NO REFUGE ,Access denied:medical and humanitarianneeds of Zimbabweans

in South Africa
MEDECINS SANS FRONTIERESDOCTORS WITHOUT BORDERS

June 20091

Photo: © Austin Andrews
Zimbabweans sleep in the shadows of a stairwell in the Central Methodist Church in downtown Johannesburg. The Church provides a ‘safe
haven’ where thousands of Zimbabweans seek refuge every night.

MEDECINS SANS FRONTIERESDOCTORS WITHOUT BORDERS

MSF in Cape Town
Unit 23B, No. 14
Waverly Business Park
Wyecroft Road
Mowbray 7700
Cape Town, South Africa
Tel: +27 21 448 1058
Fax: 27 21 448 3128
Email: msfb-capetown@brussels.msf.org
MSF in Johannesburg
49 Jorissen Street
3rd Floor, Orion House
Braamfontein 2017
Johannesburg, South Africa
Tel: +27 11 403 4440
Fax: +27 11 403 4443
Email: msfb-johannesburg@brussels.msf.org
MSF in Musina
5 Frost Avenue
Musina 0900
South Africa
Tel/Fax: +27 15 534 2335
Email: msfb-musina@brussels.msf.org
Published by:
Médecins Sans Frontières, June 2009www.msf.org.za
Design/artwork: Designs4development (info@d4d.co.za)
2

NO REFUGE ,Access denied:medical and humanitarianneeds of Zimbabweans

in South Africa

MSF in South Africa
MusinaJohannesburg

Swaziland

Bloemfontein
LesothoCape Town

Khayelitsha

DurbanPort Elizabeth

Médecins Sans Frontières (MSF) is an international, independent, medical humanitarian organisation that delivers emergency aid topeople affected by armed conflict, epidemics, health care exclusion and natural or man-made disasters. The organisation works in morethan 60 countries throughout the world and has been working in South Africa since 1999 providing HIV/AIDS and TB treatment, as
well as care for survivors of sexual violence, in Khayelitsha (Western Cape) and HIV/AIDS treatment in Lusikisiki (Eastern Cape). MSF
started providing medical and humanitarian assistance for Zimbabweans seeking refuge in Musina and Johannesburg in 2007. MSF
also has a large presence in Zimbabwe, treating more than 25,000 people on antiretroviral therapy in the country and, most recently,
deploying a major emergency intervention and treating more than 50,000 patients in response to the cholera epidemic.

Contents
A MATTER OF SURVIVAL

2

Summary3

WE ARE HERE BECAUSE WE WERE SUFFERING IN ZIMBABWE

6Fleeing Zimbabwe

7

NO REFUGE, ACCESS DENIED

8The South African government’s response

9

Neglect and deportation

9

Gaps in access to health care

10

CROSSING THE BORDER

12Violence, chronic disease, and epidemic outbreaks in Musina

13

Sexual violence

14

HIV/AIDS and TB in a highly mobile population
Cholera outbreak

15

SEARCHING FOR SAFETY

18

Central Methodist Church in Johannesburg

19

Communicable diseases and outbreak response

20

Facilitating access to secondary and specialised care

20

The plight of unaccompanied minors

21

STRUGGLING TO SURVIVE IN THE SHADOWS

24

Conclusion

25

REFERENCES

26

1

INSERT MAP OF SOUTH AFRICA WITH PROJECT LOCATIONS IDENTIFIEDWITH SMALL MSF LOGOS

A matter ofSurvival“25% percent of the entire Zimbabwean population has fled Zimbabwe toneighbouring countries, especially South Africa, as a matter of survival. They
are raped, beaten, and robbed while crossing the border, they struggle to findbasic shelter and other assistance in South Africa, and they are subjected toxenophobic violence, abuse, and neglect, even when trying to access healthcare. There have been some positive developments in the past month regarding
the legal status of Zimbabweans seeking refuge in South Africa, but the jury is
still out on whether these new policies will improve the deplorable conditions inwhich they live.”- Rachel Cohen, MSF Head of Mission in South Africa
Photo: Joanna Stavropoulou/MSF, A woman receives treatment for cholera in the southern town of Beitbridge, Zimbabwe, on the border of South
Africa. The recent cholera outbreak in Zimbabwe was Africa’s worst in more than 15 years, killing over 4,300 people2Summary
Each day, thousands of Zimbabweans cross theborder into South Africa, many risking their lives toflee economic meltdown, political turmoil, and acritical lack of access to health care in their country.
In the past several years, the crisis in Zimbabwe
has given rise to food insecurity, an unprecedented
cholera epidemic, political violence, rampant
unemployment, an escalating HIV crisis and thenear-total collapse of the health system. This
breakdown in Zimbabwe has driven nearly onequarter of the entire population into neighbouring
countries, particularly South Africa.
And despite claims that Zimbabwe is ‘normalising’
following the establishment of a Government of
National Unity, Zimbabweans continue to cross theborder every day, legally and illegally, in massive
numbers as a matter of survival.
Upon arrival, many Zimbabweans endure further
suffering in South Africa, without access to proper
health care, shelter or safety. During their journey
to and within South Africa, they are subjected
to violence, physical and verbal abuse, police
harassment, inhumane living conditions andxenophobic attacks.
The South African Constitution guarantees accessto health care and other essential services to all
those who live in the country – including refugees,
asylum-seekers, and migrants – regardless of legal
status. However, in practice, the fear of arrest,
deportation, and xenophobia, coupled with a lackof accurate information about their rights, has kept
many Zimbabweans from accessing basic services
necessary for survival. Today, Zimbabweans arestill often charged exorbitant fees to access public
facilities despite policies to the contrary, turned
away from hospitals when they need admission,discharged prematurely, or subjected to harshtreatment by health staff in the public services.
In 2007, Médecins Sans Frontières (MSF) opened
two projects to respond to the specific health needsof Zimbabweans seeking refuge in South Africa.

