1. HISTORY OF THE PROJECT
This cooperation project was first conceived in December 1992 and from the beginning thought of for Mozambique, which was then considered the poorest country in the world.
Due to the fact that Niassa has always been the most forgotten province of the country and due to the fact that the Bishop of that diocesis is known to be interested in such projects and the geographical boundaries of the Diocese are similar to those of the county), we immediately started to inquire about the precise needs and about the possibilities to cooperate in that county.
The needs turned out to be enormous, especially in the area of Mother and Child healthcare and the local people responsible were eager for cooperation. However this project, which offered mainly free help in healthcare and technical training, has had a long and complicated start to life.
It was difficult to turn this idea into a credible project worthy of indispensable minimum financing, but it was even more difficult to obtain authorisation in Maputo to work in Niassa. Thus the arrival of the first team of volunteers in Niassa only became possible in October 1997.
2. THE REALITY OF NIASSA.
2.1. The geographical situation
Niassa is the largest of the 10 provinces in Mozambique, covering an area of 129,362km2 in the extreme Northeast of the country, a plateau area with beautiful granite mountains, bordering Tanzania and Malawi.
The communication routes, which are dirt roads, are very difficult especially during the rainy season which lasts from November to May. The railway, presently being renovated, is still very deficient and really only functions in the Cuamba area in the south of the province.
The capital of the province, Lichinga, is more than 2,000 km distart from Maputo.
2.2. The social situation
The population of Niassa consisted of around one million people in 1999, considerably scattered. These people were mainly returnees from refugee camps, poverty-stricken and without any form of professional training due to the fact that they could only stay and receive humanitarian help in the countries that had received them. They weren_t even allowed to farm for their own consumption.
It has always been the least cared for province of Mozambique, considered by other Mozambicans as no mans land due to the fact that this was really the case not only during the colonial era but also after independence.
The population lives off what they farm eating mainly "chima", a gruel made of peeled and washed corn with little nutritional value to which they sometimes add beans and cassava or dry fish for those who are better off.
2.3. Ethnic groups, Habits and Culture
There are three main ethnic groups in Niassa: the Anyanja, the Ayao and the Macúas, each one has their own language, some distinct habits and beliefs and all clearly show rivalry.
A matriarchy exists in all three ethnic groups and women are very much appreciated for being those that continue the clan and the family line. In general, the more children they have the more appreciated they will be by their husbands and the higher they will be thought of in society. On the other hand, when they lose the ability to procreate they lose all their appreciation within their society.
The majority of the province is Muslim but the Ayao are the least Christian. They ended up imposing some of the customs that they have in common with the Macúas or the Anyanja, such as the rites of passage of the boys and girls, without which they are not considered members of society and it is for this reason that it is carried out as early as possible, usually at around the age of eight or nine.
As well as the circumcision of the boys, the deflowering and surgical removal of the clitoris and the smaller lips of the girls, the rites of initiation imply a series of theoretical and practical teachings which condition the sex life leading to a high percentage of adolescent mothers, anaemic with stomachs bigger than themselves and who frequently die during badly assisted births or arrive at the hospital, with a dilacerated perineum, a few days after a complete rupture of the rectum, urethra and bladder.
According to the teachings received during the rites, a girl, especially if she is an Ayao, cannot refuse copulation with anyone who demands it, as long as the pretender is circumcised.
This fact associated with the existence of polygamy, common to the three ethnic groups, explains the high incidence of sexually transmitted diseases and the fact thatthey frequently appear in girls of 9 or 10 years of age.
2.4. The structure of the State Health System
The constitution of the Republic of Mozambique gives each citizen the right to medical and sanitary assistance.
To fulfil this right the government created a national health service and defined four levels of health care:
The first level would cover the health centres and clinics.
The second level would cover district, general and rural hospitals.
The third level would cover provincial hospitals and the fourth level the central and specialized hospitals.
Theoretically, the first three levels of assistance would be represented in Niassa: the third level being represented by the provincial hospital of Lichinga, the second level by the rural hospital of Cuamba and the first level by a few health clinics spread out around the 15 districts of the province.
In fact, in October 1997 there were two Mozambican doctors in the province of Niassa: the province director of health and the director of Lichinga hospital, both almost exclusively occupied by political-administrative tasks. Four Ukrainian doctors and two doctors recently graduated from Cuba, one from Rwanda and an other from Burundi, worked in Lichinga hospital.
