Fighting AIDS in Mozambique
MAPUTO-As night falls along the highways of rural Mozambique, lights come on in the barracas, open-air roadside bars. Some are cane huts lit by kerosene lamps; others are concrete, with metal roofs, spinning lights, and blaring music. Truckers heading from Mozambique's ports along the Indian Ocean to landlocked countries in southern Africa pull to the side of the road. It doesn't take long for a few girls to wander over and strike up a conversation, then a negotiation: How much for sex? And where? The woman may ask the trucker to use a Jeito, a brand of condom widely available at these way stations. But he may offer a little more money to keep the condom in its wrapper.
These women are rarely full-time sex workers. They come out to the barracas when they need cash for school fees or clothing. And part-time prostitution is not the only unorthodox sex practice that's common in Mozambique. To prove their virility, men often take a second or third wife. Women spend years scarring their legs and stomachs to make themselves sexually attractive. Migrant workers often return to their families from jobs, and sexual liaisons, abroad. And in some regions, when a man dies, his wife must sleep with one of her husband's male relatives, a practice known as sexual cleansing. This mix of sexual economy and cultural practice is a petri dish in which HIV grows and spreads with speed and ease. About 1.4 million of Mozambique's 19 million people are believed to be infected.
Into this scene comes a flood of money from President Bush's Emergency Plan for AIDS Relief and its "ABC" approach. ABC stands for "Abstinence, Be faithful, use Condoms," the three-pronged strategy generally agreed to be the most effective way of preventing the spread of HIV. Mozambique is one of 15 countries selected to receive the bulk of the money in a five-year plan to spend $15 billion. But the money comes with strings attached, including rules that encourage abstinence-only education and de-emphasize condoms. The people fighting AIDS agree that the politicization of this aid, and ignorance of local practices, threaten to undermine its effectiveness.
In Washington, the United States has become adept at smooth talk about the ABC approach, mentioning just enough science and just enough religion. "Abstinence works, being faithful works, condoms work. They all have a role in the important mix," Randall Tobias, the head of Bush's plan, told Congress in March. Tobias makes it sound like all three are deployed equally, which is far from the case. Last year, for example, the United States gave $100 million in grants for abstinence-only education to the 15 countries, with the great bulk going to faith-based groups. (Science does not back up the effectiveness of these programs. A recent report from the American Foundation for AIDS Research said that "evidence does not support" the abstinence-only emphasis as a way to stop HIV in young people and that comprehensive sex education would be more effective.)
New internal guidelines for implementing ABC say that abstinence and partner reduction (A and B) strategies can be used ad hoc, but any approach involving condoms must also include messages about A and B. The rules list seven points that condom programs must mention, only one of which actually deals with the use of condoms. The rest involve abstinence, condoms' limited effectiveness, and ways to reduce the risk of transmission. What's more, the Bush AIDS initiative restricts distribution of condoms to "high-risk" groups such as sex workers, members of the military, and migrant laborers. It forbids discussing condoms with people under age 14. The result pits the letters of ABC against one another, dissolving the three-prong approach, while often making it hard to talk about condoms at all.
On the ground, nearly every independent group disagrees with that strategy. "We promote condom use," said an official at the World Bank, which gives millions of dollars to Mozambique to fight AIDS. "We don't have a moral angle, because we're not a moral institution. We can fund as many condoms as the government of Mozambique is willing to buy and can distribute effectively." The United States enters the scene as the 800-pound gorilla, pushing its agenda along with its vast quantities of money, thereby shifting how the issue is addressed. That shift is beginning to confound groups with long-standing experience in Mozambique.
Take Júlio Pacca, head of the Mozambique office of Pathfinder International, which operates more than 100 youth centers doing AIDS education all across the country. "When you are talking about the fight against HIV transmission, you must talk about condoms," he said. In the tiny town of Buzi, a Pathfinder organizer regularly gathers teens from area schools for peer counseling and lessons on reproductive health. The information the teens take home helps overcome myths about HIV, including the rumor that it's contained in condoms. Pathfinder did not bother to ask for money from the U.S. initiative, though they may apply in the future.