MSF mobile clinics, operating in and around Musina
town at the border with Zimbabwe, in addition to a
fixed MSF clinic at the Central Methodist Church in
Johannesburg, provide general primary health care,referrals to existing hospitals or specialised medical
facilities, and other humanitarian assistance,
including shelter, water and food.
MSF medical teams treat 4,000-5,000
Zimbabweans each month, mainly for respiratory
tract infections, including a substantial proportionof tuberculosis; sexually transmitted infections;
gastro-intestinal and diarrhoeal conditions; andstress-related ailments. More than 30% of HIV tests
performed are positive. Yet, this is just the tip of theiceberg. There are thousands more Zimbabweans
who never come forward to access MSF or other
health services, choosing instead to protect
themselves by becoming invisible in South African
society.
Because many patients have endured multiple
traumatic events and exhibit symptoms of posttraumatic stress, MSF also provides psychologicalsupport in both Musina and Johannesburg. In
addition, MSF teams treat a rising number ofsurvivors of sexual violence and see a worrying
increase in the number of unaccompanied children
travelling from Zimbabwe into South Africa.
The recent announcement by the South African
Department of Home Affairs that a new system
will be put in place to regularise the legal statusof Zimbabweans in South Africa, and to stop
the systematic deportation of Zimbabweans,
is a welcome departure from the government’s
previous policy of aggressive harassment, arrest,and deportation. Whether the fate of vulnerable
Zimbabweans in South Africa will improve depends
upon how and when these new policies will be put
into practice.
This report highlights the plight of Zimbabweans
seeking refuge in South Africa, the appalling
conditions in which they live, and their ongoing lackof access to adequate protection, shelter, and basic
services, particularly health care, in South Africa.

3

4

Zimbabweans under attack: a chronology of desperation• January 2008: Police raid the Central Methodist Church in Johannesburg, detaining 350 people, before acourt interdict secures their release. The presiding judge refers to the treatment of the detainees as being worse
than during the days of apartheid.
• March 2008: Increase in political tension, violence, and intimidation in Zimbabwe on the eve of generalelections.
• May 2008: Xenophobic attacks erupt in Alexandra township in Johannesburg, then spread throughout Gauteng
and to Western Cape and Kwa-Zulu Natal, killing 62 people and displacing more than 100,000.
• June 2008: Continued increase in election-related violence in Zimbabwe prior to the run-off elections.
• July 2008: Department of Home Affairs opens Reception Office at Musina Showground. Thousands ofZimbabweans previously in hiding flock to seek asylum.
• November 2008: Department of Health declares a cholera outbreak primarily affecting Zimbabweans in
Limpopo Province, and later Gauteng, Mpumalanga, and other provinces.
• February 2009: 100 police and ‘Red Ants’ attempt to raid people sleeping in front of the High Court next to theCentral Methodist Church, harassing, intimidating, and arresting Zimbabweans sleeping on the street.
• March 2009:• South Africa authorities forcibly expel thousands of Zimbabweans from Musina Showground.
• Thousands of Zimbabweans flee from Musina to Johannesburg, the majority to the Central Methodist
Church. More than 4,000 people seek refuge inside and around the Church at the height of the crisis.
• Local businesses in Johannesburg’s Central Business District (CBD) sue the municipality, City of
Johannesburg, and the Central Methodist Church, complaining that the thousands of Zimbabweans and thecrowded and unhygienic environment around the Church are bad for business.
• Local businesses erect large metal gate in front of the Church to prevent Zimbabweans from being able tosleep in the direct vicinity of the Church, effectively cutting people off from the Church and subjecting themto extreme vulnerability and potential violence and abuse.
• April 2009: Department of Home Affairs, under pressure from NGOs and human rights groups, announces
special dispensation permit under the Immigration Act for those without legal documents and a moratorium
on deportations. However, arrests and deportations continue, roll out of the special dispensation is slow, andconfusion remains high, leading to continued chaos and uncertainty.
• May 2009:• DHA announces a new 90-day ‘visa free’ entry permit, but it only applies to Zimbabweans who have travel
documents.

Photo: Sara Hjalmarsson/MSF, In March 2009, South African authorities forcibly expelled thousands of Zimbabweans from Musina Showground,ordering that all temporary shelters be taken down and burnt.

5

WE ARE HERE BECAUSE
WE WERE SUFFERINGIN ZIMBABWE“Things are really not well in Zimbabwe. My children live only on one or two
meals per day. My family is hungry. No bread, no soap, no meat; these things
are not available or if they are, we cannot afford it. I came to South Africa sothat maybe my family can survive this crisis.”- A Zimbabwean man in his 30s (MSF patient in Musina)

Photo: © Dirk-Jan Visser, A Zimbabwean child stands before the empty shelves of a big supermarket in Bulawayo. Zimbabwe is currently
the most food-aid dependent country in the world.

6

Fleeing Zimbabwe
Over the past several years, an estimated three
million Zimbabweans have crossed the Limpopo
River into South Africa. The situation has become
particularly acute in the past year and a half.1
In Zimbabwe, currently the most food aiddependent country in the world, seven million
people out of the remaining population of ninemillion are presently food insecure;2 Africa’s worst
cholera outbreak in more than 15 years struck
100,000 people, killing over 4,300;3 15% of
the adult population is HIV-positive;4 94% of the
population is unemployed;5 and several reports haveclaimed thousands were beaten and intimidated bygovernment security and paramilitary forces during
last year’s electoral cycle. The cholera epidemic waswidespread, affecting all provinces, and the generalcase fatality rate (CFR) was above 5% even after an
emergency response was established, whereas therate for a controlled epidemic is defined by a rateof one percent or less. This signalled a near totallack of capacity of public services, including water,
sanitation, and health systems, to cope.
Political instability and mismanagement led toeconomic freefall with skyrocketing inflation
exceeding a staggering 89 sextillion percent.6 The
economic collapse brought about a virtual standstillin industrial and agricultural production, severe
shortages of essential goods, and a near-collapse ofbasic infrastructure and public services, including
the once-vaunted health system. MSF has beenworking in Zimbabwe since 2000 and witnessed
a continuous deterioration of the humanitariansituation during this period.7
The establishment of a Government of National
Unity in February 2009 has led some to speculatethat the situation in Zimbabwe has ‘normalised’ andZimbabweans who fled to neighbouring countries
should now return home. But the political andeconomic situation in Zimbabwe today is far fromstable and the health system continues to exist ina state of near-collapse. As a result, Zimbabweans
will continue to flee to South Africa in desperation
and will require both guaranteed protection andproper assistance to address their medical andhumanitarian needs.

