise, experience, knowl-
edge and resources when it comes to dealing with cholera
outbreaks (Funke et al., 2010). These actors can often provide
support that governments themselves are not able to garner
in times of cholera crisis. The presence of these transnational
actors, however, raises difcult questions. Do these organisations
need a government’s permission to become involved? What if
governments are inadequately responding to cholera outbreaks
but do not want the involvement of non-government actors?
Given these complex factors, it is clear that the issue of chol-
era preparedness and response is nested within a multi-actor,
multi-level agency context.
The problem of a reactive response to cholera
In many developing countries, the approach to cholera out-
breaks is a reactive ‘emergency response’ and directed at
controlling the outbreak and minimising mortality. In the event
of a cholera outbreak, it is assumed that the health sector in
the affected country will take the lead in notifying the relevant
national institutions as well as the resident WHO ofce. The
national health sector can ofcially ask the relevant ministries
or departments, other UN afliates, international non-govern-
mental organisations (INGOs) and non-governmental organisa-
tions (NGOs) for nancial assistance and/or technical expertise
to contain the outbreak. Otherwise, the onus will rever t to the
WHO to initiate dialogue with the national government in a
combined effort to contain the outbreak.
The WHO is the U N afliate that is responsible for global
health issues. WHO operations in UN member states address
the health needs of resident populations through collaborations
with several partners. These include other UN agencies, donors,
international and local NGOs, WHO collaborating centres, the
private sector and civil society. The WHO, therefore, takes the
lead in assisting member states to prepare and respond to chol-
era emergencies (World Health Organisation, 2007).
Some countries or regions are completely unprepared when
a cholera outbreak occurs. Inconsistency in the development
of appropriate policies and their implementation has also been
noted (WHO, 2007; 2009). Also, the burden of responding to
cholera often lies with the health emergency units in national
health departments rather than in an institutionalised section of
the depar tment dedicated to a response to cholera in particular.
Often emergency health units have to deal with multiple health
crises at once (e.g. swine u and measles), resulting in the units’
capacity being stretched too thin to adequately deal with any
one crisis in detail (Funke et al., 2010).
Socio- political dimensions of the cholera issue in the
SADC region
What is evident in literature (Cumberland 2009; Schaetti et al.,
2009), and has been con rmed in this study’s empirical nd-
ings, is the widespread awareness that cholera preparedness,
response and prevention is a highly politicised issue in many
countries.
The International Health Regulations (IHR) provide an indi-
cation of high level political involvement in, and recognition of,
the issue of communicable diseases. Since 1969, the IHRs have
undergone many revisions to the point of their adoption into
international law in 2007. The IHRs provide the legal frame-
work for international co-operation for the control of infectious
diseases such as cholera (WHO, 2007). Amongst other things,
these standards oblige WHO member states to notify WHO
of any outbreaks of diseases in their countries that have the
potential to cross borders and threaten public health worldwide
(Funke et al., 2010). The fact that it has taken so long to award
international legal status to these reg ulations indicates that it is
a highly sensitive and political matter to try to convince govern-
ments to take ownership of the management of health issues
within their sovereign ter ritories. It is an ongoing challenge to
implement the IHRs, due to weak political will to do so (Funke
et al., 2010).
Socio-cultural dimensions of cholera
Another issue that has clearly emerged from the literature
review and participatory process is the reality that there is a
powerful socio-cultural discourse that exists in relation to chol-
era. This means that it is critical to consider ‘community-held
ideas, fears and individual help-seeking behaviour regarding
the infectious disease’ in order to come up with solutions and
responses that are relevant and appropriate to specic groups
of people (Schaetti et al., 2009). In addition, it is also vital to
recognise that cultural beliefs and practice are not homogenous,
but differ across time, place and population. Such observations
stress the importance of including site-specic analyses when
doing research on the acceptance of interventions in response to
cholera (Schaetti et al., 2009).
Socio-cultural responses to illness manifest in many differ-
ent ways. Some communities, for example, see diarrhoea as a
normal part of life (Cumberland, 2009). This perception places
people at risk as they do not react quickly to the symptoms of
cholera. Others see cholera as a disease that is associated with
poverty and lack of hygiene (Cumberland, 2009). This ‘embar-
rassing’ stigma has been known to cause people to stop talking
about the illness and to resist t reatment to avoid being exposed
to the community’s judgement of people who have cholera. This
behaviour is problematic because talking about the problem is
an important way of addressing it.
Another issue relates to perceptions of trust. Will a specic
community primarily turn to western medicine or traditional
healers with their health problems? Will a specic person turn
to a known community healer or an ad hoc (often foreign-run)
cholera relief camp to treat their illness? For example, studies
in relation to the viability of a cholera vaccination in Tanzania
revealed that there was a perception in some Tanzanian commu-
nities that this vaccination would result in infertility (Schaetti et
al., 2009).
Also, certain culture-specic behaviour may increase com-
munities’ vulnerability to cholera. In terms of religious beliefs,
Jehovah’s Witness followers, for example, are likely to resist

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treatment via intravenous drip, which is the standard treatment
for cholera. In households where polygamy is practiced there
is a bigger risk of cholera spreading due to multiple households
being linked to each other, either because the women and chil-
dren live together or because the men move regularly between
multiple households. The way that food is consumed and shared
is another point for consideration. Are bowls shared or sepa-
rate? Is food communally prepared by women in a community
or do families prepare food separately? It has been found, for
example, that high risk points for cholera transmission are large
gatherings, such as funerals, where food, drink and space are
shared by a crowd of people (United Nations Ofce for the
Co-ordination of Humanitarian Affairs, 2009).
Role of the media in raising the political prole of
disasters and thereby attracting funding: the CNN
effect
In recent years, observers of international affairs have raised the
concern that the media have increased their ability to affect the
conduct of, particularly, United States (US) diplomacy and for-
eign policy. Dubbed the ‘CN N effect’, the impact of new global,
real-time media is typically regarded as substantial. As part of
the CNN effect, the media may function alternately or simulta-
neously as: a policy agenda-setting agent; an impediment to the
achievement of desired policy goals; and an accelerant to policy
decision-making by shortening decision-making response time
(Livingston, 1997). While the ‘CNN effect’ most commonly
refers to the effect that news media have on politics and govern-
ment during political conict, the media also have a noteworthy
effect on decisions made during natural disasters. As videos
and images are broadcast worldwide immediately after or even
during natural disasters, these images may convince the public
to donate money or pressure governments for immediate action.
However, sensationalising cholera outbreaks in Africa provides
controversial stories for international audiences, and supports
the image of Africa as a poverty-stricken, malfunctioning and
diseased continent (WHO, 2004a). In addition, selective media
coverage means that some cholera outbreaks will attract inter-
national attention, commitment to help and resources at the
expense of others (Funke et al., 2010).
The media’s role is not only negative and can also be useful
in terms of performing an educational and knowledge-dissem-
inating function. Public health authorities are generally inter-
ested in using the media to provide information on preventative
and control measures, i.e. public ser vice announcements. At
the same time, however, journalists will often want to focus on
spreading or even sensationalising a story. It is therefore impor-
tant to establish a balance between these 2 interests (WHO,
2004a).
Conclusion
As is evident from the discussion above, cholera epidemics have
been on the increase in Af rica, and are not only a health prob-
lem but should also be understood and addressed from a social,
cultural and political point of view. Concer ted efforts are there-
fore required to establish a proactive long-term strategy consist-
ing of national multi-sectoral and multi-level plans to deal with
this issue in a co-ordinated way. Supply of safe water, adequate
sanitation, and basic domestic and personal hygiene are critical
measures for the prevention and control of cholera and other
waterborne and food-borne diseases. Furthermore, governments
should prioritise the known high risk areas, as cholera generally
affects urban and peri-urban high-density areas more than r ural
low-density areas. Health education is also key, and messages
regarding safe water use and storage, hand washing, safe food
handling and disposal of human excreta are important and can
be communicated through radio, television, community leaders,
schools and public loud speakers.
For these initiatives to succeed, ownership should lie with
the national governments of the individual SADC member
states. SADC (through, for example its health desk) and the
African Union (AU), as well as other governing bodies on
the continent, have an important role to play in encouraging
national member states to admit to having a problem. This
could be done by forming a regional cholera response team and
circulating a regional case denition of cholera that should be
adhered to by all SADC member states. There is also a need for
improved inter- and intra-country co-ordination and informa-
tion exchange (Funke et al., 2010).
National governments (and specically their health min-
istries or departments) need a national response plan whereby
they commit individually, with the support of supra-national
entities, to addressing cholera outbreak situations. At the same
time they also need to communicate with each other during such
a situation. However, it is also necessary that public health care
entities at the provincial and local level are sufciently equipped
by the national government to deal with cholera outbreaks, as
it is at these levels that much of the ‘on the ground’ response
action to cholera takes place. Cholera outbreak management
should therefore be co-ordinated at the national level, but clear
directions should be given to actors at the sub-national level on
how to respond to the outbreak with some level of autonomy and
authority (Funke et al., 2010). To this end, mechanisms must
be established for ensuring good collaboration between volun-
teers from NGOs and national health care workers in the eld.
Developing or maintaining good relationships between key
actors may be facilitated by recording details of responsibilities
in embassies of United Nations (UN) representations, organis-
ing regular briengs and providing regular information on the
epidemiological situation and on the effectiveness of outbreak
responses (WHO, 2004a).
Instead of constantly reacting to cholera outbreaks, it is sug-
gested that proactive steps be taken to prevent future outbreaks
(WHO, 2009; Funke et al., 2010). The need for a proactive rather
than a reactive process would allow countries or regions to
prevent future outbreaks and pre-plan or respond rapidly dur-
ing outbreaks. This would be the best way to reduce the risk of
community-wide spread of the disease (National Department of
Health, 2006). A proactive approach saves valuable time as it
replaces the need to rst complete an outbreak investigation. In
addition, such an approach allows for more rapid implementa-
tion of control measures and therefore could save many lives
(National Department of Health, 2006).
In order to successfully implement effective cholera preven-
tion and a proactive response plan, short-, medium- and long-
term objectives have to be in place to address existing gaps.
Also, a proactive response plan needs to make provision for
preparedness at local, national, regional and international scale
and should be reviewed periodically (Funke et al., 2010).

Recommendations

As alluded to above, a proactive plan needs to have short-,
medium- and long-term objectives, which should include the
following:

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Short term:
• Moving cholera out of the health crisis units of national health
departments. A space needs to be institutionalised in national
health departments for dealing with, talking about and
responding to annual cholera outbreaks. Too often cholera is
overshadowed by other, more immediate health crises, such
as the recent (2009/10) outbreak of swine u in the SADC
region. In addition, nancial resources need to be provided
for surveillance, education and additional medical supplies.
• Doing v ulnerability mapping of areas that are prone to chol-
era, due to environmental or infrastruct ure reasons or other
unforeseen reasons (e.g., disasters such as ooding, vulner-
ability of bordering countries prone to cholera outbreaks
and conditions of disaster, political unrest and health system
break-down) (Fun ke et al., 2010).
• Developing an early warning system for prediction of
cholera outbreaks due to environmental change (Ford et
al., 2009) and compiling a cholera outbreak prevention
and response plan. Such a plan describes the step-by-step
process of an outbreak response, the logistical ar range-
ments, the need for and quantities of supplies and the list
of people serving on the outbreak response team (National
Department of Health, 2006).
• Appointing an outbreak response team. This team should
consist of a multi-disciplinar y and multi-sectoral team con-
tracted to assist with preventing, detecting and containing
the outbreak (National Department of Health, 2006).
• Writing a communication plan. This plan should not only
structure the communication during the outbreak response
but should make provision for structured networks and
forums to discuss interim goals and objectives, as well as
provide a platform to share and develop the outbreak pre-
vention and response plan within and between different
sectors and at different scales (Funke et al., 2010).
• Continuing the implementation of the IHRs. It is important
that states are held accountable for keeping to the commit-
ments made by signing these regulations.
• Understanding community specic perceptions and behav-
iour in those communities that are vulnerable to cholera
outbreaks. Such understanding is critical to supporting the
process of determining what the most effective and appro-
priate interventions are for approaching the cholera chal-
lenge in the short-, medium- and long-term.
• Recognising that, even where an effort has been made to
understand the culture-specic perceptions and behaviour
of a community, any solutions or responses to a cholera
outbreak need to be locally accepted (rather than imposed
in a top-down manner). This entails engaging in the long-
term project of education and awareness creation in order to
prepare communities for what to expect and do, par ticularly
in high-r isk cholera times (such as the rainy season).

Medium term:
• Tracking incidence and reporting trends for cholera over the
last decade.
• Planning for increased timelines of reporting cholera during
peak transmission season or at known vulnerable areas,
including being on high alert in border areas (National
Department of Health, 2006).
• Educating health-care providers and community partners
(food and water operators), as well as the general public,
regarding the prevention, symptoms, treat ment and control
of cholera. In addition, general health and hygiene aware-
ness training should be given to vulnerable communities on
an ongoing basis. In addition, instructions on the emergency
treatment of water and how to mix oral rehydration solutions
(ORS) should be given. Education materials should also be
prepared for emergency situations (National Department of
Health, 2006).
Long term:
• Ensuring that all people in the country have provision for
safe water, sanitation, hygiene and health services. A reas
that are known to be prone to cholera outbreaks should be
given priority.
• Ongoing education of health workers as well as communi-
ties to help with the prevention and management of future
outbreaks.
• Strengthened monitoring and surveillance of environmental
data as well as disease data to help with early detection and
control of cholera outbreaks.
As is evident from the above, responding to cholera in the
SADC region is a dif cult task. Extensive knowledge and
understanding of the unique social, economic and political
contexts in SADC states needs to be developed. In addition,
adequate sharing and exchange of information are needed
to address the challenges that face the successful design and
implementation of proactive cholera prevention, preparedness
and response strategies. Such strategies should capacitate all
actors at different scales and divide responsibilities amongst
them, thereby enabling them to make a combined effort to better
manage this recurring and debilitating health disaster.
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Overview © UNICEF/Pirozzi/2007 Poor water, sanitation and hygiene (WASH), including garbage management, directly and indirectly cause under-five, infant and maternal deaths worldwide and also affect the health of older children and adults. Zimbabwe’s economic downturn of 2000-2009 created a capacity gap for managing the aging infrastructure and limited further expansion of services. The collapse of water revenues from the late 1990s led to a decline in all WASH infrastructure and services, including water resources development and management in all parts of the country. This significantly diminished the quality and reliability of services, culminating in the 2008-2009 cholera outbreaks, which resulted in more than 100,000 cases and over 4,000 deaths. Results from the 2014 Multiple Indicator Cluster Survey show that 76 per cent of households have access to improved sources of drinking water. However, this number hides a wide disparity in access to safe drinking water between urban areas (98.4 per cent) and rural areas (67.5 per cent) and also within urban areas. Some parts of Harare, for instance, have not had water supplies for up to five years. Data from the 2012 National Population Census show that 25% of households do not have any type of toilet facility. The availability of proper sanitation facilities is much higher in urban than in rural areas. MICS 2014 reports that open defecation is at 31.7 per cent, affecting mostly rural areas, where 44 per cent of the population practices open defecation. The current water and sanitation situation in Zimbabwe is the result of the lack of investment in these sectors during and after the economic crisis of the last decade. Other factors relate to its enabling environment. Legislation and policies on WASH exist but are not fully implemented. There is also a lack of monitoring and evaluation, which has an impact on the overall quality of water and sanitation and on the formulation of adequate strategies and data collection nationwide. On the demand side, there is no public awareness of water access issues in rural areas as they are rarely covered by the media. Rural water issues are thus concealed from the public and are not brought to the attention of leaders. This is further aggravated by limited stakeholder consultation during preparation of the national development plan, resulting in issues of equity not being given due consideration. The promotion of hygiene practices has continued to receive inadequate attention despite its potential to save lives in a context of high levels of open defecation and 42 per cent of child faeces being disposed of unsafely. The WASH situation in schools remains very weak, with wide disparities in student-toilet ratios and a majority of rural schools lacking suitable hygiene facilities for girls. One in five schools use unsafe water sources. UNICEF’s WASH programme aims to improve equitable use of safe drinking water, sanitation and hygiene practices. Our key interventions include rehabilitation of water and sanitation infrastructure in urban and rural areas, sanitation and hygiene promotion (including elimination of open defecation in communities and school hygiene promotion, capacity-building to improve WASH sector coordination and efficiency and building more equitable service outcomes and quality, WASH information management system to improve data reliability, equity analysis and use of technological innovations, including emergency preparedness and response, and engagement with the private sector.

The ZIMBABWE Situation

Our thoughts and prayers are with Zimbabwe – may peace, truth and justice prevail.

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• Despotism cracks
• Zimbabwe chiefs in plot to exile Mugabe
• Mugabe ‘sees he is at the end of road’
• Refugees recall a different Zimbabwe
• Deal readied to urge Mugabe to resign
• Tanzanian maize furore
• Your country needs you

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The Times
            Despotism cracks
            Plans to oust
Mugabe raise the pressure on him

            Reports from
Zimbabwe that two of the top people in the ruling
party have recently
discussed the removal of President Mugabe from office
are the first real
signs that the catastrophe now engulfing the country is
beginning to
undermine its leadership. The proposal by the commander of the
armed forces
that the 78-year-old President should resign has apparently
been discussed
not only with the Speaker of parliament but also with Morgan
Tsvangirai, the
embattled leader of the opposition Movement for Democratic
Change. Only a
year ago this would have been unthinkable. But with
widespread starvation
only months away, even those who have had the greatest
stake in perpetuating
the Mugabe tyranny now realise that his rule must be
ended.
           
The details of this extraordinary plot are vague, and it is not
clear whether
Mr Mugabe faces the kind of palace putsch that has ended the
rule of so many
other African strongmen or a dignified retirement that he
himself may now be
seeking. Mr Tsvangirai is the only person to have
confirmed that these talks
took place, and he has always said that Mr Mugabe
would never leave office
peacefully or voluntarily. The fact that Mr
Tsvangirai, who has seen his
supporters murdered and his party cheated of
election victory, is now
offering Mr Mugabe immunity from prosecution
suggests that not only the
opposition believes that the President has
criminally abused his office but
so also do his own party lieutenants.
            Until recently Mr
Mugabe seemed to thrive on the hatred that his
despotic rule has provoked.
The more he was denounced, especially abroad,
the more he was able to portray
himself as a struggling African patriot
surrounded by enemies. This was the
tactic in his plan to steal the
election. This was the way he cemented the
loyalty of the young thugs
designated war “veterans” and the Zanu (PF)
officials, by playing on tribal
and racial divisions to create an embattled
group of supporters who knew
they had everything to lose if they abandoned
him.
            With the entire infrastructure of Zimbabwe falling
apart,
however, the tactic is also failing; too many loyalists have
neighbours,
families and fellow tribesmen who are suffering. They can see
that, unless
Mr Mugabe goes, even their own privileged positions will be
threatened once
the food and fuel runs out and the electricity fails. As with
Ceausescu’s
Romania, there comes a point in national suffering when even the
military
and security apparatus turn against the despot in order to save
themselves.
            That point has not yet been reached in Zimbabwe.
The Government
is still harassing its critics, arresting Harare’s opposition
mayor and 21
others yesterday for not getting permission for a public rally.
The
“retirement” plotters seem to have got cold feet. And Mr Mugabe has
been
bolstered by the ill-timed and ill-judged endorsement of South
Africa’s
Labour Minister, who last week called for closer relations with
Zimbabwe and
suggested that South Africa should copy its seizure of
white-owned farms.
            South Africa should know better. President
Mbeki’s Government
now has an unusual chance to remove the threat of chaos on
its northern
border without being seen to act under Western pressure. All
Zimbabwe’s
anxious neighbours should encourage the Zanu (PF) leadership to
press for
the resignation of Mr Mugabe. A dignified departure, though
undeserved,
would be far better than violence, and neighbouring countries
have shown
that founding Presidents can resign with honour. The West,
meanwhile, should
keep a wary distance to avoid any accusations of
encouraging a coup. But it
need make no secret of its hopes that Mr Mugabe’s
own associates will at
last recognise their country’s plight and turn out the
man who has led them
to this disaster.

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The Times
            Zimbabwe chiefs in plot to exile
Mugabe
            by Jan Raath in Harare

            TWO of
the most senior figures in Zimbabwe’s ruling Zanu (PF)
party have offered to
deliver President Mugabe’s resignation to secure a
negotiated settlement of
the country’s deepening crisis, The Times has
learnt.
            The
secret deal put to Morgan Tsvangirai, leader of the
opposition Movement for
Democratic Change (MDC), would also give Mr Mugabe,
78, immunity from
prosecution and allow him to go into exile abroad. A
government of national
unity would run Zimbabwe until new elections were
held in about two years’
time.
            Sources connected to the Zanu (PF) leadership said they
believed
Mr Mugabe had agreed. Whether the deal will go ahead is
unclear.
            Colonel Lionel Dyck, a respected white former
Zimbabwean Army
officer who has acted as go-between, put the proposals to Mr
Tsvangirai
before Christmas. The Zanu leaders pulled back after he initially
condemned
the plan, apparently fearing a trap.
            Mr
Tsvangirai told The Times that Emmerson Mnangagwa, the
Speaker of parliament
and number three in the Zanu (PF) hierarchy, and
General Vitalis Zvinavashe,
commander of the armed forces, had assured him
that Mr Mugabe would stand
down as the first step.
            “Part of the deal would, of course,
include Mugabe resigning,”
said Mr Tsvangirai. “It is the critical element.
As far as Mnangagwa and
Zvinavashe are concerned, it’s part of the
deal.”
            Sources said Mr Mnangagwa and General Zvinavashe have
already
secured assurances from Mr Mugabe. “He wants to go,” said
one.
            Mr Tsvangirai said the MDC was ready to offer Mr Mugabe
immunity
for crimes committed in pursuit of his lawless, violent campaign
of
repression of his opponents and the seizure of nearly all white-owned
farms
in the country.
            “That would be the leadership we
would give if people are
prepared to say ‘forget the past, let’s move
forward’,” the MDC leader said.
“We have to give dialogue a
chance.”
            The sources say the British Government had been made
aware of
this plan, and had offered its support. The Malaysian Government is
believed
tentatively to have agreed to offer Mr Mugabe
asylum.
            The disclosure of the secret talks comes as England’s
cricket
authorities are about to meet to decide whether to participate in
next month
‘s World Cup game in Harare.
            Until now it was
believed that Mr Mugabe would cling to power no
matter what the cost to his
strife-torn country. But the economic meltdown
since the President was
returned to power in rigged elections last March,
and drastic food shortages
that have left tens of thousands facing
starvation, have forced Zanu (PF)’s
power-brokers to stage what appears to
be a gradual coup.
           
Mr Tsvangirai said Mr Mugabe had been sustained in office by Mr
Mnangagwa and
General Zvinavashe, and their offer showed “they are the ones
calling the
shots”. Sources in Harare say that once it becomes known Mr
Mugabe has
accepted he must go, it will be impossible for him to cling to
power for much
longer.
            Sources said the initiative was started about five
months ago
when Colonel Dyck, who is regarded as “an honest broker” with no
ties to
either of the main parties, made an approach to General Zvinavashe,
his
former commander.
            After a series of wide-ranging
consultations, he presented a set
of principles drafted by Mr Mnangagwa and
General Zvinavashe to Mr
Tsvangirai shortly before
Christmas.
            It proposed Mr Mugabe’s resignation, a
transitional period of
about two years in which both parties would administer
the country, and then
elections. It was not decided who Zimbabwe’s interim
leader should be.
            The sources said Mr Tsvangirai agreed to
the proposals, to the
delight of the two ZANU(PF) leaders. However, two days
later,he denounced
the initiative as a “dirty plan” in which Colonel Dyck was
“being used to
promote an agenda that seeks to legitimise the rogue regime”‘
Soon after
ZANU(PF) pulled back and Colonel Dyck withdrew as go-between. Mr
Tsvangirai
explained that he feared he was being used in a succession
struggle inside
Zanu (PF). He now believes the halt in negotiations is only
temporary. “The
pot is boiling,” he said.
            “The nation is
really suffering. We have to find a solution to
the current crisis, and that
is a burden on the MDC, on ZANU(PF) to consider
seriously. This is the only
way we can break the impasse.”

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The Times
            January 13, 2003
            Mugabe ‘sees he
is at the end of road’
            From Jan Raath in
Harare

            TRAPPED by a disaster of his own making,
President Mugabe of
Zimbabwe appears finally to have accepted that he has
reached the end of his
22-year rule of violence, corruption, lawlessness and
abuse of power.
            “Never has he been so vulnerable,” Morgan
Tsvangirai, leader of
the opposition Movement for Democratic Change, said in
an interview with The
Times at the weekend. “I think given the chance he
would take the first
opportunity to get away from all of
this.”
            Citing Mr Mugabe’s age, his family and his
security
considerations, coupled with the departure of President Moi of
Kenya, Mr
Tsvangirai continued: “The isolation is now intense … It’s very
obvious
all over the country that Mugabe has become a liability to his own
party.”
            Morale in the ruling Zanu (PF) party plumbed new
depths in early
December when Mr Mugabe addressed the party’s annual
conference and failed
to mention the famine that has brought seven million
people to starvation,
national fuel shortages and inflation of about 200 per
cent. “Mugabe lost it
there,” Mr Tsvangirai said. “Zanu (PF) was more
disillusioned than at any
time.”
            Mr Tsvangirai said that
in December Lionel Dyck, a former
Zimbabwe army officer, communicated to him
the offer of the 78-year-old
dictator’s resignation, which was made by
Emmerson Mnangagwa, the ruling
party’s third-in-line, and General Vitalis
Zvinavashe, commander of the
defence forces. Mr Tsvangirai said that he was
told that the two men were
“the ones who are keeping Mugabe (in office),
otherwise he would have
resigned long back”.
            The two
ruling party officials make a formidable combination. Mr
Mnangagwa, the
secretary for administration in the ruling party’s politburo,
is nicknamed
“the son of God” for the widely-held assumption that he is Mr
Mugabe’s
natural successor. He is held in awe because of his former position
as State
Security Minister, and is regarded as still holding influence in
the
service.
            General Zvinavashe is commander of the army and
airforce, and
whoever he allies himself with can be regarded as unassailable.
Military
sources say that his relationship with Mr Mugabe is uneasy. They
also say
that shortly before the presidential elections in March last year, a
group
of senior military officers advised Mr Mugabe to retire while he could
still
do so honourably. He refused.
            Observers said that
the offer to remove Mr Mugabe demonstrated
his rapid loss of influence, and
the evaporation of confidence in him, that
came with his inept handling of
the country’s economic collapse.His record
of remorseless consolidation of
power suggests that the result of the
resignation offer would have been
arrests, possibly on charges of treason,
had it been made without his consent
and if he were fully in control. “It
explains they are the ones calling the
tune,” Mr Tsvangirai said.
            He expressed reluctance to
negotiate with either General
Zvinavashe or Mr Mnangagwa. “There are certain
individuals who, even if you
use the most effective detergent, they will not
come clean.”
            Mr Mnangagwa led the Central Intelligence
Organisation, Mr
Mugabe’s secret police, when it helped the army’s notorious
Five Brigade to
carry out genocide in the western provinces of Matabeleland
in the
mid-1980s.
            Both men were named in a United Nations
report last year as
major beneficiaries of the illegal diamond trade in the
Democratic Republic
of Congo.
            Two years ago Mr Mnangagwa
was found by a High Court judge
illegally to have ordered the release from
prison of the son of his former
mistress, who was serving a sentence for
armed robbery. The judge’s orders
for further investigations were
ignored.
            Mr Tsvangirai said, however, that if Mr Mnangagwa
were appointed
by Zanu (PF) to be its negotiator, the opposition party would
deal with him.
“Everyone is desperate for a solution,” he
said.
            He is open-minded on Mr Mugabe’s future. “He is too
insecure to
retire in Zimbabwe. Whatever way the political outcome goes I
think for a
certain duration he would go outside the
country.
            “If a negotiated settlement would be achieved, part
of the deal
would include his guarantees,” he said. “We have reached a stage
where if
Mugabe is a stumbling block to the solution, and for us to move
forward, if
people are asked to make the sacrifice of giving him immunity,
let it be.”

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The Australian
Refugees recall a different Zimbabwe
By Penny
Brown
January 13, 2003
“WHAT I want people to see is that what is
happening in Zimbabwe is
bordering on genocide – not only with Mugabe killing
the white farmers but
also with him killing all the black people who will not
support him,” says
actor Chloe Traicos.
To set the record straight,
Traicos has produced a one-hour documentary,
Stranger in My Homeland, which
will screen at the Perth International Arts
Festival from January 31. It is
comprised of interviews with seven
Zimbabweans – white and black – now living
in Perth after recently fleeing
their homes.
Through their personal
stories the documentary reveals “just how bad things
are” in Zimbabwe, says
Traicos.
“The things that people tell you, you don’t read about it
anywhere; it’s not
on the Internet or anything. They actually give you
graphic details of how
horrific things are . . . One of the people was an
eyewitness to the
Matabele massacres of the early 1980s.”
Another
person interviewed by Traicos describes the climate of fear in
Zimbabwe:
“Here [in Australia] if someone threatens to kill you, you at
least know that
they may be afraid of the law and not do it because they
don’t want to go to
jail. There, the law is against you, so if someone
threatens to kill you, you
just pray that they are kind enough to have mercy
and not do
it.”
Traicos grew up in Zimbabwe but fled to Perth with her family – in
1998,
following Robert Mugabe’s edict on the seizure of white-owned
farms.
Although not a farming family, her parents were alarmed by Mugabe’s
stance –
alarmed enough to leave their home and emigrate to
Australia.
The land seizures started in March 2000, after Mugabe lost a
referendum on
changing the constitution to allow for the compulsory
acquisition of land
from commercial farmers. Since then, the socioeconomic
situation has
deteriorated rapidly as the hundreds of thousands of rural
workers who were
forced to relocate also face drought and
famine.
Although Traicos says the Zimbabwean community in Perth is
growing, she says
many, newly arrived and still traumatised by their
experiences, were
reluctant or afraid to speak with her.
The
documentary has been 12 months in the making, and carries the same name
as
her first play, which was staged at Perth’s Blue Room in 2000 and told
the
story of a white farming family in Zimbabwe who are run off their
land.
In this work, Traicos draws parallels between the situation in
Zimbabwe and
Nazi Germany. “Hitler used the Jews, a wealthy minority group,
as a
scapegoat in the same way Mugabe has used the whites. Hitler told
the
starving Germans that it was the Jews’ fault they were all starving.
In
exactly the same way, Mugabe has blamed the starvation of the blacks on
the
whites.”
Traicos finds it hard to reconcile the reality of
Zimbabwe today with the
images of her childhood: “It was an ideal place to
grow up. There never was
any racial tension there when I was growing up. It
was newly independent.”
The documentary, she hopes, will show Australians
that “these people are
refugees – a lot of them can’t go back, they don’t
have a home”.

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International Herald Tribune
      Deal readied to urge Mugabe to
resign
         The Associated Press The Associated Press  Monday, January
13, 2003

HARARE, Zimbabwe President Robert Mugabe would resign
and a new
power-sharing government would be formed under a deal that has
been
discussed by Zimbabwe’s governing party and opposition officials,
mediators
said Sunday.
.
The offer was made by two of the governing
party’s most powerful figures –
the Parliament speaker, Emmerson Mnangagwa
and the armed forces chief of
staff, General Vitalis Zvinavashe – in an
effort to help Zimbabwe regain
international legitimacy, renewed aid and
investment during a period of
transitional rule, the mediators
said.
.
The mediators, fearing allegations of treason if the deal
collapses, said
assurances Mugabe would step down were conveyed to the
opposition Movement
for Democratic Change, or MDC.
.
Mugabe, who led
the nation to independence in 1980, won a new six-year term
in elections last
March that independent observers said were deeply flawed.
.
The MDC, along
with Britain, the European Union and the United States, has
refused to accept
results, saying voting was rigged and influenced by
violence and
intimidation.
.
The early retirement of Mugabe has long seemed
inconceivable.
.
The MDC leader, Morgan Tsvangirai, confirmed receiving
the offer and, in a
departure from recent opposition policy, said his party’s
lawmakers were
ready to vote with the governing party for a constitutional
amendment
allowing the creation of a caretaker government once Mugabe stepped
down.
.
Any agreement would include guarantees of immunity for Mugabe, 78,
from
prosecution over alleged misrule and human rights violations during his
23
years in power, Tsvangirai said.
.
Officials of the governing party
were unavailable for comment Sunday.
.
There has been no word on an offer
from Mugabe himself, who was scheduled to
head home from a two-week vacation
that included a trip to Thailand. He is
expected to return to his office
Monday.
.
His absence as the nation faced food and gasoline shortages has
fanned harsh
criticism at home.
.
The MDC has repeatedly called for
Mugabe to go on trial.

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Zim Standard
      Tanzanian maize furore
      By Henry
Makiwa
      AS the Zanu PF government ponders what to do with the
donated maize
from Tanzania which has been condemned by the Grain Marketing
Board, fears
abound that the consignment may have brought into the country,
the deadly
Larger grain borer pest which is notorious for the damage it has
wreaked to
grain reserves in East Africa.
      The pest which was
accidentally introduced into Tanzania in the early
80s, has since proved
dangerous to grain reserves and has the potential to
cause tremendous storage
losses.
      Agricultural experts say the Larger grain borer, which
feeds on dried
maize can cause up to 40% of loss in a period ranging from
three to six
months, making it an undesirable addition to any agro-based
economy.
      In separate interviews with The Standard, agricultural
experts said
the Zanu PF government had become so desperate for a solution to
the food
crisis that it had willingly accepted maize even from poor Tanzania
without
making all the necessary safety checks.
      “Everyone with
agricultural know-how is aware that the larger grain
borer causes havoc in
Tanzania and Togo and it beats me why the Zanu PF
government was prepared to
accept maize so easily from that country,” said
an agricultural and extension
worker.
      Renson Gasela, the shadow minister for Lands and
Agriculture in the
Movement for Democratic Change, yesterday expressed
outrage at the way Zanu
PF had handled the issue of the Tanzania
donation.
      “The government should have queried the standards of the
donation
before accepting it and because it has now imported a deadly pest-we
are
headed for a serious problem. The pest is known throughout East Africa
and
is a perennial headache for farmers in that region,” he
said.
      Made, who could not be reached for a comment yesterday had
officiated
at a colourful ceremony in Victoria Falls last week to mark the
arrival of
the grain.
      Tanzanian officials could not be reached
for comment either.

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Greetings,
The illegitimate regime of Robert Gabriel Mugabe continues to
tighten
its death grip on the country and the people of Zimbabwe. Zimbabwe
is
currently suspended from the Commonwealth due to the massive rigging
of
the 2002 elections.
The greatest enemy of a regime, which has
institutionalised human
rights abuses as an instrument of state policy and
means to cling on
to power, is a free press and a free flow of
information.
The attempts of the illegitimate Mugabe regime restrict the
free flow
of information are well documented and the publishers and
journalists
who continue to attempt to publish the truth about the situation
in
Zimbabwe are brave people and true heroes who will be acknowledged
for
their courage once the people of Zimbabwe have been freed from
the
state sponsored terror inflicted upon them by this murderous
Mugabe
regime.
The free flow of information within Zimbabwe is now at
greater risk
than ever before. First, the fixing of the price of newspapers
in a
hyperinflationary climate will soon lead to the closure of
the
independent and opposition publications. Secondly, it is noted
that
the regime is buying controlling interests in these
independent
publications as a means to controlling the flow of news. The
above two
factors together with the banning of foreign correspondents and
the
forced state registration of local journalists presents a clear
and
present danger to the free flow of information both in and out
of
Zimbabwe and between Zimbabweans at home.
It is vital that an
alternative means of keeping Zimbabweans informed
both at home and in
diaspora about what is happening in the Zimbabwe.
This information flow will
complement the short-wave radio broadcasts
from overseas.
This
information flow will be achieved through mass email and fax
transmissions of
news bulletins. The bulletins can then be Xeroxed
(photocopied) and
distributed on the streets.
It is important that recipients of these
bulletins are not targeted by
Mugabe’s CIO thugs and as such the mailing list
must be as
comprehensive as possible and certainly include Zanu-PF members
and
supporters and all government departments. No bulletins will
be
transmitted until the list is large enough and the recipients
diverse
enough so as to not allow individuals to be targeted for
victimisation
by agents of the state.
So as to compile a large list of
email and fax recipients you are
asked to submit as many as possible,
including those friendly to the
regime, to the following address:

Zim-gateway@lycos.com

Email is
free but faxes are not. Once established an appeal will go
out to those
residing in a safe location that have access to a fax and
the means to meet
the cost of as many faxes as they can afford. Your
country needs
you.
This is an initiative by Zimbabweans for Zimbabweans towards a new
and
finally free Zimbabwe —  free at last from the
psychological
strangleholds of the Mugabe and Smith regimes.
Aluta
continua

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Cholera in Zimbabwe

2 December 2008 –
As of 1 December 2008, the Ministry of Health in Zimbabwe has reported a total of 11 735 cholera cases with 484 deaths since August 2008, affecting all provinces in the country. The overall case fatality rate is 4% but has reached up to 20–30% in remote areas. Out of the total number of cases, 50% have been reported from Budiriro, a high density suburb of the capital city, Harare. Beitbridge, a town bordering South Africa, has reported 26% of all cases. In the last two days, two additional areas have been affected: Chegutu (in Mashonaland West province) and Mvuma (in Midlands province). Reports have also been received from the Ministries of Health in neighbouring countries confirming cholera cases have occurred in Musina (South Africa), Palm Tree (Botswana) and Guro district (Mozambique).

Cholera outbreaks have become more frequent in Zimbabwe since the early 1990s. However, with the exception of the large outbreaks that occurred in 1999 and 2002, the disease has been kept under control through intensified prevention and preparedness activities.

Cholera is mainly transmitted through contaminated water and food and is closely linked to inadequate environmental management. Recent interruptions to the water supplies, together with overcrowding, are aggravating factors in this epidemic. ZINWA (Zimbabwe National Water Authority) has pledged to correct the water supply and sewage system as a matter of urgency.

The Ministry of Health and WHO, together with its health sector partners (UNICEF, IOM, OXFAM-GB, Medecins du Monde, ICRC, ACF, MSF‐Spain – Holland & Luxemburg, Plan International, GOAL, Save the Children-UK and others), have established a comprehensive and coordinated cholera response operational plan to address the needs of the population in the affected areas, emphasizing a multi-sectoral response. WHO is procuring emergency stocks of supplies to meet identified gaps and is deploying a full outbreak investigation and response team, including epidemiologists, water and sanitation engineers and social mobilization specialists. In addition, an epidemiologist and three data managers from the WHO Inter-country Support Team in Harare are assisting the WHO Country Office in data monitoring, analysis and mapping.

Communities are being encouraged to protect themselves against cholera by adhering to proper food safety practices as well as to good personal hygiene. Early rehydration at home by using oral rehydration salts is paramount to diminishing mortality.

Mass chemoprophylaxis with antibiotics is strongly discouraged, as it has no effect on the spread of cholera, can have adverse effects by increasing antimicrobial resistance and provides a false sense of security.

Once an outbreak has started, WHO does not recommend the use of the current internationally available WHO prequalified oral cholera vaccine. This is due to its 2-dose regimen, the time required to reach protective efficacy and the high cost and heavy logistics associated with its use.

The use of the parenteral cholera vaccine has never been recommended by WHO due to its low protective efficacy and the occurrence of severe adverse events.

In controlling the spread of cholera, WHO does not recommend any special restrictions to travel or trade to or from affected areas. However, neighbouring countries are encouraged to strengthen their active surveillance and preparedness systems.

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Wilfrid Laurier University

Scholars Commons @ Laurier

Political Science Faculty Publications Political Science

11-1-2010

Mugabe’s Zimbabwe, 2000–2009: Massive Human
Rights Violations and the Failure to Protect
Rhoda E. Howard-Hassmann
Wilfrid Laurier University, hassmann@wlu.ca

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Mugabe’s Zimbabwe, 2000–2009: Massive Human Rights Violations and the Failure to Protect

”
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HUMAN RIGHTS QUARTERLY

Human Rights Quarterly 32 (2010) 898–920 © 2010 by The Johns Hopkins University Press

Mugabe’s Zimbabwe, 2000–2009:
Massive Human Rights Violations and
the Failure to Protect

Rhoda E. Howard-Hassmann*

AbSTRAcT

This article reviews human rights violations in Zimbabwe from 2000 to
2009, under the rule of Robert Mugabe. It argues that these violations,
including state-induced famine, illegal mass expulsions, and systemic rape,
constituted crimes against humanity. The article considers what African
regional organizations, including the African Union and the Southern
African Development Community, and various organs of the international
community did, and might have done, to restrain Mugabe and his inner
circle from committing these violations. It concludes that the lack of force-
ful action by African and international organizations constituted a failure
to protect the people of Zimbabwe.

* Rhoda E. Howard-Hassmann is Canada Research Chair in International Human Rights at
Wilfrid Laurier University, Waterloo, Canada, where she holds a joint appointment in the
Department of Global Studies and the Balsillie School of International Affairs. She is also a
Fellow of the Royal Society of Canada. In 2006 the Human Rights section of the American
Political Science Association named Dr. Howard-Hassmann its first Distinguished Scholar of
Human Rights. Among many other published works on human rights, she is co-editor of the
2007 volume, The Age of Apology and author of Reparations to Africa (Univ. of Pennsylvania
Press 2008) and Can Globalization Promote Human Rights? (2010).

This article relies in part for background factual material on Dr. Howard-Hassman’s
entry on Zimbabwe in Encyclopedia of Human Rights (David P. Forsythe, Editor-in-Chief,
Oxford Univ. Press 2009), and on a section on Zimbabwe in her Reparations to Africa. Dr.
Howard-Hassman is grateful to Leah Sarson and Matthew Overall for research assistance.
She also thanks the Canada Research Chairs program for the funds and time necessary for
this research and Wilfrid Laurier University for sponsoring her Chair.

2010 Mugabe’s Zimbabwe, 2000–2009 899

I. INTRodUcTIoN

This article reviews human rights violations in Zimbabwe from 2000 to 2009
and argues that they constituted crimes against humanity. It considers what
African regional organizations and various organs of the international com-
munity did, and might have done, to restrain Robert Mugabe and his inner
circle from committing these massive human rights violations, and argues
that the lack of forceful action by African and international organizations
constituted a failure to protect the people of Zimbabwe.

This article does not discuss any events that occurred after 2009.

II. RobERT MUGAbE ANd HUMAN RIGHTS VIoLATIoNS IN
ZIMbAbwE

Robert Mugabe became President of Zimbabwe at independence in 1980: he
was also the most prominent leader of the1972–1980 war of independence
against white minority rule. From 1980 to 2000, Zimbabwe was a prosperous
country by African standards, in part because of a large commercial farming
sector run by white farmers, many of whom were Zimbabwean citizens. In
2000, Mugabe began to encourage “land invasions” of white-owned farms
by persons alleged to be veterans of the war of independence, although
many were too young to have fought in the war.1 In 2002, white farm own-
ers were ordered to vacate their farms immediately, and even forbidden
to finish cultivating their crops.2 These large farms produced much of the
food that had earlier made Zimbabwe the breadbasket of Eastern Africa.
Zimbabwe had produced over 2 million tons of maize in 2000, before the
land invasions took effect, but in 2008 was reported to have produced only
450,000 tons.3 Yet as late as March 2009, one of the few white farmers who
remained in Zimbabwe was ordered not to harvest a crop of an estimated
6,000 tons of fruit.4

The land invasions were violent: by 2006 about sixty white farmers had
been killed and many of their employees had been violently intimidated
and tortured.5 The invasions not only dispossessed members of the white
minority in Zimbabwe; they also rendered unemployed about 150,000 to

1. Masipula Sithole, Zimbabwe: History and Politics, in New eNcyclopedia of africa Vol. 5,
at 338 (John Middleton & Joseph C. Miller eds., 2007).

2. Andrew Meldrum, Zimbabwe’s Farmers Ordered to Stop Work, Globe & Mail (Toronto),
25 June 2002, at A13.

3. Zimbabwe: Farm Attacks Threaten Food Supply, Sw radio afr., 23 Sept. 2009.
4. Geoffrey York, A Country in Ruins: The Last Stand of Zimbabwe’s White Farmers, Globe

& Mail (Canada), 20 Mar. 2009, at A13.
5. peter GodwiN, wheN a crocodile eatS the SuN: a MeMoir of africa 81 (2006).

Vol. 32900 HUMAN RIGHTS QUARTERLY

200,000 farm workers, who, with their families, constituted about 1.5 mil-
lion to 2 million people. Many of these farm workers were immigrants from
other African countries, thus not eligible for the land that was ostensibly to
be redistributed to black Zimbabwean citizens.6

While the ostensible reason for land invasions was that the whites had
taken over the land while Zimbabwe was under colonial rule, in fact, over
80 percent of white-owned land had changed hands since independence.7
Farms offered for sale after independence had by law to be first offered to the
government on a willing-seller, willing-buyer basis, and the government had
refused the offers.8 Thus, the government could have acquired 80 percent of
white-owned land to redistribute to black Zimbabweans, but had declined
to do so. Moreover, many of the large farms taken over after 2000 were
distributed to single black owners, not to landless peasants. Mugabe’s inner
circle and relatives benefited: for example, the Minister of Home Affairs was
given five farms, and Mugabe’s wife was given two.9

By mid-2008, many farms remained empty, not yet allocated to new
settlers of any kind.10 Those few subsistence peasants or urban poor who did
receive land were often unable to produce for the market, in part because
they did not have access to inputs such as fertilizer. Those who received
large farms and actually attempted to farm were also blocked by a govern-
ment policy that ostensibly gave them ninety-nine-year leases, but that
included a clause stipulating that leases could be cancelled at thirty-days
notice; thus, the actual guaranteed lease of one month was insufficient to
use the land as collateral to obtain bank loans.11 Land that had previously
produced surpluses sufficient not only to feed the entire country but also to
export food reverted at best to subsistence production for the new occupiers
of the land and their families.

The end of large-scale cash crop production for the internal and external
markets caused a general economic crisis in Zimbabwe that also affected
peasant farmers who already had plots of land, some distributed to them
during the early decades of independence. Inflation eroded farmers’ capac-
ity to buy seeds and fertilizers, while price controls imposed ostensibly to
prevent profiteering meant that it became unprofitable for small farmers to
produce for the internal market.12 Some women and girls turned to the sex

6. huMaN riGhtS watch, Not eliGible: the politicizatioN of food iN ziMbabwe

(2003).

7. daVid blair, deGreeS iN VioleNce: robert MuGabe aNd the StruGGle for power iN ziMbabwe 177

(2002).
8. Doris Lessing, The Jewel of Africa, N.y. reV. bookS, 10 Apr. 2003, at 8.
9. Samantha Power, How To Kill a Country, atlaNtic MoNthly, Dec. 2003, at 4.
10. Hany Besada & Nicky Moyo, Picking Up the Pieces of Zimbabwe’s Economy 11 (Ctr.

for Int’l Governance Innovation, Technical Paper No. 5, 2008).
11. iNterNal diSplaceMeNt MoNitoriNG ctr., the MaNy faceS of diSplaceMeNt: idpS iN ziMbabwe 38

n.158 (2008).
12. Cash Crunch Hits Farmers as Planting Season Nears, ziMb. iNdep., 20 Aug. 2009.

2010 Mugabe’s Zimbabwe, 2000–2009 901

trade to support themselves, exacerbating the rate of HIV/AIDS; children’s
education was also adversely affected as parents could not afford school
fees.13 Extreme poverty caused social breakdown; young men could no lon-
ger afford traditional bride wealth payments (payments from the prospective
groom to the prospective bride’s family) and therefore could not marry.14
More and more Zimbabweans relied on remittances from relatives abroad
to support themselves. In order to evade price controls, many resorted to
smuggling goods into and out of the country.15

By October 2003, half of Zimbabwe’s population was considered “‘food-
insecure,’ living in a household that is unable to obtain enough food to meet
basic needs.”16 Despite the unprecedented food shortage, Mugabe distributed
state-owned grain only to his political supporters and withheld it from those
who he thought might vote against him in the farcical periodic elections
still held in Zimbabwe.17 Mugabe denied international agencies permission
to bring food into the country to feed the starving, and he intimidated,
threatened, and imprisoned all opposition. The World Food Program (WFP)
predicted that 1.4 million people, or 17 percent of the rural population,
would need food aid in 2007.18 In December 2007 it predicted that more
than 4.1 million Zimbabweans would need food aid by summer 2008.19

By early 2009, approximately 75 percent of the 9 million people left in
the country relied on the WFP and other agencies to keep them alive; this
was the highest percentage of population needing food aid of any country
in the world.20 Many Zimbabweans were so desperate that they were trading
their livestock for maize, making them even more vulnerable to hunger once
the maize was gone. Many were eating seeds meant for planting later in
2009; some of these seeds had already been treated with pesticide. Farmers
were also eating cattle suspected of being infected with anthrax.21 Others
foraged for wild foods, even eating tree bark and soil, as well as selling all
their household assets to buy food.22 Many people were living on one meal

13. Allison Goebel, “We Are Working for Nothing”: Livelihoods and Gender Relations in
Rural Zimbabwe, 2000–2006, 41 caN. J. afr. Stud. 226, 236, 242 (2007).

14. Id. at 243.
15. Hany Besada & Nicky Moyo, Zimbabwe in Crisis: Mugabe’s Policies and Failures 16

(Ctr. for Int’l Governance Innovation, Working Paper No. 38, 2008).
16. Press Release, Human Rights Watch, Zimbabwe: Food Used As Political Weapon (24

Oct. 2003), available at http://www.hrw.org/en/news/2003/10/23/zimbabwe-food-used-
political-weapon.

17. Id.
18. World Food Programme, Regional Bureau for Southern Africa, 2007 Needs for WFP

Projects and Operations 38 (2006).
19. Besada & Moyo, Zimbabwe in Crisis, supra note 15, at 11.
20. U.S. Agency for Int’l Dev. (USAID), Zimbabwe—Complex Emergency (13 Feb. 2009).
21. The Elders’ Zimbabwe Initiative, Report on the Visit to Southern Africa 5 (Nov. 2008).
22. World Food Program, WFP in Zimbabwe—Facts and Figures 24 Feb. 2009, available at

http://www.wfp.org/stories/wfp-facts-and-figures-zimbabwe.

Vol. 32902 HUMAN RIGHTS QUARTERLY

a day, or even one meal every second day, yet the WFP, lacking resources,
had had to reduce its rations to a level below the minimum needed for sur-
vival.23 While the world community called on Mugabe to allow humanitarian
agencies access to all of Zimbabwe, he continued to block distribution of
food to those who he thought supported the opposition, the Movement for
Democratic Change (MDC), led by Morgan Tsvangirai,24 distributing what
state food supply existed to his own supporters. By the end of April 2009,
the situation had improved somewhat, as a result in part of some crops hav-
ing been harvested,25 but this improvement could not be considered a sign
of permanent relief from hunger. International organizations estimated that
between 1.4 million26 and 1.74 million27 Zimbabweans would need food
aid in the peak hunger period of October-December 2009.

Mugabe rendered the Zimbabwean population even more insecure in
2005 when he instigated Operation Murambatsvina (known in English as
“Operation Restore Order” or “Operation Drive Out Trash,”) the destruction
of the homes and small businesses of approximately 700,000 urban Zim-
babweans.28 This destruction severely compromised the housing, nutrition,
and health of up to 2.4 million people.29 Mugabe’s motive for this attack
on urban dwellers may have been to intimidate or punish supporters of
the opposition MDC, although many of those affected were his own sup-
porters. Additionally, he may have been attempting to gain control of the
foreign currency that circulated in the informal economy.30 In November
2006 the government also expelled tens of thousands of gold panners and
their families from gold-producing areas. Some of these people had already
been displaced by Operation Drive Out Trash, and were trying to eke out
a living by looking for gold. The government argued that they were depriv-
ing the Zimbabwe Reserve Bank of gold it should be able to sell on the
international market.31

23. The Elders’ Zimbabwe Initiative, supra note 21.
24. huMaN riGhtS watch, ziMbabwe: reVerSe baN oN food aid to rural areaS (2008).
25. Famine Early Warning Systems Network, Zimbabwe Food Security Outlook 1 (Apr.

2009).
26. United Nations Office for the Coordination of Humanitarian Affairs: Zimbabwe, Monthly

Humanitarian Update 5 (Oct. 2009).
27. Famine Early Warning Systems Network, Zimbabwe Food Security Update 1 (Nov.

2009).
28. UN Special Envoy on Zimbabwean Evictions Briefs Security Council, uN NewS ctr., 27

July 2005, available at http://www.un.org/apps/news/story.asp?NewsID=15181&Cr=zim
babwe&Cr1=.

29. Deborah Potts, “Restoring Order”: Operation Murambatsvina and the Urban Crisis in
Zimbabwe, 32 J. S. afr. Stud. 273, 276 (2006).

30. Michael Bratton & Eldred Masunungure, Popular Reactions to State Repression: Muram-
batsvina in Zimbabwe, 106 afr. aff. 21, 25 (2006).

31. iNterNal diSplaceMeNt MoNitoriNG ctr., supra note 11, at 39.

2010 Mugabe’s Zimbabwe, 2000–2009 903

The result of land seizures and expulsions was an unprecedented social
and economic breakdown. Statistical sources on Zimbabwe in the 2000s
were inconsistent, some appearing not to reflect the severity of the many
problems caused by Mugabe’s policies, and so must be treated with cau-
tion. What follows are some statistics from reputable sources, although of-
ficial UN agencies seem to drastically underestimate the rate of decline in
all indicators of health and well-being in Zimbabwe, compared to reports
from nongovernmental organizations (NGOs). Different agencies of the UN
publish different figures. Moreover, statistics from the UN and NGOs are
not comparable; sometimes NGOs appear to quote figures from UN agen-
cies and sometimes they appear to generate their own findings. At best,
it can be stated that the situation in Zimbabwe from 2000 to 2009 was a
“major underreported humanitarian crisis,” as Kofi Annan, Jimmy Carter, and
Graça Machel, three members of the independent group of Elders, wrote
in November 2008.32

The unemployment rate in 2005 was estimated at 80 percent, and the
real GDP growth rate in 2007 was estimated at the negative rate of -6.1
percent.33 Life expectancy at birth dropped from 56.4 years from 1990 to
1995 to an estimated 37.3 years in 2005 to 2010.34 The infant mortality rate
rose from 54.3 per thousand live births from 1990 to 1995 to an estimated
58.78 per thousand in 2005 to 2010.35 Twenty-two percent of children under
five were malnourished in 2008.36 By 2008, the school attendance rate was
only 20 percent.37 The maternal mortality rate rose from 168 per 100,000
live births in 1990 to 1,100 in 2005, the increase caused both by HIV/AIDS
and a significant decline in maternal health services.38 The HIV rate itself
dropped, but that was in part because so many HIV/AIDS patients lacking
drugs and care died.39 By 2007 1.3 million children were orphans.40

By October 2008, Zimbabwe’s economy was in complete chaos; the infla-
tion rate was estimated at 231 million percent per year.41 By mid-November

32. The Elders’ Zimbabwe Initiative, supra note 21, at 1.
33. ceNt. iNtelliGeNce aGeNcy, the world factbook 2008 (2008).
34. uNited NatioNS coNfereNce oN trade & deV., uNctad haNdbook of StatiSticS (2008).
35. Id.
36. According to weight for age indicators. World Bank, World Development Indica-

tors Database (Apr. 2010), available at http://ddp-ext.worldbank.org/ext/ddpreports/
ViewSharedReport?REPORT_ID=9147&REQUEST_TYPE=VIEWADVANCED.

37. The Elders’ Zimbabwe Initiative, supra note 21, at 2.
38. phySiciaNS for huMaN riGhtS, health iN ruiNS: a MaN-Made diSaSter iN ziMbabwe (2009).
39. United Kingdom Department for International Development, Zimbabwe: Key Facts,

available at http://www.dfid.gov.uk/Where-we-work/Africa-Eastern–Southern/Zimbabwe/
Key-facts/.

40. uNicef huMaNitariaN actioN report 2008: ziMbabwe (2008).
41. Celia W. Dugger, Mugabe Claims Security Ministries, Jeopardizing Deal, N.y. tiMeS, 12

Oct. 2008, at A6.

Vol. 32904 HUMAN RIGHTS QUARTERLY

2008, it took only 24.7 hours for prices to double in Zimbabwe,42 although
in early 2009 prices stabilized after the government decided to make US
dollars legal tender and pay government employees in dollars, leaving other
Zimbabweans to continue relying on barter.43 Meantime, in late 2008, chol-
era broke out as a result of the almost complete breakdown of Zimbabwe’s
sewage systems and clean water supplies; there were over 98,000 cholera
cases in Zimbabwe between August 2008 and mid-July 2009.44

Not surprisingly, as the economy deteriorated and white farmers were
intimidated into abandoning their farms and leaving the country, civil and
political rights also entered a tailspin. Mugabe intimidated, threatened, and
imprisoned all opposition, as he had been doing during every election,
starting in 1980.45 As early as 1982, Mugabe said, with regard to those who
opposed him, “An eye for an eye and an ear for an ear may not be adequate
in our circumstances. We may very well demand two ears for one ear and
two eyes for one eye.”46 In 1993, Mugabe challenged the courts, saying,
“We will not brook any decision by any court [preventing us] from acquiring
any land.”47 In 2001, Chief Justice Anthony Gubbay, whom Mugabe himself
had appointed, resigned after Mugabe accused him of aiding and abetting
racism,48 and a mob invaded the Supreme Court shouting “Kill the judges.”49
In 2002, the government passed the Public Order and Security Act and the
Orwellian-named Access to Information and Protection of Privacy Act, both
laws stifled almost all public criticism of Mugabe.50 In the same year; the
government closed and burned offices of independent newspapers.51 A law
against ridiculing Mugabe or bringing him into disrepute mandated two
years in jail for those convicted.52 By 2008, the violations of civil and po-
litical rights were so strong that Genocide Watch issued a politicide watch,
a warning of political mass murder in Zimbabwe.53 As the 2008 elections

42. Steve H. Hanke, R.I.P. Zimbabwe Dollar (5 Feb. 2009), available at http://www.cato.
org/zimbabwe.

43. Joshua Hammer, Dictator Mugabe Makes a Comeback, N.y. reV. bookS, 25 Oct. 2009,
at 49.

44. United Nations Office for the Coordination of Humanitarian Affairs, Zimbabwe:
Cholera Update 1 (15 July 2009), available at http://ochaonline.un.org/OchaLinkClick.
aspx?link=ocha&docId=1112226.

45. Norma Kriger, Zanu (PF) Strategies in General Elections, 1980–2000: Discourse and
Coercion, 104 afr. aff. 1 (2005).

46. aidS-free world, electiNG to rape: Sexual terror iN MuGabe’S ziMbabwe 8 (2009).
47. MartiN Meredith, the fate of africa: a hiStory of fifty yearS of iNdepeNdeNce 631 (2005).
48. Robert Martin, The Rule of Law in Zimbabwe, 95 rouNd table 239, 251 (2006).
49. Meredith, supra note 47, at 641.
50. Joshua Hammer, The Reign of Thuggery, N.y. reV. bookS, 26 June 2008, at 27.
51. robert calderiSi, the trouble with africa: why foreiGN aid iSN’t workiNG 93 (2006).
52. GodwiN, supra note 5, at 205.
53. GeNocide watch, politicide warNiNG: ziMbabwe (2008).

2010 Mugabe’s Zimbabwe, 2000–2009 905

approached, murder, torture, sexual and other dismemberment, and intimi-
dation of members of the MDC and their families were common.

Morgan Tsvangirai, the leader of the MDC, won a plurality of 47.9
percent of the votes in the 29 March 2008 presidential elections,54 but was
too intimidated to stand against Mugabe in the run-off election required
when no candidate received a majority of the votes. After pressure from the
international community, Mugabe agreed to share power with his opponent;
nevertheless, for several months after the 2008 elections, Tsvangirai stayed
in South Africa, refusing to return to Zimbabwe, fearing for his life. Torture,
beatings, and assaults on ordinary MDC supporters continued, with police
refusing to investigate55; at least 153 MDC supporters were killed between
March and June 2008.56 In August 2008, several MDC Members of Parlia-
ment were arrested as they were entering Parliament to be sworn in, and
Tsvangirai’s passport was confiscated.57 Brutal attacks on white commercial
farmers also continued.58 Women who were, or were suspected to be,
supporters of the MDC or related to MDC supporters were subjected to a
systematic campaign of gang rape after the 2008 election by members of
Zimbabwe’s Central Intelligence Organization, pro-Mugabe youth militias,
and veterans of the war of liberation.59

Aside from continuing to intimidate his opponents, Mugabe also retained
control of key aspects of the government, refusing to share real power, as he
had agreed to do. In early October 2008, Mugabe declared that his party
would retain control of the military and police, two key ministries in the
supposed coalition government60; by late 2009 Mugabe had not relinquished
his control of defense, justice, and national security. Mugabe retained control
of the courts and jails, as well as the Ministry of Information, responsible
for regulating the press.61 He continued to jail independent journalists in
2009.62 In August 2009, more than a dozen MDC Members of Parliament
were arrested, and one MDC Minister was jailed.63

In 2008, upwards of a million Zimbabweans were internally displaced.
Those displaced included farm workers displaced from expropriated farms;

54. paN-africaN parliaMeNt, report of the paN africaN parliaMeNt electioN obSerVer MiSSioN: preSi-
deNtial ruN-off electioN aNd houSe of aSSeMbly by-electioNS, republic of ziMbabwe (27 June
2008).

55. huMaN riGhtS watch, falSe dawN: the ziMbabwe power-ShariNG GoVerNMeNt’S failure to deliVer
huMaN riGhtS iMproVeMeNtS 5–6 (2009).

56. Id. at 8.
57. Unspeakably Rude to the Old Man, ecoNoMiSt, 30 Aug. 2008, at 47.
58. huMaN riGhtS watch, falSe dawN, supra note 55, at 11.
59. aidS-free world, supra note 46.
60. Dugger, supra note 41.
61. Hammer, Dictator Mugabe Makes a Comeback, supra note 43, at 49.
62. huMaN riGhtS watch, falSe dawN, supra note 55, at 4.
63. Hammer, Dictator Mugabe Makes a Comeback, supra note 43, at 49.

Vol. 32906 HUMAN RIGHTS QUARTERLY

people who could not find new homes after they were displaced by Op-
eration Murambatsvina; and tens of thousands of people were displaced
by state-sponsored violence after the March 2008 elections.64 The motive
for these last displacements appears to have been to remove possible op-
position voters from their districts; indeed, the expulsions were referred to
as “Operation Mayhoterapapi (Where Did you Put Your [Voter] Cross?”).65
Ironically, in October 2009 Zimbabwe signed the newly-minted African
Union Convention for the Protection and Assistance of Internally Displaced
Persons in Africa.66

Moreover, the human rights crisis caused a massive outflow of refugees
from Zimbabwe. By 2007 there were an estimated 3 million refugees in
South Africa, with another 200,000 in Botswana and many others seeking
asylum elsewhere.67 Botswana had gone so far as to build electric fences to
keep out Zimbabwean refugees, while South Africa placed military guards
along the Zimbabwean border.68 The refugees put an enormous strain on
the resources of neighboring countries, causing a brief flare-up of ethnic
violence against Zimbabwean migrants in South Africa in 2008.69

Thus, by late 2009 the crisis had certainly not passed, and the people of
Zimbabwe were still subject to the systematic violations of their human rights
and crimes against humanity that they had been enduring since 2000.

III. STATE-INdUcEd FAMINE AS A cRIME AGAINST HUMANITY

The food crisis in Zimbabwe from 2000 to 2009 was extremely severe:
indeed, it could be considered a famine manqué. Only the WFP and its
sister agencies, along with many NGOs, prevented this crisis from turning
into an actual famine.

If one views famine as a process, rather than a state of mass starvation,
then Zimbabwe was well into that process in the early 2000s. Rangasami
argues that famine is “a process during which pressure or force (economic,
military, political, social, psychological) is exerted upon the victim com-
munity, gradually increasing in intensity until the stricken are deprived
of all assets including the ability to labour.”70 Rangasami maintains that

64. iNterNal diSplaceMeNt MoNitoriNG ctr., supra note 11, at 4.
65. Id. at 14.
66. African Union Convention for the Protection and Assistance of Internally Displaced

Persons in Africa, adopted 22 Oct. 2009.
67. Kitsepile Nyathi, Zimbabwe: Refugee Crisis as Citizens Rush To Leave Their Country,

daily NatioN (Kenya), 22 Mar. 2007.
68. ceNt. iNtelliGeNce aGeNcy, supra note 33.
69. Joshua Hammer, Will He Rule South Africa?, N.y. reV. bookS, 12 Feb. 2009, at 28.
70. Amrita Rangasami, “Failure of Exchange Entitlements” Theory of Famine: A Response,

20 ecoN. & pol. wkly 1747, 1749 (1985).

2010 Mugabe’s Zimbabwe, 2000–2009 907

famine is comprised of three stages: dearth, famishment, and mortality.71
Zimbabweans suffered for several years from a politically-induced dearth of
food that resulted in many of them being famished, even if they were not
experiencing widespread starvation. While longevity declined significantly
in the 2000s, no international agency appeared to be willing to estimate
how many Zimbabweans had actually died from malnutrition, starvation,
and diseases related to malnutrition; thus, we do not know how much, if at
all, dearth and famishment contributed to mortality.

Zimbabwe could be considered to have endured what Alex De Waal
has called “new variant famine,” in which HIV/AIDS is a core aspect of
overall famine conditions.72 The HIV/AIDs rate in 2008 in Zimbabwe for
individuals aged fifteen to forty-nine was 15.3 percent,73 a health catastrophe
that was exacerbated by the ruined economy. The severe erosion of health
services, incapacity to import necessary drugs, lack of food, poor sanita-
tion, lack of access to clean water, and high rates of emigration of medical
personnel combined with this extremely high HIV/AIDS rate to become an
example of De Waal’s worst-case scenario. “The recurrent socio-economic
shocks combine with the HIV/AIDS epidemic to create a wide, severe and
intractable famine, marked by excess adult mortality, widespread social
disruption and the establishment of a new and dangerous ecology for infec-
tious disease.”74

The policies of the Zimbabwean government from 2000 to 2009 raise
the question of whether state-induced famine should be considered a dis-
tinct crime. David Marcus compellingly argues that some state policies are
“faminogenic.” Marcus identifies four degrees of faminogenic behavior.
First-degree faminogenic behavior is intentional: “Governments deliberately
use hunger as a tool of extermination.” Second-degree faminogenic behav-
ior is characterized by recklessness: “Governments implement policies that
themselves engender famine, then recklessly continue to pursue these poli-
cies despite learning that they are causing mass starvation.” Third degree
faminogenic behavior is “marked by indifference. Authoritarian governments
. . . turn blind eyes to mass hunger.” In the fourth degree, “incompetent or
hopelessly corrupt governments, faced with food crises . . . are unable to
respond effectively.”75

71. Id.
72. Alex De Waal, AIDS, Hunger And Destitution: Theory And Evidence for the “New Vari-

ant Famines” Hypothesis in Africa, in the New faMiNeS: why faMiNeS perSiSt iN aN era of
GlobalizatioN 90 (Stephen Devereux ed., 2007).

73. UNAIDS, Zimbabwe, available at http://www.unaids.org/en/CountryResponses/Countries/
zimbabwe.asp.

74. De Waal, supra note 72, at 120.
75. David Marcus, Famine Crimes in International Law, 97 aM. J. iNt’l l. 245, 246–47

(2003).

Vol. 32908 HUMAN RIGHTS QUARTERLY

Robert Mugabe and his colleagues in the government of Zimbabwe
were clearly guilty of attempted faminogenesis in the early 2000s. Working
forward from Marcus’s fourth degree, the least criminal form of famino-
genesis, one cannot argue that famine in Zimbabwe was simply caused by
incompetence, as might be true in other African nations. Until 2000, despite
Mugabe’s increasingly repressive rule, the country was not incompetently
run. On the contrary, compared to other African countries, the quality of
life was good.

Certainly, Mugabe and his colleagues were guilty of the third degree
of faminogenesis, indifference. In 2002, faced with accusations that people
were starving, Didymus Mutasa, then Minister of National Security and
head of the secret police, said “We would be better off with only six mil-
lion people, with our own people who support the liberation struggle. We
don’t want all those extra people”76; this is a clear indication of indifference.
Moreover, Mugabe was not simply indifferent to a famine that was the result
of natural causes or of inadvertent political or economic incompetence.
Rather, he recklessly pursued his faminogenic policies even when there was
clear evidence of their detrimental consequences, thus engaging in second-
degree faminogenic behavior. In fact, he pursued first-degree faminogenic
policies; the core cause of the food deficit situation in the early years of
the twenty-first century was clearly the interest and ambitions of Mugabe
and his inner circle.

Mugabe’s intent to induce famine can be shown by his deliberate deci-
sions at various times during the decade to stop the WFP from importing
grain or distributing it to regions where there were many MDC supporters.
His intent to induce famine can also be shown by his deliberate policies
to distribute government relief grain only to those who supported him, not
to his opponents. Moreover, Mugabe recklessly pursued these faminogenic
policies even into 2009, when he was supposed to have agreed to share
power with the opposition party, as the order to a white farmer, noted above,
not to harvest his fruit, makes clear.

Famines, says Edkins, ought to be considered not natural disasters but
crimes caused by human agency.77 The criminal activities that caused mal-
nourishment in Zimbabwe in the 2000s, and might well have caused an
actual famine had not the world community stepped in to distribute food,
suggest the need for revisions of international law to name this type of crime,
pass laws against it, and mandate punishments for it. An appropriate name

76. Trevor Grundy, Whatever Happened to Didymus Mutasa?, ICC-africa update No. 78 (Inst.
for War & Peace Reporting), 4 Oct. 2006, available at http://www.iwpr.net/report-news/
whatever-happened-didymus-mutasa.

77. Jenny Edkins, The Criminalization of Mass Starvations: From Natural Disaster to Crimes
Against Humanity, in the New faMiNeS, supra note 72, at 50, 57.

2010 Mugabe’s Zimbabwe, 2000–2009 909

for the crime might be “state-induced famine.” The agent causing famine,
the state, is clear. “Induced” implies public policies that cause famine,
whether deliberately or by recklessness. Public policies by definition imply
intent; some human agents must make the policy decisions. State-induced
famine could be differentiated from famines caused by incompetence or
even by indifference, although the latter should be considered a lesser form
of crime.

Until such time as state-induced famine is recognized as a specific crime
in international law, it seems to fall under the definition of crimes against
humanity in the Rome Statute of the International Criminal Court (ICC),
where the definition of crimes against humanity includes “other inhumane
acts . . . intentionally causing great suffering, or serious injury to body or
to mental or physical health.”78 Presumably, widespread hunger deliber-
ately or recklessly caused by government actions would qualify as such
an “other” inhumane act. “Deportation or forcible transfer of population”79
is also a crime against humanity: the 2005 evictions could be considered
such a crime, although Zimbabwe might argue that the people expelled
had not been lawfully present in the areas from which they were evicted,
as required by the ICC definition of unlawful deportation.80 Rape is also a
crime against humanity.81

Thus, there were several grounds to refer Mugabe to the ICC for trial.
Yet, despite the clear evidence that Mugabe was guilty of crimes against
humanity, very little was done between 2000 and 2009 by African and
international organizations to protect the victims of his crimes.

IV. AcTIoNS TAkEN bY THE INTERNATIoNAL coMMUNITY

A. Regional Africans organizations

A standard assumption is that in cases of political crisis, those political enti-
ties closest to the offending state should take responsibility first, as they are
least likely to be seen as outsiders trying to violate sovereignty. The closest
regional political entities to Zimbabwe in the early twenty-first century were
the Southern African Development Community (SADC) and the continental
African Union (AU), but the record of both on Zimbabwe was very uncriti-

78. Rome Statute of the International Criminal Court, adopted 17 July 1998, art. 7(1)(k),
U.N. Doc. A/CONF.183/9 (1998), 2187 U.N.T.S. 90 (entered into force 1 July 2002).

79. Id. art. 7(1)(d).
80. Id. art. 7(2)(c).
81. Id. art. 7(1)(g).

Vol. 32910 HUMAN RIGHTS QUARTERLY

cal until about 2007; thereafter, both organizations were inconsistently and
weakly critical.

Thabo Mbeki, President of South Africa from 1999 to 2008, protected
Mugabe from sanctions by the AU.82 Before the 2005 Zimbabwean elections
Mbeki claimed that, “Nobody in Zimbabwe is likely to act in a way that
will prevent free and fair elections being held.”83 This reflected a general
unwillingness by many presidents of African countries to acknowledge
Mugabe’s violence. In 2005, the AU resisted calls from the US and Britain
to criticize Operation Murambatsvina.84 In 2006, it refused to make public a
report critical of Zimbabwe’s human rights record, which had been prepared
two years earlier by the AU Commission on Human and People’s Rights.85
In April 2007, leaders at the SADC meeting in Tanzania refused to confront
Mugabe, instead “reaffirm[ing] its [SADC’s] solidarity with the Government
and People of Zimbabwe.”86 In May 2007, the African bloc at the UN suc-
cessfully nominated Zimbabwe’s Environment Minister, Francis Nhema, to
Chair the UN Commission on Sustainable Development, despite allegations
that he had ruined a previously successful, white-owned farm that had been
given to him during Zimbabwe’s land redistribution.87

However, the attitude among members of the AU began to change in
2007. The president of the AU at that time, John Kufuor of Ghana, called the
situation in Zimbabwe “very embarrassing,”88 and in 2008, Raila Odinga,
the Prime Minister of Kenya, similarly referred to Zimbabwe as “a shame
and an embarrassment”89; Botswana, Zambia, and Tanzania also criticized
Mugabe.90 Botswana may have been influenced in part by the flow of refu-
gees from Zimbabwe, also a concern for South Africa. By late 2008, about
4,000 Zimbabweans per month were being deported from Botswana, and
another 10,500 from South Africa.91

After the 2008 election, Mbeki, acting for the AU and SADC, urged Tsvan-
girai to compromise with Mugabe, and Tsvangirai accepted the position of
Prime Minister while Mugabe remained president. The AU welcomed Mugabe
to its summit in June 2008, issuing a weak statement that it hoped he and

82. Ian Phimister & Brian Raftopoulos, Mugabe, Mbeki and the Politics of Anti-Imperialism,
31 reV. afr. pol. ecoN. 385 (2004).

83. Padraig O’Malley, South Africa’s Failure in Zimbabwe, boStoN Globe, 30 Mar. 2005.
84. Africa Rejects Action on Zimbabwe, bbc NewS, 24 June 2005.
85. AU Suspends Report on Zimbabwe Rights Abuses, iriN, 8 July 2006.
86. Southern African Development Community, Extra-ordinary SADC Summit of Heads of

State and Government, Dar-es-Salaam (29 Mar. 2007), available at http://www.sadc.int/
archives/read/news/984.

87. Zimbabwe Chair of UN Green Commission “Destroyed Seized Farm,” deutSche preSSe-
aGeNtur, 4 Sept. 2007.

88. Zimbabwe Situation “Embarrassing”: AU Chief, rueterS, 14 Mar. 2007.
89. Joshua Hammer, Scandal in Africa, N.y. reV. bookS, 14 Aug. 2008, at 4.
90. Zimbabwe: The Road to Talks, afr. reS. bull., 1–31 July 2008, at 17600.
91. The Elders’ Zimbabwe Initiative, supra note 21, at 7.

2010 Mugabe’s Zimbabwe, 2000–2009 911

Tsvangirai would successfully come to an agreement on a unity government.
At that meeting the AU also reaffirmed its support of SADC facilitation of the
negotiations between Mugabe and Tsvangirai, and appealed to all “states and
all parties concerned to refrain from any action that may negatively impact
on the climate of dialogue.”92 Zimbabwe was not on the official agenda of
the SADC 2009 meeting, despite its continued gross violations of human
rights, although there was some informal discussion with Mugabe, who was
in attendance.93 Undermining any implied criticism of Mugabe, however,
SADC at its 2009 meeting demanded that the West lift its targeted sanctions
(discussed below) against Mugabe and his inner circle.94

In September 2008, Mbeki was forced from power in South Africa.
Mbeki’s opponent for leadership of the ruling African National Congress,
and the winner of the April 2009 elections in South Africa, was Jacob Zuma.
Zuma originally was quite critical of Zimbabwe; indeed, his supporters in
the South African dock workers’ union refused to allow a Chinese ship car-
rying arms and ammunition for Mugabe’s security forces to land at Durban
in April 2008.95 However, as the elections approached, Zuma modified his
critical stance.96 Once he was elected president he resumed his criticisms
of Mugabe, stressing the importance of respect for human rights and good
governance in a visit to Zimbabwe in August 2009.97 His criticism, however,
was muted: at the 2009 SADC summit, he referred to the agreement between
Mugabe and Tsvangirai as a “positive development,” without criticizing the
continued murders, tortures, and rapes after the 2008 election, or Mugabe’s
many attempts to keep Tsvangirai from wielding any real power.98

The uncritical attitude of Mbeki, SADC, and the AU to Mugabe was
in part a reflection of their respect for his leadership in the anti-colonial
struggle in Zimbabwe and his support for the anti-apartheid struggle in
South Africa, which made him one of the “grand old men” of the African
liberation movement. In 2002, Mbeki claimed that attempts in the British
Commonwealth (see Section 4.B) to ostracize Mugabe were “inspired by
notions of white supremacy.”99 The AU also condemned what it saw as the

92. African Union Summit Resolution on Zimbabwe, adopted 1 July 2008, Afr. Union 11th
Sess.

93. Mugabe Wriggles off the Hook, ziMb. iNdep., 10 Sept. 2009.
94. Jonathan Elliott, Zimbabwe: Hold the Line, huffiNGtoN poSt, 29 Sept. 2009, available

at http://www.huffingtonpost.com/jonathan-elliott/zimbabwe-hold-the-line_b_303337.
html?view=screen.

95. Hammer, Will He Rule South Africa?, supra note 69, at 30.
96. Id. at 31.
97. Robert Mugabe off the Hook as Usual, ecoNoMiSt, 12 Sept. 2009, at 52.
98. Jacob Zuma, President, SADC, Opening Speech of the 29th Ordinary Summit of the

SADC Heads of States and Government (7 Sept. 2009).
99. Ian Taylor & Paul Williams, The Limits of Engagement: British Foreign Policy and the

Crisis in Zimbabwe, 78 iNt’l aff. 547, 558 (2002).

Vol. 32912 HUMAN RIGHTS QUARTERLY

EU’s double standard in denouncing Mugabe while ignoring other abusive
African leaders.100 This is part of a wider politics of resentment against the
West for the period of the slave trade, colonialism and, in the South African
case, apartheid. Any Western-led organization that attempts to criticize an
African leader is suspected of neo-colonialism.

The politics of resentment is easily manipulated as a tool to cover African
elites’ own interests: Mugabe regularly attributed attempts to force him to
change his policies to “white,” “Western,” or “imperialist” interference. In
November 2009, at the UN World Food Summit in Rome, he accused “cer-
tain countries whose interests stand opposed to our quest for the equity and
justice of our land reforms,” claiming that these countries were neo-colonial
powers who had imposed unilateral sanctions in order to undermine Zimba-
bwe’s land reforms and make Zimbabwe dependent on food imports; thus,
he blamed Western countries for the catastrophe he himself had caused.101
The fear of being charged with interference in Zimbabwean sovereignty,
or with neo-colonialism, may be one of the reasons that Western and UN
actions against Mugabe were relatively muted.

b. States and organizations outside Africa

Organizations outside Africa took relatively ineffective actions against
Mugabe from 2000 to 2009. The Commonwealth Organization is a group-
ing of countries formerly under British rule, including Zimbabwe at the
time of its independence. The Commonwealth suspended Zimbabwe in
2002 and extended that suspension in late 2003: as a result, Mugabe
withdrew Zimbabwe from the Commonwealth, charging that his expulsion
was caused by white racism.102 By 2009, Zimbabwe had not returned to
the Commonwealth. In March 2004, the European Union imposed a travel
ban and asset freeze on ninety-five individuals from Zimbabwe, including
Mugabe103 and by March 2007 then Prime Minister, Tony Blair, of Britain
was urging stronger sanctions.104 The EU extended sanctions in 2008,105 and

100. African Union Denounces EU “Double Standards” over Zimbabwe, aGeNce fraNce-preSSe,
21 Mar. 2007.

101. Robert Gabriel Mugabe, President of the Republic of Zimbabwe, Statement at the United
Nations World Food Summit (17 Nov. 2009).

102. calderiSi, supra note 51, at 93.
103. United Kingdom Parliament, House of Commons Hansard Written Answers: Zimbabwe

(2 Mar. 2004).
104. Fanuel Jongwe, Pressure Mounts on Mugabe with Blair Sanctions Call, aGeNce fraNce-

preSSe, 21 Mar. 2007.
105. Zimbabwe: The Road to Talks, supra note 90, at 17602.

2010 Mugabe’s Zimbabwe, 2000–2009 913

also said that Tsvangirai should be president.106 In 2008, the G8 expressed
its “grave concern” about Zimbabwe, especially the violence surrounding
elections, as well as its concern about the humanitarian situation and the
refusal by Zimbabwean authorities to allow non-discriminatory access to
all humanitarian agencies.107

Also in 2008, the Bush administration in the United States tightened a
travel ban on 250 Zimbabwean individuals and corporations and forbade
Americans to do business with them. In 2009, the Obama administration
pledged $73 million to Zimbabwe, but channeled it though aid organiza-
tions and UN agencies, refusing to give money directly to the government108;
Obama also refused to lift the sanctions on Mugabe and other members of
his regime.109

The US and UK introduced a resolution in 2008 in the United Nations
Security Council (UNSC) to freeze the assets of Mugabe and thirteen senior
Zimbabwean government and security officials, ban them from travel outside
Zimbabwe, and impose an arms embargo on Zimbabwe. Russia and China
vetoed the resolution on the grounds that under Chapter VII of the United
Nations Charter, the UNSC is supposed to take actions against states only
when there is a threat to international peace and security.110 Russia and China
argued that the situation in Zimbabwe did not threaten international peace
and stability, despite the spread of cholera to several African states,111 the
contamination of the Limpopo River between Zimbabwe, South Africa, and
Botswana by cholera,112 and the millions of refugees. In vetoing the UNSC
Resolution, China and Russia were defending their own interests. China was
investing in Zimbabwe and had supported Mugabe by building him a $9
million palace.113 Moreover, China opposed military interference in sovereign
states because any precedent could affect its own authority in Tibet. Russia,
susceptible to criticism of its war in Chechnya, had similar concerns.

South Africa, one of the UNSC non-permanent members at the time,
also voted against the US and UK resolution, arguing that problems in
Zimbabwe were best left in the hands of regional organizations, and that

106. African Union Has Failed the People of Zimbabwe, Gazette (Montreal), 6 July 2008, at
A16.

107. G8 Leaders, Statement on Zimbabwe, Hokkaido Toyako Summit (8 July 2008).
108. Hammer, Dictator Mugabe Makes a Comeback, supra note 43, at 49.
109. A Warm Welcome but Little Money, ecoNoMiSt, 20 June 2009, at 45.
110. Press Release, United Nations Security Council, Security Council Fails To Adopt Sanc-

tions Against Zimbabwe Leadership as Two Permanent Members Cast Negative Votes
(11 July 2008), available at http://www.un.org/News/Press/docs/2008/sc9396 .htm.

111. United Nations Office for the Coordination of Humanitarian Affairs, Regional Update
No. 8—Cholera Outbreaks/Acute Water Diarrhea in Southern Africa (3 Apr. 2009),
available at http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1109530

112. Reaching Rock Bottom, ecoNoMiSt, 6 Dec. 2008, at 65.
113. Geoffrey York, China Keeps Bad Company, Globe & Mail (Canada), 4 Mar. 2006.

Vol. 32914 HUMAN RIGHTS QUARTERLY

the AU summit in 2007 had asked for all sanctions against Zimbabwe to be
lifted.114 Zimbabwe’s Minister of Information, Sikhanyiso Ndlovu, claimed
that the UNSC resolution was a form of “international racism disguised as
multilateral action at the UN.”115 Thus, as of mid-2008, a weak statement
from the UNSC deploring violence and denial of civil liberties, and express-
ing concern about the grave humanitarian situation in Zimbabwe, remained
the only official UNSC statement.116

By 2009, after nine years of crimes against humanity, the world had
done very little that would deter Mugabe from continuing to starve and
intimidate his opponents into complete submission.

V. wHAT coULd HAVE bEEN doNE?

A. Regional African organizations

Land could not have been confiscated in Zimbabwe and people deliberately
deprived of food without prior undermining of the rule of law and of civil
and political liberties. One might think, therefore, that at an early stage in the
Zimbabwean tragedy, the AU might have used its 2003 African Peer Review
Mechanism (APRM) on political, economic, and corporate governance to
criticize Mugabe’s violations of human rights. The aims of the APRM did not
explicitly include protection of human rights, but human rights were one
objective of improved governance, along with constitutional democracy,
the rule of law, and promotion of the rights of women,117 all aspects of the
situation in Zimbabwe in dire need of protection. However, as of June 2010,
Zimbabwe was not a party to the APRM118; thus, the AU could not have
used this mechanism to protect Zimbabweans from Mugabe.

Given the absence of rule of law within Zimbabwe, use of pan-African
courts might have helped to mitigate the human rights violations. On 28
November 2008, white Zimbabwean farmers won a case at the SADC Tri-
bunal, which decided that the Zimbabwean government had violated the

114. Press Release, United Nations Security Council, supra note 110.
115. Fury as Zimbabwe Sanctions Vetoed, bbc NewS, 7 July 2008.
116. Press Release, United Nations Security Council, Security Council Condemns Violent

Campaign Against Political Opposition in Zimbabwe; Regrets Failure To Hold Free, Fair
Election, in Presidential Statement (23 June 2008), available at http://www.un.org/News/
Press/docs/2008/sc9369 .htm.

117. Magnus Killander, The African Peer Review Mechanism and Human Rights: The First
Reviews and the Way Forward, 30 huM. rtS. Q. 41, 45 n.25, 55 (2008).

118. African Peer Review Mechanism, Participating Countries, available at http://www.aprm-
international.org/.

2010 Mugabe’s Zimbabwe, 2000–2009 915

SADC treaty by denying the farmers access to the courts and engaging in
racial discrimination.119 This was a victory only in principle, however, as
the government of Zimbabwe did nothing to rectify the injustice. As late as
September 2009, Mugabe was still urging his party’s youth wing to “protect”
their lands against “new” white imperialists, and was prosecuting 170 white
farmers for refusing to leave their land; SADC made no mention of this con-
tinued disregard of its own Tribunal’s judgment at its 2009 meeting.120 The
SADC Tribunal could also have been a site for trials of alleged perpetrators
of mass rape in Zimbabwe.121

Nor were reports or trials the only mechanism available to African
regional organizations to ameliorate the massive human rights abuses in
Zimbabwe. Article 4 of the Constitutive Act of the AU refers to the “right
of the Union to intervene in a Member State pursuant to a decision of the
Assembly in respect of grave circumstances, namely: war crimes, genocide,
and crimes against humanity.”122 Thus, intervention, even armed intervention,
was not an unthinkable option. At one point in 2008, Tsvangirai asked for
an African police force to be sent to patrol Zimbabwe.123 Bishop Desmond
Tutu of South Africa also said in 2008 that “a very good argument can be
made for having an international force to restore peace,” in Zimbabwe.124
Genocide Watch called for African Union troops to intervene in the event
that the 2008 elections were followed by mass killings.125 Some civil society
groups in Zimbabwe also called for armed intervention by the AU to control
Zimbabwean private militias and security forces.126 Nevertheless, the AU did
not consider the fraudulent 2008 election and the violence that followed to
constitute the grave circumstance warranting intervention.

The AU is supposed to have an African Standby Force (ASF), established
pursuant to Article 4 (h) of the AU Constitutive Act.127 The ASF, if established,
would consist of five regional brigades totaling between 15,000 and 20,000
troops.128 As of 2009, there was no evidence that the AU has discussed using

119. Mike Campbell (Pvt) Ltd v. Republic of Zimbabwe, [2008] SADC (T) Case No.
2/2007.

120. Out with Those White Farmers; Zimbabwe’s Land Invasions, ecoNoMiSt, 19 Sept. 2009,
at 60.

121. aidS-free world, supra note 46, at 40.
122. Constitutive Act of the African Union, adopted 11 July 2000 (entered into force 26 May

2001).
123. Sonia Verma, Mugabe Gets Quiet Nod from African Leaders, Globe & Mail (Canada), 1

July 2008.
124. Tutu Urges Zimbabwe Intervention, bbc NewS, 29 June 2008.
125. GeNocide watch, supra note 53.
126. Ecumenical Zimbabwe Network, Call for International Intervention in Zimbabwe, paM-

bazuka NewS, 25 June 2008.
127. Dan Kuwali, The African Union and the Challenges of Implementing the “Responsibility

to Protect,” policy NoteS 2009/4 (Nordic Afr. Ist.).
128. James E. Shircliffe, Jr., Tip of the African Spear: Forging an Expeditionary Capability for

a Troubled Continent, ruSi J., Aug. 2007, at 58, 58–59.

Vol. 32916 HUMAN RIGHTS QUARTERLY

the ASF in Zimbabwe, although Raila Odinga of Kenya had urged the AU
in December 2008 to either send in its own troops or allow UN troops to
enter Zimbabwe.129 Yet, even if the AU had wished to send in troops, it was
already over-stretched, with troops in Burundi and Sudan whose logistical
support was paid for by Western powers.130 The UN was also overstretched
in Africa, with troops in Congo, Darfur, and Somalia.131

The reluctance to take military action does not mean that there is no
precedent for the violent overthrow of abusive regimes in Africa. In several
cases since independence, abusive governments were overthrown by former
colonial powers. France, for example, intervened to overthrow “Emperor ”
Bokassa of the then Central African Empire in 1979.132 More recently, Brit-
ish intervention in Sierra Leone brought peace after a decade of appallingly
brutal civil war. These interventions, however, are subject to the charge
of neo-colonialism: such is not the case when Africans intervene against
Africans.

In 1978, forces of the Ugandan army crossed the border into Tanzania
and occupied an 1800-square kilometer strip of territory; Tanzania retali-
ated by invading Uganda and overthrowing Idi Amin,133 whose brutal rule
in Uganda since 1971 had caused the deaths of about 500,000 people, and
whose decision to expel Uganda Asians had resulted in economic catastrophe
analogous to the consequences of dispossession of Zimbabwe’s white farmers
in the 2000s.134 However, one might argue that this precedent proves the point
that military action should not be undertaken. Tanzania’s invasion resulted
in the return of Milton Obote, Uganda’s first president after independence,
and a further loss of about 100,000 to 200,000 people in the continued
civil war until Obote in his turn was overthrown in 1985.135 Nevertheless,
this independent action by Tanzania against an abusive regime reinforces
the principle that the AU could intervene in analogous situations.

As of late 2009, the time for military action by the AU in Zimbabwe
was not yet past. Murders and tortures of opposition figures still continued,
there were massive food shortages, and there was no rule of law. A threat

129. Katharine Houreld, Odinga Calls for Intervention in Zimbabwe, Mail & GuardiaN (S.
Afr.), 8 Dec. 2008.

130. Paul D. Williams, From Non-Intervention to Non-Indifference: The Origins and Develop-
ment of the African Union’s Security Culture, 106 afr. aff. 253, 270 (2007).

131. Int’l Crisis Group, Ending Zimbabwe’s Nightmare: A Possible Way Forward 10 (16 Dec.
2008).

132. Mario J. Azevedo & Jean-Bédel Bokassa, Central African Republic: History and Politics,
in New eNcyclopedia of africa Vol. 1, at 254 (John Middleton & Joseph C. Miller eds.,
2007).

133. Fall of Idi Amin, 14 ecoN. & pol. wkly 907 (1979); library of coNGreSS, fed. reSearch diVi-
SioN, uGaNda: a couNtry Study (Rita M. Byrnes ed., 2d ed. 1990).

134. rhoda e. howard, huMaN riGhtS iN coMMoNwealth africa 99–107 (1986).
135. Id. at 70.

2010 Mugabe’s Zimbabwe, 2000–2009 917

that the AU would consider sending police, or even military, into Zimba-
bwe might have pressured Mugabe to genuinely share—or better yet, give
up—power. Yet the AU was still reluctant to take stronger measures against
Mugabe and his clique.

b. States and organizations outside Africa

Without any prospect of foreign military intervention as of 2009, forces
opposed to Mugabe’s rule in Zimbabwe were obliged to rely on the weak
sanctions available under international law. In a letter to the New York
Times, dated 26 December 2008, Gregory Stanton, then President of the
International Association of Genocide Scholars, and Helen Fein, then Ex-
ecutive Director of the Institute for the Study of Genocide, argued that the
UNSC should refer Mugabe to the ICC for trial on charges of committing
crimes against humanity136; Zimbabwean NGOs and charities had called for
Mugabe’s indictment as early as 2006.137 Australia and New Zealand, both
Commonwealth members, had urged in 2005 for Mugabe to be referred to
the ICC.138

In March 2009, the ICC indicted President Omar Al-Bashir of Sudan for
war crimes and crimes against humanity, thus establishing an African prec-
edent for indictment of Mugabe; the ICC had the right to prosecute sitting
heads of state.139 Mugabe was not too old to stand trial; older men than he
were tried in Europe for crimes committed during the Second World War.140
The international consequences of indicting Mugabe, moreover, would have
been far less destabilizing than indicting Bashir. Mugabe could not draw on
the support—and the danger to the international system that such support
implied—of the Arab and Muslim worlds. Moreover, Mugabe could not claim
to be fighting a civil war or defending his government against insurgents,
as could Bashir; there was no civil war or insurgency in Zimbabwe, merely
peaceful political opposition.

The threat of indictment by the ICC might have aided SADC and the
AU in their efforts to persuade Mugabe to share power. They could have

136. Gregory Stanton & Helen Fein, Int’l Ass’n of Genocide Scholars, Letter to the Editor of
the New York Times (26 Dec. 2008) (unpublished).

137. Tino Zhakata, ICC Prosecution of Mugabe Urged, ICC-africa update No. 51 (Inst. for
War & Peace Reporting), 27 Jan. 2006, available at http://www.iwpr.net/report-news/
icc-prosecution-mugabe-urged.

138. Australia Joins NZ on Push over Zimbabwe, Nzherald, 2 July 2005.
139. Press Release, International Criminal Court, ICC Issues a Warrant of Arrest for Omar Al

Bashir, President of Sudan (4 Mar. 2009).
140. Henry Rousso, Justice, History and Memory in France: Reflections on the Papon Trial,

in politicS aNd the paSt: oN repairiNG hiStorical iNJuSticeS 227 (John Torpey ed., 2003).

Vol. 32918 HUMAN RIGHTS QUARTERLY

promised him a comfortable retirement and no referral for trial at the ICC, or
protection from actual transport to the Court, in return from his immediate
resignation. Mugabe was already laboring under a travel ban to the EU and
the US, and was threatened by the principle of universal jurisdiction, which
asserts that states can try individuals for certain crimes, even if they were
not committed on the state’s territory or against or by that state’s citizens. In
2006, a Canadian Member of Parliament, Keith Martin, introduced a bill to
make it possible to arrest Mugabe for crimes against humanity, if he were
to set foot in Canada.141

Zimbabwe also seemed to be a good candidate to implement the
principle of the responsibility to protect (R2P). In 2001, the Canadian
government sponsored the International Commission on Intervention and
State Sovereignty.142 This Commission of twelve distinguished individuals,
including one South African, concluded that there was sometimes just cause
for military intervention against a sovereign state. The threshold for such
intervention was “serious and irreparable harm,” defined as large scale loss
of life or large-scale ethnic cleansing, whether or not with genocidal intent,
as the product of state action, state neglect, or state failure.143 Like the ICC,
however, R2P failed to identify state-induced famine as a specific crime. In
2006, the UNSC adopted a resolution on R2P, but most of the resolution
referred to the responsibility of a state to protect its own people. Only one
clause referred to the United Nations responsibility. Clause 26 noted that
“the deliberate targeting of civilians and other protected persons, and the
commission of systematic, flagrant and widespread violations of international
humanitarian and human rights law in situations of armed conflict, may
constitute a threat to international peace and security” and reaffirmed the
readiness of the UNSC, “to consider such situations and, where necessary,
to adopt appropriate steps.”144 As noted above, however, Russia and China,
with South African support, vetoed the very weak measures to punish Mugabe
proposed by the US and UK in the UNSC in 2008.

