Omar Amir’s travel to Mozambique – Part I

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.