“All of us people at the Showground [Musina], we
are not here because we want to be. We are here
because we were suffering in Zimbabwe. The masses
are hungry – they are running from their own
country.”
A 33-year-old man staying at a temporary shelter in Musina“Everything was tough. You couldn’t use the money
to buy even a loaf of bread. That is what pushed me
to leave the country. Everything was deteriorating –there was no water. It was about eight years without
running water. You could get it for about two hours
a day – you had to get up around midnight.”
A 28-year-old Zimbabwean man in Musina“I am an elderly man, but they still knocked me to
the ground and beat me while I was lying down.
I went to the hospital. When my personal history
was taken, I told them that I had been beaten up.
The medical staff at the hospital told me that it was
my fault for getting involved in politics and theyrefused to treat me. I decided to come to South
Africa.”A Zimbabwean man in his 60s (MSF patient in Musina)“The problem with Zimbabwe for me is the way theytreat pregnant women. First you have to go to thehospital and get a card – you pay R450 just for thecard. Then when you are about to give birth you
have to buy your own equipment – the blankets, thegloves, all the medical equipment that is needed.
If you are going to have a normal birth they charge
you R1,500 and if it is a C-section, you have to pay
R4,500. That’s why I came here – I couldn’t get themoney.”
A 23-year-old Zimbabwean woman who crossed the border alone 8
months pregnant, staying at a temporary shelter in Musina

7

No Refuge
ACCess denied“Sometimes we ask patients that come to our clinic why they didn’t seek healthcare before coming to us. A frequent answer to this is: ‘I can’t go to thehospital, I don’t have papers. I will have to show my documents and if theyfind out I don’t have them, they will arrest me.’”- An MSF nurse in Johannesburg

Photo: © Austin Andrews, Silhouettes walk behind a “NO ENTRY” sign at the Showground in Musina. Today Zimbabweans are no longer allowed tosleep at the Showground. If they do, they are either chased away or arrested and detained.

8

The South African government’s
response
Neglect and deportation
Despite the fact that many Zimbabweans risk
their lives to flee Zimbabwe, the South African
government has historically characterised
Zimbabweans in the country as ‘voluntary economic
migrants’ and aggressively deported them. Until
recently, approximately 17,000 Zimbabweans weredeported each month by South African authorities,
according to United Nations and the South African
Department of Home Affairs (DHA) figures.
According to DHA, in Musina alone, more than
30,000 Zimbabweans applied for asylum from Julyto December 2008. Just 53 (0.1%) were granted
refugee status.8 In addition to granting refugee
status to very few people, regular bottlenecks in theasylum-seeking process created a situation wherea large concentration of people lived in inhumane
conditions while awaiting documentation.
The government’s aggressive deportation
strategy, combined with a lack of legal status
and a dysfunctional asylum-seeking process, has
hampered the ability of Zimbabweans to realise
their rights and access the assistance to which they
are entitled under national and international law. As
a result, Zimbabweans have been more vulnerable
to abuse by police, immigration officials, criminals,
and employers.
In April 2009, under pressure from numerous
non-governmental organisations, legal, and humanrights groups, the DHA announced plans to enact
new measures to regularise the legal status of
Zimbabweans in South Africa. Zimbabwean
nationals would be eligible for a special
dispensation permit under Section 31(2)(b) of the
Immigration Act, which would allow them to stayin the country legally for up to 12 months and tohave the right to work, study, and to access healthcare and other basic services. However, they would
not have the right to housing or to social grants.9 At
the same time, the DHA announced a moratorium
on deportations of Zimbabwean nationals. In May
2009, a second announcement was made allowing
Zimbabweans a 90-day ‘visa-free entry’ into South
Africa.

These positive policy steps are significant and if
implemented appropriately, taking the specifichumanitarian needs of Zimbabweans in South Africa
into full consideration, may fundamentally change
the dire conditions under which Zimbabweanscurrently live in South Africa. However, they have
yet to translate into significant changes on the
ground for the majority of Zimbabweans. Experiencein the past month reveals several concerns andpotential pitfalls, including:• The new special legal exemption has yet to beenacted, no clear timeframe for implementation
has been given, and a lack of clarity overthe new permits has created confusion anduncertainty. As a result, Zimbabweans arestill living in fear and are subjected to ongoingharassment and intimidation.
• Another worrying concern is that the 12-monthpermit will be issued under the Immigration
Act. This may allow the United Nations Refugee
Agency, UNHCR, to abdicate its international
protection responsibility. This potentially meansthat there is no one responsible or accountable
for addressing the needs of Zimbabweans inrelation to shelter, for example. The governmentof South Africa has clearly said that housing
will not be a right to which Zimbabweans areentitled and, as ‘migrants’ do not fall under theirmandate, the UNHCR may refuse to play a rolein ensuring appropriate shelter.
• Even after the announcement of themoratorium on deportations, the South African
Police Services (SAPS) continued to deport
Zimbabweans, refusing to observe the DHA
directive. Over Easter alone there were 736
deportations from Musina, as local police
refused to recognise the new DHA policy.
• The 90-day ‘visa-free entry’ into South Africa
requires that Zimbabweans hold a passport
or emergency travel document. Obtaining a
passport in Zimbabwe can cost up to R 6,800(US$ 820), so this measure will have little
tangible benefit for the most vulnerable, who
cannot afford passports. They will continue tocross the border through non-official channels,
still susceptible to the same abuses, violence
and lack of access to services as before thepolicy change.
9Gaps in access to healthcare
Since 1996, South Africa has had a policy of free
primary health care services for everyone in the
public health system. The South African Constitution
guarantees the right to access to health care forall. In September 2007, the Department of Health(DOH) released a Revenue Directive10 reaffirmingthat refugees and asylum-seekers with or without apermit have the right to access health services andshould be treated for free at any primary health carefacility and exempted from hospital admission fees if
without appropriate resources. They are also entitledto access any antiretroviral therapy (ART) service
point, and treatment should be free.
In addition to this, the HIV & AIDS and STI Strategic
Plan for South Africa (2007-2011) includes
migrants, refugees, and asylum-seekers with orwithout legal documents, and the DOH released
a statement in April 2007 clarifying that patients

do not need to be in possession of a South African
identity book in order to access ART in particular.11
Despite such guarantees, it is clear that thesepolicies are not uniformly applied. Zimbabweans
attending MSF clinics in both Musina andJohannesburg have explained that they facesignificant barriers trying to access public healthstructures. Zimbabweans attempting to accessthe health system by themselves are often either
harassed or hindered from obtaining the services
they need, particularly in hospitals. Those that are
granted admission, usually in the event of a lifethreatening emergency, are often charged exorbitantfees and discharged prematurely, including when
they are still very sick and vulnerable.
And now that the legal status of Zimbabweans
may primarily be granted through an exemption in
the Immigration Act, it is not clear whether theseguarantees will still be considered applicable for all
Zimbabweans in need of health services.