By 2009, Zimbabwe certainly fit the criteria of R2P; the harm that
had been done to its population was serious and irreparable, and was the
product of state action. Yet despite the rhetoric about the responsibility to
protect people from their own abusive governments, there seemed to be
no responsibility to protect the people of Zimbabwe. Commentators who
discussed R2P in Africa consistently mentioned Burundi, Congo, Somalia,

141. Brian Adeba, MP’s Motion Would Indict Mugabe, eMbaSSy: caNada’S foreiGN policy NewS-
paper, 5 Apr. 2006, at 1, 12.

142. iNt’l coMM’N oN iNterVeNtioN & State SoVereiGNty, the reSpoNSibility to protect (2001).
143. Id. at xii.
144. Protection of Civilians in Armed Conflict, adopted 28 Apr. 2006, S.C. Res. 1674, U.N.

SCOR, 5430th mtg., ¶ 26, U.N. Doc. S/RES/1674 (2006).

2010 Mugabe’s Zimbabwe, 2000–2009 919

and Darfur,145 but ignored Zimbabwe. Speakers at a seminar in January
2009, organized by the Global Centre for the Responsibility to Protect,
concluded that military intervention was not an effective means to protect
in Zimbabwe, although they did urge other measures such as referring some
members of the regime to the ICC.146 The reluctance to invoke R2P was in
part a result of the fact that the principle was meant—in so far as it was
taken seriously at all—to apply only to conflict zones, as clause 26 of the
2006 UNSC Resolution noted, not to countries where people quietly starved
without any open warfare.

Thus, international armed intervention to overthrow Mugabe was not
under serious consideration as of late 2009.The Commonwealth Organiza-
tion was not meant to maintain a military force, and had never intervened
as such in Africa. By 2004 the EU had begun to establish a rapid reaction
force, intended to be used in failed or failing states,147 but had not yet used
that army in any country. If there were armed intervention in Zimbabwe
from outside Africa, it is not clear that the AU would support it. Rather, the
AU might try to defend Zimbabwe, asserting the principles of state sover-
eignty and African solutions for African problems, although it would not be
strong enough to defeat a multinational force sent in to remove Mugabe
from power. However, without actual civil war and the threat not only of
regional spillovers but of spillovers to the Western world such as piracy,
terrorism, or uncontrollable refugee flows, it was highly unlikely that any
non-African military force would intervene to protect Zimbabweans from
their oppressive government.

VI. FAILURE To PRoTEcT

The situation in Zimbabwe in the early twenty-first century showed how
far both the African and international communities were from a genuine
responsibility to protect citizens against governments that committed massive
crimes against humanity. The principle of state sovereignty continued to be
almost unassailable. There was no suggestion that regional organizations or
the international community should be willing to remove leaders engaged in
state-induced famine, as they should be willing to remove leaders engaged
in genocide or ethnic cleansing.

145. Kuwali, supra note 127; kriStiaNa powell & StepheN baraNyi, North-South iNSt., deliVeriNG
oN the reSpoNSibility to protect iN africa (2005).

146. Global Ctr. for the Responsibility to Protect, Zimbabwe: What Can Be Done, Who
Must Act? Meeting Summary (30 Jan. 2009), available at http://globalr2p.org/media/pdf/
MtgSummZimJan2009 .

147. Edward B. Davis, Sheila M. Davis & Terry Mays, The Immediate Response Forces of the
European Union and NATO 15 (Montreal, Int’l Studies Assn. 17 Mar. 2004).

Vol. 32920 HUMAN RIGHTS QUARTERLY

The almost-famine in Zimbabwe was not a result of natural disasters;
nor was it a result, as polite commentators suggested, of policy “failure.”148
It was the result of policy success; the policy was to maintain Mugabe and
his inner circle in power. Nor was the situation in Zimbabwe merely a “com-
plex emergency,” as a result of “poor governance.”149 The emergency was a
consequence of the decisions of active political agents engaged in successful
governance strategies advancing their own interests; while its consequences
were complex, its causes were not. Others referred to Zimbabwe as a fail-
ing state,150 as if lack of professional capacity and physical resources were
the cause of the disaster, rather than decisions made by a coterie of utterly
self-interested, exceptionally cruel men and women. Zimbabwe was not a
failed state: it was a deliberately destroyed state.

Euphemistic descriptions of Zimbabwe from 2000 to 2009 protected
Mugabe and his regime from punishment for crimes against humanity. Mean-
time, millions of Zimbabweans either fled the country, or risked malnutrition
and disease, from which they were protected only by the good offices of
international agencies. Those who are ruled by criminals deserve better.

148. The Elders, supra note 21, at 3.
149. uSaid, supra note 20.
150. Int’l Crisis Group, supra note 131, at 8.

Wilfrid Laurier University
Scholars Commons @ Laurier
11-1-2010
Mugabe’s Zimbabwe, 2000–2009: Massive Human Rights Violations and the Failure to Protect
Rhoda E. Howard-Hassmann
Recommended Citation
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26 Jan 2009

Zimbabwe

: as cholera escalates, red cross red crescent funding falls short
Report
from

New Zealand Red Cross

Published on
26 Jan 2009
—

View Original

The Zimbabwe Red Cross Society and the
International Federation of Red Cross and Red Crescent Societies (IFRC)
are increasingly concerned about the lack of funding received for the Zimbabwe
Cholera Appeal.

This concern comes as reports from the
Zimbabwe Ministry of Health and the World Health Organization reveal a
worsening crisis. As of 21 January, 48,623 cases had been reported, with
2,755 deaths. Most alarming, according to Red Cross Red Crescent health
experts, is the mortality rate of 5.7 per cent, an indication that the
outbreak is still far from under control. Overall, this signifies a 20
per cent increase in cholera deaths over the past week and rings alarm
bells about the need to push back this epidemic and better fund the humanitarian
effort on the ground.

“Because of the severity of this
outbreak, we fear that it will take many more weeks to get it under control,”
said Tony Maryon, the head of the IFRC’s team in Zimbabwe. “We are
committed to continue working alongside public authorities to achieve this
and to make sure that once this outbreak is under control that the Zimbabwean
people and authorities have the resources and expertise they need to reduce
the risk of future crisis.

“But we are worried that we won’t
be able to do this unless our appeal is better supported. As it stands
now, we won’t be able to continue our operations beyond the next four weeks.”

The Zimbabwe Cholera Emergency Appeal
was launched on 23 December, 2008, calling for $16.5 NZD (10.2 CHF). However
the appeal is about 60 per cent underfunded.

In the last month, the massive Red Cross
Red Crescent response to the cholera outbreak in Zimbabwe has reached hundreds
of thousands of people right across the country.

“We are active in all of the affected
areas,” explained Emma Kundishora, the secretary general of the ZRCS.
“Our volunteers and staff are on the ground, producing clean water,
establishing and supporting sanitation and treatment facilities and passing
on life-saving health awareness messages.”

The tireless work of ZRCS volunteers
has been supported by an unprecedented mass deployment of international
Red Cross and Red Crescent resources. Seven Emergency Response Units (ERUs)
arrived in Zimbabwe one month ago and are now established and operational
in the four worst-affected provinces.

“The global Red Cross has rallied
behind the people of Zimbabwe and the Zimbabwe Red Cross,” continued
Ms Kundishora. “And progress is being made. But we need the funds
to go the last mile.”

Ongoing

Primary country

Zimbabwe

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Zimbabwe: as cholera escalates, red cross red crescent …
https://reliefweb.int/…/zimbabwe/zimbabwe-cholera-escalates-red-cro… – ترجم هذه الصفحة
26‏/01‏/2009 – The Zimbabwe Red Cross Society and the International Federation of Red Cross and Red Crescent Societies (IFRC) are increasingly concerned about the lack of funding received for the Zimbabwe Cholera Appeal. This concern comes as reports from the Zimbabwe Ministry of Health and the World Health …

DRC: As Kasai humanitarian crisis reaches new heights, …
media.ifrc.org › Home › Press releases

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ترجم هذه الصفحة
09‏/01‏/2018 – DRC: As Kasai humanitarian crisis reaches new heights, Red Cross expands response to cholera outbreak … suffering in DRC is reaching new heights every day,” said Dr Fatoumata Nafo-Traoré, Regional Director for Africa at the International Federation of Red Cross and Red Crescent Societies (IFRC).

[PDF]International Federation of Red Cross and Red Crescent … …
www.ifrc.org/…/DFiD%20Multilateral%20Aid%20Review%202011…

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However, our network of 186 National Red Cross and Red Crescent Societies offers the IFRC unparallel access to vulnerable … Because funds received from donors are often restricted and earmarked it is sometimes difficult to ensure more … In Zimbabwe, the response to an unprecedented cholera crisis in 2009 – that.

Red Cross and Red Crescent Youth – International …
media.ifrc.org › Home › What we do

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About half of the volunteers of the International Red Cross and Red Crescent Movement are young people. A special focus on young people is a crucial investment, not only for today but also for the future. The safety and protection of young people in vulnerable circumstances must be addressed, taking into account their …

Cholera compounding famine risk in East Africa and …
media.ifrc.org › Home › Press releases

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Geneva, 21 June 2017 – Concurrent, killer cholera outbreaks in East Africa and Yemen are compounding famine risk in three countries, the Secretary General of the International Federation of Red Cross and Red Crescent Societies (IFRC) warned UN Member States today. Speaking during a High-Level Panel on Famine …

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Master

thesis for the Master of

P

hilosophy Degree in Environmental and

Developmental Economics

Bureaucratic Corruption in Zimbabwe

Rumbidza Evelyn Eniah Tizora

February 200

9

Department of Economics

Faculty of Social Studies

University of Oslo

i

Acknowledgements

Firstly I thank the Lord for having blessed me with the opportunity to further my studies in

a

place that has enlightened me in so many different ways. I would like to express my heartfelt

gratitude to the following people who have guided me both intellectually and emotionally

through my studies here in Oslo. To my supervisor, Halvor Mehlum I say thank you very

much for your guidance, patience, motivation and understanding. You made me appreciate

that Economics does not have to be complicated. I would like to say thank you very much to

Knut Sydsæter for the constant concern you showed me over the years I will forever feel

indebted to you. A special thank you goes to Kaya Sverre for all the advice and assistance you

gave me over the years, your readiness to help whenever you could amazed me. I also thank

the Norwegian Government for the Quota Programme that provided me with the necessary

financial resources to be able to study at the University of Oslo. I am also very grateful to all

the friends that I have made during my stay and who have helped me in one way or another

especially Mavis, Ruth, Aasta, Dora, Martha, Endashaw, Truman and Melody. Thank you so

much for your unconditional support. I owe a great debt of gratitude to those who provided

me with vital information for my thesis but for obvious reasons I cannot mention their names.

Finally but most importantly I wish to express my sincere gratitude to my family, mum, dad,

Richard, Prisca, Patience and Yeukai for their unwavering support, encouragement,

inspiration and prayers. You have been my strength, hope and courage especially when the

going got tough.

Rumbidza Evelyn Eniah Tizora

February, 2009

ii

Dedication

I dedicate this dissertation to my parents who instilled in me the importance of a good

education and my late brother Munya who I know is very proud of me wherever he is.

iii

Abstract

The declining Zimbabwean economy has resulted in corruption reaching epidemic

proportions. There is a high tolerance for it in society as it is seen as the only way to get

timely service or any service at all especially in the public sector which is infested with petty

corruption. Through some examples this paper reveals that in the education, health, justice,

transport and custom sectors it is common to find public servants charging extra for services,

seeking small favours, or using pubic facilities and materials for their own marginal personal

gain. Payment of a bribes is now a normal and accepted way of doing business and is no

longer viewed by most as an immoral act. Whilst the causes of this petty or bureaucratic

corruption can be easily identified it is important to understand the nature and culture of

corruption, how it moves from one level to the next. This paper uses an agency model of

corruption whose setup has been widely cited and serves as a foundation for empirical

research and policy design to combat bureaucratic corruption to show that the public

officials rationally make a choice to be corrupt by weighing key determinants which are, the

return of corruption against public wage levels, the penalty and probability of being detected.

Paying particular attention to the customs sector this paper uses the multi-equilibria model

by Andvig and Moene, (

1

989) “How corruption may corrupt” to show that the increase in the

bribe price in the short-run beyond a certain level may result in a shift to a high level

corruption equilibrium which is reversible if the bribe price decreases beyond a certain level.

However in the long-run this reversal may be difficult and the sector may be stuck in the high

level corruption equilibrium. The ratchet effects of corruption in both the supply and demand

may result in its continuity and movement towards full corruption in some parts of the

customs sector.

i

v

List of abbreviations

AIDS: Acquired Immune Deficiency Syndrome

CID: Central Investigation Department

CDI: Certificado de Inspección

CPI: Corruption Perception Index

CSO: Central Statistical Office

MDC: Movement for Democratic Change

RBZ: Reserve Bank of Zimbabwe

SA: South Africa

TI: Transparency International

UN: United Nations

UNESCO: United Nations Educational, Scientific and Cultural Organization

US: United States

VID: Vehicle Inspection Department

WHO: World Health Organisation

WTP: Willingness to pay

ZANU-PF: Zimbabwe African National Union Patriotic Front

ZBC: Zimbabwe Broadcasting Cooperation

ZIMRA: Zimbabwe Revenue Authority

ZIMTA: Zimbabwe Teachers‟ Association

ZUPCO: Zimbabwe United Passenger Company

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

v

List of figures and tables

Figure 1: Corrupt relationships …………………………………………………………………………………….

2

Figure 2: Possible equilibrium levels for bell shaped distribution of costs ………………………. 3

8

Figure 3: Factors that determine the corruption equilibrium level …………………………………..

38

Figure 4: Short-run equilibrium supply response to different values of the bribe ………………

40

Figure 5: Long-run equilibrium supply response to different values of the bribe …………….. 40

Figure 6: Possible equilibrium levels for identical cost values ……………………………………….. 4

3

Figure 7: Possible equilibrium levels for uniform distribution of costs ……………………………. 4

4

Figure 8: Possible equilibrium levels for double peaked distribution of costs …………………..

44

Figure 9: Corruption levels for the bus drivers at the border ………………………………………….. 4

7

Figure 10: Corruption levels after an increase in the number of buses …………………………….

47

Table 1: Corruption Perception Indices for Zimbabwe from 1998 – 2008 ………………………….. 8

Table 2: Zimbabwe‟s Inflation Rate from 1998 – 2008 ……………………………………………………. 9

vi

Table of contents

Acknowledgements …………………………………………………………………………………………………….. i

Dedication ………………………………………………………………………………………………………………… ii

Abstract …………………………………………………………………………………………………………………… iii

List of abbreviations ………………………………………………………………………………………………….. iv

List of figures and tables ……………………………………………………………………………………………… v

Table of contents ………………………………………………………………………………………………………. vi

CHAPTER 1. Overview of the study …………………………………………………………………………….

1

1.1 Introduction ……………………………………………………………………………………………… 1

1.1.1 Defining corruption ……………………………………………………………………………….. 1

1.2 Problem statement …………………………………………………………………………………….. 4

1.3 Objectives of the study ………………………………………………………………………………. 4

1.4 Justification of study ………………………………………………………………………………….

5

1.5 Methodology ……………………………………………………………………………………………… 5

1.6 Scope of the study ………………………………………………………………………………………

6

1.7 Organization of the paper ………………………………………………………………………….. 6

CHAPTER 2. Background and extent of bureaucratic corruption in Zimbabwe …………….. 7

CHAPTER 3. Some cases of corruption in the public sector …………………………………………

10

3.1 Justice system …………………………………………………………………………………………..

11

3.2 Health sector …………………………………………………………………………………………..

13

3.3 Education sector ……………………………………………………………………………………..

15

3.4 Government tenders and procurement ……………………………………………………..

18

3.5 Media ………………………………………………………………………………………………………

19

3.6 Transport sector ……………………………………………………………………………………… 19

3.7 Customs sector …………………………………………………………………………………………

22

CHAPTER 4. Methodology ………………………………………………………………………………………..

29

4.1 Model 1: Incentives for corrupt acts …………………………………………………………. 29

4.2 Model 2: Waiting time at the border for drivers ………………………………………..

45

CHAPTER 5. Conclusion ………………………………………………………………………………………….

49

References ………………………………………………………………………………………………………………..

51

1

CHAPTER 1

OVERVIEW OF THE STUDY

1.1 INTRODUCTION

With the Zimbabwean economy in doldrums corruption has become an accepted and almost

expected way of doing business especially in the public sector. If a civil servant still goes to

work today it is not because of the salary but the opportunities to enhance his paltry income

with corrupt acts using the organizations‟ resources.

1.1.1 Defining corruption

Although there are many definitions of corruption there is a consensus that corruption refers

to the acts in which the power and influence of the public office is used for personal gain

which may not be monetary at the expense of the common good and in violation of

established laws, principles, regulations and ethical considerations. A commonly used

definition is:

“The abuse of public office for private gain”.

Public office is abused for private gain when an official accepts, solicits, or exhorts a bribe. It

is also abused when private agents actively offer bribes to circumvent public policies and

processes for competitive advantage and profit. Public office can also be abused for personal

benefit even if no robbery occurs, through patronage and nepotism, the theft of assets or the

diversion of state revenues. (World Bank, 1997, p.8)

Those in the public office include politicians and public sectors officials who may be high or

low level bureaucrats. There are two major types of corruption that these officials engage in

which are grand and petty corruption as shown in fig 1. According to Arvind K. Jain (2001),

grand corruption (relationship 1) generally refers to the acts of the political elite by which

they exploit their power to make economic policies. As elected officials, or in the

government‟s role of a benevolent social guardian (Krueger 1993), politicians are supposed to

make resource allocation decisions based solely upon the interests of their principals – the

populace. A political elite that is corrupt can change either the national policies or their

implementation to serve its own interests at some cost to the populace.

2

Figure 1: Corrupt relationships

Political Leaders

(2) Appoint

High Level Bureaucrats

Elects (1) (2) Appoint Make Public Policy

Low Level Bureaucrats

Population (2) Provide services

Benefits from Corruption

Source: Jain 2001

This type of corruption may have the most serious consequences for a society as evidenced by

the effects of the Land Redistribution Programme in Zimbabwe in 1999 when the political

elite hand picked multiple farms (even those bought for resettlement with public funds) and

registered some in the names of family members to evade the official one-farm policy. In

some cases they even drove poor peasant farmers off the land they had recently been resettled

on. They also redirected huge funds from Canada, Kuwait and England provided to buy land

for resettlement.

This paper will focus on bureaucratic corruption (relationship 2) which refers to corrupt acts

of the appointed bureaucrats in their dealings with their superiors (the political elite) or with

the public. This is usually known as „petty or bureaucratic corruption‟ with the public bribing

bureaucrats either to receive a service to which they are entitled, speed up a bureaucratic

procedure or even be provided with a service that is not supposed to be available in a

particular department. This petty corruption is probably the most widespread in Zimbabwe

and is deeply embedded in the public sector where one encounters it almost everyday.

3

For corruption to take place Jain says that there are three elements that should co-exist. First

one must have discretionary power, then there must be economic rents associated with this

power and the legal/judicial system must offer sufficiently low probability of detection and/or

penalty for the wrongdoing. All these together with other factors that favour corruption are

present in Zimbabwe making it a fertile breeding ground for both grand and bureaucratic

corruption.

The greater the discretionary powers, ceteris paribus, the stronger the incentive for the

political elite or bureaucrat to succumb to temptation. Johnson, Kaufmann, and Zoido-

Lobaton (1998) argue that more discretion and regulations for officials “… leads to a higher

effective burden on business, more corruption, and a greater incentive to move to the

unofficial economy” (p.387) This is evident in Zimbabwe were the political elite who have

discretionary powers to transfer large volumes of assets and funds from public to private

hands have done so to the detriment of the society at large.

For the public officials to engage in corrupt acts they must believe that the utility of the

income from corruption is worth the inconveniences caused by the penalties associated with

such acts. The probability of being detected, prosecuted, and punished is closely related to the

values and structures of the society. These ideas can be summarised in the relationship below:

Net utility of corruption = f Income from corruption,

Legitimate income (or fair wages),

Strength of political institutions,

Moral and political values of the society,

Probability of being caught and punished

The poorly compensated public servants in the country have powerful financial incentives to

search for additional sources of income through corrupt acts as the purchasing power of their

wage is almost nothing and any income from corruption is likely to be higher than their

salaries. The moral and political values of the society are constantly being tested and eroded.

The judicial system has the reputation of applying the law in an inconsistent and capricious

manner with most in this sector having disregard for the laws, rules and procedures they are

supposed to enforce. The governmental leaders who sidestep laws are rarely prosecuted and

convicted due to the compromised role of the prosecuting function of the state. The attorney

4

general, who has the discretion to decide whether or not to prosecute, is a political appointee

therefore his discretion is generally not exercised against political colleagues or to the

detriment of the ruling party. Also the penalties provided for corruption are trivial considering

the benefits derived from most corrupt acts. There is minimal accountability and supervision

in the public sectors. Clearly all these factors result in a positive net utility of corruption in the

public sector.

1.2 PROBLEM STATEMENT

It is evident from the statistics of Transparency International (TI) that the corruption levels in

Zimbabwe have been gradually increasing. The presence and character of corruption varies

significantly from sector to sector and it is important to know how the corruption in these

different sectors is progressing and changing from one level to the next. This will provide a

better understanding of the corruption levels of the country as a whole both currently and in

the future and will also help in the formulation and implementation of more sector sensitive

policies to combat corruption. One of the sectors that has seen a huge increase in corruption

and which this paper will focus on is the customs sector. There has been an increase in both

the demand and supply of corrupt acts as more and more people are importing both luxury

goods and basic necessities from neighbouring countries mainly South Africa, Botswana and

Zambia and as far of as Japan, China and Singapore. Although the corruption has been on an

increase the question is “Will the sector reach a high level corruption equilibrium of

corruption and if so is this situation reversible?”

1.3 OBJECTIVES OF THE STUDY

The study provides some insight into how corruption has managed to infiltrate into all the

public sectors of the economy through the some examples of common cases of corruption in

the country. Then focusing on the customs sector the paper wants to answer these questions:

What are the likely future levels of corruption in the customs sector both in the short

run and in the long run?

Will the sector remain at these levels of corruption or will they change as the factors

that affect corruption also change?

How do the ratchet effects of supply and demand of corruption affect the levels of

corruption in this sector?

5

1.4 JUSTIFICATION OF THE STUDY

On 15 September 2008 Robert Mugabe, the leader of the ruling party, Zimbabwe African

National Union Patriotic Front (ZANU – PF) and the opposition leaders, Morgan Tsvangirai

and Arthur Mutambara of the Movement for Democratic Change (MDC), signed a power-

sharing deal, aimed at resolving the country’s political and economic crisis. With the

formation of the new unity governement the nation hopes that some of the ills that have been

affecting the country like corruption will finally be dealt with as the economy recovers. When

and if the agreement is finally honoured it might be tempting to assume that with the

improvement of the state of the economy will come an automatic decrease in corruption. This

may not be so especially if the major public sectors like the customs have reached high levels

of corruption. If the nature and culture of corruption in the different sectors is not understood

and addressed accordingly together with other policies to revive the economy, corruption will

slow down the path to recovery for the nation in a great way. The donor money that has been

pledged by other countries to help the country will likely fall prey to the corrupt government

officials and not achieve its intended goals.

1.5

METHODOLOGY

This paper uses two models to show how the ratchet effects on the supply and demand side of

corruption affect the equilibrium level of corruption. The main model is Andvig and Moene‟s

1989 multi – equilibria model on “How corruption may corrupt” whose hypothesis is that the

same socioeconomic structure can give rise to different levels of corruption. This model

shows that the profitability of corruption is related to its frequency and focuses on purely

economically motivated corruption. It centres its analysis on petty corruption by public

bureaucrats and does not consider political corruption as it would require a different approach.

It looks at the incentives for demanding and supplying corrupt acts as well as the possible

multiple equilibria in corruption that may result in the short and long run depending on the

different distributions of the costs over the bureaucrats and the bribe price. The second model

shows how ratchet effects on the demand side affect the corruption levels and may lead to full

corruption by using an example of bus drivers bribing the customs officials to reduce their

waiting time at the border.

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

6

1.6 SCOPE OF THE STUDY

Corruption can be found in all facets of the Zimbabwean economy be it the private or public

sector. However this paper concentrates on the public sectors mainly the customs sector

which contributes greatly to the overall corruption in the country. It will mostly focus on

corruption that takes place at the Beitbridge border post between Zimbabwe and South Africa

which is the busiest border post in Southern Africa. This post has seen an increase in the

number of cross-border or bulk traders that go to South Africa to buy basic commodities to

sell in Zimbabwe as well as individual shoppers who cross over mostly to Musina about 13km

from the border in South Africa‟s Limpopo province to buy essentials for their families and

friends. The customs is one of the sectors in which the government could be accumulating a

lot of revenue especially the much needed foreign currency but due to the rampant corruption

in this sector it is not the case.

1.7 ORGANIZATION OF THE PAPER

Chapter 2 gives a brief insight into the state of the economy and the corruption levels in the

country. Chapter 3 looks at some of the common cases of corruption in the public sector

encountered on a daily basis by the average citizen mostly based on the interviews carried out

with both the bribers and the bribees in the sector. Chapter 4 explains the theories of demand

and supply of corruption using the two models mentioned above and Chapter 5 concludes the

paper giving some ideas for future researches.

7

Chapter 2

Background and Extent of Bureaucratic Corruption in Zimbabwe

About 80 percent of the approximately 11,6 million
1
people in Zimbabwe are living in

poverty with 56% of the population living on US $1 a day whilst 80% live on less than US $2

a da

y

2
, there is an 80 percent unemployment level and the last official inflation rate was 2

31

million
3
for July 2008, the highest in the world whilst the unofficial inflation rate on

14

November 2008 was at an unbelievable 89.7 Sextillion (10
21

) percent
4
. Prices are doubling

every two to three days. The Zimbabwe dollar is practically worthless and most shops and

businesses now trade with the United States (US) dollar or the South African (SA) rand as

they are the “official” currencies.

At the time of independence in 1980, Zimbabwe had a much more developed economy than

most other nations in Sub-Sahara Africa due to its great diversity and quality of natural

resources. Other than South Africa, Zimbabwe had the most developed capital market in

Africa, leading one scholar in 1983 to proclaim, “Independent Zimbabwe is a success”

(Davidow 1982). The most unanimous opinion condensed from audit reports, donor reports,

household surveys, business environment and enterprise surveys, legislative reports and

diagnostic studies available between 1980 -1987 was that the incidences of corruption though

present were minimal no matter how they were defined and the state enjoyed a relatively high

level of integrity with very few cases of grand corruption.

According to John Makumbe in his 1994 paper “Bureaucratic Corruption In Zimbabwe:

Causes and Magnitude of the Problem,” this grand corruption was amongst the avaricious

bourgeoisie which had spent about ten to thirteen years in prison, exile or simply outside the

country during the liberation struggle and had been brought into power by the national

independence and started devising all kinds of ways of also getting their „deserved‟ share of

the country‟s wealth. Their integration into the hitherto „whites only‟ socioeconomic fabric,

by virtue of their political and bureaucratic positions, resulted in the creation of what a local

analyst called nouveau riches, who became part of the 4 percent who owned 90 percent of all

the wealth of Zimbabwe. The magnitude of bureaucratic corruption continued to increase and

1
2002 Zimbabwe Census

2
Poverty Assessment Study 2006

3
Zimbabwe Central Statistical Office (CSO) 2008

4
H:\Zimbabwe Inflation by Steve Hanks.htm

8

the press began to expose it; university students demonstrated against it; and the President

was forced by public outcry, to take some action in the Willowvale Motor Vehicle Case

(1988) in which top government officials abused their positions to source many cars each

from the government – owned automobile assembly plant and resold the vehicles at a

tremendous profit. Many other cases of corruption followed over the years contributing to the

economic downfall of the country as those involved in corruption are not creating or

generating wealth but rather consuming it and exacerbating the mismatch between aggregate

supply and demand hence driving up the inflation rate.

Zimbabwe is the 14th most corrupt nation out of a total of 180 countries recently surveyed by

Transparency International. The 2008 Corruption Perception Index (CPI) scores 180 countries

on a scale from zero (highly corrupt) to ten (highly clean). Zimbabwe, which is ranked 166th

had a score of 1,8 on the CPI scale indicating that the country is slowly heading towards the

highly corrupt level. From Table 1 and 2 with the CPI Indices and inflation figures it is clear

that as the political, economic and social crisis has deepened, so has the corruption.

Correlation, however, does not imply causality.

Table 1: Corruption Perception Indices for Zimbabwe from 1998 – 2008

Year Rank CPI Score Std Dev Surveys Confidence

Used Interval

1998 43 4,2 2,2 6 –

1999 45 4,1 1,4 9 –

2000 65 3 1,5 7 0.6-4.9

2001 65 2,9 2,9 6 1.6-4.7

2002 71 2,7 0,5 6 2.0-3.3

2003 106 2,3 0,3 7 2.0-2.7

2004 114 2,3 – 7 1.9-2.7

2005 107 2,6 – 7 2.1-3.0

2006 130 2,4 – 7 2.0-2.8

2007 150 2,1 – 8 1.9-2.3

2008 166 1,8 – 7 1.5-2.1

Source: Transparency International

9

Explanatory notes

CPI Score – measures the perceived levels of public sector corruption in a given country and

is a composite index, drawing on different expert and business surveys from business people,

academics and risk analysts. It ranges between 10 (highly clean) and 0 (highly corrupt).

Confidence range – provides a range of possible values of the CPI score. This reflects how a

country‟s score may vary depending on measurement and precision. Normally with a 5

percent probability the score is above this range and with another 5 percent it is below.

However particularly when only a few sources are available, an unbiased estimate of the

mean coverage probability is lower than the nominal value of 90%.

Surveys used – refers to the number of surveys that assessed a country‟s performance. At least

3 surveys are required for a country to be included in the CPI.

Standard deviation – indicates the differences in the values of the sources; the greater the

standard deviation the greater the differences of perceptions of a country among the sources.

Table 2: Zimbabwe’s Inflation Rate from 1998 – 2008

1336,6* = Inflation rate for January 2005

231million* = Inflation rate for June 2008

NB: All other inflation rates are for December of each year.

Source: Central Statistical Office

Year Inflation%

1998

48

1999 56,9

2000 55,2

2001 112,1

2002 198,9

2003 598,7

2004 1336,6*

2005 585,8

2006 1281,1

2007 66212,3

2008 231million*

10

CHAPTER 3

SOME CASES OF CORRUPTION IN THE PUBLIC SECTOR

The public sectors in Zimbabwe are afflicted by many dysfunctions that affect most African

bureaucracies and promote corruption like „permanent‟ and „occasional‟ absenteeism

(Nembot 2000; 298; Morice 1987); slow administrative procedures (Sarassoro 1979);

dilapidated administrations which are ill-adapted to social change (Asibuo 1992); rigid,

impersonal and ritualized implementation of the rules (Schwartz 1974); complex and opaque

regulations that are difficult to apply and leave infinite scope for discretional powers

(Fjeldstad 2003; Hope 2000; McMullan 1961); the centralization of decision-making

processes and lack of delegation at subordinate levels of the administration (Cohen 1980);

inadequate archiving or its complete absence; poor division of tasks and functions in both

spatial and sectoral terms (Darbon 2001: 29).

Although the presence and character of corruption varies significantly from sector to sector it

is common that the government officials are charging extra for services, seeking small

favours, or using pubic facilities and materials for their own direct or indirect marginal

personal gain. Below is a brief presentation of a few corrupt acts that take place in some of

the public sectors in the country. To get these accounts I interviewed a number of government

officials and people from the general public. It was not easy to have formal interviews on this

rather sensitive subject so in most cases the interviews were rather informal but very

informative. Corruption is now the norm in Zimbabwe and some people are willing to discuss

it openly as long as they are assured that what they say will not get them into some form of

trouble. It almost an accepted way of doing business. It is not to say though that there are no

more honest people in the country and all the government officials have to be bribed to do

their job. But as soon as one steps into the country they are confronted with corruption left,

right and centre and it becomes both frustrating and impossible to ignore. More so at the

points of entry into the country especially the customs offices at the Beitbridge border post,

the airport, and the roads leading to and from the border. The different accounts that I

gathered on my field trip are written in italics and they are more or less as the interviewees

narrated them to me. Some of the accounts are my own experiences as like I mentioned above

it is difficult to avoid.

11

3.1 Justice System

“Corruption within the justice system is generally defined as the use of public authority for

personal gain that results in the improper delivery of judicial services and legal protection for

citizens.”(Mary Noel Pepys, Fighting Corruption in Developing Countries, Strategies and

Analyses, 2005 pg13). Some of the main players in the justice system are the judges, lawyer,

public prosecutors, the police, court clerks, the secretarial staff, prison wardens and prison

guards. The role of the judiciary is to protect human rights and civil liberties by ensuring the

right to a fair trial by a competent and impartial tribunal. Ideally all citizens are entitled to

equal access to the courts and equal treatment by the investigative bodies, prosecutorial

authorities, and the courts themselves regardless of their position in the society. In Zimbabwe

the judiciary is not independent but controlled by the government which has placed its own

appointees in strategic posts in the legal system. The phenomenon of corruption has obviously

not spared this sector in which the powerful and rich can escape arrest, prosecution,

conviction, and literally „buy justice‟ whilst the poor are excluded from their rightful access to

fair and effective judicial services.

The workers in the justice system including the judges receive dismally low salaries and are

forced to perform their duties with meagre financial resources under abominable working

conditions that consist of crowded office space and dilapidated courtrooms among many

others. It is unfortunate that the judges who are the ultimate decision makers and the highest

governmental officials within the justice system and should be the focal points for reducing

corruption promoting the rule of law have to engage in unlawful acts sometimes with their

subordinates to make ends meet. The following examples show how corruption has spread

across the whole spectrum of the judicial system:

At the Harare Magistrates Court in the capital city there is a pending case of a foreign

currency dealer who allegedly stole US $80 000 from his associate. He was arrested

and taken to the police station. I am sure the policemen that caught him would have

accepted a bribe from him had he not been on the wanted list for other pending fraud

cases. In prison he managed to bribe the prison guard with US $5 000 to ask a

magistrate to grant him bail. This was too good an offer to refuse for a prison guard

who is paid approximately US $1 per month. In court the magistrate gave him bail

and received US $1 000 whilst the prison guard received US $500. He promised to

pay him the rest at a later date although this is highly unlikely. Out on bail he went to

12

the court clerks who are in charge of the criminal files and bribed them with US $800

so that they steal his file for him. With no case file and out on bail he is continuously

on further remand. The complainant will be lucky if he ever gets his money back. Out

of the US $80 000 he stole this dealer spent less than a tenth of that money in bribing

the government officials so that he stays out of prison.

User of the court, Harare

Corruption within the criminal process is very common because for a good sum the police can

suppress the filing of police reports, distort, destroy or even steal evidence. Sometimes they

just refuse to investigate or even protect the alleged perpetrator if he is politically powerful or

wealthy. Corruption within the civil process is also widespread with the court clerks having

the power to expedite or delay a case without detection. For the right price they can even

completely destroy a case file.

I had 25 cows stolen from my farm three months ago and when the culprits were

caught I hoped that they would be sent to prison for at least 25 years because livestock

theft carries with it a huge penalty but with this corrupt judicial system nothing was

done to them. Although the case went to court the criminals bribed all those handling

the case even the judge, who some say got around US $1 000 and the prosecutor US

$500. About 50kg of the recovered meat that was supposed to be presented as an

exhibit was said to have been eaten by the police in their canteen imagine. So with no

exhibit there was no case and the thieves got away.

Farmer, Kwekwe

Some men from Harare were caught selling elephant horns here in Kwekwe because

the price here is reportedly higher and they were arrested. Their horns which were

worth around US $25 000 disappeared in the hands of the Central Investigation

Department (CID) officers. So although the police had opened a docket for the case

there was no exhibit to present. The CID officers responsible for the mysterious

disappearance of the horns are said to have paid the judge and the prosecutor a total

of US $2 500. The owners of the horns who were released because of lack of evidence

want their horns back and are now hunting down these CID officers.

Police officer, Kwekwe

13

In some cases the powers of the CID now go beyond the domain of investigation and extend

unofficially to aspects of sentencing. Many cases do not even go to court as they are settled by

the police officers, usually without the knowledge of the judge. For example if one sells a car

for US $20 000 and does not get his money and reports the case to the police instead of

placing a charge against the alleged thief the policeman can approach the thief and tell him of

the consequences of being charged and taken to prison. The policeman then suggests that he

pays US $5 000 every week and if he has US $5 000 he can pay it there and then to the

disgruntled seller. The policeman can then ask for a bribe of about US $200 for this favour

from the accused and on taking the US $5 000 to the owner of the car will also get another US

$200 for having facilitated this agreement. Where one reports a theft but does not know who

the culprit is and only has a suspect the policeman can approach the suspect and make him

aware of what will happen to him if he is charged and taken to prison just to scare him. The

policeman can demand a bribe depending on the gravity of the accusation so that they do not

arrest him. But then being just a suspect and without any evidence nothing would have

happened to him.

At times the police and magistrates are coerced into making corrupt decisions out of fear of

retribution. Being perceived as politically incorrect and unpatriotic makes many in the legal

system decide against their better judgements. As a result there are many public officials that

have committed a lot of crimes but have never seen the door of a court house let alone that of

a jail cell. In some cases depending on their positions in the ruling party, they can get

presidential pardon as in the Willowvale Motor Vehicle Case where some of the accused who

were not forced to resign although convicted and sentenced are still involved in politics and or

government with positions of high authority. This shows how the legal system is to some

extent controlled by the ruling party and that ones‟ political affiliation can grant him

„immunity‟ when it comes to the law.

3.2 Health Sector

The role of the government in the health sector is to promote equitable access to services,

assure sustainable financing for health objectives and prevent the spread of disease. But

mainly due to corruption the Zimbabwean government has failed to perform these functions

leading to inadequate and unequal access, poor quality of health care and inefficient services.

The gravity of the problem in the health system came into light when the country was hit by a

14

cholera epidemic in August 2008 that up to date has killed 2024 with at least 40,000
5
having

contracted the disease. This is the worst cholera outbreak in Africa since 1999 when 2,085

people died in Nigeria
6
. The waterborne disease, which causes severe diarrhoea and

dehydration expectedly spread to all 10 provinces of the country mainly due to lack of clean

water and sanitation.

Every year an estimated 1 300 to 2 800 mothers die from causes associated with pregnancy

and childbirth and 12 000 people are estimated to die every month from Acquired Immune

Deficiency Syndrome (AIDS) related illnesses
7
. Most of these deaths are due to lack of access

to drugs, essential equipment and other supplies in health facilities. Malnutrition has reached

epic proportions, with five million people requiring food aid this year. Under-funding of the

Ministry of Health has led to a lack of the necessary resources needed to cope with even

curable ailments like cholera. Industrial action by health professionals over very low salaries

has often affected the country‟s health delivery services, while a serious brain drain is a

contributory factor to the crippling of the sector.

In November 2008 the government closed the major public hospitals in Harare and the second

biggest city Bulawayo as they had been operating without running water, no functioning

toilets, no soap, empty pharmacies and not enough food for patients or staff for three months.

Zimbabwe once a leader in health care, medical and nursing education also closed its medical

school in the same month and cancelled exams because there was no paper and ink to print

the exam papers. The main mortuary in the capital has been operating without electricity so

the dead are rotting.

A government doctor is paid a monthly salary less than US $100 and there is no reward for

exceptional performance so corruption has become a survival strategy for both the

government workers and the patients. The theft of drugs/supplies for personal use or resale in

the private sector is now very common in the public hospitals. Some drugs that are supposed

to be given to the patients for free are being sold to them and at times the prices are

unbelievably high considering that the drugs were supposed to be for free. Because of these

under-the-table payments to obtain drugs there is now a lower utilization of drugs amongst the

patients as some just cannot afford. Most are no longer getting proper treatment as they have

5
World Health Organization (WHO) 2008

6
United Nations (UN)

7
United Nations

15

to make do with the drugs that are available. There is also interruption of treatment or

incomplete treatment leading to the development of antimicrobial resistance.

Now some nurses only come to work on the days that they know the dispensary will be

open so that they can steal medication and sell to us. On the days that the dispensary

is closed which are many we are attended to by the student nurses. But what can they

do, they complain of inadequate salaries and we cannot blame them; it is just that us

the patients are the ones who are suffering.

Patient, Kwekwe General Hospital

Some essential services which ideally should be readily available to the patients are being

diverted for personal use.

Ambulances are now being used as taxis for ferrying passengers whilst patients are

being taken to hospitals in wheelbarrows. The drivers are shamelessly switching on

the sirens as they „pilot‟ (taking people from one point to the next) .The other day I

was called to the scene of an accident involving an ambulance only to find out on my

arrival that there were about 15 passengers that were on their way to Gweru from

Kwekwe. Luckily there were no casualties but „zvinonyadzisa‟ (its embarrassing) what

these economic hardships are making us resort to.

Police Officer, Kwekwe

The above description of the state of the ailing health sector shows how the bad governance of

the country coupled with corruption has resulted in great social costs.

3.3 Education Sector

This sector has not been impervious to the pervasive corruption that has penetrated the public

sector. Before the economic downfall that has haunted Zimbabwe for the last decade, teachers

used to be among the highly paid professionals and they could afford a decent life. With the

budgetary allocation to the education sector by the government being far less than the 26%

required by United Nations Educational, Scientific, and Cultural Organization (UNESCO) the

salaries of the teachers are so low that they cannot even afford transportation to work for the

whole month. They are even being urged by the government to take on projects to supplement

16

their salaries. As a result many are making students sell their products like sweets, „freezits‟

(frozen juice in 50ml packets) or „maputi‟ (popcorn) for them during break time:

I am very good in maths so my teacher likes me because I give the correct change and

I also sell a lot of sweets. I would want to play more with my friends during our break

but I have to do this for ma‟am, I cannot refuse. I do not want her to give me bad

marks or something like that. On some days when I sell a lot she also gives me one or

two sweets.

Grade Six Pupil, Chegutu

Some are taking regular vacations or are just absent from schools to do cross-border trading

and when they leave there are either not replaced or they are replaced by untrained school

leavers who also leave after very short periods of time. Teachers collecting salaries but not

providing the intended instruction is probably the most common form of corruption in this

sector but justified by most. An estimated 50 000 teachers have left Zimbabwe for greener

pastures to date
8
since the economic downturn. Some have gone to the United Kingdom

where they are reportedly doing odd jobs like caring for the old, while some have gone to

work in the farms and as housemaids or gardeners in neighbouring Botswana and South

Africa.

Unlike the educational funding system in the industrialized countries, education has

traditionally been the financial responsibility of the government like in most African

countries. Unfortunately due to gross economic mismanagement the government is now

turning aggressively to already poverty stricken parents to bear the heavy burden of the

astronomical costs of education and literally take care of the teachers in the public schools.

For the teachers to come to school and teach our children we have to bring them

groceries at the beginning of the term. Each child has to go with salt, sugar, cooking

oil and soap on the first day of school if they want to be allowed to sit in class. Us

parents are already struggling to access these basic commodities for our families

without having to worry about the teachers‟ groceries too.

Parent of a Pupil at Sally Mugabe Primary School, Kwekwe

8
Zimbabwe Teachers‟ Association (2008)

17

Another common form of petty corruption is the selling of admissions at all levels of

education.

In these times of economic hardships my colleagues were really surprised when I

refused a bribe from a parent whose child had dismally failed the entrance test to get

into the first grade. I was not intimidated by his expensive car and suit and I told him

point blank that “Your son has failed so we cannot accept him here.” He then told me

that if I helped him then he will show his gratitude in a big way and handed me a

khaki envelope. I could tell that it contained a lot of money because it was really thick

but I did not even bother to open it. He surely looked and sounded like a man who was

used to getting his own way but I showed him that it was not the way we did things

here that is why we manage to keep our good reputation.

Secretary at a Public School, Chegutu

The University of Zimbabwe uses the point system to screen and place the students into

different programs. But some students with low points are being admitted and/or getting into

programmes that they are not qualified for academically but financially. This is seen as more

and more students are struggling to keep up in their respective programmes and subsequent

background checks reveal that they do not qualify to be in certain programmes. The lecturers

cannot do much about it as this corruption usually involves the university‟s top officials.

Corruption is also evident in opportunities to study abroad. Information of available

scholarships is not posted on the notice boards for all the students to have an equal

opportunity to apply to, it is reserved for a select few closely linked to the chairperson‟s of the

various departments. Sometimes a directive of who must get the scholarship can even come

from high ranking government officials hence denying the deserving candidates the

opportunity to further their studies.

I know that I was not supposed to have come here because another teacher had

already been awarded the scholarship but then when I learnt of it I went to my uncle

who just made one phone call and the scholarship was given to me instead. It took

some difficulties to have the name changed but when people heard who had

recommended me they really could not say anything.

Student, Europe

18

This student did not manage to finish his degree and the scholarship went to waste. It may not

have been the case had it been used by its initial deserving recipient. These examples above

provide just a glimpse of the petty corruption that takes place in the education sector.

3.4 Government tenders and public procurement

Most examination committees for government tenders abuse their discretionary powers or

stimulate an open and fair competition (especially through the means of prior agreements

between firms or the creation of fictitious firms).

When I am applying for a tender I always make sure that I send my tender last when

my „associates‟ on the board have gone through all the other tenders and they tell me

the figures that will make me win the tender. It would be suspicious if my company

always won the tenders so I change the name all the time and create fictitious

companies. I usually give my „associates‟ a reasonable percentage of what I make. If I

do not do this I will not get the tenders. I also have „associates‟ in the accounting

department so that I can get my payment on time.

Entrepreneur, Harare

In 2006 the then Chairman of the parastatal Zimbabwe United Passenger Company (ZUPCO)

and its Chief Executive, who was also the deputy Minister of Information were charged for

jointly receiving US $20 000 after the Chairman solicited US $85 000 from Shah Gift‟s

Investment firm to facilitate a contract to supply buses. The Chairman was convicted and

given a jail sentence for two years but nothing was done to the Chief Executive although he

was forced to resign after audit reports showed a lot of unexplainable discrepancies. The

reports also revealed that there were no proper purchasing procedures leading to the payment

of people who had not supplied anything to the company. For example one of the reports

notes that a payment of Z $64million was made to someone who had not supplied anything to

the company. False requisitions of what is already in stock are very common in parastatals.

Corruption at the lowest levels in this parastatal involves drivers sometimes not issuing tickets

so that they may pocket the money at the end of day. The cash collection from bus income is

not properly accounted for and there is no proper supervision of the work of the junior staff so

chances of the drivers being caught are very low.

19

3.5 Media

Journalism should be the eyes of the people and the ears of the society but in Zimbabwe it is

also infested with corruption. This is mainly due to the poor remuneration, unfavourable

working conditions and non-existent fringe benefits for the workers. There are a lot of bribery

cases involving the state owned Zimbabwe Broadcasting Cooperation (ZBC) TV and Radio

bosses, broadcasters and electronic print journalists. Bribes are demanded from business

executives, politicians and musicians who will be given sustained and positive media

coverage, continuous air play and better ratings on local music and business charts.

For an advert that costs Z $100 000 for three minutes I pay for three slots a day with

Z $300 000 but can even get up to seven slots per day if I just give the broadcaster

Z $30 000 per extra slot. All that is required is proof of payment on my part because I

understand no-one really checks if what is on the invoice tallies with the number of

slots I am given that day.

Entrepreneur, Harare

The main corrupt practices in the transport and customs sectors involve these three main

areas:

a) the identification of road users – the checking of drivers licences

b) the technical and administrative status of vehicles – vehicle registration, technical

inspection, insurance, general external appearance.

c) transported goods and customs duty.

For the users of these transport and customs services i.e. importers, exporters, taxi, truck and

bus drivers time is crucial and any minute that they save enhances their competitiveness on

the market. As a result they are vulnerable to corruption by the customs officials and the

police. Sometimes they even take the initiative and offer the bribe so that they do not waste

time even if their affairs are in order.

3.6 Transport Sector

3.6.1 Driving licence

During driving tests the instructors point out to the testers the candidates that have paid. The

ones that have not paid usually fail unless they bring other resources into play like family ties

20

or networks of relatives, friends and acquaintances. If the candidates have not arranged with

their instructor they sometimes give the bribes, usually approximately US $50 to the

examiners during the tests. These examiners are not hesitant to tell the candidates that if they

do not „make a plan‟ it will take time before they get their licence whether they can drive or

not.

After having been driving for almost 20 years without a licence and getting away with bribing

the police in Zimbabwe a move to South Africa prompted a certain gentleman to get an

International driving licence. He explained to me:

In South Africa the police can stop you anytime and it‟s unlike Zimbabwe were you

are certain that you can bribe your way out. Here it‟s a foreign land so it‟s just good

to have a licence. I have really been reluctant to bribe for a Class 4 licence because I

know that even though I can drive they will make me fail so that they get something

from me. This time I had no choice I had to pay US $100 to get this International

driving licence that I am using here in South Africa.

To get a car cleared or acquire a registration book for ones‟ car at the Zimbabwe Revenue

Authourity (ZIMRA) offices one usually has to bribe the officials who like the customs

officials at the border have the discretionary powers of lowering the value of a car.

3.6.2 Road checks

The customs officials and the police officers who carry out road checks exploit people‟s lack

of time. The police order the drivers to park and give them their custom clearance documents,

putting the driver under unnecessary pressure of the possibility of being told to unload their

goods or having them seized although the officers have no mandate to perform customs

duties. The drivers are not aware of this and just want to be on their way so they are easily

bribed usually for SA 10 rands per passenger.

Sometimes if all the drivers‟ papers are in order for example the driving licence, insurance

certificate and registration papers they can just bluntly ask the driver to leave them “yedrink”

(money for a drink) or say “tinyareiwoka” (will you just please respect us and give us

something) or “tipeiwo yeweekend” (can you give us some money for the weekend) or

“ingoitai kuti tiende” (may you just give us something so that we go away and stop bothering

21

you). They can even find some jokes to say so that the driver relaxes, for example “How can

you be travelling in such nice cars in these difficult times? Please do leave us something.” If

this does not work they may resort to less friendlier means to get money from the motorists:

I really did not have any money on me when I was stopped at a police roadblock. I

tried to explain this to them but they would not listen. In these cash crises times it is

possible that one can actually not have any money on them although have a lot in his

bank account which he cannot access because of the daily withdrawal limits set by the

Reserve Bank of Zimbabwe (RBZ) Anyway the policeman told me to get out of my car

and he literally put his hands in my pocket, which had nothing of course but it was just

wrong, he had no right to do that but again who do I report him to everyone is corrupt

in this country. He then told me to leave him anything so I left some bread and drinks

just so that could be on my way.

Driver, Harare

If there happens to be something wrong with a drivers‟ vehicle or papers then instead of

writing a ticket and issuing it the policemen will tell the driver to “make a plan”.

On my way to the airport I was stopped at a police roadblock and since I did not have

my licence on me I was told to park the car and surrender my keys by one of the

policemen. After some pleading and explanation that I was in such a hurry the

policeman who seemed very stern and diligently doing his job when he stopped me

accepted US $5 and let me go. The amount that would have been on the ticket had it

been issued would have been much lower than the bribe but like most people I did not

have the time, patience or will to argue with the policeman so I just gave him the

bribe, he also did not seem too eager issue the ticket anyway.

Driver, Harare

This just shows that tthe police officers and Vehicle Inspection Department (VID) officers

now have no respect for the high-way code when they are the ones who are supposed to

ensure that its rules are adhered to in order to avoid endangering innocent lives. They let the

drivers of vehicles that are not road worthy or drivers that should not be on the road go as

long as they can pay the bribe.

22

3.7 CUSTOMS SECTOR

The examples below are just some of the corrupt acts that take place at the Beitbridge border

post. There are many others that may take some form or another the ones mentioned. Efforts

to get the high level officials to discuss the corruption that takes place in their sector did not

yield any results. This is a sensitive issue and they do not want to be quoted as having said

something that would put their careers a risk which is understandable considering the fortunes

that they probably make unlawfully. It is the lower ranking officials and the general public

who were more forthcoming.

3.7.1 Under declaration of goods

At the Beitbridge border post the cross-border traders are almost always racing against the

clock because the sooner they have their goods cleared through customs the sooner they have

them in the market in Zimbabwe and the more profit they will make. As a result they are

willing to bribe the officials so that they do not have to be at the border for long. For some

though it is not the saving of time that matters most but the under declaration of their goods

that the customs officials can facilitate. Hence they are willing to lurk around the customs

buildings till dark when the faking of documents and the bribing of officials are the order of

the day. There is an official table of customs clearance charges for all categories of

merchandise. The false classification of goods involves placing them in a category that incurs

a lower charge, thus minimizing the cost of their customs processing. One of my interviews

with a border official was interrupted by a call from his „friend‟ who had just arrived from the

South African side and needed to clear his goods. He was gone for almost an hour and when

he came back he just said:

Oh that was a good friend of mine who did not want to spend too long at the border so

I had to go and help him out, now he is happily on his way home. He had gone to buy

groceries at Musina so although I am not at work today I signed his customs

declaration form and showed it to my colleagues on duty and he was on his way. This

is my friend so they did not have to look at what he had bought. Of course he gave us

all „yedrink‟.

Judging from the “Kentucky Fried Chicken” take – away that this customs official was

holding the trader was not the only one who was happy. He also got US $150 to share with his

two colleagues. He also explained to me that sometimes they develop close relationships with

23

frequent cross-border traders that go beyond just a commercial one such that their exchange

of services or favours generates systems of reciprocal obligation between them. A lady may

actually end up referring to an official as my „son‟ and he refers to her as „mother‟. She will in

turn bring him small gifts when she comes from the other side of the border and may also just

phone once in a while to find out how her „son‟ is doing.

This under declaration or none declaration of goods is also common at the airport as I realised

when I arrived at the Harare International Airport.

Having been on a 12 hour flight I was happy when I was approached by a porter who

offered to “help me with my luggage”. I quickly agreed and as we waited for my bags

he started updating me on the terrible economic situation that the country was now in.

When my luggage came out loaded it onto the trolley and escorted me out of the

airport. None of my three suitcases where opened for checking by the customs officials

and so I did not declare anything. I gave him US $10 but he told me that it will be

hard to share with the other two that he was working with. I then realised that he has

to give his colleagues too so that they do not report him and so I gave him another US

$5.

3.7.2 Immigrant rebate

This is a form of corruption at the border in which the government is losing a lot of revenue.

For example if one imports a US $8 000 car that would attract duty of about US $7 000 one

can put it in the name of a returning resident to avoid paying this duty. The customs official

who clears the car at Beitbridge can be given US $500 to overlook this whilst the one whose

name was used can get around US $1500. Often in these cases the bribe given to the official

corresponds to the value that the customer will have saved. There is another form of rebate

that is ethically wrong but yields large profits for the officials.

We have the authority to confirm one‟s disability. I was supposed to do that for one

guy who had bought a car for US $75 000 from Japan but he decided to go and have it

done for him at the Zimbabwe Revenue Authority (ZIMRA) offices in Harare instead.

He probably paid just 15% of the duty paid value (VDP) instead of the 90% or 110%

if the car was 5years and below. The duty for luxury vehicles is paid in foreign

currency so he would have paid a lot of money. The customs official that did it for him

24

in the capital may have taken home about US $20 000. This is a tricky issue though

and one can only authorise a few disability cases a year to avoid raising eyebrows.

Customs Official, Beitbridge

3.7.3 “Runners”

The decentralization of customs services in one and the same administration, which forces

clients to attend different offices for the customs clearance of just one item, is a source of

minor irritation that many try to overcome by taking shortcuts that sometimes entail bribing

the officials or hiring middle men known as “runners” who do not work in the customs

officials but know what goes on at the border and work together with the customs officers so

they do not wait in the queues. The frequent border crossers have permanent runners that they

employ as I learnt from an entrepreneur who buys beverages form South Africa and sells

them in Zimbabwe.

In my business time is money especially during this festive period, to make sure that

my drivers spend as little time as possible at the border I have a runner who works for

me. My drivers give him the papers as soon as they arrive at the border and I give him

about US $100 per truckload of beverages he clears on time. He probably shares this

with some customs officials, I am not sure. I had another one but he increased his

price to US $300 so I looked for someone cheaper. There are so many of them at the

border these days.

3.7.4 “Informal tax” on passengers

The customs official also sometimes collect an „informal tax‟ usually SA 10 rands per person

in the buses crossing the border so that they do not have to unload their goods for checking.

They just pretend to be checking and then let the driver be on his way. Although this can be

considered as extortion because no service is supplied here the passengers would rather pay

than spend a lot of time at the border as this lady explained:

When I was on a Tombs bus (a trans-border bus company) on my way back to

Zimbabwe with my mother last month I was glad that we did not spend a lot of time at

the border and our goods were not checked as we had bought a lot of electrical goods,

way over US $500 each so we would have had to pay a lot of duty in foreign currency.

At the border when the official approached the bus, the driver asked him “Officer

25

mauya nebhutsu dzenyu dzebhora here timbotamba?” (to you have your soccer shoes

on today so that we can play). He said yes and the driver told us to pay SA 10 rands

each to the official and send our passports forward so that the customs official would

go and stamp them. We did not spend more than 20 minutes at the border which was

great. But imagine since we were about 75 passengers we left the official around SA

750 rands. Our bus is probably not the only one he did this to I know because there

are some buses that these officials target and they will not let them pass without the

passengers paying something. They even know the days and times that they pass and

wait for them I think. I heard the police on the South African side are also doing this

now.

Cross-border trader, Kwekwe

Sometimes this informal tax is collected even when the buses are leaving to enter South

Africa so that the bus jumps the line. The passengers may have to pay SA 20 rands each so

that their bus goes to the front. Chapter 4 uses a model to explain these queues and the

corruption involved in greater detail.

3.7.5 “Ignorance”

The officials also take advantage of the traders lack of knowledge of what exactly happens

behind the counters at the customs offices.

People who come to the border do not really know what goes on in our customs offices

and maybe think that our work is very complicated and almost “special” in a way.

Sometimes we take advantage of this “ignorance” or rather lack of knowledge and

either inflate their charges or pay charges that they are not supposed to at all. Since

they may not understand the “complex” system of custom charges they would not want

to argue with us. I know its bad but we also need to eat.

Customs Offical, Beitbridge

3.7.6 Bottlenecks

Many public officials force their users to adapt to their schedules and to submit to or accept

the timetables they set: „the user‟s time is not as important as that of the official‟ (Hertzfeld

1992: 162). Thus the personal schedules of users are seriously disrupted by different forms of

bureaucratic indifference, such as instructions to return the following day or the impossibility

26

of predicting the duration of administrative procedures. It is the officials who control the

duration and the speed of the interaction with users. This makes the customs officials exploit

this resource in corrupt exchanges as shown in the extract from an article “Nightmare at

Beitbridge Border Post” posted in The Standard (A South African Newspaper) on 6 March

2005.
9

“Where on earth do you get such sloppy service? Taking more than 12 hours to

process a file? The answer might be that I was not the only customer, but on the day

when I actually cried from tiredness I had waited for 16 hours without sleeping and

there were only five customers. The evening shift came and went and then the morning

shift came and was about to go while I was still there…………. One could tell that it‟s

either they are seeking a bribe somehow or they are out to just exercise power or else

they lack product knowledge. An example of the questions was: Why is the invoice

written Mazda 323 and there was no Familia?, and why on the payment transfer

document it was written Mazda Familia?. Anyone who knows cars will know that the

answer lies in having a physical check on the vehicle. If you are an assessor then you

should know your stuff, which includes cars. The other thing which baffled me was

being told my telegraphic transfer was not authentic. As far as I was concerned that

was the only proof of payment I had. How does one prove the authenticity of a bank

confirmation document when this is what one was given at the bank to present to

Zimra? If you are unlucky to find an officer who is in a bad mood he may decide that

freight charges were not included and one maybe charged double on freight. The

answer, of course, is the assessor has every right to doubt the authenticity of all your

paper work. One ends up paying heavy duties and amounts, which are uncalled for

because one is tired and has nowhere to complain. ………….”

Frustrated Citizen, Harare

The officials may also create artificial bottlenecks or shortages so that they may offer faster

individual service for payment. I experienced this at the ZIMRA offices in Harare when a

government official told me that.

9
http://www.thezimbabwestandard.com/letters/16159.html

27

Yes we do not have anymore number plates but that is only for “povho” (the general

public) but then for you “vehukama” (relatives) an arrangement can be made.

He then showed me the ones that he had under his desk as proof and said that at US $10, I

could have a set.

3.7.7 Certificado de Inspección (CDI) forms

When one is exporting goods from Zimbabwe they have to complete CDI forms at the border.

For a product like tobacco one can expect to get around US $30 000 per truckload. This

should be remitted to RBZ and one gets back about 60 percent of that money. In a normal

economy one can access their foreign currency anytime but in Zimbabwe one has to apply to

RBZ and state what they want to use their money for. It may take months before the request is

approved or disapproved. As a result the exporters avoid filling out CDI forms, and just bribe

the customs officials with maybe US $2 000 depending on the value of what they are

exporting and nothing goes to RBZ.

3.7.8 Vehicle Overloads and Project equipment approval

At the border corruption also exists at the higher levels and involves larger sums of bribes.

Here at the border if you snooze you loose I came to work here because there is an

opportunity to make money, if the top officials at the head are corrupt then what about

us at the tail. The VID officers who work here can take as much as US $30 000 a day

through overweight trucks and they do not accept anything less than US $500 for

overloaded vehicles. They also work with us at the bottom so that we do not tell on

them and can give us maybe USD $1 000 depending on how much they themselves will

have made. The top officials here are politically appointed and although they may be

rotated at times the predecessor always tells his successor how he can make money so

the rotation does not really solve the corruption problem. It is a vicious cycle that just

goes on and on. Also when those officials responsible for the rotations pass through

the border they have their cars filled with goods by their subordinates. So how can

they remove or move such a subordinate?

Customs Official, Beitbridge

28

Another form of corruption that takes place at higher levels involves those that may be

starting huge projects in the country for example a mine and have to import a lot of inputs.

Although one is allowed to bring in all their initial equipment duty free, this has to be

approved by the top officials at the customs offices. Most of the time this approval will be at a

cost to the entrepreneur depending on the value of the equipment that they are bringing in.

3.7.9 Border Jumpers

Everyday there are a lot of border jumpers (desperate Zimbabweans forced to leave the

country and enter South Africa illegally) who cross the border in search for a better life.

Passage to cross the Limpopo River without a passport or a valid visa usually costs around SA

100 rands which is given to the border police who sometimes even escort the jumpers part of

the way.

This chapter has given an insight into some of the forms of corruption that take place in the

public sector but the next chapter will pay particular attention to the customs officials at the

Beitbridge border post. It will use two models to make a rough forecast of what the corruption

levels will be both in the near future and in the long run in the customs sector.

29

CHAPTER 4

METHODOLOGY

4.I Model 1:

4.1.1 Incentives for corrupt acts

According to Adving and Moene a public bureaucrat, i.e. a member of a public organisation

and in this chapter a customs official supplies a corrupt act if he directly or indirectly deals

with a non-member using the public organisations resources to acquire payment against the

rules of the organisation or against the law. These resources include the bureaucrats‟ own

decision-making power and special information that is at his disposal in the public

organisation. A member of the public who may be a cross-border trader or an ordinary citizen

demands a corrupt act if he tries to bribe a bureaucrat. Then he will be known as a „briber‟

while the bureaucrats who take bribes as payments for illegal services are the „bribees‟. Some

of the assumptions of the model are:

-Only one corrupt service is transacted per period between the briber and the bribee.

-Corrupt services are homogeneous therefore the level of corrupt transactions is indicated by

the number of corrupt bureaucrats which is normalised to 1.

-All potential bribers demand the same amount of corruption.

-The bribees do not search for bribers as it is not in their best interest to be open that they are

corrupt.

Let:

y = fraction of corrupt

bureaucrats.

= fraction of non-corrupt bureaucrats.

N = number of trials, the briber has to search to find a willing bribee as he does not know who

is corrupt and who is not.

= the probability that he finds what he wants after exactly N trials.

qi = the sum of moral and real costs involved in trying to bribe a bureaucrat for the private

agent i.

b = price of corrupt services.

= excess profit of obtaining corrupt services at a price b and .

The expected profit of a briber, i.e. buyer of corrupt services is

(1)

y1

yy
N 1

)1(

)(

b

i

0)(
‘
b

i

yqbP
iii

)(

30

4.1.2 Why cross-border traders demand corrupt acts

The traders will only take part in corruption if their expected profits are positive i.e. .

Their moral and real costs, qi are low because petty corruption in the country has now become

an accepted and expected way of life that is not condemned by society as much as before.

People‟s moral values have been almost completely eroded due to the hardships that they face

everyday whilst trying to make ends meet. Since the fraction of corrupt customs officials is

quite high it lowers the search and transaction costs for the trader who has to go through less

trials N, to find a willing bribee. This results in positive expected profits and hence their

willingness to take part in corrupt acts.

The demand for corrupt services is proportional to the number of traders with a positive Pi.

This demand can be expressed as

D D(b
_
, y) (2)

Due to the positive expected profits there are a lot of traders who demand corrupt acts

therefore the demand for corrupt acts is high. The higher the bribes b, the lower D is because

high bribes result in lower profits for the traders after they sell their goods. If they pay high

bribes they either incur the cost themselves by accepting a small profit margin so that they

move their stocks quickly or transfer the cost to the end consumer and have less of their goods

being bought and/or slower sales. All these possibilities are not good for the traders so they

may lower their demand for corrupt acts the higher the bribes. Since the expected search and

transaction costs are lower the higher the incidence of corruption more private agents have

positive Pi the higher y is. As a result the demand for corruption is an increasing function of y

for a given b.

Assuming that the D function is continuous and differentiable a suitable choice of units can

derive the long run relationship between the bribe b and the normalized level of demand for

corruption y which gives the equation y D(b, y) which then gives b E(y) as the long run

demand curve. This can be reduced to

E ‘
b

y

1 D
y

D
b

were D
b

0 and 1 D
y

0 showing that the long run demand curve can be upward sloping

with supply directly influencing demand.

0
i

P

31

4.1.3 Why customs officials supply corrupt acts

The incentives for a bureaucrat to act in an honest way are the same as those that make a

worker in a private firm put in the required effort (cf.Shapiro and Stiglitz, 1984). The worker

needs a salary high enough to induce him to put in this required effort and for the customs

official at the border, his wage needs to be high enough to make him honest and not use the

organisations resources for his private gain. The wages of the customs officials and their

colleagues in the public sector are so low that those who go to work only do so to use the

organisations resources for their private gain and are not motivated to be honest. With many

people going to look for greener pastures in other countries those that are benefiting from

corrupt acts see no reason to leave.

Other assumptions of the model are:

-All bureaucrats have utility functions that are linear in money and receive the same salary w

per period.

-The value of the outside option = 0.

With the unemployment rate at 80 percent, the value of the outside option for the customs

official is almost 0 because it will be very difficult for him to get employed if he is caught

being corrupt and fired. This increases his costs of supplying corrupt acts.

-w therefore reflects the wage differential between the public and private sectors corrected for

the expected waiting time.

-w is strictly positive.

-Bureaucrats are heterogeneous with respect to the costs of supplying corrupt services.

These costs may either be internalized moral costs or organisational costs related to the

positions of the bureaucrats. The higher a rank one has the more one probably has to lose if he

is caught cheating. Besides losing his job and benefits his reputation is also damaged more so

than an official with a lower rank. The customs officials also have different moral costs

depending on their moral values which may have nothing to do with their positions.

-Each bureaucrat has the option to follow either a corrupt or a non-corrupt strategy.

-He has an infinite horizon and discounts future income with the discount factor:

The expected value of the options of the rational bureaucrat i in period t is:

(3

1 (1 r)

)1(),(max)( tVtUcbwtV
iiii

32

Were: b = bribe.

ci = bureaucrat i‟s cost of providing corrupt services.

= expected gain of choosing to be corrupt in period t.

If the bureaucrat decides to be honest and non-corrupt he is sure to keep his job and obtains

in the coming period. The loss of future income is not much of a motivation for

honesty for the corrupt customs official because his wage is very low. If he can make his

salary for the next two, three or even ten years in a single corrupt act then he is likely to be

dishonest. It may more so be the loss of the opportunity to supply corrupt acts in the future

that may induce the official to be honest in the present period. Also if the risk of getting

caught in the near future is high then he may try to get as much as he can before he is caught.

But again if one is so used to be corrupt and getting away with it one can get comfortable and

almost forget that he can get caught and be fired. This is sometimes the case in Zimbabwe

were many people are either busy with their own corrupt acts and making sure that they do

not get caught that they may not be bothered with the corruption of their fellow bureaucrats

and just turn a blind eye. There are some bureaucrats though who are honest so the corrupt

customs official is at risk of being caught by a corrupt colleague or an honest one.

The expected consequences of being corrupt are:

(4)

Were: s = the exogenously determined probability of being caught in corrupt

transactions and 0 s 1.

= the probability of not being caught.

If the corrupt bureaucrat is not caught he can start the next period with the same options as he

had in the present one. His consequences of being caught depend on whether he is caught by a

corrupt colleague or an honest one. If he is caught by a non-corrupt colleague he is reported to

higher ranking officials who are assumed to be honest. These would immediately confisticate

the bribe b and fire the corrupt bureaucrat. But in reality at the border not all superiors are

honest as some are even involved in the corrupt acts with their subordinates, here the reported

corrupt official may not be fired but just given a warning although in other cases even though

they may have done some corrupt acts together the superior may feel that protecting the

)(tUcb
ii

)1(t

V
i

))(1()))1(()1()1()( bytVystVstU
iii

(1 s)

33

corrupt subordinate and not firing him is too obvious and may damage his own reputation so

he is left with no choice but to dismiss him. Therefore in being corrupt there is a probability

of obtaining as the best option in the coming period considering that the

utility level outside the public sector is equal to 0.

On the other hand if he is caught by a corrupt colleague he can bribe him immediately with a

bribe = B so that he does not report the case and hence he keeps his job. As a result there is a

probability sy of obtaining in the coming period. This bribe B can take on

different values. It can be equal to 0 when corrupt bureaucrats agree not to report each other

in a „tit for tat strategy‟ which means that if you do not report me then I will not report you

too when and if I catch you being corrupt in the future. The two can also bargain and share the

gain of not being fired which is the future income of the corrupt bureaucrat. In the third case

which is used in this models‟ formal derivations and the one that is most common among the

customs officials B = b, i.e. the potential reporter receives the same bribe as that acquired by

the corrupt

bureaucrat.

A bureaucrat who would choose to be corrupt faced with an external bribe b will also accept

the same amount of bribe b to perform the corrupt act of not reporting the colleague that he

has caught. Anything less would be unfair leaving him disgruntled and putting the corrupt

official who has been caught at a risk of being reported to an honest superior. We therefore

have the same equation determining Vi for those who choose to be corrupt independently by

directly accepting bribes from non-members of the bureaucratic organisation or taking them

via other bureaucrats in their organisation.

In the model stationarity is assumed so and for all t. From (3) we can

then find the expected present value of following a non-corrupt strategy (which is the best

option for those bureaucrats with sufficiently high ci values and it is not rewarding to be

corrupt) is.

(5)

This is also the present value of future salaries that one would get if he keeps his job by being

honest.

s(1 y) ( b 0)

( B V
i
)

V
i
(t) V

i
U

i
(t) U

i

V
N w

1

34

The expected present value of following a corrupt strategy is:

(6)

This equation shows that as long as is positive the pay-off of choosing a corrupt strategy is

higher the higher its incidence i.e. the higher is y. At the border most of the customs officials

are corrupt resulting in a high y. This means that the expected present value of following a

corrupt strategy is also high and greater than the expected value of following a non-corrupt

strategy hence the customs officials will only be behaving rationally by choosing to be

corrupt. This rational behaviour results in an even greater fraction of corrupt officials making

the expected present value of following a corrupt strategy even greater than that of following

a non-corrupt one. This vicious cycle of corruption then leads to a high corruption equilibrium

level, a stage which maybe difficult to reverse in the long-run. The higher y is the lower the

chances of being caught by a non-corrupt colleague and being reported to an honest superior.

A rational bureaucrat chooses to be corrupt when . From (5) and (6) and using

this reduces to:

(7)

Were: = expected money gain of corruption.

= expected retained value of the bribe.

= expected loss of future incomes.

For a bureaucrat to be corrupt his costs, ci must be less than the expected money gain from

corruption but greater than expected retained value of the bribe.

Each bureaucrat is associated with a level of costs ci which are distributed over an interval

[ ] with a cumulative density such that F (c) 0 and F(c) 1 The proportion of the

bureaucrats who choose to be corrupt is for given values of y, b, w, s

and r. The number of corrupt bureaucrats is higher:

-the higher the perceived fraction of corrupt bureaucrats y;

As mentioned earlier in this paper corruption is an accepted and expected way of doing

business at the border. As a result the cross-border traders who demand the corrupt acts

V
i

c w b(1 s) ci

1 (1 s(1 y))

V
i

c

V
i

c
V

N

1 (1 r)

c
i

(1 s)b

s(1 y)w / r

(1 s)b s(1 y)w / r

(1 s)b

s(1 y)w / r

c,c

F ( )

F((1 s)b s(1 y)w / r

35

expect that most of the customs officials that they are dealing with are corrupt and so offer a

bribe for their services. This may tempt those otherwise honest officials. In some cases bribes

are accepted for procedures that may otherwise have not required any bribery.

-the higher the bribes b;

A lot of the people who cross the border may not know how their duty is calculated by the

customs officials. As a result they end up paying more that they are supposed to. The customs

officials may also take advantage of the fact that the traders want to spend as little time at the

border as possible and demand high bribes.

-the lower the salary w;

The very low wages of the officials result in a high number of corrupt customs officials as

they are left with no choice but to supplement their income through dishonest means.

-the lower the exogenously given detection probability s;

Some reasons why this is so at the border are that, the supervision is very low and almost non-

existent, since almost everyone is being corrupt they are occupied with not being caught

themselves that they may not really be concerned with what their colleagues and subordinates

are doing and they also let each other in on their corrupt deals to avoid whistle blowers.

-the higher the discount rate r;

The discount factor can also can be viewed as the probability that the present

bureaucratic regime remains in power in the succeeding period assuming that the corrupt

bureaucrat will be unemployed if a new regime which may not tolerate corrupt acts comes

into power hence no future income. The higher the probability of a regime shift the higher is r

and the higher is the incidence of corruption and a perceived value of y as the bureaucrats,

especially those appointed because of their political affiliation with the ruling party try to

acquire as much as they can to cushion themselves against the anticipated negative impacts of

a possible regime shift. The economic and political situation in the country at the moment is

very volatile and its future is uncertain. There may not be threat of a complete regime shift but

the resultant inclusive government from the power-sharing agreement may lead to a better

rule of law and intolerance of corrupt acts making the future of the corrupt officials bleak.

1 (1 r)

36

can be considered as a response function indicating the number of

bureaucrats who choose to be corrupt for a perceived level of y. Therefore the positive

equilibrium levels of y and b must satisfy

for (8)

b = E(y) (9)

(8) and (9) describe self–fulfilling consistent beliefs about the incidence of corruption and the

equilibrium bribes. Mathematically they also describe Nash equilibria in the game theoretic

sense in which:

-all bureaucrats know each others ci values.

-everyone predicts the equilibrium level(s) of y on the basis of rational behaviour from all

bureaucrats.

In reality though each bureaucrat may not know so much about the costs of the others but

knows his own cost ci and just observes last periods level of corruption and uses that to

adjusts his choice rationally in the present period.

Therefore we can write . When y(t) y(t 1) a stationary

equilibrium is reached. Such an equilibrium y* is locally stable if a small deviation from y* in

period t leads to a conversion back to y*. This is called the myopic adjustment case.

4.1.4 Possible corruption levels in the customs sector

Different equilibria incidences of corruption have their corresponding market clearing bribe

values. The distribution of ci over the bureaucrats determines the possible equilibrium levels

and there may frequently exist multiple equilibria.

The value y = 1, i.e. all the bureaucrats being corrupt is in the equilibrium set if;

(1 s)E(1) c (10)

this means that the expected value of the equilibrium bribe when all bureaucrats are corrupt

exceeds the cost of the least corrupt prone bureaucrat.

The value y = 0, i.e. no bureaucrats being corrupt is in the equilibrium set if;

F((1 s)b s(1 y)w / r

F((1 s)b s(1 y)w / r y 0 y 1

y(t) F((1 s)b s(1 y(t 1))w /r)

37

(1 s)E (0)
sw

r
c (11)

meaning that the expected value of the equilibrium bribe when all others are honest is not

high enough to cover the expected loss of future salaries and the costs of the most corrupt

bureaucrat.

4.1.5 Bell shaped distribution of ci

This is the distribution of ci that applies most to the customs officials whose costs follow a

normal distribution. This results in the case illustrated in fig. 2 with three possible equilibrium

levels of y on the supply side for a given value of b. These are points that correspond to the

Intersections between the y and F-curves. This model focuses on the myopic adjustment case

in which y1 and y3 are the stable equilibria. If the perceived level of corruption is below the

critical mass y2 the process converges step by step to y1 but if it is above y2 it converges to y3.

According to TI (2008) Zimbabwe is slowly heading towards the high corruption level y3 and

so has passed the critical mass y2. A change in a number of factors over the years has resulted

in this approach towards high corruption equilibrium. Some of these factors are presented in

fig. 3. This paper uses Adving and Moene‟s model to make a rough forecast of what might

happen to the level of corruption in the customs sector especially at the Beitbridge border post

in the short and long run depending on how the equilibrium supply of corruption responds to

different values of the bribe price which is determined by the factors in fig. 3.

Possible corruption levels in the short run.

Having started in a low corruption equilibrium an increase in the bribe b at the border post

shifted the F-curve upwards as shown in fig. 4. This was mostly due to the bad economic

situation in the country which resulted in workers receiving very low wages and hence

resorting to corruption and increasing its supply. As the situation continues to worsen the

moral values of the society are continuously being lowered as petty corruption is seen as a

justifiable way to make a living given their low salaries. The deterioration of the economy

38

Figure 2 : Possible equilibrium for bell-shaped distribution of cost

y,F

y

1

F((1-s)b-s(1-y)w/r)

y

y1 y2 y3 1

Figure 3: Factors that determine the corruption equilibrium level

Economic Environment

Wage Moral Values Rule of law Regime Shift Demand

for corrupt acts

Bribe price

Corruption Equilibrium Level

39

also saw the disintegration of the rule of law, if one knows the right people or has money then

he will not be punished for his unlawful behaviour. The lack of basic commodities increased

the demand for corrupt acts at the border greatly as many became cross-border traders and

more and more individuals were crossing over to South Africa to buy essentials.

The highest bribe which sustained this low equilibrium is b1 shown by the highest stipulated

curve. The supply of „low level‟ corruption is continuous and increasing in b for b < b1 but

for b values just above b1 the equilibrium supply of corruption will jump to point z and the

sector will be in a „high level‟ corruption equilibrium. With the continued collapse of the

economy the bribe price may soon be higher than b1. The lowest bribe which will sustain this

high equilibrium is b2 as illustrated by the lowest stipulated curve b2. The „high level‟ supply

of corrupt services is a continuous increasing function of b for b > b2 but for values of b just

below b2 the equilibrium supply of corruption will jump to t and the sector will be in a „low

level‟ corruption equilibrium. This shows that if the power sharing deal yields positive results

soon and the economic situation improves resulting in higher wages, a campaign to restore

peoples‟ moral values, more supervision, better rule of law and a decrease in the demand for

corrupt acts the bribe price and corruption levels may decrease. Points x and k are low and

high tipping points that correspond to unstable intermediate points like point y2 in fig. 2, they

are of little relevance in our myopic adjustment case. This shift back to the low corruption

equilibrium level may not be so easy in the long run and the sector may be stuck in the high

level corruption equilibrium.

Possible corruption levels in the long run.

Fig. 5 illustrates the forecast of the corruption level in the customs sector in the long-run with

b1, b2, t, x, k, z referring to points in fig. 4. The „low level‟ supply curve L is relevant for b

values in the interval [b1,b2] only when we start out in a „low level‟ equilibrium where b < b2.

The „high level‟ supply curve H is relevant for b values in the interval [b1,b2] only when we

start out in a „high level‟ equilibrium where b > b1. The dotted downward sloping part of the

supply curve is unstable as mentioned earlier. Although this supply structure and an

increasing long run demand function E(y) may result in one, two or three equilibrium levels of

y the model only focuses on the two equilibrium case. Fig. 5 shows that when the sector is in

the high level of corruption it will also have a high equilibrium bribe. In the long-run some

temporary changes that have occurred in the underlying parameters may shift the sector from

a low corruption to a high level corruption equlibrium. Due to the ratchet effects of the supply

40

Figure 4: Short-run equilibrium supply response to different values of the bribe

y,F
y

1

F((1-s)b1-s(1-y)w/r)

F((1-s)b2-s(1-y)w/r)

y

t x k z 1

Figure 5: Long-run equilibrium supply response to different values of the bribe

b

D(b,y2) H

D(b,y1) L H‟ E(y)

b1

b2

y

t y1 x y3 k y2 z 1

side these temporary shifts may give rise to permanent changes. Some of these changes that

have taken place are:

i) Demand has temporarily increased as more and more people are crossing the border for

basic commodities inducing the short-run equilibrium price to go up above b1 such that the

41

supply of corrupt services will jump into the high level regime. When demand reduces to the

normal level the equilibrium might settle on this high corruption equilibrium level.

ii) The probability of a regime shift has temporarily increased due to the political and

economic uncertainty and officials have become more corrupt prone for each level of the

bribe. This can eventually lower the critical bribe b1 in the fig. 3 and the equilibrium may

jump into the high corruption level regime. When the uncertainty is resolved and the value of

r goes back to its normal level the situation will be trapped at the high corruption equilibrium

level.

iii) Moral costs of taking bribes have been lowered as corruption has become the only way to

survive for the customs officials. Although a better economic environment in which people do

not have to be corrupt to make ends meet may restore these moral values the sector may be

trapped in the high corruption equilibrium level. Considering a first order leftward shift in the

distribution of ci means that every element ci is reduced with the same amount and the new

equilibria are characterized by

for

0 y 1 (12)

. (13)

If increases from 0 the F curve will shift upwards as shown in fig. 4 implying a higher

supply of corrupt acts to each level of the bribe. Both the low and high tipping points x and k

will consequently be reduced the more so the higher is . In fig. 5 this increase shifts both the

L and H curves to the right and lowers the critical bribes b1 and b2 as indicated by the curves

L′ and H′. As long as the long run demand curve is upward sloping the equilibrium bribes are

also increasing in .

When supply and demand determine the bribe it is economically expected that an increase in

the supply would decrease the equilibrium bribe. Currently in the customs sector it is the

opposite as predicted in the model. Although there might be an increase in the supply of

corrupt acts at the border the increase in the demand may even be greater resulting in an

increase in the equilibrium bribe. It may not be the case though that the corruption jumps

yrwysbsF )/)1()1((

b E ( y)

42

from one equilibrium level to the other but it is a gradual step by step process that takes years

or even decades. As a result it may also take a long time for the corruption level in this sector

and the country as a whole to go back to the low corruption equilibrium level even after the

economic situation in the country has improved.

The return to the low level corruption equilibrium may be slowed down further by the greed

among both low and high ranking officials. Some of the officials have become accustomed to

certain lifestyles that they feel a need to maintain through the continued supply of corrupt

acts. This lifestyle is not one that these corrupt officials flaunt to their colleagues because they

do not want to risk being investigated. The corruption by the customs officials might have

started because of greed when their wages could still sustain them. As the economic situation

is worsening and more officials cannot meet their basic living costs some have became

corrupt as a means to survive moving the sector towards the high level corruption

equilibrium. When the economic situation starts getting better the officials will no longer be

desperate as they can again live on their monthly remunerations but then the greed will still

exist amongst some. This will result in a cycle of corruption that starts and ends with greed.

There are other cost distributions that may not apply to the corruption in the customs sector

and these are briefly discussed below.

4.1.6 Identical ci values

In a special case all bureaucrats are identical, i.e. ci = ĉ for all i. Returning to the equilibria

described by (8) and (9) we have either y = 1 or y = 0 in equilibrium and for given values of s

and w both extremes can be in equilibrium. This is so if

(14)

using (10) and (11). When (14) applies we find from (7) the critical mass

, (15)

where all bureaucrats are indifferent between being corrupt and being non-corrupt. This

incidence of corruption is unstable. If the perceived y is higher than ŷ the equilibrium

converges to y = 1 but if the perceived value of y is lower than ŷ the equilibrium converges to

y = 0.

(1 s)E (1)

sw / r

ˆ c (1 s)E (0)

1 ˆ y
(1 s)b ˆ c

sw / r

43

The equilibrium supply of corrupt services as a function of the value of the bribe depends on

the initial situation. Starting by increasing b from b = 0, we get y = 0 as the equilibrium for all

values of b such that the left hand of the inequality (12) holds, i.e. for b (c s / w) /(1 s).

Higher values of b induce all bureaucrats to become corrupt. From fig. 6 it can be seen that

b (c sw / r) /(1 s) starting from and successively reducing b, y = 1 is the equilibrium as

long as .

4.1.7 Uniform distribution of ci

The costs ci can be uniformly distributed over the interval [ ]. If both (10) and (11) hold we

have a similar situation as in identical ci values. If neither (10) nor (11) hold we have a unique

stable supply side equal to y* shown in fig. 7. Here there is an increasing supply of corrupt

transactions as a function of the bribe. There is a stable equilibrium level of b and y if the

slope of the supply curve is steeper than that of the demand curve.

4.1.8 Double peaked distribution of ci

In this scenario shown in fig. 8 there are three stable supply side equilibria i.e. L, M, H for all

values of b. This may result in a three long run equilibria of b and y.

Figure 6: Possible equilibrium levels for identical cost values

b

c sw / r

1 s

c

1 s

1 y

ˆ b c(1 s)

c,c

44

Figure 7: Possible equilibrium levels for uniform distribution of costs

y,F
y

1

F((1-s)b-s(1-y)w/r)

y

y*

Figure 8: Possible equilibrium levels for double peaked distribution of costs

y,F
y

1

F((1-s)b-s(1-y)w/r)

y

L M H 1

45

4.2 Model 2:

4.2.1 Waiting time at the border for the bus drivers

Ratchet effects on the demand side of corruption can be illustrated using an example of bus

drivers bribing the customs officials in order to reduce their waiting time at the border. For

both the drivers and their passengers it is of paramount importance that they spend as little

time as possible at the border especially when they are crossing over to go to the South

African side. The passengers want to quickly buy their goods and head back home whilst the

drivers do not want their timetables disrupted by delays at the border. As a result sometimes

they are willing to bribe the officials so that they will go to the front of the line but at times

the bribe price is so high that it is not worth it to pay it as will be shown by this model using

figs 9 and 10.

Let:

d – c0 = cost of waiting for those who bribe

e – c1 = cost of waiting for those who do not bribe, here no-one bribes

a – c3 = cost of waiting for those who bribe + the bribe that they pay

c0- c3 = the bribe price

α = fraction of buses that bribe their way through the border

1-α = fraction of buses that do not bribe their way through the border

A(α) = the cost bribing

C(α) = the cost of not bribing

When the bribe = b1 there will be two equilibria as shown in fig. 9.

Equilibrium 1: No corruption

No-one pays since the bribe is higher than the cost of waiting i.e. b > d. Here all the drivers

will choose to wait and the equilibrium will be at c1 with no corruption.

Equilibrium 2: Full corruption

Here when some drivers decide to pay then all the others will find it rational to do so as well

because the one who does not pay will end up always being at the end of the line. These

ratchet effects in the demand will result in the equilibrium being at a,

with full corruption.

46

4.2.2 Decrease in the bribe

Equilibrium 1: Full corruption

The bribe can decrease from b1 to b2 if the economic situation worsens increasing the supply

of corrupt acts. This decreases the cost of those who bribe from c3 to c3‟. When this happens

the new cost of waiting for those who bribe c3‟ becomes less than the cost for those who do

not bribe therefore all the drivers will decide to bribe and the new equilibrium will be at f,

with full corruption.

4.2.3 Increase in the number of buses

The worsening of the economy may result in more people crossing the border and this

increases the number of buses as well as the demand for corrupt acts as shown in fig. 10. This

increase also happens periodically during the peak periods when there is a lot of traffic

crossing the border such that those who choose not to pay may end up spending about two

days or more at the border post. This will be a great inconvenience to both the passengers and

the drivers. In this case there is only one equilibrium with full corruption as explained below.

Equilibrim 1: Full corruption

When the number of buses increases the cost of waiting for those who bribe, d – c0 increases

since their gain from bribing has also increased and the curve tilts to d’ – c0. This increase is

equal to that for those who do not bribe which is from e – c1 to e’ – c1’. As a result all the

drivers decide to bribe the customs official and the consequences of the one that does not pay

is great as he will end up at the end of the queue and may be spend a few days at the border.

The ones that arrive after him may even leave before him if they do decide to pay. There will

be full corruption at e, were all the drivers pay since their cost of bribing plus the bribe is the

same for all and less than the cost of waiting at the border .i.e. A (α) + b < C(α).

Here it shows that when everyone pays it does not help in aggregate but benefits the customs

official who may take advantage and slow down his work to make the willingness to pay

(WTP) of the drivers increase and hence increase the bribe price.

These two models have shown that there are ratchet effects in both the supply and demand

side of corrupt acts which may lead to a high level corruption equilibrium or full corruption.

47

Figure 9: Corruption levels for bus drivers at the border

e

a

f

c3

d c1

d

c3‟

c0

α 1-α

Figure 10: Corruption levels after an increase in the number of buses

e’

b1

e c1′

d’

A A

c3

d c1

b1

c0

α 1-α

48

CHAPTER 5

CONCLUSION

Although corruption is widespread and systematic throughout the public sector in Zimbabwe

it takes different forms which need to be known, acknowledged and accepted if the country is

to move back to a low level corruption equilibrium and minimise the possibility of

recorruption. It is also important to understand the rational responses of the bribers and

bribees to the different factors that affect the corruption level through the bribe price in. This

understanding helps give a rough forecast of the corruption levels in both the short and long

run in the different sectors and the country as a whole. In the short run a shift to a high

corruption level is easily reversible when the bribe price decreases beyond a certain level but

this maybe difficult in the long run. With the economic situation worsening the bribe price in

the customs sector is likely to continue increasing and the sector will be in a high level

corruption equilibrium which will be very difficult to reverse. The ratchet effects in the

demand side of corrupt acts will also contribute to full corruption in some sections of the

sector. But if the inclusive government works towards the recovery of the economy, better

wages, more efficiency, accountability, transparency and rule of law in the public sector then

the situation may change resulting in a decrease of the bribe price.

Limitations:

Although the agency model by Adving and Moene is very relevant for the study of petty

corruption one of its main assumptions that the high level officials are honest and will fire the

corrupt official may not always apply in the customs sector where even the senior officials are

known to be very corrupt. Efforts to get interviews with them yielded no results but they

would probably have agreed with this assumption because they would want to give a false

image of honesty. Some of these high level officials are also involved in corrupt acts with

their subordinates so future researchers can consider these relationships which may help to

show some of the links between petty and grand corruption.

It was important to have a lot of interviews to get a picture of the extent of the corruption in

the country than just take the CPI Indices as they are considering that the surveys on which

the index is based may not ask the same questions, start from the same definition of

49

corruption or have the same ethical and moral yardstick. It was evident however that the

incidence of corruption in the public sector and the country as a whole is great.

Implications for further research:

These interviews revealed that corruption is a huge problem in the country that needs to be

addressed but they were just a drop in the ocean. A lot of sectoral research still needs to be

done to understand the culture of corruption in Zimbabwe although many of the forms

mentioned are the same as those found by Blundo, Olivier de Sardan, Arifari and Alou in

their research in Benin, Niger and Senegal from 1999 to 2001 and documented in their book,

“Everyday Corruption and the state: Citizens and Public Officials In Africa”(2006).

Although the thesis has shown that the customs sector might be approaching a high level

corruption equilibrium in the long run it is important to note that corruption is not an

irresolvable problem. The sector may not necessarily be stuck in this high corruption level but

it may just be more difficult and take a longer time to return to a low level corruption

equilibrium, it is not impossible.

50

References

Adving and Moene 1989. How Corruption May Corrupt. Journal of Economic Behaviour &

Organization, Elsevier Publishers, vol. 13(1), pages 63-76

Arvind K. Jain 2001.Corruption: A review. Journal of Economic Surveys, vol 15(1), pages

71-121, Blackwell Publishers Ltd, USA

Bertram I. Spector 2005. Fighting Corruption in Developing Countries. Cumarian Press, Inc ,

Bloomfield , USA

Blundo G, Olivier de Sardan J.P, Arifari N.B, Alou M.T. 2006. Everyday Corruption and the

state: Citizens and Public Officials In Africa. Glosderry, South Africa

David J. Gould and Jose A. Amaro-Reyes 1983. The Effects of Corruption Administrative

Performance Illustrations from Developing Countries. World Bank Staff Working Papers No.

580 and Management And Development Series No. 7.The World Bank Washington, D.C.,

U.S.A.

Kempe R. Hope 1997. African Political Economy: Contemporary Issues in Development

M.E. Sharpe

Makumbe, John 1994. Bureaucratic Corruption in Zimbabwe: Causes and Magnitude of the

Problem. Africa Development, vol 19(3)

Martinez-Vazquez Jorge, Arze del Granado Javier, Boex Jameson 2007. Fighting Corruption

in the Public Sector. Linacre House, Jordan Hill, Oxford U.K

Mukum Mbaku, John 2007. Corruption in Africa: Causes, Consequences, and Cleanups

Lexington Books

Shana, Goodwin 2006. The State of Corruption In Zimbabwe. unpublished, Harare.

Transparency International (2008), www.transparencyinternational.org

http://www.transparencyinternational.org/

51

Wikipedia (2008), http://wikipedia.org/

Google (2008), http://www.google.com

http://www.google.com/

Interim Version –

2

8

August

20

1

4

FRAMEWORK FOR DEVELOPING AN
Integrated Communication Strategy

for the Introduction of Oral Cholera Vaccine in
Cholera Prevention and Control Programmes

UNICEF – Programme Division

3

United Nations Plaza
New York, NY

10

01

7

USA
www.unicef.org

Commentaries represent the personal views of the authors and do not
necessarily reflect the positions of the United Nations Children’s Fund.

The designations employed in this publication and the presentation of
the material do not imply on the part of the United Nations Children’s
Fund (UNICEF) the expression of any opinion whatsoever concerning
the legal status of any country or territory, or of its authorities or the
delimitations of its frontiers.

TABLE OF CONTENTS
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

Intended users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

Goal and objective of OCV communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

Part 1 Guideline for an Integrated OCV
Communication Strategy . . . . . . . . . . . . . . . . . . . . . . . . 10

The steps in the communication planning process

Step 1 Establish a communication team and a coordination
mechanismn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Step 2 Conduct a rapid communication assessment . . . . . . . . . . . . . . . .

14

Step 3 Plan your communication strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2

Step 4 Design the creative strategy: messages, channels
and media materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4

Step 5 Plan to monitor and evaluate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

53

Step 6 Document good practices and lessons learned . . . . . . . . . . . . . .

58

Part 2 Resources and Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

Resource 1 Examples of IPC tools/communication materials . . . . . 60

1.1 Q & A for Health Promoters: A Briefing Guide from Sudan . . . 60

1.2 Leaflet on Oral Cholera Vaccine from Orissa, India . . . . . . . . . . .

64

1.3 Poster on OCV from Mass Vaccination Campaign in
Orissa, India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65

1

1.4 OCV and Cholera Prevention Leaflet from Haiti (French) . . . .

66

1.5 Key Messages on OCV and Cholera Prevention
from Guinea (French) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

Tool 1 Sample template for behaviour analysis of participant
groups in OCV introduction and cholera prevention . . . . . . . . .

68

Tool 2 Sample template for a communication action plan for an
OCV mass vaccination campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

72

Tool 3 Monitoring checklist for OCV communication strategy
implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

73

Tool 4 Planning the OCV communication campaign . . . . . . . . . . . . . . . . . . .

76

Tool 5 Organizing refresher training on IPC for health
care workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

77

REFERENCES AND ADDITIONAL RESOURCES . . . .

78

LIST OF FIGURES AND TABLES

Figure 1 Key steps in communication planning for OCV uptake . . . . . . .

11

Figure 2 The socio-ecological theory . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

Figure 3 Application of the socio-ecological model in
communication programmes . . . . . . . . . . . . . . . . . . . . . . . . . .

24

Table 1 Behaviour and participant analysis: Looking into
barriers and motivators to adoption of OCV and
cholera prevention practices . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

Table 2 Key behaviour objectives toward OCV uptake . . . . . . . . . . . . . .

19

Table 3 Checklist of activities for media engagement . . . . . . . . . . . . . . .

33

Table 4 Key messages for different stakeholders . . . . . . . . . . . . . . . . .