Nonetheless, U.S. money is slowly transforming the lay of the land. Some organizations with U.S. funding chafe at the rules but say they comply. "They want us to do capital A, capital B, little c," said an official at a group in Mozambique that gets U.S. money and asked not to be named. "We see condoms as an essential part of the array. [Bush's plan] was forced to kowtow to this right-wing lobby that really wants to see the A-B portion only. They've really downplayed the C portion." Kevin Novotny, head of the Mozambican office of the group Project HOPE, a new recipient of U.S. money under this initiative, said the rules had a chilling effect on condom education. "I didn't even put condoms in my budget," he said referring to his funding application, which aims to raise money to form youth groups to promote abstinence and educate girls about how to negotiate safe sex.
Condoms or no condoms, the need for such negotiating skills, as well as talk about fidelity, should not be downplayed. The average age of sexual debut in Mozambique is about 16, and activists peg sex between older men and younger women as another way the virus spreads. U.S. rules say condoms can be given only to high-risk groups, and not to youth. With infection rates around 15 percent in the cities and above 35 percent along the transportation corridors, and with so many infected people, it seems fair to argue that all Mozambican youths are high-risk.
"They want to experiment," said Filipe Charles, who runs a range of AIDS programs in northern Mozambique for the international aid group CARE. "Sex is good, but it has to be responsible sex." Charles uses U.S. money to teach all three parts of ABC and says the United States has taken a hands-off attitude.
The United States does fund condom promotion in Mozambique, mostly through a group called Population Services International, which is well known for condom advertising and distribution around the world. PSI had to change its accounting practices to play within the new guidelines. The group bought about 21 million condoms for Mozambique last year, using money from Britain. Its U.S. funds go to promoting condom use, not purchasing prophylactics.
If truckers use condoms, it's probably thanks to PSI. PSI runs the Jeito campaign, which distributes the condoms nationwide, sells them below cost, and promotes safe sex on bright green and yellow billboards, often showing couples in humorous situations. PSI's agents sell Jeitos even in remote areas, so most barracas have them for sale alongside the food and drink. The United States gave PSI $1.2 million for this effort in Mozambique in 2004, most of the $1.54 million allocated for non-AB prevention activities. Abstinence and fidelity programs got just over $2 million. The United States also buys condoms for free distribution at all the country's public health centers.
The United States often stresses the involvement of faith-based groups in its abstinence-promotion work, but Christian organizations are the most conflicted about how to mix messages about condoms, abstinence, and fidelity. While some would like a Western moral message to come to the fore, they also acknowledge it's not realistic, given local beliefs. "To say that everybody's going to be abstinent is crazy," Darcy DeLeon, head of the Adventist Development and Relief Agency in Mozambique, told me. "From a Christian standpoint that's what we'd like to see, but we recognize we can't force people to live to that standard, especially in the fight against AIDS." ADRA gets money for abstinence-only education, but not for work in Mozambique, according to DeLeon. Each ADRA mission can determine its own philosophy, and in Mozambique that means talking - very carefully - about condoms.
Care for Life, a small Mormon organization, is far less subtle: "If you're involved in sex very early, you will die," says the group's director, Augusto Cherequejanhe. Care For Life carries that message into hundreds of schools in central Mozambique without any reproductive health education or information about how HIV is transmitted. The group gets money indirectly from the United States for work on literacy and care for AIDS orphans, but not for its sex education program.
Perhaps information disseminated at several Catholic boarding schools in the same province offset Care for Life's harsh, unscientific program. "Condoms do not mean you can fool around. It's immoral," Sister Palmeira told me at a rural school, where abstinence and fidelity are taught in the classroom. Kids who come to the adjoining clinic-run by the same nuns-after school can get their hands on condoms. "We should advise them that condoms exist and tell them how they work. If you can't abstain, please try to use prevention methods such as condoms."
Groups in every province take a different approach. The government of Mozambique envisions a complex ABC program that adapts to each region's cultural differences, such as polygamy and sexual cleansing. Of course, that's at odds with the United States' more blanket focus on A and B, and it doesn't jibe so well with local practice either. The result is a piecemeal effort when a comprehensive, countrywide approach is needed to curb the disease. In a country as geographically and linguistically diverse as California but twice as big, the barracas are the only thing the entire nation seems to have in common.