‘Once they know you are foreign, thetreatment is different’“Once they know you are foreign, the treatment is different. But if you
are accompanied by the MSF social assistant, then the treatment isokay because they know she is there to assist and she always speaks
on your behalf, so you get treatment.”– An MSF patient in Johannesburg“Our team referred an unconscious Zimbabwean patient to a hospitalin Johannesburg. His condition was a result of assault, and the patientpresented with a severe head injury. At the hospital, the matron in
charge refused to attend to the patient who was in need of criticalemergency care, claiming that the patient was not able to say his
name, so she was not willing to attend to him. This is shocking. Every
medical professional has an obligation to provide care to a patient
who is presenting with a life-threatening condition.”– Dr Eric Goemaere, Medical Coordinator, MSF in South Africa

10“I had a patient who waspregnant, and we sent her to thehospital. When she got there, thewater had already broken. They
took her to the nurses. Whenthey looked at the patient andwhere she had come from – she
produced her papers – they said ‘A
foreigner?’, and they just walked
away. They left her on the gurney.”– An MSF doctor in Johannesburg“One woman was very ill. She had malaria and was HIV-positive. She
was in bad condition, her temperature was very high. And we referred
her to hospital, but then she came back the following day. We sawthat she still wasn’t well, so we wanted to return her to the hospital,
but she said she did not want to go there. We asked her why and she
said the nurses told her, ‘You are dirty, you are smelly. You go back to
Zimbabwe with your dirtiness.’

Photo: © Austin Andrews,
Two young women waiting
outside the MSF clinic
at the Central Methodist
Church in Johannesburg.

– An MSF health worker in Musina“A Zimbabwean mother brought her six-year old child to our clinic.
The child had been raped. She was examined by our medical doctor
and prophylactic treatment was given. Our counsellor did an initialcounselling session with the mother and referred them to Child
Welfare. From there they were referred to the hospital for further
medical follow-up. The child was turned away from the hospital
because she and the mother did not have legal documentation. It is
unacceptable and inhumane to refuse treatment for a six-year oldchild who needs essential medical care after she has been raped. Not
having legal documents cannot be a reason to deny access to healthcare.”– Bianca Tolboom, Nurse and Project Coordinator, MSF in Johannesburg“Sometimes we ask patients that come to our clinic why they didn’t
seek health care before coming to us. A frequent answer to this is: ‘I
can’t go to the hospital, I don’t have papers. I will have to show mydocuments and if they find out I don’t have them, they will arrest me.”– An MSF nurse in Johannesburg

11Crossing theBorder“A 16-year-old-girl crossed into South Africa with her two aunts and four men.
When the group was at a farm about 30 kilometres south of Musina, they sleptin the bush. At dawn they were ambushed by a group of guma-gumas. As she
was running, the young girl tripped and fell. One of the guma-gumas thensearched her and took her money. He then proceeded to violently rape her. Her
genitalia were bruised. She was infected with an STI. She cannot sit up straightand can hardly walk. She has missed her period and could be pregnant fromthe rape. She said she could not go to the hospital for fear of being deported.”– Sara Hjalmarsson, MSF Nurse and Project Coordinator in Musina

Photo: © Dirk-Jan Visser, Border jumper crossing into South Africa from Zimbabwe.

12Violence, chronic disease, andepidemic outbreaks in Musina
A harsh arrival on the banks of the Limpopo
River is the first experience of South Africa formany Zimbabweans. It is here where scores ofZimbabweans are beaten, robbed, and sometimes
raped by criminal gangs known as the ‘gumagumas.’
For newly arrived Zimbabweans who do not have an
established network in Musina town, there are few
options for shelter. They seek refuge in churches,along the railroad, and in the surrounding bush.
Many others find temporary seasonal work oncommercial farms along the border.
Initially, it was difficult for MSF teams to reach
Zimbabweans in Musina who needed medical
assistance, as most were hiding for fear of arrest
or deportation. This dynamic started to shift in
July 2008 when a Department of Home Affairs(DHA) Refugee Reception Office opened at Musina
Showground, an open field in the centre of Musina
town, to enable Zimbabweans to register andhave their claims for asylum processed. Large
numbers of Zimbabweans began to gather openly
in the Showground, the only place in the town
where they could avoid being arrested for notpossessing asylum-seeking papers or other legal
documentation.
In the months that followed, the number of people
that started queuing at the Showground to obtain
their papers, coupled with major bottlenecks inthe asylum-seeking process, resulted in significant
needs for basic shelter, water, sanitation, food andhealth care.
By February 2009, an estimated 4,000
Zimbabweans were sleeping at the Showgroundeach night without any proper shelter, protection,or assistance. It became a de facto refugee camp,
yet government authorities refused to recognise
it as such. As a result, none of the minimum
international standards for such a camp wereobserved. Thousands of Zimbabweans slept
crowded together out in the open, exposed to theharsh sun during the day and the cold at night.
They had no access to adequate food, water,
sanitation, shelter or health care and efforts by
non-governmental organisations (NGOs) to provide

basic humanitarian assistance were systematically
blocked by local authorities.
In March 2009, despite the ongoing flow of
Zimbabweans, the DHA ordered everyone to leave
Musina Showground, providing no alternative
shelter or protection. Today, people are no longer
allowed to sleep at the Showground. If they do so,they are either chased away or detained.
Those Zimbabweans who cannot afford passports
or an emergency travel permit continue to cross theborder illegally. The number of people arrested at
the border and in Musina fluctuates. However, in
May 2009, up to 400 people were being detainedin unacceptable conditions each day in a detention
centre.
Shelter remains a pressing concern. While faithbased organisations have established a few
temporary shelters in Musina where Zimbabweans
can stay for three days on average, the conditionsof these shelters are inadequate and they are often
completely overloaded. However, there is little else
available. As winter approaches, some nights there
are more than 600 people crowded into a shelter
that should not host more than 300 people. As
shelters are overburdened, many others hide in thebush.
MSF ran a daily mobile clinic at the Showground
until May 2009 when the DHA Reception Office
was moved to a private compound; the mobile
clinic now operates just outside the Showground.
In addition to the daily clinic near the Showground,
MSF operates mobile clinics on farms along theborder and in specific fixed points in Musina
town. Medical teams in and around Musina play
an essential role in epidemic surveillance as they
provide mobile diagnostic services including rapid
testing for HIV, syphilis, and malaria. Samples aresent to the National Health Laboratory Services(NHLS) for TB, cholera, and dysentery detection,
limiting the risk of epidemic spread. MSF mobile
medical teams also provide general curative
services, care for sexual and gender-based violence(SGBV), and psychological support.
Approximately 2,000 consultations are carriedout each month. The main illnesses MSF teams
diagnose and treat are respiratory tract infections,13

sexually transmitted infections, particularly HIV,diarrhoeal and gastro-intestinal diseases, and stressrelated ailments. In addition, there has been asignificant increase in the number of cases of sexual
violence.