36

Table 5 Illustrative behaviour monitoring and evaluation indicators for
adoption of OCV and cholera prevention practices . . . . . . . . . . .

55

2

ACRONYMS

BCC Behaviour Change Communication

CBO Community Based Organization

CDC Centers for Disease Control and Prevention

C4D Communication for Development

CFSC Communication for Social Change

CSO Civil Society Organization

FAQ Frequently Asked Questions

FGD Focus Group Discussion

GSM grams per square meter (measure of paper thickness)

HH Household Head

HW Health Worker

IPC Interpersonal Communication

IFRC International Federation of Red Cross and
Red Crescent Societies

IRC International Rescue Committee

ITN Insecticide Treated Bednet

KAP Knowledge, Attitudes and Practices

KII Key Informant Interview

LLIN Long Lasting Insecticide Treated Bednet

M&E Monitoring and Evaluation

NGO Non-Governmental Organization

NYHQ New York Headquarters

3

OCV Oral Cholera Vaccine

ORS Oral Rehydration Salts

PRCA Participatory Rural/Urban Communication Appraisal

PAR Participatory Action Research

PLA Participatory Learning in Action

PSA Public Service Announcement

Q&A Question and Answer

ROSA Regional Office for South Asia

SEM Socio-Ecological Model

SMART Specific, Measurable, Attainable, Relevant
and Time-bound

SMS Short Message Service

STD Sexually Transmitted Disease

UNICEF United Nations Children’s Fund

WASH Water, Sanitation and Hygiene

WHO World Health Organization

4

ACKNOWLEDGEMENTS
This document is a product of ongoing collaboration
among UNICEF, Johns Hopkins University (JHU),
International Rescue Committee (IRC) and
International Medical Corps (IMC) to develop
communication guidance and tools on oral cholera
vaccine (OCV) for governments, implementing
agencies, communities and media.

This document was prepared by Teresa Stuart with
guidance and support from the Communication
for Development team at UNICEF headquarters.
Drafts of the document were reviewed by staff from
UNICEF country, regional and headquarters offices,
the Centers for Disease Control and Prevention,
the International Federation of Red Cross and Red
Crescent Societies, the International Medical Corps
and the International Rescue Committee.

NOTE

This document is designed for use in the field. While this
version is complete, it has not yet been field tested and is
therefore considered interim. Suggestions for improvements
from teams using this guide in the field will be integrated into
a final version.

Comments should be sent to: choleratoolkit@unicef.org

5

Background

Cholera is an intestinal infection caused by the ingestion of the
bacterium Vibrio cholerae (toxigenic strains of serogroup O1 and
O

13

9). It spreads through contaminated water or food. Outbreaks are
linked to crowded living conditions, inadequate or unprotected water
supply, poor sanitation and hygiene, conditions that are rampant in
many developing countries. The risk of cholera outbreaks intensifies
during crises where essential services may be destroyed or
disrupted, e.g., in the aftermath of an earthquake, and transmission
exacerbated displacement, crowding and weather related spread
due to floods or storms. Measures for preventing cholera are based
mainly on provision of clean water, proper sanitation and education
on proper water, sanitation and hygiene practices. But once an
outbreak occurs, timely and sustainable control, treatment and
management measures to mitigate further spread of the disease
become a challenge among all partners, involving different sectors.1

1 WHO (2010). Oral Cholera Vaccines in Mass Communication Campaigns:
Guidance for planning and use. Geneva, Switzerland, p. 3

INTRODUCTION

6

Oral Cholera Vaccine (OCV) presents an additional approach for
cholera prevention and control to supplement but not to replace
existing priority cholera control measures.2 Two OCVs are currently
prequalified by WHO: Dukoral® and Shanchol™. As Shanchol™ is
less expensive, is easier to use in the field and provides longer
protection it is more commonly used in emergency setting than
Dukoral® and this document will focus on Shanchol™. While the main
communication strategies are the same for Shanchol™ and Dukoral®

some technical details differ. If Dukoral® is to be used in the OCV
campaign in your area, please contact your headquarters technical
specialist for further information.

Shanchol™ has a two-dose regimen with a minimum 2 weeks
between doses. It provides at least 5 years of protection for the
general population. It is currently licenced for use in the population
over 1 year of age.

This OCV Communication Framework aims to support cholera-prone
and outbreak countries to develop their national and sub-national
communication strategy for OCV uptake and cholera prevention,
control and management.

It is intended for use in both development and emergency contexts
as a pre-emptive/ preparedness measure in cholera endemic
countries as well as for immediate response (reactive) when an
outbreak occurs. Based on a risk assessment, an integrated approach
that includes OCV vaccination will target geographic areas and
communities that are particularly vulnerable, especially marginalized
populations, crowded and unhygienic settings, urban slums, refugee
and displaced sites, and communities that lack access to safe water,
sanitation and hygiene, and health services. In endemic contexts,
WHO recommends prioritizing young children eligible for vaccination
(over 1 year of age) because they have the greatest risk of dying,
followed by other at-risk groups, e.g., individuals with HIV, those with
moderate or severe malnutrition and older populations. However,
during epidemics all eligible age groups are targeted.

2 UNICEF (2012). Guidance Note on the Use of Oral Cholera Vaccines. New York,
USA, p. 1

7

http://www.childsurvival.net/?content=com_articles&artid=

15

46

This Framework is based on recommendations from the UNICEF
and WHO Communication Framework for New Vaccines and Child
Survival, the UNICEF Guidance Note on the use of Oral Cholera
Vaccines, the WHO Guidance for Planning OCV Mass Immunization
Campaigns, with addendum3 and the UNICEF Cholera Toolkit
particularly Chapter 7 on Communicating for Cholera Preparedness
and Response.

Intended users

This resource aims to strengthen national capacity to proactively
plan and implement a communication strategy to introduce oral
cholera vaccine as an additional approach to more effectively prevent
endemic cholera cases (pre-emptive) as well as to be prepared to
respond to (reactive) seasonal cholera outbreaks.

The intended users of this resource are:

• Programme managers of national immunization programmes

• Members of the national and sub-national communication
technical working group,

• National communication and immunization officers, managers
and consultants

• Partners implementing of communication, health, WASH,
nutrition and education

• Communication officers from UN and other international
development agencies

• Media partners

The Framework is designed to supplement traditional communication
tools and guidelines for cholera prevention and control available for
governments. This resource offers additional practical guides and
tools for effectively planning and managing communication activities
to integrate oral cholera vaccine in different settings.

3 WHO Addendum to OCV in mass immunization campaigns (2013): Addendum
Guide: Vaccination for Shanchol.

8

https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxjb

21

tZnJhbWV8Z3g6NTEyYTc1Njc1MjM3ZWFhYg

http://www.unicef.org/immunization/files/UNICEF_OCV_Guidance_20_July2012_final

http://whqlibdoc.who.int/publications/2010/97892

41

50

04

32

_eng

http://whqlibdoc.who.int/publications/2010/9789241500

43

2_eng

http://www.unicef.org/cholera/Cholera-Toolkit-2013

Goal and Objective of OCV Communication

The goal of OCV communication is to achieve broad and sustained
uptake among cholera-prone populations of oral cholera vaccine
as integral to other cholera preventive, treatment and
management actions.

The specific behaviour objective of OCV communication is to
increase the number of children, women and men from the most
at risk, vulnerable and hard to reach populations to complete
the required two doses of cholera vaccinations as an additional
preventive measure against cholera.

9

Part 1 features steps and guidelines that can help you
and your team to develop the communication strategy and
action plan.

Part 2 offers some tools and resources such as examples
of communication materials, how-to guides, suggested
templates and sample formats for planning.

The hyperlinks, footnotes and the reference list can also
help you, as the communication planner/manager, to
effectively advise and oversee specific communication tasks
in the strategy that are usually subcontracted to individual
consultants and institutional contractors.

Guidelines for an Integrated
Communication Strategy to
Introduce Oral Cholera Vaccine

PART

1
10

The communication planning process

In developing interventions, communication practitioners typically
follow a series of steps based on common elements from well-
established communication models and planning frameworks. This
is summarized in the following steps as illustrated in Figure 1. This
may be used as basis for an outline of a communication strategy
document. Ideally, the initial analytical steps should be undertaken
prior to an emergency as they can be time consuming.

The key steps in communication planningFIGURE 1

Establishing Communication Coordination
Mechanisms, Partnerships, Task Forces

Evaluation Assessing
achievement of C4D
outcomes that contribute
to programme goals

C4D Research & Ana-
lysis Study of socio –
behavioural determinants;
barriers,/enablers related
to political, economic, and
cultural context; Participant
and Channel analyses

C4D Strategy Setting
SMART communication
objectives; Participant
segmentation, Appropriate
mix of messages and
channels; Formulating M
& E indicators

Implementation &
Monitoring Mobilisation
of communities, networks
& media; message &
materials dissemination;,
Training of community
based workers; Assessing
progress in achieving C4D
outputs and outcomes

Creative Strategy & Materials Development Participatory
development and piloting of creative approaches; Pre-testing
of communication messages and materials; Production

11

STEP 1: Establish a communication team
and coordination mechanism
The success of communication efforts for cholera prevention and
OCV introduction depends on the effective coordination of a working
group responsible for its assessment, planning, implementation
and monitoring. Before initiating any assessment (or research)
and planning steps, map and assess communication partners and
allies including media organizations. Based on set criteria, it is also
suggested to have in place a Communication Sub-committee for
Cholera at the national level working as part of the National Cholera
Coordinating Committee, or the Immunization Coordinating Group
(ICG), or National Immunization Technical Advisory Group (NITAG),
whichever exists in a country.

The Ministry of Health and the ministry responsible for WASH usually
have equal representation in the National Cholera Coordinating
Committee. Whichever agency serves as national coordinator for
public health related programmes usually appoints the head of its
health education, hygiene promotion and communication division as
members of the inter-agency cholera communication sub-committee.
Member agencies also appoint the person responsible for health
education and communication to the sub-committee.

12

At the provincial or district level, establish communication teams
that will plan, manage, implement, monitor and report on the
communication intervention.

For each mechanism, there should be a clear understanding of
terms of reference, roles and responsibilities. To integrate OCV into
cholera communication, the National Cholera Communication Sub-
Committee and the Provincial/District Cholera Communication Teams
should be:

1. Functional and active

2. Able to coordinate and work quickly to assess and advise on
communication needs of intended audiences

3. Familiar with the communication plan and its implementation

4. Prepared with key messages in the form of ready-to-go press
statements, FAQs, Q&As and fact sheets for media and
spokespersons and IPC tools for health workers and community
groups

5. Able to engage, orient and mobilize spokespersons and
champions, media partners, other partners and allies.

Member agencies of the national level communication sub-
committee and the communication teams at each administrative level
should be strategically selected based on their institutional capacity
to undertake and manage advocacy, social mobilization, community
engagement, media relations and resource mobilization. Individual
members should possess technical knowledge and management
skills in the communication strategy development process –
assessment, strategy formulation for advocacy, social mobilization
and community engagement, media relations, and monitoring and
evaluation – and with experience in applying these competencies in
the health, immunization and WASH sectors.

13

STEP 2: Conduct a rapid communication
assessment
Before you start planning, conduct a cholera situation assessment.
In many settings the team will conduct this assessment, in some
settings it may be possible to hire a research agency to do the
assessment. The objectives of an assessment should include
gathering and analysis of secondary and primary data to describe
the scope and status of the cholera problem: who are affected,
where they are located, the programmes and resources that are/
or should be in place to prevent and control cholera among affected
communities, including political will to use OCV.

Continue the assessment by determining the potentially problematic
behaviour/s to address. Describe the participant or audience groups,
their existing behaviours and practices, the channels that are
available, accessible and preferred by each audience or participant
group. Try to identify how these might change during an emergency.

What are the social, cultural and other determinants to sustained
adoption of OCV and other cholera preventive and control measures?
List the barriers and motivators to desired behaviours that will need
to be addressed by the communication intervention.

• Who are the primary audience groups or those directly affected?
Who are the secondary audience groups whose actions can
support the primary group to adopt desired actions? Who are
the tertiary audience groups who need to be addressed through
advocacy?

• What are people doing or not doing that lead to the problem or
make them prone to cholera?

• Who suffers most from the problem?

14

Follow this with a channel assessment:

• What channels and media are available and preferred by different
participant groups? In which format – print, radio, TV, internet,
mobile phones, interpersonal, group?

• Which mix of channels is best suited to participant groups’
engagement in the cholera programme that could best lead
to adoption of OCV? Of other cholera preventive and control
practices?

• What key messages are preferred and culturally appropriate for
which mix of channels? In which languages?

• What kinds of communication skills among health care providers,
vaccinators and community groups need strengthening?
In which areas?

• Determine the institutional capacity and capacity gaps in
undertaking communication activities and media relations – of
your team, government implementers, and NGO/CSO/CBO
partners, including members of the coordinating group.

15

Table 1 Sample behaviour and participant analysis:
Identifying barriers and motivators to adoption of
OCV and cholera prevention and control practices

Audience/
Participant Group Motivating Factors

Behaviour Barriers
(Can be addressed by communication)

Non-Behaviour Barriers
(Can be addressed by programme)

1

Primary – Individual and family
level: Heads of households,
Mothers, Fathers and Guardians
(includes grandparents,
mothers-in-law, children,
adolescents and youth, and
extended family members.

• Desire to maintain good health,
freedom from cholera and other
diseases

• Resistance to vaccination

• Poor knowledge of vaccines and
their benefits

• Negative attitude toward health
worker

• Negative past experience with
health workers or vaccinators

• Lost time and income from
economic activities

• Long distance to vaccination site

• Costs in travel time and expenses

• Other competing priorities

2

Secondary – Community level:
Community leaders, Health
workers, vaccinators, NGOs,
CSOs and other community-
based groups, religious
leaders/groups

• Community pride in being free
from the disease

• Playing a role in saving lives

• Low capacity to facilitate social
mobilization

• Careless attitude towards clients

• Low self-esteem

• Poor interpersonal communication
and counselling skills

• Lack of leadership / initiative

• Weak supervision and monitoring
structures

• Lack of resources

3

Tertiary, subnational
Provincial/district government
leaders, local health authorities,
health professionals, clinicians,
academics, business leaders,
local media

• Political pride in disease-free
status

• Key role in agenda-setting and
resource mobilization

• Lack of political commitment

• Not clear about the issues

• Competing programmes for
limited resources;

• Desire for political image
building/ conflict of interest

4

Tertiary, national – Public
policy/societal: Policy makers,
parliamentarians, government
officials, national media

• Key role in policy making,
resource allocation

• Key role of media in public
awareness about disease
prevention

• Lack of political commitment
to allocate funds for OCV and
promote integrated cholera

programme

• Not clear about issues and data

• Lack of country-level data

16

Table 1 Sample behaviour and participant analysis:
Identifying barriers and motivators to adoption of
OCV and cholera prevention and control practices
Audience/
Participant Group Motivating Factors
Behaviour Barriers
(Can be addressed by communication)
Non-Behaviour Barriers
(Can be addressed by programme)
1
Primary – Individual and family
level: Heads of households,
Mothers, Fathers and Guardians
(includes grandparents,
mothers-in-law, children,
adolescents and youth, and
extended family members.
• Desire to maintain good health,
freedom from cholera and other
diseases
• Resistance to vaccination
• Poor knowledge of vaccines and
their benefits
• Negative attitude toward health
worker
• Negative past experience with
health workers or vaccinators
• Lost time and income from
economic activities
• Long distance to vaccination site
• Costs in travel time and expenses
• Other competing priorities
2
Secondary – Community level:
Community leaders, Health
workers, vaccinators, NGOs,
CSOs and other community-
based groups, religious
leaders/groups
• Community pride in being free
from the disease
• Playing a role in saving lives
• Low capacity to facilitate social
mobilization
• Careless attitude towards clients
• Low self-esteem
• Poor interpersonal communication
and counselling skills
• Lack of leadership / initiative
• Weak supervision and monitoring
structures
• Lack of resources
3
Tertiary, subnational
Provincial/district government
leaders, local health authorities,
health professionals, clinicians,
academics, business leaders,
local media
• Political pride in disease-free
status
• Key role in agenda-setting and
resource mobilization
• Lack of political commitment
• Not clear about the issues
• Competing programmes for
limited resources;
• Desire for political image
building/ conflict of interest
4
Tertiary, national – Public
policy/societal: Policy makers,
parliamentarians, government
officials, national media
• Key role in policy making,
resource allocation
• Key role of media in public
awareness about disease
prevention
• Lack of political commitment
to allocate funds for OCV and
promote integrated cholera
programme
• Not clear about issues and data
• Lack of country-level data

17

Participant groups and key behaviour
objectives/results

Based on your rapid assessment of determinants (barriers and
motivators) to behaviour change, plot the communication objectives
stated in terms of desired actions or behaviour results. The
following table (Table 2) shows the desired actions by different
levels of participant groups that may result from the interplay of
communication approaches, a supportive environment from the
community and health delivery system, and an enabling environment
from the government, civil society and the media.

What we ultimately seek or the goal of our communication strategy
in the national cholera prevention and control programme is to
prevent the transmission of cholera through appropriate hygiene
practices and the creation demand and maximize uptake of OCV
among families and communities.

18

Table 2 Key behaviour objectives to create/increase
demand/uptake of OCV

Participant Group A. Mothers and Fathers, Guardians, Grandparents,
Mothers-in-law, Siblings, Extended Family members

Desired Behaviour Results/ Expected Actions
• Heads of household or parents bring family members for cholera vaccination

including children aged one year and older to vaccination site at scheduled times.

• Complete two doses.

• Bring cholera immunization card (if appropriate)

• Allocate money for transportation expenses.

• Convey importance of OCV immunization and to continue practising good
hygiene and sanitation and drinking safe water to all members of the family.

• Understand that cholera causes severe diarrhoea and dehydration and that it
can quickly cause death if not treated early.

• Cholera can transmit rapidly through the fecal-oral route.

• Understand the main methods of transmission in a community to know how
to prevent it from spreading.

• Properly treat themselves and family members suffering from diarrhoea with
ORS and other safe liquids; bring to a health center as soon as possible once
symptoms begin.

• Communities know about the vaccines, that it is safe and effective but not
fully protective against cholera and other diarrheal diseases;

• Continue with other prevention and treatment practices.

Participant Group B. Frontline Health Workers
Desired Behaviour Results/ Expected Actions
• Demonstrate good interpersonal communication and social mobilization

skills and t o deliver OCV immunization tasks as per OCV immunization
policy and guidelines.

• Treat all persons/clients coming for OCV immunization with respect and
professionally; answer their questions and address their concerns and show
active interest in their opinions.

• Provide clients information regarding the cholera vaccine, the disease it protects
against, the necessity of a second dose and when it is is due, any possible side
effects and reasons it is important for the person to be vaccinated.

• Provide information on hygiene, use of safe water and food and sanitation
and how to treat cholera with ORS

• Consider the views and needs of the communities in planning OCV
vaccination schedule and venue, times and other aspects of the programme
as conveniently as possible for the client.

19

Participant Group C. Religious leaders, CSOs, local NGOs, Local
government authorities, business sector, school officials,
Youth Groups, School Children, Community groups

Desired Behaviour Results/ Expected Actions
• Help at-risk communities understand cholera; know how to treat and

prevent; explain added prevention value of OCV.

• Motivate cholera-prone communities to adopt OCV as an added measure
against cholera.

• Provide information on OCV and where and when to get it if available.

• Discuss in gatherings the importance of OCV as added prevention measure
but hygiene, safe water and sanitation and treatment when ill still important

Participant Group D.

Media

Desired Behaviour Results/ Expected Actions
• Become familiar with OCV and its role in providing additional protection

against cholera. Crosscheck facts before putting out publications.

• Provide clear and accurate facts about OCV to the public as part of a
comprehensive approach to cholera control.

• Handle allegations and rumours regarding any adverse events following OCV
immunization or other issues may serve as disincentive to parents and guardians.

• Contact relevant health officials for their advice and guidance immediately
after any allegation is made and preferably before the allegation is publicized.

• Where allegations are made in live programmes, insist on having a
spokesperson or a health official to meet with the person making the
allegation for an immediate credible response.

Table 2 Key behaviour objectives to create/increase
demand/uptake of OCV (cont’d)

20

Participant Group E. Programme Managers (MOH)

Desired Behaviour Results/ Expected Actions
• Support orientation workshops for health workers, vaccinators and

implementing partners so they can explain: that:

− OCV is safe, effective, feasible and acceptable to communities that
have received them so far

− They can integrate OCV into cholera prevention and control activities

− There are limitations in implementing traditional interventions in some
settings, and

− OCV helps mitigate disease transmission.

• Strengthen capacity and skills of agencies and institutions responsible for
cholera prevention and control with OCV immunization

• In endemic countries:

− Add OCV to the national cholera strategy

− Provide the technical guidance and tools to do it

− Access OCV through the global stockpile when appropriate (outbreaks,
humanitarian emergencies and areas of seasonal peaks)

− Get the necessary resources, OCV, vaccine supplies, funding, trained
human resources..

− Implement OCV with other cholera interventions

− Monitor and evaluate OCV use

• In countries with cholera outbreaks and in complex emergencies:

− Information about OCV should be shared and OCV included in national
cholera contingency plans

− Rapidly integrate OCV into a response strategy.

− Access OCV through the global stockpile.

− Ensure that if OCV is used, that it is integrated with traditional control
measures.

− Frame persuasive and balanced messages to ensure sustainability and
acceptance of OCV by the population.

− Help communities understand cholera, how to prevent and treat it
including using OCV.

− Motivate cholera-prone communities to adopt OCV as an added
measure against cholera.

− Support frontline health workers with interpersonal communication
skills training and equip them with appropriate IPC tools like flipcharts,
leaflets, and audio-visuals.

21

Participant Group F. Policy Makers

Desired Behaviour Results/ Expected Actions
• Issue a policy that integrates oral cholera vaccination in the national cholera

programme

• Give political commitment and manifest political will through public
pronouncements and participation in OCV and cholera prevention and
control programme activities.

• Understand the limitations of implementing traditional interventions in some
settings and how OCV may help mitigate disease transmission.

• Include OCV immunization for at risk populations in financing comprehensive
cholera prevention plans for water, sanitation and hygiene improvements.

• Include in public statements the importance of OCV as an additional
approach to cholera prevention.

Step 3: Plan your communication strategy
Communication for Development (C4D) plays a central role in the
successful introduction of oral cholera vaccine as an additional tool
in cholera prevention and control, both in endemic and epidemic
settings. C4D is a research-driven systematic process that operates
through four interrelated, interdependent and interacting approaches
with respective audiences or participant groups:

• advocacy,

• social mobilization

• communication for social change

• behaviour change communication

Table 2 Key behaviour objectives to create/increase
demand/uptake of OCV (cont’d)

22

Theoretical framework

C4D is one of the many applications of an overarching Socio-Ecological
Theory of Human Development4 (see Figure 1). The theory posits that
in order to understand individual behaviour development and social
transformation, the entire ecological system – the interconnected
influences of an individual’s social environment: family, peers,
community, institutions and society need to be taken into account. This
theory clearly has direct and practical implications for communication
planning and programming for it underpins the logic of behaviour and
social change decisions and communication strategy development
based on levels of influence (Figure 1).

4 Bronfenbrenner, U. (2005). Making human beings human: Bioecological
perspectives on human development. Thousand Oaks, CA: Sage Publications.

Model of Socio-ecological Theory of Human Development

Public Policy

Community
(cultural values, norms)

Organizational
(environment, ethos)

Interpersonal
(social network)

Individual
(knowledge,

attitude, skills)

FIGURE 2

23

Levels or orbits of influence include intrapersonal (individual’s present
knowledge, attitudes, values, skills, self-esteem, demographics),
interpersonal (families and kinship network, social networks,
social supports, friends, neighbors), organizational (workplace
norms, incentives, organizational culture, management styles,
communication networks), community (social norms, resources,
informal and formal leadership norms, communication patterns),
and policy level (legislation, policies, laws, governance,
resource allocation).

The Strategic C4D Socio-Ecological ModelFIGURE 3

ADVOCACY
(Policies, Legislation & Resource

Mobilisation)

SOCIAL MOBILISATION

Media

CBOs/
NGOs/
FBOs

Partners – partnership
building & capacity building

Policy makers & Planners

Organized
networks

Service
delivery

Civil
Society

National
Political
leaders

C4D
across all

areas

C4D
across all
areas

BEHAVIOUR CHANGE
& SOCIAL CHANGE

The community: Children,
women, young people,

farmers, caregivers,
households, families

Donors,
Private
Sector

24

Planning Strategic Communication: applying the
socio-ecological model (SEM)

The C4D socio-ecological model or SEM (Figure 2) looks at behaviour
and social change as a function of a person’s multiple levels or orbits
of influence from his or her social environment. Every individual is
part of other larger units: a family, a neighbourhood, a community,
a religion, the workplace, and the larger society. Each of these
units directly or indirectly influences how people behave. Based
on evidence from formative research, C4D uses a mix of multi-level
interventions that can be most effective as in the case of health
promotion, e.g., OCV introduction for cholera prevention and control.

The inner circle represents the core or primary participant group – the
children and adolescents, their parents and guardians, their families
and communities. Communication addressing this level seeks to
bring about positive individual behaviour change and social change
with collective groups at community and societal level

The middle circle represents the group of key influencers, the
secondary participant group (duty bearers) who can provide a
supportive environment and engage those in the inner circle toward
the desired change through social mobilization.

The outer circle represents the participant audiences for policy and
structural change and resource allocation – leaders and decision
makers who have the power to effect such change. To effect long
term change and for impact and sustainability of development
programmes and service delivery, policies, political will and resources
need to be mobilized through advocacy with leaders and decision-
makers who have the power to create policies, programmes and
structures and to allocate resources.

As illustrated in Figure 2, the four key communication approaches
are behaviour change communication, communication for social
change, social mobilization and advocacy. Media engagement
comes as a fifth approach. The pervasive nature of the mass
media makes it a fifth approach that cuts across the first four
communication approaches. When planning strategic communication,
develop a media plan to engage media organizations, media
managers, editors and journalists.

The Strategic C4D Socio-Ecological Model

25

Key communication approaches

1. Behaviour change communication (BCC)5 is the process
of applying participatory communication techniques and tools
to inform, influence, inspire & involve individuals and families in
adopting new attitudes and practices or in sustaining existing
recommended behaviours that lead toward improving and sustaining
their well-being. BCC focuses on the individual as the unit of change.

2. Communication for social change (CFSC) focuses
on groups or collectives as the unit of change. CFSC seeks to
collectively engage & empower families, communities and social
networks to positively influence and/or reinforce social norms and
practices of the community and the larger society.

BCC and CFSC approaches, as well as social mobilization and
advocacy, apply a mix of three types of interventions:

• Interpersonal communication (client-provider interaction, family/
community dialogue, group activities reinforced by the use of IPC
tools and materials)

• Community mobilization (community meetings, annual
commemorations and events, skills enhancement trainings,
encouraging participation, e.g., in media programming and
monitoring quality and uptake of services, etc.),

• Mass media (print, radio, television, Internet)

3. Social mobilization is the process of engaging a wide
network of partners, stakeholders and allies around a common
cause. It provides a supportive environment for individuals and
families to change or reinforce desired practices. Social mobilization
partners include communities (community mobilization); civil society
organizations, organized networks and associations, the media,
religious groups and individuals who can influence change.

5 See also definitions of C4D strategies in: C4D Basics (2011). UNICEF C4D
Webinar Series for Programme and Communication Specialists, p. 13-15;
UNICEF ROSA (2006). Behaviour Change Communication in Emergencies: A
Toolkit, p.

40

and UNICEF Cholera Toolkit (2013), Chapter 7, Annex 7A.

26

Social mobilization at all levels is primarily based on effective
interpersonal communication among participants. It is the tried and
tested approach to mobilize partners, allies and communities to
influence others to learn and know about, understand, and adopt
preventive behaviours against cholera including vaccination. The
social/community mobilizer as facilitator of the process becomes
more effective when the interaction with community members is
supported by well planned, engaging and stimulating communication/
IPC resources and IPC tools.

Develop the action plan for social mobilization at provincial level and
community mobilization plan at community level using the suggested
steps below.

Steps in planning for social mobilization6

1. Develop a Social/Community Mobilization Action Plan as a
major part of the Provincial/State and District Communication
Action Plan.

2. Identify mobilizers (community volunteers, youth groups,
theatre groups). The mobilizer must be aware of and sensitive to
community values, social norms and practices and understand
the barriers to the recommended behaviours. The mobilizer will
need to train community groups in participatory techniques.

3. Orient/train mobilizers especially on IPC skills, facilitating
group meeting, delivering key messages and using lively,
interactive methods.

4. Be creative and work locally in developing and using
communication materials, IPC tools and media products:–
FAQs, leaflets, brochures; audio-visuals – posters, video
documentaries, PSAs; and group media such as local story
telling, role playing and songs, etc.

6 Adapted from: The Intensification of Routine Immunization in India: Strategic
Communication Guideline (2012). Prepared by Bhawani Shankar Tripathy,
Communication Consultant for UNICEF India and Ministry of Health and
Family Welfare, Government of India (Immunization Division).

27

5. Enlist champions and role models: Set your criteria for role
models and invite their testimonials, i.e., from those who have
been OCV vaccinated and who practice recommended cholera
preventive behaviours. Use positive deviance as message
appeals for known OCV or general immunization resistors.

6. Ensure that cholera vaccination sessions use plenty of visual
aids, other communication resources and effective IPC tools to
remind and encourage people to return for the second dose and
to reinforce other cholera preventive behaviours.

7. Put in place mechanisms to get daily feedback on social
mobilization activities, focusing on challenges. Make immediate
adjustments based on feedback.

8. Ensure that visits to vaccination sites for OCV immunization
sessions are positive and memorable. Health workers and
vaccinators should see to it that community members
receiving OCV return as satisfied and happy as possible with
their experience. Any bad experience arising from vaccinators’
behavior can prevent revisits and a negative impression
about immunization.

9. Conduct IPC skills training with proper use of IPC tools for
vaccinators. Supervise practice of these skills.

10. Plan OCV vaccination sessions according to the convenience
of the community and with their support and participation
in decision-making. The objective should be to create a
comfortable, reassuring and enabling environment where OCV
immunization is welcomed.

11. Develop communication materials and IPC tools to support
social/community mobilization.

28

Some social mobilization strategies that can
influence family demand for OCV and uptake of
cholera prevention behaviours:

Mobilization through community influencers
Identify and approach prominent people from the area – community
leaders, religious leaders, and opinion leaders, other charismatic and
highly regarded members of the community. Engage and educate
them on the risks and benefits of OCV immunization along with
other key messages. Motivate them to help in reaching out to the
community. Support them with communication tools to enable them
to organize meetings in comfortable venues.

Mobilization by involving community groups
Community leaders, schools, places of worship, mothers’ clubs,
children’s clubs, youth groups and other community groups are
critical to get communities involved. They can help increase demand
for OCV immunization and practice of cholera preventive behaviours
particularly in high-risk areas. Support community dialogues and
meetings led by these groups and influentials. Define and roll out
a local a media strategy that gives community members voice and
visibility. For example, community radio programmes, radio dramas,
theatre troupes, banners, local media outreach. Engage national and
local celebrities and local “heroes” and role models.

Mobilization through NGOs/CBOs/networks
Identify and list out all potential NGOs and CBOs like women
groups, school clubs, children’s clubs, youth groups, and self-help
groups. Prepare interactive presentation and group dynamics tools
for training and orientations. Conduct a training needs assessment,
focusing especially on basic knowledge, IPC skills, understanding and
interpretation of key messages on OCV and cholera prevention tools.
Develop training agenda, session plans and materials, or customize
existing modules with involvement of partners. Organize training,
and document. Monitor community mobilization efforts through
community volunteers and using monitoring formats.

29

Mobilization through frontline health workers
Hold meetings with health workers/vaccinators/community
mobilisers to share their knowledge, views and work experience.
Create opportunities for different levels of health workers. Offer
training in IPC and counseling skills at mutually convenient times.
Remember to take care of logistics; offer small incentives and
rewards for good performance. Ensure that health workers/
vaccinators/community mobilizers are equipped in advance with
the necessary resources – IPC tools and techniques, , presentation
equipment, etc.

4. Advocacy is communication that is addressed to leaders and the
powers that be – to political, economic and social decision-makers
at national and local levels. An advocacy strategy should inform and
motivate appropriate leaders to take actions supportive of cholera
programme objectives.

The results of advocacy – a legislative framework, policies, resources
and structures – provide the enabling environment for behaviour and
social change.

For the cholera programme, advocacy aims to provide an
enabling environment for the following results:

• Commitment and political will for cholera prevention
and control programme

• National policy on an integrated cholera prevention
and control programme

• Administrative directives and public pronouncements

• Allocation of resources

• Cholera programme with OCV as a high national priority to
prepare for and respond to cholera outbreaks

Participant groups and behaviour objectives of OCV advocacy.
Based on data from your communication assessment of the cholera
situation – the political, social and communication environment in your
country – you can identify groups with whom, you should address
your advocacy. The same data would also help guide why these are
key groups and when they should be approached. See Table 1 for

30

specific behaviour objectives for OCV advocacy addressed to policy
makers and programme managers.

5. Media engagement. National and local media – print, radio,
television, the Internet and telecommunications are valuable allies
in your communication strategy. Nurture partnerships with media
executives, managers, journalists and reporters including from local
radio and TV, cable TV stations and local newspapers, social media
sites and mobile phone companies. Establish internal capacity to
manage media relations7 particularly your ability to:

• Prepare and execute a media plan;

• Organize and conduct media briefings and media conferences;

• Produce and distribute timely press statements, press releases
and other media materials;

• Coordinate responses to media enquiries and respond promptly;

• Support spokespersons with accurate messages and materials.

The Media Plan. Prepare a good media plan at national and
subnational level. Keep in mind that local media are closer to the
ground in involving community perspectives and voices – community
radio, local newspapers, cable television stations, mobile phone
companies and social networking platforms.

The media plan should include the following:

• A database of journalists: Keep a regularly updated list of print,
broadcast and online journalists and other media practitioners
covering health (local, national, international) with contact
information. Always use a computer-based database that allows
immediate updating.

7 For more on media relations, refer to: Hyer, R N and V T Covello (2005).
Effective Communication during public health emergencies: WHO Media
Handbook. Geneva, Switzerland.

31

• Media kit: Keep media informed of the cholera programme and
OCV campaign through email or hardcopy by sending regular
updates on any plans, programmes, decisions, etc. Sensitize
media about health aspects like benefits of OCV immunization
and its impact nationally and globally on cholera prevention and
control. A media kit may contain the following documents with
clear and concise key messages in both hard and soft copy
(stored in computer or on a CD):

− Frequently Asked Questions (FAQs) on OCV immunization
and traditional cholera prevention and control methods

− Fact Sheet or a Technical Brief on OCV with other cholera
prevention tools;

− Recent updates – progress made in country, specific
outbreak or at risk areas – and a few case studies;

− Graphs and charts;

− Photographs and illustrations;

− Contact addresses of spokespersons and or relevant
experts that media can contact. Remember to check and
permanently remove all old and outdated material from the
information package.

• Media release: The media release must specifically answer the
5 W’s and H: who, what, when, where, why, and how.

32

Table 3 Suggested checklist of activities for
media engagement

The Communication Sub-Committee, working with the National Cholera
Coordinating Committee shall perform the following actions:

1. Establish partnership with media organizations. Nurture sound professional
relationships with their managers, editors and reporters.

2. Prepare a database with latest contact numbers, email addresses, websites and
social media accounts (Skype, Face Time, Facebook, Twitter, LinkedIn, etc.) of:

2.1. National, state and district media executives and staff covering health issues,

2.2. Editors of major newspapers, television and radio channels

2.3. Local cable operators at district level

2.4. Telecommunications executives

2.5. Print and broadcast journalists

3. Identify, appoint and train spokespersons at national, state and district levels.

3.1. Ensure that spokespersons possess the requisite media skills, are
respected and authoritative about immunization and vaccines.

3.2. Organize media skills training for spokespersons as necessary.

3.3. Prepare key message sheets and sample scripts on OCV and cholera
prevention for spokespersons

4. Prepare a list of relevant health, WASH and immunization experts at state and
district level, with their contacts and mailing address as per the hierarchy and
share this list with key communication staff at corresponding level.

5. Keep media informed periodically about progress on the cholera situation
and OCV immunization by sharing data, progress on the OCV vaccination
campaigns, events, and key policy decisions made.

6. Prepare a standard press release format, using the cholera/OCV immunization
brand or logo (if agreed and developed) along with the state logo on official
letterhead for effective branding.

7. Provide latest data on cholera disease burden of state/district/block. Also
provide national and global data.

8. Organize media collaboration meetings with state-level; district
level journalists.

9. Seek the help of development partners, media and communication agencies
to hold media orientation seminars on OCV and other cholera prevention and
control efforts, updates, latest data, challenges, successes.

10. Produce and update a standard media kit with key messages given in the form
of frequently asked questions (FAQ) or Q&As, progress reports, case studies
with action photos, graphs and illustrations on OCV and cholera prevention and
control measures.

11. Keep media regularly informed of all cholera/OCV- related developments
through email, the Ministry website and other commonly used Internet and
social media platforms.

33

Step 4: Design the creative strategy: key
messages, channels and tools
Effective communication entails tailoring your messages according
to the level of your audience/ participant group. To create acceptance
and demand for OCV, clearly explain the benefits as well as the
potential risks and side-effects of vaccination.

Designing the creative strategy involves collaboration with
representatives of participant groups, designers and media
developers, researchers, printers and producers in developing and
pre-testing messages, communication tools and creative materials
prior to production and dissemination. Determine the appropriate
mix of channels and the kinds of communication materials/tools that
will be used to support participatory approaches. This also involves
developing the appropriate mix of interpersonal approaches and
IPC tools, use of group or mid-media, mass media and social media
based on information from the communication assessment.

The creative strategy includes the following actions:

• Formulating key messages on OCV and cholera prevention for
different stakeholders/participant groups (Table 4);

• Preparing Interpersonal communication tools for health workers,
vaccinators and community leaders to support IPC with families
and community dialogues to explain the benefits of OCV
immunization and any side effects; and other approaches to
cholera prevention and control;

• Pretesting, production and use of IPC tools and media materials
(e.g., Q&As, FAQs, flipcharts, flash cards, brochures, leaflets,
posters, audio and video formats, logo designs, graphics and
illustrations) to support IPC, social/community mobilization and
media engagement;

• Organizing community dialogues and meetings involving parents,
guardians, schoolchildren, youth groups, religious communities,
CBOs, CSOs, etc.;

• Engaging mass media (culturally appropriate and preferred
print, radio, TV formats) to reinforce and support interpersonal
communication, community engagement, social mobilization
and advocacy

34

• Using social media and social networking with digital
technologies and platforms

• Managing any adverse events following immunization (AEFI) and
counteracting rumours and misperceptions about OCV.

Pre-testing key messages and materials for OCV and
cholera prevention

Pretesting aims to determine the reaction of a sample of
your audience to your communication prior to production and
dissemination. The aim is to identify any elements that need to be
improved to make your material more effective. Pretest to ensure
that your messages and materials have the five elements of
effectiveness:

1. Understandable – Is the message clearly explained and easy to
understand?

2. Attractive – Is the message attractive enough to hold attention
and be remembered?

3. Acceptable – Does the message contain anything that is
culturally offensive, annoying or false?

4. Involving – Does the audience feel that the message/material
speaks to them and is about them?

5. Persuasive – Does the message convince the audience to take
the recommended action?

35

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures

1. Government Policy Makers and Donors (Advocacy)
QUESTIONS KEY MESSAGES

What is Oral
Cholera Vaccine?

•• It is a vaccine that can protect persons from getting
sick from cholera.

•• The cholera vaccine is given by mouth, two doses are
required.

•• Shanchol™ was prequalified by WHO in 2011.

Why use oral
cholera vaccine?

•• It can help to reduce the transmission of cholera.

•• It will help protect our communities from cholera.

Is it safe? •• It is safe and has very few (mostly minor) side effects.

Does it work? Is it
effective?

•• It offers good protection from cholera for up to 2/3 of
those vaccinated.

•• Shanchol™ is protective for at least 5 years. It is not
perfect and does not cover other causes of diarrhoea.
People still need to practice good hygiene, treat the
water, practice good sanitation and get treatment if
they are sick.

How is it used? •• Shanchol™ is given in 2 doses a minimum of 14 days
apart to adults and children older than 1 year.

•• Shanchol™ is distributed in individual glass vials
(1.5ml) with doses given directly to the individual from
the vial.

•• OCV is not a sole solution to stop cholera; it can be
used along with clean water, adequate sanitation and
good personal hygiene for prevention and early and
appropriate treatment to reduce illness and death as
part of a multi-sectoral integrated approach.

Has it been used
before?

•• It has been used in number of countries with good
results. Over 1 million doses of Shanchol™ have been
delivered in the past few years.

•• People that have received it so far have welcomed it in
their communities.

36

How can the OCVs
be accessed?
Where can they be
purchased?

•• The International Coordination Group has developed
an OCV stockpile for rapid use in epidemics and
emergencies. This stockpile can be accessed through
the International Coordination Group (ICG).

•• OCVs can also be purchased directly from the
manufacturer.

How much does it
cost?

•• Shanchol™ costs US $1.

85

per dose.

•• GAVI started to support the ICG Stockpile in 2014,
as a result, GAVI eligible countries will receive the
vaccine from the ICG Stockpile free of charge. Non-
GAVI eligible countries and non-government agencies
will have to reimburse the cost of the vaccine to the
ICG Stockpile.

What about
washing hands
and drinking clean
water?

•• People still need to practice good hygiene, treat the
water, practice good sanitation and get treatment if
they are sick.

Should we use the
money instead to
improve the water
and sanitation
systems?

Why should we
use it in our
country?

•• Long term infrastructure changes – building safe water
systems and sanitation facilities are indispensable for
cholera (and other waterborne) disease prevention
and control. These changes will have longer-term
impact on not just cholera, but also other food- and
waterborne disease prevention; however, these
changes take time and will require more resources
and cholera is a problem now.

•• OCVs can be used as a bridging tool for cholera
prevention and control while these longer-term
interventions are put into place. Ideally, there should
be a plan for OCV and longer-term interventions to
occur hand in hand. OCVs can be phased out as
infrastructure improves.

2. Mass Media (Media Engagement)

QUESTIONS THEMES
What is Oral
Cholera Vaccine?

•• It is a vaccine that can protect persons from getting
sick from cholera.
•• The cholera vaccine is given by mouth, two doses are
required.
•• Shanchol™ was prequalified by WHO in 2011.
Is it safe? •• It is safe and has very few (mostly minor) side effects.

37

Does it work? Is it
effective?

•• Shanchol™ is effective and offers good protection
from cholera, up to 2/3 of those vaccinated for at
least 5 years

•• It is not perfect and does not cover other causes of
diarrhoea. People still need to practice good hygiene
treat the water, practice good sanitation and get
treatment if they are sick.

How is it used? •• Shanchol™ is given in 2 doses a minimum of 14 days
apart to adults and children older than 1 year.
•• Shanchol™ is distributed in individual glass vials
(1.5ml) with doses given directly to the individual from
the vial.

•• OCV is not a sole solution to stop cholera; it can be
used along with clean water, adequate sanitation and
good personal hygiene for prevention and early and
appropriate treatment to reduce illness and death as
part of a multi-sectoral integrated approach. It is given
in 2 doses 14 days apart for adults and children older
than 1 year.

Why should we
use the vaccine in
our country?

•• It will help protect our communities from cholera.

•• OCV can help to reduce the transmission of cholera in
communities.

Has it been used
before?

•• More than 1 million doses of Shanchol™ have been
given over the past few years.

•• People that have received it so far have welcomed it in
their communities.

What about
washing hands
and drinking clean
water?

•• OCV is not a sole solution to stop cholera; it should be
used along with clean water, adequate sanitation and
good personal hygiene for prevention and early and
appropriate treatment to reduce illness and death.

•• All of these approaches need to be used together.

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)

38

How can the OCV
be accessed?
Where can they be
purchased?

•• The International Coordination Group has developed
an OCV stockpile for rapid use in epidemics and
emergencies. This stockpile can be accessed through
the International Coordination Group (ICG).

•• OCVs can also be purchased directly from the
manufacturer.

How much does
it cost?

•• Shanchol™ costs US $1.85 per dose.

•• GAVI started to support the ICG Stockpile in 2014,
as a result, GAVI eligible countries will receive the
vaccine from the ICG Stockpile free of charge. Non-
GAVI eligible countries and non-government agencies
will have to reimburse the cost of the vaccine to the
ICG Stockpile.

Should we use
the money to
improve the water
and sanitation
systems?

•• Long term infrastructure changes – building safe water
systems and sanitation facilities are indispensable for
cholera (and other waterborne) disease prevention and
control.

•• These changes will have longer-term impact on not
just cholera, but also other food- and waterborne
disease prevention

•• However, these changes take time and will require
more resources and cholera is a problem now.

•• OCVs can be used as a bridging tool for cholera
prevention and control while these longer-term
interventions are put into place. Ideally, there should
be a plan for OCV and longer-term interventions to
occur hand in hand. OCVs can be phased out as
infrastructure improves.

39

3. Programme Managers and Development Partners:
Ministry of Health, UN, NGOs, IO, Cholera
Coordinating Committee (Advocacy)

QUESTIONS THEMES
What is Oral
Cholera Vaccine?
•• It is a vaccine that can protect persons from getting
sick from cholera.

•• The cholera vaccine is given by mouth, two doses
are required.

•• Shanchol™ was prequalified by WHO in 2011.

How is it used? •• Shanchol™ is given in 2 doses a minimum of 14 days
apart to adults and children older than 1 year.

•• Shanchol™ is distributed in individual glass vials
(1.5ml) with doses given directly to the individual
from the vial.

•• OCV is not a sole solution to stop cholera; it can be
used along with clean water, adequate sanitation and
good personal hygiene for prevention and early and
appropriate treatment to reduce illness and death as
part of a multi-sectoral integrated approach.
Is it safe? •• It is safe and has very few (mostly minor) side effects.

Does it work?
Is it effective?

•• It is effective. It offers good protection from cholera
for up to 2/3 of those vaccinated for at least 5 years.

•• It is not perfect and does not cover other causes of
diarrhoea. People still need to practice good hygiene
treat the water, practice good sanitation and get
treatment if they are sick.

Who can take
the vaccine?

•• If your country is cholera-prone, it may be appropriate
to give at-risk populations aged one year and older
OCV vaccination at the beginning of an epidemic or in
areas adjacent to those experiencing an epidemic.

•• It is also safe for the elderly and people living with
HIV/AIDS to take the vaccine.

•• In more stable endemic settings, it may be
appropriate to target specific populations and/or
age groups.

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)
40

Why use the
vaccine?

•• OCV can help protect cholera prone communities
from the disease.

•• It can help to reduce the transmission of cholera in
communities.

What about
washing hands
and drinking
clean water?

•• OCV is not a perfect solution to stop cholera; it should
be used along with clean water, adequate sanitation
and good personal hygiene for prevention and early
and appropriate treatment to reduce illness and death.

•• All of these approaches need to be used together.

Why should we
use it in our
country? Has it
been used before?

•• More than 1 million doses of Shanchol™ have been
given over the past few years.

•• People that have received it so far have welcomed it in
their communities.

How is it used? •• OCV is usually given through a mass vaccination
campaign along with other cholera control measures.

How can the
OCV be included
into the existing
programs for
cholera?

•• WHO8 recommends that OCV should be used with
cholera control measures such as use of safe water
and sanitation facilities, good hygiene practices and
adequate case management.

How about the
existing expanded
program on
immunization
(EPI), will there be
any conflict, or can
it be integrated?

•• The WHO has guidelines on how to conduct an OCV
campaign.

•• In most countries, i is currently given as a mass
vaccination campaign, and not yet integrated into the
routine EPI schedule. It should be given 2 weeks apart
from Oral Polio Vaccine but it is ok to give at the same
time as other injectable vaccines.

How are the
vaccines accessed?

•• The International Coordination Group has developed
an OCV stockpile for rapid use in epidemics and
emergencies. This stockpile can be accessed through
the International Coordination Group (ICG).

•• OCVs can also be purchased directly from
the manufacturer.

8

8 See: WHO (2010). OCV in mass immunization campaigns: guidance for planning and
use, Annex 1.

41

4. Religious groups, CSO, local NGOs, CBOs, Local
government authorities, business sector, school
officials (Social Mobilization)

QUESTIONS THEMES
What is cholera? •• It is acute watery diarrhoea, sometimes with

vomiting.

•• Bacteria called Vibrio cholerae cause it. Cholera germs
are found in the faeces of infected people.

•• If not treated, it can cause death from dehydration (or
loss of water and salts from the body) within hours.

How does cholera
spread?

•• Cholera spreads very easily if hygiene is not good.

•• Cholera spreads when feces from infected persons
gets into the water people drink or the food they eat.

How can
community
members protect
themselves from
cholera?

If community members have cholera there are
3 things they can do to protect themselves:

1)Treat the sick person:
•• The greatest danger of cholera (and other diarrhoeal

diseases) is loss of water from the body.

•• Give oral rehydration therapy (ORT) or a mixture of oral
rehydration salts (ORS) and safe (boiled or chlorinated)
water to replace the lost fluid. If given early, ORT
saves lives.

•• Rapid action is essential!

•• Community members should go to a health center
immediately if sick while continuing to drink fluids.

2) Prevent the spread in families and
the community:

•• Community members should practice good hygiene,
keep water safe to drink and use latrines.

•• Wash hands during critical times: after using latrine,
after cleaning the child’s bottom, before preparing
food and before feeding child.

3) Get vaccinated with the oral cholera vaccine

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)

42

What is Oral
Cholera Vaccine?
•• It is a vaccine that can protect persons from getting
sick from cholera.

•• It can save lives in the community.

•• It is safe and has very few side effects.

•• But it is not perfect. It does not protect against other
types of diarrhoea.

•• Oral cholera vaccine (OCV) is taken by mouth.

•• Two doses are required. The vaccine is only effective
after the second dose. Taking 1 dose is not enough.

•• The 2 doses are taken 2 weeks apart.

•• Good hygiene remains very important. People still
need to treat the water, practice good sanitation and
get treatment if they are sick.

Who can
receive OCV?

Who should not
receive OCV?

•• In cholera-prone communities, entire families except
children under one year of age should get the cholera
vaccine if available or according to protocol.

•• It can be given to the elderly and those with
HIV/AIDS.

What to advise
the community on
Who, Where, and
When to get OCV
vaccination?

•• Inform communities on who is eligible for the vaccine
(see above).

•• If there is a campaign let communities know where
and when to get it.

•• Remind community members: Keep your vaccination
card and to bring it when you go for your second dose
of the vaccine.

5. Community Health Workers and OCV Vaccinators
(Community Mobilization)

QUESTIONS THEMES
What is cholera? •• It is acute watery diarrhoea, sometimes with

vomiting.
•• Bacteria called Vibrio cholerae cause it. Cholera germs
are found in the faeces of infected people.
•• If not treated, it can cause death from dehydration (or
loss of water and salts from the body) within hours.
43

How does
cholera spread?

•• Cholera spreads very easily and quickly if hygiene is
not good.

•• Cholera spreads when faeces from infected persons
gets into the water people drink or the food they eat.

How can
community
members protect
themselves from
cholera?

If community members have cholera there
are three actions they can do to protect
themselves:

1) Treat the sick person:
•• The greatest danger of cholera (and other diarrhoeal

diseases) is loss of water from the body.

•• Give sick person clean, safe (boiled or chlorinated)
water mixed with oral rehydration salts (ORS) to
replace the lost fluid. The ORS solution can save his/
her life if given early.

•• Rapid action is essential. Use existing national
protocols to treat patients with cholera.

•• Community members should go to a health center
immediately if sick while continuing to drink fluids.

•• Refer ill patients to a health facility.

2) Prevent the spread in families and
the community:

•• Wash hands during critical times: after using latrine,
after cleaning the child’s bottom, before preparing
food and before feeding child.

•• Remind community members to continue to
practice the key hygiene and sanitation practices as
described above

3) Get vaccinated with the cholera vaccine:

•• Entire families except children under one year of

age should get the cholera vaccine if available (or
according to protocol).

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)

44

What is Oral
Cholera Vaccine?
•• It is a vaccine that can protect persons from getting
sick from cholera.

•• It is called Shanchol™ , it is in vials; one vial is good
for one dose and is given to one person.

•• Oral cholera vaccine (OCV) is taken by mouth.
•• Two doses are required. The vaccine is only effective
after the second dose. Taking 1 dose is not enough.
•• The 2 doses are taken 2 weeks apart.

•• Each dose is 1.5 ml. The full vial needs to be
consumed.

•• OCV can save lives in the community.

•• It is safe and has very few side effects. Very rarely
people have abdominal discomfort or diarrhoea.

•• But it is not perfect and it does not protect against
other diarrhoea. Good hygiene remains very
important. People still need to treat the water, practice
good sanitation and get treatment if they are sick.

•• Inform people receiving the vaccine to come back
with any health complaints.

•• Inform people receiving the vaccine to keep the
vaccination card they receive and to bring it back
when they come for their second dose.

45

How can you
prevent cholera?

Remind community members and persons
coming for OCV vaccination that they should
continue to:

•• Wash hands often with soap and rinse with safe water
(or use ash, lime or sand, where soap is not available)

•− After every defecation;

•− Before handling food (cooking, eating, feeding children);

•− After cleaning child’s bottom;

•− After cleaning a patient with diarrhoea.

•• Use the latrine for defecation or bury faeces.

•− Do not defecate in any body of water;

•− Clean latrines and surfaces contaminated by faeces.

•• Use clean drinking water and food:

WATER:

•• Boil the water before drinking (or use chlorinated
water if possible). Always pour the water from water
containers; do not dip a cup.

FOOD:

•• Cook raw food thoroughly;

•• Eat cooked food immediately;

•• Store cooked food carefully in refrigerator;

•• Reheat cooked food thoroughly;

•• Avoid contact between uncooked/raw food and
cooked food;

•• Eat fruits and vegetables you have washed and
peeled yourself.

UTENSILS:

•• Keep all food preparation and/or kitchen surfaces clean;

•• Wash cutting boards especially well with soap and water;

•• Wash utensils and dishes with soap and water.

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)
46

6. Families, Parents, Guardians, Children, Community
Members, Cholera at-Risk Populations, General Public
(Interpersonal/Group Communication)
QUESTIONS THEMES
What is Cholera? •• It is acute watery diarrhoea, sometimes with vomiting.

•• If not treated early it can lead to death within a few
hours.

•• It can affect adults and children.

•• It is caused by a germ that is in the stool of a person
sick from cholera that can contaminate many others.

How do you get it? By poor hygiene from:
•• Not washing hands after latrine use or after cleaning a

child’s bottom

•• Not washing hands before preparing or eating food

•• Not cleaning/preparing food well

•• Shaking hands with someone who did not wash his/
her hands

•• Drinking contaminated water or food.

What do you do if
you get cholera?

If you or a family member has diarrhoea:

1) Treat the sick person. Remember:
•• The greatest danger of cholera (and other diarrhoeal

diseases) is loss of water from the body;

•• Do not panic, but act quickly;

•• Give a solution of oral rehydration salt (ORS)
prepared with safe (boiled or chlorinated) water, a
recommended sugar salt solution if not ORS and
continue breastfeeding babies;

•• Go immediately to the health center;

•• Continue giving clean liquids to drink.

2) Prevent spread of cholera in your family
and community:

•• Practice good hygiene, keep your water safe to drink
and use latrines.

3) Get vaccinated with the cholera vaccine:

•• Get yourself and your entire family, except children
under one year of age, vaccinated with the cholera
vaccine if available (or according to protocol).

47

How do you
prevent it?

•• Wash your hands often with soap and rinse with
safe water (or use ash, lime or sand, when soap is
not available)

•− After every defecation;

•− Before handling food (cooking, eating,
feeding children);

•− After cleaning a child’s bottom;

•− After cleaning a patient with diarrhoea.
•• Use the latrine for defecation or bury faeces.
•− Do not defecate in any body of water;

•− Clean latrines and surfaces contaminated by faeces

WATER:
•• Boil the water before drinking (or use chlorinated
water if possible). Always pour the water from water
containers; do not dip a cup.
FOOD:
•• Cook raw food thoroughly;

•• Eat cooked food immediately (while still hot);

•• Store cooked food carefully in cool place or refrigerator;

•• Reheat cooked food thoroughly and eat it while still hot;

•• Avoid contact between uncooked/raw food and
cooked food;

•• Eat fruits and vegetables you have washed and
peeled yourself.

UTENSILS:

•• Keep all food preparation and/or kitchen surfaces
clean;

•• Wash your cutting board well with soap and water;

•− Wash your utensils and dishes with soap and water.

Table 4 Key messages for different audience groups/
participants in oral cholera vaccination and cholera
prevention, control and treatment measures (cont’d)

48

What is Oral
Cholera Vaccine?

•• It is a vaccine that can protect you from getting sick
from cholera. It saves lives!

•• It is safe and has very few side effects.

•• But it is not perfect and it does not protect against
other diarrhoea. Good hygiene, drinking safe water,
practicing good sanitation and getting help when sick
remain very important!

How do you
take it?

•• Oral cholera vaccine (OCV) is taken by mouth – you
drink it

•• You need to take 2 doses.

•− The vaccine is only effective after the second dose.

•− Taking 1 dose is not enough.

•• The 2 doses are taken 2 weeks apart.

•• You need to fast one hour before and one hour after
taking the vaccine.

Who can
receive OCV?

•• Everyone at risk of cholera over the age of 1 year (or
according to protocol9);

•• Do not give OCV to persons who are ill or have
cholera.

Where/When
can I get OCV
vaccination?

Venue:

Date:

Time:

Look for:

99

9 During an outbreak, pregnant women may receive OCV according to protocol.

49

Choose the appropriate mix of channels and media

An appropriately selected mix of channels creates synergy and
enhances effectiveness. Choose culturally appropriate and available
channels. Combine channels and media to offset the weaknesses
of one channel with the strengths of the others. A channel analysis
at the assessment stage will help you decide on the appropriate
mix of channels that would actively involve your audience groups in
discussion and decision-making. See Table 3.

We should not be tempted to use a communication channel simply
because it is popular with the development community but may
not be affordable to or used by the intended audiences. (See also:
UNICEF Cholera Toolkit Chapter 7; Annex 7D for a description of the
different types of communication activities and channels used in
cholera response.

Manage rumours and misperceptions

The spread of rumours and misperceptions about a new vaccine like
OCV can derail any immunization programme and create a crisis.
Lack of information and mistrust of the programme can create
unanswered questions that may lead to fear, apprehension and
people’s refusal to be vaccinated. People deal with their fear and
anxiety by trying to explain the unknown with a rumour.

This is why it is essential to plan for managing rumours as part of
your communication plan; in this case, a crisis communication plan.
You will need to identify key staff that will manage rumours. Select
spokespersons who will serve as the Ministry of Health’s face for the
media. Identify spokespersons who are regarded as authoritative on
the subject and are respected and trusted by communities.

The factors that can help a rumour lead to a boycott of services can
also be turned around to help make the programme succeed10:

• Community discussion at various levels

10 Understanding Rumours: Lessons Learned from immunization in West
Central Africa. Power point presentation by Jon Shadid, Mika Kuneida and
Guy Scandlen, 2012.

50

http://www.unicef.org/cholera/Cholera-Toolkit-2013

• Trusted local opinion leaders

• Public statements by influential leaders

• Strengthened identity and values

• Resistance perceived as a moral norm and religious imperative

• Peer-to-peer pressure

• Comprehensive media coverage

WHO, UNICEF and USAID offer some tips to communication
managers in counteracting and managing rumours about
immunization.11 The communication plan should therefore prepare for
the following:

Ways to counteract rumours

• Move quickly to respond to a rumour.

• Analyze the situation.

• Clarify the extent of the rumour or misinformation (type of
messages circulating, source, persons or organizations spreading
the rumour).

• Determine the motivation behind the rumour (lack of information,
questioning of authority, religious opposition, desire for publicity
or other).

• Turn the rumour around. Go to the source and ask what the
solution is.

• Acknowledge existing shortcomings if necessary. Offer the
source an opportunity to be part of the solution.

• Invite key opinion/charismatic leaders for advocacy meetings
(politicians, traditional and religious leaders, community leaders,
celebrities, health workers).

11 Adapted from: WHO, UNICEF and USAID. Dealing with rumours. In:
Communication for polio eradication and routine immunization: Checklists and
easy reference guides. Polio Eradication Initiative, March 2002. p. 30-32.

51

• Launch a corrective campaign at the highest level, e.g. the
Minister of Health, the Governor, District Health Chief, local
health administrators, etc.

• Meet with local leaders at sites where the concerned groups
are comfortable and can feel at ease to ask questions and have
peers present.

• Invite partners, allies and the media. Strengthen alliances. Involve
all immunization partners through social mobilization committees,
communication coordinating groups, etc. Alert and collaborate
with relevant ministries and NGOs.

• Encourage onward briefings to stimulate a cascade effect.

• Conduct orientations and training sessions. Train volunteers and
health workers to handle rumours.

• Disseminate tailored information on common misconceptions
and guidelines on response. Promote positive key messages.

• Mobilize communities. Empower local people to address and
take responsibility for the issue through local channels such as
health workers, school events, community seminars, community
radio, discussion groups and social media.

• Invite support from the health community. Seek collaboration
from health professionals in the public and private sectors,
including doctors, nurses and vaccinators, volunteers and
members of partner organizations.

• Mount a mass media campaign. Involve all appropriate media
(TV, radio, newspapers, and social media.) and traditional media
commonly used in the community.

• Seek out and involve media that have already misinformed the
public. Call on previously established relationships with the media.

− Delegate one spokesperson to handle the media questions.
Display confidence and credibility.

− Invite celebrities to help explain the truth.

− Use the print and broadcast media where appropriate to
provide answers to common questions, to correct common
misconceptions and to deliver positive messages.

52

Ways to prevent rumours

• Be “proactive” – before launching the OCV campaign,
research and anticipate any potential occurrence of rumours
sand act accordingly.

• Implement continuing communication activities to prevent
and limit rumours.

• Build on-going relationships with local NGOs, religious
organizations, community groups and media that have the
respect of primary participant groups/individuals as mobilizers
and educators.

• Involve community leaders in planning and implementing
communication activities for OCV vaccination.

• Approach communities early, and make frequent contact.

• Present health issues as national social, economic and
security issues.

• Discuss FAQs on OCV vaccination with public and private
practitioners in advance to obtain their support.

• Design communication and social mobilization strategies that
establish continuity between NIDs and routine immunization.

Step 5: Plan to monitor and evaluate
Monitoring is used to determine if a communication intervention
is progressing as planned, and to make adjustments or changes
if necessary. It provides insight as to how well your planned
communication activities are being implemented and whether
strategies are achieving the intended behaviour outcomes among
participant groups. In behaviour monitoring, we use carefully
selected communication indicators assessed against the “baseline”
and data collection methods while the programme is underway to
determine “how we are doing”.

53

There are two types of monitoring that need to be addressed:

1. Behaviour monitoring refers to tracking the process, outputs
and outcomes related to the communication objectives

2. Implementation monitoring refers to tracking operations and
management of the communication intervention.

Designing a behaviour monitoring plan

The first step in designing a behaviour monitoring plan is defining
behaviour outcomes and indicators based on SMART communication
objectives (see Table 1). The Communication Coordinating Team should
appoint a Communication M&E Task Force within its ranks. Invite an
M&E specialist from your agency or from an academic institution.

Three types of indicators:

• Process indicators: What processes have been followed in the
communication strategy?

• Output indicators: In communication activities, are the outputs
(such as number of health workers trained on IPC; number of
communication tools, mass-media products, etc. developed,
pretested and produced) produced as planned?

• Outcome indicators: As a result of the process followed and
outputs used – what behaviour outcomes are we expecting
(actions on the part of participant groups)?

Your indicators should include process measures (number of cholera
prone individuals/families and communities vaccinated over a given
period); outputs (number of OCV orientations conducted; IPC
training with HWs conducted; number trained, types, number and
distribution of IPC materials, etc.); and outcomes (level of participation,
satisfaction, improved hygiene practices, changes in social norms, etc.)

The following table (Table 5) presents some illustrative indicators on
OCV uptake and other cholera prevention measures.

54

Table 5 Illustrative behaviour monitoring and
evaluation indicators for adoption of OCV and other
cholera prevention

Knowledge •• % of households who can correctly identify
cholera illness

•• % of heads of households who consider
immunization to be very important to prevent
diseases

•• % of heads of households who are aware
of the benefits of OCV immunization as a
preventive measure against cholera

•• % of heads of households who are aware that
two doses of OCV are necessary

•• % households who mention at least 3 other
cholera preventive measures (WASH related).

Attitudes •• % of household heads who intend to be
vaccinated and have their families vaccinated

•• % of household heads who are resistant to
immunization

Practices •• % of cholera prone families (in location) who
went for OCV vaccinations and were fully
immunized (completed the 2 doses) against
cholera in (year)

•• % of households with (safe drinking water)
improved water sources/safe water storage
containers

•• % of individuals who claim to wash their
hands with soap at critical times

•• % households with visible hand washing
stations

55

Social change •• % of families that participate in community
programmes to prevent cholera and other
diarrhoeal diseases

•• % of communities with zero open defecation
(over a given time)

•• Case studies that document good practices,
innovations and lessons learned from
uptake of OCV and other cholera prevention
approaches

•• Improved community system for garbage
disposal and sewerage

Advocacy •• In a cholera endemic country, national policy
and programme exists that integrates OCV
in cholera programme as part of cholera
prevention

•• Financial resources allocated to OCV
vaccination

•• # of communities engaging in public
declarations supporting OCV vaccination

•• Case studies that document political will,
public policy, resource allocation and
programme coordination in OCV integration
into cholera programme

Once the M&E Task Force approves the behaviour monitoring matrix,
the next step would be the development of guidelines for the specific
tools and methods. Both quantitative and qualitative methods
as appropriate and feasible can be used to ensure suitable data
collection and analysis.

Evaluation is done after a pre-determined period of time has
elapsed, known as an “endline” to ask, “how did we do?” i.e., to
measure the expected outcomes from a communication intervention
assessed also against the “baseline” data and indicators. Therefore,
at the early stage of writing the communication and behaviour
objectives, you need to identify the indicators.

Table 5 Illustrative behaviour monitoring and
evaluation indicators for adoption of OCV and
other cholera prevention (cont’d)

56

Indicators are evidence-based signals that help to measure
the progress (monitoring) of communication or achievement
(evaluation) of a certain behaviour or social change objective.

Examples of M&E Tools

Please refer to: Behaviour Change Communication in
Emergencies: A Toolkit for more practical tools that you can adapt
for OCV and cholera communication. These tools can guide you
in your behaviour monitoring and evaluation (M&E) tasks. In
particular, see:

• Tool 2, How to develop indicators based on behaviour results;

• Tool 9, Monitoring chart; Tool 13, Tools to monitor the
milestones, and

• Tool 8, How to facilitate a participatory exercise.

From the same Toolkit you can find tools that involve your primary
participants/stakeholders in generating in-depth, qualitative M&E
data, for example:

• Tool 3, Most significant change technique

• Tool 5, How to conduct a key informant interview

• Tool 6, How to use a pocket voting chart

• Tool 7, How to do a ranking exercise

• Tool 10, Structured observation checklist for health
workers’ communication skills

57

http://www.unicef.org/ceecis/BCC_full_pdf

Step 6: Document good practices and
lessons learned
Invest time and effort to write high quality progress reports, power
point presentations, case studies, human-interest stories and
vignettes on OCV and cholera prevention communication for different
audience groups. These will pay off by helping you:

• Critically analyze reports from the monitoring process and/or the
evaluation results as the case may be;

• Adjust or enhance your interventions and fine tune the next
iteration of strategic communication action plan;

• Provide material for sharing and networking, allowing active
discussion and feedback on progress, challenges and opportunities
and where improvements or adjustments in the operations work plan
need to be made. These are usually presented during coordination
meetings with partners, media, stakeholders and beneficiaries.

Depending on the focus and use of your documentation, those
interested will likely be the members of the national or community

58

coordinating groups, the implementing partners and allies, the
funding sponsor, the media, and the intended primary participants
who stand to gain healthy, cholera-free status from their participation
and feedback.

Documentation allows you to identify and validate innovations,
lessons learned and good practices that in turn allow partners,
allies, donors, stakeholders and direct beneficiaries to learn from
experience and to pursue the better approaches in the context of
helping to free at risk children and their families from the threat
of cholera. Case studies that use photos and charts and graphs
are often developed to document a particular practice; with the
categories as defined below.12

Lessons learned are more detailed reflections on positive
(successes) or negative (failures) lessons from implementing
certain strategies with specific participants over a longer
time frame.

Good Practices are well documented and assessed programming
practices that provide evidence of success/impact and which are
valuable for replication, scaling up and further study. They are generally
based on similar experiences from different countries and contexts.

Innovations are summaries of new programmatic or operational
approaches that are being piloted over the short term into stan-
dard programming that can demonstrate effectiveness and effi-
ciency in achieving intended results.

Some good examples can be gleaned from the Reports13,14,15 on good
practices, innovations and lessons learned in C4D experiences. These
are useful resources that showcase innovative approaches to water,
sanitation and hygiene for diarrhoea and cholera prevention and other
healthy family practices.

12 See relevant UNICEF webpage: www.unicef.org/innovations/

13 UNICEF WCARO (2012). Report on good practices and lessons learned in
UNICEF C4D experiences in the West and Central African Region.

14 UNICEF New York (2011). Developing capacities to realize the rights of
children and women: selected innovations and lessons learned from
UNICEF-assisted programmes.

15 UNICEF Report (2010). Community Approaches to Total Sanitation: India,
Nepal, Sierra Leone and Zambia.

59

http://www.unicef.org/innovations/files/LL_CapDev15August2011_final

http://www.unicef.org/innovations/files/LL_CapDev15August2011_final

http://www.unicef.org/innovations/files/CATS_field_note

http://www.unicef.org/innovations/

RESOURCE 1. Examples of IPC
tools/ communication materials

Resource 1.1 Q & A Health Promoters Briefing
Guide from Sudan16:

WHAT is cholera?
• Acute watery diarrhoea, sometimes with

vomiting

• If not treated early can lead to death within
hours in a previously healthy persons

• Affects adults and children

• Stool of sick person can contaminate
many others

16 MSF (2013). Health Promotion and Cholera Vaccination Mass Campaign
in Sudan, January 2012.

Resources and Tools
PART

2
60

HOW do you get it?
• By poor hygiene

• By not washing hands after latrine use

• By not washing hands before making or eating food

• By not cleaning/preparing food well

• By shaking hands with someone who did not wash
his/her hands

• By drinking contaminated water

61

HOW do you prevent it?
• Drink safe water

• Cover your food after cooking

• Safe, well cooked food

• Wash hands with water and soap
after latrine, after washing baby,
before preparing food and
before eating,

• Use latrines, no open defecation

• Vaccination with oral cholera vaccine

WHAT is the cholera vaccine?
• Called Shanchol

• The vaccine is an oral vaccine – you drink it

• Take 1.5ml per dose

• Need 2 doses 2 weeks apart

• Taking only 1 dose is not effective

• 1 vial is for 1 person

• The person needs to drink the full vial

• The vial contains a small amount
of liquid

62

Is the vaccine safe?
• OCV is safe

• OCV Is PREVENTION, NOT treatment

• Lifesaving!

• Gives protection, but still possible to get cholera
or other diarrheal diseases

• Other prevention measures are still important for cholera
and other diseases!

• Minimal side effects, like some diarrhea, but you can come to the
clinic for free treatment if you feel sick after vaccination

WHO can receive this vaccine?
• Everyone over 1 year of age

• Pregnant women

• The vaccine is for everybody, except for children < 1 year old

• Each person must receive two doses 2 weeks apart
for full protection!

• Not for very ill persons and those already with cholera

• If anybody feels sick after taking the vaccine, address them
to an Health Facility

• The vaccine tastes very bitter: it is normal, don’t worry, inform the
person about the bad taste

63

• As all other vaccines, OCV can have side effects.

• Side effects are generally mild: abdominal pain,
vomit, diarrhea

• If any side effects, send the person to the Health Facility

WHERE is the vaccination going to take place?
• In Doro camp and direct surrounded host communities

• House to House (like the Polio Campaign)

WHEN?
• Camp: 17th -19th January and 31st January until 2nd of February

• House to house: 22- 23 January and 4th to 5th February

Resource 1.2 Leaflet on Oral Cholera Vaccine from
Orissa, India

Source: OCV mass vaccination campaign in Orissa, India, 2012

64

Resource 1.3 Poster on OCV from mass vaccination
campaign in Orissa, India

Source: OCV mass vaccination campaign in Orissa, India, 2012
65

RESOURCE 1.4 OCV and cholera prevention leaflet
from Haiti

Source: OCV Vaccination Campaign in Haiti, 2012

Resource 1.5 Key messages on OCV and cholera
prevention from Guinea

A l’attention des populations

Qu’est-ce que le choléra ?

• Le choléra est une diarrhée grave

• Il peut entraîner la mort par perte d’eau dans le corps en
quelques heures s’il n’est pas soigné rapidement

Comment attrape-t-on le choléra ?

• On attrape le choléra par manque d’hygiène :
•− Si on ne se lave pas les mains après être allé aux toilettes
•− Si on serre la main de quelqu’un qui ne s’est pas lavé les mains
•− Si on ne se lave pas les mains avant de préparer la nourriture

66

•− Si on ne nettoie pas la nourriture
•− Si on boit de l’eau contaminée

Que faire si on attrape le Choléra ?

• Si vous avez de diarrhées ou des vomissements, allez
directement au centre de santé

• Il faut beaucoup boire! Même en allant au centre de santé,
il faut boire!

Vaccination contre le choléra

• Le vaccin est pour tout le monde dès l’âge de 1 an

• Le vaccin se prend par la bouche

• Il faut le prendre 2 fois: une fois aujourd’hui et une fois dans 2
semaines au moins pour qu’il soit efficace

• Prendre 2 fois la même journée n’est pas bon

• Nous passerons distribuer la 2ème dose dans 2 semaines

• Gardez la carte que nous vous donnons pour recevoir le 2ème vaccin

• Même les 2 prises ne protègent pas complètement. Les règles
d’hygiène doivent être suivies ! Si vous avez de diarrhées ou des
vomissements, allez directement au centre de santé

Hygiène : 3 messages clé

1. Utilisez les latrines pour faire caca

2. Lavez-vous les mains avec du savon
a. après chaque caca

b. avant de manipuler de la nourriture (cuisiner, manger, pour
nourrir les enfants aussi)

c. Les mères qui allaitent doivent se laver les mains et les seins
(verify) avec du savon et de l’eau avant de nourrir l’enfant.

3. Utilisez de l’eau traitée avec le SUR’EAU. Nettoyez très bien les
aliments, les ustensiles avant de préparer la nourriture :
d. Utilisez des bidons propres pour garder l’eau de boisson

traitée avec le SUR’EAU.

e. Lavez le récipient à boire immédiatement après usage avec
du savon.

Source: MSF cholera vaccination campaign in Guinea, March 2012.

67

TOOL 1. Sample template for
behaviour analysis of participant groups
in OCV introduction and cholera
prevention programme

Level in the
Socio-Ecological Model (SEM)

Individual/Family Level Community Level
Organizational/

Provincial, District
Policy Level

Communication Strategy
Behaviour Change
Communication (BCC)

BCC; Community
Mobilization; Social
Change

Social Mobilization;
Social Change

Advocacy

1. RESEARCH QUESTIONS FOR BEHAVIOUR ANALYSIS

1.1 Who is/are the participant group(s)? Individual level: Head of
household; father; mother,
primary caregiver

Family and friends: Children;
mother-in-law, grandparents,
other relatives, neighbours,
friends, peers

Community level:
Community leaders,
health workers,
vaccinators, community
volunteers, religious
leaders, village
influentials, CBOs, school
teachers, school children,
community media

Provincial/State and
District level: Governor,
Mayor, Representatives
of health, educational
institutions, business;
leaders of socio-cultural
and or socio-economic
organizations, CSOs,
NGOs, mass media,
social media

Head of State, policy
makers, representatives
of national institutions,
Ministry of Health, other
ministries, National
Cholera Task Force/
Coordinating Committee,
mass media organizations,
telecommunications
companies

1.2 Current Behaviour: What is/are the
current behaviour related to (OCV)
immunization and cholera prevention
and control?

Not aware of OCV; Not practising
good hygiene; open defecation

Not aware of OCV;
not assuming role as
mobilizer for cholera
prevention

No intent to integrate
OCV into cholera
prevention programme

No political will to
include OCV in cholera
programme

1.3 Key Behaviour: What is/are the
recommended key behaviour/s?

Bring family for OCV vaccination
and complete 2 doses

Motivate constituents to
go for OCV and practice
WASH

Motivate cholera-prone
communities to adopt
OCV as an added
measure against cholera.

Issue policy that
integrates oral cholera
vaccination in the national
cholera programme;
allocate funds

1.4 Other Supporting Behaviours: What
other behaviours are recommended to
prevent cholera infection and spread?

Family members continue
practising good hygiene and
sanitation, drinking safe water,
safe waste disposal. Understand
that cholera causes severe
diarrhoea and dehydration and
that it can quickly cause death if
not treated early.

Treat all persons coming
for OCV with respect;
answer their questions
and address their
concerns and show active
interest in their opinions

Help cholera at-risk to
know prevention and
control; explain added
value of OCV.

Understand limitations of
implementing traditional
interventions in some
settings, and how OCV
may help mitigate disease
transmission

68

TOOL 1. Sample template for
behaviour analysis of participant groups
in OCV introduction and cholera
prevention programme
Level in the
Socio-Ecological Model (SEM)
Individual/Family Level Community Level
Organizational/
Provincial, District
Policy Level
Communication Strategy
Behaviour Change
Communication (BCC)
BCC; Community
Mobilization; Social
Change
Social Mobilization;
Social Change
Advocacy
1. RESEARCH QUESTIONS FOR BEHAVIOUR ANALYSIS
1.1 Who is/are the participant group(s)? Individual level: Head of
household; father; mother,
primary caregiver
Family and friends: Children;
mother-in-law, grandparents,
other relatives, neighbours,
friends, peers
Community level:
Community leaders,
health workers,
vaccinators, community
volunteers, religious
leaders, village
influentials, CBOs, school
teachers, school children,
community media
Provincial/State and
District level: Governor,
Mayor, Representatives
of health, educational
institutions, business;
leaders of socio-cultural
and or socio-economic
organizations, CSOs,
NGOs, mass media,
social media
Head of State, policy
makers, representatives
of national institutions,
Ministry of Health, other
ministries, National
Cholera Task Force/
Coordinating Committee,
mass media organizations,
telecommunications
companies
1.2 Current Behaviour: What is/are the
current behaviour related to (OCV)
immunization and cholera prevention
and control?
Not aware of OCV; Not practising
good hygiene; open defecation
Not aware of OCV;
not assuming role as
mobilizer for cholera
prevention
No intent to integrate
OCV into cholera
prevention programme
No political will to
include OCV in cholera
programme
1.3 Key Behaviour: What is/are the
recommended key behaviour/s?
Bring family for OCV vaccination
and complete 2 doses
Motivate constituents to
go for OCV and practice
WASH
Motivate cholera-prone
communities to adopt
OCV as an added
measure against cholera.
Issue policy that
integrates oral cholera
vaccination in the national
cholera programme;
allocate funds
1.4 Other Supporting Behaviours: What
other behaviours are recommended to
prevent cholera infection and spread?
Family members continue
practising good hygiene and
sanitation, drinking safe water,
safe waste disposal. Understand
that cholera causes severe
diarrhoea and dehydration and
that it can quickly cause death if
not treated early.
Treat all persons coming
for OCV with respect;
answer their questions
and address their
concerns and show active
interest in their opinions
Help cholera at-risk to
know prevention and
control; explain added
value of OCV.
Understand limitations of
implementing traditional
interventions in some
settings, and how OCV
may help mitigate disease
transmission

69

Level in the
Socio-Ecological Model (SEM)
Individual/Family Level Community Level
Organizational/
Provincial, District
Policy Level

1.4 Key Behaviour Barrier: What is
the key behaviour barrier to the
recommended behaviour/s?

•• Resistance to vaccination

•• Poor knowledge of vaccines
and their benefits

•• Low capacity to
facilitate community
mobilization

•• Poor IPC skills

•• Lack of leadership/
initiative/commitment-
–Low capacity to
facilitate social
mobilization

•• Lack of leadership and
political will to support
OCV initiative

1.5 Other barriers: What are the
other underlying (behaviour and
non-behaviour) barriers to the
recommended behaviour?

(What perceived benefits come from
NOT adopting the recommended
behaviour?

What social norms hinder the adoption
of the recommended behaviour?)

•• Poor attitude toward
health worker

•• Negative past experience
with HW

•• Long distance to vaccination
venue; costs

•• Competing priorities

•• Low self-esteem

•• Careless attitude
towards clients

•• Weak supervision and
monitoring structures

•• Lack of resources

•• Lack of political
commitment

•• Not clear about
the issues

•• Several competing
programmes for limited
resources;

•• Desire for political
image building/ conflict
of interest

•• Lack of political
commitment
•• Not clear about
the issues
•• Several competing
programmes for limited
resources;

•• Desire for political
image building/ conflict
of interest

1.6 Motivating factors: What current
or traditional practices and existing
social norms could support adoption
of recommended behaviour/s toward
OCV uptake and cholera prevention
and control?

•• Desire to maintain good health,
freedom from cholera and
other diseases

•• Professional /
political pride,

•• Playing a role in
saving lives

•• Professional /
political pride,
•• Playing a role in
saving lives

•• Key role in agenda-
setting and resource
allocation

TOOL 1. Sample template for
behaviour analysis of participant groups
in OCV introduction and cholera
prevention programme (cont’d)

70

Level in the
Socio-Ecological Model (SEM)
Individual/Family Level Community Level
Organizational/
Provincial, District
Policy Level
1.4 Key Behaviour Barrier: What is
the key behaviour barrier to the
recommended behaviour/s?
•• Resistance to vaccination
•• Poor knowledge of vaccines
and their benefits
•• Low capacity to
facilitate community
mobilization
•• Poor IPC skills
•• Lack of leadership/
initiative/commitment-
–Low capacity to
facilitate social
mobilization
•• Lack of leadership and
political will to support
OCV initiative
1.5 Other barriers: What are the
other underlying (behaviour and
non-behaviour) barriers to the
recommended behaviour?
(What perceived benefits come from
NOT adopting the recommended
behaviour?
What social norms hinder the adoption
of the recommended behaviour?)
•• Poor attitude toward
health worker
•• Negative past experience
with HW
•• Long distance to vaccination
venue; costs
•• Competing priorities
•• Low self-esteem
•• Careless attitude
towards clients
•• Weak supervision and
monitoring structures
•• Lack of resources
•• Lack of political
commitment
•• Not clear about
the issues
•• Several competing
programmes for limited
resources;
•• Desire for political
image building/ conflict
of interest
•• Lack of political
commitment
•• Not clear about
the issues
•• Several competing
programmes for limited
resources;
•• Desire for political
image building/ conflict
of interest
1.6 Motivating factors: What current
or traditional practices and existing
social norms could support adoption
of recommended behaviour/s toward
OCV uptake and cholera prevention
and control?
•• Desire to maintain good health,
freedom from cholera and
other diseases
•• Professional /
political pride,
•• Playing a role in
saving lives
•• Professional /
political pride,
•• Playing a role in
saving lives
•• Key role in agenda-
setting and resource
allocation

71

TOOL 2. Sample template for a
communication action plan for an OCV
mass vaccination campaign in Country X

Audience/
Participants

Behaviour Objectives/
Desired Actions

Key
Messages Activities

Support
Materials

Outcome
Indicators

I. National Level Advocacy

II. Provincial/State Level Advocacy

III. District Level Advocacy

IV. Media Engagement

V. Social Mobilization of Partners and Allies

VI. Community Mobilization for Behaviour and Social Change

72

TOOL 3. Monitoring checklist for OCV
communication strategy implementation17
1. Are there a communication team and a working communication

coordination structure in place with competent, committed, and
collaborative members with clear terms of reference?

2. Was an assessment done to identify:
2.1. The KAP gaps, barriers and motivators to desired practices among

your participant groups (i.e. health workers, parents, guardians,
children, volunteers, at risk groups particularly the hard to reach and
resistant to immunization?

2.2. The information-seeking and sharing patterns of the affected
communities (communication network analysis)

2.3. The main barriers for affected families and communities to practice
the intended behaviour (e.g. all family members availing of cholera
vaccination services, practicing safe hygiene and sanitation)?

2.4. Are the problem behaviours, as well as the desired behaviours, clearly
identified? Are the communication objectives “SMART” (specific,
measurable, appropriate, realistic, time-bound)?

3. Did you integrate a training module on interpersonal
communication skills and social mobilization into the clinical
training on OCV for health workers?

4. Did you develop an OCV communication plan that includes
components of effective service delivery; key messages in IPC
tools, communication materials and mass media pretested? Do
these communication tools support advocacy, social mobilization
and community engagement? Does national level provide
encouragement, guidelines and funding to support decentralized
planning and implementation of integrated communication
plans? How are national and sub-national plans coordinated? Is
the whole sub-national management staff involved in the design
and implementation of the communication work plan? Are those
plans implemented? Are district administrators, religious leaders,
public officers, local opinion leaders, and chief of villages aware of
on-going cholera vaccinations? Are national communication plans
regularly revised and updated? Are lessons learned integrated
regularly within the existing plan?

17 Adapted from UNICEF ROSA (2006). Behaviour Change Communication in
Emergencies: A Toolkit, Tool 12, p. 219.

73

5. Does the plan clearly state the behaviour objectives you seek to
influence by participant group?

6. Did you prepare an implementation plan for each
communication strategy (advocacy, social mobilization,
behaviour and social change)?

7. Is there a current advocacy strategy, which integrates the lessons
learned from other country experiences? Are the objectives of
the advocacy strategy “SMART”? Do the advocacy activities
for OCV vaccination also address preventive practices against
a cholera outbreak in the country? Do the advocacy activities
stress the role of the political and social leadership and do they
focus on the actions that can be taken by them to improve their
performance?

8. Who are the partners and allies involved in social mobilization for
OCV vaccination and cholera prevention? Are there mechanisms
in place to track the partners and allies’ involvement in social
mobilization? Which other organizations should be involved? Do
the partners receive recognition and credit for their support in all
the social mobilisation activities?

9. Briefly describe community mobilization activities to address barriers
and to encourage families to get immunized against cholera:
2.1. Parents, heads of household, caretakers: Do family heads have a

positive or negative attitude in relation to immunisation? What is done
to address existing barriers to immunisation among family decision-
makers?

2.2. Service providers: Are there mechanisms in place to track health
workers’ involvement? Are they fully informed and trained in
interpersonal communication in addition to clinical aspects of OCV
vaccination?

2.3. Resistant groups, misconceptions on vaccination, and/or hard-to-
reach: How does the local communication committee use
coverage data to identify low coverage areas, resistant
groups, lost opportunities and zero-dose and one-dose
areas? Have pockets or groups with low coverage and
dropout rates at national and sub-national level been
identified at all, and where are they located?

74

10. Does it include opportunities for community ownership and
participation in areas such as formative research, material
preparation, message design and dissemination, monitoring
and evaluation?

11. Did you establish a monitoring system to keep track of
your operations and to gather feedback about desired
behaviour outcomes?

12. Did you determine the communication budget? Were there
efforts to mobilize resources to ensure funding allocation for the
communication component?

13. Are messages and materials gender-, age- and culture-sensitive
and appropriate?

14. Did you choose the most appropriate mix of the most effective
communication channels – interpersonal, mid-media, mass
media and social media?

15. Did you invite and receive feedback from the various audience(s)
of the affected community on your suggested messages and
materials (pre-testing)?

16. Do you know if the material and the messages in it reached
the people they were meant to reach (e.g. affected population,
health workers, volunteers, etc.)?

17. Do you have a system to document, share and manage the
information with partners, humanitarian organisations, UN sister
agencies, government bodies, professional organisations and
other concerned partners?

75

TOOL 4. Preparing for an OCV
Communication Campaign
Creating on-going demand for oral cholera vaccination involves time-
bound communication campaigns, which is a reality of immunization
programmes. Campaigns often require national leadership support
to ensure implementation at lower levels. The participation of local
leaders is crucial in micro planning as well as in mobilizing their
constituencies particularly the most at risk and the hard to reach
members of the population.

Planning for a campaign regardless of duration, involves the same
steps in planning a C4D strategy. Because it is time-bound, a
campaign requires that actual implementation is coordinated and
monitored at local level by local leaders with maximum participation
of community stakeholders.

Elements of a Campaign The following are the necessary elements
of an evidence-based campaign for OCV uptake combined with other
cholera prevention approaches:

• Coordination structure and internal communication system

• Communication micro plans or weekly plans with daily activities.

• Positioning key messages for different participant groups

• Advocacy with local leaders and influentials

• Social and community mobilization using IPC tools, IPC materials,
TV, radio, print media formats

• Media engagement

• IPC training of frontline workers

• Training of spokespersons

• Capacity building of implementers and stakeholders in
communication for development

• Working on resistance

• Communication protocol to respond to crisis and adverse events
following immunization

• Monitoring and evaluation protocol

76

TOOL 5. Organizing training on
interpersonal communication for health
workers and vaccinators
• Prepare a training needs assessment, a training plan, modules

and session plans with presentation materials and group dynamic
tools for groups that require strengthening skills in interpersonal
communication (IPC) and social mobilization.

• These are aimed at vaccinators, community health workers,
community mobilizers and youth volunteers.

• Be sure to integrate modules on IPC and social mobilization in the
practical component of the training of trainers (ToT) and training
rollout for vaccinators of OCV immunization.

• Select experienced training facilitators/consultants in IPC Skills
and Social Mobilization.

• Conduct the training in a timely manner, at least one month prior
to the start of programme activities.

• You can access some examples of training modules and session
facilitator’s guides on IPC and social/community mobilization. See
for example see: Training Manual on IPC18. These can be adapted
to the training needs of your specific training participants and
programme context.

18 Training Manual on Interpersonal Communication for Field Activators. Water and
Sanitation Programme, Government of Tanzania, USAID/BASICS (2009).

77

https://www.wsp.org/sites/wsp.org/files/publications/wsp-hwws-Training-Manual-on-Interpersonal-comm-tanzania

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• Zimbabwe: Cholera Information, Education and Communication
Materials – This section contains some Cholera Information, Education
and Communication materials that may be useful during the cholera
response. http://ochaonline.un.org/CholeraSituation/IPCMaterials/
tabid/5359/language/en-US/Default.aspx

• 100,000 cases – The spectre of cholera remains in Zimbabwe
www.redcross.org.au/files/Zimbabwe-Report.Pdf

1 See: WHO (2010). OCV in mass immunization campaigns: guidance for planning
and use, Annex 1.

2 During an outbreak, pregnant women may receive OCV according to protocol.

3 MSF (2013). Health Promotion and Cholera Vaccination Mass Campaign in Sudan,
January 2012.

4 Adapted from UNICEF ROSA (2006). Behaviour Change Communication in
Emergencies: A Toolkit, Tool 12, p. 219.

5 Training Manual on Interpersonal Communication for Field Activators. Water and
Sanitation Programme, Government of Tanzania, USAID/BASICS (2009).

88

http://www.pbs.org/idealab/2009/02/using-technology-in-the-fight-against-cholera-in-zimbabwe052.html

http://www.pbs.org/idealab/2009/02/using-technology-in-the-fight-against-cholera-in-zimbabwe052.html

http://ochaonline.un.org/CholeraSituation/IECMaterials/tabid/5359/language/en-US/Default.aspx

http://ochaonline.un.org/CholeraSituation/IECMaterials/tabid/5359/language/en-US/Default.aspx

http://www.redcross.org.au/files/Zimbabwe-Report

Photo Credits:
Page Cover: © UNICEF/UNI167510/Jallanzo
Page 6: © UNICEF/NYHQ0087-2011/Noorani
Page 9: © UNICEF/NYHQ1500-2012/Matas
Page 10: © UNICEF/NYHQ1348-2008/Nesbitt
Page 12: © UNICEF/NYHQ1354-2014/Pflanz
Page 15: © UNICEF/NYHQ0087-2011/Noorani
Page 18: © UNICEF/NYHQ1501-2012/Matas
Page 58: © UNICEF/UNI165181/Dormino
Page 60: © UNICEF/NYHQ1233-2014/Nesbitt
Page 62 (Left): © UNICEF/NYHQ1213-2013/Maitem
Page 62 (Right): © UNICEF/NYHQ1233-2014/Nesbitt

© United Nations Children’s Fund, September 2014

• TABLE OF CONTENTS
• ACRONYMS
• ACKNOWLEDGEMENTS
• INTRODUCTION

Intended users
Goal and Objective of OCV Communication

• PART 1: Guidelines for an Integrated Communication Strategy to Introduce Oral Cholera Vaccine
• Step 1: Establish a communication team and coordination mechanism
• Step 2: Conduct a rapid communication assessment
• Step 3: Plan your communication strategy
• Step 4: Design the creative strategy: key messages, channels and tools
• Step 5: Plan to monitor and evaluate
• Step 6: Document good practices and lessons learned
• Part 2: Resources and Tools
• Resource 1.5 Key messages on OCV and cholera prevention from Guinea
• Resource 1.4 OCV and cholera prevention leaflet from Haiti
• Resource 1.3 Poster on OCV from mass vaccination campaign in Orissa, India
• Resource 1.2 Leaflet on Oral Cholera Vaccine from Orissa, India
• Resource 1.1 Q & A Health Promoters Briefing Guide from Sudan
• TOOL 1. Sample template for behaviour analysis of participant groups in OCV introduction and chole
• TOOL 2. Sample template for a communication action plan for an OCV mass vaccination campaign in Cou
• TOOL 3. Monitoring checklist for OCV communication strategy implementation
• TOOL 4. Preparing for an OCV Communication Campaign
• TOOL 5. Organizing training on interpersonal communication for health workers and vaccinators
• References and Additional Resources with Links
• FIGURE 1: The key steps in communication planning
• FIGURE 2: Model of Socio-ecological Theory of Human Development
• FIGURE 3: The Strategic C4D Socio-Ecological Model
• Table 1: Sample behaviour and participant analysis: Identifying barriers and motivators to adoption
• Table 2: Key behaviour objectives to create/increase demand/uptake of OCV
• Table 3: Suggested checklist of activities for media engagement
• Table 4: Key messages for different audience groups/participants in oral cholera vaccination and ch
• Table 5: Illustrative behaviour monitoring and evaluation indicators for adoption of OCV and other c

Children and Youth Services Review 34 (2012) 1862–1867

Contents lists available at SciVerse ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

The relationship among deficiency needs and growth needs: An empirical
investigation of Maslow’s theory

Amity Noltemeyer ⁎, Kevin Bush, Jon Patton, Doris Bergen
Miami University, United States

⁎ Corresponding author.
E-mail address: anoltemeyer@muohio.edu (A. Nolte

0190-7409/$ – see front matter © 2012 Elsevier Ltd. All
doi:10.1016/j.childyouth.2012.05.021

a b s t r a c t

a r t i c l e i n f o

Article history:
Received 6 February 2012
Accepted 24 May 2012
Available online 1 June 2012

Keywords:
Maslow
Hierarchy of needs
Achievement
Health care
Family

Maslow’s (1954) influential theory suggests that children’s ability to be motivated by “growth needs”
(e.g., academic achievement) first requires satisfaction of “deficiency needs” (e.g., safety needs, love/belonging
needs). Given the vast number of children experiencing deficiency needs, a better understanding of these rela-
tionships can serve as a prerequisite for establishing conditions that maximize learning outcomes. In this
study, we examined Maslow’s model by testing the relationship between deficiency needs variables and growth
needs variables. Our sample was comprised of 390 economically disadvantaged students attending more than 40
schools in a Midwestern state in the U.S. Deficiency needs were measured using factors derived from a parent
survey and growth needs were measured using factors derived from a parent survey and results from an
individually-administered norm-referenced achievement test. Regression analyses were conducted to deter-
mine the relationship between a set of two deficiency needs variables (i.e., safety needs and love/belonging
needs) and four academic achievement outcome variables. All four regression models were significant, revealing
a positive relationship between deficiency needs and growth needs. The factor most significantly related to
achievement outcomes was access to health and dental care (a safety need). Implications for research and prac-
tice are discussed.

© 2012 Elsevier Ltd. All

rights reserved.

