BY LINDA MUJURU

Natasha Gwashure watches as tuberculosis ravages her 1-year-old son Anashe’s frail body. He has been ill for more than a month. Gwashure struggles to accept the diagnosis. Her only solace is that they have access to free medication.

“Without this support, the chances of defaulting on treatment because of monetary constraints would have been significantly higher,” she says.

For years, the United States Agency for International Development has stood at the front lines of Zimbabwe’s TB battle, providing critical support for detection, treatment and prevention. But this lifeline now hangs in the balance as a US executive order threatens to undermine years of progress, potentially forcing patients, like Gwashure’s son, to abandon lifesaving treatments.

TB is a particularly vicious illness. Left untreated, the mortality rate is about 50%. It spreads easily, when an infected person coughs or sneezes, or even sings or speaks.

US President Donald Trump issued an executive order on Jan. 20, his first day in office, to suspend nearly all international aid. That includes USAID programs, which administer lifesaving health and other services around the world.

The recent funding freeze leaves a huge gap in Zimbabwe, where nearly all funding for TB treatment comes from international donors. Just 4% of that funding is domestic.

In 2024, USAID allocated 7 million United States dollars for TB treatment, screening and other necessary interventions in Zimbabwe. Despite decades of medical advances, tuberculosis still rampages across the globe. TB affected 10.8 million people in 2023; 1.3 million of those were children.

In Zimbabwe, the battle against TB reveals a health care system struggling to keep up. In 2021, just a little over half of an estimated 30,000 new infections received treatment.

The human cost of scrapping USAID programs is already evident here. Hospitals that once benefited from US-backed health programs now face mounting pressure as health workers supported by these initiatives have been forced to stop working.

A local nurse, who requested anonymity for fear of retribution, says it’s strained an already overextended health care system. She says that nurses previously funded by USAID-backed organizations, who primarily cared for patients with HIV, TB and other diseases, have stopped reporting to work. And what used to be handled by a full team of nurses is now falling on just a handful.

The freeze has begun dismantling Zimbabwe’s TB care network. New Start Centre — once a cornerstone facility, providing essential CD4 count testing, TB screening, diagnosis and counseling — has already gone dark, its doors closed as funding runs dry.

Noah Taruberekera, executive director of Population Solutions for Health, which has relied on USAID support for these centers, acknowledges the dire challenges now confronting patients and health care providers. He says he is not authorized to share additional details.

The funding crisis ripples beyond TB control, casting a shadow over HIV programs — a critical concern since TB preys particularly on those with HIV. While effective antiretroviral therapy can reduce the risk of developing TB, ongoing screening and preventive measures are vital for those with HIV.

HIV co-infection affects 68% of TB cases in Zimbabwe, but the national government covers only 7% of the required TB budget. International donors contribute 60%, leaving a significant funding gap.

Despite the mounting challenges, Dr. Fungai Kavenga, deputy director of TB and prevention control in the government’s Ministry of Health and Child Care, remains hopeful.

“If donor support diminishes, I am confident that the government of Zimbabwe can still ensure a steady supply of treatment for TB patients,” he says.

But Barbara Samu, a TB patient receiving care at Beatrice Road Infectious Diseases Hospital, underscores the critical role of donor support. She received free medication because USAID supported the hospital.

“I can’t even begin to imagine where I would find the money for treatment,” she says. “I would be facing a death sentence.”

Global Press is an award-winning international news publication with more than 40 independent newsrooms in Africa, Asia and Latin America.

BY GLOBAL PRESS REPORTERS 
Summary: Scientists and doctors can’t keep up with the tidal wave of people whose bodies don’t respond to basic antimicrobial treatment.

For years, Radha Lama bought antibiotics in bulk at a clinic near her home in Kathmandu, Nepal. She took the pills whenever she had a stomachache or headache, without talking to a doctor or nurse, says her daughter Pratikchya Lama.

Now, at 57 years old, Radha Lama is on a ventilator in the intensive care unit of Nepal’s Tribhuvan University Teaching Hospital. She hasn’t been able to breathe on her own since August last year. She’s conscious but can’t move her arms or legs. She communicates only with her eyes.

