MAPUTO | A few weeks ago at the U.N., I interviewed the Health Minister of Mozambique, Paolo Ivo Garrido. By the time I got to Maputo in October, Garrido had been dismissed as health minister in a cabinet reshuffling and replaced by Alexandre Manguele. In the near term, it doesn’t matter that much. The country’s problems are daunting, no matter who’s running the health ministry.
Earlier in my trip to Mozambique, I visited the district medical center in Chibouti, a few hours north of the capital. It was a sobering view of what medicine is like in one of the poorest countries in the world. A cluster of low-slung buildings surrounding a sandy, weedy courtyard, this is the hospital for more than 200,000 Mozambicans. The windows are wide open to the hot, lazy breeze drifting into the pediatric ward.
Inside, five of the eight beds are full. Women try to calm infants. Some have malaria. Some show the signs of severe malnutrition. Some are HIV positive. The babies wail with a disturbing sound … high-pitched and inconsolable in the case of one who is very ill but appears well fed. From a 15 month old who weighs just under nine pounds, it’s a pathetic little sound. The child stares straight ahead, absent-mindedly flapping its tiny right arm, the other arm immobilized by an intravenous drip.
We stop at the bed and find the caregiver is not the child’s mother, but his grandmother. The boy, in addition to his severe malnourishment, is also HIV positive. His father recently died from AIDS. His mother, also HIV positive, is inconsolable, incapacitated, and bed-ridden at home. The boy is a twin, the grandmother explained, and his brother seems fine. The sick parents have seen declining incomes in this already dirt-poor country, but the other children seem to be eating enough.
The windows are dusty. Washing them would be a luxury because this hospital has no running water. Hospital staff fills buckets from a nearby community spigot, walk it over to the building, and dump it in a cistern. There are water buckets standing in each of the wards, filled from the cistern. The young medical director, one of only two doctors for all the people in the district, says the water is not very high quality, but it’s all he’s got. Let me repeat, this is the most advanced care available for 200,000 people here and in the surrounding villages.
The depth of the poverty feeds directly into the access to water. Neither local families nor government sources have the funds to rebuild the water system in Chibouti. The quality of the water feeds directly into the health of all the people around here, but especially the children. They are frequently fighting off diarrheal diseases that weaken their systems, leaving them less equipped to fight off the long list of diseases that are widespread in parts of Mozambique. Such weakness fills the overtaxed hospitals, and divides the limited attention of the chronically short medical staff.
In this part of southern Mozambique, it was distressingly common to see the sparse hair and distended bellies on babies that signals chronic malnutrition. There were untreated skin conditions, and orthopedic problems that would have been corrected in early childhood in other places in the world.
It was hard to imagine much of a future for that tiny boy in the bed. If they bring up his weight, stabilize his condition, and someday get him on anti-retroviral medication to fight his HIV, none of the conditions at home that landed him in the hospital in the first place will have changed.
How much health care can be delivered in a country where the per capita GDP currently hovers around $500 per year? Just a 90-minute drive from Chibouti, the Mozambique and the U.S. governments are working on a model that offers a lot of hope. At the Xai-Xai Provincial Hospital, they are doing what they can with what they’ve got.
You won’t mistake this place for a hospital anywhere else in the world. There is no blasting air-conditioning or endless supply of disposable gowns or medical instruments. What Xai-Xai does is simply take the random and sometimes chaotic practices of underfunded hospitals throughout Africa and eliminates them through training, training, and more training.
Systems reinforce best practices with available equipment for sterilizing instruments. Protocols on the handling of laundry are drilled, explained, and drilled again. Hand-washing stations are everywhere, along with exhortations to wash on the way in to the medical area, and on the way out. Charting is improved. Patients names are posted above their beds, and staff encouraged to push back against the depersonalization that sometimes accompanies overcrowding by simply calling people by their names.
It’s not medicine driven by technology. It’s not medicine driven by heavy spending on new tools. What the Xai-Xai hospital does is simply take better practice that costs nothing, and through training soaks it into the pores of the staff.
Since this place is also a training center for nurses, it is reasonable to expect these norms can be spread to other hospitals around the country. Until there is more money to spend, why not give each patient the best shot at recovery you can by eliminating bad habits in a way that hardly costs a cent?
Hyper-local solutions are necessary for Mozambique because medical facilities are so scarce, and distances so hard to cross in a country with few personal automobiles and low population density. Mozambique’s coastline stretches a distance equal to that of Seattle to Los Angeles … with little public transportation and few big population centers to encourage specialization and efficiencies of scale.
As it is, getting your kid to the doctor can be hard. So hard, that families wait until children are far more ill until they bring them in for care. The dispersed area clinics are understaffed and under-resourced. Diagnostic tools are few, medications in short supply, and the closest physician two days away. The country can’t snap its fingers and solve the physician shortage, but it’s trying to fill the supply gap at both ends of the continuum; with physicians and specialists at one end and the equivalents of licensed practical nurses and physicians assistants from elsewhere on the education spectrum.
I’ll have more on how a poor country best spends its money, the cost of a high disease burden, and what Mozambique is doing to climb off the bottom of the world’s poverty tables, in the coming days and weeks both on the NewsHour’s website and on its broadcast. Stay tuned.