1. Introduction

An expansive body of literature has proposed a positive relation-
ship between unmet basic needs (e.g., poverty) and detrimental aca-
demic outcomes for children in schools. In fact, one influential theory
(Maslow, 1954) suggests that children’s ability to be motivated by
“growth needs” (e.g., academic achievement) first requires satisfaction
of “deficiency needs” (e.g., physiological needs, safety needs, and love/
belonging needs). Unfortunately, many children attending school in
the United States experience a high level of one or more deficiency
needs. For example, poverty, food insecurity, and parental unemploy-
ment have all risen among United States school-age children in recent
years (Federal Interagency Forum on Child and Family Statistics, 2010).

Concurrent with this increase in student deficiency needs that has
the potential to interfere with learning, schools are being held responsi-
ble for achieving increasingly high academic standards (see Zigler &
Finn-Stevenson, 2007). For example, the No Child Left Behind Act
(NCLB) (2001) has required schools to demonstrate accountability for
the outcomes of all students by making adequate yearly progress to-
wards the goal of having all students proficient in reading and math
by the 2013–2014 school year. Given the pressures schools are facing
to ensure the academic competency of all students — coupled with an

meyer).

rights reserved.

increasing proportion of the student population faced with “deficiency
needs” — it is important to better understand the relationship between
deficiency needs and student academic outcomes. Such an understand-
ing could inform prevention, intervention, and policy efforts. This study
sought to provide preliminary findings on this issue using data collected
as part of a large holistic case management program designed to help
families meet deficiency needs.

2. Maslow’s theory

Abraham Maslow is a preeminent 20th century psychologist whose
most enduring contribution to the field was his “hierarchy of needs” the-
ory. Maslow initially proposed that five basic needs — arranged in a hier-
archy from lower-order to higher-order — are essential to optimal human
existence. The lower-order needs, also called “deficiency needs,” include
physiological, safety, and love/belonging needs. Higher-order needs,
or growth needs, include esteem and self-actualization needs. School
achievement is considered an esteem need that falls within this
growth needs category. Maslow (1943) proposed that only when defi-
ciency needs were sufficiently met could an individual gradually and
fully progress to the achievement of growth needs:

It is quite true that man lives by bread alone — when there is no
bread. But what happens to man’s desires when there is plenty of
bread and when his belly is chronically filled?At once other (and
“higher”) needs emerge and these, rather than physiological hungers,

http://dx.doi.org/10.1016/j.childyouth.2012.05.021

mailto:anoltemeyer@muohio.edu

http://dx.doi.org/10.1016/j.childyouth.2012.05.021

http://www.sciencedirect.com/science/journal/01907409

1863A. Noltemeyer et al. / Children and Youth Services Review 34 (2012) 1862–1867

dominate the organism. And when these in turn are satisfied, again
new (and still “higher”) needs emerge and so on. This is what we
mean by saying that the basic human needs are organized into a
hierarchy of relative prepotency. (p. 375)

Maslow further postulated that although one level of need may
take precedence at a particular time, it is possible for an individual to
be motivated by multiple needs simultaneously. For example, a child
experiencing low levels of belongingness may still be able to attend to
esteem needs, though likely not as sufficiently as if belongingness needs
were fully met. In addition, Maslow suggested that even after deficiency
needs have been satisfied, they may again become motivating if threat-
ened at a later point. For example, a parent who suddenly loses his job
may find himself temporarily sacrificing growth needs (e.g., achievement
or self-esteem) in order to devote cognitive and emotional resources to
ensuring the satiation of deficiency needs (e.g., food security for her or
his family). Only when an individual has satisfied deficiency and growth
needs would Maslow suggest that he or she has reached an optimal
level of functioning.

If it is valid, Maslow’s theory would have implications for schools,
since all children are expected to achieve academically regardless of the
degree to which deficiency needs have been fulfilled. It is extremely
popular as an explanatory theory, full of intuitive appeal. However,
the research base supporting the theory has remained weak. In 1976,
Wahba and Bridwell discussed its “uncritical acceptance” despite the
lack of empirical evidence, and they reviewed 14 studies that found
only partial acceptance of the hierarchical model. Subsequently, limited
or conflicting empirical research has been conducted to verify the theory’s
validity (e.g., Michaels, 1988; Neher, 1991).

Despite the limited breadth of research on the topic and some find-
ings to the contrary, there have been several investigations conducted
across a variety of disciplines that provide limited evidence for portions
of Maslow’s theory. One early study indicated that respondents from
different socioeconomic levels identified needs at different levels of
the hierarchy, and that individuals from lower socioeconomic back-
grounds were more concerned with deficiency needs while individuals
from middle socioeconomic backgrounds were more concerned with
growth needs (Gratton, 1980). However, the researchers did not find
that a cluster analysis showed the concepts were unitary.

Using survey methodology, Acton and Malathum (2000) also docu-
mented a relationship between the levels of Maslow’s hierarchy. Specif-
ically, they discovered that individuals with higher levels of physical,
love/belonging, and self-actualization need satisfaction made better
decisions regarding health-promoting and self-care behaviors. Studies
on college-age populations have documented similar results. Lester,
Hvezda, Sullivan, and Plourde (1983), for example, tested a measure
of the degree of satisfaction of Maslow’s proposed needs on a sample
of 166 undergraduate college students. Consistent with Maslow’s theo-
ry, the researchers found that the level of basic needs satisfaction was
related to psychological health.

When considering our specific topic of interest, we saw one limitation
of these previous investigations was their focus on college or adult
populations. We found only one study that had examined Maslow’s the-
ory in the context of children in schools. Smith, Gregory, and Pugh (1981)
developed the Statements about Schools (SAS) inventory to assess how
well students’ needs were being met across four levels of Maslow’s hier-
archy (security, love/belonging, esteem, and self-actualization) in tradi-
tional and alternative schools. The researchers found that both students
attending alternative schools and their teachers reported greater levels
of student need fulfillment related to friendship and belonging, achieve-
ment, self-actualization, and personal growth. However, this study did
not specifically examine the causal pathways between deficiency
needs and academic achievement or whether achievement of lower-
level needs was a prerequisite for achievement of higher-level needs.

Overall, the extant research base has focused more on the growth
need outcomes of happiness and psychological adjustment rather

than on academic achievement. In addition, existing literature is out-
dated and focuses much more heavily on adult rather than on child
populations. Although not specifically focused on Maslow’s theory
(i.e., on the premise that lower-level needs must be fulfilled before
higher-level needs), there has been research supporting the link be-
tween deficiencies in basic needs (e.g., poverty) and risk for academic
failure in school children. A sampling of this research helps to better de-
fine and understand the scope of deficiency needs in American children
today.

3. Deficiency needs in America’s schools

As previously mentioned, children are increasingly entering school
with unmet physiological needs. For example, almost 1 in 5 children
lived in poverty in 2008, the highest rate since 1998, and this rate is
even higher for Black and Hispanic children (FIFCFS, 2010). In addition,
secure parental employment, at 75%, has reached its lowest levels since
1996 (FIFCFS, 2010). Perhaps not surprisingly considering these statistics,
22% of children live in homes with food insecurity (lack of access at all
times to enough food), the highest percentage recorded since monitoring
began in 1995 (FIFCFS, 2010). These figures are of concern, given that
children living in poverty are at an increased risk for academic failure.
For example, Smith, Brooks-Gunn, and Klebanov (1997) found that fam-
ily poverty exerted significant effects on child cognitive abilities and aca-
demic achievement, even after controlling for family structure. Although
many explanations have been posed (for a review see Bhattacharya,
2010; West, 2007), some research has suggested that this effect of family
poverty may be caused at least in part by less cognitively stimulating and
emotionally supportive home environments (e.g., Eamon, 2002). Addi-
tionally, findings that students attending high-poverty schools have
lower achievement levels than those who attend low-poverty schools
(see Orfield, Frakenberg, & Lee, 2002), suggest that school factors
(e.g., fewer resources, lower expectations, less experienced staff) may
also contribute to this phenomenon.

Love and belonging needs are also a concern for children in schools.
In 2008, the rate of substantiated reports of child maltreatment was 10
per 1000 children through age 17 (FIFCFS, 2010). However, this issue
goes far beyond overt maltreatment to also encompass effective parent-
ing and general feelings of parent–child warmth, closeness, positive
regard, and bonding. Research has indicated that above and beyond
poverty and physiological needs, family characteristics can and do influ-
ence child academic and cognitive development. Bean, Bush, McKenry,
and Wilson (2003), for example, found that parental support positively
predicted adolescents’ academic achievement. Similarly, Anderson,
Lindner, and Bejinion (1992) found that parent warmth, monitoring,
support, involvement, and absence of conflict are consistently related
to high levels of academic and social competence. The important role
of parental emotional support in the development of child academic
skills was also documented by Eamon (2002).

Safety is another type of deficiency need that can have an impact
on child academic and cognitive competence. Although a variety of
safety needs have the potential to influence achievement, one impor-
tant safety need is access to quality health and dental care. This is a
relevant issue in the United States, considering 7.5 million children
(10% of all children) do not have health insurance, and uninsured
children are less likely to access needed health care and dental ser-
vices (FIFCFS, 2010). Although there has been limited research on
the topic, some effects of health and dental care on academic achieve-
ment have been documented. For example, Kitzman et al. (2010) con-
ducted a randomized control trial in which they examined the effect
of prenatal and infancy home visits by nurses to parents on their
12-year-old children’s academic achievement. They found that the chil-
dren of parents who had been visited by nurses, compared to a control
group, scored higher on individually-administered reading and math
achievement tests and scored higher on group-administered reading
and math standardized tests during their first six years of school. Lack

1864 A. Noltemeyer et al. / Children and Youth Services Review 34 (2012) 1862–1867

of access to health care has been speculated to affect achievement in
multiple ways. For example, it may result in increased absences from
school, failure to address vision needs, the development of chronic ill-
ness or disability, and difficulty concentrating due to illness or injury
(see Coles, 2003).

It is clear that a sizeable proportion of the school-age population
experiences one or more of the aforementioned deficiency needs.
Two things missing are a clearer understanding of (1) how physiological
needs, safety needs, and love/belonging needs relate to each other and to
academic achievement, and (2) whether or not Maslow’s hierarchy can
be an explanatory factor that is empirically supported in a school-age
sample.

One school-focused initiative that addresses issues related to
Maslow’s hierarchy has the potential to lead to further understanding
of these issues: the Butler County Success Program (BCSP). BCSP was
designed to assist students in grades K-6 (and their families) who
qualify for Temporary Aid to Needy Families (TANF). The BCSP follows
a holistic case management approach centered around 15 liaisons
assigned to work in one or more of the 40 participating schools across
8 school districts (rural, suburban, and urban settings) in one county lo-
cated in a state in the Midwestern part of the U.S., in order to assess and
help families meet basic deficiency needs (e.g., parental involvement/
supervision, access to health care, childcare, healthy food, transporta-
tion and service utilization, and financial services/resources).

Results of a recent evaluation study suggest that the BCSP has been
effective at increasing children’s positive outcomes (e.g., children’s
cognitive/academic and social competence), families’ access to basic
needs (e.g., healthy food, transportation, and medical care) and positive
parenting and parental involvement in school (Bush & Bergen, 2011).
Despite the importance of these findings, this study focused holistically
on whether or not participating students experienced more positive ac-
ademic outcomes when deficiency needs were addressed. Research has
not yet examined the relationships between particular deficiency needs
(e.g., physiological, safety, and love/belonging needs) and specific growth
needs (e.g., academic and cognitive outcomes). Examination of this issue
could have implications beyond the BCSP to serve as one piece of empir-
ical evidence to support, refute, or further clarify Maslow’s (1954) theory
while concurrently suggesting which needs might have the most cost
effective impact in terms of improving academic outcomes. The latter
contribution potentially could serve as useful information for programs
with limited resources trying to determine which needs to address with
initial supportive efforts.

4. Purpose of the study

Maslow’s (1954) influential theory suggests that children’s ability
to be motivated by growth needs (e.g., academic achievement) first re-
quires satisfaction of deficiency needs (e.g., safety needs, love/belonging
needs). Given the vast number of children experiencing deficiency
needs, a better understanding of these relationships can serve as a pre-
requisite for establishing conditions that maximize learning outcomes.
In this study, we examined Maslow’s model by testing the relationship
between deficiency needs variables and growth needs variables. We
were interested in learning more about the relationship between phys-
iological needs, safety needs, love/belonging needs, and three academic
student outcomes.

5. Methodology

5.1. Participants

Participants in the study included all students in the BCSP for whom
data on each of the variables were collected during the 2009–2010 school
year. This equated to 389 students in kindergarten through sixth grade
attending 43 schools in one county of a Midwestern U.S. state. All

participants live in families qualifying for Temporary Aid to Needy Fami-
lies (TANF) and would be considered economically disadvantaged.

5.2. Measures

5.2.1. Parent surveys
The parent survey included 81 items answered using a 4-point Likert

scale response format (See Bush & Bergen, 2011, for more details). The
response options for each item ranged from strongly agree (4 points)
to strongly disagree (1 point). Survey items designed to assess a variety
of basic physiological and safety needs were created by the research
team for the purpose of evaluating the BCSP initiative. In addition to
these items, parenting behavior was assessed with seven items from
the Parenting Behavior Measure (Peterson, Rollins, & Thomas, 1985); fam-
ily togetherness was assessed with two items derived from the Family
Adaptation and Cohesion Scale (Olson, 2000); parental optimism was
assessed with five items from the Life Orientation Test — Revised (LOT-R,
Scheier, Carver, & Bridges, 1994); and children’s social, cognitive, reading
and behavioral competence were assessed with a total of 17 items from
Harter’s (1982) Perceived Competence Scales.

5.2.2. Mini Battery of Achievement (MBA)
The MBA (Woodcock, McGrew, & Werder, 1994) is an abbrevi-

ated version of the Woodcock–Johnson Tests of Achievement. It is an
individually-administered assessment designed for individuals ages 4
through adult. The MBA screens in four areas: Reading, Writing, Mathe-
matics, and Factual Knowledge. A Basic Skills combined standard score is
derived from the first three of those areas. The test was normed with a
6026 randomly selected stratified subject sample from 100 diverse geo-
graphic communities. It has demonstrated reliability and concurrent va-
lidity with similar tests.

5.3. Procedures

All data were collected between September 2009 and February of
2010. Data were obtained for each student upon their referral to the
BCSP. BCSP liaisons explained the opportunity to participate in the
evaluation study to all eligible participants upon the first home visit. If
the parent agreed, the informed consent process took place, and the
pre-test surveys were administered either by the BCSP liaisons (90%)
or a trained research assistant (10%).

The MBA was administered to the participating children in the
school setting by either the BCSP liaison or the trained research assis-
tant. After training on administering and scoring the instrument, the
examiners were also provided feedback on their administration and
scoring by an external, trained graduate assistant. Testing procedures
were conducted in accordance with the protocol specified by the test
designers.

5.4. Independent variables

An exploratory factor analysis was conducted using the items from
the parent survey, in an effort to identify the latent constructs that un-
derlie the observed variables (Leech, Barrett, & Morgan, 2008). Principal
axis factor analysis with varimax rotation was conducted to assess the
underlying structure for the items on the survey. In addition to the as-
sumptions of normality, linearity, and independence, several additional
assumptions of factor analysis were tested and found to be tenable.
First, the Kaiser–Meyer–Olkin (KMO) measure value of .774 was greater
than the recommended .70, indicating sufficient items for each factor
(Leech et al., 2008). Also, the Bartlett test was significant at b.001, indi-
cating that the variables are correlated at a high enough level to provide
a solid basis for using factor analysis (Leech et al., 2008).

The eigenvalues (>1.0) support that the items can be reduced to
16 factors. However, examination of the screen plot suggests that after
the first two components, differences between the eigenvalues decline

Table 1
Items for each of the two predictor variables.

Factor name Items loading on the factor
Love/belonging
needs

29) I tell _______(insert child’s name) how much I love him/her.
32.) I explain to _______(insert child’s name) how good he/she
should feel when he/she does what is right.
41) I enjoy doing things with _______(insert child’s name).
42) I share many activities with _______(insert child’s name).
44) I feel close to _______(insert child’s name).
45) I know where _______(insert child’s name) is after school.
46) I know where _______(insert child’s name) is at all times
during the day.
53) I make _______(insert child’s name) feel that I will be there if
he/she needs me.
54) I am satisfied being the parent of _______(insert child’s name).

Safety needs 17) _______(insert child’s name) can see a doctor easily when he/
she is sick.
19) I have either private or state medical insurance to provide
for _______(insert child’s name) health needs.
21) _______(insert child’s name) receives poor dental care.a

64) _______(insert child’s name) sees a dentist when he/she
needs dental care.
66) I am able to get medical care for _______(insert child’s name)
at a medical clinic or hospital.

a Items were reverse coded.

1865A. Noltemeyer et al. / Children and Youth Services Review 34 (2012) 1862–1867

substantially (see Fig. 1). This finding, coupled with the fact that the first
two factors corresponded to deficiency needs on Maslow’s hierarchy,
led us to focus only on them. These two factors, which together account
for approximately 30.35% of the variance, were titled Safety Needs
(“SAFETY”) and Love/Belonging Needs (“LOVE”). SAFETY represents
only one of many safety needs. Specifically, this variable was the aver-
age score from a five-item factor on the parent report scale that mea-
sures access to health and dental care. The LOVE variable measures
love, warmth, positive regard, and closeness between the parent and
child. It represents the average score of the 11 items that comprise
that factor. Reliabilities of these two scales were within an acceptable
range (Chronbach’s alpha=.70 for SAFETY and .93 for LOVE). See
Table 1 for the items comprising each independent variable. The third
factor, which assessed physiological needs (PHYSIO) was also considered
for inclusion in the study. However, we decided not to use it given the
substantial decline in eigenvalue coupled with the low mean value, low
reliability (Chronbach’s alpha=.66), and low correlation of the factor to
other factors.

5.5. Dependent variables

There were four dependent variables investigated in this study, all
of which are indicators of growth needs.

5.5.1. MBA reading score
This variable, “MBAread” is a standard score from the previously

described MBA achievement test (Woodcock et al., 1994). The stan-
dard score has a mean of 100 and a standard deviation of ten. The score
assesses reading achievement.

5.5.2. MBA basic score
This variable, “MBAbasic” is also a standard score from the MBA

achievement test (Woodcock et al., 1994). This score, which also has a
mean of 100 and standard deviation of 10, is designed to assess a broad
spectrum of academic skills such as reading, writing, and mathematics.

5.5.3. Harter scale cognitive
This is a five-item factor (alpha coefficient of 0.57 within the cur-

rent data), referred to as “COG,” from the parent report Harter (1982).
This factor assesses parent perceptions of their child’s cognitive com-
petence. See Table 2 for the items comprising this scale.

5.5.4. Harter scale reading
This is a three-item factor (alpha coefficient of 0.67 within the current

data) from the parent report Harter (1982). Referred to as “READ,” this

Fig. 1. Scree plot.

factor assesses parent perceptions of their child’s reading competence.
See Table 2 for the items comprising this scale.

5.6. Analysis

After the factors were identified, the composite variable scale,
corresponding to each factor of interest, was obtained by averaging the
nonmissing values of the items making up that factor. Four regression
analyses were conducted. The purpose of these analyses was to deter-
mine the relationship between each of the four academic achievement
outcome variables (i.e., MBAread, MBAbasic, COG, and READ) and the
two deficiency needs variables (i.e., LOVE and SAFETY). Specifically, we
wanted to know how well the combination of the deficiency needs vari-
ables predicted each of the outcome variables. To this end, four separate
models were analyzed. Each model used LOVE and SAFETY as predictor
variables; however, Model 1 used READ as the outcome variable, Model
2 used MBAread as the outcome variable, Model 3 used MBAbasic as
the outcome variable, and Model 4 used COG as the outcome variable.

Multicollinearity was not an issue that would be expected to impact
the results of these analyses since the independent variables are factor
scales. Even after varimax rotation, their original orthogonality between
other factors would not be greatly compromised. However, as a check,
we calculated the variance inflation factor (VIF) for each variable in
each regression. VIF values were between 1.2 and 1.5. Because only

Table 2
Items on the COG and READ factors.

Factor Items loading on the factor

Parent-reported child
cognitive abilities (COG)

15) _______(insert child’s name) has trouble figuring
out the answers in school
18) _______(insert child’s name) has difficulty
understanding what he/she reads.a

55) _______(insert child’s name) is pretty slow at
finishing his/her school work.a

57) _______(insert child’s name) is very good at his/
her homework
59) _______(insert child’s name) is just as smart as
other kids his/her age.

Parent-reported child
reading abilities (READ)

26) I believe that _______(insert child’s name) reads at
or above his/her grade level.
62) _______(insert child’s name) needs a lot of help
with reading. a

69) _______(insert child’s name) reads poorly for his/
her grade level. a

a Items were reverse coded.

Table 4
Regression analysis summary for SAFETY and LOVE predicting READ.

Variable DF Parameter estimate Standard error t value Pr>t

Intercept 1 1.72 0.35 4.97 b.0001
LOVE 1 0.04 0.10 0.40 0.69
SAFETY 1 0.25 0.08 2.94 0.004

1866 A. Noltemeyer et al. / Children and Youth Services Review 34 (2012) 1862–1867

VIF values greater than 10 indicate that multicollinearity is severe enough
to be a problem, we determined this was not a concern.

6. Results

See Table 3 for means, standard deviations, and intercorrelations for
each of the variables. When analyzed with regression, Model 1 revealed
that READ had a significant relationship with the predictor variables,
F(2, 358)=6.26, pb .01. Specifically, parent-reported child reading abil-
ities were significantly associated with SAFETY (see Table 4). Increases
in health and safety need fulfillment were associated with increases in
parent-reported child reading skills. The adjusted R squared value was
.03, indicating that approximately 3% of the variance in READ was
explained by the overall model.

Model 2 also revealed a significant relationship between COG and
the predictors, F(2, 362)=11.41, pb.0001. In this model, however,
the relationship was significant when considering both LOVE and
SAFETY (see Table 5). Overall, the model explained approximately
5.41% of the variation in COG. Increases in LOVE and SAFETY need ful-
fillment were associated with increases in parent-reported child cog-
nitive competence.

In the third model, a significant relationship between the two de-
ficiency needs and MBAbasic was also documented, F(2, 274)=7.28,
pb.001. The overall model explained 4.35% of the variation in MBAbasic.
This relationship was significant only when considering SAFETY (see
Table 6). Increases in health and safety need fulfillment were associated
with increases in performance on the MBA basic skills assessment.

Finally, a significant relationship between MBAread and the predic-
tors also emerged, F(2, 274)=7.78, pb .001. However, this relationship
was significant only when considering SAFETY (see Table 7). Higher
health and safety need fulfillment was associated with higher perfor-
mance on the MBA reading test. The overall model explained 4.68% of
the variance in reading scores on the MBA test.

7. Discussion

7.1. Summary

This study provides some support for Maslow’s assertion that growth
needs such as academic progress may be positively related to improve-
ments in deficiency needs such as safety and love/belonging. The signifi-
cant positive relationships among these variables also indicates that
programs such as the BCSP, which attempt to diminish deficiency needs
of students, can have an indirect effect on their academic growth. This is
consistent with the call from Zigler and Finn-Stevenson (2007) that to
improve learning outcomes, “…we believe that educators must address
not only cognition and academics, but other developmental pathways
(e.g., physical and mental health, social–emotional behaviors) that
strongly contribute to school performance (p. 175).”

Specifically, results indicated that access to health and dental care —
a safety need — evidenced a consistently significant relationship with
each of the four academic outcome variables. As access to health and
dental care increased, higher levels of academic and cognitive perfor-
mance were found on both parent-reports and direct skill assessments.
It is possible that having access to health and dental care allows students

Table 3
Means, standard deviations, and intercorrelations for children’s reading/cognitive skills and

Variable N Mean Standard deviation 1

1. MBAbasic 291 92.02 17.49 –
2. MBAread 291 100.05 17.76 .9
3. COG 381 2.74 0.39 .1
4. READ 375 2.65 0.72 .2
5. HEALTH 381 3.17 0.51 .2
6. LOVE 365 3.54 0.40 .1

⁎pb .05, ⁎⁎pb.001.

to miss less instruction due to major medical or dental issues, since pre-
vention and early intervention care can be provided to address issues
before they become severe enough to warrant absence from school.
Also, it is possible that students who do not have access to medical or
dental care may have medical issues that could directly affect their ability
to learn. For example, untreated vision and hearing problems can result in
difficulties processing the input of learning. In addition, children with
untreated allergies, asthma, Attention Deficit Disorder, and other condi-
tions may have more difficulty attending to school instruction. These re-
lationships are particularly concerning given the alarming proportion of
children who do not have medical insurance coverage (FIFCFS, 2010).

Interestingly, love and belonging need fulfillment was less consis-
tently related to the child academic outcomes. When considering the
unique relationship of love and belonging needs with each outcome
variable, only one significant relationship was found, and that was
with parent-reported child cognitive abilities. Although it is interesting
that more significant relationships were not found, it should be noted
that this variable had the highest mean score and the lowest standard
deviation of all of the factors. Consequently, it is possible that variations
in outcomes were not found because there was no sufficient variation —
or deficits — in the love and belonging needs variable itself.

7.2. Limitations

There are several limitations that should be considered when inter-
preting these findings. First, and foremost, it is important to note that
causal conclusions cannot be drawn. Although we would intuitively as-
sume that lack of access to health and dental care would negatively im-
pact academic performance, it is possible that the safety needs variable
served as a proxy for some other construct. For example, it is possible
that lack of health care access is an indicator of family stress or some un-
known economic variable. This is unlikely, however, given non-significant
correlations between the safety needs variable and the physiological
needs variable, as well as between the safety needs variable and family
cohesion.

A second limitation is that fidelity of data collection was not checked.
Although the research assistants and liaisons were provided with high
quality training, inter-rater agreement for administration and scoring
was not conducted. Consequently, it is possible there could be some
error in the scores. In addition, the reliability of the COG and READ scales
was questionable, revealing the need to interpret these results with cau-
tion as well as the need for further research on these constructs.

Finally, there were limitations with the sample that should be ac-
knowledged. For example, all participants had economic needs and
came from one region of the U.S. Consequently, the degree to which
the results can be generalized to more heterogeneous samples is un-
known. Although participants came from 43 different schools in one

parent-reported predictor variables.

2 3 4 5 6

1⁎⁎ –
2⁎ .13⁎ –
6⁎⁎ .27⁎⁎ .56⁎⁎ –
2⁎⁎ .22⁎⁎ .24⁎⁎ .20⁎⁎ –
3⁎ .15⁎ .20⁎⁎ .10 .46⁎⁎ –

Table 7
Regression analysis summary for SAFETY and LOVE predicting MBAread.

Variable DF Parameter estimate Standard error t value Pr>t

Intercept 1 64.85 9.83 7.00 b.0001
LOVE 1 1.61 3.21 0.50 0.62
SAFETY 1 7.94 2.65 3.00 0.003

Table 5
Regression analysis summary for SAFETY and LOVE predicting COG.

Variable DF Parameter estimate Standard error t value Pr>t

Intercept 1 1.94 .177 10.95 b.0001
LOVE 1 0.13 0.05 2.38 0.02
SAFETY 1 0.11 0.04 2.60 0.01

1867A. Noltemeyer et al. / Children and Youth Services Review 34 (2012) 1862–1867

county, including rural, urban and suburban settings, structural effects
of schools were not considered (because of the relatively small sample
sizes across the 43 settings). Also related to the sample, it is possible
that the proportion of variability (r2) explained by each independent
variable might be low because the sample was large and there was
quite a bit of variability between people in the study.

7.3. Implications

These limitations inform several implications for research. For ex-
ample, future research with more sophisticated analysis techniques
(e.g., structural equation modeling) could be used to look more closely
at the causal paths between variables. Although this study provides
some support for Maslow’s theory, this type of research could more pre-
cisely examine the degree to which the fulfillment of deficiency needs is
a prerequisite to the fulfillment of growth needs. Also, researchers could
consider using a randomized control trial where the treatment group is
given intervention on safety/health needs and the control group is not.
After exploring the impact of the intervention on academic and cognitive
outcomes, we would be more certain about the nature of the relationship
and the potential for intervention to improve learning outcomes.

However, despite the study’s limitations, several implications for
practice also emerged. Although more research is clearly needed, it
appears that there may be a relationship between deficiency needs
and learning outcomes. Most notably, it seems wise to assume that
efforts to improve health/safety needs and those to improve belonging-
ness would have an impact on students’ abilities to attend to — and
profit from — instruction. There is already initial support for this notion
(e.g., Kitzman et al., 2010). Schools are an ideal place to connect families
with these services, given the fact that all families access schools in
some way. Therefore, schools should consider intensifying their rela-
tionships with various social service and medical agencies, and investi-
gate how they may be able to partner and connect families with the
services they need to promote children’s well-being.

Acknowledgments

We would like to thank the director of the Butler County Success
Program for her unwavering support of this evaluation study. We
would also like to thank the Butler County Educational Service Center,
Butler County Job and Family Services, schools and personnel in par-
ticipating school districts for their support of and involvement in the
Butler County Success Program and this evaluation. We are very grate-
ful for the invaluable assistance of the school-community Liaisons and
Miami University graduate and undergraduate students in collecting
and coding data. Most importantly, we would like to thank all the chil-

Table 6
Regression analysis summary for SAFETY and LOVE predicting MBAbasic.

Variable DF Parameter estimate Standard error t value Pr>t

Intercept 1 64.57 9.66 6.68 b.0001
LOVE 1 0.36 3.15 0.12 0.91
SAFETY 1 8.12 2.59 3.13 0.002

dren, parents, and teachers for their time and participation in this eval-
uation study.

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http://dx.doi.org/10.1007/BF00305612

http://dx.doi.org/10.1111/1467-8624.ep8587568

• The relationship among deficiency needs and growth needs: An empirical investigation of Maslow’s theory

1. Introduction
2. Maslow’s theory
3. Deficiency needs in America’s schools
4. Purpose of the study
5. Methodology
5.1. Participants
5.2. Measures
5.2.1. Parent surveys
5.2.2. Mini Battery of Achievement (MBA)
5.3. Procedures
5.4. Independent variables
5.5. Dependent variables
5.5.1. MBA reading score
5.5.2. MBA basic score
5.5.3. Harter scale cognitive
5.5.4. Harter scale reading
5.6. Analysis
6. Results
7. Discussion
7.1. Summary
7.2. Limitations
7.3. Implications
Acknowledgments
References

Demographic

Research a free, expedited, online journal
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in the population sciences published by the
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Konrad-Zuse Str. 1, D-18057 Rostock · GERMANY
www.demographic-research.org

DEMOGRAPHIC RESEARCH

VOLUME 21, ARTICLE 13, PAGES 367-384
PUBLISHED 01 OCTOBER 2009
http://www.demographic-research.org/Volumes/Vol21/13/
DOI: 10.4054/DemRes.2009.21.13

Research Article

Determinants of infant and child
mortality in Zimbabwe:
Results of multivariate hazard analysis

Joshua Kembo

Jeroen K. Van Ginneken

© 2009 Joshua Kembo & Jeroen K. Van Ginneken.

This open-access work is published under the terms of the Creative Commons
Attribution NonCommercial License 2.0 Germany, which permits use,
reproduction & distribution in any medium for non-commercial purposes,
provided the original author(s) and source are given credit.
See http:// creativecommons.org/licenses/by-nc/2.0/de/

ogailyH
Highlight

Table of Contents

1 Introduction 368

2 Data and methodology 369
2.1 Model specification 369
2.2 Source of data 371
2.3 Statistical methods 371

3 Results 374
3.1 Infant mortality 374
3.2 Child mortality 375

4 Discussion and conclusions 381

5 Acknowledgements 382

References 383

Demographic Research: Volume 21, Article 13

Research Article

http://www.demographic-research.org 367

Determinants of infant and child mortality in Zimbabwe:
Results of multivariate hazard analysis

Joshua Kembo1

Jeroen K. Van Ginneken2

Abstract

This study addresses important issues in infant and child mortality in Zimbabwe. The
objective of the paper is to determine the impact of maternal, socioeconomic and
sanitation variables on infant and child mortality. Results show that births of order 6+
with a short preceding interval had the highest risk of infant mortality. The infant
mortality risk associated with multiple births was 2.08 times higher relative to singleton
births (p<0.001). Socioeconomic variables did not have a distinct impact on infant mortality. Determinants of child mortality were different in relative importance from those of infant mortality. This study supports health policy initiatives to stimulate use of family planning methods to increase birth spacing. These and other results are expected to assist policy makers and programme managers in the child health sector to formulate appropriate strategies to improve the situation of children under 5 in Zimbabwe.

1 Joshua Kembo is a Senior Researcher in the Bureau of Market Research (BMR) at the University of South
Africa (UNISA). He recently completed his PhD (Epidemiology) in the School of Health Systems and Public
Health (SHSPH) at the University of Pretoria. Corresponding contact e-mail address is kemboj@unisa.ac.za.
2 Jeroen Van Ginneken is Visiting Professor, School of Health Systems and Public Health, University of
Pretoria and Honorary Fellow, NIDI, The Hague.

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

368 http://www.demographic-research.org

1. Introduction

Using the multivariate Proportional Hazards Regression Models this paper presents an
analysis of the impact of maternal, socioeconomic and sanitation variables on infant and
child mortality. The results presented in this paper were obtained from highly reliable
data collected as part of the Demographic and Health Survey conducted in Zimbabwe in
2005-06. The overall purpose of the paper is to determine the relative importance of
various maternal, socioeconomic and sanitation variables on infant and child mortality
in Zimbabwe between 1996 and 2005. In particular, the study will focus on the
relationship between infant and child mortality and birth order, preceding birth interval
and, maternal age at birth. Models will then be introduced to control for other relevant
socioeconomic and sanitation variables.

Using the results of multivariate analysis of data from 16 countries presented by
Hobcraft, McDonald and Rutstein (1984), Cleland and Van Ginneken (1988)
demonstrate that shifts in the reproductive pattern (as measured by birth interval, birth
order and maternal age) cannot explain the relationship between education and child
mortality. However, when Behrman (1988) uses data that permits controlling for the
education of a woman’s siblings, the education effect nearly disappears. One
interpretation of this finding is that the previously reported effects of maternal
education may simply be the effect of unobserved familial abilities and motivation
passed on from the mother.

Zerai (1996) examined socio-economic and demographic variables in a multi-level
framework to determine conditions influencing infant survival in Zimbabwe. He
employed Cox regression analysis to the 1988 Zimbabwe DHS data to study
socioeconomic determinants of infant mortality. The unique finding was that women’s
average educational levels in their community exerts a greater influence on infant
survival than the mother’s educational level. This result supports assertions that child
survival is strongly impacted by mass education (Cleland and van Ginneken 1988).

However, the author did not show the differential impact of the independent variables
on infant and child mortality. The current paper seeks to fill this gap in the existing
literature on childhood mortality, by analyzing how child and infant mortality are
differently impacted by the aforementioned variables, particularly for Zimbabwe.

Bicego (1990) applied a three-step procedure using proportional hazards
regression to estimate trends and determinants of childhood mortality in Haiti. He used
the data from the 1987 Mortality, Morbidity and Services Utilization Survey (EMMUS)
in Haiti. Maternal education and low age at birth were found to have marked effects on
neonatal survivorship but little effect thereafter. Indices that reflect community-level
access to child health services were shown to be important especially during childhood.

Demographic Research: Volume 21, Article 13

http://www.demographic-research.org 369

Manda (1999) used data from the 1992 DHS in Malawi to study the relationship
between infant and child mortality and birth interval, maternal age at birth and, birth
order, with and without controlling for other relevant explanatory variables. He also
investigated the direct and indirect (through its relationship with birth intervals) effects
of breastfeeding on childhood mortality. The study employed proportional hazards
models. The results show that birth interval and maternal age effects are largely limited
to the period of infancy.

As the child increases in age, the influence of social and economic variables on the
mortality risk is enhanced, and the relationship between biodemographic variables and
mortality risk is strengthened. The study further shows that breastfeeding status does
not significantly alter the effects of preceding birth interval length on mortality risk, but
does partially diminish the succeeding birth interval effect.

It is clear from the review of the literature above that the Cox proportional hazards
model was rarely used in the study of the determinants of infant and child mortality in
Zimbabwe. It is against this background that this paper will show the impact of several
independent variables on infant and child mortality. Our results offer an in-depth use of
DHS data and are expected to improve the understanding of the mortality situation of
children under five in Zimbabwe and of other African countries as well. Our results
should be of interest to people working with Zimbabwe and on other studies that
analyse child mortality risks. The next section deals with the methodological approach
that we used in this study.

2. Data and methodology

2.1 Model specification

Childhood mortality is analysed in two age periods: mortality from birth to the age of
12 months, which will be referred to as “infant mortality”; and mortality from the age of
12 months to the age of 60 months, which will be referred to as “child mortality”. In
both cases the dependent variable is risk of death occurring in an age interval in a
period, such as from birth to age one, in a calendar year. Based on the Mosley and Chen
(1984) determinants of childhood morbidity and mortality framework, the independent
variables that we studied in this paper were:

• Maternal (and related) factors: (child’s birth order, preceding birth

interval, maternal age, child’s sex, type of birth),
• Socioeconomic variables: (maternal education, paternal education,

wealth index and area of residence),

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

370 http://www.demographic-research.org

• Sanitation: (source of drinking water and toilet facility).

The outcome variable is the hazard ratio (relative risk) of dying in a specific age

range of childhood. The age ranges that we use in this paper are:

• Infant mortality (1q0): the probability of dying between birth and the
first birthday), and,

• Child mortality (4q1): the probability of dying between the exact age
one and the fifth birthday.

We now discuss the justification for the inclusion of the independent variables in

this study. Previous studies have shown that short birth intervals (less than or equal to
18 months), high parity (6 or more children), low maternal age (less than 20 years) and
high maternal age (35 and more years) adversely impact infant and child mortality
(Bicego 1990; Zerai 1996; Manda 1999). We will elaborate more on this point in
section 3 when we present the results from the Cox Proportional Hazard Models.
Socioeconomic variables such as wealth status determine the availability of nutritional
resources, which is especially important because once infants reach the age of 6
months; they can no longer depend on nourishment from breast milk alone.

Mother’s education is important because it facilitates her integration into a society
impacted by traditional customs, colonialism, and neo-colonialism. Education heightens
her ability to make use of government and private health care resources and it may
increase the autonomy necessary to advocate for her child in the household and the
outside world (Caldwell 1989). Distinct childhood mortality differentials by place of
residence (rural-urban) have been observed in Zimbabwe (Zimbabwe Central Statistical
Office/ Macro International Inc, 2007). These mortality differences are a result of
regional differences in health infrastructure, and communication and disease prevalence
conditions. Place of delivery is also an important determinant of mortality, particularly
neonatal mortality. Children delivered in modern health facilities usually exhibit lower
rates of mortality. However, in some cases, mortality among children delivered in
modern facilities is observed to be higher because mothers use these facilities mostly
when they have pregnancy complications.

In Zimbabwe, household contamination is still a big problem. Piped water is
provided to a minority of households. Only 36 percent of households have water piped
into the dwelling, yard or plot, while 5 percent of households use a public tap or
standpipe (ibid). Sanitation measures are still not adequate in Zimbabwe. Improvements
in hygienic sanitation facilities lower mortality through the mechanism of less exposure
of children to contamination making them less susceptible to disease and eventually
death. Only 40 percent of households in Zimbabwe have access to improved toilet

Demographic Research: Volume 21, Article 13

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facilities that are not shared with other households (ibid). This evidence confirms the
importance of sanitation in the study of determinants of childhood morbidity and
mortality.

It is against this background that in this paper we study the selected demographic
and socio-economic variables discussed above in order to determine their differential
impact on infant and child mortality in Zimbabwe. Other variables from the classical
proximate determinants model such as nutrient availability and incidence of injury are
not examined because of the absence of sufficient information on the variables
themselves from the 2005-06 ZDHS survey data.

2.2 Source of data

The study used highly reliable data collected from the 2005-06 ZDHS survey. The
2005-06 ZDHS survey collected data from a sample of 8,907 women aged 15-49 years
and 7,175 men aged 15-54 years (ibid). This ZDHS is the fourth comprehensive survey
conducted in Zimbabwe as part of the Demographic and Health Surveys (DHS)
programme. The DHS are a rich source of data on developing countries in general, and
Africa in particular. The empirical analysis in this paper for the independent variables is
restricted to 10 years before the 2005-06 ZDHS survey, that is 1996-2005, so that the
hazard ratios are based on a sufficient number of cases in each category to ensure
statistically reliable estimates.

2.3 Statistical methods

The Child Data file that was used in this study was constructed from the Individual
Woman’s Data file – Individual Recode (IR) from the 2005-06 ZDHS survey using the
CASESTOVARS command in SPSS 16.0 (SPSS Inc 2008). The data were adjusted for
sampling weights using the WEIGHT command available in SPSS 16.0. The COXREG
survival analysis command in SPSS 16.0 was further used to compute the Cox
proportional hazard ratios. The significance tests in the hazard models were performed
at three levels, that is, “p<0.05”, “p<0.01” and “p<0.001”.

The Proportional Hazards Model, which stems from the work of Cox (1972),
assumes that for an individual with a vector of covariates in x, the hazard rate (death
rate) at time t is given by:

hi(ti; xi) = ho(ti)exp(β

ixi)

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

372 http://www.demographic-research.org

where hi(ti; xi) is the underlying hazard function at time t for x=0 (that is, all covariates
at their appropriate reference levels) and βi is a vector of unknown coefficients of
covariate effects.

Table 1: Absolute and percent distribution of explanatory covariates
1996-2005, (2005-06 ZDHS)

Maternal covariate Number of live births %
Number of

under-

5 deaths
%

Birth order & preceding
birth interval

First births
2-5 and short
2-5 and medium
2-5 and long
6+ and short
6+ and medium
6+ and long

3,046
239
333

4,900
61
74

836

32.1
2.5
3.5

51.6
0.6
0.8
8.8

185
43
28

271
15
12

51

30.6
7.1
4.6

44.9
2.4
2.0
8.4

Maternal age
<20 years 20-29 years 30-39 years 40-49 years

2,018
5,266
1,953
254

21.3
55.5
20.6
2.7

131
318
135
19

21.7
52.8
22.4
3.1

Sex of child
Female
Male

4,619
4,872

48.7
51.3

286
317

47.4
52.6

Type of birth
Multiple
Singleton

277

9,213

2.9

97.1

51

552

8.5

91.5
Total 9,491 100.0 603 100.0

Demographic Research: Volume 21, Article 13

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Table 1: (Continued)

Socioeconomic
Covariate

Number of live
births

%
Number of under-

5 deaths
%

Residence

Rural
Urban

6,720
2,770

70.8
29.2

440
163

72.9
27.1

Maternal education

No education
Primary
Secondary and higher

500
3,689
5,301

5.3
38.9
55.9

29
247
328

4.8
40.9
54.3

Paternal education

No education
Primary
Secondary and higher

798
2,754
5,938

8.4
29.0
62.6

60
168
374

10.0
27.9
62.1

Wealth status

Poor
Medium

4,292
1,651

45.2
17.4

285
110

47.3
18.2

Total 9,491 100.0 603 100.0

Piped drinking water
Yes
No

Flush toilet
Yes
No

3,182
6,309

2,689
6,801

33.5
66.5

28.3
71.7

194
409

155
448

32.1
67.9

25.7
74.3

Total 9,491 100.0 603 100.0

The total number of live births between 1996-2005 was 9,491. The number of

under-5 deaths during the same period was 603. Of these deaths, 465 occurred during
infancy (0-11 months) and 138 during childhood (12-59 months). The distribution of
some explanatory variables over the total sample at risk in the overall age interval 0-59
months is presented in Table 1.

Having discussed the methodological approach in this section, we now present the
results in the next section.

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

374 http://www.demographic-research.org

3. Results

3.1 Infant mortality

The models consisting of all maternal, socioeconomic and sanitation variables are
presented in Table 2. Model I consists of maternal reproductive variables only while
model II includes socioeconomic variables with maternal reproductive variables.
Finally, model III incorporates the remaining sanitation variables.

In model I the mortality risk ratios for birth order and preceding birth interval are
in the expected direction. Births of order six or higher with short preceding birth
intervals have the highest mortality risk. Infants with these characteristics are 2.75 times
more likely to die in infancy relative to births of order two through five with long
preceding birth intervals (p<0.001). Infants of order two through five with short preceding birth intervals experience 37 percent higher risk than infants of order two through five with long preceding birth intervals (although this result did not reach statistical significance). These results, considered together, highlight the importance of parity and birth spacing in determining infant survival. High parity (birth order of 6+) and short preceding birth intervals (intervals less than or equal to 18 months) predispose children to a higher risk of mortality during infancy. Results in model I further show that maternal age of less than 20 years of age increases the risk of infant mortality by 15 percent relative to maternal age between 30 and 39 (not statistically significant). Low (less than 20 years) and high (40-49 years) maternal ages predispose children to elevated mortality risks during infancy. Multiple births are associated with an elevated mortality risk. The infant mortality risk associated with multiple births is 2.08 times greater than among single births (p<0.001).

Model II extends model I through the addition of socioeconomic controls
including place of residence, maternal education, paternal education and wealth index
(see Table 2). Infants of order 6 or higher with short preceding interval continue to
exhibit the highest risk of death. The probability of such infants dying in infancy is 2.89
times more relative to infants of orders two through five with long preceding intervals.
The U-shaped relationship of maternal age and infant mortality is not altered in the
presence of maternal and socioeconomic variables. Model II presented in Table 2 also
shows the impact of socioeconomic variables after controlling for maternal reproductive
variables. We observe that socioeconomic variables do not have a distinct impact on
infant mortality.

Model III adds controls for two household amenities, namely the piped drinking
water and improved toilet facilities. In the presence of maternal and socioeconomic
variables the odds of dying for infants born to mothers in households with access to
piped drinking water are reduced by 12 percent relative to infants born to mothers in

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households without access to piped drinking water. In the presence of maternal and
socio-economic variables, infants born to mothers in households with access to
improved toilet facilities are associated with a 38 percent lower risk of dying in infancy
compared to those born to mothers in households without access to a such facilities. We
further observe that although the odds ratios for piped drinking water and flush toilet
are in the expected direction they are both not statistically significant.

3.2 Child mortality

The results of the impact of all independent variables (maternal, socioeconomic and
sanitation) on child mortality are presented in Table 3. It is immediately clear that
determinants of child mortality are different in relative importance from those of infant
mortality. The results for maternal variables in model II of Table 3 are similar to those
of model I in the same table.

Table 2: Impact of independent variables on infant mortality, Hazard model
estimates of relative risks (RR), 1996-2005 (2005-05 ZDHS)

Model I Model II Model III
Covariate

Relative risk
Confidence

interval Relative risk
Confidence

interval Relative risk
Confidence

interval
Birth order and
preceding birth
interval a

First births
2-5 and short
2-5 and medium
2-5 and long
6+ and short
6+ and medium
6+ and long

1.101
1.369
1.474
1.000
2.747***
1.121
1.316

0.859-1.411
0.955-1.962
0.950-2.286
—————-
1.544-4.884
0.578-2.172
0.898-1.929

1.098
1.387
1.481
1.000
2.887***
1.146
1.333

0.852-1.416
0.958-2.007
0.950-2.310
—————-
1.598-5.216
0.584-2.250
0.903-1.968

1.098
1.398
1.477
1.000
2.915***
1.149
1.337

0.851-1.416
0.966-2.025
0.945-2.308
—————-
1.613-5.265
0.585-2.256
0.906-1.975

Maternal age
<20 years 20-29 years 30-39 years 40-49 years

1.147
1.090
1.000
1.032

0.796-1.653
0.824-1.443
—————-
0.618-1.725

1.150
1.092
1.000
1.080

0.788-1.678
0.816-1.461
—————-
0.616-1.892

1.132
1.090
1.000
1.081

0.775-1.653
0.815-1.459
—————-
0.617-1.894

Sex of child
Female
Male

0.992
1.000

0.829-1.187
—————-

0.987
1.000

0.823-1.185
—————-

0.979
1.000

0.816-1.176
—————-

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

376 http://www.demographic-research.org

Table 2: (Continued)
Model I Model II Model III

Covariate
Relative risk

Confidence
interval Relative risk

Confidence
interval Relative risk

Confidence
interval

Type of birth
Multiple
Singleton

2.080***
1.000

1.562-2.768
—————-

2.086***
1.000

1.563-2.785
—————-

2.060***
1.000

1.541-2.754
—————-

Residence
Rural
Urban

1.020
1.000

0.708-1.470
—————-

1.323
1.000

0.765-2.289
—————-

Maternal
education
No education
Primary
Secondary and
higher

1.000
1.071
1.039

—————-
0.658-1.742
0.619-1.742

1.000
1.074
1.055

—————-
0.660-1.748
0.628-1.770

Paternal
education
No education
Primary
Secondary and
higher

1.000
1.109
1.117

—————-
0.791-1.556
0.800-1.559

1.000
1.116
1.121

—————-
0.796-1.566
0.803-1.565

Wealth status
Poor
Middle
Rich

1.000
1.096
1.022

—————-
0.857-1.402
0.723-1.444

1.000
1.082
1.086

—————-
0.845-1.386
0.722-1.633

Piped drinking
water
Yes
No

0.885
1.000

0.597-1.311
—————-

Flush toilet
Yes
No

0.629
1.000

0.348-1.136
—————-

a Preceding birth interval: short <= 18 months, medium 19-23 months, long 24+ months. *p<0.05, **p<0.01, ***p<0.001

The addition of sanitation variables in model III does not substantially change the

impact of maternal and socioeconomic variables observed in model II. The results
presented in the full model (model III) demonstrate that first-born children have lower
mortality than children of other birth orders. First-born children are 0.57 times less
likely to die in childhood relative to children of birth orders two through five with a
long preceding birth interval. Furthermore, in the full model, order 6+ with short

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preceding interval and type of birth do not have any significant effects on child
mortality. Significance was observed for both variables in model 2 (see Table 2).

There continues to be an association between residence and child mortality in the
presence of maternal and sanitation variables. Living in rural areas increases the risks of
childhood mortality by 26% relative to living in urban areas. This was also found in the
infant mortality tables (see Table 2 above). The coefficients depicting the impact of
type of residence on infant and child mortality were not statistically significant in either
case.

The effect of maternal education, though not significant, implies a decrease in
child mortality associated with an increase in maternal schooling. Relative to children
whose mothers had no education, mortality among children whose mothers completed
primary or secondary education are reduced by 24 percent and 41 percent, respectively.
Father’s education has a substantial effect on child mortality but not on infant mortality.
Completing secondary school reduces the relative risks of child mortality by 33 percent
relative to fathers with no formal education.

Table 3: Impact of independent variables on child mortality, hazard model
estimates of relative risks (RR), 1996-2005 (2005-06 ZDHS)

Model I Model II Model III
Covariate
Relative risk
Confidence
interval Relative risk
Confidence
interval Relative risk
Confidence
interval
Birth order and
preceding birth
interval a
First births
2-5 and short
2-5 and medium
2-5 and long
6+ and short
6+ and medium
6+ and long

0.549*
1.295
0.816
1.000
1.071
0.800
1.177

0.339-0.890
0.523-3.207
0.329-2.022
—————-
0.146-7.858
0.110-5.830
0.619-2.239

0.566*
1.317
0.821
1.000
0.895
0.692
0.966

0.345- 0.928
0.530-3.270
0.331-2.038
—————-
0.121- 6.624
0.094- 5.093
0.496- 1.881

0.570*
1.307
0.822
1.000
0.902
0.719
0.977

0.347-0.937
0.525-3.252
0.331-2.039
—————-
0.122-6.680
0.098-5.293
0.502-1.900

Maternal age
<20 years 20-29 years 30-39 years 40-49 years

1.471
0.886
1.000
0.294

0.800-2.704
0.561-1.398
—————-
0.069-1.253

1.461
0.905
1.000
0.270

0.788-2.710
0.571-1.434
—————-
0.063-1.158

1.416
0.889
1.000
0.262

0.761-2.636
0.560-1.410
—————-
0.061-1.121

Sex of child
Female
Male

1.011
1.000

0.732-1.398
—————-

1.019
1.000

0.737-1.409
—————-

1.021
1.000

0.738-1.412
—————-

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

378 http://www.demographic-research.org

Table 3: (Continued)
Model I Model II Model III

Covariate
Relative risk
Confidence
interval Relative risk
Confidence
interval Relative risk
Confidence
interval
Type of birth
Multiple
Singleton

1.428
1.000

0.625-3.259
—————-

1.510
1.000

0.660-3.457
—————-

1.492
1.000

0.651-3.419
—————-

Residence
Rural
Urban

1.135
1.000

0.598-2.153
—————-

1.260
1.000

0.545-2.912
—————-

Maternal
education
No education
Primary
Secondary and
higher

1.000
0.746
0.567

—————-
0.364-1.529
0.264-1.218

1.000
0.764
0.594

—————-
0.373-1.564
0.276-1.276

Paternal
education
No education
Primary
Secondary and
higher

1.000
0.618
0.675

—————-
0.347-1.099
0.390-1.168

1.000
0.614
0.670

—————-
0.345-1.091
0.387-1.159

Wealth status
Poor
Middle
Rich

1.000
1.297
1.099

—————-
0.845-1.989
0.603-2.001

1.000
1.240
1.064

—————-
0.806-1.907
0.558-2.029

Piped drinking
water
Yes
No

0.606
1.000

0.330-1.116
—————-

Flush toilet
Yes
No

0.401**
1.000

0.171 0.940
—————-

a Preceding birth interval: short <= 18 months, medium 19-23 months, long 24+ months. *p<0.05, **p<0.01, ***p<0.001 Demographic Research: Volume 21, Article 13

http://www.demographic-research.org 379

Model III further confirms that sanitation variables are more important during
childhood than during infancy. Availability of piped drinking water in the dwelling is in
the shows a negative impact on child mortality though the alpha is not significant. The
odds of dying during childhood for children born in households with access to piped
drinking water are reduced by 39 percent relative to those born in households without
access to piped drinking water. Availability of improved toilet facilities on child
mortality is also in the expected negative direction and is significant. Relative to
children born in households with no access to a improved toilets, the relative risks of
death for children born in households with access to improved toilets is reduced by 60%
(p<0.01). This underscores the importance of good quality sanitation in the prevention of diseases such as cholera, diarrhoea and dysentery. Modern sanitation technology ensures the proper disposal of human waste, which is important in preventing the spread of these diseases.

We now compare the results of the impact of birth order, maternal age and
maternal education from the 2005-06 ZDHS survey with results from the 1994 and
1999 surveys. These results are presented in Table 4 (bivariate relationships). We do
this in order to show the relative change in the impact of these variables on under-five
mortality from the period 1985-1994 to the period 1996-2005. The relationship between
birth order and under-five mortality is U-shaped indicating higher mortality for both
first and higher order births during 1985-1994 and 1990-1999. During 1996-2005 the
relationship between birth order and under-five mortality is linear indicating the
diminished impact of birth order on under-five mortality. We note that the changes in
the relative risks of under-five mortality are not substantial between 1990-1999 and
1996-2005.

The relationships between maternal age and under-five mortality during 1985-
1994 and 1990-1999 are U-shaped. However the U-shaped relationship diminishes and
is almost flattened in the 2005-06 survey. For instance, in the 1994 survey the children
born to mothers aged less than 20 years experienced 34 percent higher mortality relative
to children born to women aged 30-39 years. In the 1999 survey they experienced 21
percent higher mortality, and in the 2005-06 survey the effect of maternal age on under-
five mortality is no longer discernible. A similar observation is obtained for the
mortality situation of children born to older mothers, that is, those aged 40-49 years.
Children born to mothers aged 40-49 years experienced 79 percent higher mortality in
the 1994 survey, 61 percent higher mortality in the 1999 survey and 7 percent higher
mortality in the 2005-06 survey relative to children born to mothers aged 30-39 years.

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

380 http://www.demographic-research.org

Table 4: Relative risks showing changes in the impact of birth order, maternal
age and maternal education on under-five mortality, 1985-1994 (1994
ZDHS), 1990-1999 (1999 ZDHS) and 1996-2005 (2005-06 ZDHS)

Variable 1985-1994 1990-1999 1996-2005

Birth Order

1
2-3
4-6
7+

1.068
0.997
1.000
1.084

0.993
0.955
1.000
1.223

0.892
0.919
1.000
1.081

Maternal age

<20 20-29 30-39 40-49

1.343
1.214
1.000
1.794

1.207
1.122
1.000
1.605

0.972
0.944
1.000
1.069

Maternal education

No education
Primary
Secondary+

1.000
0.845
0.608

1.000
0.790
0.434

1.000
1.029
0.906

Authors’ calculations are based on data from: Zimbabwe Central Statistical Office/ Macro International Inc, 1995, 2000 and 2007.

Further evidence of the diminishing impact of independent variables on under-five

mortality is shown by the changes in the impact of maternal education on under-five
mortality from the 1994 survey to the 2005-06 survey. In the 1994 survey, children
born to mothers who had completed secondary education experienced 39 percent lower
mortality, in the 1999 survey they experienced 57 percent lower mortality and in the
2005-06 survey they experienced 9 percent lower mortality relative to children born to
mothers with no formal education.

It could be that these unexpected results are explained by the hypothesis that
certain high-risk mothers and subsequently their high-risk births were missing in the
1999 and 2005-06 ZDHS surveys having died due to HIV/AIDS between the time of
the 1994 and 2005-06 surveys. It is therefore these “missing mothers” which could
explain these observed, unexpected results which show a lack of expected relationships
between the independent variables and infant and child mortality in the 2005-06 ZDHS
survey and, to a lesser extent, the 1999 ZDHS survey.

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For instance, it could be that there is a group of HIV positive women who were
older (30 years and older) and who died and who had children under the age of five
years with higher than average mortality. This group could be missing in the 1999 and
2005-06 ZDHS surveys and could not have been interviewed. This means that the
observed infant and child mortality rates among women 30 years and older for the
period 1990-2005 are actually too low. These rates would have been higher if these
missing women could have been interviewed. Further research is required to test the
credence of these hypotheses in explaining the observed changes in the determinants of
infant and child mortality from 1985-1994 to 1996-2005 in Zimbabwe.

Having presented the results of the multivariate hazard analysis in this section, we
now turn to section 4 where we discuss these results and provide concluding remarks
and implications of the study.

4. Discussion and conclusions

The results of the multivariate analysis presented in this paper show that, in general the
strengths of the relationships of the independent (maternal, socioeconomic and
sanitation) variables with the dependent variables (infant and child mortality) remain
much smaller in the 2005-06 ZDHS survey than in the other ZDHS surveys. For
instance, the results from the 1994 and 1999 ZDHS surveys show a larger impact of
maternal education on infant mortality than in the 2005-06 survey. The impact of the
mother’s education on infant mortality completely disappears in 2005-06 in Zimbabwe.
These results are rather unexpected and are not in line with observations from other
surveys conducted in neighbouring countries.

The multivariate analysis produced only relatively small changes in the strengths
of the relationships between independent and dependent variables compared to the
bivariate analysis (data not shown in this paper). In the multivariate analysis we found
no U-shaped relationship between birth order and mortality and maternal age and
mortality both in the bivariate and multivariate analysis.

We expect that children born to young mothers (aged less than 20 years) and those
born to older mothers (aged 40-49 years) should have higher mortality than those born
to mothers aged 20-39 years. The lower risks of child death among children who are
first born and those born to mothers aged 40-49 years found in this paper are deviations
from the expected mortality pattern and require further investigation. The findings
further suggest the following: birth order and preceding birth intervals, maternal age
and type of birth are dominant determinants of infant mortality, but they are less
pronounced in child mortality. Maternal schooling has a marginal impact on infant
mortality. Both maternal and paternal education affects child mortality.

Kembo & Van Ginneken: Determinants of infant and child mortality in Zimbabwe

382 http://www.demographic-research.org

On sanitation, the findings indicated that the provision of piped drinking water and
flush toilets to households has a stronger impact on child mortality than infant
mortality. The findings support the thesis that endogenous factors are dominant during
infancy while exogenous factors are dominant during the childhood age.

Adult mortality among women of childbearing age more than doubled between
1985-1994 and 1996-1999, and increased by 40 percent between 1996-1999 and 2000-
2005. Close to 60 percent of these extra deaths were to women aged 30-44 years
(Zimbabwe Central Statistical Office/ Macro International Inc, 2007). We therefore
hypothesize that a group of older women who would have had children with higher than
average mortality rates were “missing” from the 1999 and 2005-06 ZDHS surveys. It is
probable that there were a number of “missing mothers” from 2005-06 ZDHS survey
which not only led to the possible underestimation of the true levels of infant and child
mortality, but also to the lack of expected relationships between infant and child
mortality and the independent variables in the 2005-06 ZDHS survey. For example, the
1994 and 1999 ZDHS surveys show a stronger impact of maternal education on under-5
mortality. This impact completely disappears in 2005-06. We elaborated on this point in
section 3 of this paper.

We conclude that the findings presented in this paper provide further evidence of
the importance of practicing birth spacing methods. Women and men living in urban
areas or with higher educational levels are more likely to use family planning methods.
Thus family and health planning in Zimbabwe should be directed at educating men and
women with low educational levels and those in rural areas about the benefits of birth
spacing and encouraging them to use birth spacing techniques. In the long run, such
policies may be expected run to reduce childhood mortality and possibly socioeconomic
variations in mortality, as well. We also saw that in Zimbabwe multiple births are
strongly negatively associated with infant survival. This suggests that improving
maternal and child health services, screening for high-risk pregnancies and making
referral services for high-risk pregnancies more accessible, particularly to the rural
women and children, will also contribute to improvement of child survival rates.

5. Acknowledgements

This manuscript was drawn from the PhD thesis of the first author. We thank the two
anonymous reviewers for their valuable comments that helped to improve this
manuscript. Thanks also go to DHS Macro international for their permission to use the
2005-06 ZDHS data set for the analysis in this paper.

Demographic Research: Volume 21, Article 13

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• 21-13 title

Table of Contents

• 21-13 work 851

Abstract
1. Introduction
2. Data and methodology
2.1 Model specification
2.2 Source of data
2.3 Statistical methods
3. Results
3.1 Infant mortality
3.2 Child mortality
4. Discussion and conclusions
5. Acknowledgements
References

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lable at ScienceDirect

Tourism Management 30 (2009) 890–899

Contents lists avai

Tourism Management

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / t o u r m a n

Herzberg’s Two-Factor Theory of work motivation tested empirically
on seasonal workers in hospitality and tourism

Christine Lundberg a, *, Anna Gudmundson b, Tommy D. Andersson c

a School of Business and Informatics, University College of Borås, Boras 501 90, Sweden
b ETOUR, Mid-Sweden University, Ostersund, Sweden
c School of Business, Economics and Law, University of Gothenburg, Gothenburg, Sweden

a r t i c l e i n f o

Article history:
Received 9 February 2007
Accepted 2 December 2008

Keywords:
Work motivation
Seasonal
Employee
Hospitality
Tourism
Herzberg
LISREL

* Corresponding author. Tel.: þ46 33 435 4088.
E-mail address: Christine.Lundberg@hb.se (C. Lun

0261-5177/$ – see front matter � 2008 Elsevier Ltd.
doi:10.1016/j.tourman.2008.12.003

a b s t r a c t

The objective of this study was to understand work motivation in a sample of seasonal workers at
a tourism destination strongly steered by seasonality. Furthermore, it was investigated whether seasonal
workers could be divided into worker subgroups on the basis of their work motivation. A structural
equations model tested Herzberg’s Two-Factor Theory of work motivation empirically. The findings of
the study support the Two-Factor Theory of work motivation. Furthermore, results indicated that
a migrant community of workers was significantly less concerned about wage level as well as signifi-
cantly more concerned about meeting new people than resident workers. As a result of these findings, it
is suggested that management of businesses in hospitality and tourism need to consider that the
seasonal workforce consists of different kinds of worker subgroups, which have different needs to be
satisfied.

� 2008 Elsevier Ltd.

All rights reserved.

1. Introduction

The objective of this study is to understand work motivation in
a sample of seasonal workers at a ski-resort strongly steered by
seasonality, situated in northern Sweden.

Tourism is strongly steered by seasonality. An international
definition of seasonality in the hospitality and tourism industries is,
seen in the strictest sense, a peaking of demand at different times of
the year (Kennedy, 1999). Even though all destinations are subject
to some form of seasonality, research indicates that peripheral
destinations, in both the southern and northern hemispheres, have
the greatest difficulty in overcoming the problems caused by sea-
sonality (Lundtorp, Rassing, & Wanhill, 1999). Both coastal and
winter sport resorts are the most heavily affected by seasonal
fluctuations (Pearce, 1989; Murphy, 1997). Urban areas are less
affected because of the wide variety of attractions. These attractions
are in most cases not dependent on climatic conditions and
therefore not as vulnerable to climatic changes (Butler & Mao,
1997).

Baum (1999) suggests that the impact of demand variation is
one of the major operational and policy concerns of the hospitality

dberg).

All rights reserved.

and tourism industries. The supply-side behavior is affected in all
aspects including marketing (packaging, pricing, distribution),
business finance (cash flow, attracting investment) and the labor
market (sustainability of employment, nature and quality of
employment, skills availability) (Baum, 1999; Cooper, Fletcher,
Gilberg, & Wanhill, 1993).

Vaughan and Andriotis (2000) suggest that one major char-
acteristic of employment in hospitality and tourism is its
seasonal and part-time nature, which can result in seasonal
employment, underemployment, and unemployment (Jolliffe &
Farnsworth, 2003). Furthermore, the negative employment
image within the sector affects the recruitment and retention of
qualified employees. This image is created by the generally
perceived idea that work within the hospitality and tourism
industries only offers limited opportunity for promotion and
progression (Baum, Amoha, & Spivack, 1997; Hjalager & Ander-
sen, 2000), and that work is characterized by anti-social working
conditions and casualized remuneration (Baum, Amoha, & Spi-
vack, 1997).

This is problematic since tourist perceived quality is closely
related to employee performance. An essential feature of any
successful organization is motivated employees. Therefore, the
extent to which an employer is able to motivate employees is
important for the overall success of the organization on its markets.
One of the most important challenges facing managers is the

mailto:Christine.Lundberg@hb.se

www.sciencedirect.com/science/journal/02615177

http://www.elsevier.com/locate/tourman

C. Lundberg et al. / Tourism Management 30 (2009) 890–899 891

creation of a context within which employees feel motivated and
will act in order to achieve the goals of the organization. Managers
may, by influencing the context, affect the degree of work moti-
vation among the employees. Maybe nowhere is the understanding
of employee work motivation more important than in a customer
service oriented business such as the hospitality and tourism
industries.

Furthermore, it has been argued that seasonal workers
within the industry can be divided into different subgroups on
the basis of their attitudes towards seasonal jobs as well as their
behavior as seasonal workers (Lee & Moreo, 2007; Lee-Ross,
1999a,b) since employee work motivation varies between indi-
viduals, and individuals respond differently to the same moti-
vational stimulus in different situations (Lee-Ross, 1999a). The
individual differences of employees have important implications
for managerial practice. Motivational theories are useful when
studying the range of human motives to explain how the
motives affect human behavior. However, the theories do not
provide an insight of what motivates a particular individual or
group. Therefore, when searching for the specific work motiva-
tors of a particular individual or group of individuals there is no
other way than finding out what actually motivates that
particular individual or group (Wright, 1989). In the light of the
above, it is here argued that seasonal workers in hospitality and
tourism constitute an important group with which to study
work motivation.

The aim of the study is to address the issue of how seasonal
workers in hospitality and tourism are motivated in their work. This
aim will be achieved through the following objectives:

1. To understand work motivation in a sample of seasonal
workers by testing a context-adapted version of Herzberg’s
Two-Factor Theory of work motivation empirically by a struc-
tural equations model.

2. To investigate whether seasonal workers can be divided into
worker subgroups on the basis of their work motivation.

2. Work motivation

People are motivated by a great variety of needs, which in
turn vary in order of importance and over time or in different
situations. The understanding of human needs is, according to
Wright (1989), only the first step towards predicting and influ-
encing work behavior. There is no single definition of work
motivation due to the complexity of the concept. Some theorists
have found it more useful to concentrate on physiological aspects,
whilst some stress the behavioral aspects and others the ratio-
nality of human beings (Pinder, 1998). Pinder (1998, p. 11)
describes motivation as:

‘‘a set of energetic forces that originate both within as well as
beyond an individual’s being, to initiate work-related
behavior, and to determine its form, direction, intensity, and
duration’’.

This definition recognizes the influence on work-related
behavior of both environmental forces (e.g. organizational reward
systems) and forces inherent in the person (e.g. individual needs
and motives). This definition views work motivation as an ‘‘invis-
ible, internal, hypothetical construct’’ (Ambrose & Kulik, 1999, p.
231). Work motivation cannot actually be seen nor can it be
measured directly. Therefore, we use established theories when
measuring the observable manifestations of work motivation
(Ambrose & Kulik, 1999).

2.1. Herzberg’s Two-Factor Theory of work motivation

When reviewing the literature, there are two main types of
work motivation theory that have been used to explain motiva-
tional issues like levels of work motivation, job satisfaction and
what effects these aspects have on work behavior. These theories
are called need theories and process theories. While need theo-
ries concentrate on the emotional aspects of motivation, process
theories of motivation emphasize the role of cognitive processes
(however emotional factors are not ignored) (Wright, 1989).
Process theories are suitable for in-depth case-studies whereas
we believe that need theories provide a more suitable approach
in order to reach our objective ‘‘. to understand work motiva-
tion in a sample of seasonal workers at a ski-resort .’’ at
a general level. In this study need theories of motivation will
therefore be used. Need theories are based on the assumption
that people’s needs provide the force, which directs action
towards fulfillment of these needs (Wright, 1989; Pinder, 1998).
Need theories stress the identification of different needs which
motivate behavior. By identifying the needs and by fulfilling them
it is assumed that people will become motivated at work (Wright,
1989).

Herzberg’s influential need theory of the 1960’s, the Two-Factor
Theory, suggests that humans have two different sets of needs and
that the different elements of the work situation satisfies or
dissatisfies these needs (Wright, 1989). The first set concerns the
basic survival needs of a person – the hygiene factors (Herzberg,
1971; Herzberg, Mausner, & Bloch Snyderman, 2005). These factors
are not directly related to the job itself, but concern the conditions
that surround performing that job. The factors are company policy
such as for example reward system, salary, and interpersonal
relations (Herzberg, 1971; Herzberg, Mausner, & Bloch Snyderman,
2005; Tietjen & Myers, 1998). According to Herzberg, these factors
can cause dissatisfaction when not satisfied. However, when
satisfied these factors do not motivate or cause satisfaction, they
only prevent dissatisfaction (Herzberg, 1971; Herzberg, Mausner, &
Bloch Snyderman, 2005).

The second set of needs is growth needs, which refers to
factors intrinsic within the work itself, for example recognition of
a task completed, achievement, responsibility, advancement and
work itself. These factors are according to Herzberg, the moti-
vating factors, which implies that humans try to become all that
they are capable of becoming and when satisfied they work as
motivators (Herzberg, 1971, Herzberg, Mausner, & Bloch Snyder-
man, 2005). According to Herzberg, content of work, (e.g.
opportunities for responsibility and advancement) is the only
way to increase satisfaction and thereby enhance work motiva-
tion (Wright, 1989). However, when the growth factors are
missing this does not cause dissatisfaction, simply an absence of
satisfaction (Herzberg, 1971; Herzberg, Mausner, & Bloch Sny-
derman, 2005).

2.1.1. Herzberg’s theory adapted and applied in different contexts
Several studies using Herzberg’s Two-Factor Theory have been

adapted to better suit the specific context studied. One example
of a context-adapted study is Parsons and Broadbride’s (2006)
study of work motivation in a retail setting. In their study, key
factors for job motivation and satisfaction for charity shop
managers were examined. Herzberg’s division of intrinsic and
extrinsic factors was employed and examples of intrinsic job
characteristics used were responsibility, work itself, self devel-
opment (i.e. possibility to growth) and recognition. Extrinsic job
characteristics examined were for example location of work, job
security, hours of work, salary and working conditions. In addi-
tion to this, communication and organizational climate were

C. Lundberg et al. / Tourism Management 30 (2009) 890–899892

examined in the form of factors as working relationships (with
volunteers, shop staff, other shop managers, area managers and
head office), support (from area management and head office
management) and opportunity to influence organizational poli-
cies. The main findings of the study support Herzberg’s theory in
that the managers exhibit high levels of satisfaction with intrinsic
factors (e.g. variety and challenge of the job, high degree of
control) and lower levels of satisfaction with extrinsic factors (e.g.
pay, job status, working conditions).

Another adapted version of Herzberg’s motivation model was
employed in DeShields, Kara, and Kaynak’ (2005) study of deter-
minants of business student satisfaction and retention. In this
higher education context, Herzberg’s growth factors were trans-
lated into faculty performance variables (e.g. understanding,
accessible, professional, and helpful) and classes (real-world rele-
vance, course scheduling and project/cases). Hygiene factors were
constituted by advising staff (e.g. accessible, reliable, helpful, and
responsive). The principal findings of this study also supported
Herzberg’s Two-Factor Theory.

Herzberg’s Two-Factor Theory has also been applied context-
adapted in studies of the hospitality industry. One example is
Balmer and Baum’s (1993) study of guest satisfaction in the
accommodation environment. In their study, hygiene (or mainte-
nance) factors employed were pricing, facilities (cleanliness, size,
variety) and ‘‘freebies’’/extras. Motivators/satisfiers employed were
recognition of staff, sense of belonging, flexibility by hotel and
‘‘service orientation’’. Their findings indicate that Herzberg’s model
also poses as a relevant theory when attempting to understand
guest motivation in hospitality.

2.1.2. Work motivation and individual differences
Several work motivation studies have emphasized individual

differences and their affect on work motivation. One of the
earliest works on work motivation and individual differences
was McClellands need theory, presented in the 1960s. According
to this theory, needs are reflections of an individuals personal
traits. According to McClelland, there are three needs that may
differ between individuals, which need to be addressed by the
work environment: achievement, power and affiliation (McClel-
land, 1985). In 1991, Barrick and Mount presented the Big Five
Model which showed that personality measures could predict
job performance. This model has been adapted in recent
research on work motivation and personal traits. One example is
Tett and Burnetts’ (2003) use of the model for developing
a personality trait-based interactionist model of job perfor-
mance. In this model the Big Five was linked to situational
taxonomies. The Big Five was also used in Wang and Erdheim’s
(2007) study, which explored the linkages between the model
and goal orientation. Their findings show that ‘‘personality has
a significant impact on performance motivation’’ (Wang & Erd-
heim, 2007, p. 1502) It has recently been argued that ‘‘research
on personality is the fastest growing area in the motivation liter-
ature’’ (Latham & Pinder, 2005, p. 488). This claim is supported
by the numerous recent studies conducted on personality/traits
and work motivation (see e.g. Baum & Locke, 2004; Tett &
Burnett, 2003; Witt & Ferris, 2003). One example is Furnham,
Forde, and Ferrari’s (1999) application of Herzberg’s Two-Factor
Theory in a study of personality and work motivation. In their
study respondents completed the Eysenck Personality Profiler
(EPP) and a Work Values Questionnaire. It was found that
extraverts stressed the importance of growth factors in the
workplace, while introverts rated hygiene factors as more
important to them in choosing a particular job. Furnham, Forde,
and Ferrari (1999) stress that the results have implications for

both selecting employees and managing them and that it may
be useful for managers to introduce different performance
management schemes to different groups of workers.

2.1.3. Criticism of Herzberg’s theory
The Two-Factor Theory has attracted a lot of attention and

criticism has been put forward regarding the distinction between
motivators and hygiene factors. For example, the Two-Factor
Theory claims that job content or job enrichment by for example
responsibility, achievement, recognition and advancement is the
only way to increase work motivation (Furnham, Forde, & Ferrari,
1999; Parson & Broadbride, 2006; Wright, 1989). Pinder claims
that hygiene factors, like salary, interpersonal relations and
working conditions may also act as motivators (Pinder, 1998). In
addition, the Two-Factor Theory has been criticized for not taking
individual differences of needs and values into account when
explaining work motivation (Parson & Broadbride, 2006; Tietjen
& Myers, 1998).

Method dependency is another problem and variation in
methodology, (questionnaires, interviews or behavioral observa-
tions) implies that different results are obtained. Also, when
respondents answer critical incident questions, they may selec-
tively recall situational factors and projecting failures to external
factors. Evidence also questions how well the theory applies to
individual variations like gender, culture and age categories not to
mention organizational differences (Furnham, Forde, & Ferrari,
1999). However, according to Furnham, Forde, and Ferrari (1999),
the theory and its applications remain influential within the
domain of organizational theory.

3. Methodology

3.1. The setting

The field research was carried out in a ski-resort and its
surrounding villages situated in the northwest of Sweden. The
destination is situated in a peripheral area and like many other
such areas suffering in demand from a high level of out-migra-
tion among its inhabitants. The region is exposed to seasonal
fluctuations and has only one significant season. Since the
internal labor market is weak and labor a scarce resource workers
are often recruited from external markets. A large group of
mostly young people moves to the region for work during the
winter season.

3.2. Sample

Data was collected through questionnaires and in-depth
interviews. The collection of data began with six in-depth inter-
views selected from the sample. Since one of the objectives of the
study was to investigate whether the sample of seasonal workers
could be divided into worker subgroups on the basis of work
motivation, the selection of respondents for the interviews was
made to get an even distribution between people moving to the
region in order to work as seasonal workers as well as people
living in the area on a permanent basis taking on seasonal jobs.
An even distribution of respondents was also sought on a gender
basis.

The sample for the questionnaire consisted of 613 seasonally
employed individuals in the region. Contact addresses for
respondents were obtained from their places of work all of which
kept records of their employees’ addresses. It should be noted
that those companies who were willing to supply employee
information were also interested in participating in the study.

WORK

MOTIVATION

Hygiene factors

Growth factors

Fig. 1. Herzberg’s Two-Factor Theory of work motivation. Note: When needs are met,
result in work motivation /. When needs are met, result in satisfaction .

C. Lundberg et al. / Tourism Management 30 (2009) 890–899 893

There are no data on the actual number of seasonal workers at
the ski-resort. The scarcity of research conducted on seasonal
work mobility in Sweden due to the difficulty of obtaining these
types of data has been pointed out by for example Lundmark
(2006).

Our definition of a seasonal employee is a person who has
a contract with an end date – a temporary working engage-
ment within the sector and who is involved in the business
operation on a daily basis. This definition covers thereby both
residents and in-migrants and also all the different occupational
groups one can have as seasonally employed (e.g. qualified
occupations such as ski-patrollers, ski-instructors and chiefs
as well as non-qualified occupations as janitors and jobs in
housekeeping).

The sample consisted of individuals working within the
hospitality and tourism industries. The hospitality industry is
here defined as ‘‘all the business that provide food, beverages and
lodging to people who are away from home’’ (Kusluvan, 2003, p.
4) while the tourism industry ‘‘refers broadly to firms, organi-
zations and facilities providing goods and services wholly or
mainly for specific needs and wants of visitors’’ (Kusluvan, 2003,
p. 3). Forty five per cent of the respondents consisted of indi-
viduals working within the hospitality industry while the
remaining 55 % worked in the more broadly defined tourism
industry.

3.3. Data collection

The questions used during the interviews were of the ‘open-end’
type. This method was used due to the researchers’ wish to draw
a rich picture of how the respondents viewed their working and
non-working lives. The interviewers guided the respondents
around such themes as work, leisure, place of residence, work
motivation and fellow workers and allowed the respondents to
speak freely about the highlighted themes. A tape recorder was
used during the in-depth interviews to facilitate analysis of the
data. The questionnaire was distributed to all the obtained
addresses of the employees (N ¼ 613).

There were three reminders, the first contained a letter, the
second contained a letter and a questionnaire and finally the last
reminder contained a letter. A total of 266 questionnaires were
returned, of which 263 were usable. This provided a response rate
of 43 %.

WORK
MOTIVATION
Hygiene factors
Growth factors

Information

Recognition/
Feedback

Knowledge &
Training

Wage Level

Rewards
(Company
Policy and

Administration)

Interpersonal
Relations

Responsibility

Fig. 2. Measurement model of the constructs of work motivation.

3.4. Data analysis

An exploratory approach was used when collecting and
analyzing the study’s qualitative data. The analysis and interpre-
tation of the qualitative data followed Miles and Huberman’s
(1994) division of qualitative data analysis. The first part of the
analysis was data reduction, when the collected data was
‘reduced’. The second part of the analysis was data display. During
this phase data was ‘put on display’ (i.e. data is presented in
a more compact form by for example the usage of matrices, graphs
or charts). The final phase of the analysis – conclusion drawing
and verification – it was found that seasonal workers could be
divided into distinct worker subgroups on the basis of work
motivation. The quantitative data of this study tested Herzberg’s
Two-Factor Theory, which suggests that hygiene factors and growth
factors (described in Fig. 1) explain work motivation. The answers
to the questionnaire were used to identify and measure work
motivation: hygiene factors and growth factors in the presented
model.

3.4.1. Using structural equations modeling for analysis of data
Structural equations modeling (SEM) is particularly suited to

test the relevance of the Two-Factor Theory of work motivation
since the three major concepts work motivation, growth factors,
and hygiene factors all are latent variables that need to be anchored
in measurable manifest variables in order to be tested for statistical
significance. The technique has been applied in a previous study of
work motivation among nurses (Janssen, de Jonge, & Bakker, 1999).
The SEM technique is based on a two-step procedure where
initially the connection between theoretical constructs (latent
variables) and observable data (manifest variables) is established
through measurement models.

Secondly, the relations between (via measurement models
measurable) theoretical constructs are analysed by a structural
model. SEM is confirmatory in nature and the measurement
models as well as the structural model should consequently be
based on theory. In this study, the computer programme LISREL 8
(Jöreskog & Sörbom, 1993a,b) was used to compute the estimated
covariance matrix implied by the hypothesized models and
compared this covariance matrix to the covariance matrix based
on empirical data.

In the questions (cf. Table 3 for questions and Fig. 2 for
measurement model) used for indicating work motivation and
growth factors, a 5-point Likert-type scale format, ranging from
‘strongly agree’ to ‘strongly disagree’ was used for 13 of the 16
factors and a 4-point Likert-type scale format, ranging from ‘very
important’ to ‘not at all important’ were used for the remaining
three factors (FEED26P, KUNSK26B and INFO26A cf. Table 3). By
using the 5-point Likert-type scale format the respondents could
choose a neutral position.

Table 1
Profile of migrant and resident community.

Migrants Residents

Age, gender and civil status
Age 25 years 29 years
Male 50% 52%
Female 50% 48%
Single 72% 47%

Education and experience
Worked two or more seasons in the region 46% 87%
Comprehensive school certificate (9 years) 78% 78%
Upper secondary school qualification (12 years) 54% 38%
Vocational training 42% 45%
University attendance 23% 10%
Neither experience nor training in hospitality and/or tourism 9% 8%

Note: n ¼ 243.

MOTIVATION

MOTIV22D 5.28

MOTIV22E 4.65

MOTIV22F 7.68

MOTIV23A 3.99

5.02

5.02

4.69

4.39

-2.02

Fig. 3. The measurement model uses four manifest variables to measure the latent
variable work motivation. T-values are indicated. Note: MOTIV22D: receiving motiva-
tion from management. MOTIV22E: receiving motivation from managers. MOTIV22F:
receiving motivation from co-workers. MOTIV23A: motivated in one’s work.

C. Lundberg et al. / Tourism Management 30 (2009) 890–899894

In the questions used for indicating hygiene factors, a 4-point
Likert-type scale format, ranging from ‘very important’ to ‘not at
all important’ was used for all three factors. By using a 4-point
Likert-type scale format, the respondents were forced to make
a statement, not being able to choose a neutral position. The
Likert-type scale questions all contained the option ‘don’t know’.
This strategy might, according to Ryan (1995), induce in a nil
response where attitudinal responses are required. In this study
this was found to be untrue, as there were very few nil
responses.

3.4.2. Constructs included in the measurement model
The model tested was a context-adapted version of Herzberg’

Two-Factor Theory, adjusted to better suit the seasonal context in
which the study takes place (described in Fig. 2). Herzberg (1971)
included factors as responsibility, recognition, achievement, possi-
bility of growth and advancement in the construct growth factors. In
this study, responsibility was measured by statements such as
‘‘having responsibility at work’’ and ‘‘authority to make one’s own
decisions at work’’. Recognition was measured by statements such
as: ‘‘finding a ready listener for one’s ideas, thoughts and suggestions’’
and ‘‘receiving encouragement when set goals had been attained’’. In
this construct feedback as well as one dimension of Herzberg’s
achievement was included.

Herzberg’s (1971) construct possibility of growth was measured
by statements such as ‘‘receiving training for work tasks’’ and
‘‘receiving on-the-job training’’ (in the study’s model described as
‘‘Knowledge & Training’’). This interpretation of the construct was
made on the basis of Herzberg’s own description of possibility of
growth as a person’s possibility ‘‘to advance in his own skills and his
profession’’ (Herzberg, 1971, p. 194). This definition of the construct
possibility of growth also includes, in some aspects, perceptions of
advancements. However, advancement in the form of a persons’
possibility of changing his/her own status of position was not
measured in this study, since it was not considered relevant in
a seasonal context (i.e. seasonal employees having short-term
engagements with an organization and changes of employment
status during the season is usually not realistic). In this study the
construct information was also included in the measurement
model. An example of statement measuring this construct was
‘‘receiving information regarding the company (e.g. goals and
visions)’’. This inclusion of information as a construct in the model
was made on the basis of Herzberg’s description of a person’s need
of knowing more ‘‘Even if these new facts are not essential or even
directly related to the task at hand, they may nevertheless be useful for
later tasks’’ (Herzberg, 1971, p. 59) being an important part of
psychological growth. In a seasonal context, such information was
considered important due to the temporary working conditions of
seasonal employment, including the need for workers to swiftly get
introduced to their work and the organization they work for.

Salary, interpersonal relations and company policy and admin-
istration, the latter in the form of reward systems, measured
Herzberg’s construct hygiene factors. Other, in literature, suggested
constructs for measuring hygiene factors are for example factors in
personal life (i.e. some aspect of the job affecting the individual’s
personal life), status (i.e. the job giving the person a sense of
‘‘status’’), and job security (Herzberg, Mausner, & Bloch Snyderman,
2005). None of these constructs were included in the study since
they were not considered relevant in the seasonal context under
study.

3.5. Profile of sample

As a result of the interviews, a division of the seasonal
workers was made into two distinct worker subgroups: a migrant

community and a resident community. The migrant community
consisted of individuals who normally live in other areas but
come to live and work in the ski-resort during the tourism
season. The resident community consisted of individuals who
lived in the area all year around but only worked on a seasonal
basis in hospitality and tourism. In Table 1, a brief description of
some of the characteristics of the two worker subgroups is
presented.

Within the two worker subgroups there were equal proportions
of men and women. However, seven out of 10 of the migrant
community were single, in contrast to five out of 10 of the resident
community. There was also a difference between the two worker
subgroups concerning age. Members of the migrant community
were, on average, younger (mean ¼ 24.7; median ¼ 23.0) than
those from the resident community (mean ¼ 29.3; median ¼ 28.5).
A large proportion of the members of the resident community had
worked several seasons in the region, while only half of the
members of the migrant community had done this. As regards
the number of times seasonal workers had worked in the
region, members of the resident community had worked many
more seasons in the region (mean ¼ 5.4; median ¼ 3.5) than
their counterparts in the migrant community (mean ¼ 1.6;
median ¼ 0.0).

Regarding educational level, eight out of 10 had comprehensive
school certificates in the two worker subgroups. Half of the
members of the migrant community had upper secondary qualifi-
cations, while four out of 10 of members from the resident
community had this qualification. Four out of 10 had had vocational

Table 2
Summary table of statements.

Theoretical dimensions Constructs Statements used

Hygiene factors Wage level (1) How important is wage level for you to do a good job?
Rewards (1) How important are reward systems for you to do a good job?
Interpersonal relations (1) How important was ‘meeting new people’ as a motive when applying for the job?

Growth factors Responsibility (2) Do you feel that you are given responsibility in your job?
Do you have necessary knowledge to make own decisions in your job?

Recognition/feedback (3) Do you communicate your ideas, thoughts and suggestions regarding your job?
Do you feel that you have a ready listener for your ideas, thoughts and suggestions?
Do you feel that you receive encouragement when set goals have been attained?

Knowledge/training (4) Do you feel that you have received training for your work tasks?
Do you feel that you have the necessary skills to perform your work tasks?
Do you feel that you have the knowledge needed to make your own decisions in your work?
Do you feel that you receive vocational education at your place of work?

Information (3) Do you feel that your company has a well defined mission statement?
Do you feel that you have received the necessary information for you to perform your work tasks?
Do you feel that you have knowledge regarding your company (e.g. objectives, visions)?

Motivation Motivation (4) Do you feel that you are motivated by management?
Do you feel that you are motivated by your line manager?
Do you feel that you are motivated by your co-workers?
Do you feel that you are motivated by performing your job (i.e. the job itself)?

C. Lundberg et al. / Tourism Management 30 (2009) 890–899 895

training in the two worker subgroups. However, there were some
differences between the two groups concerning their university
attendance. Two out of 10 of migrant community members had
attended university, while only one of 10 of resident community
workers had attended university. Only a small proportion of
workers from both subgroups had neither experience nor training
in hospitality and/or tourism.

GROWTH

4.86

4. Results

As a result of the study’s initial in-depth interviews with
seasonal workers, a division between a migrant community and
a resident community was made. From the in-depth interviews it
became clear that social interaction between seasonal workers had
a strong impact on work motivation. This social interaction seemed
be particularly important for the migrant community.

Results from the survey also indicate differences between the
migrant community and the resident community (that live in the
region the year around). Table 3 describes differences in mean
values calculated from answers given on a 5 (or 4) point Likert
scale. Migrant workers score higher in most answers, but only two
were significantly different according to a t-test of the difference of
means at a 5% level of significance. The two items where there were
significant differences are:

� The migrant community was significantly less concerned about
wage level than its counterpart – the resident community.
� The migrant community was also significantly more concerned

about meeting new people than its counterpart – the resident
community.

HYGIENE

MOTIVATION

-1.84

0.74

Chi-Square=207.52, df=180, P-value=0.07821, RMSEA00.035

Fig. 4. The first structural model describing t-values of the factors which influence the
concept work motivation.

4.1. Measurements of latent variables

In order to measure the latent variable work motivation for the
total sample, answers to four questions were used as manifest
variables (cf. Fig. 3). The underlying logic is that the latent variable
influences the manifest variables, that is if a worker is motivated, the
answers to these questions will be positive. This is why the arrows in
Fig. 3 go from the latent to the manifest variables. The figures
indicate t-values, which show that all manifest variables are

significantly related to the latent construct work motivation. To the
right are the t-values for the error terms and these are also all
significant.

The latent hygiene factors were measured (cf. Appendix) by
answers to three questions related to wage level, rewards and
interpersonal relations (see Table 2). All three had significant
t-values.

The latent growth factors were measured by answers to 12
questions (cf. Appendix) related to responsibility, information,
recognition/feedback and knowledge/training (see Table 2). All 12
had significant t-values.

4.2. The first structural model – measuring work motivation among
seasonal workers

The results of the structural model strongly support the Two-
Factor Theory of work motivation. Fig. 4 shows t-values which is
a measure of the number of standard errors that the coefficient
is from zero. A general rule states that a t-value larger than
þ1.96 or smaller than �1.96 is required at the 5% level of
significance (Jöreskog & Sörbom, 1993a,b). A higher absolute t-
value indicates a greater confidence in the predictive power of
the coefficient.

C. Lundberg et al. / Tourism Management 30 (2009) 890–899896

The most important factors to explain work motivation are
growth factors comprising issues such as feedback, information,
responsibility and training/knowledge. The t-value of ‘‘GROWTH’’
is 4.86 which is well above the critical level þ1.96 for 5%
significance (Jöreskog & Sörbom, 1993a,b). Hygiene factors are not
significant. Although the measurement model is able to measure
both concepts, the structural model cannot detect any significant
relation between hygiene factors and the dependent concept
work motivation. The t-value for this relation is �1.84 which is
not enough for the critical level �1.96. The structural model is
also ‘‘clean’’ since there is no strong interdependence between
growth factors and hygiene factors as indicated by the t-value
0.74 in Fig. 4.

The estimates of the structural model are described in Fig. 4. The
total fit of the model is quite acceptable. Jöreskog and Sörbom
(1993a,b) suggest several indices to use for assessing the overall fit
of a model, chi-square and goodness of fit index (GFI) being
frequently used. RMSEA measures the discrepancy per degree of
freedom of the model and the index must according to Browne and
Cudeck (1993) be lower than 0.05. The first structural model run
results in a fit with normal theory weighted least squares chi-
square ¼ 207 at 180 degrees of freedom. The root mean square
error of approximation (RMSEA) ¼ 0.035, and the goodness of fit
index (GFI) ¼ 0.88.

4.3. The second structural model – measuring work motivation for
worker subgroups

Since one of the study’s objectives was to investigate
whether the sample of seasonal workers could be divided into
worker subgroups on the basis of their work motivation and
since the results of the in-depth interviews led to a division of
the seasonal workers into two distinct worker subgroups a third
variable resident was included in the second structural model.
This variable is treated as a latent variable, although it is
measured by one single manifest dichotomous variable indi-
cating if a seasonal worker is a year around resident in the
region.

The elaborated model has a much better fit to the data (i.e. the
covariance matrix). The estimates of the elaborated structural
model are described in Fig. 5. The total fit of the model is consid-
erably improved with normal theory weighted least squares chi-
square ¼ 171.1 at 174 degrees of freedom. The root mean square
error of approximation (RMSEA) ¼ 0.0, and the goodness of fit
index (GFI) ¼ 0.90.

The model continues to support the Two-Factor Theory of
work motivation by the strong and significant influence on work
motivation from the growth factors and a non-significant influ-
ence from the hygiene factors. This is indicated by a t-value of

Chi-Square=171.10, df=174, P-value=0.54787, RMSEA=0.000

GROWTH
1.00

RESIDENT1.00

HYGIENE
1.00

MOTIVATION

0.22

0.90 / 3.99

0.12 / 0.85

-0.15 / -1.13

-0.22 / -2.7

0.03

-0.25 / -1.76

Fig. 5. The second structural model describing the estimates and the t-values (in
italics) of the factors which influence the concept work motivation.

3.99 which is well above the critical value þ1.96 for the relation
between ‘‘GROWTH’’ and ‘‘MOTIVATION’’ and an insignificant
t-value of �1.13 for the relation between ‘‘HYGIENE’’ and
‘‘MOTIVATION’’. The introduced factor ‘‘RESIDENT’’ indicates an
expected positive albeit insignificant (t-value 0.85) effect on
‘‘MOTIVATION’’ from being a seasonal worker resident all year
around in the region. The factor ‘‘RESIDENT’’ also has a significant
negative effect (t-value �2.7) on the importance of growth
factors.

5. Discussion and conclusions

In this study the objective was to understand work moti-
vation in a sample of seasonal workers in hospitality and
tourism and Herzberg’s Two-Factor Theory of work motivation
was tested empirically. The findings support Herzberg’s Two-
Factor Theory and show that it still has validity. The essence
of Herzberg’s Two-Factor Theory of work motivation, as
understood in this study, is that work motivation is grounded
in the satisfaction of ‘higher’ needs or ‘self fulfillment needs’
(Pinder, 1998) and not in more mundane needs such as wage
level.

This point is nicely brought out by the SEM model where ‘wage
level’ and ‘rewards’ load on hygiene factors, which has a very weak
and insignificant influence on work motivation. Out of the three
manifest variables, ‘meeting new people’ loads strongest that
further plays down the importance of monetary rewards to explain
work motivation.

Furthermore, the study investigated whether seasonal workers
could be divided into workers subgroups on the basis of their
work motivation. The answer to this question was positive. An
interesting difference among seasonal workers is that ‘meeting
new people’ is significantly more important for the migrant
community than it is for their counterparts in the resident
community.

Another hygiene factor – wage level – was of greater
importance to the resident community members than to those of
the migrant community. This hints at a possible compensation
between the two factors, that is ‘meeting new people’ seems to
make up for a low wage level among the migrant community
and vice versa for the resident community, which is less
enchanted by meeting new people but more concerned about
wage level. This relation is probably the reason why resident
loads negatively on hygiene factors in the SEM model presented
in Fig. 5. The negative sign indicates that for non-residents
(migrants) hygiene factors, and particularly ‘meeting new
people’, are more important. This line of reasoning corresponds
well with deLeon and Taher’s (1996) findings that extrinsic
rewards (i.e. hygiene factors) are of two types: organizational
(e.g. pay, working conditions) and social (e.g. friendship, dealing
with others).

The growth factors were measured by the following manifest
variables: responsibility, information, feedback, knowledge and
training. It was found that feedback and responsibility, to the
greatest extent, had an effect on work motivation. Information,
knowledge and training had a lesser impact on work motivation,
when comparing the components of the construct growth
factors. However, it should be emphasized that all of these
components were of significant importance for the enhancement
of work motivation among the seasonal workers. Consequently,
the seasonal workers’ work motivation is derived from
intrinsic rewards when experiencing self-control in their work
situation.