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From: Adam Graham-Silverman
Subject: Fighting AIDS and Underdevelopment
Posted: Wednesday, June 1, 2005, at 11:58 AM PT
BEIRA-The pediatric ward is on the second floor of the central hospital here in Mozambique's second-largest city. The tile floors are cracked, the fluorescent lights flicker, and there is a rotten stench of urine and waste. The many beds in the doorless rooms are full of silent children and their parents. When tuberculosis and malaria are at their worst, the doctors say they have to put seven children in each bed. There is one pediatric nurse for 40 patients, and nearly one in five children does not leave the hospital alive. About three-quarters of those deaths are AIDS-related. Trash lies uncollected everywhere, and rats and roaches scurry through broken windows. Dr. Eduardo Matediane sighs as he looks at the building, which houses maternity wards, operating rooms, and other departments in addition to pediatrics. "They should just tear the whole thing down," he says.
Over his shoulder sits a freshly painted two-story building where Matediane has spent a huge amount of time over the past two years. It, too, is crowded. But relatively speaking, it is bright, clean, and efficient. It is the hospital's AIDS clinic, which is run by Health Alliance International, a Seattle-based group working to fight the disease in this sprawling southern African country. Here, HAI provides free counseling, treatment, and life-extending anti-retroviral drugs (ARVs).
HAI's funding for the clinic comes in large part from President Bush's Emergency Plan for AIDS Relief, for which he has pledged $15 billion through 2008. Mozambique got $27 million in 2004 and will get $48 million this year. It's a huge amount of money, and most observers credit the administration for taking action. But most of the money goes to independent groups like HAI, not through the central government. The idea is that these groups have the expertise to jump in and get the job done quickly without the bureaucratic delays or corruption that plague many developing nations. But in a country as poor as Mozambique, which ranks 171 out of 177 countries on the U.N. human development index, even some of the groups getting U.S. money say the country needs to develop if it ever hopes to stand on its own two feet in the battle against AIDS. A gleaming new clinic does little if the infrastructure around it is falling apart.
Beira is a port city at one end of a transportation corridor that takes goods through Mozambique to Zimbabwe, Malawi, and other landlocked parts of Africa. Truckers and migrant workers traveling these roads help spread the disease, making Beira one of the most infected parts of the country. The AIDS clinic lies within the sprawling campus of the central hospital, across the road from the Indian Ocean. The clinic opened in February of 2003 and now sees more than 2,200 people a month. As of mid-March, about 550 patients there were on ARVs. HAI's job description is to provide technical support, but in fact they run the clinic from top to bottom and pay the salaries of the Mozambican doctors, nurses, and counselors.
AIDS presents a series of challenges to Mozambique's health system. Unlike most other diseases, it never goes away, even for people on ARVs. Patients must take the drugs for the rest of their lives, so the strain on the infrastructure is always increasing. That's why doctors are urging an expansion of services that is both fast and sustainable. The central government limits the number of people who can start ARVs in a given month based on the availability of medical staff to monitor them, not just on the availability of drugs. That means severe limits on drugs in a country that has about 600 native doctors for 19 million people, 1.4 million of whom are HIV-positive.
HAI's success and the success of the clinic are closely intertwined, but that's a virtue of HAI's philosophy, not the U.S. strategy. U.S. treatment methods stand at odds with many practices in Mozambique and, increasingly, in other developing countries. For example, Bush's global AIDS plan requires FDA approval for generic ARV drugs made in countries such as India and South Africa, despite the existence of a parallel World Health Organization screening system. So far, only one generic has been approved, which leaves FDA-approved drugs made in the United States, where they lack generic counterparts. [Update June 1: The FDA approved a second drug, from Indian company Ranbaxy, on May 31.] Brand-name drug regimens can cost two to four times as much as generics and thus reduce the number of people who can be treated, according to a January report from the U.S. Government Accountability Office. The Mozambican government, with the help of the William J. Clinton Foundation, had already worked out a deal to buy cheap drugs from India. When the Mozambicans suggested the United States take its money elsewhere if it wanted to insist on brand-name drugs, Washington backed down. That's why HAI's drugs are generics from the government of Mozambique.
