The first week of June provided me a quick orientation to the excellent work of Friends in Global Health (FGH) in HIV care in Mozambique. It also served as an eye-opening reminder of the human devastation caused by AIDS when acting in concert with extremely poor primary healthcare, frequent natural disasters, population dispersion, inadequate infrastructure, and tremendous logistical challenges. These challenges have come to characterize Zambézia, the most populous province of the country and the staging ground for FGH’s PEPFAR-funded campaign to bring HIV detection and treatment to the rural areas of the country. In Zambézia, rural areas represent the second and most critical focus of PEPFAR projects which have traditionally neglected such regions due to the difficulty of operating in these settings.

Soon after arriving in Quelimane, the capital of Zambézia province, I traveled with the Friends in Global Health team to a rural district with one of the highest volumes of HIV patients seeking care. On a slightly overcast winter morning, I set out for Inhassunge district with Dr. Monica Carvalho, FGH’s clinical adviser for the district. Inhassunge is only some 25 km from Quelimane but is separated from the provincial capital by the River Cuacua. We left at 7 am from the port of Madal in Quelimane by a small ferry owned by a local shrimping company that has been giving passage to Ministry of Health staff and partners working in Inhassunge. After a 10 minute boat ride, we crossed over to Inhassunge district and traveled via land-cruiser to the district hospital in the locality of Macupia. Although the distance was only 15 km, it took us nearly 45 minutes on an extremely rough and bumpy dirt-road. Locals either walk or travel by bicycle within the district but in the rainy season the dirt roads can become virtually impassable. Dr. Monica mentioned that even in the land-cruiser it was very difficult to get to the district hospital in the rainy season due to heavy flooding, which increased the complexity of providing healthcare to the region.

On the way to Macupia, I also had the opportunity to survey the local agriculture as we wove through rice fields and small coconut plantations on the land cruiser. Villagers in Inhassunge rely on growing coconuts, rice and occasionally beans for food and income. However, several years ago, nearly all of the coconut palms in the district were destroyed by the phytoplasma-borne Lethal Yellowing Disease or LYD. Driving through Inhassunge, we passed long stretches of coconut palms which had been eaten away by LYD, leaving behind barren fields of bare trunks that looked like telephone posts. I learned that Inhassunge district has the highest incidence of LYD in Zambézia. In addition, due to inadequate rain last month, much of the rice crop has dried up, rendering it useless. These factors have exacerbated the acute poverty and under-nutrition in Inhassunge. As a result, Dr. Monica said that she was witnessing a sharp increase in the rate of malnourished patients this month. Many of the AIDS patients she sees in Inhassunge drop out of treatment as they find it extremely difficult to stay on TARV because they are severely undernourished and accordingly have a decreased tolerance for the side-effects of the drugs.

Upon reaching the district hospital, I received a tour of the facilities and an overview of how FGH works with the Ministry of Health in providing HIV testing and care. The main hospital comprises a pharmacy; lab facilities for testing HIV, malaria and TB; an emergency room with a few beds; a maternity wing with a delivery room staffed by mid-wives and maternity nurses; and 6 to 8-bed wards for men, women and children. In addition, across the main hospital building, there are several pre-fabricated consultation rooms where patients receive voluntary HIV counseling and testing, in addition to anti-retroviral therapy. In one of these rooms, Dr. Monica does consults for AIDS patients, prescribes treatment for HIV and associated opportunistic infections like TB in new patients and follows up on continuing patients. Dr. Monica typically sees the more complicated cases together with the medical technician (technico de medicina) who is employed by the Ministry of Health and certified to provide anti-retroviral treatment. Rather than creating a parallel system of AIDS care, the FGH model is to work in partnership with the Ministry of Health by increasing the capacity of its health workers through clinical mentorship. With this approach, FGH is helping to create a sustainable solution to the HIV epidemic in the long run, which can only be stemmed by the coordinated effort of NGOs, the national government and local community.

After spending some time at the district hospital, I set out for one of neighboring localities called Palan Mukula, where FGH and the Ministry of Health will soon start a satellite clinic. Once every few weeks, a clinical team from the district hospital will travel to peripheral health units such as the one in Palan-Mukula to do HIV tests, collect blood samples for CD4 counts and administer counseling and treatment. Indeed, the next phase of FGH’s project with the Ministry of Health is to expand the full range of health services to these peripheral health units which are closer to the communities.

When I reached Palan-Mukula, I realized there was a tremendous need for this expansion. Since starting at the Inhassunge district hospital in Mucupia earlier this year, FGH has already enrolled nearly 2000 patients in its anti-retroviral treatment program, although not all of these patients have adhered to treatment. But this is only the tip of the iceberg since there are many localities which are far from the district hospital and have not been able to access the services of FGH or Ministry of Health. In Palan-Mukula itself, there is a population of 12,350 who are in need of primary healthcare let alone HIV testing and treatment. However, currently, the peripheral health center in this locality provides only rudimentary services like some first aid and mid-wifery services. The situation in far-flung localities like Chirimane and Olinda is even worse as these places do not even have a peripheral health unit. For me, this has underscored the need for a mobile health clinic that can travel through the rugged terrain to these remote populations in order to provide them much needed primary care and HIV treatment. Over the coming weeks and months, the Real Medicine Foundation will work closely with Friends in Global Health and Ministry of Health, Mozambique to plan, design and implement such a mobile clinic project. Ultimately, the mobile clinic will become a part of the infrastructure of the Ministry of Health, an integral component in the plan to make HIV testing and care more proximal, community-oriented and efficient in the next phase of the campaign against AIDS.

