HIV solution: decentralizing treatment & patient empowerment

At the core of successful health programs are powerful community systems. Whether they are strong local governments, community-based organizations, or just informal groups of individuals – these types of community centered systems keep health programs focused on serving people and meeting needs in ways that will be most effective for the community.

In what has been called a model for Africa and US health programs by CDC Dr. Kebba Jobarteh, Mozambique is leading the way in restructuring how HIV treatment and support is delivered. Most countries in southern Africa have very high HIV prevalence rates as well as difficulties in providing treatment to those who need it. While there are many people in need of HIV treatment, there is a critical lack of adequate health infrastructure, clinics, hospitals, and health workers, to deliver the necessary services.

Providing treatment is just the beginning of the battle. Once an individual starts treatment with antiretrovirals (ARVs) they need to continue to adhere to a regular regimen of ARVs. Access to the medications and clinics along with regularly taking ARVs present a two-fold problem in areas where health services have long been weakened by a plethora of misfortunes: apartheid, structural adjustment programs, lack of development, under-investment, etc.

The new model developed by Doctors without Borders (MSF) puts communities at the forefront. By creating “patient groups,” treatment is decentralized to small health clinics in communities. This model spreads the responsibility to communities where there is the greatest need. The patient groups act as both a delivery system for ARV drugs as well as a support network for those with HIV. In many rural areas, people don’t have the time to travel long distances for extended periods of time to get their ARV drugs. The members of a patient group take turns traveling the distance to the health clinic. Likewise, members record whether each member of their group has taken their ARVs regularly and on time, which is then reported to the health clinic.

The model is very similar to that of “community health workers” (CHWs), who are members of the community that share knowledge and provide services when health systems can’t. As a solution to the inadequate health systems seen around the world, the “patient group” model puts those who need health services in control of their own treatment with the backing of a support network from their community. This may be a more effective model than CHWs since those who need treatment are providing the treatment. What better way to understand patient needs than to listen to the patients?

The CHW model has been popularized by organizations such as Partners in Health working in communities in developing countries. The model has now spread to urban areas and “developed” countries around the world. The patient model is yet another example of rural solutions from developing countries setting the bar for gaps in health care treatment in developed countries. A patient-centered/ people-centered approach to health delivery will make health systems more effective and successful around the world.

Featured on the Americans for Informed Democracy Blog, where I’m writing as a Global Health Analyst and reposted by Partners in Health.

carrenhos de chocque em mocambique (required to fight aid worker burn-out)

During my three-month long internship with a small-scale HIV/AIDS non-profit in South Africa, I visited a friend working in Mozambique with an HIV/AIDS activism organization as part of her Peace Corps placement. Beyond the entirely new experience of traveling to Mozambique, I met a very interesting crew of international development/ aid workers who gave me some great insights into who I might want to become if I entered the international development/aid arena. From working on a small operation in East Darfur, Sudan with a religious relief agency, to a technology focused firm constructing health curriculums funded by PEPFAR, to those doing backend all office-based, administrative work for USAID and the Clinton Foundation,  they were all at various stages in their lives and working in very different aspects of  development/ aid work. Some of the volunteers were in their 40s, others just out of college in Peace Corps, some had just come from extremely stressful environments where “guns were like sticks,” while others had just come to complete an internship for their Princeton graduate degree, all in all it was a motley group that gave a compelling snapshot of aid workers and the many directions they can come from and be headed towards.

4 August 2008

After walking from our hotel, my friend and I stopped at a “local” bar named Pirata (Pirate) to meet up with the motley crew of aid workers. We then headed into downtown Maputo for dinner at a restaurant recommended by one of the aid workers who had spent the longest time in and around Maputo (he had serious Mozambique cred). I had a supposedly traditional Mozambican dish of beans, rice, and shrimp which was very delicious or I was just supremely hungry from the day’s 8 hour bus ride from Johannesburg.

The Maputo based aid worker then took us to an odd sort of carnival hidden in what seemed like the middle of Maputo. It was randomly placed and not very large, but took me back to days of my earlier youth when we would visit the noise, lights, and crowds of the church carnival. We all were initially a bit shy about expressing our joy at the sight of children’s carnival games, but soon we were all reveling in the freedom from our assigned professional roles.

As we were the only ones at the carnival late in the evening, we had the whole place to ourselves. We all lined up and filled the bumper cars (carrenhos de chocque). The crackle of the electric wires, childish shouts of aid workers, and huge grins of pure joy made me realize that this should be a required exercise for all aid workers no matter if they are in the USA or based in a foreign country. We all need to take a step back every once in a while and just let ourselves enjoy being uninhibited by things as unimportant as bumper cars so that we can focus on important work.

A note for the future:

We all have to find what it is that helps us keep sharp and focused while also reducing stress, physical and emotional. The best thing to do is to schedule time when you can be unfocused, let loose, and enjoy time unencumbered by tasks, to-do lists, or responsibilities. My current job has a lot of frustrating client cancellations (currently the reason that I can sit and write this), long commutes with driving stress, and odd hours. As individuals who work in the field of aid, global health, and community development, we all want to love what we do, but the reality is that it is often a grind with harsh and far reaching social consequences that can cause us to resent a job. We all need to find those coping mechanisms that allow us to vent and rejuvenate our passions.



your energy is not your own

Earlier this month I wrote about how South Africa’s war into Mozambique has contributed to Mozambique checking in at one of the poorest countries in the world. It seems that the apartheid past is still too close at hand to allow Mozambique ample space to regain its footing.