The U.S. funding mechanism is also unusual. Nearly all the other countries that send money to fight AIDS in Mozambique pool their contributions in a common fund that the group manages with the Mozambican government. The government is attempting to implement its detailed, five-year national plan to fight AIDS. The U.S. initiative does not allow donations to go directly to foreign governments, so the money goes to groups such as HAI, which in turn works with the government under the guidelines of the national plan.
HAI officials say they're in Mozambique to develop the government's health system, not undermine it. So, it's ironic that they have joined with the U.S. plan, which can't invest in the government or its long-term needs. "As a general philosophy, it would be better if the United States would coordinate its funding with other donors and do it in a way that's responsive to what the governments in these countries want and need in terms of building local infrastructure," says Wendy Johnson, HAI's Mozambique field director.
The problem, U.S. officials say, is that that approach is far too slow. The spread of AIDS in Africa presents a grave emergency, and NGOs that parachute in with expertise and money can attack the problem faster. Groups like HAI have a long record of service in the country and close ties to many local organizations. Thomas Hardy of Columbia University's Mailman School of Public Health, which is setting up clinics across Mozambique, says that the funding mechanism is not important so long as the money shows up and goes to backing local groups, providing expertise, and working through the national plan. "As a practical matter, the quickest way to get kicked out of a country is to ignore what the country wants you to do," he says. Ideally, Hardy adds, you can build infrastructure and fight disease at the same time. In practice, it's not so easy. Often it depends on the priorities of the aid recipients, not the philosophy of the United States.
In the hospital, AIDS often shows up in tuberculosis patients and pregnant women. Some doctors say 60 percent of tuberculosis patients in Beira are HIV-positive, but the TB and maternity wards are not equipped to diagnose and treat HIV. Patients could be picked up from the main hospital, deposited in the AIDS clinic, and started on treatment, but in most areas there are few links between different departments to ensure that happens, and there's nothing in the U.S. plan to see that it does. At HAI, there is talk of training people who work with TB patients to spot AIDS, but it's not been done yet. HIV-testing facilities remain separate, though HAI also runs services to counsel and test pregnant women and tries to prevent them from passing the disease to their children.
Washington is concerned about numbers: How many people are on ARVs; how many people have been tested; and how many people got care. This results-based approach is an effort to keep close track of how money is spent, but many say the drive for efficiency is misplaced. "When you're so indicator-focused and that drives everything that the organization is doing, you lose the reasons why you're doing it," Wendy Prosser, one of HAI's AIDS program managers, says. There are no indicators for doctors trained, buildings built, or nurses hired. Meanwhile, the United States budgeted $4 million of its 2004 spending in Mozambique for management costs, compared with $2.6 million for testing and $1.1 million for clinical care. Still, you can't lay the blame on the U.S. government or on that of Mozambique. The fact is that this is extremely difficult work in extremely poor countries and doing it requires climbing an immensely steep learning curve.
The week after I visited Beira, HAI hosted a meeting to announce the opening of a clinic in the small city of Nhamatanda. The ceremony began with singing, dancing, and drumming. About 40 activists from religious and community groups listened to speeches from HAI and Mozambican officials then filed through the brand new building. As in Beira, this clinic operates on the grounds of a larger hospital, whose rooms overflow with patients wasting away from AIDS-related illnesses. On the day of the meeting, the hospital had no running water. Rubber gloves and needles were being boiled for reuse. In one room, a man with a broken leg lay in a traction device, his casted limb elevated. The weight holding his leg in the air was a plastic bag filled with rocks.
After the activists left, the HAI staff worked into the night.
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From: Adam Graham-Silverman
Subject: Where Does the Money Go?
Posted: Thursday, June 2, 2005, at 4:17 AM PT
SOFALA PROVINCE-In 2004, Mozambique's health ministry spent $50 million to fight AIDS. The United States dropped $27 million last year and will donate $48 million more in 2005. From the passenger seat of a pickup truck bumping along a teeth-grinding road in one of the most infected parts of the country, Aurelio Gomes has just one question: Where is the money?