More than 75% of clients seen by MSF in April wereraped while crossing the border, and nearly 60%
were raped by more than one perpetrator. Seventy
percent of the time, rapes were perpetrated with anarmed threat (gun, knife, etc.) and almost 50% ofclients had injuries due to associated violence.

Sexual violence

The Department of Health (DOH) does not require
survivors of SGBV to report to the police before
accessing medical services but in practice many
health providers, including in Musina Hospital, aretelling survivors they must first lay a charge. Thismeans that emergency medical treatment, including
post-exposure prophylaxis to prevent HIV-infection,isoften hindered or delayed.

Through its mobile clinics, MSF treats violencerelated injuries, most often rape and sexual assault,
as well as beatings, deep knife wounds, brokenbones, and whip marks – a combination of trauma
experienced during the border-passage from
Zimbabwe and in Musina town.
Women and children are particularly vulnerable
to brutal attacks by ‘guma-gumas’ (local gangs),
Zimbabwean soldiers, and police. Finding
immediate care is critically important after asexual assault to prevent HIV, sexually transmitted
infections, hepatitis, and pregnancy. Treatment toprevent HIV infection has to start within 72 hours
and emergency contraception is possible within fivedays. However, of those who manage to seek carein Musina, most do so more than 72 hours after
the rape has occurred, explaining that the delay
was because they did not know where they could
turn for treatment or needed to secure their legal
papers before seeking care. May victims also often
experience feelings of shame as a result of sexualassault, which prevents them from seeking thetreatment they need early enough.
In April 2009, MSF expanded its services forsurvivors of sexual violence to address thisimportant and unmet need and now has a fixedclinic for survivors of sexual and gender-based
violence (SGBV).

Total consultations
MSF mobile teams in Musina and on farms* May 2008-April 2009

3000
2500
2000
1500
1000
500
0

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Jan

Feb

* Breakdown only available for 2009
Farms

14

MusinaMar

April

HIV/AIDS and TB in ahighly mobile population
High rates of HIV infection among Zimbabweans
attending MSF mobile clinics in Musina pose
specific challenges. In April 2009, out of 319 HIV
tests done 35% of patients tested in MSF mobile
clinics in Musina were HIV-positive (positivity rates
are particularly high on farms). MSF teams diagnose
and treat opportunistic infections and maintain abuffer stock of antiretrovirals (ARVs) for patients
who have run out of drugs. Patients on ARVs, andthose clinically eligible for antiretroviral therapy(ART) but not yet initiated, are referred to accredited
ART sites. However, patients working on farms areoften not allowed by farm owners to leave to attend
clinics and cannot afford transportation to town.
The fact that the population is highly mobile poses
major challenges for follow-up of referrals, treatment
adherence, and continuity of care once initiated.
Although there are high levels of suspected TB
in and around Musina, only a small number ofthe sputum samples collected return positive for
TB. This can be explained by the high TB/HIV
co-infection rate (direct sputum microscopy only
detects approximately 40% of active TB casesin high HIV prevalence settings) and the lack ofavailability of more precise methods (there is noaccess to sputum culture at the Musina NHLS lab).
Still, for those who have a confirmed TB diagnosis,
there are long turn-around times for receiving lab
results and follow-up is a challenge. By the time
the MSF team receives a positive result, patients
have usually moved on from Musina and there is no
way to trace them.

Cholera outbreak
In October 2008, MSF medical teams at theShowground in Musina town started to notice
an increase in the number of cases of acutewatery diarrhoea and reported this to local healthauthorities. There were also sporadic cases ofbloody diarrhoea. Considering the lack of cleanwater and basic sanitation facilities available for
Zimbabweans at the Showground at the time, MSF
had grave concerns that diarrhoeal diseases could
spread rapidly to the thousands of people staying at
this makeshift ‘refugee camp’.
The following month, a cholera outbreak was
confirmed in Beitbridge, just across the borderin Zimbabwe. The MSF team in Beitbridge wasreinforced by an emergency medical team and amajor shipment of medical and logistical supplies
was sent to Beitbridge Hospital to create on-site
treatment capacity on the Zimbabwean side of
the border. Days later a cholera outbreak was
confirmed in Musina itself. MSF began screening
people at the Showground and other sites to identify
those with potential signs of cholera for treatment
and/or referral to Musina Hospital. MSF also
carried out hygiene promotion, water and sanitation
improvements, and education and awarenessraising activities. In Limpopo Province MSF
diagnosed and either treated or referred hundreds ofcholera cases.12

The graph below shows the increase in thenumber of cases of acute watery diarrhoea at theShowground in the month of November and theappearance of suspected cholera cases once theoutbreak was confirmed in Limpopo (epidemic
surveillance of acute watery diarrhoea at theShowground illustrates that several cases werevery likely cholera prior to week 46 but they were
not diagnosed as such until the DOH declared theoutbreak and announced a new case definition).

Photo: Rachel Cohen/MSF,

An MSF nurse treats apatient at a mobile clinic
on a farm outside Musina
town.

Number of cases of acute watery diarrhoea and cholera per week
MSF mobile clinics
Musina (2008)

60
Cases

50
40
30
20
10
0 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
Weeks

Jun

Sep
Acute watery diarrhoea

Dec
Cholera15

‘There were 13 men watching us all
the time and they raped us every day’
“There were seven of us, all girls. We were just friends, not relatives.
I was the youngest of them. We got on a bus to Beitbridge and when
we got off these men were saying that if we don’t have money tocross, we could come with them. We opted to go in their cars. They
said border jumpers travel at night so we drove around from 6 pm
to 7 am. We went to so many different places I didn’t know where wewere any more. Then they stopped at one place in the forest and thisbecame our sort of home for the next four months. There were 13 men
watching us all the time and they raped us every day. Eventually they
started to let us go to urinate by ourselves and that is how we escaped.
Now I am four months pregnant. I left Zimbabwe because I am anorphan – I am the breadwinner for my siblings and I came to find foodand find a way to support them. Now I don’t know what I am going todo, how I am going to take care of them.”– A 17-year-old Zimbabwean girl at the MSF mobile clinic, Musina Showground“Last night we learned of a group of 500 women and children who
attempted to swim across the crocodile-infested Limpopo River toreach South Africa, only to fall prey to local bandits known as ‘gumaguma.’ Five of the women who crossed were raped, and two babies
were literally taken off their mothers’ backs and thrown into the riverto drown.”– An MSF health worker in Musina“A 16-year-old-girl crossed into South Africa with her two aunts andfour men. When the group was at a farm about 30 kilometres southof Musina, they slept in the bush. At dawn they were ambushed bya group of guma-gumas. As she was running, the young girl tripped
and fell. One of the guma-gumas then searched her and took her
money. He then proceeded to violently rape her. Her genitalia werebruised. She was infected with an STI. She cannot sit up straight andcan hardly walk. She has missed her period and could be pregnant
from the rape. She said she could not go to the hospital for fear of
being deported.”– An MSF nurse in Musina
16

