From Health to Hope
A week in Mozambique with Vanderbilt's Friends in Global Health
Editor’s note: Staff writer Bill Snyder spent a week in Mozambique last November covering the efforts of a Vanderbilt-owned subsidiary, Friends in Global Health, to extend HIV/AIDS treatment – and hope – throughout the country’s rugged and disease-ravaged central province.
Legendary country singer-songwriter Don Williams croons from an MP3 player as the Land Rover careens down a dirt road around potholes and pedestrians to a health clinic in this rugged central province of Mozambique.
“Clássico!” exclaims driver Carlos Rui Lourenço about Williams, who is immensely popular throughout sub-Saharan Africa.
The intertwining of two cultures – one emerging from centuries of Portuguese rule and a devastating civil war; the other Western, modern, dominant – seems surreal at times. But it’s more cohesion than collision, and it provides a glimpse of what the world will look like … soon.
At the center of this story is an eclectic band of health and development professionals assembled by the Vanderbilt University Institute for Global Health.
With $8.4 million in annual support from the President’s Emergency Plan for AIDS Relief (PEPFAR), their immediate goal is to help extend HIV/AIDS treatment throughout the province, where nearly one in five people is infected with HIV.
But that’s just the beginning.
Zambézia is ground zero for an audacious plan to tackle a gamut of interconnected problems, from extreme poverty and rampant malnutrition to often-fatal diseases spread by contaminated water and mosquitoes, which have cut average life expectancy here to 41 years.
“There are a lot of other things that need to happen in a setting like this to improve people’s ability to care for themselves better,” says Alfredo Vergara, Ph.D., the institute’s deputy director who has worked in Mozambique for eight years. “Otherwise it seems like we’re plowing in the ocean.”
The core of the program is a Vanderbilt-owned subsidiary, Friends in Global Health, which began working with the Mozambiquan Ministry of Health two years ago.
Based in the provincial capital Quelimane (pronounced Kelly-MAWN-ee), FGH serves 12 of the province’s 17 districts, employs 150 people, and – alongside other partners – has helped quadruple to more than 11,000 the number of Zambézians receiving treatment with anti-retroviral therapy (ART).
While impressive, that’s little more than 10 percent of the estimated number of people with HIV/AIDS who are eligible for treatment, says Troy Moon, M.D., M.P.H., the agency’s clinical director and an assistant professor of Pediatrics at Vanderbilt.
The challenges, at times, seem insurmountable.
Zambézia is a largely rural province, about the size of Tennessee. Most of its 4 million inhabitants are subsistence farmers who earn the equivalent of less than a dollar a day.
In villages of mud-walled, thatch-roofed huts, men repair gearless bicycles, their primary means of transportation, while young children lug plastic drums of water from wells or nearby rivers. In the fields, women tie babies to their backs with colorful scarves before hurling broad-bladed hoes high over their heads to break up the hard black soil for the rice crop.
On this day of an historic American election half a world away, Moon and his team have driven 50 miles to Namacurra to find dozens of people crowded around portable clinic buildings in the sweltering heat of early sub-equatorial summer, waiting to be seen.
Moon examines a baby with chronic diarrhea who endured a five-hour-long bicycle ride with her mother from their remote village to get the clinic. The child, like her mother, has tested positive for HIV. Yet because of their extremely limited circumstances, “we may not get her or her mom into treatment,” the doctor sighs.
A few steps away in Namacurra’s district hospital, a young man, emaciated from AIDS, lies in a metal-framed bed, his eyes wide with desperation. The doors and windows of the ward are wide open; the air conditioning doesn’t work.
He needs a blood transfusion, “but you have to find a donor. There is no blood bank here,” says family nurse practitioner Stacey Lamers, M.S.N. “He’s afraid he’s going to die.”
Little by little, progress is being made.
The Namacurra hospital, recently renovated by other donors, had no electricity or running water until FGH arranged for minor repairs and the actual connections to be made.
Eric Manders, Ph.D., Riley Ganz and their colleagues are developing an electronic medical records system. In the remote Ile (pronounced EE-lay) district, “we could go to a paperless chart before we get running water,” says Pamela Ganz, a physician assistant and the district’s clinical adviser (who is married to Riley).