C. Lundberg et al. / Tourism Management 30 (2009) 890–899 897

Based on the in-depth interviews, special focus was set on the
importance of social factors. One of the conclusions that was
made, was that there were differences between the two worker
subgroups as regards what made the workers enjoy their jobs.
Migrant workers tended to live in occupational communities
(Lee-Ross, 1999b). Findings indicated that the members of the
migrant community defined themselves as seasonal workers and
that their present self-image was based on their occupational role
as seasonal workers. It was also found that members of the
migrant community shared attitudes, viewpoints and values as
regards, for example, their view of work and leisure. They also
often had work-based friends, which they spent most of their
waking hours together with and shared interest and hobbies
together with. This may also be a result of the fact that the
members of the migrant community also lived together. These
findings support Lee-Ross’ (1999b) argument that staff residency
plays an important role in the formation of informal work groups.
Members of the migrant community described their relationship
with co-workers as very close and that they, in some cases, were
like a family away from home. There was a strong sense of
camaraderie and inter-group support within the migrant
community based on both leisure and non-work activities (i.e.
a fusion of work and leisure time) and team working at their
place of work. The results also support Lee-Ross (1999b, p. 239)

Table 3
Differences in perceptions of work motivation factors among migrant and resident
community.

Hygiene factors Migrants Residents

Wage level (FORM24C) 3.22* 3.50*
Rewards (company policy and administration)

(FORM24G)
2.91 3.08

Interpersonal relations (NYAM) 3.41* 3.06*

Growth factors
Responsibility
– Having responsibility at work (ANSV22C) 4.43 4.54
– Authority to make own’s own decisions at work

(ANSV23G)
4.37 4.45

Recognition/feedback
– Bringing up one’s ideas, thoughts and suggestions

(FEED23H)
4.41 4.37

– Finding a ready listener for one’s ideas, thoughts and
suggestions (FEED23I)

3.91 3.83

– Receiving encouragement when set goals have been
attained (FEED26P)

3.61 3.51

Knowledge & training
– Receiving training for work tasks (KUNSK22J) 3.47 3.04
– Having the competence needed for work tasks

(KUNSK23E)
4.74 4.61

– Having the knowledge needed to make own’s own
decisions (KUNSK23F)

4.66 4.61

– Receiving on-the-job training (KUNSK26B) 3.61 3.32
Information
– The company has clear goals (INFO22A) 4.18 4.28
– Receiving necessary information for work tasks

(INFO22K)
3.97 3.75

– Receiving information regarding the company (e.g.
goals and visions) (INFO26A)

3.79 3.73

Motivation
– Motivated in one’s work (MOTIV23A) 4.38 4.30
– Receiving motivation from management (MOTIV22D 3.74 3.42
– Receiving motivation from managers (MOTIV22E) 3.93 3.71
– Receiving motivation from co-workers (MOTIV22F) 4.13 4.10

Note: n ¼ 243. Figures specify the mean response to items. Figures in italics: 4-point
Likert-type scale used for the factors FORM24C, FORM24G, NYAM, FEED26P,
KUNSK26B AND INFO26A. * : Statistically significant differences between the two
groups according to t-tests (5%). (XX): represents variables in the measurement
model (cf. Appendix).

findings that seasonal work is characterized by ‘‘job importance is
replaced by work situations characterized by hedonism and close
social bonding’’.

Based on the conclusions from the in-depth interviews, the
issue of ‘occupational community’ was brought into the model.
This was made through the manifest variable indicating whether
a seasonal worker was registered as a year around inhabitant in
the region or not. The result was a better fit of the model, but
the results did not indicate significant influences from the
variable resident, neither on work motivation nor on hygiene
factors. This is further supported by a simple comparison
(Table 3) of answers given to Likert-scale questions regarding
work motivation, where there were no differences regarding
how the two worker subgroups were motivated in their
work.

The clear evidence of how worker subgroup influences work
motivation contributes to our understanding of how individual
variations apply to the theory. The need for more evidence on
how well the theory applies to individual variations like gender,
culture and age categories not to mention organizational differ-
ences has been pointed out by Furnham, Forde, and Ferrari (1999).
These results also shed light on how individual differences of
needs and values explain work motivation which is an issue
that the Two-Factor Theory has been criticized for not taking
into consideration (Parson & Broadbride, 2006; Tietjen & Myers,
1998).

6. Management implications

So what are the implications of these results for business in
hospitality and tourism? It was shown that hygiene factors were
of importance for the general satisfaction of the workers at their
place of work, and therefore it is central for management of
businesses to meet these needs. However, in order to motivate
employees, the results suggest that the growth needs needed to
be fulfilled as well. This implies that in order to get motivated
employees, management needs to give their employees respon-
sibility and create platforms for feedback. By creating such
a context, employees’ intrinsic value is likely to improve and they
will be able to develop themselves in their occupational role. It is
also of importance to provide the employees with information,
knowledge and training.

The results also indicate that management of businesses need
to consider that the seasonal workforce consists of different kinds
of workgroups, which in some cases have different needs. It was
shown in this study that close interpersonal relations were
significant for the wellbeing of migrant community members.
Management could, by creating the necessary conditions for such
relations, both on and off work, improve the general satisfaction
among these individuals. Examples of activities which could help
develop such relations are joint living conditions for seasonal
workers supplied by employers, teambuilding training invest-
ments on e.g. handling service encounters, discounted recrea-
tional activities and kick-off events for seasonal workers. In
contrast to this group, the members of the resident community
found wage-level to be more important for their wellbeing at
their place of work.

Acknowledgements

The authors thank the anonymous reviewers of Tourism
Management for their helpful suggestions for improving this
article.

A. Appendix

The SEM results using 20 manifest variables (cf. Table 3 for explanations) and four latent variables used in the structural models.

FEED23H0.74

FEED23I0.56

FEED26P

0.48

INFO22A0.98

INFO22K0.73

INFO26A0.97

ANSV22C

0.84

ANSV23G0.82

KUNSK22J0.83

KUNSK23E1.00

KUNSK23F0.98

KUNSK26B0.83

FORM24C0.72

FORM24G1.04

FORM24L1.09

FORM24M1.09

FORM24S1.09

ATMOS7F1.10

NYAM0.00

SKRIVEN20.00

GROWTH

RESIDENT

HYGIENE

MOTIVATI

MOTIV22D

0.35

MOTIV22E 0.30

MOTIV22F 0.72

MOTIV23A

0.39

Chi-Square=171.10, df=174, P-value=0.54787, RMSEA=0.000

0.87

0.90

0.61

0.84

0.58

0.71

0.79

0.36

0.57

0.34

0.51

0.48

0.52

0.35

0.37

0.51

0.62

0.34

1.06

1.03

0.90

0.12

–

0.15

–

0.14

–

0.24

0.28

0.17

0.22-

0.13

0.18

0.16

0.26

0.19

0.10

0.25

–

0.09

0.43

-0.10

0.20

0.14

-0.22

0.13
0.12
0.10

0.06

-0.29

0.32

0.71
0.22
0.26

0.45

0.06

-0.21

-0.26

-0.15
0.18

-0.09

0.38

0.18
0.14
0.10
0.15

-0.16

0.14
0.45
0.39
0.13
0.12

-0.07

0.10
0.15
0.18
0.09
0.43

0.49

0.66

0.12

-0.13

-0.21
0.15
0.22
0.15
0.16
0.10
0.13
0.17

-0.19

-0.09

-0.17

-0.21
-0.07

-0.59

0.24
0.17
0.61
0.18
0.19
0.37
0.24

-0.25
/

C. Lundberg et al. / Tourism Management 30 (2009) 890–899898

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• Herzberg’s Two-Factor Theory of work motivation tested empirically on seasonal workers in hospitality and tourism

Introduction
Work motivation
Herzberg’s Two-Factor Theory of work motivation
Herzberg’s theory adapted and applied in different contexts
Work motivation and individual differences
Criticism of Herzberg’s theory

Methodology
The setting
Sample
Data collection
Data analysis
Using structural equations modeling for analysis of data
Constructs included in the measurement model
Profile of sample
Results
Measurements of latent variables
The first structural model – measuring work motivation among seasonal workers
The second structural model – measuring work motivation for worker subgroups
Discussion and conclusions
Management implications
Acknowledgements
Appendix
References

Cholera Modeling: Challenges to Quantitative Analysis and
Predicting the Impact of Interventions

Yonatan H. Grad1,2, Joel C. Miller2,3, and Marc Lipsitch2,4,5
1Brigham and Women’s Hospital, Division of Infectious Diseases, Boston, MA 02115
2Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of
Public Health, Boston, MA 02115
3Fogarty International Center, National Institutes of Health, Bethesda, MD 20892
4Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston,
MA 02115

Abstract
Several mathematical models of epidemic cholera have recently been proposed in response to
outbreaks in Zimbabwe and Haiti. These models aim to estimate the dynamics of cholera
transmission and the impact of possible interventions, with a goal of providing guidance to policy-
makers in deciding among alternative courses of action, including vaccination, provision of clean
water, and antibiotics. Here we discuss concerns about model misspecification, parameter
uncertainty, and spatial heterogeneity intrinsic to models for cholera. We argue for caution in
interpreting quantitative predictions, particularly predictions of the effectiveness of interventions.
We specify sensitivity analyses that would be necessary to improve confidence in model-based
quantitative prediction, and suggest types of monitoring in future epidemic settings that would
improve analysis and prediction.

The recent cholera epidemic in Zimbabwe (2008-2009) and the ongoing cholera epidemic in
Haiti (2010-2011) are catastrophes in two regions already devastated by disease and poverty.
The extent of these disasters has prompted inquiries into whether interventions – such as
vaccination, antibiotic administration, and the provision of clean water – could have slowed
or aborted these cholera epidemics, and how such interventions might be most effectively
implemented in future epidemics. Cholera spreads in areas with poor sanitation and through
contaminated water, and the ideal solution is to improve infrastructure to provide clean
water and effective sanitation — an approach that has been successful since the 19th

century.1 On the timescale of an epidemic, creation of such infrastructure is rarely feasible.
Administration of vaccine, a staple of preventive medicine, is one of the few potentially life-

5 Corresponding author: Marc Lipsitch, Professor of Epidemiology, Departments of Epidemiology and Immunology & Infectious
Diseases, Director, Center for Communicable Disease Dynamics, Harvard School of Public Health, 677 Huntington Avenue, Kresge
Building, Room 506, Boston, MA 02115, Tel (617) 432-4559, mlipsitc@hsph.harvard.edu.

SDC Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article
(www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the author.

Conflicts of Interest and Sources of Funding: The project described was supported by Award Number U54GM088558 to ML from
the National Institute Of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily
represent the official views of the National Institute Of General Medical Sciences or the National Institutes of Health. YHG received
support from National Institutes of Allergy and Infectious Disease (T32 grant AI007061). JCM received support from the RAPIDD
program of the Science and Technology Directorate, Department of Homeland Security and the Fogarty International Center, National
Institutes of Health.

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saving and implementable solutions.2-8 However, vaccines remain untested in epidemic
cholera.

Decisions regarding whether and how to pursue mass vaccination during epidemic cholera
present logistical and policy challenges. Ideally, all lifesaving interventions should be
employed, but, in practice, policy makers often have to choose among possible
interventions, as well as among strategies for deploying these interventions.

Mathematical models of disease transmission aim to provide guidance in making such
decisions. Models can estimate key parameters such as R0 (the basic reproductive number,
referring to the number of infectious cases caused by an average infectious person in an
otherwise entirely susceptible population), and the impact of control strategies. Toward this
end, several recent models based on data from the cholera epidemics in Haiti and Zimbabwe
have been published.3-7

All models are limited by their simplifying assumptions. It is important to critically evaluate
cholera models and their assumptions, so as to gauge the strength of their conclusions. Here,
we examine the assumptions implicit in mathematical models of cholera, and the ways these
models have been applied to data from Haiti and Zimbabwe. We discuss the impact of
model misspecification, parameter uncertainty, and spatial heterogeneity, and explore
specifically the impact of the unknown lifespan of cholera vibrios in water reservoirs. We
discuss why these criticisms — potentially applicable to many infectious disease modeling
efforts — are particularly germane to cholera models. Our goal is neither to compare models
directly nor to critique each model individually, but to explore the general issues that
confront cholera modeling efforts.

Cholera transmission model misspecification and parameter uncertainty
Cholera transmission depends on excretion of Vibrio cholerae by infected persons and on
ingestion of vibrios in contaminated food or water. In endemic situations, cholera
transmission is influenced by complex factors including multiple co-circulating strains, local
immunity from past outbreaks,9 weather cycles (both seasonal and climatic
oscillations 10-12), and phage that destroy V. cholerae.13 In epidemic outbreaks in
susceptible populations, many of these factors are ignored; models assume a single infecting
strain, an entirely susceptible population, and a short time scale for the epidemic such that
climatic and phage-cholera relationships can be neglected. The rate at which cholera vibrios
are excreted depends on the severity of infection, which ranges from asymptomatic infection
to cholera gravis (0.5-1L of diarrhea an hour 14), and the extent to which food and water
supplies are contaminated by sewage.

In 2001, Codeço 15 proposed a model that aims to capture transmission within a community
and is a predecessor of several recent models.3,4,6,16 While this model was explicitly
designed for simplicity and qualitative analysis (rather than for quantitative prediction), it
provides a convenient framework to illustrate concerns that frequently arise in cholera
models. A simplified version of the model is:

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S, I, and R represent the number of susceptible, infected, and recovered persons,
respectively, with a total population N = S+I+R; B represents the concentration of Vibrio
cholerae in the water reservoir used by this population. Key parameters include those
influenced by specific local geographic, aquatic, socioeconomic, and behavioral
characteristics and others that reflect the biology of Vibrio cholerae and clinical disease. We
discuss below the issues of model misspecification (in which the item modeled differs from
the item of interest) and parameter uncertainty (in which the true values of the parameters
are difficult or impossible to estimate accurately, as they pertain to this cholera model). The
model parameters include

• β, the rate at which each of the N persons contacts contaminated water from the
reservoir (units: day-1). This is an abstract concept that in the context of this model
must be related to the amount of reservoir water consumed, but is not expressed in
units that include volume and has no upper or lower bounds.

• ξ, the rate that describes how much an infected person contributes to the
concentration of Vibrio in the water reservoir – a measure of the size of the
reservoir, the daily amount of each infected person’s stool that reaches the
reservoir, and the concentration of Vibrio in the stool (units:
cells·ml-1·day-1·person-1). This compound parameter is not empirically known, and
it likely varies widely, depending on severity of infection, state of sewage
infrastructure, and size of water reservoir.

• δ, rate of removal of infectious vibrios from the water supply (units: day-1). This is
a reflection of the lifespan of V. cholerae, and depends on many factors including
whether the reservoir is stationary (such as a well) or flowing (as in a river), as well
as water salinity, water temperature, and concentration of cholera phages.17,18

Interpretation of this parameter is further complicated by the fact that viable but
unculturable vibrios persist and can remain infectious.19 Reports of data from
cholera outbreaks rarely include estimates of this parameter or relevant quantities.

• γ, the rate at which a person recovers from cholera (units: day-1). Symptoms last
less than a week. Recovered persons can continue to shed vibrios for 1-2 weeks,
with a very small fraction shedding for longer.14

• κ, the concentration of cholera that infects 50% of exposed people (units: cells/
mL). The infectious dose ranges widely, depending on the strain and context,
especially gastric acidity. In volunteers, doses of 1011 V. cholerae consistently
caused diarrhea.20 When ingested with a bicarbonate buffer, as few as 102 vibrios
can result in cholera vibrios in the stool.20 Dose is related to the severity of diarrhea
and duration of incubation, with lower doses being associated with a carrier state or
milder forms of diarrhea and longer incubation periods.20,21 While the empirical
data describe a relationship between dose (number of vibrios), the model is
parameterized in terms of vibrio concentration.

This model also assumes that the ratio of asymptomatic to symptomatic infections is
constant throughout an epidemic, and that dose determines the likelihood of infection but
not the likelihood of being symptomatic. This assumption is contrary to findings from
experimental human infections.20 Violations of this assumption may have two consequences
for cholera modeling in conjunction with case-notification data. First, severity affects the
intensity of shedding,14 and so the average contribution of an infectious person to
transmission may change systematically with time as the distribution of infectious doses
changes. Second, only symptomatic infections are likely to be reported, and so the reporting
rate may change systematically over time for the same reason.

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The infection term in this model suffers from misspecification in the sense that there is no
physically plausible process that relates the modeled state variables (concentrations of
vibrios and “rate of contact with contaminated water”) to a rate (or probability per small unit
of time) at which susceptible persons become infected. Put another way, there is no simple
way to convert measurable quantities (e.g., a measured dose-response relationship between
number of vibrios ingested and the risk of infection) into the parameters β and κ of this
model.

This base model has been augmented in multiple ways.16,22-27 Some recent models that
analyze the outbreaks in Haiti and Zimbabwe 3-7 incorporate a non-reservoir-based, person-
to-person transmission term.5-7 Also, some incorporate a hyperinfectious state for vibrios
shortly after excretion3,5,16,22. Some include an asymptomatic state for infected
persons 3-5,23, with different models assuming that 20%,5 21%,3 and 25% 4 of infected
persons are symptomatic, and that symptomatic persons are 10 (ref. 5) to 1000 (ref. 3) times
as infectious as asymptomatic ones. One model includes a latent period,5 and several models
link communities to generate meta-population models.4,5,7,25,26

The Table shows the range of several key parameter values either used or generated by the
models. Although these models have different structures, we include the ranges to illustrate
the uncertainty and inconsistency in parameters that should be biological aspects of cholera
and parameters that reflect local water infrastructure and sanitation. We note that some of
the parameters used by Codeço,15 chosen for use in an exploratory study, continue to be
used in some cholera models despite no evidence for them. For example, the rate of contact
with reservoir water is either fixed at 1 day-1 in some models or used for fitting in others,
although the physical meaning of this term is unclear as described above. Similarly, rate of
contribution of vibrio concentration in the aquatic environment is variously set at ξ=10 cells/
mL/person/day following Codeço,15 or set as low as 0.01 cells/mL/person/day based on
estimated water reservoir size, or allowed to vary in model fitting.

The problem of variability in aggregated spatial models of cholera
All of the recent models of epidemic cholera in Haiti and Zimbabwe calibrate to province-
level incidence data. Fitting models to data that aggregate local communities assumes that
parameters derived from aggregated data can be applied homogeneously, essentially saying
that everyone within a province shares the same water reservoir. Attempts to approach this
issue in recent cholera modeling include the papers by Chao et al.,5 in which the authors
address this concern by estimating local communities based on population density, making
use of LandScan (http://www.ornl.gov/sci/landscan/) and geography with respect to rivers
and highways, and by Bertuzzo et al.,4 in which the authors use administrative sub-district
populations in their model. These model improvements require additional estimated
parameters.

The obvious difficulty in calibrating models to province-level data is that cholera outbreaks
may be highly spatially heterogeneous: adjacent neighborhoods can experience very
different levels of infection,28,29 and given the dependence on water source and sanitation,
there may be significant variation at smaller spatial scales than neighborhood. Even
neighboring households may not be equally exposed to contaminated water. The shape of an
aggregate epidemic curve is influenced by the size of constituent communities, relative
timing of outbreaks in those communities, local factors that influence each community’s R0,
control measures implemented over time, fraction of asymptomatic infection, and extent of
underreporting.

Fitting a model to an aggregate epidemic curve will generate a single R0, but this R0 may
suggest a level of vaccination that would be protective in some constituent communities but

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not others. For example, in one recent paper,6 Mukandavire et al. calibrated their model to
the Zimbabwean epidemic as reported in each province and from the country as a whole;
they then derived the R0 for each of these populations. They reported a threshold vaccination
proportion ranging from 13% in Mashonaland East to 81% in Matebeleland South, with the
fraction for all provinces except for Mashonaland East reported as 34% or greater. For
Zimbabwe overall, the estimated critical vaccination fraction that would prevent an
epidemic was 17% – lower than the level of vaccination for all but one of its constituent
provinces. This discrepancy emphasizes how spatial heterogeneity can bias results.

In summary, the epidemic curves in constituent spatial units may differ both temporally and
in shape, such that the aggregated epidemic curve incorporating each of these communities
does not reflect homogeneous dynamics, as assumed in mass-action mixing.30

Consequently, an R0 estimated from aggregate data fails to capture the dynamics critical to
accurately estimate the impact of interventions in the constituent spatial units. The data from
Zimbabwe show multiple peaks and other features characteristic of heterogeneously mixed
populations 31 at province and neighborhood spatial scales.6,29 The practice of fitting
epidemic models to cumulative incidence curves rather than incidence curves can obscure
these features, while also violating statistical assumptions of independence between fitted
data points.

Use of models to predict intervention effects
Interventions such as vaccination, antibiotic administration, and provision of clean water all
can decrease the number of cholera cases. Vaccination reduces the number of fully
susceptible persons, reduces infectiousness (ie, the rate of contamination of the water
supply), and reduces the probability of becoming symptomatic when infected. Antibiotic
administration shortens the duration of illness and perhaps reduces the concentration of
vibrios excreted during illness. Access to clean water reduces consumption of vibrios. Each
of these interventions will result in qualitative decreases in the extent of the epidemic. The
benefits will be a combination of direct effects on those receiving the intervention, and
indirect effects on those who benefit from reduced exposure because others received the
intervention; in the case of vaccines, the latter effect is known as herd immunity.

The estimated direct impact of these interventions is often an input variable for transmission
models; for example, these models assume that a certain proportion of the population is
vaccinated and that the vaccine is effective in a particular fraction of the population (all-or-
nothing efficacy) or reduces the infectiousness of each contact by a fixed fraction (leaky
efficacy).32 Thus the role of the transmission models, over and above the assumptions about
how interventions affect those who receive them, is to quantify the indirect effects of
interventions – how much interventions can slow transmission and protect those who are not
directly protected by the intervention. These quantitative results about the impact of
interventions depend on the parameter values used in the model. In this sense (setting aside
issues of model specification), the value of model-based predictions depends on the extent to
which the predictions about indirect effects are robust to uncertainties about the value of
input parameters.

Uncertainties in the values of input parameters can translate into massive uncertainties in the
values of model predictions. We present an example in the Figure (see eAppendix
[http://links.lww.com] for details), and focus for this example on the impact of uncertainty
in δ, the rate of removal of cholera from the water supply. In the Codeço model,15 the
lifespan of cholera in the water supply is represented as 3 days (δ=1/3 days-1). In other
models, the lifespan of cholera in the water reservoir is set at 30 days,3,5,6,16 estimated at
approximately 4.5 days 4,25 or fitted at approximately 41 days.7 Given that this term reflects

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the rates at which infectious vibrios become noninfectious due to death or physiologic
change, one would expect the lifespan to be highly context-dependent and to vary based on
the conditions of the water reservoir. Studies from the 1960s 33,34 examined cholera lifespan
in a variety of water types (such as well-water and sea-water) and under a variety of
conditions (including sun exposure and temperature variation). In these studies, cholera
lifespan is reported from 4 to 80+ days depending on water source and condition.

Variation in the assumed survival of cholera in water directly translates into variation in the
distribution of assumed serial intervals for cholera transmission. This in turn changes
estimates of R0, the basic reproductive number, when these are obtained by fitting a model
to the initial growth rate of the epidemic.35 When these estimates of R0 are in turn used to
model interventions (by extending the model, after fitting to initial-growth data, into the
future and considering the impact of interventions on transmission), the various values of R0
can give dramatically different predictions for the population-level effects of the
interventions.

The proportion of a randomly mixing population that must be effectively vaccinated to
prevent an epidemic from taking place is known as the critical vaccination threshold. This
threshold is expressed as 1-1/R0 (effective vaccination means fraction vaccinated, or
coverage, multiplied by vaccine efficacy 36). For a model fitted to the early growth rate of
the epidemic, varying the lifespan of infectious cholera vibrios in the aquatic reservoir (a
parameter for which there are no data, but which is a key component to the serial interval)
leads to very large changes in the inferred value of R0 and the corresponding critical
vaccination threshold. Fitting the model with the lifespan of infectious vibrios set at 30 and
then at 3 days changes the fitted R0 from 6 to 1.95, while the critical vaccination threshold
decreases from 83% to 49%. Let us assume pre-epidemic vaccination of 70% of the
population with a non-leaky vaccine that has 70% efficacy (in keeping with estimates for
populations with less natural immunity than the endemic populations in which the vaccine
was trialed37). If R0 = 1.95, then pre-vaccination of a population would prevent an epidemic,
whereas if R0 = 6, then nearly all unvaccinated persons will become infected. Thus, using
parameter values found in the literature, the indirect benefits of vaccination (which is what
the model is meant to quantify) range from almost complete protection of all unvaccinated
persons to no protection. (See the eAppendix [http://links.lww.com] for further discussion of
this issue.)

If one is willing to make strong assumptions, the problems of estimating R0 based on the
initial growth rate and on assumed-duration parameters can be overcome in an idealized
model by fitting to an epidemic curve with a known peak in cases.38 However, one must
assume homogenously mixing and homogeneous population (which is implausible as we
argue in the previous section); fixed reporting ratio throughout the epidemic, which is not
the case39,40; fixed asymptomatic to symptomatic ratio throughout the epidemic, for which
we know of no supporting data; and a single-peaked epidemic, which has not been the case
in multiple locations in both Haiti and Zimbabwe.29,41 Even if these assumptions were
tenable, this approach can only be used once the epidemic has peaked and so cannot be
employed at the start of an epidemic to guide interventions.

The claims made in this section are particular to the actual parameter values required for
cholera models and the range of uncertainty that exists for them, in particular for the
duration of infectiousness in contaminated water. Sensitivity analyses are necessary in all
prediction models for infectious disease transmission, but here we argue, more specifically,
that the uncertainty in just one parameter of cholera models can nearly eliminate the
predictive power of these models. Within the range of possible values of this parameter, the

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qualitative predictions of the model range from substantial indirect vaccine effects to almost
no indirect vaccine effects.

Perspective: What is special about cholera?
The process of fitting models to data on the early growth of an epidemic, then running the
models forward to test the predicted impact of interventions, has been applied extensively to
other infectious diseases. Are the critiques presented here generally applicable to all
transmission models fitted to early epidemic data, or are there particular challenges
pertaining to cholera or a limited class of infections including cholera?

Such approaches have been frequently applied in planning for pandemic influenza and in the
response to SARS and the 2009 influenza pandemic. For these respiratory diseases, a
common approach has been to estimate the early growth rate from daily or aggregated case
counts, combine this estimate with a (usually exogenous) estimate of the distribution of
serial intervals, and produce an estimate of the early values of the reproductive number of
the infection. Relatively high-quality estimates of the serial interval distribution were
available from contact tracing for SARS, leading to rather consistent estimates of the initial
reproductive number around 3.42-44 Likewise, several sources of data provide estimates for
the serial interval of pandemic influenza around 2-4 days, 45,46 with corresponding estimates
of early reproductive numbers ranging from around 1.3 to a bit over 2, depending on the
pandemic and the setting.45-49 While these estimates vary (reflecting true variation,
methodological choices, and statistical noise), the range of variation in estimates is less than
described above for epidemic cholera. The influenza literature contains explicit
considerations of the appropriate values for natural-history parameters 45,50,51 (including
critiques 45 of previously used values 48), discussions of the impact of data processing
assumptions on reproductive number estimates,35,49 and extensive sensitivity analyses
exploring the consequences of alternative parameter values.52-54

Moving beyond parameter-value uncertainty to issues of model structure, the literature on
respiratory diseases has considered how varying assumptions about the scale and “local-
ness” of mixing,55,56 the relative importance of various settings for transmission,54

seasonality,57 and other factors affect the predicted natural history of an epidemic and
impact of control measures. The importance of heterogeneity is recognized in modeling
many diseases.58-61

In summary, the issues raised here about the reliability of quantitative predictions from
cholera models are applicable to other diseases, including those for which real-time (and
retrospective) model fitting has been attempted, such as influenza and SARS. In these
diseases, as well, sensitivity analyses to uncertain or heterogeneous parameters are needed,
and have indeed been employed.42,62,63 However, there appears to be less heterogeneity and
less uncertainty about parameter values for these diseases, perhaps because of their direct
person-to-person transmission route, which reduces the impact of environmental variables
on parameter values and improves one’s ability to measure relevant quantities. Thus, while
the same issues should be considered in other diseases, we believe the magnitude of
uncertainty in the predictions of models is greater for cholera than for SARS and influenza.

Suggestions for improvements
Each of the uncertainties described here provides a potential avenue for advancing cholera
modeling. Additional monitoring, where possible, of spatial heterogeneity and the model’s
quantifiable variables will aid in understanding the mechanisms and dynamics of cholera
transmission.

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For example, the accuracy of model predictions can be improved by line-listing data
describing an outbreak in high spatial and temporal resolution, coupled with descriptions of
water resources, storage, and use, and by direct quantitation of vibrio concentration, or
measurement of fecal coliform contamination as a proxy.64 Such data would also improve
understanding of the extent to which critical variables vary across epidemic settings. In the
context of an ongoing epidemic, treatment and prevention efforts must be primary. Still, we
note that data relevant to model-building have been obtained in past epidemics.64 Also,
coordination with demographic, geologic, and aquatic databases 4,5 can help improve the
understanding of cholera transmission dynamics under various conditions.

From the perspective of model misspecification, one possible improvement is to restructure
the rate of infection to reflect quantifiable variables. For example, some model
misspecification can be avoided by collecting empirical data on drinking rates. This could
allow the contact rate (currently units of day-1) to be changed to a drinking rate (units of
volume per time), with the probability of infection then formulated as a function of the dose
of ingested vibrios rather than a function of the concentration of vibrios. Better data on the
dose-response relationship for cholera – including differences between ingestion of a given
dose all at once and ingestion of the same dose over several hours or days – would help to
constrain the infection terms.

Lastly, the survival of vibrios in a water supply, as shown in our simple sensitivity analysis,
may have a significant impact on model-based predictions. The magnitude of the effect may
be limited under circumstances in which person-to-person transmission outweighs
waterborne transmission (see eAppendix [http://links.lww.com]). This further emphasizes
the need for monitoring, and suggests the importance of assessing the sensitivity of results to
variations in this parameter.

Conclusions
The uncertainties in epidemic cholera modeling described above suggest that current
quantitative estimates of benefits from intervention strategies are handicapped by uncertain
model structure. Such uncertainties include the role of person-to-person transmission, a lack
of data about critical parameters, including the rate of contamination of communal water
supply and the rate of loss of infectious vibrios from the aquatic reservoir, and spatial
heterogeneity of parameters among communities. For quantitative modeling to improve its
predictions and offer better guidance to policy-makers during episodes of epidemic cholera,
innovative approaches are needed for gathering data on neighborhood-level water
consumption and contamination, as well as higher spatial-resolution case-reporting.

The analyses and suggestions presented here are intended to provide assistance in critically
interpreting the results of cholera models and to point out avenues for further exploration in
terms of data collection and modeling development. This is not to dismiss recent cholera
modeling efforts or to suggest a particular threshold for modeling accuracy beyond which
the use of models is valid. As discussed by George Box, 65 all models are wrong, but some
are useful. The extent to which a model is useful depends on the question being asked, and
then on an assessment of how a model’s uncertainties and simplifying assumptions influence
the strength of its conclusions.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

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Appendix
In the model we present, based on Codeço,1 the basic reproductive number (R0) and the rate
of exponential growth (r), defined as the per capita change in number of new cases per unit
of time, are:

These equations indicate that for a given growth rate, varying parameter values within their
plausible range of uncertainty can lead to large changes in R0, with important consequences
for the models predictions about the effects of interventions.

As an example, take the starting point in which the duration of infection with cholera is 5
days, the lifespan of cholera in the water supply is 30 days, the size of the population is
10000 individuals, the concentration of V. cholerae in the water reservoir resulting in 50%
probability of infection is 1×106 cells/mL, and the contact rate is 1 per day. Assuming an
initial growth rate of 0.1 per day and solving for the contamination rate (ξ), then using the ξ
term to derive R0, we calculate R0 = 6. Alternatively, assuming the lifespan of cholera in the
water supply is 3 days, then, for the same growth rate, R0 = 1.95. We consider the effect of
giving 70% of the population a vaccine that gives full immunity to 70% of recipients, but
has no effect on the remainder. We assume the vaccine is distributed prior to the
introduction of cholera. We model this as shifting individuals to the “Recovered”
compartment in the model.

The examples above reflect the relationship among the growth rate, basic reproductive
number, and disease-generation time, defined as the average amount of time between when
an individual is infected and when the person who infected that individual was infected.2

Given two of the three, one can determine the third. Because the generation time depends on
the duration of cholera infection and the lifespan of cholera in the water reservoir, then, for a
given positive growth rate, R0 depends on these variables. Lack of knowledge of the lifespan
of V. cholerae in a water reservoir then means we can only guess at the disease generation
time, and hence a positive growth rate is compatible with a wide range of values of R0.

Note that in both expressions for R0 and r, the terms ξ, β, κ, and S0 appear only as the
combination ξβS0/κ. If we were to assume δ and γ are fixed and fit the model to an
observed value of r, then we are specifying the combination of ξβS0/κ, and so R0 is
uniquely determined. This holds regardless of how we allow ξ, β, S0, and k to vary in the fit;
the relation between R0 and r is not sensitive to these parameters. In other words, a
sensitivity analysis of the impact of varying one of these parameters while fitting to another
of the parameters is uninformative, as their product will remain the same. Introduction of
terms to account for hyperinfectivity, differing infectivity for asymptomatic and
symptomatic individuals, and person-to-person infection, will add terms to, and therefore
influence, these relationships, but the core structure remains.

Combining these observations, the similar values for R0 reported by several recent cholera
models may reflect use of similar values of δ and γ and hence a similar serial interval. The
variation seen in ξ and β likely then reflects differences in other parameter estimates and
model differences. However, while we might know the distribution of duration of infection
with cholera, we do not know the lifespan of cholera in a water supply. Because the relation

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between r and R0 is sensitive to this parameter, and our knowledge of it is poor, sensitivity
analyses should investigate wide ranges of this parameter.

The serial interval for the model discussed here can be calculated as follows. Start with one
infected individual, who recovers at rate γ and increases the concentration of vibrios in the
water reservoir at rate ξ. These vibrios decay at rate δ. The expected concentration of
vibrios due to the infected individual at time t is given by:

As infectiousness is proportional to vibrio concentration when concentrations are low, to
obtain the serial interval distribution we can normalize BI(t) by its integral over time, which
is

The serial interval has a mean equal to the sum of the mean duration of human
infectiousness and the mean duration of vibrio viability in the water,

Thus for these parameters, this ranges from 8 days (5 + 3) to 35 days (5+30) — an
uncertainty of almost 4.5 times. Plotting the serial interval distribution for the two sets of
parameters used in the example above yields eFigure (http://links.lww.com).

The parameter uncertainty emphasized here is importantly dependent on the most uncertain
(and probably variable) parameter that influences timing of infectiousness, the decay rate of
cholera infectivity in water. One might argue that this dependence is an artifact of assuming
a purely waterborne transmission route, without accounting for person-to-person
transmission, which in this context means transmission through contaminated food or water
containers within households or at communal meals. The role of waterborne transmission is
to extend the duration of infectiousness traceable back to one infected person from the
duration of that person’s shedding to the (possibly much longer) time that the vibrios shed by
that person remain infectious in the water reservoir. In a model with primarily person-to-
person transmission, the serial interval would be shorter and less uncertain.

If one were certain of the relative proportion of person-to-person and waterborne
transmission of cholera within an epidemic (and if it could be assumed constant in space and
time), then the parameter uncertainty described in the main text of this paper would be
reduced. However, in models incorporating direct person-to-person transmission, the
relative role of this route vs. waterborne transmission is either fitted, for which there may be
an identifiability problem, or assumed, based on little or no data, especially for any
particular ongoing outbreak. In the absence of knowledge about the relative importance of
person-to-person and waterborne transmission, the uncertainty in the serial interval remains
unchanged.

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65. Box GEP. Science and Statistics. JASA. 1976; 71(356):791–799.

Grad et al. Page 14

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Figure. Influence on R0 of lifespan of cholera in water reservoir
A. In this example, the early growth rate is 0.1 per day, starting population of susceptible
individuals is 10000, contact rate with cholera = 1 per day, the concentration of cholera in
the aquatic reservoir at which 50% of the population is infected is 106 cells per mL, and the
duration of cholera infection is 5 days. Solving for ξ given this growth rate and varying
values for δ yields different R0. Solid line (δ = 1/30 days-1): ξ = 4 cells per mL*infected
individual*day; R0 = 6. Dotted line (δ = 1/3 days-1): ξ = 13 cells per mL*infected
individual*day; R0 = 1.95. B. For the same parameter values in A, we have modeled the
impact of having vaccinated the population prior to introduction of the epidemic at 70%
coverage with a vaccine of 70% efficacy. Note that there is no epidemic at this vaccine
coverage for the example where R0 = 1.95.

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Grad et al. Page 17

Table
Parameters assumed or fitted based on mathematical models of cholera

Parameters Range

Rate of contact with reservoir water (days-1) 1×10-5 – 1

Duration of cholera infection (days) 2.9-14

Cholera lifespan in water reservoir (days) 3-41

Rate of contribution to V.cholerae concentration in the aquatic environment (cells*mL-1*individual-1*day-1) 0.01 – 10

Concentration of cholera that yields 50% chance of infection (cells/mL) 105-106

Multiplier for infectiousness of freshly shed vibrio (hyperinfectious state) 50-700

Duration of hyperinfective state (hours) 5-24

Ranges are drawn from several references 3-7,15. Note that not all parameters are used in all models (for example, Bertuzzo et al.,4 Tuite et al.,7

and Mukandavire et al.6 do not include a hyperinfective state in their models) and that there is variation in which parameters are fixed and fitted to
data.

Epidemiology. Author manuscript; available in PMC 2013 July 01.

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Visual Ethics: Ethical Issues in Visual Research

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ESRC National Centre for Research Methods Review Paper

Visual Ethics: Ethical Issues in Visual Research

Rose Wiles1, Jon Prosser2, Anna Bagnoli2, Andrew Clark2,
Katherine Davies2, Sally Holland3, Emma Renold3

1National Centre for Research Methods Hub, University of Southampton.
2NCRM Real Life Methods Node, University of Leeds and University of Manchester.
3NCRM Qualiti Node, University of Cardiff.

October 2008

National Centre for Research Methods

NCRM/011

Contents

1. Introduction

2. Frameworks, professional guidance, regulation and legal rights and
duties for visual researchers

2.1 Ethics, morality and legality
2.2 Approaches to ethics
2.3 Professional ethical guidelines
2.4 Ethical regulation
2.5 Legal issues

3 Consent Issues

3.1Researcher-generated images
3.2Anonymising visual data: reflections on the Young Lives and
Times project – Anna Bagnoli
3.3 Respondent-generated images
3.4 Photo elicitation and informed consent: reflections from the
Living Resemblances project – Katherine Davies.

3 Anonymity and confidentiality

4.1Photos and film identifying individuals
4.2Obscuring identity in images
4.3 Reflections on the dissemination process: the (Extra)ordinairy
Live Project – Emma Renold & Sally Holland
4.4Identifying people in images
4.5Images of place
4.6Reflecting on attempts to anonymise place – Andrew Clark

4 Further ethical issues

4.1 The construction of images
4.2 How images are consumed

5 Conclusion: towards some guidance for researchers

Useful Resources

References

Abstract

This review outlines the key ethical issues with which visual researchers need
to engage, drawing on literature from established visual researchers as well
as practical illustrations from current research projects being undertaken
within the National Centre for Research Methods (NCRM). Its focus is on the
ethical issues associated with research using photographs, film and video
images (created by researchers, respondents or others) rather than other
visual methods. It is intended as an introduction to assist researchers in
identifying what ethical issues might arise in undertaking visual research and
how these might be addressed. The review commences with an outline of
research ethics frameworks, professional guidance, regulation and legal rights
and duties which, to varying degrees, shape visual researchers’ ethical
decision making. It then goes on to explore the core ethical issues of
consent, confidentiality and anonymity and discusses the ethical
considerations that these raise with examples of how these can be managed.
The paper concludes with a brief discussion of the ethical issues raised in
relation to the construction and consumption of images. The authors stress
the importance of researchers engaging with theories (or approaches) to
research ethics in their ethical decision making in order to protect the
reputation and integrity of visual research.

1. Introduction
There has been a rapid growth and re-interest in visual methods in the last
decade or so. Researchers using visual methods work within a range of
disciplinary frameworks and settings. Visual methods are the traditional
domain of anthropologists and have only relatively recently re-emerged as
popular among sociologists as well as applied social researchers working in
areas such as education, social policy and social work (see Pink, 2003, 2006,
2007a, 2007b).

‘Visual methods’ comprise a vast array of different types of approaches and
data. Prosser (2007; Prosser & Loxley, 2008) identifies four different types of
visual data: ‘found data’; ‘researcher created data’; ‘respondent created data’
and ‘representations’. Visual data include photographs, film, video, drawings,
advertisements or media images, sketches, graphical representations and
models created by a range of creative media. This review focuses on the
ethical issues associated with photographs, film and video images (created

by
researchers

, respondents or others) rather than other visual methods. Clearly
there are ethical issues that arise from researcher or respondent created
drawings and other creative forms of data (see, for example, Clark, 2006;
Prosser & Loxley, 2008) but, arguably, these are not quantitatively different to
those that can emerge from particular types of text-based data (Rose, 2007).
It is in the types of visual data that produce visually identifiable (or potentially
identifiable) individuals that the central issues of visual methods arise. These
are the subject of this review. For a discussion of various other types of visual
methods and the ethical issues that arise see Prosser & Loxley (2008).

This review outlines the key ethical issues with which visual researchers need
to engage, drawing on literature from established visual researchers as well
as practical illustrations from current research projects being undertaken
within the National Centre for Research Methods (NCRM). It is intended as
an introduction to assist researchers in identifying what ethical issues might
arise in undertaking visual research and how these might be addressed. The
review commences with an outline of issues of research ethics including
ethical frameworks and ethical and legal regulation which, to varying degrees,
may shape researchers’ ethical decision making. It then goes on to explore
the core ethical issues with which visual researchers need to engage. The
focus is primarily on issues relating to consent, anonymity and confidentiality.

2. Frameworks, professional guidance, regulation and legal rights and
duties for visual researchers
2.1 Ethics, Morality and Legality
Clarification of the links, overlaps and differences between morals, ethics,
ethical approaches, ethical frameworks, ethical regulation and legal regulation
are an important starting point for this paper. These are illustrated, and
discussed, below. Figure 1 illustrates the influence of approaches to ethics on
regulation, and practice. Figure 2 illustrates the range of factors influencing
ethical issues (and decision-making) encountered by researchers.

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Figure 1: The Influence of Approaches to Ethics on Regulation and Practice

Professional
Guidelines

Research
Community

Ethical
Regulation

Approaches
to Ethics

Figure 2: Factors Influencing Ethical Issues and Decision-Making

Ethics
Approaches

Professional
Guidelines

Legal
Regulation

Ethical
Regulation

Research
community

Researcher’s
moral

framework

ethical issues
encountered

by
researchers

All individuals have a moral outlook about what is right and wrong that guides
their behaviour. This moral outlook is shaped by individuals’ experiences and
interactions and the specific moral beliefs held are inevitably individual (see
Gregory, 2003). Nevertheless society has a large amount of agreement on
specific moral principles about right and wrong (such as justice and fairness)
even though there is considerable disagreement about the application of
these principles to particular circumstances and contexts. Ethical approaches
and frameworks are the application of key moral norms (or principles). Ethical
behaviour in research demands that researchers engage with moral issues of
right and wrong. To do this they draw on ethical principles identified by the
research community to which they belong. For the purposes of the discussion
here ethics and morals can be seen as interchangeable. The specific ethical
issues that researchers identify in their research are informed by their own
moral outlook and their understanding of ethics in research (so they can be
understood as ethical issues or moral issues). The frameworks for thinking
about and managing them are informed largely by the ethical principles
derived from the various approaches to ethics which are set out in
professional ethical guidelines as well as various textbooks on the topic.
Some of these ethical issues can be considered prior to the research
commencing but many are emergent and only become apparent as the
research proceeds. Researchers can draw on a range of resources from the
literature and the research community to assist their thinking in how to
manage such issues. It is crucial that they resolve the issues in ways that
accord with their moral beliefs but also in ways that do not contravene the
established ethical standards of their profession.

Researchers’ ethical decision-making is also strongly influenced by ethical
and legal regulation. Researchers are legally obliged to conform with legal
regulation relating to their research. Ethical regulation does not carry such
weight but nevertheless researchers are generally obliged to comply with
ethical regulation by their institution or by the organisations they are
conducting research with or for. It should be noted that conforming with
ethical or legal regulation does not necessarily equate with ethical (or moral)
behaviour; compliance with regulation in many contexts is often the minimum
requirement and ethical behaviour demands more careful consideration of the
issues involved. The specific implications of regulation are explored in the
relevant sections below. This paper now explores ethical approaches,
guidelines and regulation.

2.2 Approaches to ethics
There are a range of approaches to research ethics (see Israel & Hay, 2006;
Alderson, 2004: 98). Consideration of these is important in helping to guide
researchers in thinking through the ethical challenges with which they are
confronted. The most common approaches are consequentialist, non-
consequentionalist, principalist and ethics of care.

People using consequentionalist approaches argue that ethical decisions
should be based on the consequences of specific actions so that an action is
morally right if it will produce the greatest balance of good over evil. Using a

consequentionalist approach a researcher would assess what the outcome of
a specific decision might be and decide on an action that they believe would
result in the most beneficial outcome. For example, a researcher might argue
that it would be acceptable to undertake covert visual research, for example
on youth crime, if the findings of the research could be seen as benefiting
society as a whole.

People using non-consequentionalist approaches argue that consideration of
matters other than the ends produced by actions need to be considered and
that ethical decisions should be based on notions of what it is morally right to
do regardless of the consequences. A researcher adopting a non-
consequentionalist approach might, for example, argue that it is morally right
to maintain a confidence even if the consequences of that might not be
beneficial or in the interests of the wider society.

Non-consequentionalist approaches are related to prinicipalist approaches
(see Beauchamp & Childress, 2001) which draw on the principles of respect
for people’s autonomy, beneficence, non-malificence and justice in making
and guiding ethical decisions in research. Respect for autonomy relates to
issues of voluntariness, informed consent, confidentiality and anonymity.
Beneficence concerns the responsibility to do good, non-malificence concerns
the responsibility to avoid harm and justice concerns the importance of the
benefits and burdens of research being distributed equally. People using
principalist approaches make ethical decisions on the basis of these specific
principles. Each of these principles is viewed as important but it is recognised
that they may conflict with each other and in such cases it is necessary to
make a case for why one might need to be chosen over another. Principalist
approaches are widely used and form the basis of evaluation of applications
for ethical approval by many research ethics committees (Israel & Hay, 2006:
37). The principle of respect for autonomy may present considerable
difficulties for visual researchers in relation to confidentiality and anonymity.

An ethics of care approach is an important but less common model. In this
approach, ethical decisions are made on the basis of care, compassion and a
desire to act in ways that benefit the individual or group who are the focus of
research (Mauthner et al, 2002). This is an approach used in much feminist
and participatory research where researchers develop close relationships with
their participants (see Edwards & Mauthner, 2002). Most established visual
researchers call for the development of collaborative relationships in research
which bears some relationship with an ethics of care approach (Harper, 1998;
Pink, 2003, 2006, 2007a; Banks 2001; Rose, 2007). Gold’s (1989) argument
for a covenantal ethics accords with this approach.

While the specific ethical approach researchers adopt in their research guides
ethical decision making, it is recognised that research is situated and
contextual and that the specific dilemmas that arise are unique to the context
in which each individual research project is conducted. Some researchers
have argued that decisions about ethical dilemmas cannot be reached by
appeal to higher principles and codes (see Simons and Usher, 2000) and that
researchers have to approach each ethical challenge within the context in

https://www.researchgate.net/publication/235674612_Visual_methodologies_An_introduction_to_the_interpretation_of_visual_materials?el=1_x_8&enrichId=rgreq-ced74e1ff0867f72bff1c5b92052650f-XXX&enrichSource=Y292ZXJQYWdlOzI1MzMxMTc1MjtBUzoxMzgzMzgwNDAyOTEzMjhAMTQwOTk5Mzc2Nzg1OA==

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which the research is conducted (Renold et al, 2008; Birch et al, 2002, p1-2).
Prosser has noted that there is an absence of accepted ethical practice in
visual methods and of theoretical positions on which to make judgements
(Prosser, 2000). While the emergent nature of ethical issues is not disputed,
nevertheless an understanding of, and engagement with, these ethical
approaches provides an important basis from which researchers can think
through, and argue, their ethical position.

2.3 Professional ethical guidelines
There are a wide range of professional guidelines and codes aimed at
providing frameworks to enable researchers to think through the ethical
dilemmas and challenges that they encounter in their research (e.g. SRA,
2003; BSA, 2002; BERA, 2004; GSRU, 2005). These are drawn, to varying
degrees, from the ethical approaches outlined above. Such guidelines are
necessarily very general; they do not provide answers to how researchers
should manage the specific situations that they might encounter in their
research but rather outline principles to enable researchers to think through
the specific situations that occur (Wiles et al, 2006). These guidelines
recognise the situated and contextual nature of the ethical challenges that
arise when conducting research. The principles addressed in these codes
generally relate to issues of the well-being and rights of research participants,
informed consent, privacy, confidentiality and anonymity. The central issues
can be summarised as:

i) researchers should strive to protect the rights, privacy, dignity and
well-being of those that they study;

ii) research should (as far as possible) be based on voluntary
informed consent

iii) personal information should be treated confidentially and
participants anonymised unless they choose to be identified;

iv) research participants should be informed of the extent to which
anonymity and confidentiality can be assured in publication and
dissemination and of the potential re-use of data.

These issues are ones that are relevant to all research but the ethical issues
raised by visual research are, arguably, distinct from those raised by purely
textual data. Discussion of the ways in which these issues impact on visual
research and consideration of the issues will be discussed in detail below.
Here the focus is on the extent to which guidelines and codes (and regulation
and law) provide guidance specifically in relation to visual research.

The general nature of these professional codes and guidelines mean that the
ethical issues relating to visual methods are not specifically addressed within
most codes. The American Anthropological Association (1998), The
RESPECT code of practice for socio-economic researchers (2004), the British
Education Research Association Ethical Guidelines (2004) and the Social
Research Association Ethical Guidelines (2003) make no specific mention of
visual methods in identifying principles of research ethics.

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Two general professional guidelines identify visual methods as having specific
ethical issues (British Sociological Association, 2002; Association of Social
Anthropologists of the UK and Commonwealth, 1999). The issues identified
relate to consent for the collection and dissemination of visual material and
the importance of copyright clearance (issues relating to copyright are
discussed below in the section on legal considerations). In these two
guideline documents, these issues are not discussed at length.

The British Sociological Association Visual Sociology Group’s statement of
ethical practice (2006) also identifies these issues but in considerable detail;
this statement provides detailed guidance for visual researchers and is a
useful resource to help visual researchers to consider some of the possible
difficulties that they might encounter in their research. In contrast to other
professional guidelines, these are more prescriptive. The guidelines outline
the importance of consent, both to participation and to the ways and forms the
visual data collected will be used. Written consent for the use of images that
identify individuals is noted as preferable as is providing an opportunity for
study participants to see the visual data collected on them and reflect on its
proposed use. The importance of careful consideration of issues of consent
when conducting and disseminating research over the internet are identified
and researchers are advised to err on the side of caution in making
judgements about the well-being of on-line research participants. Caution is
also advised in relation to covert research which, because of the ethical and
legal issues it poses, is deemed as necessary only in ‘certain circumstances’.
The guidelines note the importance of attendance to national laws and
administrative regulation that are pertinent to visual research. In relation to
research with children, the need to consider child protection issues and make
provision for the potential disclosure of abuse is noted. Legal issues are
particularly relevant to the risks relating to the creation, possession and
dissemination of images of illegal activity (e.g., criminal damage, assault, hate
crime, sexual violence). The statement notes that illegal images should
always be given to the relevant authorities. They also note the care that
needs to be taken in relation to images of sexual activity. In cases where
research raises potentially challenging ethical issues researchers are urged to
obtain ethics clearance from a professionally recognised research ethics
committee; such clearance is generally necessary for all research conducted
by academic and professional researchers working in institutional settings.

Members of these professional organisations would be expected to abide by
the principles outlined in these codes and guidelines although, in most cases,
these guidelines are not enforceable. There is currently no professional
register of social researchers that researchers can be struck off for not abiding
by ethical guidelines. However, it is of note that the BSA visual sociology
group note that ‘if members are found to be using sexually inappropriate or
illegal images (as defined by UK law) by the BSA –Visual Sociology Group,
the individual will be excluded from participation or attendance at any of the
group’s events or those of any organisation with which the groups has an
affiliation or relationship’ (p2). Nevertheless, researchers are not obliged to
be members of these organisations. Social researchers can, and do, conduct
research without being members of a professional organisation and as such

these frameworks provide a very weak form of regulation of practice.
Institutional and legal regulation however does provide more pressing
frameworks for the conduct of visual research.

2.4 Ethical Regulation
The regulation of social research in the UK has been steadily increasing over
the last decade, culminating in the development of the ESRC Research Ethics
Framework and the subsequent formation of research ethics committees in
universities (ESRC, 2005; Tinker & Coomber, 2004). Research ethics
committees have been operating for some time for researchers conducting
research in health care settings1 and a framework has been developed more
recently for social care2. Organisations outside of academia have also
developed systems of ethical review and monitoring (See, e.g., GSR, 2005).
The result of these developments has been that virtually all research
conducted by researchers (with the possible exception of some self-employed
researchers) is subject to some form of ethical review by a recognised ethics
committee. This ‘ethics creep’ is viewed as moving UK social research in the
direction of the highly regulated system of review by Institutional Review
Boards (IRBs) in the US (Dingwall, 2006). Ethics committees vary widely in
the ways in which they assess applications for review and the conclusions
they come to, even in highly regulated and established systems such as that
for the review of research in the NHS (Edwards et al, 2004). However, the
general principles they assess are fairly uniform and are likely to comprise
those outlined in the ESRC Research Ethics Framework: ‘integrity, honesty,
confidentiality, voluntary participation, impartiality and the avoidance of
personal risk to individuals and groups’ (ESRC, 2005, p26; see also Israel &
Hay, 2006: 37). The key issues that are likely to be assessed by all
committees are voluntary informed consent, the confidentiality of information
provided by participants, the anonymity of study participants, the avoidance of
harm and researcher integrity.

There has been considerable criticism of the regulation of social research with
concerns raised by ethnographers in particular about the limitations this
places on their research (Murphy & Dingwall, 2007). Ethical regulation poses
potential problems for visual researchers (Prosser & Loxley, 2008). Concerns
have been raised by the visual research community who fear that ethics
committees will render some visual research undoable or will specify
limitations to visual researchers’ practice, such as pixelating or obscuring
faces to preserve anonymity, that will result in data becoming meaningless
(Prosser & Loxley, 2008; Sweetman, 2008). Concerns have been expressed
among visual researchers that research designs with a visual element will be
altered or diluted to meet the requirements of Ethics Committees. This is
certainly a concern expressed among visual researchers in North America
who have noted that the fear of litigation has resulted in IRBs central concern
being to protect the institution rather than the rights of participants or
researchers (Gunsalus et al, 2007; see also
http://www.c4qi.org/qi2005/papers/rambo ).

1 See http://www.nres.npsa.nhs.uk/
2 See http://www.dh.gov.uk/en/Researchanddevelopment/A-
Z/Researchgovernance/DH_081435

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Some visual researchers who are unhappy about the ethical regulation to
which they are subject have sought to sidestep it by referring to their work as
investigative journalism and as subject to the less stringent code of conduct
for journalists. The code of conduct for journalists (National Union of
Journalists, 2006) maintains that information should be collected by
straightforward means and that journalists should attend to issues of
individuals’ privacy. However it also calls on the principle of freedom of the
press and other media and consideration of the public interest. While
researchers may welcome avoiding ethical regulation, many would argue that
the common practices employed by the press are not appropriate for social
research (Schwartz, 2003). In any case, researchers conducting research as
members of staff of an academic or social research institution are likely to find
it difficult to have their work interpreted as journalism rather than research and
thereby to sidestep ethical review by a recognised ethics committee. Given
institutions’ concern with litigation they would be likely to be subject to
disciplinary procedures if they sought to do so. Researchers working outside
of these organisational constraints may, however, be less restricted.

2.5 Legal issues
Visual research is subject to a number of legal considerations which relate to
both the taking of images (photos or film) and the use to which images are
subsequently put. Various guidelines on photographers’ rights provide helpful
information relating to the UK (McPherson, 2004) as well as other countries
(Krages, 2006; Bateman, undated). Williams et al’s (undated) discussion of
the ethical issues in the archiving of qualitative data also provides useful
information on the law in relation to various forms of visual images. In
consideration of these legal issues it is important to bear in mind that these
provide a framework of the minimum standards that need to be adhered to but
that these, by themselves, do not necessarily equate with ethical or moral
practice. Masson (2004) notes:

‘There is a close relationship between law and ethics but not everything
that is legal is ethical. Frequently law … attempts only to set the
minimum acceptable standard. The aspirations of ethical practice are
higher … It can never be appropriate to defend proposed practice
solely on the basis that it is legal’ (p43)

UK law enables individuals to film or take photos of places or individuals from
or in a public place, including taking photos of private property. However,
photographing someone in a place where they have a reasonable expectation
of privacy might be considered to be an invasion of privacy. There is currently
no privacy law in the UK but photographing someone where they might
reasonably expect to be private could be considered to be against the article 8
of the European Convention on Human Rights (see Williams et al, undated;
McPherson, 2004; SRA, 2003: 36). Persistent or aggressive photography
could also come under the legal definition of harassment (McPherson, 2004).

While the law in relation to taking images in public places is explicit, what is
legal and what is sanctioned in practice do not always coincide. There are

numerous examples of photographers in the UK (and elsewhere) being
stopped from filming in public places by various state officials (see, for
example, http://www.bakelblog.com/nobodys_business/2008/06/cops-bully-
vide.html). The situation is complicated by the difficulties in defining what
constitutes a public space. Managers of shopping malls and public service
organisations (such as hospitals, Local Authority leisure centres or libraries)
may not view their organisations as public places for the purposes of
researchers wishing to take images, although this may be largely dependent
on what images are being made. There is also the issue that some areas of
public places might be viewed as more private than others. Various authors
urge researchers to make themselves familiar with their legal right to take
images in public places and to resist challenges to this (e.g., Krages, 2006).

UK copyright law in relation to still and moving images favours researchers in
that copyright rests with the person taking the image, or their employing
institution. Williams et al (undated) note that a research participant who
agrees to have their photograph taken or be subject to video recording has no
legal rights over the subsequent use of their image. This also applies to the
archiving and reuse of visual data (Williams et al, undated). However, they
note that a case could be made for a respondent retaining rights over the
words spoken in a video recording as the copyright for their words rests with
them. They note that, in the light of this, it is advisable to request that
interviewees assign copyright to the researcher (p3). In the case of
respondent-generated visual data (e.g., photos a study participant has taken),
copyright rests with the respondent and it is necessary for them to assign
copyright to the researcher for their subsequent use by the researcher.
Clearly these legal conditions need to be managed within a context in which
researchers need (and arguably want) to develop and maintain good
collaborative relationships with study participants; it would be inadvisable for
researchers to rely on these legal conditions to determine their research
practice.

Visual research with children poses particular difficulties. The law around the
process of consent for children to participate in all types of research is
complex and relates to the notion of capacity or competence (see Heath et al,
2007; Masson, 2004; Alderson & Morrow, 2004). Children who are able to
understand the implications of participation in a research study are viewed as
having the ‘capacity’ to make a decision about whether or not to take part in
research. Parental consent is needed if a child is not viewed as having the
capacity to consent (Masson, 2004). However, in practice researchers often
seek parental consent (in addition to children’s consent) regardless of a
child’s capacity to consent in order to safeguard them from any problems that
might arise. In the current climate of concern about photographs of children, it
is advisable that visual researchers seek consent from children, parents and
any other gatekeepers who provide access to the children; such conditions
are likely in any case to be imposed by an ethics committee or gatekeepers.
Criminal Records Bureau (CRB) checks are also necessary for researchers
working with children and with other groups deemed ‘vulnerable’. There are
several useful resources which explore the legal issues around research with

https://www.researchgate.net/publication/42798227_Doing_Research_with_Children_and_Young_People?el=1_x_8&enrichId=rgreq-ced74e1ff0867f72bff1c5b92052650f-XXX&enrichSource=Y292ZXJQYWdlOzI1MzMxMTc1MjtBUzoxMzgzMzgwNDAyOTEzMjhAMTQwOTk5Mzc2Nzg1OA==

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children, especially in relation to consent and competence (see, e.g. Morrow
& Richards, 2002; Alderson & Morrow, 2004; Farrell, 2005).

A further legal issue regarding research with children concerns confidentiality
in cases where a child discloses that they are being seriously harmed or
mistreated. Failure of a researcher to take appropriate action in such cases
could result in legal liability. In the UK, people who suspect a child is being
mistreated are not legally obliged to report this. However, a range of
professionals (such as teachers and social workers) are obliged to do so
under Local Authority child protection procedures. Images or data of serious
crime involving children should be handed over to the police (BSA – visual
sociology group, 2006). Serious crime in this context comprises images of
physical, sexual or psychological abuse. Researchers need to clarify how the
disclosure of such information will be managed as part of the informed
consent process with children (Masson, 2004; Wiles et al, 2007). There is no
law relating to actions in the case of images or data of less serious crime and
researchers are left to make their own decisions on appropriate actions, if
any. In the case of adults, there is no law that obliges researchers to pass
images or data of adults engaged in criminal activity to the legal authorities.
However, researchers should be aware that research data given in confidence
do not enjoy legal privilege and they may be liable to subpoena by a court
(Wiles et al, 2007). There are no cases of this occurring in the UK. It may be
prudent for researchers to think through the implications of giving people
cameras to take images reflecting their lives and how they will manage being
presented with images that portray some form of unlawful or morally
questionable activity.

All researchers are also subject to the Data Protection Act which demands
that data is kept securely and does not lead to any breach of agreed
confidentiality and anonymity (BERA, 2004: 9; ESRC, 2005, p18). Providing
researchers have consent for the use and re-use of images it does not appear
that visual data provide any additional challenges in relation to data protection
than those posed by other forms of research.

The preceding discussion has illustrated some of the frameworks that inform
the ethical issues that researchers encounter. We now turn to the specific
issues of consent, confidentiality and anonymity and explore the challenges
these raise for visual researchers and the ways in which they can be
managed.

3. Consent issues

3.1 Researcher-generated images
Informed consent is a central principle in ethical research and is no less
central to visual research than other types of research. While a case has
been made for the importance of enabling researchers to continue to have the
right to undertake covert research (Tysome , 2006) there is a general
consensus that covert research is not ethical except in some specific
circumstances (Rose, 2007). In such cases the onus is on the researcher to

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demonstrate that the need for the research outweighs the deceit involved.
Still and video cameras provide researchers with the capability of conducting
covert research fairly easily. Researchers can easily hide from public view
when taking photographs or use strategies that conceal the subject of the
photograph or devices, such as a telephoto lens, that enable photographs to
be taken from a distance (Prosser, 2000). Direct covert or clandestine
photography or film research is viewed by many visual researchers as both
unethical and as intellectually limiting given that it often provides ‘only
superficial data which can easily be construed the result of ‘outsider’
arrogance’ (Prosser & Schwartz, 1998; see also, Prosser 2000; Pink, 2003,
2006, 2007a). Such research provides very limited understanding of people’s
views and experiences which are central to much visual research (Pink,
2006)3.

However, while many visual researchers may not condone covert research,
they might question whether it is necessary to always obtain consent from
individuals who are the subject of photographs. Clearly when taking images
of groups of people in public spaces or at events it is not practical, or indeed
necessary, to obtain consent from people present. However, when taking
images of identifiable individuals (whether in public or private spaces), or of
people in private spaces or organisations where people might reasonably
expect not to be photographed or filmed, then it is polite and good ethical
practice to seek consent. For much research seeking express consent is also
in the interests of obtaining good data (Banks, 1995, 2001; Pink, 2003, 2007a;
Prosser, 2000). Visual researchers identify the importance of developing
relationships of mutual trust with study participants so that the images that are
taken emerge from collaborations between researcher and study participant
and are jointly owned (Harper, 1998; Gold, 1989; Pink, 2003, 2006, 2007a;
Banks, 2001; Renold et al, 2008). The intellectual reasons for adopting this
approach are addressed by Pink (2003) and Banks (2001) who argue that it is
only through engaging with participants that a researcher can come to know
the phenomenon they are studying. Prosser (2000, p120) too notes the
importance of consent for the reputation of researchers in the field:

‘Of course, the most dramatic, even sensational images may be of
those not wanting their photo taken, but that is no reason for taking
photographs. Such actions are not only dishonest, but also counter-
productive to the enhancement of sociological knowledge. Ultimately
the reason for not taking photographs of participants if they are hostile
to the idea is not a matter of privacy or morality but the likelihood of
such action compromising rapport – a necessity for any researcher
hoping to remain in the field.’

Consent entails not only consent to take or make visual images but also
consent to use images subsequently. In the collaborative mode of working,
consent to take images and to use them subsequently entails the express
agreement of the individual(s) concerned. This may involve gaining express

3 The exception to this is ethnomethodolgical approaches whose focus is the objective exploration of
interaction.

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consent for the particular images used and the specific formats and contexts
in which they are to be used (Pink, 2006, 2007a; Renold et al, 2008). Some
researchers might view initial consent to cover both consent for making
images and for their use, others might view these as things that have to be
negotiated separately. Pink (2007a) notes that there is no consensus on this
issue. This is an issue that researchers have to consider within the context of
their research.

The precise form that that consent might take is varied and the appropriate
means of consent needs to take into account the context of the research. In
some cases, for example when visual data is being obtained for illustrative
purposes or general but not specific consent has been given, a verbal request
before photographing or filming may be appropriate. This might entail simply
asking if an individual objects to having their image taken and explaining (if
necessary) the purpose of taking the image (Banks, 2001). In other
situations, for example when conducting ethnographic work with a community,
written consent (or consent recorded by some other means) after extensive
discussion is necessary (Banks, 2001; Rose, 2007). This discussion should
involve explaining to research participants in detail the purposes of the
research, the images that it is anticipated will be taken, the process of consent
for obtaining and using specific images and the plans for dissemination (Rose,
2007). Once detailed consent is obtained researchers may still choose, with
participants’ agreement to this practice, to take photographs or film without
study participants’ awareness of the specific images being taken in the
interests of obtaining ‘natural’ images.

With the increase in ethical regulation, there has been a significant move to
the use of signed consent forms for research participants. Signed consent
forms are viewed as safeguarding researchers and their employing
institutions, making issues of consent clear to research participants and
ensuring attention to issues of copyright (Pink, 2007a). However, using
signed consent forms does not negate the necessity of explaining the
research to potential participants and for what precisely their consent is being
sought to do. Equally, as Pink (2007a) notes, signed consent does not give
researchers the right to use images in unrestricted ways. Often it is the case
that consent forms are used at various different points during the research
process as the need for specific visual data or the significance of particular
images emerges. In some contexts, rather than written consent, filmed or
audio-recorded consent may be more appropriate. Some researchers are
reluctant to use any form of formal consent and view oral agreement from an
individual as sufficient. This may be particularly the case where people have
low levels of literacy or are wary of legalistic procedures (Banks, 2001).
Several authors note that informed consent is a problematic concept in that it
is highly unlikely that study participants can truly understand the research, the
outputs it may have and what participating in the research will be like for them
(Pink, 2007a; Prosser, 2000; Gross et al, 1988); this may be particularly the
case in relation to film making (Prosser, 2000) and for visual data that may be
archived. An example of a consent form used in a recent study conducted
within the National Centre for Research Methods is included in the appendix.

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Research involving children will require consideration of issues around
capacity to consent as outlined in the section above on regulatory and legal
frameworks. This will involve exploring whether the child is able (or
‘competent’) to consent on their own behalf or whether, additionally, parental
consent is also needed. If a child is able to fully understand what participating
in a study involves they are, in theory, able to consent on their own behalf.
However, gatekeepers of children under 16 (or in some cases 18) who are
being accessed via schools or other organisations may insist on parental
consent, as may a Research Ethics Committee (Heath et al, 2007). If
parental consent is deemed necessary difficulties arise if parent and child
have different views on participating; a parent can prevent a child participating
if they withhold consent although they cannot force a child to participate if the
child does not consent. Particularly problematic may be issues around
consent for the use of images where children’s and parents’ views may not be
in accord. The experience of some visual researchers is that children and
young people often want their images to be made public. The importance of
negotiations with children around these issues is highlighted by many
researchers (Renold, 2008; Flewitt, 2005).

The following illustration drawn from a current NCRM research project
highlights some of these consent issues in relation to children. This
illustration draws on issues relating to both researcher-generated and
respondent-generated visual data

3.2 Anonymising visual data: Reflections on the Young Lives and Times
Project
Anna Bagnoli, NCRM Real Life Methods Node, University of Leeds

The Young Lives and Times project4 is a prospective qualitative longitudinal
study which is investigating the everyday lives, relationships, and identities of
a cohort of young people born in 1992/1993, tracking them over time through
their teenage years and into early adulthood. The young people are drawn
from metropolitan and rural Yorkshire and come from a variety of
backgrounds. In 2008 the project participated in the ESRC Festival of Social
Science with a two-day event at the West Yorkshire Playhouse in Leeds on
March 14 and 155. The first day of the event was dedicated to the young
people taking part in the project as key research users, and involved them in a
drama workshop run by a local children’s theatre company. The second day
was targeted on local practitioners and the general public and included a
display of the young people’s own artwork as well as multimedia installations
about the project. Participation in the Festival was a significant experience
which allowed the team to take the research outside of academic circuits,

4 Phase 1 of this project (October 2005-September 2008) was funded by the ESRC as part of the NCRM
Real Life Methods Node. Phase 2 (October 2008-June 2011) is funded under the ESRC Timescapes
initiative.

5 The event ‘Timescapes: exhibiting the Young Lives and Times project through drama and visual display’
was funded by the ESRC with grant no. RES-622-26-0074.

engaging with innovative forms of dissemination within the community.
Organising the event, however, meant revising the policy on visual ethics and
data anonymity that we had followed until that point.

At recruitment, we had collected written consent from both young people and
their parents. The forms we used for this purpose, however, proved
inadequate to cover our needs in terms of visual ethics. In our initial promise
of protecting participants’ identities ‘at all times’ we had not fully taken into
account the implications of using the wide-ranging array of visual methods we
applied in the first wave of fieldwork. These included drawings and graphic
elicitation methods, such as self-portraits, timelines, and relational maps, as
well as video diaries, photo elicitation, collages, and videoed walkabouts.
Since on the grounds of that initial form showing any of these data outside of
the research team was going to be problematic, we produced further consent
forms for each of the methods. The new formulation was making it possible
for the materials to be shown in academic contexts such as talks and
seminars. Ensuring participants’ rights to anonymity was thus potentially in
tension with our own dissemination activities.

Organising the Festival event posed us further ethical questions. One
important change to our initial policy was implied by the decision to organise
the 1st day of the event as a gathering of our research participants, something
that the young people themselves had requested of us in focus groups that
we ran when designing the study. Giving the young people a chance to meet
each other obviously meant disclosing their identities to the others involved in
the project. Setting up a display of participants’ artwork on the 2nd day meant
going through a series of anonymisation issues that depended both on the
type of visual method used and on the criteria which were followed in the
organisation of the exhibition. Our main aim in running this event was giving
something back to the young people involved in our study. Displaying artwork
produced by each one of them, so that this could properly be a collective
exhibition, was therefore a priority. Organisation of the event, however, had to
be done in very short time, with no specialised technical support. Time,
technical means and know-how were an issue, and the decisions taken in
anonymising data were sometimes only the best I could find pragmatically, yet
perhaps not those I would have chosen ideally.

On a technical level, anonymising graphic materials such as drawings is
rather straightforward. Removing identifiers from all these data was however
rather time-consuming. Identifiers obviously include names of people and of
places, and less obviously also the occasional contextual information which
might be sensitive. Given that here I was working on putting together a visual
display, the aesthetic value of the end result was another important factor in
guiding my decisions. For what is the meaning of showing something that has
been so much tampered with to end up being extremely different from the
artwork that was originally produced? One might wonder whether even the
authors might have been able to recognise some of the drawings that
eventually went on display, once all the significant names had been removed.
Aesthetic considerations were particularly important when anonymising the
photographs. In technical terms, the anonymisation of photographs and

videos is rather more complex than that of drawings. Videos in particular
require specialised software that we did not have. Within the interactive
installations that I created for the exhibit therefore, only one video extract was
used in which no people were present, and which showed the camera
zooming on a bird jumping in a field. In the case of photographs, good editing
can be achieved with software like Photoshop. However, blurring photographs
may sometimes be inadequate to keep anonymity and the aesthetic results
may not be that pleasing either.

Blurring face details in a photograph sometimes makes little sense: why would
one want to show a portrait with a blurred face in an exhibit? One also has to
be aware of the fact that, when observed from a close distance, a blurred
image may seem perfectly anonymous. But try and put the same picture on a
wall and stand away from it: details will become more clearly visible as you
increase your distance! In some cases pixelating was perfectly appropriate,
for instance with the collages that 5 of the girls involved in the study had
produced. The quality of the pictures in these collages was not very high in
the first instance, and thus pixelating was not too much of an invasive
process. The overall meaning of the artwork was not substantially altered by
blurring some of the photographs. More problematic was pixelating high
quality photographs. To this end I looked for some effect in Photoshop that
could allow me both to cover details and to maintain the sense of the picture. I
ended up applying a ‘cut out’ effect on the faces in the photograph, which
made them look like stylised masks, and thus less ‘real’, whilst keeping
something of the original details in a way which I thought was aesthetically
acceptable. The feedback we got from the young people on the day though
indicated that this work had not been much appreciated. In fact, the very need
of anonymising the visuals was questioned by the young people.

3.3 Respondent-generated images
Thus far we have focused on images taken by researchers. In cases where
images are taken by study participants as part of a research project or where
images owned by research participants are sought then different ethical
issues may arise.

There has been an increasing trend for researchers to give research
participants still or video cameras and to ask them to take images of their
lives, identity or communities (e.g., Heath & Cleaver, 2004; Renold et al,
2008) or to conduct video diaries (e.g., Holliday, 2000; Gibson, 2007). These
are often then used for data elicitation purposes. Where visual data is being
used purely for elicitation purposes then issues of consent are relatively
unproblematic. However, if researchers wish to include these photos in
dissemination of the research then some particular issues of consent emerge.
Consent for the subsequent use of an image in the research in relation to
issues of copyright can be managed relatively easy with negotiation with the
research participant and, with their agreement, signing of a consent form to
assign copyright to the researcher. However, there are additionally issues
around consent for any subjects of photographs or film that a research
participant takes. While legally the film or photograph taker owns the image,

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and can assign copyright to the researcher if they wish to do so, the people in
the images have not necessarily given their consent to the image. Even if
they have, they are unlikely to know the purposes to which the image may be
put (Rose, 2007). Managing this issue is complex. At the very least, it
demands that researchers who give cameras to participants think through the
implications of what images they might be presented with by study
participants and brief them about seeking permission and explaining the
purpose prior to taking images of others. In some cases this may be all that is
required but researchers are advised to be circumspect in the use of images
of identifiable others and to consider whether or not someone might be at risk
of harm or moral criticism as a result of use of the image. It may be possible
to ask for subsequent consent from the individual portrayed in relation to the
specific use to which the image is to be put via the research participant who
took the image.

Similar issues emerge in relation to research which focuses on visual material
owned, or in the possession of, research participants. Research exploring
photos in study participants’ photo albums is one example of this type of work.
Albums may contain photos taken by the research participant of various
individuals for whom issues of consent may arise. Albums may also contain
photos taken by others, and therefore in copyright terms, not ‘owned’ by the
research participant. Some of the challenges inherent in this type of work
and how they might be managed are contained in the following illustration of
research which involved the use of family photographs from respondents’
photo albums.

3.4 Photo elicitation and informed consent: reflections from the Living
Resemblances project
Katherine Davies, NCRM Real Life Methods Node, The University of
Manchester.

The Living Resemblances project is investigating the social significance of
family resemblances or likenesses. One of the methods we used in the
research was photograph elicitation using family photos as part of a set of
interviews in participant’s homes.

Taking photos of photos – consent for using images for analysis
• Photo elicitation using family albums took place during the course of

wider semi-structured interviews
• At the end of their interview participants were asked whether a digital

photograph of their photographs could be taken for analysis purposes
within the research team. Verbal consent for this was tape recorded

Seeking consent to photograph participant’s photographs at the end of the
interview can pose practical difficulties for the researcher6 and decisions
about when to raise the issue of consent often need to be made during the

6 Participants often showed me lots of photos at once and it wasn’t always easy to be systematic when
photographing them at the end of the discussion, sometimes resulting in photographs being missed or
difficulties matching images to the corresponding extract of the interview transcript.

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context of the interview so the researcher can weigh up the potential risks to
rapport of asking ‘too soon’. Most participants were happy to allow the
photographing of their photographs but it is not always helpful to turn the
conversation onto ‘official business’ in the middle of elicitation.

Negotiating levels of consent
There are a number of different levels of usage of family photographs and it is
important to think about the ethical and practical issues involved in seeking
consent for these different levels. For example, although we were happy that
tape-recorded verbal consent was adequate for us to photograph photographs
and use them within the research team for analysis purposes (and the
majority of participants were happy to consent to this level of usage during
their interview), we felt it was necessary to seek more formal consent before
sharing the images with a wider audience. We also felt that showing an image
during a presentation (as long as it is not reproduced in handouts or on
websites and that the presentation is run from a data stick and deleted from
any computers) was different to publishing it in a form where copies are
publicly available and that archiving photographs (for example in Qualidata)
requires another level of consent again.

We rejected the idea of archiving photographs, figuring the confidentiality
issues were too great and that the interview transcripts could be re-used
fruitfully without the accompanying images. We also drafted a number of
consent forms listing the remaining levels of usage, asking people to decide
whether they consented for their photos to be used in presentations only or
presentations and printed publications and so on. The resulting forms didn’t
leave the drawing board; they were complex, confusing and potentially
worrying and off-putting to participants. Ultimately we felt we should provide
participants with a simple decision where they could answer yes or no to
having their photographs published (we made sure to list all possible levels of
usage in the form, see appendix for the form used).

Who can give consent?
During his interview, one participant – Andrew – had only felt able to provide
consent for me to photograph images of him and his children, he didn’t feel he
had the right to give consent for me to photograph a photograph he owned of
his brother’s children despite us having discussed this particular image at
length. This raises numerous questions about who can provide consent for
family photos. Legally, the photographer ‘owns’ the image (although this
becomes less clear when applied to photographs of photographs or family
photos where it is not always clear who the photographer was) but ethically, is
it sufficient to ask participants to provide consent for the use of the
photographs they have in their homes or should all the people who appear in
the photos (and the parents/guardians of children) be asked to consent before
they can be used?

We did originally consider seeking consent for all living people who appear in
any photos we might want to publish. After considerable thought we realised
that this would prove to be such a huge administrative task that it would
prevent us seeking consent for many of the photos collected in the research.

We also wondered about the ethical implications of contacting the family
members of our research participants who might not know anything about the
project or even be on good terms with the participant. We decided to leave it
up to the participants who had shown us the photos to decide whether they
needed to ask permission from other family members before consenting to
their publication (and although only Andrew raised this issue in the first phase
of consent (for me to take a photo to use during analysis) a number did report
wanting to do this before consenting for their photos to be used more widely).

Image by image consent
Following on from this, one of the most important considerations in negotiating
informed consent is that people may feel differently about providing consent
for different images. We have already seen that Andrew felt he couldn’t give
consent for me to photograph all his photos. Isabel also had no problem
providing consent for photos of people who are now deceased but before
consenting to the publication of the other images she felt she would have to
check with everyone who appeared in them. Pauline felt the same and
requested more time to contact her daughters and discuss it with them before
signing her form. Similarly, some photos may have a particular poignancy or
sensitivity to the participant or their relatives, affecting whether consent is
given, and which the researcher may not always be aware of.

For these reasons we attached a print out of all photographs with the consent
form and gave participants the option of giving consent for us to use some,
but not all, of their images (see appendix for a copy of the form used).
Although this did complicate the form (in the event all participants managed to
complete the form correctly, although I did offer to return to explain the details
in person and for this reason I would urge researchers to start negotiating
consent for the use of photographs soon after the initial interview) it is a
crucial element of ethical practice and many participants took the opportunity
to give consent for some but not all of their photos.

The decisions people made regarding consent for particular photographs
highlight the importance of thinking about consent image by image. For
example, although Isabel had felt more confident giving consent for photos of
deceased family members, David and Marilyn had the opposite reaction and
gave full consent for the use of photos of their grandchildren and children but
wished to keep older photographs (including an old black and white picture of
David’s uncle) more private. People obviously employ their own highly
complex ethical systems of ‘consent hierarchies’ to their family photos to help
them make decisions about their use in projects such as this and therefore as
researchers, so must we.

4. Anonymity and confidentiality
One of the central ethical issues confronting visual researchers is how to
manage the research convention of anonymity and confidentiality in relation to
visual material. As the preceding discussion has indicated, anonymity and
confidentiality are long-established principles in social research practice
(Wiles et al, 2007). Yet much visual material makes the anonymisation of

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individuals or locations problematic if not impossible (Clark, 2006). This
presents a dilemma for visual researchers; on the one hand the purpose of
employing visual data is because the visual image is able to reveal more
about phenomena than can text alone so, in the interests of research, there is
a drive to publish and present unadulterated visual images (Sweetman, 2008;
Knowles & Sweetman, 2004) but on the other, there may be pressure from
regulatory bodies to uphold the principle of anonymisation. The situation is
complicated by the fact that individuals appear commonly to want to be
identified in their visual images, a similar situation to that which frequently
emerges in text-based research (Grinyer, 2002). This appears to be
particularly the case in relation to visual research with children and young
people and people with disabilities who have argued for their right to be made
visible. The management of these issues and the implications of different
decisions will now be explored.

4.1 Photos and film identifying individuals
As a first step in considering these issues, researchers clearly have to
carefully consider the implications of using the data they have collected for
individuals and the institutions or communities of which they are part (Gold,
1989; Pink, 2007a). They also need to consider how the research, and
indeed the images, may be used in the future (Davidov, 2004; Barrett, 2004).
This may sometimes mean making the decision not to use aspects of visual
data. In other cases, participants may ask for their image to be obscured or
not used (Pink 2007a). Similar issues occur for researchers who use text but
with visual images the implications are greater because of the likelihood of
identification (even if images are obscured). The implications of identification
may, of course, not always be clear to researchers but as Pink (2007a) notes,
it is crucial that researchers seek to understand the political, social and
cultural contexts in which images will be viewed and interpreted (see also
Davidov, 2004).

The issue of internal confidentiality, that is confidentiality between members of
a specific community or group, is also one that warrants consideration.
People who are interconnected can easily identify others in visual images
from jewellery, clothes, gestures or gait, even when attempts have been made
to anonymise individuals. It can also be difficult for researchers to ensure the
confidentiality of images taken by respondents for research purposes.
Research participants who make videos or take photographs for the purposes
of a research project can use the images as they see fit which may not accord
with the aims of the project. This can be a particular problem with young
people who may post photos or video created for research purposes on
Facebook or other internet sites.

Still and moving visual images may portray clearly identifiable individuals.
These sorts of images can be anonymised only by altering the image in some
way so as to obscure individuals’ identity. More commonly visual researchers
present these types of visual material in their entirety thereby enabling
individuals to be identified, with their consent (Pink, 2007a). Issues of
consent are obviously paramount in decisions about the use of images and,
as discussed above, different considerations may be necessary in relation to

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researcher-generated images than for respondent-generated or owned
images.

4.2 Obscuring identity in images
Methods of obscuring people’s identity include increasing the pixilation of
facial features in order to blur them (see http://www.yowussup.com/pixelating-
images.php), the use of specific anonymisation software that converts visual
images into cartoons or drawn images (see http://www.virtualdub.org/ and
http://compression.ru/video/cartoonizer/index_en.html) and blocking out eyes,
faces or other distinguishing features. In social research, the former
approaches are more common. Blocking out eyes or faces is relatively
common in medical research, arguably reflecting medicine’s interest in people
as bodily parts rather than whole individuals. As noted above, obscuring
facial features alone may not be adequate to ensure anonymity. Obscuring
facial features is a contentious practice and has been subject to criticism by
social researchers (Williams et al, p7; Sweetman, 2008). Nevertheless, it is
recognised that there are some groups or types of images that necessitate the
identities of individuals being obscured. The increasing moral panic over
photographs of children makes it likely that researchers will experience
difficulties in using identifiable images of children for general viewing and it is
common practice for researchers working with children to use specialist
software to anonymise children’s images (Flewitt, 2005; see also the example
below for an illustration of the images produced by this software). Certainly
caution needs to be exercised in the ways that images of children are used
and stored (see Williams et al, p6).

In other types of research where these difficulties do not exist, obscuring
identities is problematic for a number of reasons. First, is that the purpose of
visual images is that they can portray something additional to that of text
alone so to tamper with images in ways that obscure certain important details,
such as people’s facial expressions, makes the purpose of collecting visual
images questionable. Clearly, if the images collected are not concerned with
individuals, identity or interaction but with a more general scene, such as a
market place, a street or a festival, then blurring faces, arguably, may not
impact negatively on the overall aim of the work. However in much research,
obscuring faces affects readers’ ability to make sense of visual data because
faces are necessary to enable us to interpret physical, psychological, social
and emotional aspects of individuals. Without seeing faces we cannot begin
to interpret basic social facts about individuals, such as their age and social
class, let alone how they feel and what they, or researchers, are intending to
portray by the image. Further, many studies using visual data, especially in
sociology, focus on aspects of people’s identity; people are photographed or
filmed dressed in particular clothes or displaying particular aspects of
themselves which represent their identities (Back, 2007, Holliday, 2004,
Knowles & Sweetman, 2004). In such contexts blurring faces makes no
sense.

A second, and perhaps more important, criticism of blurring or obscuring
faces is that this objectifies people and removes their identity. Viewing images
with faces obscured can be disconcerting. Without faces people appear not

as people at all but as objects, this does not accord with a duty to treat people
with respect. Indeed, one might argue that it becomes too easy to fail to treat
people with respect when we cannot see their faces (which is why people
subject to harm are often hooded). Obscuring or blurring images also has
negative connotations which may be communicated to people in their viewing
of the research. Pixilation of images has associations with crime; it is a
commonly used device in the media when talking with ‘criminals’ or ‘victims’ of
crime who fear being identified (Banks, 2001). A third implication, if not
criticism, of obscuring faces is that it can be difficult to do well with some
visual data (where there are a number of people present for example) and
may involve a substantial amount of work on the part of the researcher. It
also raises questions about the impact on the integrity of the data and
whether the result of changing visual data results in ‘sanitised’ findings. A
further implication is that it limits the potential for data to be reused (Williams
et al, undated). The following example illustrates some of these issues in
relation to research with young people.

4.3 Reflections on the dissemination process: the (Extra)ordinairy Lives
Project
Emma Renold & Sally Holland, NCRM Qualiti Node, University of Cardiff

Background
The (Extra)ordinairy lives project was a demonstrator project within the ESRC
National Centre for Research Methods’ Qualiti node based at Cardiff University. It
aimed to explore the ordinary everyday lives of young people who are looked after
by the local authority in foster, residential or kinship care. The research design was
intentionally participatory with the central methodological aim to develop a research
environment in which a small number of children and young people (aged between
10 to 20) could choose their own methods to record and represent aspects of their
lives and identities (e.g. visually, textually, orally and aurally). Eight young people
took part in fortnightly ‘me, myself and I’ project sessions over one school year
(2006-7), where they could explore any aspect of their everyday lives using any
combination of methods and media . One-to-one visits and fieldwork episodes also
took place in between the group sessions, by arrangement. During the group
sessions young people worked on their own individual projects, but also engaged
in much interaction and socialising. These research activities, combined with our
critical reflexive participatory approach proved to be quite productive in generating
a rich and diverse assemblage of multi-modal representations of everyday lives
(pasts, presents and futures). These activities were akin to what Code (1995) terms
‘vigilant methods’, that is methods specifically aimed to cultivate more equitable
and ethical field-relationships through de-mystifying the research process and
rupturing the researcher gaze. Our methodology was one which we hoped would
maximize children and young people’s agency in the research process through
techniques which encouraged young people to actively consider and reconsider
their participatory status, from data generation, through to analysis, representation
and communication of findings. While some of the ‘findings’ of our research
(especially methodological discussions) were of little interest to the participants, we
regularly shared parts of papers we had written or presented with the young
people, to demonstrate how their data is transformed into academic outputs. Most

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were keen to share in dissemination with their immediate carers and with policy
makers.

Beyond Outcomes: The Everyday Lives of Young People in Care 18 months from
the start of the fieldwork and following the individual analysis sessions with each
young participant (see Holland et al, 2008), we invited the young people in our
study to take part in a semi-public dissemination of our findings by organising an
event7 for young people in care (including our participants). Due to ethical issues
relating to anonymity, three short films were commissioned by a local film-maker
(who was also a qualitative social scientist) which would recreate some of the
young people’s narratives and visual imagery using a combination of animation and
actors. Participants were consulted about the content of these films and here is a
short extract from a lengthy discussion between a young person and a researcher
about what theme she would like represented in film:

Nevaeh: I think family’s the big one.
Emma: Family’s a big one. So something about the family, you think.
Nevaeh: I’ve got my own family now. And then like belonging.
Emma: Belonging. Yep, yep, OK.
Nevaeh: Yeah.
Emma: Cause that was a big, that is one of our big themes and, yeah.
Nevaeh: It’s mad, like seeing it all –
Emma: Isn’t it?
Nevaeh: Like … that’s you (staring down and gesturing towards the folders full

of transcribed conversations and interviews)

The ‘Beyond Outcomes’ event was well attended by local young people in care and
care leavers. It featured an address by a Government Minister and involved an
actress from a popular fictional television show about children in a children’s
residential unit. It also raised a number of ethical issues relating to participation and
dissemination. Firstly, in terms of content, we wished to give our participants a
choice over the aspects of their lives that they wished to portray publicly (and
anonymously). The majority of this material was indeed ‘everyday’ and in line with
project aims and tended, understandably, to focus upon the positive and uplifting
aspects of everyday life and relationship cultures. Pets, soft toys, football matches,
visits to parks and the young people’s own photos and videos of themselves and
their families and friends were shown in a 15 minute assemblage of still and
moving images. All were annonymised using specialist visual software with a
selection of quotes adding meaning and direction to the multi-media collage. The
following two images of the same photo illustrate the software used
(http://www.virtualdub.org/ and http://compression.ru/video/cartoonizer/index_en.html)

7 ‘Beyond Outcomes’: The Everyday Lives of Young People In Care was funded by ESRC Research
Festival of Social Science (RES-622-26-0002). The event took place on 10th March (4-5:30pm) at the
Millennium Centre, Cardiff. This event was aimed specifically for young people who live in local
authority care (foster, residential or kinship care settings) to visually communicate research findings of
the ExtraOrdinary Lives research project and generate discussion on young people’s representations of
the everyday lives of being ‘in care’.

The three professional films that drew on and recreated data portrayed both
positive and more negative stories from everyday lives, including stories about first
flats (disappointments and dreams), a cartoon about a young person seeing

another resident in her former bedroom, and some tales of conflict and violence in
school. Some important narratives from the research participants could not be
presented at this event due to participants being aware of each others’ identities
and the potential for unwanted sharing of highly personal material. The film about
conflict in school was withdrawn by the young person whose experiences it
portrayed, as she was anxious about her foster carer realising it was her and was
keen to avoid any negative representations of her interactions with others (“I’m not
showing anything bad”). She is happy for ‘her’ film to be shown to academic
audiences when neither she nor anyone she knows is present. Some young people
who attended the event, but who had not been research participants, expressed an
opinion that the data products portrayed too ‘rosy’ a picture of the lives of young
people in care. The event had indeed censored some of the data due to the wishes
of participants and the researchers ’ own concerns about audience and purpose of
the event. Whilst in most contexts the participants would be entirely unidentifiable
through the anonymised data, in front of peers and carers they could have been
identifiable and it was therefore unethical to present any aspects of their data with
which they were uncomfortable.

Our experiences of this dissemination event is that, on a positive note, our young
participants were able to make informed choices about how, when and where their
experiences could be portrayed. However, it must be recognised that involving
research participants fully in dissemination can potentially lead to a less than
comprehensive picture of research ‘findings’, particularly when the research
includes personal narratives. If participants are always present at dissemination
events, then personal material from other participants may not be able to be
included, where participants know each others’ identities. Therefore, we would
suggest that participative dissemination can risk producing sanitized findings,
although we would acknowledge that this will not be the outcome in all contexts

4.4 Identifying people in images
The more common approach favoured by social researchers is to present
visual data in its entirety, with consent, and not to attempt to anonymise
individuals (see for example, Back, 2004; Holliday, 2004). In this mode of
working, pseudonyms are not generally used.

As noted above, visual researchers identify the importance of developing
relationships of mutual trust with study participants so that the images that are
taken emerge from collaborations between researcher and study participant
and are jointly owned (Gold, 1989; Pink, 2003, 2006, 2007a; Banks, 2001;
Harper, 1998). Pink (2003) and Banks (2001) argue for collaboration as a
means to empower participants to represent themselves in the images that
are produced and disseminated in ways that meet their own objectives. Such
practice will involve showing participants and allowing them to comment on
images prior to wider publication or presentation (Pink, 2006) and
consideration of the political, social and cultural contexts in which images will
be viewed and interpreted (Pink, 2007a).

These are laudable aims but are far from straightforward. They involve the
need for researchers to make efforts to firstly, understand what the
implications of identifiable images of individuals being disseminated might be

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and secondly, explain to individuals in ways that they can comprehend the
various implications. Previous research in relation to text based methods
reveal that study participants are often very keen to be identified in research
(Grinyer, 2002; Wiles et al, 2007) but do not necessarily understand what the
implications may be. There is a tension here between study participants’ right
to decide how their image is used and researchers’ responsibility to inform
participants of the implications this might have. Most research participants
have limited understanding of the research process and the ways in which
research is presented and disseminated. Even with detailed discussion about
this on the part of researchers, participants are unlikely to fully comprehend
the ‘taken for granted’ aspects of research practice. The extent to which
research participants are aware of the varying ways, and contexts in which,
images may be consumed is questionable as is their knowledge about the
longevity of images in the public domain and the potential for future uses of
images. This is not to argue for paternalism on the part of researchers but
rather for the recognition that collaboration with research participants on
issues around anonymity and dissemination involve more than meeting
participants’ wishes; researchers need to carefully consider and explain the
various implications to individuals. In some contexts it may be appropriate for
researchers to take responsibility for the possible outcomes of research and
to protect study participants from themselves.

There are a range of ways that visual research can be disseminated, such as
public exhibitions, film showings or events, the use of digital media (such as
DVDs or the internet) or more conventional forms of dissemination through
presentations at conferences or meetings and book or journal publications.
The mode of dissemination presents different implications for study
participants in relation to anonymisation and identification and these need to
be carefully considered and negotiated with study participants (Pink, 2006,
2007a). Both researchers and participants may be most concerned and
aware of issues in relation to a public showing of research in their or the
broader community but much less so in relation to an academic presentation
or publication. However, this does not negate the need for researchers to be
respectful of the ways in which they present their data in these formats. A
further issue that warrants exploration with participants is consideration of the
implications of images entering and remaining in the public domain through
publication in books and articles. While an individual may be happy for a
specific image of them to be made public at one point in their lives they may
be less so in the future as their circumstances change (See Barrett, 2004;
Williams et al, undated), yet once an image enters the public domain it may
be difficult or impossible to remove it (see Banks, 2001, p131).

Visual data lend themselves to means of dissemination other than
conventional academic publications because these often fail to do justice to
the dynamic and interconnected nature of visual and textual data. This is
particularly the case with some types of visual data, such as video diaries and
observational film. Visual researchers have experimented with various ways
to disseminate their research and producing DVDs and the use of hypermedia
is particularly popular (Dicks et al, 2006). Consideration of ways of restricting
access to these is likely to be important, especially if images involve children.