“Life here became difficult when I was raped. I was looking for workand I found a security guard who said there were some people whowanted a maid to work in the house. I went with him and got into acar. There were three other men and two women. One woman wanted
to jump out of the car and they blindfolded her. When I started
screaming they let me out of the car with that guy in the forest, andhe raped me. Afterwards, he beat me up. Then he left me there. Later,when I got tested for HIV, I tested positive.”

Photo: © Austin Andrews,
A temporary women's
shelter at the Old Catholic
Church in Musina.

– A 38-year-old Zimbabwean woman at Central Methodist Church, Johannesburg“Every week we see women coming to our mobile clinics in Musina
after being raped. They have tried to go to the hospital for emergency
medical treatment, but at the hospital they have been refused
medical treatment if they have not first reported the case to thepolice. Most of these women did not dare to go to the police andtherefore they were left without the critical medical treatment
needed to prevent HIV and other conditions within 72 hours after therape.”– Sara Hjalmarsson, MSF Nurse and Field Coordinator in Musina“Most women who are raped have noone to talk to, no food, no
shelter, no money, and noone who can help them overcome thetraumatic experience. We have seen several cases where women are
raped at the border crossing and later again in Musina. They haveserious health needs and deep psychological scars.”– Angie Huyskens, MSF Psychologist in Musina
17

Searching forsafety“There was a patient who worked here in the centre of Johannesburg with two otherZimbabweans, and their South African colleagues had said several times already,‘We don’t want you here. Go back to Zimbabwe. You’re taking our jobs.’ One night
they told him they were having a team meeting and they went into a room, closed thedoors, and one of the guys started to beat the Zimbabweans with a sjambok, which
is a kind of whip. The other South African colleagues were all watching and singing.
It was of course very traumatising. The patient told me he does not want to go backto work, and he does not know where to go. He just wants to stay inside the church
building because that’s the only place where he feels relatively safe.”– Bianca Tolboom, MSF Nurse and Project Coordinator in Johannesburg
Photo: © Austin Andrews, The busy scene at the intersection of Smal and Pritchard Streets as Zimbabweans arrive at the Central Methodist Church
to seek shelter for the night, bedding down in cramped conditions either inside or outside on the pavement.

18

Central Methodist Church in
Johannesburg
Although there are tens of thousands ofZimbabweans living in Musina at any given time,the majority do not stay long. Johannesburg is the
final destination for most Zimbabweans. Today,
Johannesburg’s inner-city is home to millionsof refugees, asylum-seekers, and migrants of allnationalities.

month in early 2008 and reaching more than
2,700 patients in March 2009. Initially, theMSF clinic was primarily frequented by Church
residents. However, today more than 50% of theZimbabwean patients are from outside the Church
area – an indication of the poor access to healthcare
elsewhere in the area for Zimbabweans.

The Central Methodist Church in downtown
Johannesburg provides a ‘safe haven’, where
thousands of Zimbabweans seek refuge each night,
either in the Church itself or on the street in front.
People live in crowded, unhygienic conditions, fillingnearly every inch of available space inside the fivestorey building. Up to 2,000 people sleep on pews,
stairs, and the hard floor of the Church. Outside on
the footpath, hundreds and sometimes thousands ofZimbabweans who cannot squeeze into the Church
sleep among cardboard boxes, as close to thebuilding as they can get.

As with the mobile MSF clinics in Musina, themain diagnoses at the MSF clinic at the Central
Methodist Church are respiratory tract infections,sexually transmitted infections, diarrhoeal andgastro-intestinal conditions, and stress-related
ailments. Minor therapeutic procedures are also
carried out (dressing, injections, sutures). There is asmall dispensary and on-site lab at the clinic, whererapid tests are carried out and samples are taken foranalysis at the NHLS.

Since December 2007, MSF has operated a fixedclinic connected to the Central Methodist Church,
and works in close collaboration with the Churchcommunity to provide basic health services andreferral of patients to the public health system for
more specialised medical treatment. In addition toproviding basic health care, the key aim of the MSF
clinic is to actively facilitate access for Zimbabweans
to existing health services in Johannesburg.
In the past year, the number of consultations has
steadily increased, starting with 750 patients per

However, in the last several months, the Central
Methodist Church has increasingly come under
threat. In February and March 2009, Zimbabweans
in and around the Church were faced with a police
raid and legal action by neighbouring businesses.
Due to increased overcrowding in both the Churchand sidewalks outside, businesses complained thatthe thousands of Zimbabweans and the unhygienic
and cramped environment were bad for business.
Consequently, they erected a large, imposing irongate in front of the Church building. This effectively
barred Zimbabweans directly from the Church,leaving them exposed to the violence on the streets.

Nowhere to go

Total consultations
MSF clinic at Central Methodist Church
May 2008 – April 2009

3000
2500
2000
1500
1000
500
0
May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

April

19

Zimbabweans, such as bus stations, taxi ranks,
food distribution points, and densely populated
residential buildings.
MSF teams introduced key measures to improve thehygiene and sanitation conditions both inside andoutside the Church by providing mobile latrines,
repairing the toilet system inside the Church,
deploying special cleaning and disinfection teams
and providing hand-washing points and containers
at entrance points where food vendors could clean
their cooking tools.
MSF also collaborates closely with the DOH
in response to other communicable diseases
diagnosed. In March 2009, a patient living at theCentral Methodist Church was diagnosed withmeningococcal meningitis. The diagnosis was
confirmed the following day, close contacts wereidentified by MSF staff, and prophylaxis provided by
DOH was administered within 24 hours. The healtheducation teams from both MSF and DOH met andcoordinated activities to ensure that the population
living in and around the Church were well informed
about the disease.

