My two-week sojourn in Gile district allowed me to observe the full-spectrum of rural health programs being run by the Ministry of Health, Friends in Global Health (FGH) and other partners. Having surveyed the clinical activities of FGH in the district during my first few days in Gile, I now needed to learn about the health outreach and education programs in the communities themselves. On June 14, I had the perfect opportunity to spend time out in the villages and observe the realities of life in rural Mozambique.

I set out from the peripheral health center in the locality of Moneia with the goal of visiting some community health councils in the surrounding communities. I was accompanied by Mr. Dambini, the district Ministry of Health supervisor, who oversees the activities of the community health councils. These councils are organized, trained and supported jointly by the Ministry of Health and World Vision, as part of a community outreach program called COACH. So far, out of 200 communities in all of Gile, currently 27 communities have set up well-organized health councils through COACH. Thus, there is definitely much more room to scale up this program which has proved to be quite successful so far.

My meeting with the health council in Nahoa proved to be the most instructive and interesting. Nahoa is a poor community of several hundred people that lies 20 km from the Moneia health center and about 40 km from Gile town. The community health council here is fairly dynamic and active. Soon after I arrived in Nahoa, we met with the council members—eleven in number—in a small open-sided mud hut in a central part of the village. After introductions, Senor Dambini explained the roles and functions of the council. The council is formed by elders and influential members of the community. It comprises activists who provide basic home-based care to AIDS patients, reproductive health counselors, influential ‘mothers’ in the community who provide nutritional counseling for children and IMCI (Integrated Management of Childhood Illness) health workers who go house-to-house to do basic pediatric evaluations. Typically, the activists and health workers are volunteers who are chosen by the council to represent them, although they sometimes receive small incentives such as t-shirts.

Later in the day, I had the chance to accompany one of the IMCI workers as he made the rounds from house to house. At each house, the health worker looked through the child’s growth chart and made sure the vaccination record was up to date. He would examine the child and deliver nutritional counseling if he or she looked undernourished. We visited several families and in almost every instance children were malnourished. In some cases, the child had symptoms of malaria and the health worker filled out a referral slip for the case to be seen at the health center in Moneia. The IMCI health workers are instructed to refer serious childhood illnesses like persistent diarrhea, unexplained fever and suspected malaria or tuberculosis to the district health centers.

Following the IMCI worker also provided me a walking tour of the village. I observed families living in mud-huts around small patches of farming land. I walked past thatched toilets with no drainage and very poor sanitation. I saw small children playing in the dirt. Older children were working in the fields. Many of them had symptoms of malnutrition; a few even had early signs of kwashiorkor. In fact, the IMCI worker told me that the two biggest problems among children in the community were acute malnutrition and malaria.

Before I left Nahoa, I was invited to observe a drama put on by the health council relating to malaria. This was the highlight of my day in the communities. The council often organizes participatory health-related theatre pieces for the benefit of the community members. The drama started out with one of the health workers—playing a malaria patient— lying prone on the floor, shivering as if with chills. One of the ‘mothers’ in the council played the role of the frantic mother of the patient. A traditional healer was summoned and quickly pronounced that the patient was possessed by demons that needed to be exorcised. Following an unsuccessful exorcism, featuring a rattle and medicinal water, an IMCI agent arrived and counseled the mother to take the patient to the health center. After a lot of convincing, the patient was finally picked up and carried to the hospital where he received anti-malarial medication. Eventually, after home care involving the regular administration of medicines and blankets and a theatrically contrived convalescence, the patient recovered fully. A joyous mood overtook the audience as they clapped and celebrated the banishing of malaria.

Afterwards, Mr. Dambini giving a debriefing session on the performance. He emphasized that mosquitoes—and not evil spirits—were the causative agent of malaria and highlighted the importance of expediting suspected cases to the health center without delay. On a different note, Dambini also lectured on the negative consequences of not receiving childhood vaccinations. The whole production was then wrapped up with the activistas leading a chant about the benefits of vaccinations for children. Here and there, mothers from the community would be prompted to join in, initiating a form of collective participatory learning.

As I observed the theatre and participatory learning activities, I realized that the community health council was enacting a real grass-roots mobilization for health education. What I saw in Nahoa was a well run community program—one which provided health education, entertainment and self-actualization for the community. No program to combat something as complex as AIDS can survive on testing and treatment alone. I realized then that the community health council would be a great forum for the mobile clinic to integrate outreach and education activities into its program. This week, after many discussions with FGH staff, Mr. Dambini and Dr. Kizito, the District Director of Health, I have formulated a plan to do this. Although the plan is in its conceptual stages, the idea is not only to generate publicity and referrals to the mobile clinic through the community health council but also to film their activities, demonstrations (eg nutritional demonstration to prepare enriched foods) and dramas and project them on a screen attached to the mobile clinic. There is a local traveling cinema group in Mozambique called CinemArena that is showing educational movies for HIV and we can adapt their model to our mobile clinic project. In this way, we can amplify the impact of the health council while incorporating health education into the mobile clinic activities, making it an integrated treatment, testing and education platform for the community. Mr Dambini has already agreed to be our liaison to the health councils for this purpose. The next steps will be to learn more about CinemArena and consult with them to help us implement this combined mobile clinic/cinema idea.

On June 9, I packed my bags and departed for a two week survey of Gile district. Gile is a mountainous area in the north-east of Zambezia province, easily one of the most isolated and challenging regions in rural Mozambique. Considering the highly dispersed population and tremendous need for basic healthcare—let alone HIV/AIDS services—in Gile, it had been suggested by Friends in Global Health (FGH) as an ideal place to pilot the mobile clinic. Accordingly, I undertook the 400 km journey to Gile from Quelimane on a clear Monday morning with Dr. Emilio Valverde, FGH’s clinical adviser for the region.

