Journey to Gile
June 9, 2008
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.