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The internet offers considerable opportunities for global dissemination but,
without restricted access to sites, raises the possibilities that images can be
copied and reproduced in contexts other than those for which they were
obtained (Banks, 2001; Pink, 2007a; Prosser, 2007). As Pink notes these
may have negative or harmful consequences for the people represented and
can be disseminated globally on-line (Pink, 2007a). The need for restricted
access is also raised in relation to the archiving of visual material for reuse
(Williams et al, undated).

4.5 Images of place
Still images or videos of private or public places or locations (such as inside
houses, schools, in parks and on streets) also present a threat to
anonymisation of individuals whether or not individuals are portrayed in
images. The inclusion of images of place in studies of community is common
practice (Crow & Wiles, 2008) and has also been used in studies of
educational and other organisations (Prosser, 1992). While locations are
often (but not always) given a pseudonym, the images and descriptions make
it relatively easy to identify, or at least make an educated guess, where a
study is located (Clark, 2006). Frequently, images of place used in research
are absent of people (e.g., Savage, 2002) or of identifiable individuals (e.g.,
Foster, 1999) but this does not necessarily mean that a community or an
institution and the individuals or members that make it up cannot be identified
from it. There are considerable examples of community research where
people have been unhappy about the way they or their community has been
characterised and of the ramifications this has had (see Crow & Wiles, 2008).
This indicates a need to consider carefully the implications of taking images of
place and that as much care needs to be taken over issues of anonymity and
consent in relation to images of place as to images of individuals. Some of
the challenges in anonymising visual data relating to place are explored in the
following illustration.

4.6 Reflecting on attempts to anonymise place
Andrew Clark, NCRM Real Life Methods Node, University of Leeds

‘Connected Lives’ is a project exploring social networks and community
interactions through a multi-dimensional inner-city neighbourhood case study.
We are seeking to understand how networks, neighbourhoods and
communities are experienced and defined in different contexts, over time and
across space. We are using a variety of qualitatively-driven methods to
collect data including a number of visual methods. Visual data has been
generated by participants through a day-diary and a neighbourhood
walkaround in which they are provided with a disposable camera with which to
photograph aspects of their networks, neighbourhoods and communities. In
addition, we have produced a considerable amount of researcher-generated
visual data in the form of photographs taken in the field over the course of the
research.

The visual data produced through these methods comprises both researcher
and participant created images, including images produced by the participant

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without the researcher present. The photographs tend to consist of three
types of image:

1. Photographs of people in which the locations or settings is not always

clear.
2. Photographs of places including panoramic images of the urban

landscape, and close-range images of objects within the landscape,
including shops, pubs, and places of worship.

3. Photographs of people in place including for example, individuals in
street scenes and public spaces.

We are now faced with the challenge of whether to anonymise this visual data
relating directly to place and if so how.

The challenge of anomyising place
There were a number of reasons why we considered anonymising place in
our visual data. One is to protect the identities of the fieldsite and individuals
(participants or others) who live or work there. While it may, in theory, be
relatively straightforward to disguise place in text through the use of
pseudonyms or limiting the amount of geographical context it is almost
impossible to adequately anonymise place in visual data; those familiar with
the places will continue to recognise them. Partly due to our aim to
disseminate results of the research we did not aim to achieve complete
anonymity of place, but rather decide in which contexts to use images of
place, among which audience, and the purposes for which we are presenting
a photograph of place.

Despite our best efforts, we did not entirely resolve the challenges of
anonymising place. In some instances a failure to anonymise place can also
unwittingly reveal the identities of individual participants as well. For example,
the use of a quotation positioned alongside a particular photograph (in this
case, of a patch of waste-ground in my research site) during a seminar paper
I gave was sufficient for enable one member of the audience who was familiar
with the research site to identify the participant who gave the quotation, even
though I believed I had anonymised both participant and name of the fieldsite
and ensured there was, seemingly, no identifying feature in the photograph8.
Perhaps the processes through which histories and individuals combine to
produce particular narratives about place may be too powerful to guarantee
anonymity of either people or place. Consequently it may not be possible to
guarantee anonymity in visual data about place among audiences who are
familiar with those places.

A further reason for anonymising place arises from the ways in which visual
images can be used to reproduce particular representations of place.
Photographs of place can become an accomplice to power, perpetuating
particular stereotypes and myths about places. For example, one participant
chose to take photographs of rubbish left in a social housing estate in our

8 After the event I discussed what had happened with the participant concerned. Ironically, the
participant was more interested in why I had wanted to anonymise him/her in the first place.

fieldsite to demonstrate the poor upkeep of the area and what she interpreted
to be a lack of care by residents.
It is not the image alone that can reproduce particular views and
representations, but the juxtaposition of image with text. A comment made by
a participant in relation to particular café in the fieldsite could have significant
repercussions if accompanied by the visual image:

SP: This place here, xxxx [name of a café], I’ve heard stories about it
Researcher 1: What sort of stories?

SP: Er, that it’s basically a drugs haven. Which I’m surprised, I’ve
never seen police here before. So you’d think well surely, I mean it’s
pretty much advertised, usually has some kind of dubious advertising
on the door.
(Walking interview)

For another participant, the power of the image lay in its production.
Photographing a particular place provided opportunity to reify a concern she
had about assumed exclusivity of a third sector organisation. QS encouraged
us to take a photograph as ‘proof’ that she could then use to demonstrate how
a particular organisation was acting, in her view, in an inappropriate way.
While, as requested, we took the photograph of the Centre, to reproduce it to
other audiences would have repercussions for those who are associated with
the Centre:

QS: I mean I’m bringing you round here.
Researcher 1: Yeah.
QS: Cos I want to show you, look, xxxx Community [Centre], I want you to get
a picture of that.
Researcher 2: [laughs] You want me to get a picture of that?
QS: Yeah I do cos I want to see when it’s gonna become community, that’s
what I wanna do.
(Walking interview)

We cannot publicly reveal either of the photographs discussed above because
of clear implications they would have for the groups and individuals
associated with both places. Like textual data, this ongoing negotiation over
which photographs we do and do not show to audiences outside the research
is central to decisions about how to anonymise place. The process needs to
recognise the context behind the production of the visual data and consider
the potential implications for revealing particular images not just for
participants, but also for those who may not have any connection with the
research other than through the accident of geography.

Anonymising place through method
On the whole, when images do not include people’s faces, we found that
participants raised few doubts about photographing places. They rarely
expressed concern about content, even when images included photographs
that may identify them or people they know. For example, participants have
taken photographs of houses where they used to live, houses where family or

friends currently live, of shops, cafes and pubs they frequent, all of which
would be instantly recognisable to those familiar with the places.

However, some participants were aware of broader ethical issues around
photographing place which resulted in them practicing their own
anonymisation strategy while engaging with the visual methods. The content
of participants’ photographs was determined not only by what they wanted to
reveal to researchers about their lives and their places but also by their ethical
concerns over what they were willing, and not willing, to photograph. Some
chose not to take any photographs, arguing that they felt uncomfortable or
self-conscious producing such data and others were selective about the
content of their images. While this was in part due to the degree of comfort
using a particular method, it also alludes to a form of censuring of visual data.
This included photographing place:

QS: …Yeah. All these shops here, as you can see, most of them have gone

into takeaway. I don’t know if they’ll be offended [by] you taking pictures
here

(Walking interview)

QS takes pride in calling herself ‘local’ and was reluctant for us to take
photographs in an area of the neighbourhood with which she was less
familiar. This was, she claimed, an area where the store owners were not
local and lived outside the neighbourhood, where she knew fewer people on
the streets, and where, ultimately, we can surmise she felt out of place. In
determining where, and crucially where not, to take photographs, PR thus
reveals how her depth of place attachment intertwines with her ethical
concerns about photographing place.

On reflection
It is important to recognise that guaranteeing complete anonymity of place
(and at times, people within those places) is fraught with danger. While it may
be possible to anonymise people through pixilation for example, this cannot
be done so easily with place. Moreover, it is important to question what
purpose anonymising place may serve. Would an image of a street scene
anonymised so as to disguise people and location (for example by disguising
store names) serve any purpose or would it represent a fabricated, sanitised
picture to illustrate any accompanying text? It may be more preferable to not
include over-anonymised images of place rather than present images simply
for illustration. We have found it more appropriate to decide whether
particular photographs should, or should not, form part of the ‘public face’ of
the research. For it is not necessarily the image alone that can create ethical
challenges, but the combination of image and accompanying text. Comments
and stories about particular images can make both participants and place
recognisable to others.

The history of anthropology and community research, including those that
have used visual methods, is littered with examples of individuals and

communities being distressed about the way they have been portrayed in
research (Pink, 2003; Rose, 2007: 252; Crow & Wiles, 2008). Arguably, more
collaborative research approaches have made cases where research
participants experience dissatisfaction with their treatment by researchers
relatively rare. Nevertheless, exploration with research participants of their
wishes for the ways visual data should be used and consideration of the
implications this might have is a complex task.

5. Further Ethical Issues

Aside from issues of consent, confidentiality and anonymity, there are a
number of other ethical issues that arise in the practice of visual methods
which it is important for the visual researcher to consider. Central among
these are i) how images are constructed and ii) how images are consumed.
These issues, taken together with consent, confidentiality and anonymity, do
not exhaust the ethical issues that emerge in visual research but we view
them as comprising the central ethical issues that all visual researchers need
to consider; this does not negate the need to consider the additional and
specific ethical issues that emerge within the specific contexts of individual
research projects.

In this section we briefly review issues around the construction and
consumption of images to aid researchers’ thinking on these issues. The
issues outlined by Pink (2003) are helpful in this context. She notes that, in
any project, a researcher needs to attend to: the internal meanings of an
image; how it was produced; and, how it is made meaningful by its viewers.
She notes the key issues to be considered by researchers are:
i) the context in which the image is produced
ii) the content of the image
iii) the contexts and subjectivities through which the images are viewed

5.1 The construction of images
One of the difficulties with visual data is that images tend to be viewed as
representations of social reality but are inevitably constructions of a social
reality that are influenced by the attributes of both the researcher and subject
(Pink, 2003; Harper, 2004). As Prosser (2000, p124) notes:

‘The still camera and movie camera … replicate accurately what is set
before them. However, importantly, they do so at our bidding’

There are various ways in which researcher and/or subject contribute to the
construction of images. Researchers may use a particular lens to photograph
a subject, ‘set up’ a specific photograph or use software to alter a photograph
in order to make or illustrate a specific point (Gross et al, 2003; Prosser, 2000;
Prosser & Loxley, 2008). Similar issues apply to film. There are also a range
of less-conscious ways in which a researcher may influence the way in which
an image is constructed; social class, gender, ethnicity and other social
attributes of the researcher all operate to influence the choice of visual images
(Harper, 2004). The same is true for research participants who may choose

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to present themselves in ways in photographs or films that differ from their
everyday reality (Gianotti, 2004). Ethical research demands that researchers
are explicit about the methods and contexts in which the image has been
created; it is unethical to use images to knowingly deceive or give a false
impression (Prosser, 2000; Rose, 2007). Researchers also need to provide
reflexive accounts to enable others to make sense of the visual data
presented.

5.2 How images are consumed
The issues discussed above are pertinent in relation to the consumption of
images. Images are not only created but also consumed within a social
context (Banks, 1995). Furthermore, the way that images are consumed may
be different to that which the researcher intended (Pink, 2007a; Gold, 1989).
It is crucial to consider how the image or film will be interpreted and, in order
to minimise misinterpretation, use visual data with text to make explicit the
intended meaning (Prosser, 2000). Consideration of how visual data will be
interpreted (and subsequently used) involves knowledge about the political,
social and cultural contexts in which data will be viewed (Pink, 2007a). Rose
(2007) argues that there are two aspects which influence the ways in which
images are viewed: the social practices in which images are viewed and the
social identities of the viewer. Visual researchers need to carefully consider
these issues in order to take seriously the promises they have made to their
study participants.

6. Conclusion: towards some guidance for visual researchers?
This review has outlined some of the issues for consideration by visual
researchers undertaking research using film, photos or video. We recognise
that the ethical issues that visual researchers encounter in their research are
situated and emerge in relation to the specific contexts of individual research
projects; this inevitably makes providing guidance about good ethical practice
in visual methods problematic. This review has, nevertheless, identified some
of the ethical considerations that arise in relation to the core ethical issues of
consent, confidentiality and anonymity and provided examples of some of the
ways in which these issues can be managed. Our aim is that these will
provide a useful resource to aid novice visual researchers to think through,
and manage, the important ethical issues that visual methods raise.
However, we also view it as important that the ethical decisions that visual
researchers make are informed by an understanding of, and engagement
with, theories (or approaches) to ethics. Ethical decisions in research should
not be made in isolation but in the context of a thought-through and
considered framework that accommodates a researcher’s moral outlook as
well as professional guidelines. In the current climate of increasing ethical
regulation it is crucial that researchers are able to understand, articulate and
argue the ethical or moral case for the decisions they make about the design
of their research and the ethical issues that emerge throughout the research
process. This is crucial for the on-going reputation and integrity of visual
research.

Useful Resources

British Sociological Association – Visual Sociology Group’s statement of
ethical practice (2006)
www.visualsociology.org.uk/about/ethical_statement.php

Research ethics in art, design and media
http://www.biad.uce.ac.uk/research/rti/ethics/bibliography.html

Software for anonymising visual images:
http://www.yowussup.com/pixelating-images.php; http://www.virtualdub.org/
and http://compression.ru/video/cartoonizer/index_en.html)

ESRC Researcher Development Initiative on visual methods
http://www.education.leeds.ac.uk/research/visual-methods/

International Visual Studies Association

IVSA

Websites on visual methods and visual ethnography
http://www.photoethnography.com/
http://www.lboro.ac.uk/departments/ss/visualising_ethnography/

Creative visual methods
http://www.artlab.org.uk/

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https://www.researchgate.net/publication/258182424_Researching_Researchers_Lessons_for_Research_Ethics?el=1_x_8&enrichId=rgreq-ced74e1ff0867f72bff1c5b92052650f-XXX&enrichSource=Y292ZXJQYWdlOzI1MzMxMTc1MjtBUzoxMzgzMzgwNDAyOTEzMjhAMTQwOTk5Mzc2Nzg1OA==

https://www.researchgate.net/publication/233569668_The_Management_of_Confidentiality_and_Anonymity_in_Social_Research?el=1_x_8&enrichId=rgreq-ced74e1ff0867f72bff1c5b92052650f-XXX&enrichSource=Y292ZXJQYWdlOzI1MzMxMTc1MjtBUzoxMzgzMzgwNDAyOTEzMjhAMTQwOTk5Mzc2Nzg1OA==

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Appendices: sample consent form

Dear

Many thanks for taking the time to participate in an interview for our project on
family resemblances. It was a real pleasure to talk with you about you and your
family.

During the interview you showed me some of your family photographs and you
agreed to let me photograph them for use in the analysis of the research.

During the interview we also discussed some of the possible uses and outcomes
of the research data including a report for our funders (Economic and Social
Research Council), presentations and publications for academics and use in the
training of other researchers.

We would like to use some photographs in these (electronic and print) reports,
presentations and publications. Real names will not be used with the
photographs. We may or may not publish your photographs, but in case we do I
would be grateful if you would read the enclosed form and decide if you would
give consent for us to use the images.

Please complete the form by signing one of the three boxes:

1. Sign box one if you give permission for us to publish the photos
2. Sign box two if you give permission for us to publish some but not all of the
photos. Please don’t forget to state the numbers of the photos you give
permission for us to use
3. Sign box three if you would prefer us not to use the photos outside the
research team

Once completed, it would be helpful if you could return a signed copy of the form
in the stamped addressed envelope enclosed. Please don’t hesitate to contact
me if you are having difficulty understanding the (rather complicated!) form or if
you have any questions. I would be more than happy to come and talk about it
with you in person if that would be helpful.

Thanks again for your contribution to the project.

Kind Regards,

Katherine Davies

Photo Reproduction Rights Form

Living Resemblances Project, University of Manchester
www.reallifemethods.ac.uk/resemblances

This form refers to photographs that you supplied, or photographs that you allowed
Katherine Davies to make, as part of the Living Resemblances project in which you
have participated. All photographs will be securely stored by the research team. As
discussed with you, photographs may be shared within the research team to help them
in their analyses. We would also like to use some photographs (in electronic or print
form), in reports, presentations, publications and exhibitions arising from the project.
Please could you sign one of the boxes below to indicate whether or not you are
happy for us to do this. We have attached numbered prints of your photographs to
assist you, and for your records. We won’t use any photographs outside the research
team without your permission.

Please sign either 1, 2, or 3 below:

1. I give my consent for these photographs to be reproduced for educational and/or
non-commercial purposes, in reports, presentations, publications, websites and
exhibitions connected to the Living Resemblances project. I understand that real
names will NOT be used with the photographs.

signed……………………………………………………………………
.date……………………………………………

OR

If you would like to give permission for us to publish some, but not all, of the photos
please list the numbers of the photos you will allow us to use:
2. I give my consent for photo
numbers……………………………………………………………………………

…………………………………………………………………………………………………………….(please
specify)
to be reproduced (in electronic or print form), for educational and/or non commercial
purposes, in reports, presentations, publications, websites and exhibitions connected
to the Living Resemblances project. I understand that real names will NOT be used
with the photographs.

signed…………………………………………………………………….
date……………………………………………

OR

3. I do not wish any of these photographs to be reproduced in connection with the
Living Resemblances project.

signed…………………………………………………………………….
date……………………………………………

Thank you for participating in our project. If you have any queries about this form or
about the project or your participation in it, please do not hesitate to contact Katherine
Davies: 0161 275 2516, Katherine.Davies@manchester.ac.uk

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Indiana Law Journal

Volume 74 | Issue 3 Article 8

Summer 1999

International Control of Cholera: An
Environmental Perspective to Infectious Disease
Control
Julia A. Jones
Indiana University School of Law

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Recommended Citation
Jones, Julia A. (1999) “

International Control of Cholera: An Environmental Perspective to Infectious Disease Control

,” Indiana Law
Journal: Vol. 74: Iss. 3, Article 8.
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International Control of Cholera: An
Environmental Perspective to Infectious

Disease Control

JuLAA. JoNEs”

“From the time the cholera proclamation was issued, the local garrison shot
a cannon from the fortress every quarter hour, day and night, in accordance
with the local superstition that gunpowder purified the atmosphere.”1

INTRODUCTION

Cholera has remained a persistent global health problem despite the advent of
modem medicine and international health policy. The landmark 1991 outbreak in
Peru recently brought cholera to the attention of the world.’ With hundreds of
thousands of cases in Peru, cholera emerged within only a few months as one of the
Western Hemisphere’s most important public health problems of the early 1990s.’
As is often the case when cholera infects a previously uncontaminated area such as
Peru, microbiologists, clinicians, and public health officials are frequently
unprepared. The result can often be delayed or inadequate diagnosis and
inappropriate treatment leading to unnecessary morbidity and mortality. In addition,
cholera has proven difficult to control. In many parts of the world, cholera has
demonstrated resistance to multiple antimicrobial agents and vaccines, complicating
both treatment and public health prevention measures.4 Cholera’s defianpe of
medical measures reinforces the necessity to control the disease at its
source-contaminated water. It is a disease that should be controlled through the
environment that gives it life.

The re-emergence of cholera shocked the global community into recognizing the
link between disease and environmental conditions as well as appreciating the
deficiencies in the provision of water and basic sanitation facilities in many nations.
The result has been to evoke efforts to increase research, development, and policy-
making in sanitation and drinking water quality.

Cholera is also an inescapable reminder of nations’ geographic and
environmental interconnection. As states share natural resources, trade interests,

* JDJiS.E.S. Candidate, 1999, Indiana University School of Law-Bloomington & School
of Public and Environmental Affairs; M.S., 1995, Purdue University, B.A, 1993, Earlham
College. I dedicate this Comment to my father, Dr. Robert B. Jones. Also, I would like to thank
Professor David P. Fidler for all his assistance.

1. GABRiE GARCIAm RQTEZ, LOVE IN THE ThuA OF CHOLERA 111-12 (1988). The quotation
reflects the prevailing misperceptions concerning the cause, transmission, and prevention of
cholera at the end ofthe 19th centuy. The fear and superstition of cholera often lead to inadequate
attempts of regulation.

2. See infra text accompanying note 44.
3. See infra tm accompanying notes 44-47; see also R.I. Glass et al., Epidemic Cholera in

theAmericas, 256 Sci. 1524,1524 (1992).
4. See infra text accompanying notes 20-23.

INDIANA LAW JOURNAL

and public and environmental health concerns, they also share cholera. Without the
option of complete isolation, no one state is invincible from the spread of cholera.

This Comment attempts to analyze international law and reemerging infectious
diseases, specifically focusing on cholera. First, it defines both the infectious
disease concept and cholera, the disease itself. Second, this Comment evaluates the
reasons why cholera remains a threat to the interhaational community. By closely
examining the factors that contribute to the spread of cholera, this Comment
illustrates the complexities of infectious disease regulation on an international scale.
Third, current attempts to control emerging infectious diseases, specifically cholera,
are analyzed. Many of these attempts are founded on similar principles with similar
goals, and still they prove inadequate to limit the spread of cholera. Finally,
recommendations to improve the control of cholera, which can also be applied to
infectious disease generally, are provided. These recommendations seek to foster
an investigation of alternative means to aid in the international regulation of
cholera.

I. CHOLERA: A REEMERGING INFEcTIOUs DISEASE

Cholera is a reemerging infectious disease that threatens the global community,
yet to understand the extent of its threat, the nature of the disease must be
understood. This Part intends to lay the background of cholera. Following a brief
introduction to the infectious disease concept, the biology, history, and
epidemiology of cholera will be presented.

A. The Infectious Disease Concept

Infectious diseases are diseases that spread when one organism transmits a
bacterium, virus, parasite, or fungus to another new organism.’ Infectious diseases
can be transmitted through air, water, direct contact with bodily fluids (for example,
blood, saliva, feces, and urine), and intermediary organisms such as insects.6 Each
newly infected organism then serves as a host and can transmit an infectious disease
to other susceptible organisms, thereby increasing the numbers infected.

Public health authorities usually label both emerging and reemerging infectious
diseases as “’emerging infectious diseases”‘ (“EIDs”) and define EIDs as diseases
with an “‘infectious origin whose incidence in humans has increased within the past
two decades or threatens to increase in the near future.” 7 Included in this definition

5. See David P. Fidler, Return of the Fourth Horseman: Emerging Infectious Diseases and
International Law, 81 MINN. L. REv. 771,776-77 (1997); see also, e.g., INSTITUTE OF MED.,
EMERGING INFECTIONS: MICROBIAL THREATS TO HELTH IN THE UNITED STATES 41 (1992)
(providing, as an example, candidiasis, which is a fungal disease that can affect the gastro-intestinal
tract, vagina, and mouth, and which is often associated with AIDS).

6. See, e.g., Bernard N. Fields, Pathogenesis of Viral Infections, in EMERGING VIRUsES 69,
70 (Stephen S. Morse ed., 1993).

7. Fidler, supra note 5, at 778 (quoting U.S. CENTERS FOR DISEASE CONTROL AND
PREvEtoN,ADDRFEsSING EMERGING INFECTIOus DISEASE TmREATS:A PREVENiON STRATEGY
FORTHEUNiTED STATES 1 (1994)).

1036 [Vol. 74:1035

INTERNATIONAL CONTROL OF CHOLERA

are diseases that have reemerged in traditional locations, such as cholera in India,
or in new regions, such as cholera in the Western Hemisphere.

B. Cholera Description

Cholera is a reemerging infectious disease caused by the bacterium Vibrio
cholerae 01 which occurs in both epidemic and endemic forms.’ Humans can be
afflicted by cholera which causes severe diarrhea and vomiting, and rapidly can lead
to dehydration and death if not promptly treated.9 However, typically only about two
percent of persons infected with cholera manifest life-threatening symptoms. More
than ninety percent of cholera episodes are of mild or moderate severity and are
difficult to distinguish from other types of acute diarrhea.”

Cholera is transmitted primarily through ingestion of water contaminated with
human feces, including foods that have been washed in contaminated water.”
Transmission of cholera by person-to-person physical contact appears to be
extremely rare. 2 Furthermore, chronic human carriers of cholera are uncommon
and are not known to play any role in cholera transmission or persistence- 3 There
are no animal reservoirs, but cholera does have environmental reservoirs. It is
indigenous to water and is frequently found in both fresh and salt water, as well as
estuarine environments.”4 Cholera has a tendency to adhere to the exoskeleton of
crabs, shrimp, and other crustaceans, yet it is also found in zooplankton, in
mollusks, and inthe roots of aquatic plants.” As a result of its indigenous reservoir
in water, food has become a concern for transmission of cholera. Contamination of
foods with Vibrio cholerae 01 most often results from direct or indirect contact
with the feces of infected persons or water contaminated with fecal matter.
Generally, contact occurs in one of the following circumstances: (1) fecally
contaminated water for washing or preparing raw foods; (2) ice made from fecally
contaminated water; (3) handling of food by infected persons who have failed to
wash their hands after contact with feces; and (4) fecally contaminated water used
to irrigate fruits and vegetables that grow close to the soil. 6

8. See Paul A. Blake, Epidemiologic Aspects of Cholera, in CHOLERA ON THE AMERICAN
CONTINENrs 11, 12 (A.F. Pestana de Castro & W.F. Almeida eds., 1993); Jose Martines et al.,
DiarrhealDiseases, in DISEASE CONTROLPRiORrms I DEVELOPING CoUNRmS 91, 99 (Dean
T. Jamison etal. eds., 1993).

9. See Blake, supra note 8, at 12.
10. See id.
11. See id. at 15; see also Gunther Craun et al., Prevention of Waterborne Cholera in the

United States, 83 J. AM. WATER WORKs ASS’N 40,42 (1991).
12. See Blake, supra note 8, at 15.
13. See id.
14. See Maria Therezinha Martins, Water as a Vehicle for Cholera, in CHOLERA ON THE

AMERICAN CoTINENTnS, supra note 8, at 65.
15. See id.
16. See Fernando Quevedo, Foods and Cholera, in CHOLERA ON TEA.MERcAN CONTINENTs,

supra note 8, at 71, 74.

1999] 1037

INDIANA LAW JOURNAL

Human fatality rates may be as high as fifty percent when cholera strikes a
community that has inadequate sanitation treatment facilities. 11 In contrast, a well-
developed treatment program for cholera can limit the fatality rate to less than one
percent.’8 Inmost cases of cholera, administering a solution of oral rehydration salts
is a successful treatment, or, for more severe cases, intravenous fluids and
antibiotics such as tetracycline are used in treatment.’ 9

Efforts to develop cholera vaccines have spanned eleven decades and have
resulted in little success. Public health officials have abandoned vaccines as a
method to control cholera because they induce only weak or short-term immunity.2″
Data from field trials of oral vaccines administered in Bangladesh demonstrated
limited protection of three years for fifty-one percent of those immunized, with
children suffering the greatest loss of immuno-protection provided by the vaccine.2′
Vaccination does not eliminate cholera from the human body, and, therefore, is not
likely to prevent transmission of infection since it can still be carried and excreted.22

Recently a new strain of cholera called Vibrio cholerae 0139 or “Bengal” cholera
that is resistant to multiple antibiotics has emerged in Bangladesh and East Africa. 3

Of concern is that the cholera vaccines currently used for Vibrio cholerae 01,
which have had less than desirable results, will not work against this new strain.
Overall, currently available cholera vaccines do not prevent cholera.

C. History and Epidemiology

Throughout history, cholera has remained a persistent international problem.
Sanskrit, Arabic, and Chinese writings dating back at least two millennia have been
found to contain descriptions of cholera.24 The history of cholera preceding the
1950s is commonly understood as having occurred in a series of pandemics, each
originating in India. 2′ The first cholera pandemic, lasting from 1817 to 1823,
surfaced in Calcutta and spread rapidly through India and Asia, yet failed to impact
Europe. 6 Over the next fifty years, six more cholera pandemics would occur across
the world, including Africa and South America.2 ‘ As a result of the first pandemic,

17. See World Health Org., Cholera, Fact Sheet N107, March 1996 (visited March 18, 1999)
[hereinafter Cholera Fact Sheet].

18. See id.
19. See id.
20. See John J. Mekalanos & Jerald C. Sadoff, Cholera Vaccines: Fighting an Ancient

Scourge, 265 Sci. 1387, 1387 (1994).
21. See id. at 1388.
22. See Craun et al., supra note 11, at 42.
23. See Martines et al., supra note 8, at 99; Travellers Med. and Vaccination Ctr., Travel

Health News, Cholera Killed 5,000 in Africa Last Year (visited Jan. 19,1999) .

24. See Mekalanos & Sadoff, supra note 20, at 1387.
25. See Blake, supra note 8, at 13.
26. See GEoFFERY MARKS &WLIAMK. BE ATY, EPmllhIcs 193-94 (1976).
27. See Paul A. Blake, Historical Perspectives on Pandemic Cholera, in VIBRIo CHOLERAB

AND CHOLERA: MOLEcuLAR TO GLOBAL PERSPECTIVES 293,293 (1. Kay Wachsmuth et al. eds.,
1994) (noting that, although historians differ on the exact dates of the pandemics, the most
commonly used dates are: pandemic one from 1817 to 1823; pandemic two from 1829 to 1851;

1038 [Vol. 74:1035

INTERNATIONAL CONTROL OF CHOLERA

England passed the Quarantine Act of 1825, even though quarantine measures
already had proved ineffective in halting the spread of cholera.28 Shortly thereafter,
a second pandemic (1826-37) affected all of Europe. This pandemic was not
notable for the fatality rate, but rather it was notable for the concentrated public
attention on efforts to stop the spread of cholera.29 For instance, the Cholera
Prevention Act of 1832 was enacted by England to give the British government a
wide range of public health emergency powers.3″ Throughout the mid-1800s cholera
reemerged three more times on the European continent (1848-49, 1853-54, and in
1866).”‘ The 1866 epidemic was the last cholera epidemic to erupt in England, and
its relatively attenuated impact was attributed to the effectiveness of sanitary
reform.32 Additionally, by 1900 cholera apparently had also been eliminated from
the western hemisphere.33 The seventh cholera pandemic began in 1961 in the
Pacific Islands. 4 It then spread rapidly throughout Asia, reaching Bangladesh in
1963, India in 1964, and the USSR, Iran, and Iraq in 1965-66. In 1970 cholera
reemerged in Africa where it had been in remission for more than 100 years. 5

Then, in 1991 it struck Latin America.36

II. THi GLOBAL THREAT OF CHOLERA

Cholera is a global threat and no simple answer exists to explain why cholera has
remained such a significant problem. This Part will begin by explaining the
persisting problem of cholera, followed by an examination of why global control of
cholera continues to pose such monumental challenges to the development of legal
and public health strategies. Within that examination, the most frequently cited
factors contributing to cholera will be analyzed. The factors are not discussed in
order of importance or priority, nevertheless, those factors that have links to the
environment will be emphasized.

A. The Persisting Problem

Cholera is a disease in resurgence that threatens the global community, sparing
no nation from its potential reach. With the modern scale of global commerce and
travel, cholera outbreaks are a danger to virtually every nation.37 Cholera is most

pandemic three from 1852 to 1859; pandemic four from 1863 to 1879; pandemic five from 1881
to 1896; pandemic six from 1899 to 1923; and pandemic seven from 1961 to current).

28. See Lewis C. Vollmar, Jr., The Effect ofEpidemics on the Development ofEnglish Law
from the BlackDeath Through the IndustrialRevolution, 15 J. LEGALED. 385,413 (1994).

29. See id.
30. See id. at 415.
31. See id. at 415-18.
32. See id. at 417.
33. See id. at 418.
34. See Cholera Fact Sheet, supra note 17.
35. See id.
36. See infra text accompanying note 44.
37. See Fidler, supra note 5, at 774 (citing the globalization problem to combating the spread

of infectious diseases).

1999] 1039

INDIANA LAW JOURNAL

threatening to those developing nations where the people are the least protected and
the public health community is the least prepared for a cholera outbreak. Medical
science has failed to develop an assured method of cholera prevention, but the
answer to cholera prevention does not lie within the medical sciences, rather it is
found in the environmental sciences. Many developed nations, such as the United
States, no longer suffer from cholera because, as a nation, they have engineered and
implemented safe sewage and drinking water systems. Unfortunately, not every
nation in the world shares the same status of development and the number of recent
cholera cases remains astonishing.

As of February 26, 1998, the number of cholera cases reported to the World
Health Organization (“WHO”) for 1997 totaled 134,565 with 6059 deaths.38 As of
April 7, 1998, the cumulative number of 1998 cases of cholera reported, beginning
with January 1, 1998, has hit a grand total of 49,226 with 1772 deaths.39 However,
the true scale of the global cholera problem is not adequately reflected by these
numbers, because they only represent reported cases and not the potential thousands
of unreported cases that occur each year.

Currently, numerous eastern and southern African states are afflicted by severe
outbreaks of cholera, often with averages of sixty-five new cases per day.” Chad,
Mozambique, Democratic Republic of Congo, Somalia, Uganda, and Zambia have
all reported recent cholera outbreaks’ To illustrate the severity and persisting
problem of cholera in these nations, since January 1, 1998, a total of 16,982 cases
with a fatality rate of five percent has been reported in Uganda.42 Overall, the WHO
estimates that seventy-nine million people in Africa are currently at risk of being
infected with cholera. 3

A recent example of the severity of cholera in the western hemisphere is the
outbreak in Peru in 1991. Emerging almost simultaneously in several cities along
the coast of Peru, cholera spread rapidly, infiltrating other urban areas and crossing
the Andes to reach the headwaters of the Amazon in less than a month. Cholera
spread to contiguous countries and, in less than ten months, it was the scale of an
epidemic, spanning a continent The United States as well as twelve Latin American
countries all reported domestically acquired cases of cholera that were believed to
be related to the Peruvian outbreak.’ The number of reported cases in Peru
increased to a staggering 20,000 per week within the first eight weeks of the

38. See World Health Org., Global Cholera Update Oast modified Apr. 8, 1998)
.

39. See World Health Org., Communicable Diseases Surveillance and Response (CSP),
Cholera in Uganda, Disease Outbreaks Reported, 7 April 1998 (visited Mar. 18, 1999)
.

40. See id.
41. See id.
42. See id.
43.See George A.O.Alleyne, Infectious Diseases-A Global Problem (last modified Jan. 29,

1999) .
44. See Robert V. Tauxe & Paul A. Blake, Epidemic Cholera in Latin America, 267 JAMA

1388, 1388 (1992).
45. See id.

1040 [Vol. 74:1035

INTERNATIONAL CONTROL OF CHOLERA

epidemic.”‘ By the end of 1991, the total number of cholera cases in Peru was close
to 300,000 and another 60,000 cases had been reported by other Latin American
countries in the same year.47 Although mitigated in 1991, the epidemic did not fully
subside. According to the WHO, during January 1998 a total of 2863 cases, with
sixteen deaths, had been documented in Peru compared to only 174 cases and one
death in the corresponding period of 1997.”‘ These numbers portray the magnitude
of the problem and how cholera continues to re-surge.

B. Why Global Control Is a Problem: Factors
Contributing to Cholera

There is no one explanation of why cholera has not been conquered by the efforts
of modem medical science. Its perpetual re-emergence is a complex phenomenon
that encompasses health, environmental, social, political, and economic factors.
This Part attempts to address the most significant of these factors.

A critical error in the control of infectious diseases has been the focus on the
actual microbe as the foe, combined with a response to seek and destroy it. A more
enlightened understanding would embrace an ecological perspective to control the
spread of diseases. The spread of cholera is influenced by both naturally occurring
environmental phenomena as well as by human alterations to the environment.
Scientific research supports the viewpoint that changing the natural environment
may create conditions conducive to the re-emergence of infectious diseases.49

Human manipulation, invasion, and degradation of the environment can create new
vectors for transmission of infectious diseases that did not formerly exist. Scientists
have identified Hemorrhagic fever, Lassa fever, Lyme disease, La Crosse
Encephalitis, and ehrlichiosis as infectious diseases that have already been
identified as having spread following observed environmental changes.”°

1. Changing Ecosystems and Human Influence

Human activity alters ecosystems that will ultimately affect the spread of
infectious diseases. Scientists have identified three general forces that are
influenced by human activity and that can influence the extent to which infectious
diseases impact humans. These forces include: the change in abundance, virulence,

46. See Eduardo Salazar-Lindo, Cholera in Peru, 1991: The Extent of the Epidemic, Modes
of Tranmissqon, andLesonsLearned, in CHOLERA ON THA RCAN CONTIEs, supra note
8, at 21, 23.

47. See id.
48. See World Health Org., Communicable Diseases Surveillance and Response (CSR),

Cholera in Peru, Disease Outbreaks Reported, 25 Feb. 1998 (visited Mar. 12, 1999)
[hereinafter Cholera in
Peru].

49. See Ann Gibbons, Where Are ‘New’ Diseases Born?, 261 Sci. 680, 680-81 (1993)
(reporting on two projects which provide evidence that environmental change may lead to the
emergence or re-emergence of infectious diseases).

50. See Fidler, supra note 5, at 801-02 (citing reports that changes to the environment are
associated with outbreaks of infectious diseases).

1999] 1041

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or transmissibility of microbes; the probability of human exposure to
microorganisms; and an increase in human vulnerability to infection and to
infections’ consequences. 5 Human migration, urbanization, travel, and trade all can
influence the probability of human exposure to microorganisms. Furthermore, the
abundance, virulence, and transmissibility of infectious diseases can be influenced
by human alterations to the environment, with cholera serving as a perfect example.

a. Urbanization

Urbanization taxes natural resources, alters ecosystems, heightens environmental
degradation, and increases the risk for rapid spread of infectious diseases.52

Urbanization is a function of population growth; as populations increase, so do the
number and sizes of cities. Thus, a chain reaction of events occurs. Population
growth forces increased urbanization and with increased urbanization comes
increased environmental degradation. Population estimates indicate that each year
the world’s population increases by approximately seventy million people.53 Such
numbers indicate that urbanization will continue creating more environmental
degradation and stressing water resources. These conditions only serve to augment
human susceptibility to cholera.

A fundamental issue of urbanization is urban water quality and sanitation. As
mentioned previously, drinking-water qualify and sanitation-system adequacy are
of critical importance in avoiding water-borne disease outbreaks such as cholera.
Cities with inadequate sanitation systems and large populations may, in effect, serve
as reservoirs for cholera. As of 1990 nearly 1.3 billion people in the developing
world lacked access to clean water and an estimated two billion lived in regions
lacking adequate systems for disposing human waste.54 Many cities with existing
sanitation systems are challenged to maintain drinking-water quality and city
sanitation systems. Clearly this is a greater challenge for some developing nations
that lack resources needed to maintain existing systems or to build new systems and
implement hygiene infrastructures. 5 Given future population projections,
developing nations will continue to face enormous obstacles in meeting urban
drinking-water and sanitation needs.

b. Trade and Travel

The volume and ease of international trade and travel presents boundless
opportunities for the spread of infectious diseases. Individuals, merchandise and
even vehicles of transportation can serve as carriers for disease. The large-scale
movements of goods and people around the globe has heightened the concern that
infectious diseases will be introduced into areas where they did not previously exist

51. See MaryE. Wilson, Infectious Diseases: An Ecological Perspective, 311 BRrr. MED. J.
1681, 1682 (1995).

52. See id. at 1681-82; see also Fidler, supra note 5, at 807.
53. See INsTITUTE OF MED., supra note 5, at 49.
54. See Wilson, supra note 51, at 1682 (citing WoRLD BANK, WORLD DEVELOPMENT REPORT

(1993)).
55. See Fidler, supra note 5, at 807.

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INTERNATIONAL CONTROL OF CHOLERA

or reinfect traditional areas more frequently.56 Such concern does not go unfounded.
One theory proposed for the 1990 cholera outbreak in South America is that a
freighter discharged contaminated ballast water originating from China into
Peruvian coastal waters.”

Throughout history cholera has been associated with trade and travel and has
been credited for instigating the early development of health regulations to
minimize cholera epidemics in Europe.” ‘ As early as 1849, cholera was understood
to ‘Tollow major routes of commerce, [and] … always appear[] first at seaports.” ’59

The clear threat of the spread of infectious diseases associated with trade promoted
the convening of the first International Sanitary Conference in 1851.’ Other
international sanitary conferences followed during the nineteenth century marking
a significant development in establishing a regulatory regime that restricts the
spread of cholera and allows for trade. A primary objective of these conferences
was to reduce the burden on trade that excessive measures, such as quarantine
regulations, had created.6 Fear, and not science, had driven nations to adopt trade-
damaging, quarantine measures. The International Sanitary Convention of 1903
recognized the inappropriateness of quarantine measures that had historically been
used to fight the spread of infectious diseases. Article 11 of the 1903 Convention
held that “[n]o merchandise is capable by itself of transmitting plague or cholera.
It only becomes dangerous when contaminated by plague or cholera products.”62 As
science continued to reveal the nature of cholera, further steps to properly regulate
the disease were made. The International Sanitary Convention of 1926 reads that
“the importation of fresh fish, shellfish and vegetables may be prohibited unless
they have undergone a treatment calculated to destroy cholera vibrios.”’63

Additionally, the Sanitary Conference of 1903 marked the beginning of landmark
accomplishments in international disease control by initiating a surveillance system
based on a process for notification of disease outbreaks and by prohibiting party

56. See Harvard Working Group on New and Resurgent Diseases, New and Resurgent
Diseases, The Failure of Attempted Eradication, 25 ECOLOGIST 21, 24 (1995) [hereinafter
Harvard Working Group].

57. See id.
58. See DAviDP.FIDLE I 1TERNAnONALLAwANDIb* OUs DisESEs (forthcoming 1999)

(manuscript at 319, on file with author) (noting how trade serves as a contributing factor to
infectious disease spread); Wilson, supra note 51, at 1682.

59. Warren Windelstein, Jr., A New Perspective on John Snow’s Communicable Disease
Theory, 142 AM. .EPIDEMIoLOGY S3, S6 (Supp. 1995). Dr. John Snow was the physician to
Queen Victoria of England and has been given credit for stopping the second pandemic (1829 to
1851) in London and for proving its connection to drinking water that had been mixed with
sewage. See id. passim.

60. See N. Howard-Jones, OrIgwins ofInternationalHealth Work, 1 BRrr. MED. J. 1032, 1034
(1950).

61. See FIDLER, supra note 58 (manuscript at 319).
62. International Sanitary Convention, Dec. 3, 1903, art 11, 35 Stat. 1770, 1779, 1 Bevans

359, 365.
63. International Sanitary Convention, June 21, 1926, art. 17(b), 45 Stat. 2492, 2560, 2

Bevans 545, 559.

1999] 1043

INDIANA LAW JOURNAL

states to engage in excessive measures against a state that notified others of an
outbreak.

6 4

Despite the advances made by the International Sanitary Conferences and more
modem regulations, excessive regulatory measures of infectious diseases have been
and are still common.65 The ease of the spread of infectious diseases continues to
instill fear into public health officials, and with fear often comes excessive
measures of trade regulation that often have tremendous economic repercussions.
Such fear is genuine as evidenced by the 1991 cholera outbreak in Peru which
substantially impacted the Peruvian economy. Peru incurred an estimated loss in
trade of $12.9 billion (U.S.).66 As a result of reduced tourism, Peru suffered an
estimated $500 million in losses.6 Much of this damage can be attributed to trade
damaging public health measures imposed on Peruvian exports by other WHO
member states.6 For Peru, neither international law on infectious disease control
nor international trade law provided sufficient economic protection against the
actions taken by fellow WHO member states.69

The economic damage incurred by Peru demonstrates the gravity in developing
reasonable and disease-specific health regulations. Additionally, it demonstrates the
need to restrict the level of response states may take against a disease-afflicted
state. Regulations designed to control cholera need to be tailored to the
characteristics of cholera, and not to false, nonscientific conclusions. Necessary
regulation of an infectious disease is disease specific and depends on the scientific
understanding of that disease. Properly constructed regulations will allow for the
maximum amount of travel and trade while ensuring safety from the international
spread of cholera.

2. Flooding and Wet Weather

Environmental changes can be induced by human activity or purely as a result of
natural circumstances. Regardless of the source of change, cholera outbreaks may
result. Flooding and severe wet weather are environmental changes that have
repeatedly been blamed for cholera outbreaks. Flooding can cause contamination
of water systems and create favorable conditions for cholera. A January 1998 report
exclaimed that heavy flooding in the Democratic Republic of Congo exacerbated

64. See Fidler, supra note 5, at 834.
65. See, e.g., David Fidler, Cholera, Impact on Commercial Fishing-East Africa (04) (visited

Feb. 16,1999) ; see also
infra Part IV.D.

66. See Alan W. Randell et al,FAOActivities in Latin America and the Caribbean to Control
the Spread of Cholera, in CHOLERA ON THE AMRICAN CONTImNNTs, supra note 8, at 87, 96.

67. See Salazar-Lindo, supra note 46, at 25.
68. See Restrictions on xporsfrom Peru Following the Cholera Epidemic, GATT Doc. No.

C/M/248 (Mar. 12, 1991) (continuing an argument by a Peruvian representative that restriction
of Peruvian expoirs violated General Agreement on Tariffs and Trade (“GATT”) rules and WHO
recommendations); see also FIDLER, supra note 58 (manuscript at 358-59).

69. See FlLER, supra note 58 (manuscript at 335-36) (discussing that GATT, Article XX(b)
provides for a sovereign right for a state to adopt and enforce public health measures if such
measures are “necessary to protect human, animal, or plant life or health”).

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INTERNATIONAL CONTROL OF CHOLERA

a cholera outbreak claiming the lives of thousands of people.7″ Many of the victims
were children.7 For the last eight years in Zambia, cholera has resurfaced and
claimed many lives with every rainy season.72 In October of 1997, reports from
Zambia claimed that once again heavy rains had brought to its region flooding and
cholera.73

Not all flooding is a result of purely natural occurrences. In some ecological
situations, flooding is a direct result of human-induced changes to the environment.
Clear-cutting of timber in flood sensitive ecosystems can contribute to the
frequency and severity of flooding.74 Therefore, reduction of clear-cutting may
prevent flooding and may reduce the likelihood of associated cholera outbreaks.

As currently understood, El Nifto is a naturally occurring phenomenon that has
been associated with cholera outbreaks. Many countries in the Americas are
experiencing unexpected outbreaks of cholera associated with the extreme weather
conditions brought by the arrival of El Niflo. In fact, floods and storms attributed
to El Nifto have been proposed as the cause or at least as a contributing factor for
the 1997-98 resurgence of cholera in Peru.7″ During 1998, Bolivia, Hoiaduras,
Ecuador, and Nicaragua all reported cholera outbreaks associated with the effects
of El Nifto.76

3. Climate Change-Global Warming

The health ramifications of global warming may become one of the largest public
health challenges for the upcoming century.77 For instance, climatic factors may
directly influence the re-emergence of infectious diseases. Increases in water
surface temperatures and water levels are believed to have the capacity to lead to
higher incidents of water-borne infectious diseases such as cholera.7″ Climatologists
have identified upward trends in global temperatures.79 Over the past century ocean
surface temperatures have risen by an estimated 0.7 degrees Celsius, and now
climatologists expect a future temperature increase of 2.0 degrees Celsius by the
year 2100.80

70. See Floods Bring Cholera Death to Congo, ELECTRoNIc MAIL & GUARDIAN, Jan. 16,
1998 (reporting that 231 people died
from cholera and over 1235 had been struck with cholera since December 1997).

71. See id.
72. See Joseph Chanda, Wet Conditions, Cholera Alert!, AFmicANnws ONLiNE, TIMs OF

ZAMBIA, Oct. 30, 1997 .
73. See id.
74. See Zygmunt J.B. Plater, From the Beginning, A Fundamental Shift ofParadigms A

Theory and Short History ofEnvironmentalLaw, 27 Loy. L.A- L. Rav. 981,985 (1994).
75. See Cholera in Peru, supra note 48.
76. See World Health Org., Communicable Diseases Surveillance and Response (CSR),

Cholera in LatinAmerica andElNinoDirease Outbreaks Reported, 31 Mar. 1998 (visited Mar.
18,1999) .

77. See Jonathan A. Patz et al., Global Climate Change and EmergingInfectious Diseases,
275 JAMA, 217, 217 (1996).

78. See id.
79. See id. at 218.
80. See id. at 220.

1999] 1045

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Climate changes may have direct effects on the spread of infectious diseases.
Climate change will likely impact regional food supplies, human migration patterns,
and urbanization which may, in turn, alter human susceptibility to disease.
Susceptibility to cholera may be a repercussion of malnutrition caused by global-
warming-induced stress on agriculture.”‘ Susceptibility to cholera may also ensue
from stressed drinking-water resources and sanitation systems caused by mass
migration to cooler geographic areas.”

The WHO estimates that climate change could have a major impact on water
resources and sanitation. As the world’s population continues to grow, availability
of fresh water per capita is expected to decline substantially.8 3 This will decrease
the available drinking water, lower the efficiency of local sewerage systems, and
may lead to increased concentrations of cholera bacteria in raw water supplies.
Reduction in water supplies may necessitate the use of poorer quality water
sources.8 4 Ponds and wells, in addition to irrigation and drainage systems, may be
altered by climate change.8″ For instance, hydrological alterations induced by
climate changes of any of these systems may result in higher incidences of cholera
infections, such as water flow alterations. A climate-induced increase in cholera
resulting from a reduction or alteration in water supplies is most likely to occur in
developing countries that do not have adequate sanitation systems and drinking-
water supplies.

Climate change may alter the global distribution of cholera and may place new
populations at risk. For example, algae blooms, also called phytoplankton, grow in
aquatic environments and often harbor pathogens such as cholera. 6 They are
triggered by climatic events and are likely to increase in occurrence as a result of
global warming.8 7 Global warming can affect algae bloom growth in three distinct
ways: (1) algae bloom growth may be augmented by temperature increases in
nutrient-replete waters; (2) increased growth of pathogens in algae blooms may
result from temperature increases; and (3) the geographic range in which algae
blooms occur may expand as a result of temperature increases.8

Algae blooms can be affected by natural occurrences that are not so clearly
associated with global warming. For instance, in 1987 one species of toxic
phytoplankton previously confined to the Gulf of Mexico, traveled north up the East
Coast of the United States due to an influx of warm gulf stream water.8 9 This influx
of warmer ocean water temperatures may have been the result of El Nifio. El Nifto,
which is known to bring with it an influx of rain, nutrients from land, and warmer

81. See id. at 217.
82. See id. at 221.
83. See WORLD HEALTIH ORG., CLIMATE CHANGE AND HUMAN HEALTH 136 (A/J. McMichael

et al. eds., 1996).
84. See id. at96.
85. See id. at 97.
86. See Patz et al., supra note 77, at 220.
87. See id.
88. See id.
89. See id. (noting the spread of Gymnodinium breve up the East Coast).

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INTERNATIONAL CONTROL OF CHOLERA

sea surface temperatures, is considered to be another climatic event that evokes
growth of algae blooms.9″

Algae blooms can serve as reservoirs for cholera through two mechanisms.9 ‘ One
is by the association of cholera to zooplankton. Zooplankton are aquatic organisms
that reside in and feed on algae blooms, and they serve as vectors for cholera.92

Therefore, cholera should always be a consideration when algae blooms occur.
Dormant forms of Vibrio cholerae 01 not only have exhibited the capability of
prolonged survival, but also have been found to persist on the sheaths and
exoskeletons of marine organisms that are associated with algae blooms.93 Under
certain nutrient pH, and temperature conditions, cholera, in this dormant form, can
be triggered to cause a cholera epidemic.94 Thus, the spread of cholera may be
influenced fundamentally by incidents of algae blooms resulting from the discharge
of urban effluents consisting of high concentrations of pollutants. The relationship
between cholera and algae blooms truly exemplifies the connection between disease
and the environment and illustrates the significance of both human-induced and
natural disturbances of the coastal ecosystem to the transmission of cholera.

III. CuRRENT ATTEMPTS TO CONTROL THE CHOLERA
THREAT: INTERNATIONAL LAW AND CHOLERA

Multiple areas of international law and regulation have impacted the global
control of cholera. Some facets of international law recognized the need to address
‘cholera decades ago and took action, while others have developed more indirect
regulations of cholera epidemics and outbreaks. This Part will survey those areas
of international law that have either directly or indirectly impacted the control of
cholera including the International Health Regulations, various international
organizations’ activities, international environmental law, and international trade
law. Although all of these areas will be discussed, the greatest emphasis will be
given to international environmental law. General sources of international
environmental law will be explained followed by an evaluation of the applicability
of marine pollution and water pollution laws and regulations to cholera.

A. Multilateral Agreements: International Health
Regulations

International law is critical to the control of infectious diseases such as cholera.
International law enables states to come to reasonable agreements pertaining to
disease control, and subsequently to develop rules and guidelines to reflect these
agreements. To date, the WHO has served as the organization that has
predominately designed and administered cholera regulations and guidelines. Their

90. See Harvard Working Group, supra note 56, at 2027.
91. ee id.
92. See id.
93.See Anwarl Huq et al,Detection of Vibrio Cholerae 01 in the Aquatic Environment by

Fluorescent-Monoclonal Antibody and Culture Methods, 56 APPLIED ENvTL. 1fICROBIOLOGY
2370,2370-71 (1990).

94. See id. at 2371.

1999] 1047

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authority to do so is derived from Article 21 of the World Health Organization
Constitution. Article 21 provides the WHO with the authority to create regulations
to address “‘sanitary and quarantine requirements and other procedures designed
to prevent the international spread of disease.”‘ 95 Pursuant to this authority, the
World Health Assembly (“WHiA”) adopted the International Sanitary Regulations
in 1951, which were revised and renamed the International Health Regulations in
1969 and were later amended in 1973.96 The International Health Regulations
(“IHRs”) replaced what was a piecemeal set of treaties with a comprehensive set
of international public health rules designed to control diseases.97 Currently, the
IMRs are undergoing further revisions and will be presented for WHA approval by
the year 2000.”8

The IHRs have three important elements that deserve recognition. First, the IHIRs
are binding on all WHO member states.99 Second, the IHRs have the purpose to
achieve the greatest global protection against the spread of infectious disease, while
maintaining minimal interference with world trade and travel.”1 Finally, the IHRs
intend to both prevent the spread of infectious diseases from endemic areas and to
contain them upon arrival into noninfected areas.”‘ One method that the IHRs use
to achieve this last element is to address public health issues at ports of entry. 2

Article 14, which can be directly applied to cholera, requires airports and seaports
to maintain safe drinking water as well as proper methods for disposal of
excrement, refuse, and waste water.

1 0 3

The IHRs require a duty of notification for those diseases subject to its
regulations. 1 4 Currently, cholera is one of three diseases subject to the IHRs’9
surveillance requirements which mandate that a member state report incidences of
cholera to the WHO.’ Notification of cholera cases is also required if cholera is
transferred within a country to a noninfected area’ 0 6 Article 5 requires that for

95. Fidler, supra note 5, at 835 (quoting Constitution of the World Health Organization, July
22, 1946, art. 21, 62 Stat. 2679,2685, 14 U.N.T.S. 185, 192 [hereinafter WHO Const.]).

96. See P.. DELON, THE INERNATIONAL HEALTH REGULATIONS: APRAcTIcAL GUIDE 9 (1975)
(discussing the history of the International Health Regulations).

97. See WoRLD HEALTH ORG.,INTERNATIONALHEALTH REGULATIoNS (1969) art. 86, at 38-39
(3d ed. 1983) [hereinafter INT’L HEALTH Racs.] (listing treaties the IHRs replaced).

98. See World Health Org., Revision of the International Health Regulations: Progress
Report, July 1998,73 WKLY. EPIDEMIOLOGicALREC. 233,234 (1998).

99. See DELON, supra note 96, at 9 (citing INTERNATIONAL HEALTH REGULATION, Annexes
I & ff (2d ed. 1969)); see also WHO Const., supra note 95, art. 22, 62 Stat. at 2685, 14 U.N.T.S.
at 193. The member states can be exempted by submitting reservations to the IHRs or rejecting
the 1973 amendments. Notable member states that have submitted reservations include South
Africa, Australia, and Singapore. See DELON, supra note 96, at 9.

100. See DELON, supra note 96, at 10; see also INT’L HEALTH REGs., supra note 97, at 5
forward.

101. See DELON, supra note 96, at 10.
102. See id.; see also INT’L HEALTH REGS., supra note 97, arts. 14-22, at 15-18.
103. See INT’LHEALTHREGs., supra note 97, art. 14, at 15.
104. See id. arts. 2-5, at 10-11.
105. See id. art. 1, at 8 (identifying the diseases subject to the IMRs as cholera, plague, and

yellow fever); id. arts. 2-5, at 10-11.
106. See id. art. 3, at 11.

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INTERNATIONAL CONTROL OF CHOLERA

diseases in which notification is required, supplemental information about “the
source and type of the disease, the number of cases and deaths, the conditions
affecting the spread of the disease, and the prophylactic measures taken” must be
reported.” 7 Upon notification, the WHO then provides this information to the health
administrations of all member states.”‘

In addition to the surveillance and notification requirements, cholera is
specifically subject to other sections of the IHRs. °9 Article 62(1) requires that upon
discovery of a cholera case on any transportation carrier, the receiving member
state may isolate the infected individual for a time period not to exceed the cholera
incubation period of five days from the date of disembarkation or may choose to
apply surveillance.”‘ Article 63 imposes restrictions on the bacteriological
examination of foodstuffs carried as cargo.”‘ Additionally, the IRs restrict the
severity of measures that a member state can impose on a person infected with
cholera. In cases where cholera is suspected, Article 64(1) prohibits submitting any
person to rectal swabbing.”‘ Article 64(2) provides, however, that a person coming
from a cholera-infected area and who exhibits symptoms may be required to submit
to a stool examination.” 3

However, these IHRs that pertain specifically to cholera may enjoy a limited
remaining life-span. The WHA in 1995 directed the WHO to undertake the task of
revising the IHRs.” 4 The revision intends to move from a disease-specific reporting
system to a syndrome reporting system, which will affect how cholera is handled.’
Yet, the extent to which the revisions will alter the method of handling cholera
remains to be seen.

B. International Organizations’Activities

1. World Health Organization

In addition to administering the MlRs, the WHO Global Task Force on Cholera
Control developed guidelines for cholera control.” 6 The guidelines emphasize the
prevention of cholera, being prepared for a cholera outbreak, early response to an

107. Id. art. 5, at 11.
108. See id art 11, at 14. “Notification… by means of the Weekly Epidemiological Record

and the automatic telex service discharges [the WHO’s] responsibilities for notification under
Articles 11 (first sentence),” 20-22, and 85. Id. art. 11, at 14 note a (parenthetical in original).

109. See id. arts. 50-75, at 26-33 (illustrating that the IHRs have specific provisions for plague,
cholera, and yellow fever).

110. See id. art. 62(1), at 30.
111.Seeid. art. 63, at 30.
112. See id. art. 64(1), at 30.
113. See id. art. 64(2), at 30.
114. See Revision and Updating of the International Health Regulations, WHA Res. 48.7,

48th World HealthAssembly, 12th Plenary Mtg., WHO Doc. WHA/48/1995/REC/1 (1995).
115. See id.
116. See World Health Org., Guidelines for Cholera Control (visited Feb. 17, 1999)

[hereinafter Guidelines for Cholera
Control].

1999] 1049

0INDIANA LAW JOURNAL

outbreak threat, and preventing the spread of an outbreak. 7 According to the
WHO, cholera can be prevented by ensuring safe water supplies, promoting
environmental sanitation, and promoting food safety.”‘

To discourage use of ineffective methods of cholera control, the WHO guidelines
acknowledge that chemoprophylaxis, vaccination, and travel and trade restrictions
are incapable of regulating the spread of cholera and should not be heavily relied
upon. Chemoprophylaxis (an antibiotic treatment of an entire community) fails to
control the spread of cholera because of the time delay in distribution of the drug,
possible reinfection after the drug treatment has been completed, and difficulties in
achieving community cooperation to take the drug.” 9 Vaccinations not only are
ineffective in some persons who are vaccinated, but also frequently lack the
necessary potency to be effective. 2 Additionally, cholera vaccinations provide only
three to six months of protection and do not reduce the incidence of asymptomatic
infections or prevent the spread of an infection.’ Finally, as discussed previously,
the WHO recognizes that travel and trade restrictions are ineffective.’ 22

To prevent the spread of cholera the WHO guidelines advise health education,
proper disposal of dead bodies, and disinfection.’ Outbreaks can be more
effectively controlled if people are educated as to how cholera spreads and how to
recognize unsafe conditions. Key points that the WHO emphasizes for public
education include: (1) only drink water from a safe source or water that has been
properly disinfected by boiling or chlorination; (2) completely cook food or reheat
it and eat food while it is still hot; (3) unless foods can be peeled or shelled, avoid
uncooked foods; (4) wash hands after contact with fecal matter and before
preparing and eating food; and (5) promptly and safely dispose of human excreta. 4

Also, the WHO guidelines strongly emphasize disinfection and use of adequate
sanitation. Incineration is the suggested method of disposal for semisolid wastes,
and disinfectants such as cresol or lysol should be used to clean areas of concern
such as toilets.’ 2′ For victims who have died from cholera, the WHO recommends
that funerals be “held quickly and near the place of death” and with minimal
physical contact with the body.’26

In addition to developing disease specific guidelines, the WHO has revised its
Guidelines for Drinking-Water Quality which can be directly applied to cholera
control. 27 The content of these guidelines illustrates an increasing awareness that

117. Seeid.
118. See id. §§ 3.1-.3.
119. Seeid. § 7.3.1.
120. See id. § 7.3.2.
121. See id.
122. See id. § 7.3.3.
123. See id. §§ 7.1-7.2.
124. See id. § 7.1, box 10.
125. See id. § 7.2.
126. Id. The WHO suggests, for victims of cholera, limiting ritual washing of the dead or

funeral feasts in order to minimize contributing to the spread of an epidemic. See id.
127. See World Health Org., Specific Programmes in Environmental Health, Drinking- Water

Qualitv Guidelines (visited Feb. 11,1999) . Volumes one and two of the WHO GuidelinesforDrinking- Water Quality

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INTERNATIONAL CONTROL OF CHOLERA

environmental protection, once put into regulations, can be an effective approach
to disease prevention. For instance, volume two, section 11.1.2, which discusses
source protection of drinking water, is applicable to the preventative control of
cholera. Section 11.1.2 states that to protect drinking-water sources: (1)
geographical areas should be determined where sewage and sludge may not be
applied, and (2) discharge of sewage effluents should be strictly controlled.’28

Additionally, section 11.1.2 emphasizes the protection of sources of groundwater,
such as springs and wells; they should always be located and constructed in a
manner which will protect them from surface drainage and flooding. 9

2. Pan American Health Organization

The Pan American Health Organization (“PAHO”) is an international public
health agency that serves as the specialized organization for the health of the Inter-
American System. 3 The PAHO promotes health care strategies by assisting
countries in preventing the spread of infectious disease epidemics, promoting
information exchange and technical cooperation including education, promoting
interaction with non-governmental organizations for health care purposes, and
lending financial assistance for programs to prevent AIDS transmission.”‘

One of the highest priorities of the PAHO is protecting food against disease
contamination. At the Seventh Inter-American Meeting, PAHO created a food
protection plan, approved by authorities of the PAHO participating countries, that
had five objectives: (1) establish an organization of integrated national food
protection programs; (2) improve quality of laboratory work; (3) improve site
inspection methods; (4) create an institution that will serve as an epidemiological
surveillance system specifically for food-borne illnesses; and (5) promote
protection of food by utilizing community participation.’ In response to the 1991
cholera epidemic that afflicted the Americas, the PAHO not only established a
cholera task force, but also developed a two-step tactical strategy that consisted of

are currently available, and volume three is expected to be published this year. Volume one
describes the criteria used in selecting contaminants to be considered, the approaches used to derive
the guideline values, and essential information required to understand the basis for each value. See
id. Volume two elaborates greatly on the health risk assessments of microbial contaminants
presented in volume one. See id. Volume three is intended to serve a different purpose than
volumes one and two; it contains recommendations and information concerning the surveillance
and control of drinking water for small communities, particularly in rural areas of developing
countries, and regarding measures to safeguard their water supplies. See id.

128. See 2 WoRLDHEALTHORG., GUiDELnS FORDRNKTNG-WATERQUALITY §11.1.2, at 108
(2d ed. 1996).

129. See id.
130. See PanAm. Health Org.,AboutPAHO (last modified Jan. 15,1997)

.org/english/whatpaho.htm>.
131. See id.
132. See Claudio Almeida, Prospects for Technical Cooperation of the Pan American Health

Organization in Food Protection in View of the Cholera Epidemic on the American Continents,
in CHOLERA ON THBAiMmcAN CoNTrmNmrs, supra note 8, at 61, 62.

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short-term efforts and long-term efforts. 33 The short-term efforts concentrated on
controlling the epidemic through basic measures for food hygiene and sanitation,
whereas the long-term efforts focused on developing and improving environmental
sanitation and food protection infrastructures.’

3. Panel of Experts on Environmental Management for
Vector Control

In 1981, the Panel of Experts on Environmental Management for Vector Control
(“PEEM”) was created by the joint effort of the WHO, the Food Agricultural
Organization (“FAO”), the United Nations Environmental Programme (“UNEP”),
and the United Nations Centre for Human Settlements (“UNCHS”). The function
of PEEM is “to create a framework for inter-agency and inter-institutional
collaboration [in order to] promot[e] the.. . use of environmental management for
disease vector control as a health safeguard in the context of land and water
resources development projects.”‘135 Pursuant to its initial establishment, PEEM
expanded its focus also to incorporate “human settlements, urbanization and urban
environmental management including urban water supply, sanitation, drainage and
solid waste disposal.”‘ 36

The significance of the formation of PEEM to cholera is twofold. First, it
represents a growing understanding in the international public health arena that
disease control must be achieved by taking proactive measures. This organization
emphasizes the importance of controlling the vector, the element that carries the
disease and promotes its proliferation, to prevent disease, instead of simply reacting
to an outbreak. Hence, they utilize preventative health policy by focusing on the
vectors of disease. The value of preventative health policy is critical to the control
of cholera. Prevention equals elimination of disease spread. Second, PEEM’s
policies that promote the extensive use of environmental management for disease
control are a powerful means to get public health officials to recognize the critical
link between environmental protection and human health.

PEEM’s program activities include promotion, research and development, and
capacity building. As a promotion effort, PEEM has organized several seminars in
Kenya, Benin, and Zambia on water resources development and vector-borne
diseases. One example of PEEM’s capacity-building efforts is the series of
workshops conducted by PEEM on the promotion of environmental management
for disease vector control.’37

133. See id.
134. See id.
135. World Health Org.,EnvironmentalManagementfor Vector Control and Health in Water

Resources Development (visited Mar. 19, 1999) .

136. Id.
137. See id.

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INTERNATIONAL CONTROL OF CHOLERA

C. International Environmental Law

Perhaps one of the most useful, and most overlooked, areas of international law
applicable to infectious diseases is international environmental law. The lack of
prior investigation into its application to cholera mandates the need for a detailed
examination of the sources of international environmental law and how those
sources can be applied to the control of cholera.

1. Sources of International Environmental
Law

International environmental law has evolved rapidly since the end of the 1960s,
emerging as a new and dynamic addition to the international law regime.’
Identified sources of international environmental law include: (1) international
conventions concerning environmental protection; (2) customary international law;
(3) judicial decisions; (4) non-binding resolutions adopted by international
organizations; and (5) non-binding declarations of principles as well as
recommendations by international conferences.’ 39

The first source of international environmental law is that of conventions
combined with the international mechanisms for implementing them. 4 ‘ Treaties are
an effective means of protecting the environment because they can be tailored to
address specific environmental concerns of individual geographic areas. 4 ‘
Additionally, it is a fundamental obligation of international law that treaties are
observed and their obligations are performed in good faith.’42 Under such an
obligation, states which are party to a treaty are likely to supervise implementation
of treaty provisions by other party states. Another beneficial characteristic of
treaties is that they often require state parties to undertake precise obligations or
refrain from specific conduct.’43 One example is the reporting of environmentally
damaging incidents to a particular international organization which is intended to
fulfill a supervisory role. Treaties, with or without the incorporation of supervisory
international organizations, can be viewed as one mechanism to promote
cooperation among states.’44

International environmental law founded in customary law is extremely useful
because the vertical hierarchy of international environmental law is unclear and
incomplete. In contrast to treaties, international customary law is largely a

138. SeeALEXANDREKISs & DnAH SHELTON, INTERNATIONAL ENVIRONMENTAL LAW 33,36-
37(1991).

139. See id. at 96-113.
140. See id. at 98; see also Lakshman Guruswamy, International Environmental Law:

Boundaries, Landmarks, and Realities, NAT. RESOURCES & ENV’T, Fall 1995, at 43,43-44.
141. See Kiss & SHELTON, supra note 138, at 96-97.
142. See Vienna Convention on the Law of Treaties, openedfor signature May 23, 1969, art.

26,1155 U.N.T.S. 331,339,8 I.LM. 679, 690.
143. See Kiss & SHELTON, supra note 138, at 98.
144. See id. at 99-100.

1999] 1053

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consequence of uniformities of behavior among states rather than the result of a
formal written agreement.1 4 ‘ Hence, customary law requires common recognition
among states that a certain practice is obligatory.’46 Customary law must be factual
and definable. Generally, for a rule or principle to emerge as customary law, the
following basic requirements must be fulfilled: (1) concordant practice by multiple
states; (2) general consent in the practice by states; and (3) opiniojuris-that the
custom is understood to be law.’

4 7

Given the requirements to establish customary law, perhaps it is surprising to
suggest that customary’international law has a role in an area of law as new as
international environmental law. However, international environmental law has
evolved rapidly, and with that development is the possibility to have rapid
development of customary laws pertaining to the environment. For instance, it is
feasible to discern from current norms “evidence of a general practice, accepted as
law,” even if only a short period of time has passed in which this practice has
arisen.

148

International customary law can be incorporated into treaties as tools for
protecting the environment. For example, the Conference-on the Law of the Sea
which met between 1973 and 1982 adopted a treaty in which a consensus on several
new norms arose even before the treaty was adopted. 49 One of these norms, later
codified in Part V of the Convention, recognized the exclusive economic zones in
which the sovereign rights of the coastal states to conserve and manage natural
resources and the marine environment are to be maintained.’

Judicial decisions of the International Court of Justice must not be overlooked.
Cases such as Trail Smelter,”‘5 Corfu Channel,”12 and Lake Lanoux”‘. have made
significant contributions to the development of international environmental law.
Trail Smelter has often been considered as having established the foundations of
international environmental law with regards to transfrontier pollution.” 4 Inclusive
in the definition of transfrontier pollution is water pollution that affects a shared

145. See id. at 78.
146. See id. at 106.
147. See id. See generally KARoL WOLFKE, CUSTOM IN PRESENT INTERNATIONAL LAW 9-44 (2d

ed. 1993) (outlining the scope and terminology of international law, and exploring the elements
of international custom as defined by various international legal authorities).

148. Kiss & SHELTON, supra note 138, at 105.
149. See id.
150. See United Nations Convention on the Law of the Sea, opened for signature Dec. 10,

1982, art. 192, 21 I.L.M. 1261, 1309 [hereinafter UNCLOS].
151. Trail Smelter Arbitration (U.S. v. Can.), 3 R.I.A.A. 1905 (Temp. Trib., Decision of Mar.

11, 1941).
152. Corfu Channel (U.K. v. Alb.), 1949 I.C.J. 4 (April 9).
153. Affaire du lac Lanoux [Lake Lanoux Arbitration] (Spain v. Fr.), 12 R.IA.-A 281 (Trib.

Arbitral Nov. 16, 1957).
154. See Kiss & SHELTON, supra note 138, at 107. Trail Smelter was the first case of

transboundary pollution. See id. at 103. The court in Trail Smelter recognized the responsibility
of a state for acts of pollution that originated within it and that cause damage to other states. Trail
SmelterArbitration, 3 R.I.A.A. at 1938-80.

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international watercourse.’ The foundations laid by Trail Smelter were confirmed
by a more general principle enunciated in Corfu Channel followed by the Lake
Lanoux arbitration which then further re-enforced them in the context of
transfrontier water pollution.’56

Finally, the last source of international environmental law that will be addressed
is the role of non-binding resolutions adopted by international organizations, such
as the WHO, and the recommendations and declarations of principles of
conferences such as the Stockholm Declaration of the United Nations Conference
on the Human Environment.”5 7 These non-binding sources of regulation are
extremely valuable to international environmental law because they are often the
product of policy experts and scientists who truly understand the needs that must
be met in order to protect the environment. Non-binding resolutions and
recommendations can serve as the forerunners to treaty law,’ and they can be
adopted into treaties by participating states.

2. Marine and Water Pollution

International environmental law that pertains to marine and water pollution is
critical in the evaluation of the international control of cholera. Marine pollution is
predominately derived from land-based sources of pollution such as sewage, and
industrial and agricultural runoff. Land-based sources of pollution that contaminate
marine environments can contribute to the spread of infectious diseases such as
cholera, yet they are not the sole source of infectious disease spread.

The vital importance of the world’s freshwater resources cannot be
underestimated. Three percent of the earth’s total water is fresh water and seventy-
seven percent of this fresh water is trapped in the polar ice cap and glaciers. 59 The
world’s supply of freshwater is unevenly distributed, often unreliable, and faces
increasing and serious environmental stress. Furthermore, it is important to realize
that a substantial number of these freshwater resources are also considered to be
shared resources. Approximately 214 river basins across the world are shared by

155. See Kiss & SHELTON, supra note 138, at 116-18.
156. See id at 107-08. The Iansboundary pollution principle set out in Corfu Channel was that

every state has an obligation to not knowingly allow its territory to be used contrary to the rights
of others. 1949 LCJ. at 45. Lake Lanoux set forth the principle that if one country, such as France,
polluted a water source which it shared with another country (in this case Spain), damaging the
second country’s interests, the damaged country can claim that its rights have been impaired by
the polluting country’s actions. Lake LanouxArbitration, 12 RLA.A. at 303.

157. See Kiss & S-mLTON, supra note 138, at 110-13; Report of the United Nations
Conference on the Human Environment Stockholm, U.N. Doe. A/CONF.48/14/Rev. I passim
(1972) [hereinafter Stockholm Declaration].

158. See generaly Peter II Sand Lessons Learned in Global Environmental Governance, 18
B.C. ENvTL. AIr. L. Rv. 213,239-41 (1991) (discussing the development of “soft laws” and
manner in which such laws evolve into treaties).

159. See The State of the World Environment, U.N. Env’t Programme, at 27, U.N. Doe.
UNEP/GC.16/9 (1991).

1999] 1055

INDIANA LAW JOURNAL

two or more states. 6 Additionally, in at least fifty states, more than seventy-five
percent of their land is within a shared river basin region, and it is estimated that
thirty-five to forty percent of the world’s population lives in these shared river basin
regions.

16 1

Treaties that protect inland and marine waters are critical to the control of
cholera. Although deserving of significant attention, land-based sources of marine
pollution have not been given priority in the development of environmental laws to
protect the marine environment. Nevertheless, some law does exist. The 1982
United Nations Convention on the Law of the Sea (“UNCLOS”) has refined its
marine protection and preservation requirements. Under the Convention, states
have the general “obligation to protect and preserve the marine environment.”””
This general obligation may be viewed as inhibiting states from exercising their
sovereign rights. However, it does not. Rather, the UNCLOS obligation dictates
that state sovereign rights may only be exercised within the context of protecting
and preserving the marine environment. The Convention grants states varying
degrees of competence to prescribe and apply laws to “prevent, reduce, and control
pollution of the marine environment” from different sources.” Among these
sources of marine pollution are pollution from land-based resources’ and pollution
from dumping.’ The consequence of this state proscribed discretion is that land-
based marine pollution does not typically enjoy the same level of pollution
prevention standards as other forms of marine pollution. Furthermore, criticism of
the UNCLOS provisions suggests that they fail to “force coastal States to adopt
international standards or standards at least as effective as international
standards.”‘ 66 The UNCLOS also obligates states to undertake cooperative
measures, including notification, consultation, information exchange, and technical
assistance.

6 7

In addition to the UNCLOS, regional treaties exist that pertain to land-based
marine pollution. Many of these regional treaties developed under the direction of
the UNEP do not go beyond the scope of the UNCLOS.’ For instance, Article 7
of the Convention on Co-operation in the Protection and Development of the
Marine and Coastal Environment of West and Central African Region states that
parties “shall take all appropriate measures to prevent, reduce, combat and control
pollution of the Convention area caused by discharges from rivers, estuaries, coastal
establishments and outfalls, coastal dumping or emanating from any other source

160. See id. at 29.
161. See id.
162. UNCLOS, supra note 150, art. 192, at 1309.
163.Id. art. 104, at 1308.
164. See id. arts. 207,213, at 1310-11.
165. See id. arts. 213, 216, at 1310, 1312.
166. FIDLRsupra note 58 (manuscript at 746) (describing how Arficle 208(3) (pollution from

sea-bed aclivities), Article 210(6) (dumping), and Article 211(2) (pollution for vessels) have higher
pollution standards than that of land-based marine pollution).

167. See UNCLOS, supra note 150, arts. 197-203, at 1308-09.
168. See FIDLER, supra note 58 (manuscript at 746).

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INTERNATIONAL CONTROL OF CHOLERA

on their territories.” 69 In addition to regional treaties developed by UNEP efforts,
there are several treaties which protect the marine environment such as the 1974
Convention for the Prevention of Marine Pollution for Land-Based Sources, and the
1974 Convention on the Protection of the Marine Environment of the Baltic Sea.1

7
1

Protection of inland waters by international environmental law has not proven
sufficient Apart from specific treaty regimes, there is little support for the view that
water pollution resulting from industrial effluents, agricultural runoff, or domestic
sewage discharge is per se prohibited.17 1 “[E]vidence of state practice [to protect
waters often] is inconsistent [and] few… treaties endorse an absolute prohibition
on detrimental alteration of water quality. , 17′ Rather, what appears to be the trend
in treaties is the requirement of states to regulate and control water pollution by
prohibiting only certain forms of pollutant discharge.7 Furthermore, conventions
concerning the protection of rivers are often limited to specific regions and do not
encompass entire river basins.”7 To illustrate, conventional international provisions
provide limited protection of the Rhine River because they encompass only a region
from the river’s mouth to its exit from Lake Constance. ‘ The segment of the river
above Lake Constance is protected by another treaty. 76 Additionally, individual
treaties define the waterway to be protected differently, thus resulting in an extreme

169. Convention on Co-operation in the Protection and Development of the Marine and Coastal
Environment ofWest and Central African Region, openedfor signature Mar. 23, 1981, art. 7, 20
I.L.M. 746, 749; see also Convention for the Protection of the Natural Resources and
Environment ofthe South Pacific Region, openedfor signature Nov. 25, 1986, art 7, S. TREATY
Doc. No. 101-21, at 10 (1990), 26 LL.M. 38, 45-46; Kuwait Regional Convention for Co-
operation on the Protection of the Marine Environment from Pollution, openedfor signature Apr.
24, 1978, art VI, 1140 U.N.T.S. 133,157; Convention for the Protection of the Mediterranean
SeaAgainst Pollution, openedfor signature Feb. 16,1976, art 8,1102 U.N.T.S. 27,41.

170. Convention forthe Prevention of Marine Pollution from Land-Based Sources, opened for
signatur June 4,1974,13 IL.M 352; Convention on the Protection of the Marine Environment
of the Baltic Sea Area, openedfor signature Mar. 22,1974, 13 I.L.M. 546.

171. See PAnRCIAW. BNIB &ALANE. BYLE, INToRNATioNAL LAAND m ENIRoNMENT
224 (1992).

172. Id at 224-25. Treaties that do absolutely prohibit pollution include: Agreement Concerning
Frontier Watercourses, Apr. 24, 1964, Fin.-U.S.S.R., art. 4, 537 U.N.T.S. 231, 254; Treaty
Concerning the Regime of the Soviet-Polish State Frontier and Co-operation and Mutual
Assistance in Frontier Matters, Feb. 15, 1961, U.S.S.R.-Pol., art. 19, 42 U.N.T.S. 161, 256
[hereinafter Soviet-Polish Frontier Treaty]; Agreement Concerning the Regime of the Soviet-
Czechoslovakia Frontier and the Procedure for the Settlement of Frontier Incidents, Nov. 30, 1956,
U.S.S.R.-Czech., art. 14, 266 U.N.T.S. 243, 312 [hereinafter Soviet-Czechoslovakia Frontier
Agreement]. See also Act of Santiago Covering Hydrologic Basins, June 26,1971, Arg.-Chile, 3
CHLT. 818 (Chile).

173. See BimI & BOYLE, supra note 171, at 225. In determining certain forms of prohibited
pollutant discharge, states are also required to distinguish between new and existing pollution
sources. See id.

174. See KIss & SHELToN, supra note 138, at 203.
175. See id.
176. See id.

1999] 1057

INDIANA LAW JOURNAL

variance of protective legal force. Some treaties refer to watercourses,’ 77 others to
water systems,’78 and still others to frontier waters.’ Variances in defining
waterways can lead to inconsistent and inadequate protection against pollution.

Legislation passed by the European Community (“EC”) is arguably the most
developed international protection against water pollution. The EC has
implemented numerous directives aimed at protecting human health by establishing
water quality standards for a variety of sources and uses. The directives tend to be
technical in nature and set standards for human consumption,'”0 bathing,’ and
fishing.12

At the forefront of international customary law applied to water resources is the
duty not to cause appreciable or significant harm. 83 It prescribes that no state may
use its territory or allow the use of its territory in a way that causes serious damage
to another state.’84 This principle further mandates that states make conscious
efforts to avoid transboundary pollution which can be applied to both water quantity
and quality.

185

The obligation not to cause significant harm to other states by transboundary
water pollution is complicated by the customary law principle of equitable
utilization. The duty of equitable and reasonable utilization is another widely
recognized rule of international customary law that applies to transboundary water

177. See U.N. Convention on the Protection and Use of Transboundary Watercourses and
International Lakes, Mar. 17,1992,31 I.L.M. 1312.

178. See, e.g., Agreement Between the Government of the Federal People’s Republic of
Yugoslavia and the Government of the Hungarian People’s Republic Together with the Statute
ofthe Yugoslav-Hungarian Water Economy Commission, Aug. 8, 1955, Yugo.-Hung., in UNrrED
NATIONS LEOISLATiv SERis: LEGISLATInvE TEXTs AND TREATY PROVISiONS CONCERNING THE

UTLIZATION OF NERNATIONAL XvEFORPRPosEs OTHER THAN NAVIGATION 830, U.N. Doe.
STJLEG/SER.B/12, U.N. Sales No. 63.v.4 (1963).

179. See, e.g., Agreement Concerning the Use of Water Resources in Frontier Waters (with
annex), Mar. 21,1958, Czech.-Pol., 538 U.N.T.S. 89.

180. See Council Directive 75/440,1975 O.. (L 194) 26 (concerning the quality required of
surface waters intended for abstraction of drinking water); Council Directive 79/869, 1979 O.J.
(L 217) 44 (relating to the methods of measurement and frequency of sampling and analyzing of
surfacewaters to be used for drinking); Council Directive 80/778, 1980 OJ. (L 299) 11 (relating
to the quality of water intended for human consumption).

181. See Council Directive 76/160, 1976 O.3. (L 31) 1 (concerning the quality of bathing
waters).

182. See CouncilDirective 78/659, 1978 O.J. (L 222) 1 (concerning the quality of fresh water
needing protection or improvement in order to support fish life); Council Directive 79/923, 1979
0.3. (L 281) 47 (relating to the quality required of shellfish waters).

183. See ANDnNoL AEmPETHELEGALREGmEFOR TRp sBOUNDARY WATER PoLLUTIoN:
BENDscDsB ONANDCoNT , RNT30-31 (1993) (stating that the duty to prevent significant
transboundaty harm is a well-established principle of customary law as evident by its reflection in
international agreements such as Principle 21 of the Stockholm Declaration and Part V of
UNCLOS).

184. See Dante A. Caponera, The Role of Customary International Water Law, in WATER.
RESOuRCES POLICY FoRAsiA 365,380-81 (Mohammed Ali et al. eds., 1987).

185. See id.

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INTERNATIONAL CONTROL OF CHOLERA

pollution.s It is founded on the ideal of an equality of rights, or shared sovereignty,
and should not be confused with equal division.”8 7 Additionally, the principle of
equitable utilization purports that each state is entitled, within its territory, to a
“reasonable and equitable share in the beneficial uses of the waters” of a shared
river, lake, or basin. 8 ‘ Thus, under the principle of equitable utilization, a state
rightfully may use its waters for discharge, but in doing so a state may not deprive
another state of its right to an equitable share of water which it intends to utilize for
its own purposes.”s The challenge lies within striking the perfect balance between
equitable utilization and a duty not to harm.

A duty not to cause environmental harm to other states was also recognized by
the international judiciary system. The Trail Smelter case left a long-lasting impact
on international environmental law applicable to water pollution. 9 ‘ Two key
principles were established under Trail Smelter. The first is the recognized
“responsibility of a state for acts of pollution having their origin on its territory and
causing damage on the territory of other states.”” The significance of this principle
is profound in that now a state may be held responsible for failing to enact
necessary legislation and for not enforcing its environmental laws against offenders
within its jurisdiction.’92 The second principle to arise from Trail Smelter is the
recognition of international responsibility to solve environmental problems. 93 The
Trail Smelter judgment affirmed the existence of an international environmental law
forbidding transboundary pollution. Lake Lanoux Arbitration’94 later reaffirmed
those same principles established by Trail Smelter holding that a state is prohibited
against utilizing a sovereign right pertaining to international waterways that will be
detrimental to another state. 195

Finally, many significant non-binding declarations and principles have evolved
since the 1972 Stockholm Declaration on the Human Environment. The Stockholm
Declaration does not specify types of protective measures of freshwater sources
from pollution. Nevertheless, pollution protection of water sources can fall within
Principle 6 of the Stockholm Declaration. Principle 6 calls for ceasing “[t]he
discharge of toxic substances or of other substances and the release of heat, in such
quantities or concentrations as to exceed the capacity of the environment to render

186. See NOLLKAEMPER, supra note 183, at 61.
187. See BIRNIE & BoYLE, supra note 171, at 217,220.
188. Helsinki Rules on the Uses ofthe Waters of International Rivers, art. IV (without cmts. and

annex), Aug. 20, 1966, 52 I.L.A. 477,486 [hereinafter Helsinki Rules].
189. See L.F.E. Goldie, Equity and the International Management of Transboundary

Resources, 25 NAT. R.EsotRces J. 665, 676, 680-83 (1985).
190. Trail Smelter Arbitration (U.S. v. Can.), 3 RLA.A. 1905 (Temp. Trib., Decision of Mar.

11, 1941).
191. Kiss & SHELTON, supra note 138, at 125; see also TrailSmelterArbitration, 3 RIA.A.

at 1965.
192. See Kiss & SHELTON, supra note 138, at 125
193. See id.
194. Affaire du lac Lanoux [Lake Lanoux Arbitration] (Spain v. Fr.), 12 RIA. 281 (Trib.

Arbitral Nov. 16, 1957).
195. See Kiss & SHELTON, supra note 138, at 125-26; see also Lake LanouxArbitration, 12

RLA.A. at 316.

1999] 1059

INDIANA LAW JOURNAL

them harmless.”‘ 96 A principle that applies particularly to water sources is found
in Article IV of the Helinski Rules which establishes the principle that each state
within an international drainage basin has the right to a reasonable and equitable
part of the beneficial use of the basin waters.” 7 Additionally, Article X adds that,
in conforming to the principle of equitable utilizafion under Article IV, each state
should refrain from introducing new pollutants into international drainage basin
waters or increasing levels of pollution that are likely to cause serious damage to
the territory of another state in the drainage basin.’98

3. International Environmental Law and Cholera

If applied to the global control of infectious diseases, international environmental
law could serve as an effective regulatory regime to aid in the control of cholera.
International environmental law pertains directly to the health of the environment
and not directly to the prevention of the spread of infectious diseases. However,
common sense and experience indicate that human health is dependent on the health
of the environment. Cholera and contaminated drinking water are clearly linked.
Therefore, cholera and the quality of the aquatic environment are clearly linked.
Utilizing international environmental law to protect the health of the environment
can, in turn, protect the health of humans and prevent cholera outbreaks.

Rules and duties embodied in treaties are perhaps the greatest tools for the
environmental control of infectious diseases. Treaties can specifically address the
protection of water sources from sewage discharge and land-based pollution runoff
that typically lead to environmental conditions conducive to cholera outbreaks. By
establishing these environmental standards for shared water sources, treaties may
also have the beneficial effect of motivating states to apply similar protective
standards to internal or local water sources. Such a spillover effect would aid in
preventing cholera outbreaks. More directly, treaties can specifically set forth
environmental standards to protect against cholera. Treaties not only can set
standards, but also can require information exchange to ensure that each state that
is a party to the treaty has adequate technical knowledge to protect its water sources
from cholera contamination. Furthermore, provisions can be incorporated into
treaties that require states to cooperate in the prevention of cholera and once an
outbreak occurs.

A few treaties already contain environmental provisions applicable to the control
of cholera. One example is the UNCLOS which obligates states “to protect and
preserve the marine environment” and “to prevent, reduce and control pollution of
the marine environment”’99 from different sources which include pollution from
land-based resources 00 as well as pollution from dumping. 2 0′ Additionally, the

196. Stockholm Declaration, supra note 157, at 4.
197. Helsinki Rules, supra note 188, art. IV, at 486.
198. See id. art. X, at 496-97.
199. UNCLOS, supra note 150, arts. 192, 194(1), at 1308.
200. See id. arts. 207,213, at 1310, 1311.
201. See id. arts. 210,216, at 1310, 1312.

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INTERNATIONAL CONTROL OF CHOLERA

UNCLOS obligates states to undertake cooperative measures, including
notification, consultation, information exchange, and technical assistance

°. 2 ” The
UNCLOS can be interpreted as an indirect means to prevent cholera because the
primary objective of the treaty is to protect marine water quality. Inclusive in the
obligation to prevent and control pollution of the marine environment is the
requirement not to discharge sewage and other land-based pollutants that carry
cholera.

Other regional treaties and conventions exhibit similar pollution prohibitions as
found in the UNCLOS and similarly can be applied to cholera. Some examples
include the 1974 Convention for the Prevention of Marine Pollution from Land-
Based Sources, and the 1974 Convention on the Protection of the Marine
Environment of the Baltic Sea.2 3 Both of these conventions contain provisions that
protect marine waters from land-based pollution. Again, cholera can be indirectly
controlled under these conventions by protecting against water pollution which may
give rise to cholera outbreaks.

Protection of inland waters by international environmental law is less common
than treaties to protect the marine environment. This is a significant drawback in
looking for means to control cholera via international environmental law treaties
because most cholera outbreaks occur from contaminated freshwater systems.
Nevertheless, some do exist and should be used as general examples of how to
protect inland water sources from infectious disease contamination. The EC has
implemented numerous directives that establish water quality standards for various
sources and uses, all of which are aimed at protecting human health. The EC
directives set standards for human consumption, bathing, and fishing. 4 By
establishing specific criteria for water quality, the EC has addressed the issue of the
spread of water-borne infectious diseases, and has significantly reduced the
-likelihood of a cholera outbreak through legal measures. Effectively, what the EC
has done is to establish a legal regime that protects against cholera by protecting
the environment. Although the EC as a whole can be considered a unique
international structure unlike any other in the world, specific EC directives can,
nonetheless, be used as general law-making models to ensure adequate, global
protection against cholera by other states.

202. Id arts. 197-201, at 1308-09.
203. Convention for the Prevention of Marine Pollution from Land-Based Sources, supra note

170, at 353. Article I of the convention states that parties
pledge the nselves to take all possible steps to prevent pollution of the sea, by which
is meant the introduction by man, directly or indirectly, of substances or energy into
the marine environment … resulting in such deleterious effects as hazards to human
heath, harm to living resources and to marine eco-systems.

Id; Convention on the Protection of the Marine Environment of the Baltic Sea Area, supra note
170, at 547 (stating in Article 3 that the parties “shall individually or jointly take all appropriate
legislative, administrative or other relevant measures in order to prevent and abate pollution and
to protect and enhance the marine environment of the Baltic Sea Area”).

204. See supra notes 180-82.

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International customary law can serve as a legal construct to control cholera. The
customary duty not to cause “appreciable or significant harm”” 5 to transboundary
water resources can be interpreted as a duty to protect waters from cholera
contamination. Embodied in this duty is the obligation that states make reasonable
efforts to avoid transboundary pollution affecting both water quantity and quality.
Customary law does not concisely define “appreciable or significant harm,” thus,
leaving it open for broad interpretation. Under a broad interpretation, discharge of
sewage and other forms of fecally contaminated water that may give rise to cholera,
all fall well within the customary law definition of “appreciable or significant
harm.” As a result, an argument can be made that customary law imposes
obligations on states to protect inland and marine waters which includes the duty
to protect from cholera contamination and spread. The argument can be supported
further by the judicial decisions of Trail Smelter and Lake Lanoux. Those cases
established the general proposition that a state can be held responsible for
transfrontier water pollution, 6 and, if the definition of pollution includes cholera,
states then can be held responsible for discharging cholera contaminated sewage or
other pollutants that might give rise to a cholera outbreak. If nothing else,
application of such responsibility will encourage cholera-afflicted states to take
greater measures to minimize spreading the disease to non-afflicted states.

The structure of international customary law has a fundamental benefit in its
application to the control of cholera. International customary law develops from an
accepted mode of behavior and, therefore, is likely to experience less resistance
from states than other newly proposed rules and regulations. Less resistance by
states may lead to more rapid adoptions of environmental laws for water resources
that will indirectly serve to control cholera. In some regards this has already
occurred. International environmental law derived from customary law has arisen
rather quickly since the 1960s. The observed rapid development of this area of law
leaves hope not only for more environmental laws to develop, but also for
customary law which will serve as a mechanism to develop laws for environmental
disease control. In addition, history has illustrated that customary law principles are
commonly incorporated into treaties. This, in turn, inspires the belief that customary
law principles concerning the environmental control of cholera will eventually be
incorporated into treaties.

The concept that human health will be protected by protecting the environment
is enumerated already in non-binding international environmental law. The
Stockholm Declaration proclaims that the “Conference calls upon Governments and
peoples to exert common efforts for the preservation and improvement of the human
environment, for the benefit of all the people and for their posterity.””2 7 Principle
1 of the Stockholm Declaration asserts that humans have a fundamental right to
“adequate conditions of life, in an environment of a quality that permits a life of
dignity and well-being, and .. . bear[] a solemn responsibility to protect and

205. See NOLLKABeMPER, supra note 183, at 36.
206. See supra text accompanying notes 190-95.
207. Stockholm Declaration, supra note 157, at 4.

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improve the environment.””‘ Thus, Principle 1 sets a standard of environmental
quality. Principle 24 reinforces the idea that states must work together to overcome
global challenges: “Co-operation through multilateral or bilateral arrangements or
other appropriate means is essential to effectively control, prevent, reduce and
eliminate adverse environmental effects resulting from activities conducted in all
spheres.”2” 9 By utilizing the guiding principles of the Stockholm Declaration,
human health can be protected, including protection from cholera.

In 1992 the Rio Declaration sought to build upon the principles set out in the
Stockholm Declaration twenty years before. It specifically addressed issues of
environmental quality and development. Principle 1 of the Rio Declaration
proclaims that human beings are “entitled to a healthy and productive life in
harmony with nature.”210 Such language infers a human right to live in an
environment free of conditions that would seriously compromise health standards.
Principle 1 of the Rio Declaration, as applied to cholera, would appear to require
suitable water quality standards in order to prevent cholera. Furthermore, under
consideration of the special circumstances of developing countries, Principle 4
proclaims that “environmental protection shall constitute an integral part of the
development process and cannot be considered in isolation from it.” ” Therefore,
the Rio Declaration purports that development and environmental protection shall
go hand-in-hand, and that, in turn, will directly serve to protect human health from
diseases including cholera. Lastly, Principle 15 proclaims the use of the
precautionary approach in order to protect the environment.2 1 2 The precautionary
approach incorporates the value of taking measures to prevent detrimental results
from environmental degradation.

Principles in the Helsinki Rules can provide protection of international rivers.213

As noted before, protection of water sources can be utilized as a preventative
measure in the control of cholera. Chapter 3, Article X of the Helsinki Rules
proclaims that a state “must prevent any new form of water pollution or any
increase in the degree of existing water pollution in an international drainage basin
which would cause substantial injury in the territory of a co-basin State.” 214 For the
purposes of Chapter 3, “water pollution” is defined as “any detrimental change
resulting from human conduct in the natural composition, content or quality of the
water of an international drainage basin. 2 15 Such language renders the definition
of pollution flexible. Therefore, Chapter 3 can be applied to sewage, legally
requiring prevention of the increase or the initial pollution of human waste to a
water source. By prohibiting this form of pollution, the amiable conditions for
cholera can be limited, thereby reducing the likelihood of cfholera outbreaks in an

208. Id.
209. Id. at5.
210. Rio Declaration on Environment andDevelopment, U.N. Conf. on Env’t & Dev., at 2,

U.N. Doe. A/CONF.151/5 (1992).
211.Id.
212. See id. at4.
213. Helsinki Rules, supra note 188, art. IL at 484-85.
214. Id. art. X, at 496-97.
215. Id. art. IX, at 494-95 (emphasis added).