Photo: © Dirk-Jan Visser,
Zimbabweans sleep on
the floor of the Central
Methodist Church at nightwith nowhere else to stay
Photo: © Shayne
Robinson/EPA,
A Zimbabwean patient istreated by an MSF doctor
and nurse at the MSF clinic
at the Central Methodist
Church.

Facilitating access to
Communicable diseases and secondary and specialisedcareoutbreak response
As in any overcrowded and unhygienic setting,people staying in the Central Methodist Church
in Johannesburg are exposed to a serious risk ofcommunicable disease outbreaks. This risk is
mitigated, at least in part, by effective collaboration
between MSF and the Gauteng Department
of Health (DOH). MSF carries out epidemic
surveillance and prevention, and works with the
DOH to intervene rapidly in case of epidemic
outbreaks.
In response to the November 2008 cholera
outbreak, MSF, in collaboration with the DOH,
organised an emergency response to help preventthe spread of cholera and ensure quick accessto treatment for patients presenting with cholera
symptoms. The emergency response included
active case finding; rapid detection and referral ofpatients through a network of Church residents
and community leaders; isolation of symptomaticpatients and treatment of moderate cases at a small
oral rehydration unit; and referral of severe cases tohospital. MSF also carried out hygiene promotion
and information and education campaigns in highrisk areas and places with large concentrations of20

One of the main aims of the MSF clinic in
Johannesburg is to facilitate access to health carefor Zimbabweans who are otherwise not accessing
the health system due to fear of arrest, deportation,
discrimination, or poor treatment. Each month,
MSF refers approximately 80 patients to secondaryand specialised services in Johannesburg, primarily
for TB treatment and other chronic diseases, ARTinitiation for HIV, emergencies related to trauma,comprehensive care for victims of sexual violence,
and acute severe conditions such as pneumonia
requiring hospital-level care.
The key to ensuring patients are admitted whenreferred is a confirmed diagnosis, an MSF referral
letter, and the accompaniment of an MSF ‘social
assistant.’ MSF also subsidises hospital fees, amajor barrier for Zimbabweans who cannot afford topay for the treatment they urgently need and are stillcharged high amounts.
This system works well for the few who are able
to access services through MSF. However, there
are thousands of Zimbabweans in need of healthservices who face major obstacles, as illustrated by
testimonies from MSF patients and health workers.

The plight ofunaccompanied children

about the situation the children face, providing

During the past year, MSF has witnessed a steadyincrease in the number of unaccompanied
children coming to Musina and to the Central
Methodist Church in Johannesburg.

organisations and agencies are fully aware of

At the Central Methodist Church there has been a
sharp increase in the number of unaccompanied
minors arriving – particularly in the first half of2009. As of May 2009 there were 150 children
between seven and 18 years staying at the
Church. These children are extremely vulnerable
and exposed to many forms of abuse.
To respond to this critical situation, MSF
started a special counselling programme forunaccompanied minors. Three counsellors
work with the children, providing emotional,
educational and psychological support. Children
frequently ask for help to find a place where they
feel more protected and where living conditions
are more suitable. Many children battle to sustain
themselves in this situation, sometimes leading tovery worrying behaviour and survival strategies.
MSF has repeatedly expressed concerns to the
Department of Social Development and UNICEF

a list of names and relevant details about
each individual child. Despite the fact that key
the extreme vulnerability of this group, no viable

Photo: © Dirk-Jan Visser,
Two Zimbabwean children
seek shelter in the Central
Methodist Church in
Johannesburg.

solution has yet been proposed or implemented.

“Some have lost both parents due to HIV/AIDS
or other causes. They weren’t going to school;some of the children were heading the family
themselves. One 12-year-old boy was looking
after his sisters who were 7 and 5. Some realisedthat their parents no longer had the means tolook after them, so they just decided they had togrow up overnight and say this is what I’m goingto do. During their journeys some have been
exploited. Some have been raped. A 12-yearold girl was raped in Pretoria, and she ended up
here. She got an infection and her behaviour
completely changed after that. Once something
like that happens to a child you fear for moreabuse.”– An MSF counsellor, Johannesburg
21

Xenophobic violence erupts

Photo: © Erin Trieb, Victims of xenophobic violence wait in long lines before moving into temporary tent-housing in Johannesburg in June 2008.

In May 2008, targeted xenophobic attacks erupted in Alexandra township. The violence rapidly spread across Johannesburg and toseveral other cities and provinces in South Africa (Gauteng, Western Cape, and Kwa-Zulu Natal), killing 62 people, injuring 670 andcausing the displacement of approximately 100,000 foreign nationals, including large numbers of Zimbabweans.
In the immediate aftermath of the violent attacks, MSF provided emergency medical assistance, treating approximately 150 violencerelated injuries, including gun shot wounds, stab wounds, lacerations, burns, and other injuries in the first days of the emergency inAlexandra, Diepsloot, and other areas affected by the violence.
In the subsequent weeks, as the violence subsided, mobile MSF teams provided health care, blankets, plastic sheeting, and hygienekits in 15 community halls, police stations, and churches to which people fled for safety in Johannesburg, and later in seventemporary ‘camps’ established by the government. The main pathologies treated were those related to displacement, such as diarrhoea,
respiratory infections, and stress-related illnesses.
From May to September, a total of 11,000 medical consultations and an additional 11,000 mental health consultations were carriedout in the camps in Johannesburg and Pretoria, as well as in Cape Town, where MSF also responded to the needs of displaced foreign
nationals in Khayelitsha. In addition, MSF distributed 10,000 blankets and 10,000 hygiene kits.
The xenophobic attacks of May 2008 were preceded by several significant events witnessed by MSF, the most striking of which
was a violent police raid on the Central Methodist Church in January 2008. During the night of 31 January 2008, police raided theCentral Methodist Church and detained approximately 350 people who were seeking refuge there. The MSF team gained access to thedetainees taken to Johannesburg Central Police Station and were able to assess their health conditions.
The team found suspected fractured ribs, possible lung contusions, patients with chronic illnesses, and patients on treatment for
HIV and TB, who lost their treatment during the arrest. Police refused MSF’s repeated requests for patients in need of referral to be
immediately taken to hospital. After a rapid civil society response, a court interdict eventually resulted in the detainees being released.

