Working in MSF, I have the privilege to work with some extraordinary individuals. Since arriving in Zimbabwe, I have been fortunate enough to be working alongside one such medical professional, Zakariah Mwatia, the outgoing project coordinator in Epworth. Same as many of my colleagues, Zak carries his passion for humanitarian medical work with a quiet serenity and dignity that, until you get to know him better, could be mistaken for shyness. As he’s moving on after 2 years and 8 months in Zimbabwe, I took the opportunity to persuade him to share some of his experiences. Here’s an account of our conversation.

Paul: “I know you, Zak, as Epworth’s project coordinator, and we’ll get on to that later. But the period before MSF is an interesting place to start, so what’s your background?”

Zak: “I grew up in a rural town called Kakamega, which is in Western Kenya near the border with Uganda. Between 1993 and 1996 I trained as a Registered Community Health Nurse, and was then sent by the Ministry of Health to Northern Kenya where I worked in progressively more responsible positions in hospital ward supervision. I relocated to the District Hospital in 1999, where I was promoted to District Nursing officer, responsible for supervising 21 rural health clinics.”

Zak with a patient at a therapeutic feeding centre

Zak with a patient at a therapeutic feeding centre

Paul: “When did you first come across MSF? Tell me a bit about your experiences before coming to Zimbabwe”

Zak: “In 1998-99 there was an episode of extreme weather in Kenya which caused unexpectedly high incidence of Malaria and also severe malnutrition. I was seconded by the Ministry of Health to MSF for a short time to work in a nutritional centre in Northern Kenya. I had read about MSF before that, when I was studying nursing, but this was the first time I saw MSF in action. After that, in Nov 2004 whilst on holiday from my job as DNO, a friend called me to say that there was an opening in South Sudan for a nurse supervisor with MSF. I applied by telephone, and was invited for an interview in Nairobi the next day. The next 72 hours was a bit hectic – the only quick way to Nairobi was by air, but I was half a day’s drive from the airport, and there was no bus. So I hitched a ride, dressed for the interview, in the back of a truck transporting goats to market, only to discover when I arrived at the airport, that the plane was delayed by six hours. Arriving late for the interview, I was seen anyway, and offered a 12 month contract, starting immediately – it was a nutritional crisis, and they wanted me to travel as soon as possible. I gave my notice to the hospital, packed a few things, and flew to South Sudan. It took three days, from leaving my home in Kenya for the interview to arriving in the project in Sudan and being put to work in an extremely busy nutrition ward.”

“South Sudan was extremely challenging, but also very rewarding. In the first project we saw a huge number of malnourished children – up to 40 new admissions every day – in the therapeutic feeding programme. I followed on with another 1-year contract from ’05 to ’06, where we saw cholera and Kala Azar spread across a wide area. I was an outreach nurse, and the team would go on walking clinics, away from the base for days at a time, carrying all the drugs and equipment on donkeys. Then, for the next two years, I was based in a number of large hospital projects, always working in extremely busy wards, and always learning more and more about good management in MSF programmes. In November ’08 MSF sent me to Geneva to do a specialist training course in the clinical management of HIV / AIDS and then, after a short break back home in Kenya, I came to Zimbabwe in March 2009.”

Paul: “So what is it that makes you spend so much time away from home – what is it about MSF that you like that much?”

Zak: “I’m a nurse. It can be a challenging profession in Africa, because you may have all the necessary knowledge, yet still you find obstacles to doing a good job due to scarcity of resources. When I worked in Kenya, people would suffer due to the lack of basic things – drugs, equipment, medical items. MSF put a simple solution to this very basic problem in front of me. When you have all the necessary resources to use your skills, it is very gratifying. When you see a child with severe malnutrition, it is very disturbing; it’s hard to look on the suffering brought about by lack of good food, where the child’s system has actually started to break down its own body tissues. But with the right treatment, the change is incredible – when a child that seemed only a moment away from death smiles for the first time only two or three days after treatment started – when you see them running around a couple of weeks later – that’s the motivation. Whether malnutrition or HIV, whether adult or child, the transformation that happens when the right course of treatment is given to someone that was on the verge of death is extremely rewarding, addictive even. I want to see it again and again.

Paul: “More than two and a half years working in Zimbabwe – you must have seen quite some changes in the project. What do you think has been its biggest success?”

Zak: “Scaling up access to anti-retroviral Therapy (ART). When I started here, we didn’t have the capacity to treat everyone that needed ART – we had to limit treatment to pregnant women, people co-infected with other illnesses, and the very sick. Setting boundaries to treatment caused all sorts of problems. It was clear that a different, more inclusive approach was needed. When we started to scale up access to ART, the results were initially chaotic and challenging. The community began to understand that the programme was for everyone, and people were bringing their relatives in wheelbarrows and on beds – we had huge numbers of extremely sick patients. Now, more than two years on, when I see them walking into the clinic for a regular check-up and to collect their drugs, it’s very rewarding.

Paul: “What would you say to the individual donors of MSF – the people whose private gifts support MSF?”

Zak: “Together, we are doing a good job, giving hope to the hopeless, reducing the number of orphans by saving parents’ lives; that means fewer broken homes, fewer children in poverty. Our intervention breaks the cycle of despair. I look at people on ART, two or three years on, taking their children to school, going to work – donors’ gifts have gone so far towards restoring the dignity of people in Epworth.”