Lama has a catheter that doctors say she’ll probably need for the rest of her life. If it’s removed, they say, she’ll undoubtedly get an infection. And for Lama, a basic infection — one that most people would treat with a simple course of antibiotics — can be deadly.

“We now have no alternative antibiotics to give her,” Dr. Pushkar BK says.

Lama isn’t alone. In Mongolia, 2,000 miles to the northeast, Dashzeveg Tsend says he’s bought and taken antibiotics throughout his life, whenever he felt he needed them.

In October last year, he checked into a hospital with a fever and blisters in his groin. Doctors discovered he had MRSA, a type of staph infection — and that the bacteria causing the infection had become resistant to multiple antibiotics. Now, he’s bedridden and relies on oxygen, catheters and IV support to survive.

Antimicrobial resistance is among the biggest health crises of the modern era. Bacteria that have evolved to resist the drugs designed to eliminate them kill more than 5 million people per year, according to the World Health Organization. By 2050, more people will die from AMR than from cancer, according to the Fleming Initiative, a London-based AMR research organization.

Thirty years ago, the leading causes of death due to illness were often roughly divided into two categories: cancer or heart attacks and strokes, says Lorenzo Moja, a scientist serving as team lead of the World Health Organization’s Model List of Essential Medicines.

Today, he says, there is a third category: antimicrobial resistance.

Someone hospitalized for a heart issue or even a bone fracture — anything that weakens the body — can easily contract a resistant bacterium. The person might get several forms of antibiotics, but the bacterium resists all of them “and makes a mockery of the drugs,” Moja says.

The reasons for AMR are complex. A person might get infected with resistant bacteria from dirty drinking water or a poor sanitation system. In many cases, doctors prescribe a wrong dose of antibiotics — or the wrong antibiotic altogether. Pharmacies and informal medicine stalls sell the pills to people who take them “like candy,” as one Nepali doctor put it. Many people can’t afford to take a full antibiotic dose. It’s also caused by the antibiotics used in animals raised for food, which leech into the environment through their waste. In each of these scenarios, bacteria have a chance to grow stronger and ultimately thwart even the most aggressive treatments. Often, it’s not obvious why a patient isn’t beating an infection. Bacteria just grow stronger, until the patient dies.

And even though AMR isn’t always identified and diagnosed, “many of us have family members who have died from resistant bacteria,” says Anahi Dreser, an AMR researcher at the National Institute of Public Health of Mexico.

But like most other problems, it doesn’t hurt equally.

The drivers of AMR are most prevalent in all but the richest countries.

“These disparities that exist really have nothing to do with AMR. They’re linked to politics or corruption or generally the system of health services and sanitation,” says Isabella Impalli, a research analyst at One Health Trust, a research firm funded by the World Health Organization and other major organizations. Impalli is one of the authors in a major AMR research report series published in 2024 in The Lancet.

An earlier study published in The Lancet showed that nearly all children under age 5 who die due to antibiotic resistance live in what the World Bank defines as low- and middle-income countries, based on gross national income per capita. Children in sub-Saharan Africa are especially at risk: They are 58 times more likely to die of antibiotic resistance than those in high-income countries.

When poverty is an incubator

Among the dozen or so antibiotic-resistant bacteria that WHO lists as “priority pathogens” is the one that causes tuberculosis. That’s a particular problem in Africa, where half a million people die every year from the illness — more than 30% of all global TB deaths.

In Zimbabwe, Taurai Chingoma was diagnosed with tuberculosis nearly 20 years ago. Now 62 years old, he says he still feels weak all the time and can’t do any hard physical labor. He was once a carpenter, but doesn’t have a stable source of income now. He’s constantly worried that the TB will return.

That’s all because he couldn’t afford to complete a full course of antibiotics.

“Imagine taking 14 tablets at once each day!” he says. “Coming from poor backgrounds, we cannot afford proper meals, so we end up skipping some doses of the medicine.”

Unlike typical antibiotic courses that last a few days or weeks, TB treatment demands a strict regimen for at least six months, and sometimes up to two years. For many people, that’s too long to keep up. Bacteria remain in their body when they stop taking antibiotics, and grow stronger.