The maternity hospital of Lichinga with more than 4000 in patients annually, with an average percentage of occupation around 150%, with a high percentage of risk pregnancies, distocic births (as most births take place at home, assisted by traditional or untrained midwives), and complicated puerperium, was the exclusive responsibility of the young Rwandan doctor, on duty 24 hours a day.
The paediatric unit with fifty beds, but often with one hundred or more children, was the responsibility of the young graduate from Burundi.
Only one young South African doctor, a missionary of the Protestant Church, worked in the Cuamba hospital in 1997.
The scarce health centres, all of them situated in the old nationalized missionary buildings, are still the responsibility of medical staff or general nurses and cover a minute percentage of the population.
2.5. The role of the local Church within the Health Care
Aware of this situation, which is particularly serious in the rural areas of Niassa, the Church has tried to find ways in which it could help to train hospital staff and provide health care to the population.
In this respect the Church has been able to accomplish a project which involves communal health clinics to provide basic health care to the rural population. The population built these clinics themselves, with local materials, some of them were renovated with bricks but always produced locally.
Presently, this project counts on 55 (+8) health clinics served by 82 basic health care agents, whose continuous training is supported by a team from the diocese which coordinates this same project.
The objectives of these health clinics are:
To provide sanitary education and to ensure basic sanitation; to attend to people and to give basic health care, namely supervising pregnant women and child health; to encourage the population to participate in the vaccination program and also to collaborate in the detection, treatment and the follow up of patients with leprosy and tuberculosis.
As it was impossible to reopen more differentiated health structures, as was the wish of the Episcopal conference, the Bishop of the diocesis in Lichinga has always fought for the presence of qualified Christian medical staff in the local health structures. They managed to have a religious nurse admitted in the paediatrics_ department of the hospital in Lichinga but, without the back-up of a team, she gave up after almost one year of work which she considered to be frustrating and extremely wearing.
So it was with great enthusiasm that the Bishop of Lichinga received the proposition from the FIAMC project which would place a team of voluntary health medical staff in Niassa, willing to work with the local medical staff, collaborating in the providing of health care, concerned about continuous training and available to collaborate in other tasks of the diocese.
3. THE FIAMC PROJECT
Right from the beginning the objectives defined by the project were the following:
3.1.1. To collaborate with the education for health of the population, connected to the aforementioned project of community health clinics and to the literacy program involving all the districts of Niassa, which is an initiative of the diocese financed by both Cáritas and by Miserior (two charity organizations). This literacy program uses a methodology which leads to a basic education and to development and covers training in themes such as:
- parasitic illnesses
- alcoholism and health
- sexuality and sexually transmitted diseases
3.1..2. To collaborate in the permanent training of the medical health staff and health agents, giving priority to areas of preventative medicine and basic care, female and mother-child health, paediatrics_ and neonatology, gynaecological surgery through the abdomen and through the vagina, namely the surgical correction of vasico-vaginal fistulas and of urinary incontinence with other etiologies.
3.1..3. To collaborate with, integrated in the local health teams, the providing of medical-surgical care, namely training the teams in the hospitals of Lichinga and Cuamba. Also to collaborate with the work of eventual mobile teams in order to allow for more efficient assistance of the population.
3.2 The three stages of the project
This project, concluded in December 2001, was developed in three stages.
3.2.1. First Stage
In the first stage we kept teams of three to five medical health staff in Niassa for eighteen months, involving a total of thirteen voluntary people, four doctors and nine nurses, who were there for periods of a minimum of three months without receiving salaries.
The providing of care was the main concern for all the teams.
These teams, integrated in the respective departments, made an effort to collaborate in the best possible way, not heeding work hours and always trying to find solutions in accordance with the existing conditions, making a permanent effort to merge into the local culture. They carried out their activities in all departments of the provincial hospital in Lichinga, in the health centre, in various district health clinics and also in the communal health clinics. Every time a training course brought together various Basic General Health Agents (known as APES - Agentes Polivalentes Elementares de Saúde), bringing a large number of patients who had been forewarned of the presence of the more qualified team and the observations of these patients was used to give a better training to the APES.
The women and children were the largest group of patients, therefore our main concern. For this reason we always kept one or two volunteers in the maternity and in the paediatric department of the hospital in Lichinga.
Our most difficult task was to change the behaviour.
The very young and insecure foreign doctors acted in a defensive manner, trying to make us believe that we were ignorant of the varied African pathology.