FGH also is helping train desperately needed health care personnel. In much of Zambézia, there is only one doctor for every 120,000 to 250,000 people. Medical care is provided largely by nurses and técnicos de medicina (medical technicians), who have two years of training post high school. With an average caseload that exceeds 50 patients a day, they also are overwhelmed.
Young, bearded, always in motion, Moon seems to thrive on the challenges and frustrations that confront him each day.
“If you support one more nurse to go through school, if you supply one computer to the provincial hospital, or if you buy a fax machine so somebody in Alto Molócuè (pronounced mol-Oqway) can fax a medical requisition and avoid a six-hour drive to deliver it,” he explains, “there are a lot of small things you can do … to give them the tools so they can do it.”
And while thousands of HIV-positive Zambézians do not yet have access to the drugs that can keep their infections at bay, Vanderbilt researchers have shown that basic primary health care – including treatment of co-infections like tuberculosis and malaria – can slow progression of the disease by up to two years.
“Furthermore, you substantially reduce their infectiousness,” says Sten Vermund, M.D., Ph.D., the charismatic physician- scientist who directs Vanderbilt’s Institute for Global Health.
On Nov. 6, 2008, Moon and his team drive 250 miles to Alto Molócuè with a load of boots, bleach and laboratory supplies to help health officials rein in an outbreak of cholera, a highly contagious bacterial infection that can be quickly fatal.
Two days after the first cases were reported in late October, a makeshift field hospital – tents over plastic ground cloths to catch and disinfect the watery diarrhea – had been erected. The cholera victims lie helplessly on wooden cots, while a sterile solution drips into their veins to replace the fluid they’ve lost.
That’s the only treatment. But despite such rudimentary conditions, all 69 survive.
Addressing the source of the outbreak, fecal contamination of the river that is the town’s major water supply, will have to wait. Yet that doesn’t dampen the sense of relief and accomplishment.
Later in the day, provincial health director Amindo Tonela, M.D., embraces Moon in a victory hug. It’s a gesture that validates the FGH approach, engaging and partnering with local communities; helping them devise sustainable ways of addressing urgent health challenges.
The approach needs to be much bigger than public health, argues Vergara, an epidemiologist who directed the Centers for Disease Control and Prevention’s AIDS program in Mozambique for six years before joining the Vanderbilt faculty.
“We’re talking about education…nutrition…transportation… all of those things,” he says. “If we are not in some way trying to address them, what we can do for something as focused as keeping people on ART for a long time really falls short.”
Toward that end, Vergara last fall led a team of Vanderbilt experts to Mozambique to brainstorm what he calls “wraparound” programs.
They included Carol Etherington, M.S.N., R.N., assistant professor of Nursing; Ted Fischer, Ph.D., professor of Anthropology; Graham Reside, M.Div., Ph.D., executive director of the interdisciplinary Cal Turner Program for Moral Leadership in the Professions; and Bart Victor, Ph.D., the Cal Turner Professor of Moral Leadership in the Owen Graduate School of Management.
One idea from the trip is now being pursued by Fischer and students from the Owen School. They’d like to establish a “Plumpy’nut” factory in Alto Molócuè that would employ people with HIV/AIDS.
“Plumpy’nut” is a high-protein, peanut-based food made by a French company that has dramatically reduced malnutrition rates throughout Africa. Since area farmers grow the same raw ingredients, why not produce a homegrown version of the product?
“Development is really the creation of freedoms,” Victor points out, “capabilities to make the choices and execute on the choices that one would want for oneself.”
Victor says he was inspired by Vergara and Vermund – “not just by their vision, but by their abilities to execute on that vision.”
Vanderbilt, through FGH, is positioned to lead “what is arguably the most significant trend in global public health today, which is this interdisciplinary approach,” he says, and to be led. “We have as much to learn in this country as we have to teach,” says Etherington, who is known internationally for her expertise in crisis response.
As long as FGH exhibits humility and a willingness to listen, traits important in any culture, “I don’t think we’ll have any problem,” adds Paulo Pires, M.D., the agency’s provincial clinical coordinator. “The people, they are willing to improve, to study, to change.”
Perhaps a woman working at a Quelimane gas station said it best, the morning after the son of a Kenyan man was elected president of the United States:
“We are all Africans now.”