"It is a big joke, as you can see," he says, gesturing at the potholed dirt and flat plains dotted with cane houses. "There is no money here." It's a frequent refrain from Gomes, one of the most embittered yet proactive people I met in Mozambique. For the Mozambican doctor who resembles the aging Muhammad Ali, the desire to treat HIV/AIDS quickly has meant abandoning the international donors he sees as a patronage network and bureaucratic nightmare. After butting against that wall too long, Gomes struck out on his own.
"Don't say you give money to Mozambique," he chastises the international community of his imagination. "You give money to the government of Mozambique." Whether they work together or not, Gomes believes foreign donors like the United States and the government are not working for the country.
After spending countless hours trying to get money from these groups, Gomes hooked up with a Franciscan organization that was starting clinics in central Mozambique. He's worked in health and development for years, but he says top officials won't meet with him. He didn't get money from President Bush's giant new global AIDS initiative; he got it from the National Institutes of Health, an organization that never saw his face. After more months of battling the government, he just got permission to start treating AIDS patients with antiretroviral drugs, the cocktails that can prolong the lives of people with the disease.
Gomes' four clinics are, literally, in the middle of nowhere. "People don't like to live close together or near the road," Gomes says as we bounce through the landscape, pink and purple clouds swirling overhead. Roadside stalls offer nuts, oil, and tall bags full of homemade charcoal topped with straw. We pass men on bikes with live goats strapped to the seats. Burning piles of cut grass along the side of the road obscure the route. A formal economic system barely exists. Unemployment may be 80 percent.
The African sunset takes nearly two hours to play out, but it is dark when we arrive at the first clinic, in Mangunde, more than four hours' drive from Beira. The next morning I see that it would be an exaggeration to call Mangunde a town. It's a school, a farm, and a three-building, one-story hospital, all run by the Franciscans. If it weren't for them, Mangunde would be just another dusty intersection. But Gomes' work is bearing fruit. The clinic now sees 2,000 people each month, and the nuns are putting the finishing touches on a new building designed to treat AIDS patients.
These clinics will get ARVs from the Community of Sant'Egidio, a Catholic lay group based in Rome and affiliated with the Vatican. Sant'Egidio helped set up the 1992 peace agreement that ended 17 years of civil war in Mozambique, so it has a special status for some Mozambicans. That status allowed them to establish the country's first ARV clinics as well as the first public diagnostic labs in sub-Saharan Africa. Now they run 13 clinics and have 3,900 people on ARVs, about half the country's total. Sant'Egidio says that by plunging ahead it dragged the country to the realization that it could treat AIDS on a large scale. Like Gomes, they operate with the government's consent, but outside its structures, a position in which the group takes pride.
"The word 'emergency' can accord with the word 'quality,' " Stefano Capparucci told me the day before I embarked on my journey with Gomes. Capparucci, who, with his round glasses, cigarettes, and flannel shirt looks like a shop teacher, is one of a rotating group of Italian medical volunteers who spend a month at a time in the country. He showed me around a Sant'Egidio AIDS hospital in Manga Chingussura, a slum outside Beira. The one-story building held several small exam rooms, an ice-cold pharmacy, and computers logged onto a database linked to clinics all over the country; as blood samples, patients, and drugs shuttle among hospitals and labs, the computers keep efficient track of the system.
Patients lined up to meet with doctors and get supplies of ARVs, as well as antibiotics and TB drugs. Sant'Egidio also provides its patients with food: sugar, flour, oil, beans, and, for nursing mothers, formula and a filter that makes water safe to mix it with. It's what Capparucci calls the "golden standard," treatment equal to Western norms. "We could do the minimum, but it's not our philosophy," he said. "We hope in the future we will be here to do the golden standard for everybody." Sant'Egidio's drug regimen costs $300 per person per year, almost half the cost of the cheapest drugs the U.S. government buys to treat AIDS patients overseas. Add in care and lab tests, and treating an AIDS patient costs them $700 a year.
Sant'Egidio also trains Mozambican volunteers to work in their communities, educating people about AIDS and bringing sick people to the clinics. Most are HIV-positive women who Sant'Egidio has restored to life with ARVs. As we walked past an open-air, metal-roofed waiting area, one volunteer whose daughter died of AIDS read aloud to the group, translating a Portuguese text on health and hygiene into the local language. She was an older woman, full of enthusiasm. "Oh, how I love this grandmother," Stefano beamed. The feeling was mutual. The volunteers ran to greet Stefano when we arrived, and kissed me hello, thinking I was also Sant'Egidio.