The consequences of resistance in cases of TB are especially serious. Since most people infected with tuberculosis do not show symptoms and act as reservoirs for the bacteria, the spread of both the disease and antibiotic-resistant strains is pervasive. About 1 in 3 deaths from antimicrobial infections are due to drug-resistant TB.

Like Chingoma, most Zimbabweans struggle to pay for basic health care. Ninety-three percent of the population in the country has no access to health insurance due to the high costs of subscriptions, according to the Association of Healthcare Funders of Zimbabwe.

Without insurance, a visit to a public health clinic might cost the equivalent of 5 United States dollars, and 15 dollars at a private clinic. The only option for many poor Zimbabweans is to buy antibiotics at medicine stalls, without a prescription or directions.

And those medicines might very well be fake. The Medicines Control Authority of Zimbabwe has found that active ingredients weren’t present in many of the drugs sold informally — or even through formal prescriptions.

“These medicines can cause harm by worsening the condition and may even result in death,” says Davison Kaiyo, a public relations official at the authority.

Half of all Ugandans find it difficult to pay for their medical visits. Nearly all of them must borrow money or sell something to meet their health care needs, according to a report by Makerere University, Johns Hopkins University and other partners.

And people who can afford treatment often wind up with the wrong medicine.

Pharmacists provide on-the-spot diagnoses and give out antibiotics to find out if they’ll work, without any lab testing, says Dr. Catherine Abala, of Mulago National Referral Hospital’s pediatric wing.

“People are exposed to antibiotics for an infection they don’t have; but because of using them, the same bugs are going around,” she says.

Across Africa, the right antibiotics are often unavailable in the first place. The World Health Organization organizes antibiotics into three categories: “access,” for low-cost drugs used for common infections; “watch,” for higher-cost drugs used for severe infections; and “reserve,” last-choice antibiotics for multidrug-resistant infections.

Across the continent, only 14% of the reserve-class antibiotics are accessible and 80% of antibiotics consumption is that of access-class antibiotics, according to a report released by the African Union in August 2024.

The report notes over-reliance on a few available drugs, even when they are not the primary choice for treatment.

The wrong Rx

E. coli, the pathogen that causes most urinary tract infections, is of particular concern because it is widely resistant to antibiotics. It is listed in the priority category of antibiotic-resistant pathogens, according to the World Health Organization.

Around the world, Global Press Journal interviewed people who buy antibiotics to take whenever they suspect they have a UTI.

Since 2012, Carmen Ana González Miranda repeated the same cycle whenever she had a UTI: take antibiotics, get better, have symptoms again, and take more antibiotics.

“The thing is that here in Puerto Rico, there is a belief that any little thing can be solved with antibiotics,” she says.

When the drugs weren’t working, González switched doctors. She saw a gynecologist, then a urologist, then a gastroenterologist.

Finally, she went to an infectious disease specialist who discovered she had developed antibiotic resistance that will likely be lifelong, and potentially deadly if she gets another infection.

Global medical guidelines are clear about when antibiotics should and should not be used. They can’t cure viral illnesses like the flu or common cold. Broad-spectrum antibiotics can’t be prescribed as a first-line treatment, and in most cases antibiotics shouldn’t be prescribed for long periods of time.

And yet, inappropriate prescriptions are prevalent globally. Like González, people want treatment for especially for urinary tract infections, even if there’s no microbiological confirmation of the problem.

The rise of multidrug-resistant bacterial strains of E. coli globally has reduced effective treatment options.

Bishnu Raj Karki, in Nepal, had bladder surgery after persistent UTIs in 2020. After the surgery, he got another UTI, which didn’t improve even after he took antibiotics. He crossed the border into India in hopes he’d get effective treatment. There, he was diagnosed with kidney inflammation and was prescribed a 42-day antibiotics course.

Things got worse from there. The UTI returned, and Karki had chills, a high fever, nausea and other symptoms. Now 71 years old, he still struggles to recover and requires dialysis three times a week. He’s spent more than 2 million Nepali rupees (about 14,800 dollars) on his treatment so far.

“If my UTI flares up, I know I can die at any moment,” he says.