In gynaecology, laparotomies were carried out both when they were needed and when they were not needed, in unbelievable situations such as to carry out a ligamentopexy in a case of primary amenorrhoea attributed to uterine retroflection.
A great deal of diplomacy was needed to teach them to elaborate clinical histories and to establish diagnostic and therapeutic protocols with them, which were adapted to the local conditions, mainly in the specific areas of gynaecology and paediatrics.
In the same manner, we carried out corrections of the procedures followed during labour and of the surgical procedures done in gynaecology and obstetrics, which had been carried out with no respect for the anatomy and using techniques leading to a worsening of septic situations which were already bad enough due to the logistic situations.
In the maternity hospital, the care provided to the newborn child was practically non-existent, both immediately after birth and in the following hours, even if the newborn child had a low weight and/or if the mother was maintained interned further than the usual eight to ten hours. Tact and a firm hand were also needed here to change behaviour.
Following theoretical and practical training given to nurses, midwives and auxiliary staff, codes of practice were established for different basic procedures, mainly in the delivery room, in the paediatric department, in the emergency department and in the surgical wards.
Various actions were still developed with the view of education for health of the population, not only with the relatives of the patients in the hospital, especially in the paediatrics department, but also in secondary schools, in different neighbourhoods and on the local radio, especially because it was necessary to use every possible means to fight against the cholera epidemics.
3.2.2. Second Stage
In the second stage of the project, with the collaboration of the Portuguese Institute for Cooperation, it was possible to arrange internships in Portugal for two doctors and two nurses from the provincial hospital of Lichinga.
These had to be intensive internships with a duration of four months due to the fact that it proved impossible to substitute the medical staff at a local level.
One of the doctors did an internship in gynaecology-obstetrics where he was given various opportunities to learn about clinical and surgical procedures. He participated in a total of one hundred and one surgeries, eleven of which were via the vagina and seven for the correction of urinary incontinence, and he took the place of a surgeon in at least nine complete hysterectomies. Since we had managed to acquire a scanner for Lichinga, he was also specifically trained in the areas of gynaecological and obstetric scanning.
The other doctor did an internship in the Paediatric surgery department, which was in fact something that was extremely lacking in Lichinga.
He carried out the normal tasks of an intern in this specialized area and participated in one hundred and seventy surgeries, being the surgeon in thirty of them.
Both of these doctors participated in the training courses of the respective departments, being given the opportunity to present themes in the clinical sessions.
The two nurses, under the supervision of one of the Nursing technical colleges of Oporto, did an internship in medicine and surgery departments and participated in lessons at the college.
The objective of these internships was to give intensive training to medical staff who would become promoters of development in the health units of Niassa.
3.2.3 Third Stage
In the third stage of the project we kept teams of three to five medical health staff, again in Niassa, for nine consecutive months. This involved a total of ten voluntary people, three doctors and seven nurses, who were there for periods of between three and six months.
After a short stay at the hospital in Lichinga in order to evaluate the possible progresses and regresses and to strengthen the dynamics of permanent training implemented earlier and now under the responsibility of the medical staff who did their internships in Portugal, the team of voluntary people moved to the city of Cuamba in order to develop actions in the rural hospital of the city as well as in the health centres and communal health clinics.
In the rural hospital of Cuamba the situation was serious. In March 2001 the only Mozambican doctor posted to the hospital was a recent graduate, badly prepared and constantly travelling. A German surgeon, paid by an NGO, and a voluntary South African doctor saw to practically all the consultations, but were still subordinate to two medical staff, non-doctors, one in surgery and another in medicine, the latter having the role of district director of health.
In the paediatrics department, with twenty-four beds, an Angolan doctor, paid also by an NGO, worked irregular hours.
The surgical medical staff worker was hostile towards the German doctor_s work because he was paid for simulated operations.
He was the person responsible for the maternity hospital, with nineteen beds and an average of seven births per day, and for the gynaecology appointments as he only allowed the German doctor to act in these areas in emergency situations.
Both these medical staff workers had a large political backup so the provincial director of health did not have much control about the situation.
Only the fact that we had a previous experience and a strong motivation to help the people allowed us to dare work in such an atmosphere.
Even though our action covered the whole hospital, once more we gave more weight to maternal and child health and for this reason we always kept one or two volunteers in the maternity hospital and in the paediatrics department.