Not everyone is so magnanimous. "They are scaling up quickly with lots of mistakes," says Dr. Eduardo Matediane, an obstetrician who helped start an AIDS clinic at the government's central hospital in Beira. "If you scale up quickly, quality will go down." Treatment is all well and good, he said, but patients need to be monitored and programs developed so they can be sustained. The central hospital gives extensive counseling to patients before they start ARVs. Some patients come into the clinic every day for the first six weeks of treatment to deal with side effects and make sure they stick to the pills. Sant'Egidio did not participate in efforts to coordinate a nationwide approach to the disease and doesn't always work with other groups. The fact that volunteers come and go each month means that lines of command and communication are often unclear to outsiders. "Sant'Egidio doesn't get it," says Wendy Johnson, the Mozambique field director for Health Alliance International, a U.S. group working with the Mozambican government.
To Gomes, the government symbolizes inefficiency. Once private money is spent, the government swoops in and declares it a success. " 'We give you permission to do treatment, so we can take credit,' " he says mockingly. "I say bullshit." Gomes wonders why so much money has come in to the government plan and yet so many patients are being treated by Sant'Egidio. Johnson and others say that for the impoverished health system to ever stand alone, investment should go through the government, even if that takes longer. "We're not in competition to try to see who can treat the greatest number of AIDS people in the shortest period of time," Johnson says, puzzled at Sant'Egidio's approach. The AIDS epidemic will probably get much worse before it gets better, which is why she thinks investment is important to improve conditions in health, transportation, and other sectors. "We're all in this together."
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From: Adam Graham-Silverman
Subject: Making a Difference
Posted: Friday, June 3, 2005, at 3:29 AM PT
TETE—The Médecins Sans Frontières SUV lurches to a stop and we jump out of the back. Besufekad Yirgu, an Ethiopian doctor who everyone calls Besu, walks between two houses in this residential neighborhood. The city, sandwiched between Malawi and Zimbabwe, is hot, dusty, and suffering a drought. On a mat behind one house lies a very sick woman. Flies attack the weltlike sores on her legs, and her eyes look too dead to form the accusing glare of the sick I've gotten used to seeing in Mozambican hospitals.
Her mother rattles off the symptoms: vomiting, terrible headache, weight loss. She is too weak to sit or stand, upset by movement, and very unhappy. She moans, objecting to the touch of the doctor, and tries to roll on her side. Her mother hovers around her, trying to keep her flesh covered.
Besu examines her neck and makes a diagnosis: meningitis, brought on by AIDS. He gives her pills and water, and she forces them down. In less than a minute, she spews them back up, then lies down again. The effort to protect her modesty is over. She has been sick for two weeks.
"Why did you wait so long?" Besu asks the mother bitterly, not expecting an answer. He turns to me. "In the West, such a patient would be admitted immediately and given a lumbar puncture." If it weren't for his group's community volunteers, the family would never have found medical treatment. In the next two days, Besu said, she would probably have gone into a coma and died. As it is, she'll have to find transport to the hospital, where doctors will be awaiting her arrival.
The visit is the first stop in an afternoon of house calls that MSF—known in the United States as Doctors Without Borders—makes nearly every day. Without these expat physicians, who take no money from the United States or most other large-scale donors, these patients would not get seen, diagnosed, or treated.
Back in the SUV, Besu, frustrated by the stigma that kept the woman lying in the dirt, rather than a hospital, lists the names of drugs his patient needs to take his mind off what he's just seen. "This is as bad as it gets," he concedes. We drive across the Zambeze River and follow a dusty track for nearly 45 minutes into the brush, through huge ditches, across streams, and down a grade so steep I worry the car will flip. Dust fills the air. Still, it's beautiful. Big open skies and high clouds.
We pass through a cane-shack town and come to a small hut on a hillside. A very thin woman with a lazy eye and totally parched skin sits outside with her mother and son. She cannot walk, so we reach beneath her arms and lift her onto a chair. She is in her late 20s, but her breasts are withered, dry and old, cracked and shrunken.