In many cases, antibiotics are taken “like candy,” says Dr. Prabhat Adhikari, an infectious diseases and critical care specialist at the Center for American Medical Specialists in Nepal, who oversees Karki’s care.

The doctor says a prescription of a 42-day antibiotic for a UTI is bad practice and likely caused Karki to develop antibiotic resistance — the problem that ultimately caused his kidney failure.

AMR in cases of UTI are alarmingly high in Nepal, Adhikari says. A 2021 study shows that 84% of UTI cases there showed resistance to at least one antibiotic, while 54% are multidrug resistant.

“The quality of life of patients with UTI just keeps decreasing,” Adhikari says.

‘Much bigger challenge than HIV’

Antibiotics are, in many ways, miracle drugs. When Alexander Fleming discovered penicillin in 1928, it was considered one of the century’s greatest scientific achievements. Health care changed dramatically when the treatment became widely available in 1945. Communicable diseases like malaria and tuberculosis, and even infections now considered mere aggravations, like strep throat, became much more easily treated. People lived longer.

Now, irresponsible use of those antibiotics has created “a much bigger challenge than HIV,” says Tapiwanashe Kujinga, director for the Pan-African Treatment Access Movement in Zimbabwe.

The path to reverse the impacts of AMR and preserve antibiotics as life-saving drugs starts with reducing the rate of bacterial spread in the first place.

Basic handwashing is a powerful start, says Impalli, the research analyst with One Health Trust.

Soap, she says, can be more effective than the most powerful antibiotic.

Clean drinking water and functional sanitation systems are also key, she adds, as is universal distribution of basic vaccines.

“We have a tendency to talk about AMR as if it’s something that is so big that we shouldn’t even address it,” Impalli says. “It is a really big issue, and it crosscuts so many different areas. So it’s important to emphasize there are tools out there that are proven to help the problem.”

There is global movement toward AMR solutions. At the High-Level Meeting on Antimicrobial Resistance, a gathering of senior officials in September 2024, UN Deputy Secretary-General Amina Mohammed said that more than 90% of countries now have plans to combat AMR.

The need for action is critical.

“If things continue as they are now, infectious diseases associated with resistant microorganisms are going to become the leading cause of mortality,” says Leandro Martín Redondo, coordinator of an AMR project at the National Agricultural Technology Institute in Argentina.

Even routine surgeries won’t be possible, he says.

Fleming predicted that this moment would come. Public demand for antibiotics would begin an era “of abuses,” he said in a 1945 article in The New York Times.

He was clear about the stakes: “The thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism.”

Some interviews were translated from Spanish, Mongolian and Nepali.

Global Press is an award-winning international news publication with more than 40 independent news bureaus across Africa, Asia and Latin America.

BY GAMUCHIRAI MASIYIWA

Summary: Since the pandemic, many major economies like the United Kingdom have tightened restrictions on visas. Migrant health care workers from Zimbabwe struggle as they must live apart from their children and spouses.

When Tanya moved to Ireland for care work in 2022, she was certain of three things: Her family would join her soon. Her husband would find work. And her children would attend a good school. Initially, her move was smooth. Visas and permits were no problem. But once in Ireland, reality proved harsh for Tanya, a Zimbabwean who asked Global Press Journal to use her middle name for fear of jeopardizing her visa status.

The country’s visa restrictions for the general employment permit meant that for her husband to join her, she’d have to earn at least 30,000 euros annually for two years (about 31,500 United States dollars per year). To reunite with each of her three children, she would need to bring in increasingly more.

Tanya earns an income of about 27,000 euros per year (about 28,400 dollars). She spends her time caring for children with autism, but her own children live without her in South Africa.

“I struggle to sleep. I am always emotional. I have become too sensitive and negative towards life,” Tanya says.

Her story is common in a global economy increasingly reliant on migrant workers, who now constitute 4.9% of the global workforce. The demand has risen steadily since 2013 and surged during the pandemic. But as demand increases, so do restrictions on visa policies regarding family members who want to move to be with their spouses or parents in the world’s biggest economies.

Health care workers like Tanya in particular are in high demand. Approximately 15% of the global health care workforce is employed outside their home country or country of training.