Similar to what we had done in Lichinga, through the providing of care and the implementation of the dynamics of continuous training, we tried to change behaviour in the accompanying of the birth, in pospartum and in the care of the newborn child. The revival of the newborn child was a matter of a specific theoretical-practical training from which the result making of codes of practice.
In the paediatrics_ department, right from the beginning, as well as the care given to the in and the out-patients, the constant training of nurses and auxiliary staff, the daily teaching of the mothers of interned children was carried out in subjects such as hygiene, nutrition, fighting diarrhoea and dehydration, respiratory diseases, namely pneumonia, and malaria.
It must be said that the teaching of the mothers was always followed with great attention and interest and motivated the enthusiasm of the nurses of the department themselves. These nurses then assumed a much more active role which in turn made communication with the women easier, as they were able to express themselves easier as some of the women communicated almost exclusively in the Macúa language. These women needed not only theoretical but also practical training, namely in the area of more nutritative food preparation.
During an epidemic of whooping cough, we participated in campaigns of disease detection, administration of therapeutics and vaccination in three districts of Niassa.
We also collaborated in the tetanus vaccination campaign, not only with the administration of the vaccine but also with motivation sessions, mainly in schools.
We collaborated closely with the coordinating team of the communal health clinics and participated in the training sessions.
Whenever it was possible to accompany the missionary team in their visits to the communities, namely in isolated places where the access to health care is delayed and difficult, we provided the consultations to the patients who had all been prewarned.
We also followed 277 children attending eight nurseries belonging to the parish of Cuamba.
4. SOME RESULTS
Although it is impossible to evaluate the statistics correctly estimating that around 14% of in patients referred to complications of a birth that had occurred outside, we can calculate that during our presence in the maternity units of Lichinga and Cuamba the mortality rate of mothers dropped from a ratio of more than 10/1000 to 1.6/1000;
the uterine ruptures dropped from a ratio of more than 6% to 2%;
the registered rate of stillbirths was 1.9%, where the usual calculated rates were above 5%;
around 95% of the births that we registered were dystocic and 10% were caesareans and also
the newborn babies with low weight were above 14%.
In paediatrics we found the most frequent pathology to be malaria, which made up 50% of interned patients and was the main cause of death, followed by pneumonia which made up 12% of interned patients. Cases of serious malnutrition made up 10% of interned patients. Meningitis, sepsis and neonatal tetanus as well as gastroenteritis were also a frequent cause for patients to be interned. We are perfectly aware of the improvement in the quality of the care given but we cannot present statistical data.
4.3. The project as seen by the bishop of the diocesis
The following is an extract from a letter sent by Dom Luis Gonzaga Ferreira da Silva in September 2001:
"As to the fruit that was harvested from the Project, it was surely an abundant crop. There cannot be many projects in Mozambique which have produced as much fruit as this one. Congratulations. I am happy about the collaboration given by the diocesis".
5. FINAL CONSIDERATIONS
5.1 The Importance of gratitude
We consider very important the fact that all the people who volunteered travelled there without any additional pay and only with guaranteed paid travel and board.
This fact allowed:
- a more perfect partnership with the local staff whose resources are minimal
- greater local credibility
- an easier merging into the local culture
- a better guarantee of strong motivation and dedication to the work
5.2. The footprints that we left
Given the complex situation described, we doubt that the health care staff who was trained are sticking to the most correct methods.
It would be necessary to extend this mission and, if possible, to recreate non-profit making private medical units, well run and where selected personnel could provide continuing education.
We are still sure that a lot of the teaching which we spread through the population has remained, as well as the memory of the love and attention which we put in the care that we provided. Some of our names were adopted as names for the children of grateful mothers.
In the African culture which consists so much of tradition, the doctors and nurses of this team of volunteers will be talked about on the verandas, in the sitting rooms of the houses, for generations to come.
We are also happy that we worked so much with women, and hope that the proverb of Niassa comes true:
"If you brought up a boy, you brought up a person; if you brought up a girl, you brought up a whole family."
And, in this context a family is so large that it spreads beyond the boundaries of a village.
Our thanks to :
- The Portuguese Institute for Cooperation (Instituto Português da Cooperação)
- The Portuguese Institute of Youth (Instituto Português da Juventude)
- Calouste Gulbenkian Foundation
- The Diocesis of Lichinga
- The Mission of Consolata
- The Parish of St. Anthony of Olivais in Coimbra
- Various benefactors