1999] 1063

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area. One must recognize, however, the unfortunate restrictions of the Helsinki
Rules to the control of cholera. Chapter 1, Article II, clearly states that the general
rules of international law set forth in the Helsinki Rules apply to water of an
international drainage basin which geographically extends over two or more
states.216 This restriction limits the applicability of these rules to only those water
sources that cross state boundaries.

Taken collectively these international principles, customs, and treaties, created
to protect the environment, can be applied as an indirect control of the spread of
infectious diseases. Cholera can be regulated through international environmental
law because it protects the same environment that serves as a reservoir for cholera:
water. As was explained in this Part, certain sources of international environmental
law are specifically applicable to cholera because they focus on providing pollution
protection for water resources. By guarding against pollution, international
environmental law is taking a precautionary approach to defend against cholefa.

D. International Trade Law

Given the intertwined relationship of trade and infectious diseases, international
trade law is another area of law that has impacted international cholera control. The
General Agreement on Tariffs and Trade (“GATT”) was the first multilateral trade
agreement that attempted to provide rules for global trade.217 Article XX of GATT
specifically attempts to balance the sovereign right of states to take measures for
the protection of health with limitations on the abuse of this right.218 Article XX
reads:

Subject to the requirement that such measures are not applied in a manner which
would constitute a means of arbitrary or unjustifiable discrimination between
countries where the same conditions prevail, or a disguised restriction on
international trade, nothing in this Agreement shall be construed to prevent the
adoption or enforcement by any contracting party of measures… necessary to
protect human, animal or plant life or health….”

Yet, this balance of rights did not protect Peru during its 1991 cholera outbreak.
Peru’s economy suffered substantially as a result of actions taken against Peruvian
exports by other states. Peru complained to the GATT Council repeatedly that the
GATT rules were being ignored and other states were imposing trade-damaging
health protection measures against Peru that lacked scientific support or clear
public health rationales.22

216. See id. art. I1, at 484-85.
217. See FIDLER, supra note 58 (manuscript at 334).
218. See id.
219. GeneralAgreement on Tariffs and Trade, Oct. 30, 1947, art. XX, 61 Stat. A3, A60-61, 55

U.N.T.S. 187,262.
220. See FIDLER, supra note 58 (manuscript at 344).

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The Agreement on the Application of Sanitary and Phytosanitary Measures (“SPS
Agreement”)’ that grew out of the Uruguay Round of Negotiations is now the most
important of the international trade laws to impact cholera control. The SPS
Agreement puts forth measures to protect life or health of humans, animals, and
plants, but at the same time these measures are not intended for use to negate the
benefits of trade liberalization.222 Among the key elements of the SPS Agreement
is the requirement that sanitary and phytosanitary (“SPS”) measures be based on
scientific principles and evidence, and that states bound to the SPS Agreement must
base their SPS measures on international standards. 2″

The significance of the SPS Agreement to cholera resides within the requirement
that science be the basis for health protective measures. The SPS Agreement
precisely dictates that member states will apply SPS measures only to the extent
necessary to protect life or health of humans, animals, and plants; these measures
will be based on scientific principles and will cease to be maintained if sufficient
scientific evidence does not exist.22 Such language powerfully impacts the degree
of action that can be taken to protect health and limit international trade. No longer
can health policy that affects trade be created out of fear, superstition, or any other
illegitimate basis. Scientific evidence must exist and support the rationale for
enacting tariffs or other trade restrictions against a cholera-afflicted state, and in
doing so will ensure that policy is made fairly and for legitimate reasons.

In addition, the SPS Agreement dictates that SPS measures be based on
international standards, thereby promoting global uniformity for health standards.”‘
Application of international standards should promote fairness and deter
discrimination. International standards may also provide a means to restrict states
from taking extreme and excessive actions against a cholera-afflicted state, because
they will not be able to take restrictive action until an international standard is met.

IV. DEFICIENCIES IN THE INTERNATIONAL CONTROL OF
CHOLERA

Cholera is an age-old nemesis. All attempts to eradicate the disease on a global
scale have failed. Indeed some developed nations have seemingly eliminated the
threat that cholera will re-emerge, but so long as cholera outbreaks persist
somewhere in the world, it will remain a health threat to all of humanity. Re-
emergence and reoccurring outbreaks of cholera are attributable to several factors:
environmental degradation, urbanization, poor sanitation, ineffective vaccines,
ineffective regulations, and increased trade and travel. Among the most significant
of these factors are the deficiencies in the current cholera control regime. This Part

221. Agreement on the Application of Sanitary and Phytosanitary Measures, Apr. 15, 1994,
Marrakesh Agreement Establishing the World Trade Organization, Annex 1A, THE REsULTs OF
THE URUGUAY ROUND OF MuLTLATI.. TRADE NEGOTiATiONS: THE LEGAL Tmtrs (1994)
[hereinafter SPS Agreement].

222. Id. art. 2(3).
223. Id. arts. 2(2), 3(1); see also FIDLER, supra note 58 (manuscript at 351).
224. SPS Agreement, supra note 221, art. 2(2), 2(3).
225. Id. art. 3(1).

1999] 1065

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will examine the failed effectiveness of the four areas of international law that have
attempted to control cholera: IRs, the WHO Guidelines, international
environmental law, and international trade law. Finally, this Part will conclude with
an examination of how the concept of the human right to health also has failed in
the control of cholera.

A. Failed Effectiveness of the 1HRs

The JHRs have failed in preventing the international spread of cholera and other
infectious diseases as evidenced by recent outbreaks and the continuing re-
emergence of cholera.2 6 The JHRs have been inadequately applied, misapplied, and
have proven to be substantively insufficient. The surveillance system of the IHRs
is flawed in that member states often fail to notify the WHO that a cholera outbreak
has occurred and are reluctant to share surveillance information.227 As a result of
this breakdown in surveillance, a vicious cycle has developed of insufficient
notification that gives rise to excessive regulatory measures taken by member states
and these excess measures then give rise to failure to notify.22 Three reasons have
been proposed as to why surveillance has failed: (1) the time lag in diagnosis of
cholera; (2) the concern for maintaining national honor; and (3) the very real fear
of excessive reaction by neighboring states.

2

29

The lack of enforceability of the HIRs duties further detracts from its overall
effectiveness. No provisions in the mHRs provide any international organization with
enforcement power in connection with duties established in the IHRs.Y
Enforcement is further weakened by the WHO’s reluctance to issue enforceable
legal rules, and instead choosing to issue “non-binding recommendations.””‘
Hence, many of the objectives of the IHRs are undermined by the lack of
enforceability.

The failure of the H-IRs to adequately meet international health needs has been
recognized. The IHRs are undergoing revision in accordance with a resolution

226. See DELON, supra note 96, at 23; Fidler, supra note 5, at 846; Mario Masana Wilson &
Cdsar Chelala, Letter From BuenosAires: Cholera Is Walking South, 272 JAMA 1226 passim
(1994) (describing the spread of a cholera epidemic from three initial towns in Peru to all the
countries in SouthAmerica, with the exception of Uruguay, and to all Central American countries).

227. See Cholera 0139 Spreading-SoutheastAsia: Requestfor Info (visited Mar. 23, 1999)
(describing that an
unidentified Southeast Asian country is currently afflicted by a large cholera outbreak but is
suppressing the information in violation ofthe WHO member states requirements); see also Fidler,
supra note 5, at 844 (citing WORKING GROUP ON EMERGING AND RE-EMERGING INECTIOUS
DIsEASs,NATIONAL SCIENCE AND TECH. COUNCIL COMM. ON INT’L SCIENCE, ENG’G AND TECH.,
INFEOUS DIsEAsES-ACLoBAL HEALTH THREAT 4 (1995)) (discussing the reluctance to share
surveillance information); Laurie Garrett, The Return oflnfectious Disease, FOREIGNAFF., Jan.-
Feb. 1996, at 66,74 (noting the reluctance of many nations to report infectious disease outbreaks
to the WHO).

228. See DELON, supra note 96, at 24; Fidler, supra note 5, at 847.
229. See DELON, supra note 96, at 24.
230. See Fidler, supra note 5, at 848.
231. Id.

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adopted by the World Health Assembly in 1995.232 This action was taken in
recognition that the regulations have fallen behind the current health needs of the
global community. New patterns of risk, such as profound advances in
transportation and increased environmental degradation, present new challenges to
the international disease control community that did not exist when the IHRs were
last revised. The revisions are intended to facilitate epidemic surveillance and
control activities at regional, national, and international levels.233 Descriptions of
the “best public health practices” as well as syndromes of international importance
will be include& 4 The revised IHRs are currently in draft form and WHA approval
is anticipated in 2000.235 With these revisions, hopefully many of the flaws
discussed in this Comment will be rectified. However, the effectiveness of the new
revisions to regulate the spread of cholera will remain inconclusive until the revised
IHRs are adopted and implemented.

B. Failed Effectiveness of the WHO Guidelines

The WHO cholera and drinking-water quality guidelines provide information and
recommendations that are critical to the adequate control of cholera. However, the
persistent re-emergence of cholera is evidence that the WHO guidelines have had
only limited effectiveness in controlling cholera. The failure of the WHO guidelines
to control cholera can be attributed to the fact that the WHO guidelines are just that,
guidelines. They have no binding force under law. States can observe these
guidelines and even incorporate them into their own laws, however, there is no
international binding force that requires states to accept and follow the WHO
guidelines. Until the WHO guidelines are established in multilateral and bilateral
agreements or imposed by customary law and national law, they remain merely
guidelines that have no enforceability.

In addition, a major flaw of the WHO cholera guidelines thus far is their failure
to incorporate enough environmental protection. The WHO Guidelines for Cholera
Control state that “all efforts must be made to provide safe drinking-water, as well
as safe water for food preparation,” yet they do not address how this is to be
achieved.Y6 The greatest environmental, precautionary advice provided by the
guidelines is to sterilize water by boiling.2 37 In fact, it appears that the Guidelines

for Cholera Control fail to give any practical guidance to prevent cholera by means
of protecting water from cholera contamination. To find the WHO guidance for
water protection, persons interested in preventing cholera must turn to the

232. See World Health Org., supra note 98, at 234; World Health Org., Revision of the
International Health Regulations: Progress Report December 1996, 72 WKLY.
EPIDEMIOLOGICAL R.c. 9, 9 (1997) [hereinafter WHO, 1996 Progress Report]; World Health
Org.,Internalional Health Regulations (last modified Apr. 24, 1998) .

233. See WHO, 1996 Progress Report, supra note 232, at 9-10.
234. See id.
235. See World Health Org., supra note 98, at 234.
236. Guidelinesfor Cholera Control, supra note 116, § 3.1.
237. See id.

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Guidelines for Drinking-Water Quality.238 Herein lies the problem. The failure to
incorporate drinking-water guidelines in the WHO cholera prevention strategy itself
is a profound deficiency. Without directly addressing the environmental conditions
that give rise to diseases such as cholera, the WHO guidelines will always err on
the side of being reactive instead of proactive, and they will never provide a
comprehensive and foolproof strategy to prevent cholera.

C. Failed Effectiveness of International Environmental
Law

International environmental law has some fundamental drawbacks that may limit
its effectiveness to control cholera. First, much of international environmental law
is created through a rather slow treaty-making process. Ratification of agreements
by states takes time, and will often delay the practical effectiveness of international
agreements.239 Second, because no state is obliged to sign or ratify a treaty, most
international environmental laws are based on consensus or unanimity. 240 Therefore,
there is no guarantee that all states that should be bound to a treaty will be bound.
A third drawback is that internationally agreed upon standards tend to reflect the
“lowest common denominator,”24 and consequently result in failure to set the ideal
standard for environmental or human health protection.

Traditional “treaty-making” is a useful method to formulate a framework for
international relations and to establish generally accepted principles of behavior.

24 2

Therefore, it is a constructive means to establish proactive and long standing
precautionary principles for environmental and health management. However, once
established, these principles are slow to change and often fail to offer the
mechanisms that are capable of contending with the evolving nature of infectious-
disease control. Control of infectious diseases involves unforeseeable changes of
circumstances as well as emergency situations. Critical to the success of
international infectious disease management is a system’s capacity to react well to
rapidly changing situations. Without this critical component integrated into a
regulatory scheme, cholera will never be adequately controlled. Thus, it is feasible
that treaty-made international environmental law may lack the flexibility and
emergency response qualities necessary to effectively regulate cholera.

Additionally, many of the obligations and duties that treaties implement are
overly- broad and thus lack sufficient specificity to be truly effective in controlling
cholera through environmental measures. For instance, although the UNCLOS
requires party states to take measures to prevent and control pollution of the marine
environment, it fails to set specific standards or give sufficiently detailed guidelines.

238. See generally 2 WORLD HEALTH ORG., supra note 128. The WHO dedicated an entire
volume to guidelines for drinking-water quality, yet only a few sections, such as 11.1.2 and 11.23,
address source protection or environmental protection. See id. §§ 11.1.2,11.2.3, at 108,109-10.

239. See Sand, supra note 158, at 219.
240. See id.
241. Id.
242. See id.

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INTERNATIONAL CONTROL OF CHOLERA

An argument has been made that the UNCLOS provisions are so overly-broad and
lack specificity that they are likely to have little practical effect.

243

Another problem with the application of international environmental law
contained in treaties to cholera is that the majority of international environmental
agreements pertaining to water resources focus on the marine environment and not
on sources of drinking water. For example, the International Convention for the
Prevention of Pollution of the Sea by Oil,244 the Convention on the Prevention of
Marine Pollution by Dumping Wastes and Other Matter,” 5 the Convention on the
Protection of the Marine Environment of the Baltic Sea Area,24 and the
International Convention for the Prevention of Pollution from Ships247 all pertain
exclusively to the oceans and seas. To compound matters, many of these same
agreements focus on inorganic pollution whereas cholera is most commonly a result
of organic pollution. Illustrative of this is the Convention on the Prevention of
Marine Pollution in which sewage, sludge, or other biological wastes are not among
the materials listed as prohibited from dumping.

248

Therefore, not only is there a lack of international environmental law to protect
inland water sources, but those treaties that do protect marine environments still do
not contain provisions to prohibit pollution by substances that can contribute to a
cholera outbreak. Furthermore, evidence of state practices to protect waters is
inconsistent, and few treaties endorse an absolute prohibition on detrimental
alteration of water quality.249 In short, apart from the possibility of specific treaty
regimes that directly address water quality, there is little evidence that water
pollution from industrial effluents, agricultural runoff, or domestic sewage
discharged is per se prohibited. 2 1 Without per se prohibition or strictly imposed
limitations on these cholera-conducive types of water pollutants, the threat of
cholera outbreaks will remain.

243. See .R. CH n.cmL &A.V. Lows, Tnm LAW oF THE SEA 278 (rev. ed. 1988).
244. International Convention for the Prevention of Pollution of the Sea by Oil, May 12,1954,

12 U.S.T. 2989,327 U.N.T.S. 3.
245. Convention on the Prevention of Marine Pollution by Dumping of Wastes and Other

Matter, Dec. 29, 1972, 26 U.S.T. 2403, 1046 U.N.T.S. 120 [hereinafter Convention on the
Prevention of Marine Pollution].

246. Convention on the Protection of the Marine Environment of the Baltic Sea Area, supra
note 170.

247. International Convention for the Prevention of Pollution From Ships, Nov. 2, 1973,
TI.A.S. No. 10561, 12 I.LL 1319.

248. Convention ofthe Prevention of Marine Pollution, supra note 245, art. XII & annexes I-Il,
26 U.S.T. at2411, 2465-66,1046 U.N.T.S. at 143,203 (prohibiting specifically the dumping of
inorganic compounds, metals, and radioactive materials; however, sewage and other biological
materials, except for those used for warfare, are not prohibited dumping substances under this
convention).

249. See, e.g.,ia arts. V-VI, 26 U.S.T. at 2409-10, 1046 U.N.T.S. at 141-42. Some treaties do
absolutely prohibit detrimental alteration of water quality. See, e.g., Agreement Concerning
Frontier Watercourses, supra note 172, art. 4, at 254; Soviet-Polish Frontier Treaty, supra note
171, art. 19, at 256; Soviet-Czechoslovakia Frontier Agreement, supra note 172, art. 14, at 312;
Act of Santiago Covering Hydrologic Basins, supra note 172.

250. See BmNm & BoYLB, supra note 171, at224.

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Finally, none of the international environmental agreements address infectious
disease control generally or cholera control specifically. Therefore, it is left to
deduction as to whether international environmental law does, indeed, apply to the
control of cholera.

The application of customary law to environmental problems faces some
challenges, and therefore, will face similar challenges as applied to cholera. Among
these challenges include ascertaining the custom, a state’s liberty not to recognize
custom, and the uncertainty in establishing a custom. Additionally, how quantity and
quality of a shared resource can be determined by using custom is not fully clear.
Furthermore, as the use and development of treaties increases, the reliance on
customary law may diminish, thereby, weakening its legal potency. Two obvious
disadvantages exist in the application of international customary law for water
resources to cholera control. First, is the fact that it applies to marine and water
pollution and not to cholera prevention. Second, water pollution protection has been
limited in scope by equitable utilization, thereby reducing the degree of protection
afforded to water resources and cholera prevention. Despite these difficulties,
customary law still serves as an important role in the legal structure of international
environmental law that can be applied to the international control of cholera.

D. Failed Effectiveness of International Trade
Law-Excessive Measures and Trade

In application of the IHRs, WHO member states have repeatedly taken excessive
measures to control the spread of cholera which are often in the form of trade and
travel restrictions.2″‘ These restrictions are commonly unauthorized and
unnecessary to prevent the spread of cholera, and violate international trade
agreements.

As recently as December 1997, the EC responded to an outbreak of cholera in
East Africa by imposing import bans against East African fishery products.252 This
action was in violation of the IHRs and the SPS Agreement. The IHRs establish the
maximum degree of action that a WHO member state may apply to goods coming
from a country suffering a cholera outbreak.253 Under the IHRs, WHO member
states are not authorized to impose import bans on products from cholera-afflicted
nations. 4 Additionally, the WHO Guidelines for Cholera Control specifically state
that trade restrictions do not prevent the spread of cholera.255 The WHO advises that
travel and trade restrictions have never proven to be an effective method of
controlling the spread of cholera, but, instead, that “sound public health practices
are the most effective approach.” ‘256 Furthermore, the WHO has never documented

251. See DELON, supra note 96, at 24.
252. See Fidler, supra note 65.
253. See INT’L HEALTH REGS., supra note 97, arts. 62-63, at 30.
254. See David Fidler, Cholera, Impact on Commercial Fishing-East Africa (02) (visited Feb.

16, 1999) .
255. Guidelinesfor Cholera Control, supra note 116, § 7.3.3.
256. James Chin, PRO> Cholera-Afica: WHO Guidelines for Control (visited Feb. 16,

1999) .

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a cholera outbreak due to commercially imported food substances.257 Thus, the EC
import ban is neither supported by the WHO guidelines nor is it in compliance with
the IHRs. Although not formally a WHO member state, the EC is comprised of
individual WHO member states who are bound by the IHRs, and individually each
member state would be in violation of the IHRs upon complying with a ban on
fishery products from East Africa.25

In addition, the EC could well be in violation of the SPS Agreement that
mandates risk assessment based on scientific principles and evidence.” 9 The EC
bears the burden of adequately discerning that the ban is reasonable given the
results of a scientific risk assessment. Without such scientific evidence, proven by
scientific methods of risk assessment, the EC is in violation of the SPS Agreement
for imposing such a sanitary measure.26

Many failed attempts to control the spread of cholera focused on controlling the
movement of individuals or even whole populations. Identification of traveling
infected persons is difficult, personally invasive, and expensive to enforce
effectively. Additionally, control of travel may produce tourism loss due to
disruption of the industry. For these reasons, the WHO recommends that states
should not utilize quarantine and frontier control measures to prevent the spread of
cholera.26′ Rather, resources are better spent addressing the environmental concerns
associated with cholera.

E. Right to Health

Current international regulations to control cholera can be argued to have violated
an international right to health. International human rights law can be one legal
basis that would require the establishment of an international public health strategy
to combat cholera effectively. However, to date this has not occurred. Many public
health systems remain inadequate and have proven to be incapable of preventing
the spread of infectious diseases.

The right to health has its foundation in public health movements of the
nineteenth century that drove sanitation reforms designed to alleviate infectious
disease epidemics.262 The first declaration of a human right to health appeared in
the WHO Constitution in 1946 which stated: “The enjoyment of the highest
attainable standard of health is one of the fundamental rights of every human
being … .,263 Following this declaration came other declarations and treaties

257. See Guidelinesfor Cholera Control, supra note 116, at box 12.
258. See Fidler, supra note 65.
259. See id. (referring to Articles 5(1) and 5(2) of the SPS Agreement); see also SPS

Agreement, supra note 221, arts. 5(1), 5(2).
260. See Fidler, supra note 65.
261.See James Tulloch, Global Considerations in the Control of Cholera, in CHOLERA ON T-I

AMmcAN CoNTINENT, supra note 8, at 3, 7.
262. See FIDLEi, supra note 58 (manuscript at 489-90).
263. WHO Const., supra note 95, pmbl., 62 Stat at 2685, 14 U.N.T.S. at 186.

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expressing the right to health. 264 However, to interpret the right to health as a
guarantee of individual good health is to discount the epidemiological lessons
history has taught to humans: infectious diseases do not recognize a right to human
health. In fact, regardless of the number of declarations or treaties preserving a
right to health, infectious diseases have always and will continue to cause illness
and death.

Establishing an international right to health standard is complicated by the
variance of the environment between developing and developed nations. To
reconcile such variance, the principle of progressive realization has been applied.
This principle purports that the right to health “does not provide an absolute world
standard but is rendered relative to the world health inequalities” between
developing and developed countries.265 Hence, the right to health can be designed
to reflect the reality of a nation’s capabilities to provide for the public health. A
significant problem with the application of progressive realization is the potential
to overuse it. It may retard the pursuit of improving public health standards and
serve as an excuse for the lack thereof.

The inadequacy of public health systems in many developing nations reflects a
widely recognized truth that the minimum core obligations of states to individuals’
rights to health are not being fulfilled.2″ Cholera exemplifies the inadequacies.
Cholera is easily preventable and treatable, yet it still kills thousands of people each
year. The inability of many nations to halt its re-emergence and spread has brought
to light the weaknesses of public health systems all over the globe. In 1991, the
WHO estimated that 120 million people in Latin America were at risk of
contracting cholera because of “poor sanitation, deterioration in maintenance of
water systems, and contaminated food.” 267 In short, the cholera epidemic that swept
Peru and other sections of Latin America demonstrated the weaknesses of the Latin
American public health system. The incapabilities of state public health systems to
overcome cholera outbreaks can be interpreted as a defeat of the minimum core
approach to the human right to health.

264. See FIDLER, supra note 58 (manuscript at 489-90). Some treaties mentioned include: the
Intemational Covenant on Economic, Social, and Cultural Rights, entered into force Jan. 3,1976,
993 U.N.T.S. 3, 6 I.L.M. 360; the African Charter oi Human and Peoples’ Rights, openedfor
signature June 26,1981, OA.U. Doe. CAB/LEG/67/3/Rev.5, 21 I.L.M. 58; the Convention on
the Rights of the Child, GAl Res. 44/25, U.N. GAOR, 44th Sess., Supp. No. 49, U.N. Doe.
A/44/736 (1989), reprinted in 28 ILM. 1448; and the Additional Protocol to the American
Convention on Human Rights in the Area of Economic, Social, and Cultural Rights, Nov. 17,
1988,28 I.LM. 146 (not yet in force). See FIDLER, supra note 58 (manuscript at 489-90).

265. CHARLEsO. PANNEmORGANwINTERNAIioNAL HEALTH ORDER ANINQuY nINTo Tm
INTERNATIONAL RELATIONS OF WORLD HATHAND MDICAL CARE 313 (1979).

266. See FIDLER, supra note 58 (manuscript at 489-90).
267. Allyn Lise Taylor, Making the World Health Organization Work. A Legal Frameworkfor

UniversalAccess to the ConditionsforHeath, 18 AM. J.L. & MED. 301, 308-09 (1992) (citations
omitted).

1072 [Vol. 74:1035

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V. RECOMMENDATIONS

The following Part sets forth recommendations to improve the control of cholera.
The recommendations include the need for enhanced international cooperation in
the fight against infectious diseases, the need for international environmental law
to have a greater involvement in the control of infectious diseases, the need to
improve efforts of environmental protection that will aid in controlling cholera, and
the application of the concept of global health jurisprudence. Enhancing sanitation
and environmental surveillance efforts are two mechanisms that will aid in
environmental protection. Application of the precautionary principle also can assist
in the control of cholera through environmental avenues. These recommendations
are not the exclusive means to improve the global control of cholera, rather they
seek to foster further investigation of alternative means to aid in the international
regulation of cholera.

A. Need for Enhanced International Cooperation

There is an obvious need for enhanced international cooperation and information
exchange for cholera that goes beyond the current efforts of the WHO and PAHO.
Cooperation and information exchange once an epidemic has surfaced is not an
effective means to proactively prevent the spread of cholera. Precautionary
information exchange on the conditions, including the environmental conditions,
that give rise to cholera is needed.

Greater cooperation among states, with a particular emphasis on maintaining
water quality standards and preventing cholera contamination of drinking water, is
needed. This can be partially achieved by utilizing the already established
frameworks of cooperation for water resources. Also, there is the need for greater
efforts to integrate data collection on health and global environmental changes.
Diseases like cholera, which arise with degradation of environmental conditions,
will only be eliminated if the environmental conditions that are associated with it
are recognized and prevented. Therefore, to prevent cholera, data must be collected
on environmental changes associated with cholera outbreaks and integrated with the
human health aspects of disease control. Clearly a fusion between the health of the
environment and human health is necessary to prevent cholera.

The established cooperative efforts of international water resources have
applicability to cholera control. As a result of the importance of and the potential
conflicts arising over water resources, many of the institutions of the United
Nations (“U.N.”) are engaged in activities involving water management and
facilitating intergovernmental cooperation.26 One of the most substantial

268. See DanteA. CaponeraPatterns of Cooperation in International Water Law: Principles
and Institutions, in TRANSBOUNDARY REsouRCEs LAw 1, 11 (Albert E. Utton & Ludwik A.
Teclaffeds., 1987). Institutional support is provided to the institutions of Benin-Togo, Cameroon-
Chad, Senegal, Burundi, Rwanda, Tanzania, Gambia, Guinea, Paraguay, Brazil, Uruguay, Greece,
Yugoslavia, Liberia, and Sierra Leone. See id. at 11 n.30.

1999] 1073

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recommendations for water resources cooperation comes from the plan developed
at the U.N. Water Conference held in 1977. The plan stated that:

“States sharing water resources … should cooperate in the establishment of
programs, machinery, and institutions necessary for the coordinated
development of such resources… and establish joint committees… to provide
for the… collection, standardization and exchange of data, the management of
shared water resources, the prevention and control of water pollution, the
prevention of water associated diseases, mitigation of drought, flood control,
river improvement activities, and flood warning systems.”26′

In addition, non-binding principles of international environmental law contain
cooperation requirements. Principle 24 of the Stockholm Declaration declares that
“cooperation through. multilateral or bilateral arrangements is essential in
international relations to protect and improve the environment.””27 Following the
Stockholm Declaration, the U.N. Environmental Programme was created “to
implement international cooperation regarding environmental aspects of shared
water resources.”

271

These established principles and organizations to promote cooperation among
nations represent only a fraction of the cooperation requirements found in
international environmental law that can and should be applied to the control of
infectious diseases. They are powerful tools that are intended to prevent
environmental harm, but can be used to prevent infectious diseases as well. It is
bewildering that the existing principles and legal frameworks to protect water have
not been mentioned or integrated in the control strategies of infectious diseases.
Their utility to cholera control is invaluable.

International cooperation does face a fundamental challenge in its application to
cholera control. Requirements for states to cooperate with one another are rarely
found outside of international agreements, thus, rendering cooperation as a
conditional obligation. However, an exception is found in principles of international
customary law, and for the purposes of controlling cholera it is the exception and
not the norm that should be used. The exception is the duty to cooperate, which is
a relatively well accepted principle of international customary law that has been
applied generally to environmental issues. Applicable to the prevention of cholera
is the duty to cooperate in protection of water resources, especially with regard to
“the spread of waterborne diseases.” ‘272 This duty can be interpreted in two ways.
On the one hand, it can be understood to impose a duty for states to take individual
actions within their jurisdictions to protect against infectious water-borne diseases,
such as cholera, as a cooperative effort to curb the international spread of disease.
On the other hand, the duty to cooperate can be understood as requiring states to
work directly with each other in order to develop strategic plans and agreements to
combat the spread of infectious diseases.

269. Id at 11 (quoting REPORT OF ThmUNrrED NATIONS WATER CONFERENCE at 180, Mar. 14-
25, 1977, U.N. Sales No. E.77.ILA12 (1977) (emphasis added) (omissions in original)).

270. Id. at 12 (citing Stockholm Declaration, supra note 157, prine. 24, at 5).
271. Id.
272. Id. at8.

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Enhanced international cooperation may help in the control of cholera by
alleviating some of the existing health inequalities between developed and less-
developed nations. Cholera is a potential threat to all countries, yet it takes its
greatest toll on developing countries. Poorer nations often lack the economic
resources to improve water quality and sanitation, thereby, leaving then more
susceptible to cholera outbreaks. International cooperation, as established in
treaties or by customary law, may help to diminish cholera outbreaks by
encouraging international efforts to ensure that all nations provide adequate water
quality and sanitation- These efforts can be in the form of enhanced monetary aid
to build and maintain needed sanitation systems or increased international efforts
in education about disease prevention. Cooperation can also take the form of
enhanced information exchange in health and environmental policy, sanitation
technology, and public health systems.

With every undertaking that involves as many issues as the control of cholera,
there will exist challenges. But, policy and law makers sh6uld not be discouraged
by these challenges. Rather, these challenges should be an indicator of why
international cooperation is so critical. Through augmented international
cooperation, nations may be able to share resources, knowledge, policies, and
technology that will directly reduce the fear of cholera and friction among states
while also helping to formulate an international framework for the effective control
of cholera.

B. Need for Environmental Law to Have a Greater
Involvement in the Control of Infectious Diseases

Environmental regulations can be viewed as a means to prevent human disease
through protection of the human environment. Water is among the most critical of
natural resources to protect in order to guard human health. Scientific evidence has
demonstrated that water quality is directly related to cholera epidemics.273

Historically, water was probably one of the first natural resources to be stored,
distributed, and polluted. As a reservoir and transmission medium for human
disease, water has been a leading problem in environmental health through history.
Cholera is reliant on water as its primary vector of transmission and food as a
secondary vector. Therefore, cholera has an environmental mode of transmission.
This mode of transmission can easily be seen as the subject of expanded
environmental regulations to protect interests in trade, tourism, pollution
prevention, and human health. Regional or local environmental regulations could
increase regulatory measures on public sanitation systems for the control of all
water-borne diseases like cholera.

To control cholera, environmental regulatory efforts must go beyond the actions
taken by PEEM and have more enforceability than the guidance published by the
WHO. Specific environmental laws that are applicable to the control of cholera,
like those described in the previous Part, should be used. However, laws that
promote environmental cooperation are not enough. Individual states must impose

273. See Blake, supra note 8, at 15.

1999] 1075

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stricter environmental water quality regulations if they are to cohesively defeat the
continuing re-emergence of cholera. Treaties that specifically set water quality
standards for shared water sources should be established if they are not already in
existence. Entering into such agreements would follow an often accepted view that
activities causing threats to the environment should be regulated by international
legal rules. 4 Hence, actions taken by states that cause cholera contamination of
water sources threaten the environment and merit regulation by international
mechanisms.

Another advantage to the establishment of agreements is that they often ensure
a level of due diligence among states. A higher level of water quality standards
could be imposed globally giving rise to states’ expectations that the obligations
thus created would be respected. Therefore, creating international agreements for
drinking water or sanitation may have a greater success of preventing cholera,
because states would then feel obligated by due diligence to uphold their agreement.

C. Efforts to Improve Environmental Protection to Aid in
Cholera Control

1. Sanitation

Cholera is a preventable disease. If sanitary measures are taken to improve
environmental conditions, the threat of cholera largely dissipates. Cholera can be
reliably prevented by ensuring that all populations have access to safe drinking
water, enough water to practice good hygiene, and adequate sanitation systems.
Unfortunately, these features are distant goals for many countries with endemic
cholera, and both poverty and illiteracy constitute significant barriers to
improvement. For much of the world’s population, adequate sewage treatment
plants are not currently affordable nor will they likely be in the future.2″ Upgrading
existing sewage disposal systems for some states is beyond their economic
capabilities, so many cities have not kept pace with their growing populations, and,
thus, provide inadequate sewage disposal. The WHO has taken these facts into
account, and has proposed methods of sanitation that are inexpensive yet still
effective to prevent cholera epidemics. Among these methods are boiling drinking
water vigorously, making water safe by chlorination, and teaching the importance
of hand washing with soap or ash after any contact with excretaY.

2 6

Chlorination is one of the best weapons against cholera. The WHO reports that
over nine million people die because their water is not chlorinatedY.2 7 Such a

274. See NOLLKAEMPER, supra note 183, at 210.
275. See RussELL F. WHALEY & TALAL J. HASHIM, A TmrBOOK OF WoRD HEALTH A

PRACTICAL GUIDE TO GLoBAL HEALTH CARE 235 (1995).
276. See Guidelines for Cholera Control, supra note 116, §§ 3.1,.3 (discussing different

techniques in preventing cholera transmission).
277. See Kenneth Smith, The Media’s War on Essential Chemicals: Targeting Chlorine, 6:2

PiORrrms 6, 8 (1994); Frank B. Cross, Paradoxical Perils of the Precautionary Principle, 53
WASH. & LEE L. REv. 851, 883 (1996).

1076 [Vol. 74:1035

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statistic is not surprising considering that, during the 1980s, 1.8 billion people
lacked access to clean drinking water and 1.7 billion lacked access to adequate
sanitation services. Despite efforts to supply new drinking water sources and
sanitation services, these numbers have not decreased.27 Not all the deaths
mentioned above are cholera related; however, some have suggested that thousands
who died during the cholera outbreak in Peru could have been saved had the
Peruvian government ensured that their country’s drinking water was chlorinated.

279

Furthermore, the pursuit to sustain high quality drinking water at minimum
economic expense is ongoing. Researchers have developed low-cost, relatively
simple procedures to create an environment with safe drinking water. The Center
for Disease Control is now promoting one cheap and effective technique: “bucket-
lids” and a “table-top purification system” using table salt.2″ The technique
requires a simple water purification system in which table salt is separated into
chlorine and sodium with electrodes, using local power lines, solar panels, or car
batteries to run small power generators. The new extracted chlorine, then, is put
into local drinking-water sources.2 81 This technique not only meets the WHO
standards, but also is estimated to cost only fifteen cents per month per family of
five.

2 82

Implementation of new technologies cannot be imposed on states unless these
technologies are somehow required by inclusion into a treaty, another international
agreement, or dictated by national law. Without the force of law, new technologies
have limited or no effectiveness in preventing disease. From a scientific standpoint,
cholera may be preventable so long as these technologies are used; however,
without the legal constraints binding states to use these practices, cholera will
continue to flourish.

The current water quality standards adopted by the WHO are recommendations
and are not legally binding.283 The nonlegal nature of such guidelines leaves states
with too much latitude to ignore them. The solution is to adopt the WHO guidelines
for water quality standards as legally binding rules. Another recommendation that
will aid in the prevention of cholera is to incorporate the WHO standards for water
quality and sanitation into treaties and other legally binding instruments. By doing
so, states would be obligated to maintain specific sanitation practices that, in turn,
would prevent cholera epidemics.

Another critical element of sanitation and drinking-water supplies is
sustainability. Policy decisions and scientific developments to improve sanitation
and drinking-water quality must be done with sustainability as the objective.
Methods of development and improvement must be financially and operationally

278. See Pamela LeRoy, Troubled Waters: Population and Water Scarcity, 6 COLO. J. INT’L
ENVTL. L. & POL’Y 299,314 (1995).

279. See Susan W. Putnam & Jonathan Baert Wiener, Seeking Safe Drinking Water, in RISK
VERsus RisK: TRADE-OrFS INPROTECTING rHALTHAND THE ENVIoNMNT 124,125 (John D.
Graham & Jonathan Baert Wiener ads., 1995).

280. Constance Holden, Purification in the Time of Cholera, 265 ScI. 476,476 (1994).
281. See id.
282. See id.
283. See NOLLKAEMPER, supra note 183, at 210-11.

1999] 1077

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realistic. Personnel at both the managerial and operative levels must be adequately
trained in order to ensure optimal conditions are maintained. Communities, not just
public health officials, must be informed of the necessary steps to take to ensure a
sustainable level of safe drinking water. Population growth projections as well as
environmental conditions must be considered when designing sanitation systems.
Overall, sustainability must remain a component of the policy and technical
engineering for sanitation and drinking-water systems in order to ensure the public
health.

2. Environmental Surveillance

Environmental surveillance offers unique opportunities to recognize the
environmental conditions ripe for a cholera outbreak before the outbreak occurs.
This precautionary approach to surveillance is significantly different from the
traditional surveillance approach which is to only report outbreaks. Environmental
surveillance can be achieved by many different procedures.. One procedure already
used by environmental scientists is bioindicators. Bioindicators are biological
organisms such as plant life or microorganisms that are sensitive to toxins and
environmental changes. Illnesses, death, or rapid growth of the bioindicator can be
indicative of poor environmental health.” 4 Thus, bioindicators can be used as an
early warning sign that environmental changes have occurred which might give rise
to cholera outbreaks. Algae blooms can serve as bioindicators for the development
of favorable conditions for cholera.”‘ By monitoring the occurrence of algae
blooms, cholera can be indirectly monitored. A current method of monitoring algae
blooms is by satellite imagery.” 6 Once an algae bloom is discovered by satellite
imagery, it should be sampled and tested for cholera. 287 By monitoring algae blooms
by satellite imagery, environmental conditions associated with cholera can be
monitored, cholera can be detected, and a potential epidemic can be avoided.

Surveillance of community sewage also would be an effective means of limiting
the degree and severity of cholera outbreaks. Such an environmental surveillance
would be of particular value in areas where cholera has not been confirmed but is
suspected or in areas bordering regions with cholera. One suggested technique of
surveillance is the use of “Moore swabs.” 288 “Moore swabs” are placed in city
sewage effluents and then tested for the presence of cholera. 8 9 In addition to
specifically monitoring for Vibrio cholerae, cities with some form of public
sanitation system could require a more general environmental surveillance
technique. Operators of public water systems could be required to watch closely for

284. See Andrew Haines et al., Global Health Watch: MonitoringImpacts ofEnvironmental
Change, 342 LANCRT 1464, 1466 (1993).

285. See supra text accompanying notes 86, 91-94.
286. See Haines et aL, supra note 284, at 1466; Harvard Working Group, supra note 56, at 24-

25.
287. See Haines et al., supra note 284, at 1467.
288. Timothy J. Barrett et al., Use ofMoore Swabsfor Isolating ibrio Cholerae from Sewage,

11 J. CLINICAL MCROBIOLOGY 385 passim (1980).
289. See id. at 385-87.

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INTERNATIONAL CONTROL OF CHOLERA

defects that could allow contaminants to enter the water system. Environmental
surveillance should not replace current surveillance procedures as established by
international regulations and agreements, but instead, act as an additional method
used to improve cholera control.

The WHO, as an already well recognized international organization, is ideal to
play a key role in coordinating a global infectious disease watch based on
environmental health initiatives. In order to effectively do so, the WHO would need
to become involved in global observation systems that monitor ocean, terrestrial,
and climate changes. “Existing collaborative program[]s with other UN agencies
[(FAO, UNEP) will position the WHO] to promote interdisciplinary activity on
climate and ecosystem health” that would, in turn, clearly benefit human health.29°

3. Application of the Precautionary Principle

Few principles are better established in the philosophy of environmental law than
the precautionary principle. The precautionary principle is based on the ideal that
governments have a duty to “take precautions to protect public health and the
environment, even in the absence of clear evidence of harm and notwithstanding the
costs of such action.”29′ The principle requires reduction and prevention of
environmental and health impacts irrespective of the existence of risks. Action is
required, under the precautionary principle, even if risks are not yet certain but only
probably, or even possible.292 The crucial point is to prevent or reduce the risk of
environmental harm. The precautionary principle does not weigh economic analysis
and scientific proof as much as might be expected. Instead, the precautionary
principle emphasizes: (1) the vulnerability of the environment; (2) the limitations
of environmental science to accurately predict threats and formulate preventative
measures; (3) the availability of alternatives; and (4) the need for long-term
comprehensive economic considerations that include environmental degradation
and the costs of waste treatment as factors. 93

With the growing international concern for the environment, the precautionary
principle is rapidly assuming a central role in international environmental
protection. The 1992 Rio Declaration of the U.N. Conference on the Environment
explicitly declared that “[i]n order to protect the environment, the precautionary
approach shall be widely applied by States according to their capabilities.”2 9 4

Utilization of the precautionary principle has been extended by international

290. Haines et al., supra note 284, at 1469.
291. Frank B. Cross, Paradoxical Perils of the Precautionary Principle, 53 WASH. & LEE L.

REv. 851, 851 (1996).
292. See Lolhar Glndling, The Status in IntrnationalLaw of the Principle ofPrecautionary

Action, 5 IrN’LJ. ESTUARiEs & COASTALL. 23,26 (1990).
293. See Ellen Hey, The Precautionary Concept in Environmental Policy and Law:

Institutionaliing Caution, 4 Gao. INT’L ENVTL. L. REV. 303,308 (1992).
294. Rio Declaration on Environment and Development, supra note 210, prine. 15, at 4.

1999] 1079

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delegates to aid in confronting the issues of climate change and sustainable
development.

295

Increased prevalence of the precautionary principle in international
environmental law suggests a shift in lawmaking approaches from responsive to
preventative. This shift in international environmental law to focus on risk aversion
has a twofold impact on the control of infectious diseases such as cholera. First, by
taking a precautionary approach to prohibiting environmental degradation and
pollution, indirect improvements to infectious disease control are made. Enhanced
proactive protection of the environment will eliminate conditions that are
predisposed to disease outbreaks. By virtue of protecting the environment, public
health has been protected. Finally, with environmental protection regulations
already in place, public health costs can be reduced. Preventative health measures
often produce less cost than necessary response measures, and in the case of
cholera, lives are saved and illness avoided by having already ensured
environmental protection of water. Second, the precautionary approach can be
directly applied to the control of cholera. Precautionary measures can be taken, as
they have been for the environment, for the prevention of cholera. Sanitation, itself,
is a precautionary measure. Ensuring availability of safe drinking water and the
establishment of waste treatment facilities prevents cholera outbreaks.296 Therefore,
it is important to re-emphasize the need for the worldwide implementation of
sanitation measures as a cholera precautionary action.

Local measures based on the precautionary principle also can be taken to fight
cholera. These may include local regulations that require chlorinated drinking water
and regular testing of water sources for cholera. In addition, if national and local
governments have not already done so, precautionary food protection measures
should be imposed to mandate proper food handling. It is without argument that
some of these preventative actions have been attempted to control cholera, yet they
have failed. Perhaps they have failed because of either delayed implementation or
a lack of enforcement capabilities. Nevertheless, what is certain is that the
precautionary approach has significant utility in the control of cholera. The
precautionary principle can be incorporated into multilateral or bilateral agreements
for the control of cholera. It can also serve as an underlying principle in
international organizations’ policies, action plans, and guidelines. Irrespective of
the way it is used, the precautionary principle should be used as another means to
control cholera.

The precautionary principle is not without its critics. One commentator asserts
that the precautionary principle’s implication “is profoundly damaging to science
and society: Scientific uncertainty, rather than the normal verified hypotheses of

295. See Gregory D. Fullem, The Precautionary Principle: Environmental Protection in the
Face of Scientific Uncertainty, 31 WILLAivBTr L. REV. 495, 504 (1995) (finding that
“[i]ntemational delegates confronting the issue of global warming have also embraced the
precautionary approach”); Richard B. Howarth, Sustainability Under Uncertainty: A
Deontological Approach, 71 LAND EcON. 417, 420-25 (1995) (defending the precautionary
principle, both philosophically and through economic modeling).

296. See Guidelinesfor Cholera Control, supra note 116, § 3.1.

1080 [Vol. 74:1035

INTERNATIONAL CONTROL OF CHOLERA

cause and effect, becomes the basis for policy. The subjunctive becomes
governmental imperative.”w Another critic claims that the precautionary principle
replaces environmental risk with risk to wealth of a country.

29

Despite criticisms, the precautionary principle has gained notable recognition as
a guiding doctrine in international environmental law, yet its applicability is not
limited to the environment It encourages the best of all measures to take in the fact
of potential harm prevention. Therefore, its utility to the control of cholera may
prove to be indispensable. The precautionary approach coupled with enhanced
international cooperation may very well render the threat of cholera immaterial.

D. Application of Global Health Jurisprudence

A final recommendation is to apply the newly developed concept of global health
jurisprudence to the control of cholera.299 This concept developed from the
recognition that international law alone cannot ensure global health, but rather
global health will only be achieved by encompassing both international and national
law as applied to public health issues.0 It is naive to believe that international law
will provide the solution to all global health problems without the accompaniment
of improved national systems.3 ‘

Global health jurisprudence puts into practice what may already be evident:
international and national law are interdependent. Reform of international law often
reflects the legal trends and developments that have occurred at the national level,
and reform of national public health law is often dependent on legal activity at the
international level.3″2 This interwoven relationship between international and
national public health law is the critical element, recognized by global health
jurisprudence, that can and should be utilized to improve the effectiveness of the
international control of cholera.

In order to conceptualize the application of global health jurisprudence to the
control of cholera, it must be clearly defined. Global health jurisprudence is the
“body of rules, strategies, and procedures that allows law in all its forms to support
public health.”3 3 The goal it sets forth seems to have two components: (1) to
identify approaches, concepts, and standards that emanate from various sources of
international and national law, and (2) to foster discourse among states of these
identified approaches, concepts, and standards in order to establish the necessary

297. Patrick Michaels, Environmental Rules Should Be Based on Science, INSIGHT ON THE
NEMs, Apr. 12,1993, at 21, 21.

298. See F. Sherwood Rowland, Failure at the Earth Summit, 256 Sci. 1101,1109 (1992).
299. See David P. Fidler, The Future of the World Health Organization: What Role for

InternationalLaw?, 31 VAND. . TRANSNAT’LL. 1079, 1116 (1998).
300. See id. at 1116-17.
301. See Ian Brownlie, The Expansion oflnternationalSociety: The Consequencesfor the Law

of Nations, in THE EXPANSION OF INTERNATIONAL SOcIETY 357, 368 (Hedley Bull & Adam
Watson eds., 1984).

302. See Fidler, supra note 299, at 1116-17.
303.Id. at 1117.

1999] 1081

INDIANA LAW JOURNAL

legal mechanisms to address global health issues.114 In addition to lawmaking,
global health jurisprudence also plays a role in international policymaking.

3 0S

With the application of global health jurisprudence to the control of infectious
diseases, cholera outbreaks likely would be less frequent and possibly less severe.
Global health jurisprudence will establish a better international framework to
regulate public health issues generally, as well as provide a system in which already
existing national laws, regulations, and strategies, that have proven to be effective
in preventing cholera, can be applied globally. For example, under global health
jurisprudence, public health measures utilized by the EC to prevent cholera could
be applied on an international scale or at least extended to developing countries.
Global health jurisprudence establishes not only vertical relationships among
international organizations and states, but also horizontal relationships between
international organizations and between states.3″ 6 This bi-directional foundation of
relationships greatly improves the potential for effective international cooperation,
communication, and regulation of cholera.

Global health jurisprudence is a fairly new concept, and as any new legal tool it
will evolve and be refined with use. Therefore, it is much too early to critique its
success or failures. Until global health jurisprudence is applied to the global control
of infectious diseases, specifically cholera, its potential success in controlling
disease spread and eliminating disease occurrence remains somewhat uncertain.
Nevertheless, global health jurisprudence is a refreshing new legal concept
applicable to international infectious disease control, and perhaps exemplifies the
direction international infectious disease control should follow.

CONCLUSION

Cholera is a disease in resurgence that threatens the health of the global
community. It is a disease that has killed thousands, taxed trade relations, scarred
economies of cholera-afflicted nations, and thrived on environmental degradation.
Vaccines against cholera prove ineffective, and susceptibility to cholera infection
is remarkably high once cholera has contaminated drinking-water sources.
Furthermore, the modern scale of global commerce and travel makes a cholera
outbreak a threat to virtually every nation.0 7

In evaluating the factors that contribute to its spread and the current regulatory
regime for infectious diseases, it becomes evident that to prevent cholera, states and
international organizations must take a proactive, cooperative approach.
Environmental, social, and economic factors that allow for cholera outbreaks must
be addressed and globally coordinated responses must be initiated. Apparently, a
grave mistake that nations made in the past in their attempts to regulate cholera was

304. See id.
305. See id. at 1118-22 (discussing the policy-making role of global health jurisprudence and

the current debate by policy experts and legal scholars).
306. See id. at 1118-21.
307. See Fidler, supra note 5, at 794-800 (citing the globalization problem in combating the

spread of infectious diseases).

1082 [Vol. 74:1035

1999] INTERNATIONAL CONTROL OF CHOLERA 1083

to overlook the importance of the environmental factors. At the core of cholera
epidemics lies poor sanitation and inadequate drinking water. Controlling these
environmental factors is the key to defeating the cholera epidemic.

The environment in which people live is an important factor in the realization of
human health. Human societies both modify, and are modified by, their physical
surroundings. Human health is affected by those modifications. Globally, the
environment is experiencing deterioration at an alarming rate and human health is
placed in a parallel peril. Cholera is a clear example of the detrimental effects that
environmental degradation can have on human health. Cholera re-emerges when
water resources are polluted by human waste or wastes that contribute to algae
blooms. With an increase in the number and geographic range of algae blooms,
cholera outbreaks can be expected to increase. In sum, cholera teaches a broad
lesson: if humans do not care for their environment, then they will not be able to
adequately protect themselves from infectious diseases.

Indiana Law Journal
Summer 1999
International Control of Cholera: An Environmental Perspective to Infectious Disease Control
Julia A. Jones
Recommended Citation

International Control of Cholera: An Environmental Perspective to Infectious Disease Control

SPECIAL TOPICS

Cleft Deformities in Zimbabwe, Africa

Socioeconomic Factors, Epidemiology, and Surgical Reconstruction

Annette M. Pham, MD; Travis T. Tollefson, M

D

I
n the African country of Zimbabwe, a variety of socioeconomic factors have contributed to a
lack of specialty care and resources for the indigent population. Although cleft lip and palate
has a lower incidence in Africa (0.67 per 1000 births) than in Latin America or Asia, access to
reconstructive surgery is often difficult to obtain. A surgical team worked with Zimbabweans

at the Harare Central Hospital, Harare, to perform cleft surgery for 39 patients. We review the epide-
miology of cleft deformities in Africa, our experience with 39 patients with cleft lip and palate, and the
techniques used to address 2 patients with midfacial clefts. To our knowledge, this retrospective case
review and epidemiologic literature review is the first review of cleft care in Zimbabwe. Poverty in
Zimbabwe, caused in part by the highest inflation rate in the world, has contributed to the emigration
of a large number of specialists to other countries. In addition, the health care system is overwhelmed
by a high prevalence rate of human immunodeficiency virus (25%), leading to a drastically reduced
parental life expectancy (mean life expectancy, 36 years). Primary and secondary cleft lip and palate
repairs were completed without complications. Children requiring care beyond the scope of this mis-
sion were referred to the Republic of South Africa. The cooperation among the Zimbabwean admin-
istration, physicians, and nurses was integral to the organization and successful execution of this re-
constructive surgical mission. Ultimately, until the socioeconomic conditions improve in Zimbabwe,
training and continuing education of local physicians are imperative to advance the care of children
with cleft lip and palate. Arch Facial Plast Surg. 2007;9(6):385-391

According to ancient folklore, Great Zim-
babwe was considered to be the capital
of one of the world’s oldest civilizations.
Its name derives from the words zimba
(palace) and bwe (stone), referring to the
ancient city built from stone. Modern-
day Zimbabwe is a land-locked country
in south-central Africa, bordered by
Botswana, Mozambique, the Republic of
South Africa, and Zambia, and slightly
smaller than California in area. The popu-
lation in Zimbabwe is 12 million people,
with approximately 2 million living in the
capital city, Harare. The official language
is English, but the 2 most common native
languages spoken are Shona and Nde-
bele. Zimbabwe has the highest literacy rate
(91%) in Africa.1 However, Zimbabwe has
the lowest mean life expectancy in Africa,
36 years (in the United States, the life ex-
pectancy is 78 years).1

Similar to other African countries, Zim-
babwe has been affected by the mass exo-
dus of skilled professionals (ie, physicians,
engineers, scientists, educators) to more de-
veloped countries—the “brain drain.”2 The
impact on the health care sector is consid-
erable, contributing to increased medical
fees and costs, overcrowded central hospi-
tals, and lack of access to specialty care.2

In particular, a gap between lack of spe-
cialty care in cleft surgery and resources for
the indigent population was identified. The
incidence of cleft deformities in Zimba-
bwe, to our knowledge, is not cited in the
literature. However, in Malawi, Africa, the
incidence of clefts (all types) has been re-
ported to be about 0.67 per 1000 births.3

This is comparable with the incidence rate
reported in the United States for the popu-
lation of black individuals (0.7:1000).4

Author Affiliations: Department of Otolaryngology–Head and Neck Surgery,
University of California, Davis Medical Center, Sacramento.

For editorial comment
see page 382

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In October 2006, a US surgical team affiliated with the
organization Operation of Hope worked with physicians
and nurses in Harare Central Hospital (HCH) to evaluate
63 patients (23 patients with cleft lip and palate, 24 with
an isolated cleft lip, 10 with an isolated cleft palate, 2 with
a median cleft, and 4 with other diagnoses [microstomia,
ecotodermal dysplasia, bilateral swelling, and Tessier cleft
No. 25,6]). We performed 42 procedures for 39 patients on
5 consecutive operating days (Table). The preoperative
preparation, socioeconomic factors, and epidemiology are
described herein. Surgical reconstruction and postopera-
tive care will also be addressed, including the manage-
ment of a unique subset of midfacial clefts.

METHODS

In Zimbabwe, British colonial influence helped to create a par-
liamentary government system divided into departments called
ministries. The Ministry of Health infrastructure is designed for

an efficient, widespread distribution of information and re-
sources. The public health care system is organized based on ge-
ography, which consists of rural clinics where village health work-
ers (such as midwives and nursing or medical assistants) manage
day-to-day health care issues. At the next level, primary care phy-
sicians evaluate patients in the ward clinics. If additional levels
of care are required, patients are then sent to the district hospi-
tals or to the provincial hospitals for specialty care access. Ter-
tiary level care is available at the 2 main central hospitals in the 2
largest cities, Harare and Bulawayo.

Via this network of public health care levels, information re-
garding the planned cleft surgical procedures was disseminated
prior to the team’s arrival. Patients and their caregivers (predomi-
nantly mothers) were transported by bus from the rural areas to
the district or provincial hospitals and then on to HCH where the
surgical procedures were to be performed. In some cases, fami-
lies traveled from afar and were given room and board in the hos-
pital until the screening clinic, where eligibility for surgery was
determined. The mean time for travel from home was 3 hours,
although some traveled as long as 8 hours by bus.

Identification numbers and screening cards were assigned
and completed for all patients (Figure 1). The surgical team
worked closely with the medical staff at HCH to ensure con-
tinuity of care. Surgical residents from the HCH program also
evaluated the patients, performing preoperative examinations
and laboratory evaluations. In addition, nurses and nursing stu-
dents were responsible for ensuring the flow of the screening
process, obtaining vital signs, and assisting in translation for
non–English-speaking families.

Our cleft surgical team screened patients based on age,
weight, notable medical or surgical history, and complexity of
the deformity to determine eligibility for surgery. In most cases,
medical and surgical history were easy to obtain because par-
ents kept a notebook containing physician notes from birth,
which served as a personal, portable “medical record.” Over-
all, among the 63 patients who were evaluated there was a pre-
dominance of cleft deformities of the lip and palate. A variety
of other facial deformities were evaluated, as already de-
scribed. Thirty-nine patients were then chosen for a total of 42
procedures.

SURGICAL PROCEDURES

ANESTHESI

A

Working with the anesthesiologists from HCH was a
unique experience. The anesthesia team consisted of sev-
eral members, including the attending anesthesiolo-
gists, residents of different training levels, nurse anes-
thetists, and students. Each child was brought into the
operating room with a parent, who held the child while
sedation was induced with mask anesthesia. Once the pa-
tient was sedated, the patient was placed onto the oper-
ating table, and a member of the anesthesia team es-
corted the parent to the preoperative holding area.

In Zimbabwe, the primary inhalational agent used is
halothane, which is less commonly used in the United
States. It is most commonly used in underdeveloped coun-
tries because of its lower cost.7 However, one concern as-
sociated with the use of halothane is the sensitization of
the myocardium to arrhythmias after exogenous admin-
istration of catecholamines. When using halothane, the
surgeon must limit the epinephrine level to decrease
the risk of cardiac arrhythmias.7 (When using isoflu-
rane, enflurane, or desflurane, the subcutaneous dose of

Table. Diagnoses and 42 Procedures Performed
for 39 Patients on 5 Consecutive Operating Days

Patient No./
Sex/Age, mo Diagnosis Procedure

1/F/36 Cleft palate Cleft palate repair
2/M/60 Cleft palate Cleft palate repair
3/M/48 Cleft lip and palate Cleft lip and palate repair
4/F/12 Cleft lip Cleft lip repair
5/M/36 Cleft lip Cleft lip repair
6/M/18 Cleft lip Cleft lip repair
7/M/9 Cleft lip Cleft lip repair
8/M/12 Cleft lip Cleft lip repair
9/M/48 Cleft lip Cleft lip repair

10/M/18 Cleft lip Cleft lip repair
11/M/19 Cleft lip Cleft lip repair
12/M/5 Cleft lip Cleft lip repair
13/F/36 Cleft lip Cleft lip repair
14/F/36 Median cleft lip Cleft lip repair
15/F/16 Cleft palate Cleft palate repair
16/M/5 Cleft lip Cleft lip repair
17/F/36 Cleft palate Cleft palate repair
18/M/264 Cleft nasal deformity Cleft rhinoplasty
19/M/48 Cleft palate Cleft palate revision
20/M/24 Cleft lip, palate Cleft lip revision and

cleft palate repair
21/M/60 Cleft palate Cleft palate revision
22/F/96 Cleft palate Cleft palate repair
23/F/60 Cleft palate Cleft palate repair
24/M/60 Cleft palate Cleft palate repair
25/F/36 Cleft palate Cleft palate revision
26/F/48 Cleft palate Cleft palate revision
27/F/96 Cleft palate Cleft palate revision
28/F/7 Cleft lip Cleft lip repair
29/M/7 Cleft lip Cleft lip repair
30/M/24 Cleft lip Cleft lip repair
31/F/216 Median cleft lip Cleft lip repair and

rhinoplasty
32/M/13 Cleft lip Cleft lip repair
33/M/96 Cleft lip Cleft lip repair
34/M/36 Microstomia Commissuroplasty
35/F/96 Cleft lip Cleft lip repair
36/F/36 Cleft lip Cleft lip repair
37/M/11 Cleft palate Cleft palate repair
38/M/12 Cleft lip Cleft lip repair
39/F/96 Cleft palate Cleft palate revision

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Figure 1. An example of the screening card used to record patient data. After the patient is evaluated, the diagnosis and surgical plan are recorded. Screening
cards are then used to maintain medical records of all the patients evaluated.

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epinephrine can be up to 4-fold greater than that used
with halothane before arrhythmias occur.8)

Also, most arrhythmias associated with halothane use
are secondary to hypercapnia or an inadequate anesthetic
level.7 To prevent these potential cardiac adverse effects,
communication was a key part of the surgical process when
carefully injecting local anesthetic using lidocaine, 1%, with
epinephrine in a 1:100 000 ratio. Furthermore, the anes-
thesia team prevented hypoventilation and hypercapnia by
manually controlling the patient’s respiratory rate.

Once the surgery was completed, every patient was
extubated in the recovery room rather than in the oper-
ating suite. The turnover of the operating suite was thus
quite efficient. All patients were successfully extubated
in this manner. There were no anesthetic complications
and no need for reintubations.

GENERAL SURGICAL TECHNIQUES

We performed a total of 42 procedures for 39 patients (Table).
This included 10 cleft palate repairs as well as 6 cleft pal-
ate revisions using a variety of techniques, such as 2-flap,
3-flap, Furlow, or von Langenbeck palatoplasties, based on
the type of cleft encountered.4 There were 20 primary cleft
lips (Figure 2) and 1 cleft lip revision—all repaired using
a modified Millard rotation-advancement flap technique.

Among the 20 cleft lips, 2 were bilateral. Divergent schools
of thought exist regarding bilateral cleft lip repair with or
without a primary rhinoplasty at the time of repair.9,10 His-

torically, the cleft nasal deformity was not addressed dur-
ing the primary cleft lip repair. The deficient columellar length
in the bilateral cleft nasolabial deformity has been addressed
with forked flaps (Cronin technique) and V-Y advancement
techniques. However, dissatisfied with the surgical results,
a group of cleft surgeons shifted their focus from second-
ary to primary nasal repair, thus developing new strategies
to achieve an ideal primary nasolabial repair.9,10

One such strategy in the United States is the use of pre-
surgical orthopedics (eg, nasoalveolar molding) to im-
prove columellar length and to facilitate a primary naso-
labial repair. This strategy is, however, not feasible in
Zimbabwe because of the lack of resources and/or expe-
rienced orthodontists. Primary rhinoplasty during the bi-
lateral cleft lip repair was performed to limit the number
of future procedures. The prolabial incisions were con-
tinued into the marginal incisions to expose the lower lat-
eral cartilages. Dome-binding sutures (5-0 Prolene ab-
sorbable sutures; Ethicon Inc, Somerville, New Jersey) were
placed to improve tip projection. Suspension sutures from
the lower lateral cartilages to the upper lateral cartilages
were placed bilaterally. Silastic nasal conformers (sizes 3
and 4; Porex Surgical Inc, Newnan, Georgia) were used
to retain the nostril size and prevent stenosis.

In addition, a 22-year-old man presented with the stig-
mata of a previously repaired bilateral cleft lip, which had
affected his self-esteem. During rhinoplasty, poor nasal
tip projection was addressed with a V-Y columellar ad-
vancement and interdomal sutures. The surgery had a

B

D
A

C

Figure 2. There were 20 primary cleft lips repaired. A, Preoperative and B, postoperative photographs of a patient with a unilateral incomplete cleft lip.
C, Preoperative and D, postoperative photographs of a patient with a unilateral complete cleft lip.

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profound effect on the young man and his family. On our
return to the United States, his mother related:

Words fail me to extend/express my heartfelt gratitude at the love and
commitment shown by yourself and Team you travelled [sic] with to
Zimbabwe. . . . Thanks to you all, by the grace of God, he now has a
good looking nose, the change has done wonders to his outward ap-
pearance, its truelly [sic] amazing. With time I believe he’ll get over
the complex and build up a confidence in himself and who he ought
to be and not what circumstance tried to make him.

A FEW RARE CASES

Of 63 patients screened, there were 2 patients with me-
dian cleft lips. A rare occurrence, the median, or mid-
line cleft lip, has an incidence ranging from 0.43% to
0.73%.11 In 1976, Paul Tessier, MD, classified craniofa-
cial clefts according to an ordered numbering system that
could involve the soft tissue, the skeletal framework, or
both (Figure 3).5,6 Within this classification system, there
is a spectrum of cleft severity. For instance, a Tessier No.
0 cleft can present with variations such as minimal lip
notching in the midline to a complete cleft midline cleft
lip and possible bifid nasal deformity. Severe cases oc-
cur with extension into the skull base (cranium bifidum
occulta).5 Other features may include an alveolar cleft be-
tween the 2 central incisors; a broad nasal bridge; hy-
pertelorism; a thickened, duplicated, or absent septum;
and/or a broad tip with columellar and tip bifidity.5

Several techniques have been described to address the
bifid nose associated with the median cleft lip. Using a
combined intraoral approach with a modified fork flap
incision at the base of the columella, Turkaslan et al5 ad-
dressed the base of the nose and the duplicated septum.
The intraoral approach allowed wide exposure of the base
of the nose and the piriform apertures, the anterior max-
illary segment, and the cleft area. The modified fork flaps
raised at the nasal sill were then used to achieve colu-
mellar lengthening. In another report of the treatment
of 2 cases of bifid nose, Miller et al13 suggested that a mid-
line nasal incision extending from the midline of the na-
sal tip to the nasal root optimized exposure of the struc-
tural relationships. Unfortunately, this technique leaves
a midline nasal scar that does not fall within the borders
of aesthetic units.

We chose a modified external rhinoplasty approach. The
median cleft lip and nasal bifidity of a 3-year-old girl were
repaired with a modified V-Y columellar advancement tech-
nique. Previously, a cleft lip repair had been unsuccess-
ful. In addition to the cleft lip and bifid nose (Figure 4A),
she had a diastema between the 2 central incisors as well
as an alveolar cleft noted on imaging (Figure 4B). After
the cleft lip was repaired using a modified white roll tri-
angle flap technique, the nose was addressed by extend-
ing the midline incision just onto the columella. The me-
dial crura were accessed, and suture technique was used
to narrow the columella and to improve the subtle bifid-

Figure 3. A young girl presented with a rare Tessier No. 2 cleft anomaly.5,12
She also had a congenital nasal mass with an associated pit (black arrow),
which would require further workup prior to excision.

B
A
C

Figure 4. A 3-year-old with a previous attempt at repair of her median cleft
lip. A, Along with a median cleft lip, the patient had a bifid nose and a
diastema at the 2 central incisors. Note also the hypertelorism. B, A plain
radiograph in the anterior-posterior view demonstrates a median cleft
through the skeletal framework (yellow lines). C, The midline cleft lip was
repaired using a modified V-Y columellar advancement technique. An
immediate postoperative result demonstrates the incisions for the cleft lip
revision with extension onto the midline columella.

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ity created by the divergent lower lateral cartilages. An im-
mediate postoperative photograph illustrates the inci-
sions used and preliminary results (Figure 4C).

An 18-year-old woman with a median cleft lip and a bi-
fid nose also presented for repair (Figure 5). An external
rhinoplasty approach was used to address the duplicated
septum and divergent lower lateral cartilages (Figure 6).
The fibrofatty intradomal tissue was rotated superiorly into

the supratip and secured as a vascularized flap prior to dome-
binding suture placement (Figure 7). Both patients had
mucosalized tracts extending in the midline maxillary buc-
cal sulcus within the bony cleft (Figure 8).

POSTOPERATIVE CARE

Our team worked with the nurses and pharmacists to un-
derstand standardized order sets and medicine formula-
tions for optimization of postoperative issues such as fluid
management, antibiotic use, and pain control. The par-
ents also played a vital role in the patients’ postopera-
tive care. Although breastfeeding of children with cleft
lips is a controversial issue among cleft surgeons, we en-
couraged the mothers of the patients with cleft lip to nurse
postoperatively for several reasons. Breastfeeding sim-
plified postoperative management of oral intake for moth-
ers and nurses and also allowed the mothers to be inti-
mately involved in their children’s care—a practical as

BA

Figure 5. An 18-year-old woman with a median cleft lip and nasal bifidity (A) that is accentuated when smiling (B).

Figure 6. An intraoperative photograph depicting exposure of the duplicated
septum (black arrow) and divergent lower lateral cartilages using an external
rhinoplasty approach.

Figure 7. A vascularized fibrofatty tissue flap is rotated into the supratip
region to augment the deficient area in the bifid tip secondary to the
divergent lower lateral cartilages. Interdomal sutures (5-0 Prolene; Ethicon
Inc, Somerville, New Jersey) were used to address the nasal bifidity.

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well as a psychological advantage. Multiple studies have
reported that early postoperative breastfeeding did not
increase the risk of wound complications.12,14,15 In addi-
tion, breastfeeding was not only more economical than
spoon-feeding, it simplified the postoperative regimen and
even enhanced weight gain.12,14

A discharge clinic was held after the last operating day.
Patients who lived in Harare or neighboring towns were
discharged when appropriate and returned for a postop-
erative visit at the discharge clinic. The team removed
the sutures, and local wound care was emphasized.

Patients who had traveled far from home remained in
the hospital until the discharge clinic. Afterward, trans-
portation was arranged for patients and their caregivers
to return home. Patients whose deformities had been re-
paired later in the week had absorbable sutures placed.
There was also another discharge clinic 1 week later for
patients still needing additional postoperative care prior
to the last team members’ return to the United States.

COMMENT

Performing cleft surgical procedures can be both a re-
warding and a challenging experience. Although pro bono
missions for these reconstructive surgical procedures con-
sist of a short time period spent screening, operating, and
performing early postoperative care, the success of the
mission is determined by the planning and preparation
prior to the trip as well as the participation and coordi-
nation among the people of the hosting country. In Zim-
babwe, the Ministry of Health distributed information prior
to our arrival as well as during our stay to facilitate our
outreach efforts.

The physicians, nurses, and staff at HCH were accom-
modating and flexible. They organized nursing staff,
operating room personnel, and even hospital rooms to
create an efficient working environment. Of utmost im-
portance, the interaction between the Zimbabwean sur-
geons and our team in the operating room facilitated the
exchange of cleft repair techniques. This is important be-
cause ultimately these surgeons will be treating the chil-
dren independently.

In conclusion, a long-term relationship between Op-
eration of Hope and the Zimbabweans will ensure that
the gap between a lack of specialty care in cleft surgery
and needs of these patients can be overcome. Future goals
will include education and surgical training to em-
power the medical staff dedicated to staying in Zimba-
bwe despite the “brain drain.”

Accepted for Publication: June 1, 2007.
Published Online: October 22, 2007 (doi:10:1001
/archfaci.9.6.qsp70001).
Correspondence: Travis T. Tollefson, MD, Cleft and
Craniofacial Program, Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology–Head and
Neck Surgery, University of California, Davis School of
Medicine, 2521 Stockton Blvd, Suite 7200, Sacramento,
CA 95817 (travis.tollefson@yahoo.com).
Author Contributions: Study concept and design: Pham
and Tollefson. Acquisition of data: Pham and Tollefson.
Analysis and interpretation of data: Pham and Tollefson.
Drafting of the manuscript: Pham. Critical revision of the
manuscript for important intellectual content: Pham and
Tollefson. Administrative, technical, and material sup-
port: Pham. Study supervision: Tollefson.
Financial Disclosure: None reported.
Additional Contributions: The directors of Operation
of Hope—Joseph Clawson, MD, Jennifer Trubenback,
and Stephen Clawson—arranged this mission. We
thank them for their diligent work to make this surgical
mission possible.

REFERENCES

1. World Health Organization Global Health Atlas. 2003. http://globalatlas.who.int
/globalatlas/. Accessed November 9, 2006.

2. Chetsanga CJ, Muchenje TB. An Analysis of the Cause and Effect of the Brain
Drain in Zimbabwe. Harare, Zimbabwe: Scientific and Industrial Research and
Development Centre; 2001.

3. Msamati BC, Igbigbi PS, Chisi JE. The incidence of cleft lip, cleft palate, hydro-
cephalus and spina bifida at Queen Elizabeth Central Hospital, Blantyre, Malawi.
Cent Afr J Med. 2000;46(11):292-296.

4. Sykes JM, Senders CW. Cleft palate. In: Cotton RT, Myer CM, eds. Practical Pe-
diatriatric Otolaryngology. Philadelphia, PA: Lippincott Williams & Wilkins;1998:
809-824.

5. Turkaslan T, Ozcan H, Genc B, et al. Combined intraoral and nasal approach to
Tessier No:0 cleft with bifid nose. Ann Plast Surg. 2005;54(2):207-210.

6. Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts.
J Maxillofac Surg. 1976;4(2):69-92.

7. Cote CJ. Pediatric anesthesia. In: Fleisher LA, Johns RA, Savarese JJ, Wiener-
Kronish J, Young WL, eds. Miller’s Anesthesia. 6th ed. New York, NY: Churchill
Livingstone; 2005:2374-2375.

8. Savino JS, Floyd TF, Cheung AT. Cardiac anesthesia. In: Cohn LH, Edmunds LH
Jr, eds. Cardiac Surgery in the Adult. 2nd ed. Columbus, OH: McGraw-Hill; 2003:
249-281.

9. Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip: review, revisions, and
reflections. J Craniofac Surg. 2003;14(5):609-620.

10. Mulliken JB. Bilateral cleft lip. Clin Plast Surg. 2004;31(2):209-220.
11. Apesos J, Anigian GM. Median cleft of the lip: its significance and surgical repair.

Cleft Palate Craniofac J. 1993;30(1):94-96.
12. Darzi MA, Chowdri NA, Bhat AN. Breast feeding or spoon feeding after cleft lip

repair: a prospective randomized study. Br J Plast Surg. 1996;49(1):24-26.
13. Miller PJ, Grinberg D, Wang TD. Midline cleft: treatment of the bifid nose. Arch

Facial Plast Surg. 1999;1(3):200-203.
14. Weatherley-White RCA, Kuehn DP, Mirrett P, et al. Early repair and breast-

feeding for infants with cleft lip. Plast Reconstr Surg. 1987;79(6):879-885.
15. Cohen M, Marschall MA, Schafer ME. Immediate unrestricted feeding of infants

following cleft lip and palate repair. J Craniofac Surg. 1992;3(1):30-32.

Figure 8. Patient 31. Both patients with midfacial clefts (patients 14 and 31)
demonstrated a mucosalized tract (black arrow) between the bony
maxillary cleft.

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EmergingProblems in Infectious Diseases

Zimbabwe experiences the worst epidemic of cholera in Africa

Peter R. Mason

Biomedical Research & Training Institute and the University of Zimbabwe College of Health Sciences, Harare, Zimbabwe

Abstract
A severe outbreak of cholera has been reported in Zimbabwe since mid 2008, with so far over 92,000 cases and over 4,000 deaths. This

outbreak has differed from previous outbreaks in being mainly urban and with a high case-fatality rate. Breakdown in the supply of clean

water has been the main underlying cause but breakdown in health service delivery in Zimbabwe has also contributed to the magnitude and

severity of the outbreak.

Keywords: cholera, epidemic, Zimbabwe

J Infect Developing Countries 2009; 3(2):148-151.

Received 18 February 2009 – Accepted 25 February 2009

Copyright © 2009 Mason. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Cholera is endemic in a number of countries in

southern Africa, and minor outbreaks have been

recorded in Zimbabwe many times in the past. These

outbreaks have usually occurred in communities that

border endemic regions, particularly in the provinces

of Manicaland and Mashonaland East, on the border

with Mozambique. Outbreaks have increased in

frequency and severity in the past 15 years, and have

become more difficult to control. The first large

outbreak of cholera was reported in 1992, in

Manicaland and Mabvuku/Tafara – suburbs on the

eastern edge of Harare – with just over 2,000 cases

and a mortality of 5%. The following year there were

5,385 cases and 381 (6%) deaths. The next outbreak

in 1998 had more than 1,000 cases and 44 deaths, and

the following year there were 5,637 cases with 385

deaths. Most of these cases were in Chipinge and

Chiredzi, in the south-east of the country again close

to the Mozambique border. During 2002, 3,125 cases

were reported in Manicaland and Mashonaland East,

including 192 fatalities. In October 2003, 304 cases

with 11 deaths were reported in Kariba, on the border

with Zambia, and a further 99 cases, 16 of them fatal,

were reported from Binga, a small fishing community

on the shore of Lake Kariba. The Binga cases

probably originated in Kariba, and the high mortality

was probably related to the difficulty of

communications – six people had already died before

the outbreak came to the attention of the health care

authorities. The common feature of all of these

outbreaks was that they occurred in border

communities and were therefore probably imported

from endemic regions in surrounding countries.

While they were serious outbreaks, they were

contained within a short time because of an effective

and efficient response by the health care system.

Thus, while they were unwelcome incidents, they

posed little threat to the wider communities of

Zimbabwe.

During the past 5-10 years, the health system in

Zimbabwe has been compromised by critical

shortages of finance and declining infrastructure. Key

health personnel have become demoralized by poor

pay packages and their inability to practice their

medical professions because of shortages of

diagnostics, drugs and support systems. Many health

professionals have left Zimbabwe, leading to a

critical shortage of human resources especially in the

Mason – Zimbabwe experiences the worst epidemic of cholera in Africa J Infect Developing Countries 2009; 3(2):148-151.

149

periphery. Many of the clinics established in rural

areas during post-independence development are no

longer functioning. Even in larger urban areas, health

care has been dramatically compromised by the

economic crisis in Zimbabwe. A number of District

Hospitals have been closed in the past few months,

and services at Referral Hospitals in major cities have

been severely limited. The surveillance and

monitoring of disease outbreaks depends to a great

extent on having personnel in place at functional

community health care clinics, so surveillance has

also been severely compromised – to the extent that

data completeness is estimated to be only 30%.

The current outbreak of cholera that began in

mid-2008 is different from previous outbreaks in a

number of ways. This is by far the largest and most

extensive outbreak of cholera yet recorded in

Zimbabwe and indeed in Africa. Unlike previous

outbreaks, most cases have appeared in urban centres,

far from the borders with endemic neighbouring

countries. Indeed, there is much evidence that

Zimbabwe is now a source of cholera infection for

other countries in the region. Understanding the

reasons for this dramatic shift in epidemiologic

characteristics will need intensive research, but the

current pressures are first to try to contain the

epidemic and to reduce the high mortality, and there

has been only limited investigation. In this report, I

will present some of the epidemiological data; later

we expect to have more information from

microbiological studies

Initial outbreak
The present outbreak started in mid-2008 with

the first cases, reported on 20 August, from St.

Mary’s and Zengeza wards of Chitungwiza, a large

urban centre on the outskirts of Harare. This

outbreak, with 118 cases, was well managed and

quickly brought under control through effective

diagnosis and treatment. Although most cases were

diagnosed clinically, Vibrio cholerae was isolated

from 18 (30%) of 59 specimens submitted for

examination, thus supporting the clinical evidence for

an outbreak of cholera. Following this initial

outbreak, a second wave of infections was reported a

few months later. This outbreak occurred more

widely within Chitungwiza, with numerous wards

being affected. By 20 December there were over 600

cases and 104 deaths in the city. The case fatality

ratio in this outbreak was extremely high at 15%, a

situation attributed to the breakdown of health

services in urban areas as result of the economic

crisis in Zimbabwe, and rapid transmission of

infections to people who were already under stress

from hunger.

Both of these outbreaks occurred in urban areas,

with no obvious direct connections to countries

where cholera was endemic, though the initial import

into the community may well have been from a

visitor or recent traveler.

Fig 1. Emergence of cholera in Zimbabwe: Cumulative

cases August 2008-February 2009

Spread through Zimbabwe

Following these urban outbreaks, new cases

were reported with increasing frequency from rural

communities in different provinces. Large outbreaks

were recorded in Beitbridge, on the border with

South Africa, during November 2008 and in Norton,

a small town west of Harare in December 2008.

Cases

were, however, appearing countrywide, and by

the end of December 2008, cholera had been reported

from all 10 provinces in the country. As noted above,

spread to South Africa, Mozambique, Botswana and

Zambia is also suspected to have occurred – all four

countries have reported cases of cholera and cholera

deaths in districts that border Zimbabwe. The data

from the provinces are shown below; the importance

of large outbreaks in urban areas of Harare is quite

clear.

0

10000

20000

30000

40000

50000

60000

70000

80000

A
u

g
-N

o
v

D
e

c
h

a
lf

1

D
e
c
h
a
lf

2

Ja
n

h
a

lf
1

Ja
n
h
a

lf
2

F
e

b

Cumulative cases

Deaths

Mason – Zimbabwe experiences the worst epidemic of cholera in Africa J Infect Developing Countries 2009; 3(2):148-151.

150

Fig 2. Cases of cholera reported in different provinces

August- December 2008

Transmission
Cholera is transmitted mainly through

contaminated water and food, and the breakdown in

water supply and sewerage disposal in urban areas is

believed to be the underlying cause for the rapid

emergence of cholera in the cities. The transfer of

responsibility for water supply and sewerage disposal

from City Councils to the Zimbabwe National Water

Authority (ZINWA) has been closely linked to the

current outbreak. Since the transfer of responsibility,

parts of Harare and Chitungwiza have been without

running water for more than 2 years. People have

become dependent on shallow wells that may become

readily contaminated because of the lack of sewage

disposal. Although ZINWA has promised on many

occasions to correct the supply problems, lack of

finance from central government (and possibly other

factors concerning management shortcomings) has

limited their ability to do this. At present,

international donor agencies are providing support to

try to improve the water supply situation. In the long

run, these measures may be able to control the

epidemic.

Vibrio cholerae has been isolated from more

than half of the suspect cases tested, with at least two

serotypes involved in the outbreak. Serotype Ogawa

has been described in isolates from Harare and

Beitbridge (Matabeleland south), while both Ogawa

and Inaba serotypes have been found in Mashonaland

West (Chegutu and Makondi districts). Molecular

studies are expected to add to our understanding of

epidemiological patterns and virulence factors in the

outbreaks in different parts of the country, and we

hope that such studies can be undertaken soon, using

isolates collected during the outbreak.

Cholera fatalities
Case fatality ratios (CFR) in most districts

exceed 5%, based on cases recorded at health clinics.

Outside of the clinics, community fatality ratios are

estimated by WHO to be 22-48%. In most provinces

about 40% of all cholera deaths occur in the

community, and the figures on case fatality may need

to be adjusted accordingly. The CFR in most

outbreaks around the world is about 1%. A number

of factors have been put forward as possibly

contributing to such high CFR, including bacterial

virulence factors, poor nutrition and poor immunity

of infected persons, delays in diagnosis, and

difficulties of accessing appropriate treatment.

Death from cholera is usually a result of dehydration,

and fatalities can often be prevented by the use of

oral rehydration salts (ORS). The main problem

facing infected people in Zimbabwe is lack of access

to ORS – whether at the clinic or at home. The

economic collapse in the country has meant that

clinics and hospitals are no longer able to acquire and

stock even basic medicines and materials to provide

health care. Even though basic ORS packs would be

relatively inexpensive, they are not available. Many

of the clinics in rural areas are closed, because there

are no staff, so patients have to travel to clinics in

urban areas for treatment. The cost of transport is

often beyond the means of the rural poor, leading to

delays in accessing health care. The alternative is to

use home-based ORS. In the past, many health

education programs highlighted the way to prepare

ORS at home, mainly to support home-based

management of diarrhea in children. Sadly, the costs

of the simple basic ingredients of ORS – salt, sugar

and clean water – are also beyond the means of many

in the current economic situation.

The future
Understanding why this situation happened may

help in making decisions about how to control and

prevent further epidemics. Outbreaks of cholera have

been reported many times in the past in Zimbabwe,

but until now all have been focal outbreaks and have

0
1000
2000
3000
4000
5000
6000
7000
8000
9000

10000
Cases

Mason – Zimbabwe experiences the worst epidemic of cholera in Africa J Infect Developing Countries 2009; 3(2):148-151.

151

been contained quickly. The current outbreak has

been continuing for at least six months and so far

shows no sign of abating, with hundreds of new cases

and many fatalities reported daily. The loss of life –

over 3,500 people have died so far – has reminded all

involved in health care that even those diseases that

we thought we could control may return with a

vengeance, if circumstances permit it.

The breakdown in water supply and sewerage
disposal in high density urban areas was

undoubtedly a main factor in the emergence and

rapid spread of infections. While economic

factors may be important contributors to this

breakdown, there is also the inability of ZINWA

to deliver the service with which they were

entrusted – the supply of safe water to residents

of major towns and cities. An investigation into

the operations of ZINWA is needed to identify

failures and ensure that such failures do not

recur. The decision by central government to

remove responsibility for urban water supply

from ZINWA and return responsibility to city

councils is a step in the right direction.

The breakdown in health service facilities, with
shortages of clinic staff, was a major factor in

delaying detection and management of cases, and

contributes to the high case-fatality ratio

experienced in this epidemic. Attempts are

currently being made to provide more realistic

pay and conditions of service for health care

personnel, to retain the staff who remain.

Assistance from international agencies,

particularly UNICEF, has been pledged for this

program.

The lack of diagnostic services has meant that
clinical indications of infection have only rarely

been confirmed by laboratory isolations and

characterizations of infections. While clinical

diagnosis is effective in outbreak situations,

laboratories do have a role to play in detecting

and identifying pathogens, and the powerful

technologies of molecular epidemiology can

make significant contributions to implementing

effective control measures. Capacity building, to

ensure that personnel can detect pathogens in

both clinical and environmental specimens, is an

important component of a good control strategy.

Failure of primary care facilities to provide even
simple conditions for case management has

contributed to the high CFR. The provision of

ORS at all primary care clinics would have done

much to reduce the mortality in this epidemic.

Support from international donor agencies to

ensure adequate stocks of ORS should help to

reduce CFR in the immediate future, but long

term commitment by government for financial

support for health services is needed.

Finally, the general economic crisis of
Zimbabwe, where unemployment is at 94% and

where there are critical shortages of food and

basic commodities, has contributed to an

increasingly vulnerable population. It is perhaps

difficult to imagine that people do not have

resources to buy salt and sugar, but that is the

reality of Zimbabwe. Most shops now sell goods

only for foreign currency, and the source of such

currency is only through the “black market”

which is beyond the reach of the majority of the

population. Add to this the high cost of transport

to health care centres for those who require

rehydration, and the reasons for the high

mortality in this epidemic can be appreciated.

Now is the time for a recognition of the need for

vigilance in recognizing disease outbreaks at an early

stage, and while we are currently dealing with the

crisis of cholera, there are many other infectious

diseases that are waiting to emerge – anthrax, typhus

and typhoid being only a few. Collaboration between

Zimbabwe and international partners is essential for

effective surveillance and response programs, and

with ongoing changes in the political situation we

have to hope that such international collaborations

can again thrive.

Corresponding Author
Prof. P. R. Mason, BRTI, PO Box CY1753

Causeway, Harare, Zimbabwe

pmason@brti.co.zw

Note in proof: The total number of cases of cholera
as of 23 March 2009 was 92,432 with 4,072 deaths

(CFR 4.4%). The indications are that control

measures are starting to have an effect, and the

numbers of new cases reported on a daily basis have

been declining.

Overall Health Situation
Zimbabwe’s overall health service has been steadily
declining for the last five years. Once a system that
neighbouring countries referred patients for special
care to, the Zimbabwean health service today is
wracked by critical shortages of essential drugs and
skilled and experienced personnel.

Another challenge is there has been no
comprehensive assessment of Zimbabwe’s health
system since 2006, making it difficult to assess its
true state. Also, its disease surveillance and early
warning system, which depends on a weekly
epidemiological system, has been compromised in
terms of timeliness and completeness of data, which
is only around 30%. Staffing and financial
limitations are impacting on Zimbabwe’s ability to
produce a national health profile.

Universal access to basic health services is
compromised due to deteriorating infrastructure,
staffing and financial resources. Reactivating
primary health care services should keep being
addressed as a matter of emergency.

Zimbabwean health facilities face a massive gap –
estimated this year at 70% – in required medicines
due to reduced local manufacturing capacity, which
has been weakened by a lack of foreign currency.
This is despite support received from different
partners through UNICEF’s procurement systems.

Cholera Update
A large cholera outbreak is affecting most regions of
the country, with more than 11 700 cases and 473
deaths recorded between August and 30 November.
This represents a case fatality rate (CFR) of 4.0%
nationally, but reached 50% in some areas during the

early stages of the outbreak. The CFR benchmark
should be below 1%.

Cholera outbreaks in Zimbabwe have occurred
annually since 1998, but previous epidemics never
reached today’s proportions. The last large outbreak
was in 1992 with 3000 cases recorded.

Areas recording high CFRs have been demonstrating
weaknesses in case management and/or infection
control practices. Potential causes of the high CFR
that must be addressed are 1) delays in people
seeking treatment: 2) poor accessibility to health
facilities: 3) gaps in case management: and
4) inadequate infection control. Cholera cases have
also been reported either side of Zimbabwe’s border
with South Africa, Botswana and Mozambique,
demonstrating the subregional extent of the outbreak.
In South Africa, the Ministry of Health has
confirmed more than 160 cholera cases, including
three deaths. Cases have also been reported in
Johannesburg and Durban.

This cholera outbreak has strained Zimbabwe’s
overburdened health care system and resulted in a
nationwide shortage of medicines and other
materials for treatment, aggravating the scarcity of
health care providers and the poor access to overall
care. The outbreak can spread quickly into areas
without access to safe water and sanitation. Case
fatality rates may rapidly escalate in populations
without rapid access to simple treatments.

Cholera is easily preventable by ensuring access to
safe water and appropriate hygiene, while deaths can
be prevented with quick access to simple,
standardized treatment regimens.

Zimbabwe
Cholera and
Health
Situation

WHO Response
And Needs

1 December 2008

WHO Response Strategy
WHO and its Health Cluster partners are finalizing a
“Cholera Response Operational Plan” to control the
current outbreak. The response must be viewed as an
emergency measure within the context of a severely
deteriorated health care system and civil
environment. The response should be multi-sectoral
in support of the Zimbabwean Ministry of Health
and partner agencies intervening in the field.

The objectives of the response are to:
1. Reduce the epidemic spread by:
• Ensuring access to safe water and sanitation

conditions, particularly in health facilities;
• Reinforcing community mobilization;
• Ensuring safe isolation and infection control

practices in health structures (including
funerals);

• Strengthening Health Cluster coordination.
2. Decrease mortality by:
• Ensuring early case detection;
• Improving access to health care;
• Ensuring adequate care, including feeding

support.
The response should cover needs in the domains of
epidemiology, surveillance and response; water and
sanitation; infection control; social mobilization; and
logistics. This coordinated approach will involve
close collaboration with public health authorities in
Zimbabwe and neighbouring countries, as well as
nongovernmental organizations and United Nations
agencies including UNICEF. An Inter-Agency
Rapid Assessment Team must be established to
investigate and confirm outbreaks.

The emphasis must be on rapidly addressing the
known risk factors for cholera transmission.
Immediate priorities include:

• Standardized case reporting to understand their
distribution, guide treatment priorities, and
inform prevention messages;

• Ensuring access to safe water and sanitation;
• Standardized case management to reduce

mortality;
• Producing treatment and prevention materials,

as well as prevention messaging campaigns to
mitigate the risk to populations.

WHO Response Operations to
Date
WHO and its Health Cluster partners are monitoring
and responding to the outbreaks reported in multiple
areas (including Mutare, Chimanimani, Guruve,
Concession, Chiredzi, Mwenzie, Kwekwe, Gutu,
Chivi, Bikita, Zvimba) and supporting cholera
treatment centres in 26 districts.

WHO’s close relationship with the Ministry of
Health is providing added value for health sector
players. WHO and the Ministry of Health are
collaborating to provide the cholera case and
mortality data by district that is used in the daily and
weekly cholera situation updates issued by OCHA.

At the Health Cluster meeting on 25 November,
several gaps were identified in the detection,
assessment, organization of response, case
management and surveillance and information
management. In response, WHO has been airlifting
emergency stocks of supplies from United Nations
Humanitarian Resource Depot in Dubai and
mobilizing additional drugs and supplies through
WHO Country Office in South Africa.

WHO headquarters, in liaison with its African
regional office and Harare-based Inter Country
Support Team, is deploying a full outbreak
investigation and response team, including
logisticians, epidemiologists, social mobilization,
communications officer and specialists in water and
sanitation.

WHO, on behalf of the Health Cluster, produced a
document titled Zimbabwe Health Situation: Let us
show our Leadership and act NOW!, which was
provided on 25 November to and endorsed by the
Ministry of Health. The document called for an
emergency response to the cholera outbreak. The
Health Cluster is also finalizing its Cholera
Operational Response Plan as well as the provincial
distribution of agencies to lead cholera outbreak
response.

Health Priorities and Needs
US$ 2 million in financial support is required to
cover the cost of health response activities for the
next three months, including providing:

• Cholera and diarrhoeal disease kits;
• Emergency health kits;
• Water purification equipment;
• 10 portable laboratory kits for diagnosis;
• Personnel (including for epidemiological

control and Health Cluster coordination);
• Cholera treatment training.

For more information:

Zimbabwe:
Dr Custodia Mandlhate
WHO Representative
Tel: +263 4 253730 ⎜ Fax: +263 2 253724

mandlhatec@zw.afro.who.int

Geneva:
Jukka Sailas
External Relations, Health Action in Crises
Tel: +41 22 791 4778 ⎜ Fax: +41 22 791 4844

sailasj@who.int http://www.who.int/disasters

82

Annals Academy of Medicine

Cholera in Zimbabwe–Dale Fisher

Commentary

Cholera in Zimbabwe
Dale Fisher,1,2FRACP, DTM&H

Cholera in Zimbabwe remains uncontrolled, with cholera-
associated deaths continuing to be reported in 9 of the
nation’s 10 provinces.1 In the 4 months since the outbreak
began in August 2008, more than 35,000 suspected cases
have been reported, including 1753 deaths. All provinces
are affected but Harare sees almost one third of cases. It is
possible that the cumulative numbers could double over the
next few months, especially as January to March is a rainy
season. The case fatality rate is a remarkably high 3% to
10%, reflecting the difficult circumstances faced by local
healthcare providers and the increasingly involved external
agencies.

A state of emergency was declared in the first week of
December 2008 by the Health Minister, at which time an
appeal for international help was made. For cholera in
Zimbabwe this is an exceptional period, as the endemic
situation has seen annual epidemics for over a decade. The
current spread with such extraordinary numbers is well
tracked, with an onset around 20 August 2008 in
Chitungwiza City near Harare.2

In disadvantaged settings Vibrio cholera is predominately
transmitted by contaminated water, whereas in developed
regions it is via food contaminated by cholera-carrying
water, shellfish being a significant reservoir. Endemic
regions see excess numbers during wet seasons, particularly
when floods occur.

The most common clinical presentation is severe
diarrhoea, but most infections are asymptomatic or have
only mild diarrhoea.3 The latter circumstance is
advantageous to the organism, in terms of sustainability in
a population in which potable water supply, hygiene and
sanitation are suboptimal. Prolonged human carriage of
V. cholerae in individuals is rare and unimportant to
disease transmission.

The incubation period maybe less than a day and up to 5
days, and is linked to the bacterial inoculum. The onset is
classically abrupt with voluminous (classically rice water)
stools, often with a fish-like odour. Vomitus is generally
clear and watery. Fluid loss from diarrhoea can be up to 1
litre per hour, causing life threatening dehydration and

1 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
2 Department of Medicine, National University Hospital, Singapore

Address for Correspondence: A/Prof Dale Fisher, Department of Medicine, Yong Loo Lin School of Medicine, 5 Lower Kent Ridge Road, Singapore 119074.
Email: mdcfda@nus.edu.sg

electrolyte and acid/base disturbance that potentially appear
within hours. Significant obstetric complications include
miscarriage and premature labour.4

Treatment alters the natural history of severe cholera, for
which case fatality can be as high as 50%. Currently the
Zimbabwe Ministry of Health and Child Welfare (MoHCW)
is receiving assistance from groups including WHO, Medcin
sans Frontieres (MSF), UNICEF, Oxfam, the Centres for
Disease Control and Prevention (CDC, USA), Plan
International and the Red Cross.

Managing individuals with cholera is simple, and focuses
on replacing fluids and electrolytes at the same rate as their
loss occurs. This is after an initial period of “catch up”.
Indeed, cholera deaths should be completely preventable
and any such event highlights the difficulties of
implementing a sustainable and widely accessible treatment
system.

Fluid and electrolyte restoration and maintenance may
require intravenous therapy if severe, but usually oral
rehydration solution (ORS) is adequate. The cholera cot is
a useful adjunct to treatment of patients with severe
diarrhoea. It has a hole to facilitate defaecation and also
measurements of losses.

Antibiotics are recommended in severe disease, and can
both shorten the illness duration, and lessen the diarrhoea
and thus the need for possibly scarce health resources
including hospital care and ORS. Resistance to many
antibiotics via a number of mechanisms has been
documented.5 Doxycycline for 1 to 3 days is regarded as
first line, but resistance is well recognised. Co-trimoxazole,
ciprofloxacin, chloramphenicol and erythromycin are also
potentially useful.

