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."