The woman is taking drugs to treat tuberculosis and antiretrovirals to treat HIV. Her son, who is 10 and HIV-positive, also takes ARVs. The MSF nurse, who speaks the local language, goes through the days of the week with the boy to make sure he is taking the right pills on the right days. The boy walks miles every day to attend school—and to get their pills.
"The woman will be OK," Besu says as we depart. The last time he saw her, she was inside the hut, unable to move or breathe. In a way, the woman and her son are lucky; ARV drugs are free and available. But it's not drugs—or money—that Mozambique needs. "We can fill the warehouses on the docks of African countries full of ARVs but if we don't have the cadre of physicians, nurses, technicians, we're going to have nothing but pills on our hands, and we're not going to save anybody's life," says one skeptic within the U.S. government.
Back in Tete, where the infection rate is about 22 percent, MSF runs an AIDS clinic that treats 1,800 people a month. It operates as a part of the Mozambican health system, and provides treatment, counseling, management, and drugs. For now, MSF pays the workers' salaries. The group hopes to hand control over to local doctors someday, but right now the two Mozambican doctors tasked with spending time at the AIDS clinic are so overwhelmed with their work in the regular hospital that they are never there.
One MSF lab technician has been waiting since June of last year for a new machine that will measure the strength of the virus in a patient's blood. Until it arrives, she ships blood samples via DHL to hospitals in neighboring provinces that have the equipment. The local lab tech, when he shows up for work, is often drunk, she says. "If you build it, they will come?" cracks the U.S. government official. "If you build it there's nobody there."
Perhaps 500,000 people need antiretroviral medicines in Mozambique; less than 10,000 get them. Official plans call for 200,000 on ARVs by 2008, the largest scale-up effort in Africa. The United States and other donors are pouring money in, but they face exorbitant startup costs whose price is more than money.
No one, including the U.S. government, disputes the need for more doctors, nurses, and technicians, or that throwing drugs into the situation without commensurate staff and facilities will be anything but a disaster. The United States requires the groups it funds to report how many people they've counseled and put on drugs, but there is no equivalent for measuring staff hired, nurses trained, or labs built. In other words, there's nothing to require the work or measure whether it gets done, which makes the encouragement for building infrastructure toothless. Mouzinho de Assuncao Saíde, head of the health ministry's AIDS program, says the country will need 3,000 new health professionals in the next 10 years.
The lack of resources doesn't just affect treatment. When local groups come forward to apply for money, they're often ill-equipped to put together formal proposals. And there's no one to train them, according to Maria Semedo, who runs Mozambique's National AIDS Council's office in rural Sofala Province.
In the isolated northern province of Nampula, the HIV infection rate has remained relatively low, around 10 percent. That gives AIDS workers there hope that they can stem the epidemic before it grows. It has been sheltered from disease, but also from relief efforts: When I visited a program run by the international relief group CARE, only nine people were on ARVs. CARE is planning to start a clinic similar to MSF's in the Nampula central hospital. When I visited, the space consisted of a few file cabinets in a dusty hallway.
On the ride back into Tete, Besu marveled at the "Lazarus effect" ARVs have. Apart from any physical pain, people with AIDS can be ostracized from their communities. But once on ARVs and looking healthy, they can resume work and family life. As the MSF truck drove through the dusty town, a man flagged us down. Inside his three-room hut lay a boy, several chickens, and a baby goat the size of a cat. Besu hauled the boy into the light of the doorway and lifted his shirt, sending up a cloud of dust. Besu tapped his stomach and back. It made a hard, solid sound in both places—signs of built-up fluid. The goat galloped around nipping at the chicken. Tuberculosis, Besu said, but the boy will be all right once he gets drugs to treat the disease. Once the TB is gone, he can start ARVs to keep his AIDS in check.
Like the meningitis patient's trip to the hospital, that may or may not happen. Mozambique will hit its targets for treating AIDS patients only if everything falls into place in every sector of the government and international community. In the city of Chimoio, south of Tete on the country's main north-south highway, a health ministry official sighed when asked how realistic it is to expect everything and everyone to come through. "Sometimes we make plans even though not all plans will be fulfilled," he said. "We still make plans."