The regular daily Zimbabwe cholera updates often report
in excess of 100 deaths in 1 day.6,7 This recent toll illustrates
the tremendous ongoing challenge in establishing treatment
systems while attempting to curtail transmission.

Worldwide, cholera outbreaks have been well documented
over the last 2 centuries even before microbiological
capabilities developed. The epidemiologic investigation
by John Snow in 1854 in London, which culminated in

January 2009, Vol. 38 No. 1

83Cholera in Zimbabwe–Dale Fisher

removal of the handle of the Broad Street pump perhaps
carries the greatest notoriety. Pandemics of different
serotypes of V. cholerae have been well documented. The
current pandemic caused by El Tor, or serotype 01, was
first identified in Indonesia in 1905. However, its spread
was not observed until after 1960, initially to India, Africa,
Southern Europe then South America in 1991.8 It is,
however, the failure of public health systems, often due to
civil conflict, which results in a local surge of cases and
mortality above its baseline endemic rate. In Monrovia,
Liberia, June 2003 saw the cholera case numbers increase
around 8-fold due to fighting and population movement.
June to September 2003 saw 1.4% of the population meet
the case definition for cholera.9

Outside of publicly declared national emergencies, the
incidence of cholera is difficult to reliably quantify in most
affected countries. In 2005, 131,934 cases and 2272 deaths
were notified worldwide. It is estimated that this may
represent only 5% to 10% of the actual figures. Included in
that reporting year were just 516 Zimbabweans, 26 of
whom died.10

Outbreaks of classic infectious diseases, such as cholera,
are somewhat inevitable in the circumstances currently
presented by Zimbabwe. The well described and devastating
political turbulence and economic collapse witnessed over
the last decade has produced a loss of infrastructure
necessary to facilitate domestic food production and
maintain essential services including water, sanitation and
hygiene.11

The primary objectives of the WHO response to control
the cholera outbreak in Zimbabwe are to reduce the spread
of the epidemic by strengthening epidemiological and
laboratory surveillance, ensuring access to safe water and
sanitation together with sound infection control practices
in healthcare facilities. By assisting in the early detection of
cases and facilitating easy treatment access and appropriate
case management, mortality should fall.

The WHO including its Global Outbreak and Alert
Response Network (GOARN) and its partner organisations
have deployed epidemiologists, logisticians, public health
experts, infection control specialists, communications and
social mobilisation experts, and also procured diarrhoeal
disease and emergency health kits and medical supplies for
the affected areas across Zimbabwe. More than half of the
now 172 cholera treatment centres (CTCs) are receiving
assistance from external non-government organisations
(NGOs). The average population served by a CTC is
211,000 with a peak of 670,000 people served per CTU in
Harare.12

The cholera outbreak in Zimbabwe is massive, the victims
are now measured in the tens of thousands and the response
required is complex. Moreover in this same country, people

aged 15 to 54 have an HIV prevalence of 18%. While many
questions about the significance of co-infection remain
unanswered, one can only reflect on how the people can
cope with the social and health circumstances now
confronting them continuously. At times of crisis such as
this, it must be very difficult for the people of Zimbabwe to
imagine any light at the end of this long tunnel.

Acknowledgement

The author would like to acknowledge the team from the World Health
Organisation’s Global Outbreak and Alert Response Network (GOARN) for
providing up to date information on the situation in Southern Africa. The
National University of Singapore is a GOARN partner.

REFERENCES
1. Weekly Situation Report on Cholera in Zimbabwe No. 09, 6 January

2009. Available at: http://www.reliefweb.int/rw/rwb.nsf/db900SID/
MCOT-7N4DGC?OpenDocument. Accessed 15 January 2009.

2. World Health Organisation. Cholera in Zimbabwe. Epidemiological
Bulletin number 1, 15 December 2008. Available at: http://www.who.int/
hac/crises/zwe/zimbabwe_cholera_epi_bulletin1_15dec2008 .
Accessed 15 January 2009.

3. Tauxe RV, Mintze ED, Quick RE. Epidemic cholera in the new world:
translating field epidemiology into new prevention strategies. Emerg
Infect Dis 1995;1:141-6.

4. Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. Lancet
2004;363:223-33.

5. Sack DA, Lyke C, McLaughlin C, Suwanvanichkij V. Antimicrobial
resistance in shigellosis, cholera and campylobacteriosis. WHO 2001.
Available at: http://whqlibdoc.who.int/hq/2001/WHO_CDS_CSR_
DRS_2001.8 . Accessed 2 February 2009.

6. Daily cholera update and alerts, 9 January 2009. Available at: http://
www.reliefweb.int/rw/rwb.nsf/db900sid/YSAR-7N5SQY/$File/
full_report . Accessed 15 January 2009.

7. Daily cholera update and alerts, 9 January 2009. Available at: http://
w w w . w h o . i n t / h a c / c r i s e s / z m b / s i t r e p s / z i m b a b w e _ c h o l e r a _
update_12jan2009 . Accessed 15 January 2009.

8. Swerdlow DL, Mintz ED, Rodriguez M, Tejada E, Ocampo C, Espejo L,
et al. Waterborne transmission of epidemic cholera in Trujillo, Peru:
lessons for a continent at risk. Lancet 1992;340:28-33.

9. Cholera epidemic after increased civil conflict – Monrovia, Liberia,
June-September 2003. Centers for Disease Control and Prevention
(CDC). MMWR Morb Mortal Wkly Rep 2003;52:1093-5.

10. Weekly epidemiological record, 4 August 2006, No. 31, 2006, 81, 297-
308. Available at: http://www.who.int/wer/2006/wer8131 . Accessed
15 January 2009.

11. Zimbabwe: Complex Emergency Situation Report #2 (FY 2009) Available
at: http://www.reliefweb.int/rw/rwb.nsf/db900sid/MYAI-7N22YV/
$File/full_report and http://whqlibdoc.who.int/hq/2001/
WHO_CDS_CSR_DRS_2001.8 . Accessed 15 January 2009.

12. World Health Organisation. Cholera in Zimbabwe. Epidemiological
Bulletin number 5, 10 January 2009. Available at: http://www.who.int/
hac/crises/zwe/zimbabwe_epi_bulletin_5_4_10jan2009 . Accessed
15 January 2009.

As predicted in this article there has been a large increase in the
number of cases through January with WHO now reporting the
outbreak to measure over 60,000 cases and 3100 deaths. Available at:
http://www.who.int/en/.
Editor

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Zimbabwe Cholera and health situation – 1 December 2008

WHO response and needs

Overall Health Situation

Zimbabwe’s overall health service has been steadily declining for the last five years. Once a system that neighbouring countries referred patients for special care to, the Zimbabwean health service today is wracked by critical shortages of essential drugs and skilled and experienced personnel.

Another challenge is there has been no comprehensive assessment of Zimbabwe’s health system since 2006, making it difficult to assess its true state. Also, its disease surveillance and early warning system, which depends on a weekly epidemiological system, has been compromised in terms of timeliness and completeness of data, which is only around 30%. Staffing and financial limitations are impacting on Zimbabwe’s ability to produce a national health profile.

Universal access to basic health services is compromised due to deteriorating infrastructure, staffing and financial resources. Reactivating primary health care services should keep being addressed as a matter of emergency.

Zimbabwean health facilities face a massive gap – estimated this year at 70% – in required medicines due to reduced local manufacturing capacity, which has been weakened by a lack of foreign currency. This is despite support received from different partners through UNICEF’s procurement systems.

• Areas Affected by Cholera and Athrax Outbreaks map (September – November 2008)
  pdf, 278kb

Cholera Update

A large cholera outbreak is affecting most regions of the country, with more than 11 700 cases and 473 deaths recorded between August and 30 November. This represents a case fatality rate (CFR) of 4.0% nationally, but reached 50% in some areas during the early stages of the outbreak. The CFR benchmark should be below 1%.

Cholera outbreaks in Zimbabwe have occurred annually since 1998, but previous epidemics never reached today’s proportions. The last large outbreak was in 1992 with 3000 cases recorded.

Areas recording high CFRs have been demonstrating weaknesses in case management and/or infection control practices. Potential causes of the high CFR that must be addressed are

• delays in people seeking treatment:
• poor accessibility to health facilities:
• gaps in case management: and
• inadequate infection control.

Cholera cases have also been reported either side of Zimbabwe’s border with South Africa, Botswana and Mozambique, demonstrating the subregional extent of the outbreak. In South Africa, the Ministry of Health has confirmed more than 160 cholera cases, including three deaths. Cases have also been reported in Johannesburg and Durban.

This cholera outbreak has strained Zimbabwe’s overburdened health care system and resulted in a nationwide shortage of medicines and other materials for treatment, aggravating the scarcity of health care providers and the poor access to overall care. The outbreak can spread quickly into areas without access to safe water and sanitation. Case fatality rates may rapidly escalate in populations without rapid access to simple treatments.

Cholera is easily preventable by ensuring access to safe water and appropriate hygiene, while deaths can be prevented with quick access to simple, standardized treatment regimens.

WHO Response Strategy

WHO and its Health Cluster partners are finalizing a “Cholera Response Operational Plan” to control the current outbreak. The response must be viewed as an emergency measure within the context of a severely deteriorated health care system and civil environment. The response should be multi-sectoral in support of the Zimbabwean Ministry of Health and partner agencies intervening in the field.

The objectives of the response are to:

1. Reduce the epidemic spread by:

• Ensuring access to safe water and sanitation conditions, particularly in health facilities;
• Reinforcing community mobilization;
• Ensuring safe isolation and infection control practices in health structures (including funerals);
• Strengthening Health Cluster coordination.

2. Decrease mortality by:

• Ensuring early case detection;
• Improving access to health care;
• Ensuring adequate care, including feeding support.

The response should cover needs in the domains of epidemiology, surveillance and response; water and sanitation; infection control; social mobilization; and logistics. This coordinated approach will involve close collaboration with public health authorities in Zimbabwe and neighbouring countries, as well as nongovernmental organizations and United Nations agencies including UNICEF. An Inter-Agency Rapid Assessment Team must be established to investigate and confirm outbreaks.

The emphasis must be on rapidly addressing the known risk factors for cholera transmission. Immediate priorities include:

• Standardized case reporting to understand their distribution, guide treatment priorities, and inform prevention messages;
• Ensuring access to safe water and sanitation;
• Standardized case management to reduce mortality;
• Producing treatment and prevention materials, as well as prevention messaging campaigns to mitigate the risk to populations.

WHO Response Operations to Date

WHO and its Health Cluster partners are monitoring and responding to the outbreaks reported in multiple areas (including Mutare, Chimanimani, Guruve, Concession, Chiredzi, Mwenzie, Kwekwe, Gutu, Chivi, Bikita, Zvimba) and supporting cholera treatment centres in 26 districts.

WHO’s close relationship with the Ministry of Health is providing added value for health sector players. WHO and the Ministry of Health are collaborating to provide the cholera case and mortality data by district that is used in the daily and weekly cholera situation updates issued by OCHA.

At the Health Cluster meeting on 25 November, several gaps were identified in the detection, assessment, organization of response, case management and surveillance and information management. In response, WHO has been airlifting emergency stocks of supplies from United Nations Humanitarian Resource Depot in Dubai and mobilizing additional drugs and supplies through WHO Country Office in South Africa.

WHO headquarters, in liaison with its African regional office and Harare-based Inter Country Support Team, is deploying a full outbreak investigation and response team, including logisticians, epidemiologists, social mobilization, communications officer and specialists in water and sanitation.

WHO, on behalf of the Health Cluster, produced a document titled Zimbabwe Health Situation: Let us show our Leadership and act NOW!, which was provided on 25 November to and endorsed by the Ministry of Health. The document called for an emergency response to the cholera outbreak. The Health Cluster is also finalizing its Cholera Operational Response Plan as well as the provincial distribution of agencies to lead cholera outbreak response.

Health Priorities and Needs

US$ 2 million in financial support is required to cover the cost of health response activities for the next three months, including providing:

• Cholera and diarrhoeal disease kits;
• Emergency health kits;
• Water purification equipment;
• 10 portable laboratory kits for diagnosis;
• Personnel (including for epidemiological control and Health Cluster coordination);
• Cholera treatment training.

• Zimbabwe Colera and health situation report in PDF format
  pdf, 98kb

For more information:

Zimbabwe:

Dr Custodia Mandlhate, WHO Representative
Tel: +263 4 253730 ; Fax: +263 2 253724

mandlhatec@zw.afro.who.int

Geneva:
Jukka Sailas, External Relations, Health Action in Crises
Tel: +41 22 791 4778 ; Fax: +41 22 791 4844

sailasj@who.int

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Master

thesis for the Master of

P

hilosophy Degree in Environmental and

Developmental Economics

Bureaucratic Corruption in Zimbabwe

Rumbidza Evelyn Eniah Tizora

February 200

9

Department of Economics

Faculty of Social Studies

University of Oslo

i

Acknowledgements

Firstly I thank the Lord for having blessed me with the opportunity to further my studies in

a

place that has enlightened me in so many different ways. I would like to express my heartfelt

gratitude to the following people who have guided me both intellectually and emotionally

through my studies here in Oslo. To my supervisor, Halvor Mehlum I say thank you very

much for your guidance, patience, motivation and understanding. You made me appreciate

that Economics does not have to be complicated. I would like to say thank you very much to

Knut Sydsæter for the constant concern you showed me over the years I will forever feel

indebted to you. A special thank you goes to Kaya Sverre for all the advice and assistance you

gave me over the years, your readiness to help whenever you could amazed me. I also thank

the Norwegian Government for the Quota Programme that provided me with the necessary

financial resources to be able to study at the University of Oslo. I am also very grateful to all

the friends that I have made during my stay and who have helped me in one way or another

especially Mavis, Ruth, Aasta, Dora, Martha, Endashaw, Truman and Melody. Thank you so

much for your unconditional support. I owe a great debt of gratitude to those who provided

me with vital information for my thesis but for obvious reasons I cannot mention their names.

Finally but most importantly I wish to express my sincere gratitude to my family, mum, dad,

Richard, Prisca, Patience and Yeukai for their unwavering support, encouragement,

inspiration and prayers. You have been my strength, hope and courage especially when the

going got tough.

Rumbidza Evelyn Eniah Tizora

February, 2009

ii

Dedication

I dedicate this dissertation to my parents who instilled in me the importance of a good

education and my late brother Munya who I know is very proud of me wherever he is.

iii

Abstract

The declining Zimbabwean economy has resulted in corruption reaching epidemic

proportions. There is a high tolerance for it in society as it is seen as the only way to get

timely service or any service at all especially in the public sector which is infested with petty

corruption. Through some examples this paper reveals that in the education, health, justice,

transport and custom sectors it is common to find public servants charging extra for services,

seeking small favours, or using pubic facilities and materials for their own marginal personal

gain. Payment of a bribes is now a normal and accepted way of doing business and is no

longer viewed by most as an immoral act. Whilst the causes of this petty or bureaucratic

corruption can be easily identified it is important to understand the nature and culture of

corruption, how it moves from one level to the next. This paper uses an agency model of

corruption whose setup has been widely cited and serves as a foundation for empirical

research and policy design to combat bureaucratic corruption to show that the public

officials rationally make a choice to be corrupt by weighing key determinants which are, the

return of corruption against public wage levels, the penalty and probability of being detected.

Paying particular attention to the customs sector this paper uses the multi-equilibria model

by Andvig and Moene, (

1

989) “How corruption may corrupt” to show that the increase in the

bribe price in the short-run beyond a certain level may result in a shift to a high level

corruption equilibrium which is reversible if the bribe price decreases beyond a certain level.

However in the long-run this reversal may be difficult and the sector may be stuck in the high

level corruption equilibrium. The ratchet effects of corruption in both the supply and demand

may result in its continuity and movement towards full corruption in some parts of the

customs sector.

i

v

List of abbreviations

AIDS: Acquired Immune Deficiency Syndrome

CID: Central Investigation Department

CDI: Certificado de Inspección

CPI: Corruption Perception Index

CSO: Central Statistical Office

MDC: Movement for Democratic Change

RBZ: Reserve Bank of Zimbabwe

SA: South Africa

TI: Transparency International

UN: United Nations

UNESCO: United Nations Educational, Scientific and Cultural Organization

US: United States

VID: Vehicle Inspection Department

WHO: World Health Organisation

WTP: Willingness to pay

ZANU-PF: Zimbabwe African National Union Patriotic Front

ZBC: Zimbabwe Broadcasting Cooperation

ZIMRA: Zimbabwe Revenue Authority

ZIMTA: Zimbabwe Teachers‟ Association

ZUPCO: Zimbabwe United Passenger Company

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

v

List of figures and tables

Figure 1: Corrupt relationships …………………………………………………………………………………….

2

Figure 2: Possible equilibrium levels for bell shaped distribution of costs ………………………. 3

8

Figure 3: Factors that determine the corruption equilibrium level …………………………………..

38

Figure 4: Short-run equilibrium supply response to different values of the bribe ………………

40

Figure 5: Long-run equilibrium supply response to different values of the bribe …………….. 40

Figure 6: Possible equilibrium levels for identical cost values ……………………………………….. 4

3

Figure 7: Possible equilibrium levels for uniform distribution of costs ……………………………. 4

4

Figure 8: Possible equilibrium levels for double peaked distribution of costs …………………..

44

Figure 9: Corruption levels for the bus drivers at the border ………………………………………….. 4

7

Figure 10: Corruption levels after an increase in the number of buses …………………………….

47

Table 1: Corruption Perception Indices for Zimbabwe from 1998 – 2008 ………………………….. 8

Table 2: Zimbabwe‟s Inflation Rate from 1998 – 2008 ……………………………………………………. 9

vi

Table of contents

Acknowledgements …………………………………………………………………………………………………….. i

Dedication ………………………………………………………………………………………………………………… ii

Abstract …………………………………………………………………………………………………………………… iii

List of abbreviations ………………………………………………………………………………………………….. iv

List of figures and tables ……………………………………………………………………………………………… v

Table of contents ………………………………………………………………………………………………………. vi

CHAPTER 1. Overview of the study …………………………………………………………………………….

1

1.1 Introduction ……………………………………………………………………………………………… 1

1.1.1 Defining corruption ……………………………………………………………………………….. 1

1.2 Problem statement …………………………………………………………………………………….. 4

1.3 Objectives of the study ………………………………………………………………………………. 4

1.4 Justification of study ………………………………………………………………………………….

5

1.5 Methodology ……………………………………………………………………………………………… 5

1.6 Scope of the study ………………………………………………………………………………………

6

1.7 Organization of the paper ………………………………………………………………………….. 6

CHAPTER 2. Background and extent of bureaucratic corruption in Zimbabwe …………….. 7

CHAPTER 3. Some cases of corruption in the public sector …………………………………………

10

3.1 Justice system …………………………………………………………………………………………..

11

3.2 Health sector …………………………………………………………………………………………..

13

3.3 Education sector ……………………………………………………………………………………..

15

3.4 Government tenders and procurement ……………………………………………………..

18

3.5 Media ………………………………………………………………………………………………………

19

3.6 Transport sector ……………………………………………………………………………………… 19

3.7 Customs sector …………………………………………………………………………………………

22

CHAPTER 4. Methodology ………………………………………………………………………………………..

29

4.1 Model 1: Incentives for corrupt acts …………………………………………………………. 29

4.2 Model 2: Waiting time at the border for drivers ………………………………………..

45

CHAPTER 5. Conclusion ………………………………………………………………………………………….

49

References ………………………………………………………………………………………………………………..

51

1

CHAPTER 1

OVERVIEW OF THE STUDY

1.1 INTRODUCTION

With the Zimbabwean economy in doldrums corruption has become an accepted and almost

expected way of doing business especially in the public sector. If a civil servant still goes to

work today it is not because of the salary but the opportunities to enhance his paltry income

with corrupt acts using the organizations‟ resources.

1.1.1 Defining corruption

Although there are many definitions of corruption there is a consensus that corruption refers

to the acts in which the power and influence of the public office is used for personal gain

which may not be monetary at the expense of the common good and in violation of

established laws, principles, regulations and ethical considerations. A commonly used

definition is:

“The abuse of public office for private gain”.

Public office is abused for private gain when an official accepts, solicits, or exhorts a bribe. It

is also abused when private agents actively offer bribes to circumvent public policies and

processes for competitive advantage and profit. Public office can also be abused for personal

benefit even if no robbery occurs, through patronage and nepotism, the theft of assets or the

diversion of state revenues. (World Bank, 1997, p.8)

Those in the public office include politicians and public sectors officials who may be high or

low level bureaucrats. There are two major types of corruption that these officials engage in

which are grand and petty corruption as shown in fig 1. According to Arvind K. Jain (2001),

grand corruption (relationship 1) generally refers to the acts of the political elite by which

they exploit their power to make economic policies. As elected officials, or in the

government‟s role of a benevolent social guardian (Krueger 1993), politicians are supposed to

make resource allocation decisions based solely upon the interests of their principals – the

populace. A political elite that is corrupt can change either the national policies or their

implementation to serve its own interests at some cost to the populace.

2

Figure 1: Corrupt relationships

Political Leaders

(2) Appoint

High Level Bureaucrats

Elects (1) (2) Appoint Make Public Policy

Low Level Bureaucrats

Population (2) Provide services

Benefits from Corruption

Source: Jain 2001

This type of corruption may have the most serious consequences for a society as evidenced by

the effects of the Land Redistribution Programme in Zimbabwe in 1999 when the political

elite hand picked multiple farms (even those bought for resettlement with public funds) and

registered some in the names of family members to evade the official one-farm policy. In

some cases they even drove poor peasant farmers off the land they had recently been resettled

on. They also redirected huge funds from Canada, Kuwait and England provided to buy land

for resettlement.

This paper will focus on bureaucratic corruption (relationship 2) which refers to corrupt acts

of the appointed bureaucrats in their dealings with their superiors (the political elite) or with

the public. This is usually known as „petty or bureaucratic corruption‟ with the public bribing

bureaucrats either to receive a service to which they are entitled, speed up a bureaucratic

procedure or even be provided with a service that is not supposed to be available in a

particular department. This petty corruption is probably the most widespread in Zimbabwe

and is deeply embedded in the public sector where one encounters it almost everyday.

3

For corruption to take place Jain says that there are three elements that should co-exist. First

one must have discretionary power, then there must be economic rents associated with this

power and the legal/judicial system must offer sufficiently low probability of detection and/or

penalty for the wrongdoing. All these together with other factors that favour corruption are

present in Zimbabwe making it a fertile breeding ground for both grand and bureaucratic

corruption.

The greater the discretionary powers, ceteris paribus, the stronger the incentive for the

political elite or bureaucrat to succumb to temptation. Johnson, Kaufmann, and Zoido-

Lobaton (1998) argue that more discretion and regulations for officials “… leads to a higher

effective burden on business, more corruption, and a greater incentive to move to the

unofficial economy” (p.387) This is evident in Zimbabwe were the political elite who have

discretionary powers to transfer large volumes of assets and funds from public to private

hands have done so to the detriment of the society at large.

For the public officials to engage in corrupt acts they must believe that the utility of the

income from corruption is worth the inconveniences caused by the penalties associated with

such acts. The probability of being detected, prosecuted, and punished is closely related to the

values and structures of the society. These ideas can be summarised in the relationship below:

Net utility of corruption = f Income from corruption,

Legitimate income (or fair wages),

Strength of political institutions,

Moral and political values of the society,

Probability of being caught and punished

The poorly compensated public servants in the country have powerful financial incentives to

search for additional sources of income through corrupt acts as the purchasing power of their

wage is almost nothing and any income from corruption is likely to be higher than their

salaries. The moral and political values of the society are constantly being tested and eroded.

The judicial system has the reputation of applying the law in an inconsistent and capricious

manner with most in this sector having disregard for the laws, rules and procedures they are

supposed to enforce. The governmental leaders who sidestep laws are rarely prosecuted and

convicted due to the compromised role of the prosecuting function of the state. The attorney

4

general, who has the discretion to decide whether or not to prosecute, is a political appointee

therefore his discretion is generally not exercised against political colleagues or to the

detriment of the ruling party. Also the penalties provided for corruption are trivial considering

the benefits derived from most corrupt acts. There is minimal accountability and supervision

in the public sectors. Clearly all these factors result in a positive net utility of corruption in the

public sector.

1.2 PROBLEM STATEMENT

It is evident from the statistics of Transparency International (TI) that the corruption levels in

Zimbabwe have been gradually increasing. The presence and character of corruption varies

significantly from sector to sector and it is important to know how the corruption in these

different sectors is progressing and changing from one level to the next. This will provide a

better understanding of the corruption levels of the country as a whole both currently and in

the future and will also help in the formulation and implementation of more sector sensitive

policies to combat corruption. One of the sectors that has seen a huge increase in corruption

and which this paper will focus on is the customs sector. There has been an increase in both

the demand and supply of corrupt acts as more and more people are importing both luxury

goods and basic necessities from neighbouring countries mainly South Africa, Botswana and

Zambia and as far of as Japan, China and Singapore. Although the corruption has been on an

increase the question is “Will the sector reach a high level corruption equilibrium of

corruption and if so is this situation reversible?”

1.3 OBJECTIVES OF THE STUDY

The study provides some insight into how corruption has managed to infiltrate into all the

public sectors of the economy through the some examples of common cases of corruption in

the country. Then focusing on the customs sector the paper wants to answer these questions:

What are the likely future levels of corruption in the customs sector both in the short

run and in the long run?

Will the sector remain at these levels of corruption or will they change as the factors

that affect corruption also change?

How do the ratchet effects of supply and demand of corruption affect the levels of

corruption in this sector?

5

1.4 JUSTIFICATION OF THE STUDY

On 15 September 2008 Robert Mugabe, the leader of the ruling party, Zimbabwe African

National Union Patriotic Front (ZANU – PF) and the opposition leaders, Morgan Tsvangirai

and Arthur Mutambara of the Movement for Democratic Change (MDC), signed a power-

sharing deal, aimed at resolving the country’s political and economic crisis. With the

formation of the new unity governement the nation hopes that some of the ills that have been

affecting the country like corruption will finally be dealt with as the economy recovers. When

and if the agreement is finally honoured it might be tempting to assume that with the

improvement of the state of the economy will come an automatic decrease in corruption. This

may not be so especially if the major public sectors like the customs have reached high levels

of corruption. If the nature and culture of corruption in the different sectors is not understood

and addressed accordingly together with other policies to revive the economy, corruption will

slow down the path to recovery for the nation in a great way. The donor money that has been

pledged by other countries to help the country will likely fall prey to the corrupt government

officials and not achieve its intended goals.

1.5

METHODOLOGY

This paper uses two models to show how the ratchet effects on the supply and demand side of

corruption affect the equilibrium level of corruption. The main model is Andvig and Moene‟s

1989 multi – equilibria model on “How corruption may corrupt” whose hypothesis is that the

same socioeconomic structure can give rise to different levels of corruption. This model

shows that the profitability of corruption is related to its frequency and focuses on purely

economically motivated corruption. It centres its analysis on petty corruption by public

bureaucrats and does not consider political corruption as it would require a different approach.

It looks at the incentives for demanding and supplying corrupt acts as well as the possible

multiple equilibria in corruption that may result in the short and long run depending on the

different distributions of the costs over the bureaucrats and the bribe price. The second model

shows how ratchet effects on the demand side affect the corruption levels and may lead to full

corruption by using an example of bus drivers bribing the customs officials to reduce their

waiting time at the border.

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

http://en.wikipedia.org/wiki/Zimbabwe_African_National_Union

6

1.6 SCOPE OF THE STUDY

Corruption can be found in all facets of the Zimbabwean economy be it the private or public

sector. However this paper concentrates on the public sectors mainly the customs sector

which contributes greatly to the overall corruption in the country. It will mostly focus on

corruption that takes place at the Beitbridge border post between Zimbabwe and South Africa

which is the busiest border post in Southern Africa. This post has seen an increase in the

number of cross-border or bulk traders that go to South Africa to buy basic commodities to

sell in Zimbabwe as well as individual shoppers who cross over mostly to Musina about 13km

from the border in South Africa‟s Limpopo province to buy essentials for their families and

friends. The customs is one of the sectors in which the government could be accumulating a

lot of revenue especially the much needed foreign currency but due to the rampant corruption

in this sector it is not the case.

1.7 ORGANIZATION OF THE PAPER

Chapter 2 gives a brief insight into the state of the economy and the corruption levels in the

country. Chapter 3 looks at some of the common cases of corruption in the public sector

encountered on a daily basis by the average citizen mostly based on the interviews carried out

with both the bribers and the bribees in the sector. Chapter 4 explains the theories of demand

and supply of corruption using the two models mentioned above and Chapter 5 concludes the

paper giving some ideas for future researches.

7

Chapter 2

Background and Extent of Bureaucratic Corruption in Zimbabwe

About 80 percent of the approximately 11,6 million
1
people in Zimbabwe are living in

poverty with 56% of the population living on US $1 a day whilst 80% live on less than US $2

a da

y

2
, there is an 80 percent unemployment level and the last official inflation rate was 2

31

million
3
for July 2008, the highest in the world whilst the unofficial inflation rate on

14

November 2008 was at an unbelievable 89.7 Sextillion (10
21

) percent
4
. Prices are doubling

every two to three days. The Zimbabwe dollar is practically worthless and most shops and

businesses now trade with the United States (US) dollar or the South African (SA) rand as

they are the “official” currencies.

At the time of independence in 1980, Zimbabwe had a much more developed economy than

most other nations in Sub-Sahara Africa due to its great diversity and quality of natural

resources. Other than South Africa, Zimbabwe had the most developed capital market in

Africa, leading one scholar in 1983 to proclaim, “Independent Zimbabwe is a success”

(Davidow 1982). The most unanimous opinion condensed from audit reports, donor reports,

household surveys, business environment and enterprise surveys, legislative reports and

diagnostic studies available between 1980 -1987 was that the incidences of corruption though

present were minimal no matter how they were defined and the state enjoyed a relatively high

level of integrity with very few cases of grand corruption.

According to John Makumbe in his 1994 paper “Bureaucratic Corruption In Zimbabwe:

Causes and Magnitude of the Problem,” this grand corruption was amongst the avaricious

bourgeoisie which had spent about ten to thirteen years in prison, exile or simply outside the

country during the liberation struggle and had been brought into power by the national

independence and started devising all kinds of ways of also getting their „deserved‟ share of

the country‟s wealth. Their integration into the hitherto „whites only‟ socioeconomic fabric,

by virtue of their political and bureaucratic positions, resulted in the creation of what a local

analyst called nouveau riches, who became part of the 4 percent who owned 90 percent of all

the wealth of Zimbabwe. The magnitude of bureaucratic corruption continued to increase and

1
2002 Zimbabwe Census

2
Poverty Assessment Study 2006

3
Zimbabwe Central Statistical Office (CSO) 2008

4
H:\Zimbabwe Inflation by Steve Hanks.htm

8

the press began to expose it; university students demonstrated against it; and the President

was forced by public outcry, to take some action in the Willowvale Motor Vehicle Case

(1988) in which top government officials abused their positions to source many cars each

from the government – owned automobile assembly plant and resold the vehicles at a

tremendous profit. Many other cases of corruption followed over the years contributing to the

economic downfall of the country as those involved in corruption are not creating or

generating wealth but rather consuming it and exacerbating the mismatch between aggregate

supply and demand hence driving up the inflation rate.

Zimbabwe is the 14th most corrupt nation out of a total of 180 countries recently surveyed by

Transparency International. The 2008 Corruption Perception Index (CPI) scores 180 countries

on a scale from zero (highly corrupt) to ten (highly clean). Zimbabwe, which is ranked 166th

had a score of 1,8 on the CPI scale indicating that the country is slowly heading towards the

highly corrupt level. From Table 1 and 2 with the CPI Indices and inflation figures it is clear

that as the political, economic and social crisis has deepened, so has the corruption.

Correlation, however, does not imply causality.

Table 1: Corruption Perception Indices for Zimbabwe from 1998 – 2008

Year Rank CPI Score Std Dev Surveys Confidence

Used Interval

1998 43 4,2 2,2 6 –

1999 45 4,1 1,4 9 –

2000 65 3 1,5 7 0.6-4.9

2001 65 2,9 2,9 6 1.6-4.7

2002 71 2,7 0,5 6 2.0-3.3

2003 106 2,3 0,3 7 2.0-2.7

2004 114 2,3 – 7 1.9-2.7

2005 107 2,6 – 7 2.1-3.0

2006 130 2,4 – 7 2.0-2.8

2007 150 2,1 – 8 1.9-2.3

2008 166 1,8 – 7 1.5-2.1

Source: Transparency International

9

Explanatory notes

CPI Score – measures the perceived levels of public sector corruption in a given country and

is a composite index, drawing on different expert and business surveys from business people,

academics and risk analysts. It ranges between 10 (highly clean) and 0 (highly corrupt).

Confidence range – provides a range of possible values of the CPI score. This reflects how a

country‟s score may vary depending on measurement and precision. Normally with a 5

percent probability the score is above this range and with another 5 percent it is below.

However particularly when only a few sources are available, an unbiased estimate of the

mean coverage probability is lower than the nominal value of 90%.

Surveys used – refers to the number of surveys that assessed a country‟s performance. At least

3 surveys are required for a country to be included in the CPI.

Standard deviation – indicates the differences in the values of the sources; the greater the

standard deviation the greater the differences of perceptions of a country among the sources.

Table 2: Zimbabwe’s Inflation Rate from 1998 – 2008

1336,6* = Inflation rate for January 2005

231million* = Inflation rate for June 2008

NB: All other inflation rates are for December of each year.

Source: Central Statistical Office

Year Inflation%

1998

48

1999 56,9

2000 55,2

2001 112,1

2002 198,9

2003 598,7

2004 1336,6*

2005 585,8

2006 1281,1

2007 66212,3

2008 231million*

10

CHAPTER 3

SOME CASES OF CORRUPTION IN THE PUBLIC SECTOR

The public sectors in Zimbabwe are afflicted by many dysfunctions that affect most African

bureaucracies and promote corruption like „permanent‟ and „occasional‟ absenteeism

(Nembot 2000; 298; Morice 1987); slow administrative procedures (Sarassoro 1979);

dilapidated administrations which are ill-adapted to social change (Asibuo 1992); rigid,

impersonal and ritualized implementation of the rules (Schwartz 1974); complex and opaque

regulations that are difficult to apply and leave infinite scope for discretional powers

(Fjeldstad 2003; Hope 2000; McMullan 1961); the centralization of decision-making

processes and lack of delegation at subordinate levels of the administration (Cohen 1980);

inadequate archiving or its complete absence; poor division of tasks and functions in both

spatial and sectoral terms (Darbon 2001: 29).

Although the presence and character of corruption varies significantly from sector to sector it

is common that the government officials are charging extra for services, seeking small

favours, or using pubic facilities and materials for their own direct or indirect marginal

personal gain. Below is a brief presentation of a few corrupt acts that take place in some of

the public sectors in the country. To get these accounts I interviewed a number of government

officials and people from the general public. It was not easy to have formal interviews on this

rather sensitive subject so in most cases the interviews were rather informal but very

informative. Corruption is now the norm in Zimbabwe and some people are willing to discuss

it openly as long as they are assured that what they say will not get them into some form of

trouble. It almost an accepted way of doing business. It is not to say though that there are no

more honest people in the country and all the government officials have to be bribed to do

their job. But as soon as one steps into the country they are confronted with corruption left,

right and centre and it becomes both frustrating and impossible to ignore. More so at the

points of entry into the country especially the customs offices at the Beitbridge border post,

the airport, and the roads leading to and from the border. The different accounts that I

gathered on my field trip are written in italics and they are more or less as the interviewees

narrated them to me. Some of the accounts are my own experiences as like I mentioned above

it is difficult to avoid.

11

3.1 Justice System

“Corruption within the justice system is generally defined as the use of public authority for

personal gain that results in the improper delivery of judicial services and legal protection for

citizens.”(Mary Noel Pepys, Fighting Corruption in Developing Countries, Strategies and

Analyses, 2005 pg13). Some of the main players in the justice system are the judges, lawyer,

public prosecutors, the police, court clerks, the secretarial staff, prison wardens and prison

guards. The role of the judiciary is to protect human rights and civil liberties by ensuring the

right to a fair trial by a competent and impartial tribunal. Ideally all citizens are entitled to

equal access to the courts and equal treatment by the investigative bodies, prosecutorial

authorities, and the courts themselves regardless of their position in the society. In Zimbabwe

the judiciary is not independent but controlled by the government which has placed its own

appointees in strategic posts in the legal system. The phenomenon of corruption has obviously

not spared this sector in which the powerful and rich can escape arrest, prosecution,

conviction, and literally „buy justice‟ whilst the poor are excluded from their rightful access to

fair and effective judicial services.

The workers in the justice system including the judges receive dismally low salaries and are

forced to perform their duties with meagre financial resources under abominable working

conditions that consist of crowded office space and dilapidated courtrooms among many

others. It is unfortunate that the judges who are the ultimate decision makers and the highest

governmental officials within the justice system and should be the focal points for reducing

corruption promoting the rule of law have to engage in unlawful acts sometimes with their

subordinates to make ends meet. The following examples show how corruption has spread

across the whole spectrum of the judicial system:

At the Harare Magistrates Court in the capital city there is a pending case of a foreign

currency dealer who allegedly stole US $80 000 from his associate. He was arrested

and taken to the police station. I am sure the policemen that caught him would have

accepted a bribe from him had he not been on the wanted list for other pending fraud

cases. In prison he managed to bribe the prison guard with US $5 000 to ask a

magistrate to grant him bail. This was too good an offer to refuse for a prison guard

who is paid approximately US $1 per month. In court the magistrate gave him bail

and received US $1 000 whilst the prison guard received US $500. He promised to

pay him the rest at a later date although this is highly unlikely. Out on bail he went to

12

the court clerks who are in charge of the criminal files and bribed them with US $800

so that they steal his file for him. With no case file and out on bail he is continuously

on further remand. The complainant will be lucky if he ever gets his money back. Out

of the US $80 000 he stole this dealer spent less than a tenth of that money in bribing

the government officials so that he stays out of prison.

User of the court, Harare

Corruption within the criminal process is very common because for a good sum the police can

suppress the filing of police reports, distort, destroy or even steal evidence. Sometimes they

just refuse to investigate or even protect the alleged perpetrator if he is politically powerful or

wealthy. Corruption within the civil process is also widespread with the court clerks having

the power to expedite or delay a case without detection. For the right price they can even

completely destroy a case file.

I had 25 cows stolen from my farm three months ago and when the culprits were

caught I hoped that they would be sent to prison for at least 25 years because livestock

theft carries with it a huge penalty but with this corrupt judicial system nothing was

done to them. Although the case went to court the criminals bribed all those handling

the case even the judge, who some say got around US $1 000 and the prosecutor US

$500. About 50kg of the recovered meat that was supposed to be presented as an

exhibit was said to have been eaten by the police in their canteen imagine. So with no

exhibit there was no case and the thieves got away.

Farmer, Kwekwe

Some men from Harare were caught selling elephant horns here in Kwekwe because

the price here is reportedly higher and they were arrested. Their horns which were

worth around US $25 000 disappeared in the hands of the Central Investigation

Department (CID) officers. So although the police had opened a docket for the case

there was no exhibit to present. The CID officers responsible for the mysterious

disappearance of the horns are said to have paid the judge and the prosecutor a total

of US $2 500. The owners of the horns who were released because of lack of evidence

want their horns back and are now hunting down these CID officers.

Police officer, Kwekwe

13

In some cases the powers of the CID now go beyond the domain of investigation and extend

unofficially to aspects of sentencing. Many cases do not even go to court as they are settled by

the police officers, usually without the knowledge of the judge. For example if one sells a car

for US $20 000 and does not get his money and reports the case to the police instead of

placing a charge against the alleged thief the policeman can approach the thief and tell him of

the consequences of being charged and taken to prison. The policeman then suggests that he

pays US $5 000 every week and if he has US $5 000 he can pay it there and then to the

disgruntled seller. The policeman can then ask for a bribe of about US $200 for this favour

from the accused and on taking the US $5 000 to the owner of the car will also get another US

$200 for having facilitated this agreement. Where one reports a theft but does not know who

the culprit is and only has a suspect the policeman can approach the suspect and make him

aware of what will happen to him if he is charged and taken to prison just to scare him. The

policeman can demand a bribe depending on the gravity of the accusation so that they do not

arrest him. But then being just a suspect and without any evidence nothing would have

happened to him.

At times the police and magistrates are coerced into making corrupt decisions out of fear of

retribution. Being perceived as politically incorrect and unpatriotic makes many in the legal

system decide against their better judgements. As a result there are many public officials that

have committed a lot of crimes but have never seen the door of a court house let alone that of

a jail cell. In some cases depending on their positions in the ruling party, they can get

presidential pardon as in the Willowvale Motor Vehicle Case where some of the accused who

were not forced to resign although convicted and sentenced are still involved in politics and or

government with positions of high authority. This shows how the legal system is to some

extent controlled by the ruling party and that ones‟ political affiliation can grant him

„immunity‟ when it comes to the law.

3.2 Health Sector

The role of the government in the health sector is to promote equitable access to services,

assure sustainable financing for health objectives and prevent the spread of disease. But

mainly due to corruption the Zimbabwean government has failed to perform these functions

leading to inadequate and unequal access, poor quality of health care and inefficient services.

The gravity of the problem in the health system came into light when the country was hit by a

14

cholera epidemic in August 2008 that up to date has killed 2024 with at least 40,000
5
having

contracted the disease. This is the worst cholera outbreak in Africa since 1999 when 2,085

people died in Nigeria
6
. The waterborne disease, which causes severe diarrhoea and

dehydration expectedly spread to all 10 provinces of the country mainly due to lack of clean

water and sanitation.

Every year an estimated 1 300 to 2 800 mothers die from causes associated with pregnancy

and childbirth and 12 000 people are estimated to die every month from Acquired Immune

Deficiency Syndrome (AIDS) related illnesses
7
. Most of these deaths are due to lack of access

to drugs, essential equipment and other supplies in health facilities. Malnutrition has reached

epic proportions, with five million people requiring food aid this year. Under-funding of the

Ministry of Health has led to a lack of the necessary resources needed to cope with even

curable ailments like cholera. Industrial action by health professionals over very low salaries

has often affected the country‟s health delivery services, while a serious brain drain is a

contributory factor to the crippling of the sector.

In November 2008 the government closed the major public hospitals in Harare and the second

biggest city Bulawayo as they had been operating without running water, no functioning

toilets, no soap, empty pharmacies and not enough food for patients or staff for three months.

Zimbabwe once a leader in health care, medical and nursing education also closed its medical

school in the same month and cancelled exams because there was no paper and ink to print

the exam papers. The main mortuary in the capital has been operating without electricity so

the dead are rotting.

A government doctor is paid a monthly salary less than US $100 and there is no reward for

exceptional performance so corruption has become a survival strategy for both the

government workers and the patients. The theft of drugs/supplies for personal use or resale in

the private sector is now very common in the public hospitals. Some drugs that are supposed

to be given to the patients for free are being sold to them and at times the prices are

unbelievably high considering that the drugs were supposed to be for free. Because of these

under-the-table payments to obtain drugs there is now a lower utilization of drugs amongst the

patients as some just cannot afford. Most are no longer getting proper treatment as they have

5
World Health Organization (WHO) 2008

6
United Nations (UN)

7
United Nations

15

to make do with the drugs that are available. There is also interruption of treatment or

incomplete treatment leading to the development of antimicrobial resistance.

Now some nurses only come to work on the days that they know the dispensary will be

open so that they can steal medication and sell to us. On the days that the dispensary

is closed which are many we are attended to by the student nurses. But what can they

do, they complain of inadequate salaries and we cannot blame them; it is just that us

the patients are the ones who are suffering.

Patient, Kwekwe General Hospital

Some essential services which ideally should be readily available to the patients are being

diverted for personal use.

Ambulances are now being used as taxis for ferrying passengers whilst patients are

being taken to hospitals in wheelbarrows. The drivers are shamelessly switching on

the sirens as they „pilot‟ (taking people from one point to the next) .The other day I

was called to the scene of an accident involving an ambulance only to find out on my

arrival that there were about 15 passengers that were on their way to Gweru from

Kwekwe. Luckily there were no casualties but „zvinonyadzisa‟ (its embarrassing) what

these economic hardships are making us resort to.

Police Officer, Kwekwe

The above description of the state of the ailing health sector shows how the bad governance of

the country coupled with corruption has resulted in great social costs.

3.3 Education Sector

This sector has not been impervious to the pervasive corruption that has penetrated the public

sector. Before the economic downfall that has haunted Zimbabwe for the last decade, teachers

used to be among the highly paid professionals and they could afford a decent life. With the

budgetary allocation to the education sector by the government being far less than the 26%

required by United Nations Educational, Scientific, and Cultural Organization (UNESCO) the

salaries of the teachers are so low that they cannot even afford transportation to work for the

whole month. They are even being urged by the government to take on projects to supplement

16

their salaries. As a result many are making students sell their products like sweets, „freezits‟

(frozen juice in 50ml packets) or „maputi‟ (popcorn) for them during break time:

I am very good in maths so my teacher likes me because I give the correct change and

I also sell a lot of sweets. I would want to play more with my friends during our break

but I have to do this for ma‟am, I cannot refuse. I do not want her to give me bad

marks or something like that. On some days when I sell a lot she also gives me one or

two sweets.

Grade Six Pupil, Chegutu

Some are taking regular vacations or are just absent from schools to do cross-border trading

and when they leave there are either not replaced or they are replaced by untrained school

leavers who also leave after very short periods of time. Teachers collecting salaries but not

providing the intended instruction is probably the most common form of corruption in this

sector but justified by most. An estimated 50 000 teachers have left Zimbabwe for greener

pastures to date
8
since the economic downturn. Some have gone to the United Kingdom

where they are reportedly doing odd jobs like caring for the old, while some have gone to

work in the farms and as housemaids or gardeners in neighbouring Botswana and South

Africa.

Unlike the educational funding system in the industrialized countries, education has

traditionally been the financial responsibility of the government like in most African

countries. Unfortunately due to gross economic mismanagement the government is now

turning aggressively to already poverty stricken parents to bear the heavy burden of the

astronomical costs of education and literally take care of the teachers in the public schools.

For the teachers to come to school and teach our children we have to bring them

groceries at the beginning of the term. Each child has to go with salt, sugar, cooking

oil and soap on the first day of school if they want to be allowed to sit in class. Us

parents are already struggling to access these basic commodities for our families

without having to worry about the teachers‟ groceries too.

Parent of a Pupil at Sally Mugabe Primary School, Kwekwe

8
Zimbabwe Teachers‟ Association (2008)

17

Another common form of petty corruption is the selling of admissions at all levels of

education.

In these times of economic hardships my colleagues were really surprised when I

refused a bribe from a parent whose child had dismally failed the entrance test to get

into the first grade. I was not intimidated by his expensive car and suit and I told him

point blank that “Your son has failed so we cannot accept him here.” He then told me

that if I helped him then he will show his gratitude in a big way and handed me a

khaki envelope. I could tell that it contained a lot of money because it was really thick

but I did not even bother to open it. He surely looked and sounded like a man who was

used to getting his own way but I showed him that it was not the way we did things

here that is why we manage to keep our good reputation.

Secretary at a Public School, Chegutu

The University of Zimbabwe uses the point system to screen and place the students into

different programs. But some students with low points are being admitted and/or getting into

programmes that they are not qualified for academically but financially. This is seen as more

and more students are struggling to keep up in their respective programmes and subsequent

background checks reveal that they do not qualify to be in certain programmes. The lecturers

cannot do much about it as this corruption usually involves the university‟s top officials.

Corruption is also evident in opportunities to study abroad. Information of available

scholarships is not posted on the notice boards for all the students to have an equal

opportunity to apply to, it is reserved for a select few closely linked to the chairperson‟s of the

various departments. Sometimes a directive of who must get the scholarship can even come

from high ranking government officials hence denying the deserving candidates the

opportunity to further their studies.

I know that I was not supposed to have come here because another teacher had

already been awarded the scholarship but then when I learnt of it I went to my uncle

who just made one phone call and the scholarship was given to me instead. It took

some difficulties to have the name changed but when people heard who had

recommended me they really could not say anything.

Student, Europe

18

This student did not manage to finish his degree and the scholarship went to waste. It may not

have been the case had it been used by its initial deserving recipient. These examples above

provide just a glimpse of the petty corruption that takes place in the education sector.

3.4 Government tenders and public procurement

Most examination committees for government tenders abuse their discretionary powers or

stimulate an open and fair competition (especially through the means of prior agreements

between firms or the creation of fictitious firms).

When I am applying for a tender I always make sure that I send my tender last when

my „associates‟ on the board have gone through all the other tenders and they tell me

the figures that will make me win the tender. It would be suspicious if my company

always won the tenders so I change the name all the time and create fictitious

companies. I usually give my „associates‟ a reasonable percentage of what I make. If I

do not do this I will not get the tenders. I also have „associates‟ in the accounting

department so that I can get my payment on time.

Entrepreneur, Harare

In 2006 the then Chairman of the parastatal Zimbabwe United Passenger Company (ZUPCO)

and its Chief Executive, who was also the deputy Minister of Information were charged for

jointly receiving US $20 000 after the Chairman solicited US $85 000 from Shah Gift‟s

Investment firm to facilitate a contract to supply buses. The Chairman was convicted and

given a jail sentence for two years but nothing was done to the Chief Executive although he

was forced to resign after audit reports showed a lot of unexplainable discrepancies. The

reports also revealed that there were no proper purchasing procedures leading to the payment

of people who had not supplied anything to the company. For example one of the reports

notes that a payment of Z $64million was made to someone who had not supplied anything to

the company. False requisitions of what is already in stock are very common in parastatals.

Corruption at the lowest levels in this parastatal involves drivers sometimes not issuing tickets

so that they may pocket the money at the end of day. The cash collection from bus income is

not properly accounted for and there is no proper supervision of the work of the junior staff so

chances of the drivers being caught are very low.

19

3.5 Media

Journalism should be the eyes of the people and the ears of the society but in Zimbabwe it is

also infested with corruption. This is mainly due to the poor remuneration, unfavourable

working conditions and non-existent fringe benefits for the workers. There are a lot of bribery

cases involving the state owned Zimbabwe Broadcasting Cooperation (ZBC) TV and Radio

bosses, broadcasters and electronic print journalists. Bribes are demanded from business

executives, politicians and musicians who will be given sustained and positive media

coverage, continuous air play and better ratings on local music and business charts.

For an advert that costs Z $100 000 for three minutes I pay for three slots a day with

Z $300 000 but can even get up to seven slots per day if I just give the broadcaster

Z $30 000 per extra slot. All that is required is proof of payment on my part because I

understand no-one really checks if what is on the invoice tallies with the number of

slots I am given that day.

Entrepreneur, Harare

The main corrupt practices in the transport and customs sectors involve these three main

areas:

a) the identification of road users – the checking of drivers licences

b) the technical and administrative status of vehicles – vehicle registration, technical

inspection, insurance, general external appearance.

c) transported goods and customs duty.

For the users of these transport and customs services i.e. importers, exporters, taxi, truck and

bus drivers time is crucial and any minute that they save enhances their competitiveness on

the market. As a result they are vulnerable to corruption by the customs officials and the

police. Sometimes they even take the initiative and offer the bribe so that they do not waste

time even if their affairs are in order.

3.6 Transport Sector

3.6.1 Driving licence

During driving tests the instructors point out to the testers the candidates that have paid. The

ones that have not paid usually fail unless they bring other resources into play like family ties

20

or networks of relatives, friends and acquaintances. If the candidates have not arranged with

their instructor they sometimes give the bribes, usually approximately US $50 to the

examiners during the tests. These examiners are not hesitant to tell the candidates that if they

do not „make a plan‟ it will take time before they get their licence whether they can drive or

not.

After having been driving for almost 20 years without a licence and getting away with bribing

the police in Zimbabwe a move to South Africa prompted a certain gentleman to get an

International driving licence. He explained to me:

In South Africa the police can stop you anytime and it‟s unlike Zimbabwe were you

are certain that you can bribe your way out. Here it‟s a foreign land so it‟s just good

to have a licence. I have really been reluctant to bribe for a Class 4 licence because I

know that even though I can drive they will make me fail so that they get something

from me. This time I had no choice I had to pay US $100 to get this International

driving licence that I am using here in South Africa.

To get a car cleared or acquire a registration book for ones‟ car at the Zimbabwe Revenue

Authourity (ZIMRA) offices one usually has to bribe the officials who like the customs

officials at the border have the discretionary powers of lowering the value of a car.

3.6.2 Road checks

The customs officials and the police officers who carry out road checks exploit people‟s lack

of time. The police order the drivers to park and give them their custom clearance documents,

putting the driver under unnecessary pressure of the possibility of being told to unload their

goods or having them seized although the officers have no mandate to perform customs

duties. The drivers are not aware of this and just want to be on their way so they are easily

bribed usually for SA 10 rands per passenger.

Sometimes if all the drivers‟ papers are in order for example the driving licence, insurance

certificate and registration papers they can just bluntly ask the driver to leave them “yedrink”

(money for a drink) or say “tinyareiwoka” (will you just please respect us and give us

something) or “tipeiwo yeweekend” (can you give us some money for the weekend) or

“ingoitai kuti tiende” (may you just give us something so that we go away and stop bothering

21

you). They can even find some jokes to say so that the driver relaxes, for example “How can

you be travelling in such nice cars in these difficult times? Please do leave us something.” If

this does not work they may resort to less friendlier means to get money from the motorists:

I really did not have any money on me when I was stopped at a police roadblock. I

tried to explain this to them but they would not listen. In these cash crises times it is

possible that one can actually not have any money on them although have a lot in his

bank account which he cannot access because of the daily withdrawal limits set by the

Reserve Bank of Zimbabwe (RBZ) Anyway the policeman told me to get out of my car

and he literally put his hands in my pocket, which had nothing of course but it was just

wrong, he had no right to do that but again who do I report him to everyone is corrupt

in this country. He then told me to leave him anything so I left some bread and drinks

just so that could be on my way.

Driver, Harare

If there happens to be something wrong with a drivers‟ vehicle or papers then instead of

writing a ticket and issuing it the policemen will tell the driver to “make a plan”.

On my way to the airport I was stopped at a police roadblock and since I did not have

my licence on me I was told to park the car and surrender my keys by one of the

policemen. After some pleading and explanation that I was in such a hurry the

policeman who seemed very stern and diligently doing his job when he stopped me

accepted US $5 and let me go. The amount that would have been on the ticket had it

been issued would have been much lower than the bribe but like most people I did not

have the time, patience or will to argue with the policeman so I just gave him the

bribe, he also did not seem too eager issue the ticket anyway.

Driver, Harare

This just shows that tthe police officers and Vehicle Inspection Department (VID) officers

now have no respect for the high-way code when they are the ones who are supposed to

ensure that its rules are adhered to in order to avoid endangering innocent lives. They let the

drivers of vehicles that are not road worthy or drivers that should not be on the road go as

long as they can pay the bribe.

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3.7 CUSTOMS SECTOR

The examples below are just some of the corrupt acts that take place at the Beitbridge border

post. There are many others that may take some form or another the ones mentioned. Efforts

to get the high level officials to discuss the corruption that takes place in their sector did not

yield any results. This is a sensitive issue and they do not want to be quoted as having said

something that would put their careers a risk which is understandable considering the fortunes

that they probably make unlawfully. It is the lower ranking officials and the general public

who were more forthcoming.

3.7.1 Under declaration of goods

At the Beitbridge border post the cross-border traders are almost always racing against the

clock because the sooner they have their goods cleared through customs the sooner they have

them in the market in Zimbabwe and the more profit they will make. As a result they are

willing to bribe the officials so that they do not have to be at the border for long. For some

though it is not the saving of time that matters most but the under declaration of their goods

that the customs officials can facilitate. Hence they are willing to lurk around the customs

buildings till dark when the faking of documents and the bribing of officials are the order of

the day. There is an official table of customs clearance charges for all categories of

merchandise. The false classification of goods involves placing them in a category that incurs

a lower charge, thus minimizing the cost of their customs processing. One of my interviews

with a border official was interrupted by a call from his „friend‟ who had just arrived from the

South African side and needed to clear his goods. He was gone for almost an hour and when

he came back he just said:

Oh that was a good friend of mine who did not want to spend too long at the border so

I had to go and help him out, now he is happily on his way home. He had gone to buy

groceries at Musina so although I am not at work today I signed his customs

declaration form and showed it to my colleagues on duty and he was on his way. This

is my friend so they did not have to look at what he had bought. Of course he gave us

all „yedrink‟.

Judging from the “Kentucky Fried Chicken” take – away that this customs official was

holding the trader was not the only one who was happy. He also got US $150 to share with his

two colleagues. He also explained to me that sometimes they develop close relationships with

23

frequent cross-border traders that go beyond just a commercial one such that their exchange

of services or favours generates systems of reciprocal obligation between them. A lady may

actually end up referring to an official as my „son‟ and he refers to her as „mother‟. She will in

turn bring him small gifts when she comes from the other side of the border and may also just

phone once in a while to find out how her „son‟ is doing.

This under declaration or none declaration of goods is also common at the airport as I realised

when I arrived at the Harare International Airport.

Having been on a 12 hour flight I was happy when I was approached by a porter who

offered to “help me with my luggage”. I quickly agreed and as we waited for my bags

he started updating me on the terrible economic situation that the country was now in.

When my luggage came out loaded it onto the trolley and escorted me out of the

airport. None of my three suitcases where opened for checking by the customs officials

and so I did not declare anything. I gave him US $10 but he told me that it will be

hard to share with the other two that he was working with. I then realised that he has

to give his colleagues too so that they do not report him and so I gave him another US

$5.

3.7.2 Immigrant rebate

This is a form of corruption at the border in which the government is losing a lot of revenue.

For example if one imports a US $8 000 car that would attract duty of about US $7 000 one

can put it in the name of a returning resident to avoid paying this duty. The customs official

who clears the car at Beitbridge can be given US $500 to overlook this whilst the one whose

name was used can get around US $1500. Often in these cases the bribe given to the official

corresponds to the value that the customer will have saved. There is another form of rebate

that is ethically wrong but yields large profits for the officials.

We have the authority to confirm one‟s disability. I was supposed to do that for one

guy who had bought a car for US $75 000 from Japan but he decided to go and have it

done for him at the Zimbabwe Revenue Authority (ZIMRA) offices in Harare instead.

He probably paid just 15% of the duty paid value (VDP) instead of the 90% or 110%

if the car was 5years and below. The duty for luxury vehicles is paid in foreign

currency so he would have paid a lot of money. The customs official that did it for him

24

in the capital may have taken home about US $20 000. This is a tricky issue though

and one can only authorise a few disability cases a year to avoid raising eyebrows.

Customs Official, Beitbridge

3.7.3 “Runners”

The decentralization of customs services in one and the same administration, which forces

clients to attend different offices for the customs clearance of just one item, is a source of

minor irritation that many try to overcome by taking shortcuts that sometimes entail bribing

the officials or hiring middle men known as “runners” who do not work in the customs

officials but know what goes on at the border and work together with the customs officers so

they do not wait in the queues. The frequent border crossers have permanent runners that they

employ as I learnt from an entrepreneur who buys beverages form South Africa and sells

them in Zimbabwe.

In my business time is money especially during this festive period, to make sure that

my drivers spend as little time as possible at the border I have a runner who works for

me. My drivers give him the papers as soon as they arrive at the border and I give him

about US $100 per truckload of beverages he clears on time. He probably shares this

with some customs officials, I am not sure. I had another one but he increased his

price to US $300 so I looked for someone cheaper. There are so many of them at the

border these days.

3.7.4 “Informal tax” on passengers

The customs official also sometimes collect an „informal tax‟ usually SA 10 rands per person

in the buses crossing the border so that they do not have to unload their goods for checking.

They just pretend to be checking and then let the driver be on his way. Although this can be

considered as extortion because no service is supplied here the passengers would rather pay

than spend a lot of time at the border as this lady explained:

When I was on a Tombs bus (a trans-border bus company) on my way back to

Zimbabwe with my mother last month I was glad that we did not spend a lot of time at

the border and our goods were not checked as we had bought a lot of electrical goods,

way over US $500 each so we would have had to pay a lot of duty in foreign currency.

At the border when the official approached the bus, the driver asked him “Officer

25

mauya nebhutsu dzenyu dzebhora here timbotamba?” (to you have your soccer shoes

on today so that we can play). He said yes and the driver told us to pay SA 10 rands

each to the official and send our passports forward so that the customs official would

go and stamp them. We did not spend more than 20 minutes at the border which was

great. But imagine since we were about 75 passengers we left the official around SA

750 rands. Our bus is probably not the only one he did this to I know because there

are some buses that these officials target and they will not let them pass without the

passengers paying something. They even know the days and times that they pass and

wait for them I think. I heard the police on the South African side are also doing this

now.

Cross-border trader, Kwekwe

Sometimes this informal tax is collected even when the buses are leaving to enter South

Africa so that the bus jumps the line. The passengers may have to pay SA 20 rands each so

that their bus goes to the front. Chapter 4 uses a model to explain these queues and the

corruption involved in greater detail.

3.7.5 “Ignorance”

The officials also take advantage of the traders lack of knowledge of what exactly happens

behind the counters at the customs offices.

People who come to the border do not really know what goes on in our customs offices

and maybe think that our work is very complicated and almost “special” in a way.

Sometimes we take advantage of this “ignorance” or rather lack of knowledge and

either inflate their charges or pay charges that they are not supposed to at all. Since

they may not understand the “complex” system of custom charges they would not want

to argue with us. I know its bad but we also need to eat.

Customs Offical, Beitbridge

3.7.6 Bottlenecks

Many public officials force their users to adapt to their schedules and to submit to or accept

the timetables they set: „the user‟s time is not as important as that of the official‟ (Hertzfeld

1992: 162). Thus the personal schedules of users are seriously disrupted by different forms of

bureaucratic indifference, such as instructions to return the following day or the impossibility

26

of predicting the duration of administrative procedures. It is the officials who control the

duration and the speed of the interaction with users. This makes the customs officials exploit

this resource in corrupt exchanges as shown in the extract from an article “Nightmare at

Beitbridge Border Post” posted in The Standard (A South African Newspaper) on 6 March

2005.
9

“Where on earth do you get such sloppy service? Taking more than 12 hours to

process a file? The answer might be that I was not the only customer, but on the day

when I actually cried from tiredness I had waited for 16 hours without sleeping and

there were only five customers. The evening shift came and went and then the morning

shift came and was about to go while I was still there…………. One could tell that it‟s

either they are seeking a bribe somehow or they are out to just exercise power or else

they lack product knowledge. An example of the questions was: Why is the invoice

written Mazda 323 and there was no Familia?, and why on the payment transfer

document it was written Mazda Familia?. Anyone who knows cars will know that the

answer lies in having a physical check on the vehicle. If you are an assessor then you

should know your stuff, which includes cars. The other thing which baffled me was

being told my telegraphic transfer was not authentic. As far as I was concerned that

was the only proof of payment I had. How does one prove the authenticity of a bank

confirmation document when this is what one was given at the bank to present to

Zimra? If you are unlucky to find an officer who is in a bad mood he may decide that

freight charges were not included and one maybe charged double on freight. The

answer, of course, is the assessor has every right to doubt the authenticity of all your

paper work. One ends up paying heavy duties and amounts, which are uncalled for

because one is tired and has nowhere to complain. ………….”

Frustrated Citizen, Harare

The officials may also create artificial bottlenecks or shortages so that they may offer faster

individual service for payment. I experienced this at the ZIMRA offices in Harare when a

government official told me that.

9
http://www.thezimbabwestandard.com/letters/16159.html

27

Yes we do not have anymore number plates but that is only for “povho” (the general

public) but then for you “vehukama” (relatives) an arrangement can be made.

He then showed me the ones that he had under his desk as proof and said that at US $10, I

could have a set.

3.7.7 Certificado de Inspección (CDI) forms

When one is exporting goods from Zimbabwe they have to complete CDI forms at the border.

For a product like tobacco one can expect to get around US $30 000 per truckload. This

should be remitted to RBZ and one gets back about 60 percent of that money. In a normal

economy one can access their foreign currency anytime but in Zimbabwe one has to apply to

RBZ and state what they want to use their money for. It may take months before the request is

approved or disapproved. As a result the exporters avoid filling out CDI forms, and just bribe

the customs officials with maybe US $2 000 depending on the value of what they are

exporting and nothing goes to RBZ.

3.7.8 Vehicle Overloads and Project equipment approval

At the border corruption also exists at the higher levels and involves larger sums of bribes.

Here at the border if you snooze you loose I came to work here because there is an

opportunity to make money, if the top officials at the head are corrupt then what about

us at the tail. The VID officers who work here can take as much as US $30 000 a day

through overweight trucks and they do not accept anything less than US $500 for

overloaded vehicles. They also work with us at the bottom so that we do not tell on

them and can give us maybe USD $1 000 depending on how much they themselves will

have made. The top officials here are politically appointed and although they may be

rotated at times the predecessor always tells his successor how he can make money so

the rotation does not really solve the corruption problem. It is a vicious cycle that just

goes on and on. Also when those officials responsible for the rotations pass through

the border they have their cars filled with goods by their subordinates. So how can

they remove or move such a subordinate?

Customs Official, Beitbridge

28

Another form of corruption that takes place at higher levels involves those that may be

starting huge projects in the country for example a mine and have to import a lot of inputs.

Although one is allowed to bring in all their initial equipment duty free, this has to be

approved by the top officials at the customs offices. Most of the time this approval will be at a

cost to the entrepreneur depending on the value of the equipment that they are bringing in.

3.7.9 Border Jumpers

Everyday there are a lot of border jumpers (desperate Zimbabweans forced to leave the

country and enter South Africa illegally) who cross the border in search for a better life.

Passage to cross the Limpopo River without a passport or a valid visa usually costs around SA

100 rands which is given to the border police who sometimes even escort the jumpers part of

the way.

This chapter has given an insight into some of the forms of corruption that take place in the

public sector but the next chapter will pay particular attention to the customs officials at the

Beitbridge border post. It will use two models to make a rough forecast of what the corruption

levels will be both in the near future and in the long run in the customs sector.

29

CHAPTER 4

METHODOLOGY

4.I Model 1:

4.1.1 Incentives for corrupt acts

According to Adving and Moene a public bureaucrat, i.e. a member of a public organisation

and in this chapter a customs official supplies a corrupt act if he directly or indirectly deals

with a non-member using the public organisations resources to acquire payment against the

rules of the organisation or against the law. These resources include the bureaucrats‟ own

decision-making power and special information that is at his disposal in the public

organisation. A member of the public who may be a cross-border trader or an ordinary citizen

demands a corrupt act if he tries to bribe a bureaucrat. Then he will be known as a „briber‟

while the bureaucrats who take bribes as payments for illegal services are the „bribees‟. Some

of the assumptions of the model are:

-Only one corrupt service is transacted per period between the briber and the bribee.

-Corrupt services are homogeneous therefore the level of corrupt transactions is indicated by

the number of corrupt bureaucrats which is normalised to 1.

-All potential bribers demand the same amount of corruption.

-The bribees do not search for bribers as it is not in their best interest to be open that they are

corrupt.

Let:

y = fraction of corrupt

bureaucrats.

= fraction of non-corrupt bureaucrats.

N = number of trials, the briber has to search to find a willing bribee as he does not know who

is corrupt and who is not.

= the probability that he finds what he wants after exactly N trials.

qi = the sum of moral and real costs involved in trying to bribe a bureaucrat for the private

agent i.

b = price of corrupt services.

= excess profit of obtaining corrupt services at a price b and .

The expected profit of a briber, i.e. buyer of corrupt services is

(1)

y1

yy
N 1

)1(

)(

b

i

0)(
‘
b

i

yqbP
iii

)(

30

4.1.2 Why cross-border traders demand corrupt acts

The traders will only take part in corruption if their expected profits are positive i.e. .

Their moral and real costs, qi are low because petty corruption in the country has now become

an accepted and expected way of life that is not condemned by society as much as before.

People‟s moral values have been almost completely eroded due to the hardships that they face

everyday whilst trying to make ends meet. Since the fraction of corrupt customs officials is

quite high it lowers the search and transaction costs for the trader who has to go through less

trials N, to find a willing bribee. This results in positive expected profits and hence their

willingness to take part in corrupt acts.

The demand for corrupt services is proportional to the number of traders with a positive Pi.

This demand can be expressed as

D D(b
_
, y) (2)

Due to the positive expected profits there are a lot of traders who demand corrupt acts

therefore the demand for corrupt acts is high. The higher the bribes b, the lower D is because

high bribes result in lower profits for the traders after they sell their goods. If they pay high

bribes they either incur the cost themselves by accepting a small profit margin so that they

move their stocks quickly or transfer the cost to the end consumer and have less of their goods

being bought and/or slower sales. All these possibilities are not good for the traders so they

may lower their demand for corrupt acts the higher the bribes. Since the expected search and

transaction costs are lower the higher the incidence of corruption more private agents have

positive Pi the higher y is. As a result the demand for corruption is an increasing function of y

for a given b.

Assuming that the D function is continuous and differentiable a suitable choice of units can

derive the long run relationship between the bribe b and the normalized level of demand for

corruption y which gives the equation y D(b, y) which then gives b E(y) as the long run

demand curve. This can be reduced to

E ‘
b

y

1 D
y

D
b

were D
b

0 and 1 D
y

0 showing that the long run demand curve can be upward sloping

with supply directly influencing demand.

0
i

P

31

4.1.3 Why customs officials supply corrupt acts

The incentives for a bureaucrat to act in an honest way are the same as those that make a

worker in a private firm put in the required effort (cf.Shapiro and Stiglitz, 1984). The worker

needs a salary high enough to induce him to put in this required effort and for the customs

official at the border, his wage needs to be high enough to make him honest and not use the

organisations resources for his private gain. The wages of the customs officials and their

colleagues in the public sector are so low that those who go to work only do so to use the

organisations resources for their private gain and are not motivated to be honest. With many

people going to look for greener pastures in other countries those that are benefiting from

corrupt acts see no reason to leave.

Other assumptions of the model are:

-All bureaucrats have utility functions that are linear in money and receive the same salary w

per period.

-The value of the outside option = 0.

With the unemployment rate at 80 percent, the value of the outside option for the customs

official is almost 0 because it will be very difficult for him to get employed if he is caught

being corrupt and fired. This increases his costs of supplying corrupt acts.

-w therefore reflects the wage differential between the public and private sectors corrected for

the expected waiting time.

-w is strictly positive.

-Bureaucrats are heterogeneous with respect to the costs of supplying corrupt services.

These costs may either be internalized moral costs or organisational costs related to the

positions of the bureaucrats. The higher a rank one has the more one probably has to lose if he

is caught cheating. Besides losing his job and benefits his reputation is also damaged more so

than an official with a lower rank. The customs officials also have different moral costs

depending on their moral values which may have nothing to do with their positions.

-Each bureaucrat has the option to follow either a corrupt or a non-corrupt strategy.

-He has an infinite horizon and discounts future income with the discount factor:

The expected value of the options of the rational bureaucrat i in period t is:

(3

1 (1 r)

)1(),(max)( tVtUcbwtV
iiii

32

Were: b = bribe.

ci = bureaucrat i‟s cost of providing corrupt services.

= expected gain of choosing to be corrupt in period t.

If the bureaucrat decides to be honest and non-corrupt he is sure to keep his job and obtains

in the coming period. The loss of future income is not much of a motivation for

honesty for the corrupt customs official because his wage is very low. If he can make his

salary for the next two, three or even ten years in a single corrupt act then he is likely to be

dishonest. It may more so be the loss of the opportunity to supply corrupt acts in the future

that may induce the official to be honest in the present period. Also if the risk of getting

caught in the near future is high then he may try to get as much as he can before he is caught.

But again if one is so used to be corrupt and getting away with it one can get comfortable and

almost forget that he can get caught and be fired. This is sometimes the case in Zimbabwe

were many people are either busy with their own corrupt acts and making sure that they do

not get caught that they may not be bothered with the corruption of their fellow bureaucrats

and just turn a blind eye. There are some bureaucrats though who are honest so the corrupt

customs official is at risk of being caught by a corrupt colleague or an honest one.

The expected consequences of being corrupt are:

(4)

Were: s = the exogenously determined probability of being caught in corrupt

transactions and 0 s 1.

= the probability of not being caught.

If the corrupt bureaucrat is not caught he can start the next period with the same options as he

had in the present one. His consequences of being caught depend on whether he is caught by a

corrupt colleague or an honest one. If he is caught by a non-corrupt colleague he is reported to

higher ranking officials who are assumed to be honest. These would immediately confisticate

the bribe b and fire the corrupt bureaucrat. But in reality at the border not all superiors are

honest as some are even involved in the corrupt acts with their subordinates, here the reported

corrupt official may not be fired but just given a warning although in other cases even though

they may have done some corrupt acts together the superior may feel that protecting the

)(tUcb
ii

)1(t

V
i

))(1()))1(()1()1()( bytVystVstU
iii

(1 s)

33

corrupt subordinate and not firing him is too obvious and may damage his own reputation so

he is left with no choice but to dismiss him. Therefore in being corrupt there is a probability

of obtaining as the best option in the coming period considering that the

utility level outside the public sector is equal to 0.

On the other hand if he is caught by a corrupt colleague he can bribe him immediately with a

bribe = B so that he does not report the case and hence he keeps his job. As a result there is a

probability sy of obtaining in the coming period. This bribe B can take on

different values. It can be equal to 0 when corrupt bureaucrats agree not to report each other

in a „tit for tat strategy‟ which means that if you do not report me then I will not report you

too when and if I catch you being corrupt in the future. The two can also bargain and share the

gain of not being fired which is the future income of the corrupt bureaucrat. In the third case

which is used in this models‟ formal derivations and the one that is most common among the

customs officials B = b, i.e. the potential reporter receives the same bribe as that acquired by

the corrupt

bureaucrat.

A bureaucrat who would choose to be corrupt faced with an external bribe b will also accept

the same amount of bribe b to perform the corrupt act of not reporting the colleague that he

has caught. Anything less would be unfair leaving him disgruntled and putting the corrupt

official who has been caught at a risk of being reported to an honest superior. We therefore

have the same equation determining Vi for those who choose to be corrupt independently by

directly accepting bribes from non-members of the bureaucratic organisation or taking them

via other bureaucrats in their organisation.

In the model stationarity is assumed so and for all t. From (3) we can

then find the expected present value of following a non-corrupt strategy (which is the best

option for those bureaucrats with sufficiently high ci values and it is not rewarding to be

corrupt) is.

(5)

This is also the present value of future salaries that one would get if he keeps his job by being

honest.

s(1 y) ( b 0)

( B V
i
)

V
i
(t) V

i
U

i
(t) U

i

V
N w

1

34

The expected present value of following a corrupt strategy is:

(6)

This equation shows that as long as is positive the pay-off of choosing a corrupt strategy is

higher the higher its incidence i.e. the higher is y. At the border most of the customs officials

are corrupt resulting in a high y. This means that the expected present value of following a

corrupt strategy is also high and greater than the expected value of following a non-corrupt

strategy hence the customs officials will only be behaving rationally by choosing to be

corrupt. This rational behaviour results in an even greater fraction of corrupt officials making

the expected present value of following a corrupt strategy even greater than that of following

a non-corrupt one. This vicious cycle of corruption then leads to a high corruption equilibrium

level, a stage which maybe difficult to reverse in the long-run. The higher y is the lower the

chances of being caught by a non-corrupt colleague and being reported to an honest superior.

A rational bureaucrat chooses to be corrupt when . From (5) and (6) and using

this reduces to:

(7)

Were: = expected money gain of corruption.

= expected retained value of the bribe.

= expected loss of future incomes.

For a bureaucrat to be corrupt his costs, ci must be less than the expected money gain from

corruption but greater than expected retained value of the bribe.

Each bureaucrat is associated with a level of costs ci which are distributed over an interval

[ ] with a cumulative density such that F (c) 0 and F(c) 1 The proportion of the

bureaucrats who choose to be corrupt is for given values of y, b, w, s

and r. The number of corrupt bureaucrats is higher:

-the higher the perceived fraction of corrupt bureaucrats y;

As mentioned earlier in this paper corruption is an accepted and expected way of doing

business at the border. As a result the cross-border traders who demand the corrupt acts

V
i

c w b(1 s) ci

1 (1 s(1 y))

V
i

c

V
i

c
V

N

1 (1 r)

c
i

(1 s)b

s(1 y)w / r

(1 s)b s(1 y)w / r

(1 s)b

s(1 y)w / r

c,c

F ( )

F((1 s)b s(1 y)w / r

35

expect that most of the customs officials that they are dealing with are corrupt and so offer a

bribe for their services. This may tempt those otherwise honest officials. In some cases bribes

are accepted for procedures that may otherwise have not required any bribery.

-the higher the bribes b;

A lot of the people who cross the border may not know how their duty is calculated by the

customs officials. As a result they end up paying more that they are supposed to. The customs

officials may also take advantage of the fact that the traders want to spend as little time at the

border as possible and demand high bribes.

-the lower the salary w;

The very low wages of the officials result in a high number of corrupt customs officials as

they are left with no choice but to supplement their income through dishonest means.

-the lower the exogenously given detection probability s;

Some reasons why this is so at the border are that, the supervision is very low and almost non-

existent, since almost everyone is being corrupt they are occupied with not being caught

themselves that they may not really be concerned with what their colleagues and subordinates

are doing and they also let each other in on their corrupt deals to avoid whistle blowers.

-the higher the discount rate r;

The discount factor can also can be viewed as the probability that the present

bureaucratic regime remains in power in the succeeding period assuming that the corrupt

bureaucrat will be unemployed if a new regime which may not tolerate corrupt acts comes

into power hence no future income. The higher the probability of a regime shift the higher is r

and the higher is the incidence of corruption and a perceived value of y as the bureaucrats,

especially those appointed because of their political affiliation with the ruling party try to

acquire as much as they can to cushion themselves against the anticipated negative impacts of

a possible regime shift. The economic and political situation in the country at the moment is

very volatile and its future is uncertain. There may not be threat of a complete regime shift but

the resultant inclusive government from the power-sharing agreement may lead to a better

rule of law and intolerance of corrupt acts making the future of the corrupt officials bleak.

1 (1 r)

36

can be considered as a response function indicating the number of

bureaucrats who choose to be corrupt for a perceived level of y. Therefore the positive

equilibrium levels of y and b must satisfy

for (8)

b = E(y) (9)

(8) and (9) describe self–fulfilling consistent beliefs about the incidence of corruption and the

equilibrium bribes. Mathematically they also describe Nash equilibria in the game theoretic

sense in which:

-all bureaucrats know each others ci values.

-everyone predicts the equilibrium level(s) of y on the basis of rational behaviour from all

bureaucrats.

In reality though each bureaucrat may not know so much about the costs of the others but

knows his own cost ci and just observes last periods level of corruption and uses that to

adjusts his choice rationally in the present period.

Therefore we can write . When y(t) y(t 1) a stationary

equilibrium is reached. Such an equilibrium y* is locally stable if a small deviation from y* in

period t leads to a conversion back to y*. This is called the myopic adjustment case.

4.1.4 Possible corruption levels in the customs sector

Different equilibria incidences of corruption have their corresponding market clearing bribe

values. The distribution of ci over the bureaucrats determines the possible equilibrium levels

and there may frequently exist multiple equilibria.

The value y = 1, i.e. all the bureaucrats being corrupt is in the equilibrium set if;

(1 s)E(1) c (10)

this means that the expected value of the equilibrium bribe when all bureaucrats are corrupt

exceeds the cost of the least corrupt prone bureaucrat.

The value y = 0, i.e. no bureaucrats being corrupt is in the equilibrium set if;

F((1 s)b s(1 y)w / r

F((1 s)b s(1 y)w / r y 0 y 1

y(t) F((1 s)b s(1 y(t 1))w /r)

37

(1 s)E (0)
sw

r
c (11)

meaning that the expected value of the equilibrium bribe when all others are honest is not

high enough to cover the expected loss of future salaries and the costs of the most corrupt

bureaucrat.

4.1.5 Bell shaped distribution of ci

This is the distribution of ci that applies most to the customs officials whose costs follow a

normal distribution. This results in the case illustrated in fig. 2 with three possible equilibrium

levels of y on the supply side for a given value of b. These are points that correspond to the

Intersections between the y and F-curves. This model focuses on the myopic adjustment case

in which y1 and y3 are the stable equilibria. If the perceived level of corruption is below the

critical mass y2 the process converges step by step to y1 but if it is above y2 it converges to y3.

According to TI (2008) Zimbabwe is slowly heading towards the high corruption level y3 and

so has passed the critical mass y2. A change in a number of factors over the years has resulted

in this approach towards high corruption equilibrium. Some of these factors are presented in

fig. 3. This paper uses Adving and Moene‟s model to make a rough forecast of what might

happen to the level of corruption in the customs sector especially at the Beitbridge border post

in the short and long run depending on how the equilibrium supply of corruption responds to

different values of the bribe price which is determined by the factors in fig. 3.

Possible corruption levels in the short run.

Having started in a low corruption equilibrium an increase in the bribe b at the border post

shifted the F-curve upwards as shown in fig. 4. This was mostly due to the bad economic

situation in the country which resulted in workers receiving very low wages and hence

resorting to corruption and increasing its supply. As the situation continues to worsen the

moral values of the society are continuously being lowered as petty corruption is seen as a

justifiable way to make a living given their low salaries. The deterioration of the economy

38

Figure 2 : Possible equilibrium for bell-shaped distribution of cost

y,F

y

1

F((1-s)b-s(1-y)w/r)

y

y1 y2 y3 1

Figure 3: Factors that determine the corruption equilibrium level

Economic Environment

Wage Moral Values Rule of law Regime Shift Demand

for corrupt acts

Bribe price

Corruption Equilibrium Level

39

also saw the disintegration of the rule of law, if one knows the right people or has money then

he will not be punished for his unlawful behaviour. The lack of basic commodities increased

the demand for corrupt acts at the border greatly as many became cross-border traders and

more and more individuals were crossing over to South Africa to buy essentials.

The highest bribe which sustained this low equilibrium is b1 shown by the highest stipulated

curve. The supply of „low level‟ corruption is continuous and increasing in b for b < b1 but

for b values just above b1 the equilibrium supply of corruption will jump to point z and the

sector will be in a „high level‟ corruption equilibrium. With the continued collapse of the

economy the bribe price may soon be higher than b1. The lowest bribe which will sustain this

high equilibrium is b2 as illustrated by the lowest stipulated curve b2. The „high level‟ supply

of corrupt services is a continuous increasing function of b for b > b2 but for values of b just

below b2 the equilibrium supply of corruption will jump to t and the sector will be in a „low

level‟ corruption equilibrium. This shows that if the power sharing deal yields positive results

soon and the economic situation improves resulting in higher wages, a campaign to restore

peoples‟ moral values, more supervision, better rule of law and a decrease in the demand for

corrupt acts the bribe price and corruption levels may decrease. Points x and k are low and

high tipping points that correspond to unstable intermediate points like point y2 in fig. 2, they

are of little relevance in our myopic adjustment case. This shift back to the low corruption

equilibrium level may not be so easy in the long run and the sector may be stuck in the high

level corruption equilibrium.

Possible corruption levels in the long run.

Fig. 5 illustrates the forecast of the corruption level in the customs sector in the long-run with

b1, b2, t, x, k, z referring to points in fig. 4. The „low level‟ supply curve L is relevant for b

values in the interval [b1,b2] only when we start out in a „low level‟ equilibrium where b < b2.

The „high level‟ supply curve H is relevant for b values in the interval [b1,b2] only when we

start out in a „high level‟ equilibrium where b > b1. The dotted downward sloping part of the

supply curve is unstable as mentioned earlier. Although this supply structure and an

increasing long run demand function E(y) may result in one, two or three equilibrium levels of

y the model only focuses on the two equilibrium case. Fig. 5 shows that when the sector is in

the high level of corruption it will also have a high equilibrium bribe. In the long-run some

temporary changes that have occurred in the underlying parameters may shift the sector from

a low corruption to a high level corruption equlibrium. Due to the ratchet effects of the supply

40

Figure 4: Short-run equilibrium supply response to different values of the bribe

y,F
y

1

F((1-s)b1-s(1-y)w/r)

F((1-s)b2-s(1-y)w/r)

y

t x k z 1

Figure 5: Long-run equilibrium supply response to different values of the bribe

b

D(b,y2) H

D(b,y1) L H‟ E(y)

b1

b2

y

t y1 x y3 k y2 z 1

side these temporary shifts may give rise to permanent changes. Some of these changes that

have taken place are:

i) Demand has temporarily increased as more and more people are crossing the border for

basic commodities inducing the short-run equilibrium price to go up above b1 such that the

41

supply of corrupt services will jump into the high level regime. When demand reduces to the

normal level the equilibrium might settle on this high corruption equilibrium level.

ii) The probability of a regime shift has temporarily increased due to the political and

economic uncertainty and officials have become more corrupt prone for each level of the

bribe. This can eventually lower the critical bribe b1 in the fig. 3 and the equilibrium may

jump into the high corruption level regime. When the uncertainty is resolved and the value of

r goes back to its normal level the situation will be trapped at the high corruption equilibrium

level.

iii) Moral costs of taking bribes have been lowered as corruption has become the only way to

survive for the customs officials. Although a better economic environment in which people do

not have to be corrupt to make ends meet may restore these moral values the sector may be

trapped in the high corruption equilibrium level. Considering a first order leftward shift in the

distribution of ci means that every element ci is reduced with the same amount and the new

equilibria are characterized by

for

0 y 1 (12)

. (13)

If increases from 0 the F curve will shift upwards as shown in fig. 4 implying a higher

supply of corrupt acts to each level of the bribe. Both the low and high tipping points x and k

will consequently be reduced the more so the higher is . In fig. 5 this increase shifts both the

L and H curves to the right and lowers the critical bribes b1 and b2 as indicated by the curves

L′ and H′. As long as the long run demand curve is upward sloping the equilibrium bribes are

also increasing in .

When supply and demand determine the bribe it is economically expected that an increase in

the supply would decrease the equilibrium bribe. Currently in the customs sector it is the

opposite as predicted in the model. Although there might be an increase in the supply of

corrupt acts at the border the increase in the demand may even be greater resulting in an

increase in the equilibrium bribe. It may not be the case though that the corruption jumps

yrwysbsF )/)1()1((

b E ( y)

42

from one equilibrium level to the other but it is a gradual step by step process that takes years

or even decades. As a result it may also take a long time for the corruption level in this sector

and the country as a whole to go back to the low corruption equilibrium level even after the

economic situation in the country has improved.

The return to the low level corruption equilibrium may be slowed down further by the greed

among both low and high ranking officials. Some of the officials have become accustomed to

certain lifestyles that they feel a need to maintain through the continued supply of corrupt

acts. This lifestyle is not one that these corrupt officials flaunt to their colleagues because they

do not want to risk being investigated. The corruption by the customs officials might have

started because of greed when their wages could still sustain them. As the economic situation

is worsening and more officials cannot meet their basic living costs some have became

corrupt as a means to survive moving the sector towards the high level corruption

equilibrium. When the economic situation starts getting better the officials will no longer be

desperate as they can again live on their monthly remunerations but then the greed will still

exist amongst some. This will result in a cycle of corruption that starts and ends with greed.

There are other cost distributions that may not apply to the corruption in the customs sector

and these are briefly discussed below.

4.1.6 Identical ci values

In a special case all bureaucrats are identical, i.e. ci = ĉ for all i. Returning to the equilibria

described by (8) and (9) we have either y = 1 or y = 0 in equilibrium and for given values of s

and w both extremes can be in equilibrium. This is so if

(14)

using (10) and (11). When (14) applies we find from (7) the critical mass

, (15)

where all bureaucrats are indifferent between being corrupt and being non-corrupt. This

incidence of corruption is unstable. If the perceived y is higher than ŷ the equilibrium

converges to y = 1 but if the perceived value of y is lower than ŷ the equilibrium converges to

y = 0.

(1 s)E (1)

sw / r

ˆ c (1 s)E (0)

1 ˆ y
(1 s)b ˆ c

sw / r

43

The equilibrium supply of corrupt services as a function of the value of the bribe depends on

the initial situation. Starting by increasing b from b = 0, we get y = 0 as the equilibrium for all

values of b such that the left hand of the inequality (12) holds, i.e. for b (c s / w) /(1 s).

Higher values of b induce all bureaucrats to become corrupt. From fig. 6 it can be seen that

b (c sw / r) /(1 s) starting from and successively reducing b, y = 1 is the equilibrium as

long as .

4.1.7 Uniform distribution of ci

The costs ci can be uniformly distributed over the interval [ ]. If both (10) and (11) hold we

have a similar situation as in identical ci values. If neither (10) nor (11) hold we have a unique

stable supply side equal to y* shown in fig. 7. Here there is an increasing supply of corrupt

transactions as a function of the bribe. There is a stable equilibrium level of b and y if the

slope of the supply curve is steeper than that of the demand curve.

4.1.8 Double peaked distribution of ci

In this scenario shown in fig. 8 there are three stable supply side equilibria i.e. L, M, H for all

values of b. This may result in a three long run equilibria of b and y.

Figure 6: Possible equilibrium levels for identical cost values

b

c sw / r

1 s

c

1 s

1 y

ˆ b c(1 s)

c,c

44

Figure 7: Possible equilibrium levels for uniform distribution of costs

y,F
y

1

F((1-s)b-s(1-y)w/r)

y

y*

Figure 8: Possible equilibrium levels for double peaked distribution of costs

y,F
y

1

F((1-s)b-s(1-y)w/r)

y

L M H 1

45

4.2 Model 2:

4.2.1 Waiting time at the border for the bus drivers

Ratchet effects on the demand side of corruption can be illustrated using an example of bus

drivers bribing the customs officials in order to reduce their waiting time at the border. For

both the drivers and their passengers it is of paramount importance that they spend as little

time as possible at the border especially when they are crossing over to go to the South

African side. The passengers want to quickly buy their goods and head back home whilst the

drivers do not want their timetables disrupted by delays at the border. As a result sometimes

they are willing to bribe the officials so that they will go to the front of the line but at times

the bribe price is so high that it is not worth it to pay it as will be shown by this model using

figs 9 and 10.

Let:

d – c0 = cost of waiting for those who bribe

e – c1 = cost of waiting for those who do not bribe, here no-one bribes

a – c3 = cost of waiting for those who bribe + the bribe that they pay

c0- c3 = the bribe price

α = fraction of buses that bribe their way through the border

1-α = fraction of buses that do not bribe their way through the border

A(α) = the cost bribing

C(α) = the cost of not bribing

When the bribe = b1 there will be two equilibria as shown in fig. 9.

Equilibrium 1: No corruption

No-one pays since the bribe is higher than the cost of waiting i.e. b > d. Here all the drivers

will choose to wait and the equilibrium will be at c1 with no corruption.

Equilibrium 2: Full corruption

Here when some drivers decide to pay then all the others will find it rational to do so as well

because the one who does not pay will end up always being at the end of the line. These

ratchet effects in the demand will result in the equilibrium being at a,

with full corruption.

46

4.2.2 Decrease in the bribe

Equilibrium 1: Full corruption

The bribe can decrease from b1 to b2 if the economic situation worsens increasing the supply

of corrupt acts. This decreases the cost of those who bribe from c3 to c3‟. When this happens

the new cost of waiting for those who bribe c3‟ becomes less than the cost for those who do

not bribe therefore all the drivers will decide to bribe and the new equilibrium will be at f,

with full corruption.

4.2.3 Increase in the number of buses

The worsening of the economy may result in more people crossing the border and this

increases the number of buses as well as the demand for corrupt acts as shown in fig. 10. This

increase also happens periodically during the peak periods when there is a lot of traffic

crossing the border such that those who choose not to pay may end up spending about two

days or more at the border post. This will be a great inconvenience to both the passengers and

the drivers. In this case there is only one equilibrium with full corruption as explained below.

Equilibrim 1: Full corruption

When the number of buses increases the cost of waiting for those who bribe, d – c0 increases

since their gain from bribing has also increased and the curve tilts to d’ – c0. This increase is

equal to that for those who do not bribe which is from e – c1 to e’ – c1’. As a result all the

drivers decide to bribe the customs official and the consequences of the one that does not pay

is great as he will end up at the end of the queue and may be spend a few days at the border.

The ones that arrive after him may even leave before him if they do decide to pay. There will

be full corruption at e, were all the drivers pay since their cost of bribing plus the bribe is the

same for all and less than the cost of waiting at the border .i.e. A (α) + b < C(α).

Here it shows that when everyone pays it does not help in aggregate but benefits the customs

official who may take advantage and slow down his work to make the willingness to pay

(WTP) of the drivers increase and hence increase the bribe price.

These two models have shown that there are ratchet effects in both the supply and demand

side of corrupt acts which may lead to a high level corruption equilibrium or full corruption.

47

Figure 9: Corruption levels for bus drivers at the border

e

a

f

c3

d c1

d

c3‟

c0

α 1-α

Figure 10: Corruption levels after an increase in the number of buses

e’

b1

e c1′

d’

A A

c3

d c1

b1

c0

α 1-α

48

CHAPTER 5

CONCLUSION

Although corruption is widespread and systematic throughout the public sector in Zimbabwe

it takes different forms which need to be known, acknowledged and accepted if the country is

to move back to a low level corruption equilibrium and minimise the possibility of

recorruption. It is also important to understand the rational responses of the bribers and

bribees to the different factors that affect the corruption level through the bribe price in. This

understanding helps give a rough forecast of the corruption levels in both the short and long

run in the different sectors and the country as a whole. In the short run a shift to a high

corruption level is easily reversible when the bribe price decreases beyond a certain level but

this maybe difficult in the long run. With the economic situation worsening the bribe price in

the customs sector is likely to continue increasing and the sector will be in a high level

corruption equilibrium which will be very difficult to reverse. The ratchet effects in the

demand side of corrupt acts will also contribute to full corruption in some sections of the

sector. But if the inclusive government works towards the recovery of the economy, better

wages, more efficiency, accountability, transparency and rule of law in the public sector then

the situation may change resulting in a decrease of the bribe price.

Limitations:

Although the agency model by Adving and Moene is very relevant for the study of petty

corruption one of its main assumptions that the high level officials are honest and will fire the

corrupt official may not always apply in the customs sector where even the senior officials are

known to be very corrupt. Efforts to get interviews with them yielded no results but they

would probably have agreed with this assumption because they would want to give a false

image of honesty. Some of these high level officials are also involved in corrupt acts with

their subordinates so future researchers can consider these relationships which may help to

show some of the links between petty and grand corruption.

It was important to have a lot of interviews to get a picture of the extent of the corruption in

the country than just take the CPI Indices as they are considering that the surveys on which

the index is based may not ask the same questions, start from the same definition of

49

corruption or have the same ethical and moral yardstick. It was evident however that the

incidence of corruption in the public sector and the country as a whole is great.

Implications for further research:

These interviews revealed that corruption is a huge problem in the country that needs to be

addressed but they were just a drop in the ocean. A lot of sectoral research still needs to be

done to understand the culture of corruption in Zimbabwe although many of the forms

mentioned are the same as those found by Blundo, Olivier de Sardan, Arifari and Alou in

their research in Benin, Niger and Senegal from 1999 to 2001 and documented in their book,

“Everyday Corruption and the state: Citizens and Public Officials In Africa”(2006).

Although the thesis has shown that the customs sector might be approaching a high level

corruption equilibrium in the long run it is important to note that corruption is not an

irresolvable problem. The sector may not necessarily be stuck in this high corruption level but

it may just be more difficult and take a longer time to return to a low level corruption

equilibrium, it is not impossible.

50

References

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Organization, Elsevier Publishers, vol. 13(1), pages 63-76

Arvind K. Jain 2001.Corruption: A review. Journal of Economic Surveys, vol 15(1), pages

71-121, Blackwell Publishers Ltd, USA

Bertram I. Spector 2005. Fighting Corruption in Developing Countries. Cumarian Press, Inc ,

Bloomfield , USA

Blundo G, Olivier de Sardan J.P, Arifari N.B, Alou M.T. 2006. Everyday Corruption and the

state: Citizens and Public Officials In Africa. Glosderry, South Africa

David J. Gould and Jose A. Amaro-Reyes 1983. The Effects of Corruption Administrative

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U.S.A.

Kempe R. Hope 1997. African Political Economy: Contemporary Issues in Development

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Makumbe, John 1994. Bureaucratic Corruption in Zimbabwe: Causes and Magnitude of the

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Martinez-Vazquez Jorge, Arze del Granado Javier, Boex Jameson 2007. Fighting Corruption

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Mukum Mbaku, John 2007. Corruption in Africa: Causes, Consequences, and Cleanups

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Shana, Goodwin 2006. The State of Corruption In Zimbabwe. unpublished, Harare.

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51

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