The Zambezi, Africa's fourth largest river, rises in Zambia and flows along the borders of Namibia, Botswana and Zimbabwe to Mozambique, where it spills into the Indian Ocean. Since mid December 2007, early and torrential seasonal rains across northern Zimbabwe, southern Zambia, Malawi and central and northern Mozambique – intensified by a La Niña in the Pacific and possibly climate change – have waterlogged and destroyed fields, washed out roads and villages, and destroyed livelihoods. The worry for Mozambique is that most of that water drains out to the east along the Zambezi River valley through the center of the country. By early January 2008, it already had caused flooding in the Zambezi valley with 13 dead and 102,330 displaced and 57,000 hectares arable land flooded. At that time, the Mozambican government estimated that up to 95,000 people had already been moved to resettlement areas, but over 200,000 people were still at risk and needed to be evacuated.

It is anticipated that this year’s flooding in Mozambique could cause more material damage than the catastrophic experience of 2000/2001. Recent reports found that most households affected by the flooding of February 2007 are yet to recover and are experiencing severe food insecurity. About 285,000 people were affected and 29 killed in the Zambezi River basin last year during the worst floods to hit the country in six years. According to Mozambique's Ministry of Health, there are increasing numbers of people with diarrhea and vomiting. Cholera is a serious threat. In Mutarara, one of the most affected areas in the Zambezi high basin, there is no reliable road access. Water levels are higher than those seen in the peak of last year’s flood, and helicopter landing sites used for the delivery of aid last year are submerged this time.

The INGC (Instituto Nacional de Gestão de Calamidades, Mozambique's disaster management agency) already has a serious shortage of space in the resettlement areas (partly because this year's flood has already engulfed some of the resettlement areas set up last year, which were not built on high enough ground). More than 80% of households in resettlement areas and 75% outside them face extreme food shortages.

In 2000, half a million people fled the rising water, 800 died. Steadily rising rivers mean the flooding in Mozambique is far from over, but the real challenge is convincing those defiant to evacuate to leave their possessions behind and head for higher ground, and keep those already rescued from returning before the water has subsided. According to Paulo Zucula, Director of the INGC, "70% of the people have been moved, but 30% are still missing, for two reasons: some are resisting to move - they want to stay; and a number of people have decided to move back to flooded areas." Reluctance to leave and the desire to return arises from the evacuees' fear of losing what little livestock, crops and property they possess. Some 40% of Mozambique's population lives on less than $1US/day. So they risk everything to save what they have. And people keep coming back because the riverbanks are the most fertile areas. The places they have been resettled to on higher ground are by far not as productive which makes it difficult to survive.

The children and families arriving on small boats and canoes having been flooded out of their houses are among the poorest I have ever seen. The children’s symptoms of extreme chronic malnutrition beat any description. And family after family arrives seeking shelter in areas where there just is no food, no access to clean water or sanitation.

Many refugees have constructed makeshift homes out of wood, sticks, palm fronds, and grasses. The refugee camps lack essential resources such clean water, sanitation, healthcare, and electricity.

Zambézia is one of Mozambique’s most populous provinces with over 4 million inhabitants. The estimated HIV prevalence is of over 20%, in some regions it reaches up to 40%. As a whole, the country of Mozambique is one of the poorest countries on the planet (168 of 177 in the 2005 human development index), 70% of the population lives below the national poverty line. The access to healthcare is extremely limited. There are 600 trained physicians and 6,000 nurses for a country of almost 21 million people. Since most of the healthcare professionals are in the major cities of Maputo and Pemba, this equates to 1 doctor for every 100,000 people in many of the remote rural areas. Approximately 40% walk more than 20 km to reach a primary care facility. In rural settings such as Zambézia, only approximately 4% of those needing ART treatment are currently enrolled.

Mozambique covers a total area of 801,590 sq km, slightly less than twice the size of California. According to Mozambique’s Minister of Health, Dr Ivo Garrido, a surgeon, who I met with in early February, urgent help is needed to support the current healthcare infrastructure. Mozambique is divided into 128 districts; there are 1,200 small health units with a total of only 200 labs. Calculating that every health unit would have a target population of 10,000, the country would need 2,000 of these small health units, and thus is 800 short. In many provinces, the maternal/infant mortality is immense. Many pregnant women needing a c-section would have to walk 500km to receive help. It is obvious that both, mother and child will die. Many simple life-saving surgeries are just not accessible to a vast percentage of the population.

Considering all these factors, we decided to modify the concept for our refugee clinic (which has been made possible by Medical Mission International www.mminternational.org.uk) and to create and design a mobile clinic – which then can be duplicated and multiplied – to bring the medical care to the people who need it the most.

We decided to partner with the Vanderbilt University team in Zambézia province, Friends in Global Health, LLC (www.friendsinglobalhealth.org), whose "Projecto Rural Moçambicano Vanderbilt" from the "Plano Presidencial para combate ao SIDA" (PEPFAR) was officially accepted by the Provincial Health Directorate (DPS - Direcção Provincial da Saúde) of Zambézia province in April 2007.

From their website: “Vanderbilt University’s Institute for Global Health (VIGH) has received PEPFAR funds to support HIV care and treatment programs in rural districts of Zambézia Province, an environment with extremely limited resources and medical staff/facilities. Clinics in the districts of Ilé, Alto Molòcué, Namacurra and Inhassunge are currently supported. The FGH staff employs a holistic approach in the development of a comprehensive model for rural healthcare and treatment that integrates health and social services, addresses human resource and infrastructure constraints, and develops a sustainable health care system.”