22‘Everyone is failing to protect us’“I have just been attacked in my home. The reason I came to South Africa is becauseof fear – I came looking for asylum, but South Africa has also neglected us. Everyone
is failing to protect us. I just want to find a safe and peaceful place to live. It seems likeSouth Africa can’t accommodate Zimbabweans anymore. Again, I have no food andclothes. I am back in the same situation that I was in back in Zimbabwe.”– A 40-year-old Zimbabwean man treated by MSF in Thokoza Community Hall, May 2008

“Some people are good, they say ‘Come into my house, I want to give you something.’
Other people there were some who shouted at us when we were getting water – ‘There is
no water for Zimbabwean people.’ They said there is water for South Africans only. And
sometimes when we are looking for food we are told ‘Go away – you mess up our space.’
Life here is tough.”– A 23-year-old Zimbabwean man sleeping outside the Central Methodist Church, Johannesburg“There was a patient who worked
at a cleaning company here in
the centre of Johannesburg with
two other Zimbabweans, andtheir South African colleagues
had said several times already,‘We don’t want you here. Go backto Zimbabwe. You’re taking ourjobs.’ One night they told him they
were having a team meeting andthey went into a room, closed
the doors, and one of the guys
started to beat the Zimbabweanswith a sjambok, which is a kindof whip. The other South Africancolleagues were all watching andsinging. It was of course very
traumatising. The patient told
me he does not want to go backto work, and he does not know
where to go. He just wants tostay inside the church building
because that’s the only place
where he feels relatively safe.”– Bianca Tolboom, MSF Nurse and Project
Coordinator in Johannesburg
Photo: Henrik Glette/ MSF, MSF nurse treats a rubber bullet wound, following xenophobic attacks in Johannesburg.

23

struggling
to survive

in the shadows

Photo: © Austin Andrews, A hand clasps the metal fence, erected by local businesses, in front of the Central Methodist Church at night.

24

Conclusion
Zimbabweans continue to face an economiccrisis, political instability, and poor access to basic
services, including health care, in their country.
They flee to South Africa as a matter of survival. On
arrival in South Africa they do not find refuge, butinstead are faced with an unacceptable continuationof their suffering, without access to proper healthcare, shelter, or safety.
MSF medical teams witness the daily failure of boththe South African government and UN agencies toensure that the basic medical and humanitarianneeds of vulnerable Zimbabweans are met.
The South African Constitution guarantees access tohealth care and other essential services to all who
live in the country – including refugees, asylumseekers, and migrants – regardless of legal status.
But in reality, Zimbabwean patients continue to be
rejected, charged exorbitant fees, subjected to long
delays or inappropriate treatment, or prematurely
discharged, placing health care out of reach formany. This is a breach of medical ethics andviolates the Constitution.
The government of South Africa must do more toensure that health staff is properly informed about
the rights of refugees, asylum-seekers, and migrants
to access the public health system, regardlessof legal status. In addition, it is essential that
secondary and specialised care is free for those
Zimbabweans who cannot afford it, as no patientin need of health care should be denied access forfinancial reasons.
Every day, MSF teams treat sick and vulnerable
Zimbabweans who are falling through the cracks inSouth Africa: victims of violence; people with basic
ailments as well as life-threatening chronic diseases
such as HIV and TB; and people with psychologicalconditions linked to the trauma they haveendured. MSF provides counselling and psychosocial support for particularly vulnerable patients,

especially unaccompanied children and survivors of
sexual violence, and responds to emergency needs
resulting from xenophobic attacks and disease
outbreaks when they arise.

Photo: © Austin Andrews,
Night falls over a temporary
men’s shelter in Musina.

Government and relevant UN agencies must takespecial urgent steps to ensure that emergency
medical care for survivors of sexual violence is
not hindered or delayed and that unaccompanied
children have access to shelter, protection,
counselling, legal documentation, health care,education, and other basic rights.
While there have been positive developmentsin the past months to regularise the legal statusof Zimbabweans in South Africa and to stop
deportations of Zimbabweans, these measures
have yet to translate into tangible improvementsin the lives of most Zimbabweans seeking refugein South Africa. Until this happens, Zimbabweans
will continue to suffer, struggling to survive in the
shadows of South African society.

25References
1. According to information obtained from the DHA by the South African History Archives (SAHA) and the
University of Witwatersrand, between 2000 and March 2008, there were 66,578 new applications
for asylum from Zimbabweans. Of these, 710 applicants were granted refugee status and 4,040
were rejected. Over 62,000 cases remain pending. In the first quarter of 2008, there were more than
10,000 Zimbabwean asylum-seekers – more than applied in the entire year of 2005 – and only 19
approvals.
2. International Federation of Red Cross and Red Crescent Societies, 2009. 100,000 cases: The spectre ofcholera remains in Zimbabwe
3. WHO, 2009. WHO Daily Cholera Updates. 20 May 2009
4. UNAIDS, Zimbabwe Country Profile, November 2008. http://www.unaids.org/en/CountryResponses/
Countries/zimbabwe.asp
5. Mail & Guardian - Zim unemployment skyrockets. Mail & Guardian. 30 January 2009
6. Hanke, S. 2008. New Hyperinflation Index (HHIZ) Puts Zimbabwe Inflation at 89.7 Sextillion Percent,
CATO Institute. http://cato.org/zimbabwe
7. Beyond cholera: Zimbabwe’s worsening crisis, MSF, February 2009.
8. South Africa is a signatory to the 1951 Refugee Convention and the Organisation of African Unity(OAU) Refugee Convention. According to the OAU convention, a refugee is a person who, “Owing toexternal aggression, occupation, foreign domination or events seriously disturbing or disrupting publicorder in either a part or the whole of his or her country of origin or nationality, is compelled to leave
his or her place of habitual residence in order to seek refuge elsewhere.” The government, supported
by UNHCR, has historically taken the position that the vast majority of Zimbabweans in South Africa
are not refugees and that the situation in Zimbabwe does not warrant a group application of the OAUConvention-based refugee definition.
9. Section 31(2)(b) Permits for Zimbabwean Nationals in South Africa, Consortium for Refugees andMigrants in South Africa, April 2009.
10. DOH Revenue Directive-Refugees/Asylum-Seekers With or Without Permit (BI 4/29 REFUG/ASYL 82007).
11. BI 4/29/ART, April 2007.
12. At the same time, MSF teams in Zimbabwe mobilised a massive emergency response to theunprecedented cholera epidemic raging across that country, treating more than 50,000 cases in all but
one Zimbabwean province.

26

27

MEDECINS SANS FRONTIERESDOCTORS WITHOUT BORDERS

28