Mozambican thoughts

By Roberta Pastore (Epiet Cohort 11, WHO, Maputo, Mozambique)

Village on the road between Pemba and Metuge, Cabo Delgado Province, Mozambique

I’m an ex EPIET fellow, cohort 11, from Italy, based in Direction Geral de la Santé (DGS), Geneva. Among all the sentences that I can use to describe myself, I feel comfortable with this one. Being part of the EPIET family was an important experience, a tipping point for changes in working and personal life. One and half year after the end of the fellowship, it happens to me to think about EPIET like a comfortable womb/nest/family, where many inputs, new knowledge, information, experiences can be slowly assimilated, assembled, digested and re-elaborated, a place where one can farsi le ossa (Italian idiomatic expression for “cut his teeth”). The fellowship was sometimes tough, but most of the times everything was well organized, socially friendly, ready to offer a security net to face upcoming problems through supervisors, facilitators, fellows, training and review modules.

I wouldn’t generalize this picture to everyone but for me is fairly true. Imagine being based in small, clean, safe, rich and fully equipped Geneva. Imagine now moving from this rather quiet picture to a loud, chaotic, disorganized working and living environment. How to avoid thinking about EPIET as a safe place?

I’m currently working in WHO country office in Mozambique, as technical officer providing technical support to the MoH on TB control programme and Health Information System.

Not surprisingly the difference between Geneva and Maputo is massive, because of the magnitude of problems to face, the difference in availability of human resources, infrastructure, education (particularly in public health), cultural and emotional factors.

Let’s start with some figures. The TB incidence in Switzerland is 6.7/100.000 population with 28.812 physicians ready to attend the patients, versus TB incidence of 443/100.000 pop in Mozambique with 542 physicians struggling to attend patients who are most of the times also malnourished and HIV+. Of course there’s a world behind the numbers. I remember the weekly meetings in DGS when it was discussed each new TB case in Geneva to organize the contact tracing and appropriate investigations, with dedicated staff and the support of the most suitable means (PCR, TB spot, genotyping). In Mozambique, one is lucky if there is one heath worker to follow up the treatment of dozen of cases and one lab within 100 kilometres to perform a simple microscopy. And forget about the contact tracing! First of all who is going to do it? If there are undertrained volunteers to do it, who should they screen? Given the number of people living in the same household, even the closest contacts are too many to screen them systematically.

As I said, it’s easy to expect this chasm between two countries which are the stereotypes of developed and developing world, but it is difficult to fall into this abyss and adapt to a world where the limitations are much more than the opportunities. The key words in the daily work in Maputo are standardize, synthesize, reduce, rationalize, optimize and simplify, simplify, simplify. To do so, it’s extremely important to set up priorities, select urgent interventions cut the unnecessary activities; of course everything should be done using evidence based criteria.

Mozambique is heavily dependent on international aid, both financially and technically, and there are countless uni-bi-multilateral partners (it took me months to figure out who is doing what).

The international cooperation is obviously endorsing the principles of working on priorities scientifically defined, coordinating the efforts and optimizing the recourses.

The results of the willingness to follow those principles and their actual implementation are very interesting. The principles are translated in a surprising number of guidelines for evidence based planning, matrix of indicators for monitoring and evaluation, and strategic plans. Not to mention the millions of meetings to jointly deliver all those documents. The whole process to simplify and rationalize the interventions is complicated, cumbersome, heavy and exhausting especially for the national staff.

And don’t forget the additional effort required to the health sector to collect all the missing evidences needed for planning and the information for the M&E. Since I’m working also on the health information system, I have seen at first hand the difficulties for the staff in the field daily dealing with tons of reporting forms on all different kind of data. It’s really too much, especially taking into account the very limited capacity to analyse and use the data at sub national level.

To make a long story short, the international cooperation, to which I belong, is not so efficient in simplifying and really helping this country. There are of course many reasons behind this suboptimal efficiency. Beside the serious reasons, I think there are also irrational factors related to human nature. We all studied too much and we are used to have too many tools to be ready to accept the idea that we have to give up to 90% of what we could do in order to make the disease control programmes work better but at ground-to-ground level in this setting. Why to chose one single treatment regimen when we could tailor it on each patient, why to settle for super-aggregated data from paper forms when we could implement a patient based electronic register, and so on?

We suffer when we have to oversimplify. It’s the same form of suffering as when we had to summarize a long, demanding and beloved research study in 225 words for the abstract to submit to ESCAIDE and squeeze everything in 10 slides (including the title slide). Learning (or try to learn) how to get rid of words and details, how to select and justify each pixel on the slides (how to forget the review modules!) without diminishing the clearness and usefulness of information provided was the best lesson during EPIET. At least for me, at least here.

I miss to work on the subtleties of a well designed research protocol, to analyse nice double entered databases, to have a group of people to discuss the best logistic regression model. Some days I feel frustrated by the lack of scientific rigour and time and efforts needed for minor achievements. In spite of everything, I really like to face the challenges of this job. Each small result has a special taste and it’s surprisingly rewarding. Each drop in the beautiful and warm Indian Ocean washing Mozambique shore has a delightful sound.

During the diving classes they teach us how to reach the boat when is against the tide. Working here become sometimes like swimming against the tide. It’s worthless. One must cross the current, taking more time, relaxing, sparing energies and maybe enjoying the company of some dolphins and whale-sharks in the meanwhile. Take it easy. A luta continua. E a vida também.

By the way, Mozambique is wonderful!

Bathing and laundering in Rio Lúrio, Nampula Province, Mozambique