Mozambique is supposedly going to increase energy supplies to South Africa to aid in its electricity shortages. What? Mozambique is going to aid South Africa when Mozambique is facing energy shortages of its own and has South Africa to thank for its apartheid debt? What I later read was that 75% of the energy produced by Mozambique’s Cahora Bassa Dam is already sold to South Africa. The reason for the increase is because the Dam recently received refurbishment that has increased production.

Disturbingly, in later research it came to light that the Cahora Bassa Dam was a joint project of Electricity Supply Commission (ESCOM, as it was known prior to 1987), latterly Eskom, Johannesburg, South Africa and Hidroelectrica de Cahora Bassa (HCB), a firm owned 82% by the government of Portugal and 18% by Mozambique. So it is not the government of Mozambique swaying to its former apartheid aggressor, it is the economic interest of two major energy companies one owned by South Africa and the other controlled by Portugal. Where is the voice of the Mozambican people? Why can they not benefit from the very energy that they produce? The answer to that question is all too easily given from the previous statement. The Eskom company is also known by its Afrikans name: Elektrisiteitsvoorsieningskommissie. Now we have arrived at the conclusion that an Afrikans company operating out of South Africa with a known past of the apartheid government decimating the Mozambican population. Did this company gain its assets on the river during the apartheid fueled war with Mozambique? Is the company now profiting from the current and war-time suffering of the Mozambican people? All signs point to yes in both questions. Apartheid is still alive and well in the energy industry of southern Africa.

An apartheid era company and the Portuguese, former colonial power, lay claim to the energy supply of southern Africa, Mozambique remains pushed aside, and South Africa gains from the increase in energy where I am sure the wealthy benefit the most. Resources need to rest in the hands of the people, so that the benefit lays in the homes of the people. We who would claim to support and promote democracy need to remember that the Greek, “demos” (prefix of democracy) means ‘the people’ or ‘the poor.’ Those who face the harshest challenges should receive the greatest benefit.

what apartheid has done with affordable transportation

A week of riots and clashes sparked in the capital as the government attempted to raise fuel prices by 50%. Mozambique is often unheard of in international news, but a week of violent riots in Maputo leaving 100 injured and four dead were enough to bring the world’s poorest country to the headlines. The fuel price jump was proposed as a response to the 14% rise in diesel fuel costs. Food prices have also experienced an increase due to the rise in fuel costs. The reason that riots erupted was not only because of rising fuel costs, but mainly because of the low wages that people in Mozambique make. The more interesting question may be why is Mozambique so poor and why would the government seek a 50% increase in price to meet the demand?

Mozambique is moderately large country on the East coast of Africa. With a history of Portuguese colonial rule, civil war, effects of apartheid, and a wide-reaching famine, Mozambique has had great difficulty in bringing its people out of desperate poverty. Mozambique gained independence in 1975, but was quickly pulled into war against white rule in Rhodesia and South Africa. The apartheid government of South Africa not only oppressed its own people, it engaged in near full-scale war with Angola and Mozambique as well as raiding and blockading Lesotho, Botswana, Zambia, Zimbabwe and Malawi. “This was a war against ordinary people, in which schools and health posts were primary targets and civilians were massacred on buses and trains. At least two million Mozambicans and Angolans died in the war South Africa waged against them; millions more had to flee their homes.” writes Action for Southern Africa and the World Development Movement in an Africa Action Report.

A generation of children never received education because schools were destroyed, mothers and children died because health services were devastated, and now the region cannot rebuild because they are asked to pay again for the injustices of the apartheid regime through debts. The war waged by the South African apartheid government made Mozambique one of the poorest countries in the world. Over one million people died between 1977 and 1992, the economy was destroyed along with the countryside, and the country was left with a legacy of landmines. The South African government supported a rebel group called RENAMO. RENAMO or Mozambican National Resistance was formed after independence as an anti-communist conservative political party. It fought against the FRELIMO (Mozambican Liberation Front) and the Zimbabwean government of Robert Mugabe which was overthrowing the white Rhodesian rule. RENAMO received support from South Africa as well as the Central Intelligence Organization of Rhodesia and the CIA of the United States. RENAMO was known for its widespread brutality and human rights abuses. It was instrumental in destroying the economy of Mozambique and ensuring that a southern African country under black rule could not be stable.

The US and South African backed RENAMO insurgency destroyed the basic infrastructure and industry of Mozambique. With this extreme loss of income Mozambique was forced to turn to the IMF and World Bank in order to create the infrastructure destroyed by apartheid. “Mozambique has been forced to delay universal primary education until 2010 because it has to repay the apartheid-caused debt.” notes the Africa Action Report. This debt cause by apartheid South Africa is easily deemed odious. Meaning the debts imposed were against the interests of the local populace, and as such should be written off as unlawful under international law.

On top of the apartheid debt and lack of infrastructure, in 2001 Mozambique experienced terrible flooding that has threatened nearly a quarter of the country with death by famine. Again in 2007 terrible flooding forced almost 60,000 people to be evacuated from the Zambezi River Valley. It was said to have been worse that the flooding in 2001. Roads were destroyed, bridges washed away, hundreds of homes disappeared under water – this on top of apartheid debt and a landmine scarred countryside. There is hope for Mozambique. Tourism is increasing and international investment is at a high, but at what cost? The government of Mozambique needs to ensure that it does not sell out its future in investment schemes that will rob indigenous peoples of their lands and leave the country empty of resources.

Mozambique has suffered and is still suffering from the white empowered South African apartheid government system backed by none other than the United States of America. If you would like to understand the current rioting in the capital of Maputo, you need only look back to apartheid to recognize why the 170th of 175 countries listed on the development index sits right next to the richest country in all of Africa.