Having endured 8 hours on a treacherous and jagged dirt road, I was thankful to finally enter the environs of Gile as the evening merged into nightfall. We ascended a sloping road and crossed a rough log bridge into Gile town, in the heart of the district. The journey had already done much to convince me that we should indeed launch Real Medicine’s mobile clinic project in Gile. On the way there, I had encountered a striking landscape with verdant hills and statuesque mountains. But I had also seen numerous families living in great poverty and scores of patently malnourished children lining the road as we rolled past.

The next few days reinforced my initial impressions about the acute lack of development in Gile. The vast majority of the district has no electricity, cell phone reception or paved roads. The mountainous terrain and make-shift bridges over the numerous rivulets make it very difficult for people—particularly sick people— to travel even short distances. Indeed, the terrain poses a challenge to all but the most sturdily built vehicles. In some places, the bridges are only wide enough to permit the passage of a vehicle the width of a land-cruiser. As I traveled through Gile, I noted these logistical constraints which certainly have obvious implications for the design of the mobile clinic but in a way also underscore the need to bring mobile health services to isolated communities.

Currently, healthcare operations in Gile originate from the district hospital in Gile town. The hospital functions as the nerve center for all clinical and outreach activities in the district. It lies in a central part of Gile town and is equipped with a maternity wing, general wards for men, women and children with 6-8 beds each, several consultation and emergency rooms, a pharmacy, a lab, a database room, a counseling and testing area and administrative offices. It is staffed with several medical technicians (technico de medicina), preventive medicine technicians (technico de medicina preventiva), maternity nurses, mid-wives, lab agents, pharmacists and database managers. In addition, there is an ambulance and a driver. FGH also pays for two social assistants that coordinate the community outreach activities such as peer educators for HIV/AIDS and the ‘bushkativa’ work of activistas (community activists) which involves going into the community to track down patients who have abandoned anti-retroviral treatment.

However, the hospital does not have a surgical facility or staff. Thus, surgical emergencies (such as C-sections) can only be handled at the rural hospital in the neighboring districts of Alto Molocue or Nampula, each of which is half a day’s travel by car. This means that many patients—mostly women experiencing complicated pregnancies—die before they ever receive surgical care.

Dr. Emilio and Dr. Kizito, the District Director of Health, are based at the Gile district hospital. A few times a week, however, they set out for one of the peripheral health units distributed about the district, each meant to serve the population of a single locality. These health posts largely function as satellite clinics with HIV testing and treatment occurring when the Dr. Kizito or Dr. Emilio go out there with a clinical team. However, since only 5 out of 14 localities in Gile are covered in this manner, nearly two-thirds of the population still has no access to health services of any kind.

The Ministry of Health in Gile is prevented from expanding their services not only by a major lack of funds but also by a dearth of medical professionals in Mozambique. Before Dr. Emilio from FGH started working in Gile, there was only one physician for the entire district, a population of 170,589 people.

The lack of healthcare resources is deeply disturbing when one considers the swelling epidemic of HIV in Gile. An estimated 14% of the population or 23,883 people are thought to be infected with the virus. Right now, 40-50 new cases are being found each month and the numbers are growing. In fact, since FGH started working in Gile last November, more than 600 people have already tested positive. Approximately, 10% of these patients are already dead.

Perhaps the biggest tragedy, though, is the situation of children amidst the growing HIV/AIDS crisis. Within the family structure, children can often be the lowest priority when it comes to healthcare. Due to the great difficulty of accessing medical services, parents will not make the effort to bring an HIV-positive child regularly to a health center to receive treatment. Instead, they resign themselves to the likelihood that the child will not survive, investing their hopes in having other children who might be healthy. At the satellite clinic in the locality of Moneia, I saw this dynamic playing out. A child who had tested positive was not brought back to the health center for CD4 counts the following week. Dr. Emilio told me that this was a common occurrence in Gile—after being tested, many HIV-positive children were never seen at the health center again.

Not surprisingly, given the context of a virtually non-existent healthcare infrastructure, Friends in Global Health and the Ministry of Health have only begun to address these tremendous challenges posed by the HIV epidemic in Gile. However, valuable progress has already been made in some areas, particularly Gile town and the locality of Moneia. At this point, nearly 160 patients in total—including 10 children—have been started on anti-retroviral treatment, most of whom remain adherent to treatment. The next step will involve expanding to more localities in Gile which are in urgent need of care. For this purpose, mobile clinics are a perfect solution to accessing scattered rural populations in remote areas of Gile. Eventually, mobile clinics can become part of a highly decentralized and effective network of satellite and mobile units that will deploy resources according to local needs. Both PEPFAR and WHO—through its Commission for Macroeconomics and Health—have called for just such a dispersed and close-to-client network of clinics to combat HIV in rural sub-Saharan Africa.

The mission of the Real Medicine Foundation over the next several weeks is to prepare the groundwork necessary to realize this vision of efficient, decentralized health care. During my time in Gile, I will collaborate with Friends in Global Health to complete a field survey of communities in the district, including an assessment of the roads, logistical barriers and distances to existing healthcare centers. This will not only inform the design concept for the mobile clinic but will also allow us to map out remote population centers that we can target with the mobile clinic. The long-term plan is to test drive the mobile clinic in Gile before expanding to other sites in Zambezia province in the long run. Consequently, careful planning and implementation along with a good monitoring and evaluation program is needed at this stage to ensure the project’s success in the future.

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.”