The situation is especially pronounced in big economies like the United Kingdom, United States and Australia, where labor shortages and aging populations strain health care systems.

On the supply side, it’s countries with smaller economies like Zimbabwe that are among the main exporters of talent, especially health care talent. The migration of health workers from Zimbabwe is so severe that in 2023, the World Health Organization added it to a “red list” of 55 countries from which international recruitment of health care personnel is discouraged, due to the critically low numbers of health workers remaining to serve their home populations.

Some countries, including Switzerland, the UK, Australia and Denmark, relaxed their visa requirements during the pandemic but have since reverted to previous policies, says Godfrey Kanyenze, director of the Labour and Economic Development Research Institute of Zimbabwe, a research think tank.

There has been a rollback of what Kanyenze calls “sensible arrangements” that had enabled migrant workers to relocate with their families.

In one such reversal, the UK implemented new measures in December 2023 to curtail migration into the country, which then-Home Secretary of State James Cleverly described as “far too high.”

Among the changes is that care workers — who were in such high demand at the onset of the pandemic that the UK had to introduce a special visa for them in 2022 — can no longer relocate with their families.

The policy also increased the salary threshold — or the minimum amount of money one must earn to qualify for the visa — for all migrant workers by close to 50%. Now, migrant workers need to earn at least 38,700 British pounds (about 49,000 dollars) per year to retain their visa status.

In most cases, low-skilled workers such as care workers earn too little to meet these income requirements, says Hilda TinevimboMahumucha, senior legal consultant with Women and Law in Southern Africa, Zimbabwe, a gender justice organization.

In 2023, Sweden, a major migration hub, also announced new restrictions on low-skilled labor migration into the country. Scheduled to take effect this year, migrant workers from “third world countries” will be required to earn a monthly minimum of approximately 2,200 euros (about 2,300 dollars) to obtain a work permit, and even higher income requirements to bring family members to join them.

Receiving countries capitalize on the skill sets of migrant workers without bearing any of the costs, especially the cost of training people, says Abel Chikanda, an associate professor at the School of Earth, Environment and Society at McMaster University in Canada.

“[They] are essentially benefitting from human resource that they did not contribute towards,” he says.

For example, in the case of health worker migration, annually, Africa loses about 2 billion dollars invested in medical training when its health workers migrate abroad. Meanwhile, destination countries enjoy substantial savings by bypassing these costs.

The human cost

In the end, it is migrant workers and their families who pay the steepest price, each in their own way.

Senzeni Chiutsi, a psychologist based in Harare, says that while migration allows parents a chance to support their families economically, the children they leave behind are prone to stress and trauma.

A 2018 study on the effects of migration on children and adolescents left behind by their parents noted signs of depression and loneliness. And 8 in 10 of those interviewed reported having once considered suicide.

Already, the distance between Tanya and her children is widening. On the rare occasions she visits them, her 9-year-old son finds more comfort in video games, while her two girls remain behind the closed doors of their bedrooms.

“One time when I went there, my second child said, ‘Mommy … I don’t even know [the last time] I was hugged,’” Tanya says.

Although she stays in touch through phone calls, it is difficult because of the time difference and her working hours. By the time she is home, her children are already asleep.

The emotional cost of being abroad is just too high, she says.

“One of my friends normally jokes about how we were given the wrong information coming here,” she says. “If you’re doing well in Zimbabwe … I don’t see a need of coming here.”

That’s a big question mark. Most people move because their governments have failed to keep their end of the bargain by providing workers with fair conditions such as adequate pay, says Chikanda, the professor.

If Tanya were employed as a care worker in Zimbabwe, she would earn an annual income of about 4,284 dollars — a sixth of what she is earning abroad.

Even so, she’s set a deadline for herself of this year to return to her family if they can’t join her in Ireland.

“What if they’ll be broken adults?” she says. “It’s not like I’m going to be rich, to be honest.”

Gamuchirai Masiyiwa is a Global Press Journal reporter based in Harare, Zimbabwe.

Global Press is an award-winning international news publication with more than 40 independent news bureaus across Africa, Asia and Latin America.