Zak with Minister for Health & Child Welfare, the honourable Dr. Henry Manzonera at the opening of the Overspill clinic

Zak with Minister for Health & Child Welfare, the honourable Dr. Henry Manzonera at the opening of the Overspill clinic


Paul: “So what’s next?”

Zak: “A good rest! I’ll take a week or two on holiday, and then I’m going home to see my family – to attend to some family business. In the New Year there’s an MSF training course that I have applied for, and then by March 2012 – another MSF mission – more to learn – new opportunities – let’s see.”

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World AIDS Day I

World Aids Day – December 1st, 2011 – a day on which the slogan, “Getting to Zero” is meant to have some resonance. Zero New HIV Infections. Zero Discrimination and Zero AIDS Related Deaths. Let’s have a look at these noble ambitions one at a time in the Zimbabwean context.

Start with the last one – zero AIDS related deaths – that would be brilliant for Zimbabwe. It would be quite a journey, because in 2009 (the last year for which figures are available) 83,000 people died from AIDS. There are two ways to stop people dying from AIDS; the more costly, in terms of human and financial resources, is to put them on treatment – anti-retroviral therapy (ART) – for the rest of their lives. The cheaper way to prevent AIDS deaths is to make sure that people don’t catch the virus in the first place. Neither response works alone. Prevention and treatment have to go hand in hand. MSF chooses to concentrate the majority of resources on treatment, because that’s what doctors do best – that’s what we’re here for. So zero AIDS related deaths in Zimbabwe means that, by direct intervention or by advocacy or by system support, we have to double the number of people living with HIV on treatment – and then double the number again. Today there are around 300,000 people in Zimbabwe on treatment and around 1,200,000 people living with HIV, all of whom will eventually need the best treatment available if we’re going to prevent them from dying of AIDS. That’s quite a tough challenge.

Zero discrimination – that should be a little easier – let’s see. At the local level we’re trying to challenge discrimination. One of the best methods is by integration – we no longer run HIV / AIDS facilities as such, we run health facilities where HIV infection is one of the conditions catered for. It’s not easy in a country that has an overall shortage of doctors – the wish to roll out an integrated healthcare system is severely constrained by lack of resources, human and financial. Whilst the stigma has reduced along with the prevalence rate – from 23.7% HIV prevalence in 2001 to 14.3% in 2009 (according to UNAIDS) – restrictive practices remain. The intent is there, but putting national policy into operation is still some years off – an integrated response to HIV remains a distant target. So we strive to eliminate discrimination, but it’s like turning a super tanker – you make the necessary adjustments, but it takes an age for the effect to be seen.  Is discrimination at the local level the only challenge? What about the international response to HIV AIDS – is that inclusive and open and fair, or is it also discriminatory?

We heard with dismay last week that the Global Fund Round 11 was cancelled. The massive leap forward in HIV treatment worldwide that has been delivered by Global Fund projects is mirrored in Zimbabwe. Although MSF funding is separate, we link into a great deal of capacity that is Global Fund initiated or supported. The scale-up that currently sees nearly a third of a million Zimbabweans supported with ART is supported by government, NGO & international institutional funding, the majority of which comes via the Global Fund. So why the reversal of policy? What has happened to the promises? A look at an article by Jeffrey Sachs in the Huffington Post may go some of the way towards explaining it – the reluctance of the US – the largest contributor to the Global fund – to deliver on pledged funding.

Nairobi Hands Off protest

Hands Off protest in Nairobi

“The Obama Administration had pledged $4 billion during 2011-13 to the Global Fund, or $1.33 billion per year. Now it is reneging on this pledge. For a government that spends $1.9 billion every single day on the military ($700 billion each year), Washington’s unwillingness to follow through on $1.33 billion for a whole year to save millions of lives is a new depth of cynicism and recklessness.” Where the world’s largest economy leads, the others follow – see this report from the Access Campaign on how the European Union is trying to protect its trading interests via protectionist pressure on India – the manufacturer of choice for most of the HIV drugs used in Zimbabwe.

I characterise the actions of the US and the EU as extremely discriminatory. No doubt there are all sorts of internal political excuses for the US to re-think its funding strategies towards the life-saving objectives of the Global Fund, just as there is going to be justification from the EU for opposing the production of essential affordable drugs in India. But consider this definition: DISCRIMINATION – treatment or consideration of, or making a distinction in favour of or against, a person or thing based on the group, class, or category to which that person or thing belongs rather than on individual merit. Both these decisions are being made, despite promises to the developing world, earnestly made in repeated rounds of high-profile international forums, on the merit of millennium development goals and development assistance targets, because the donor prefers to discriminate against the silent HIV positive majority and in favour of the vociferous few that demand political favour irrespective of morality.

Looking to the third World Aids Day ambition – zero new HIV infections – I wanted a different perspective, so I called on a well-known character in Zimbabwean civil society. Catherine Murombedzi is a journalist for Zimbabwe’s largest selling daily newspaper – The Herald. Catherine is living positively, and writes a regular column about the effects of HIV on Zimbabwean society. So I thought, “An interesting twist – the foreigner asking the journalist for a story – and who better to ask than Catherine.” So I asked her what she thought was the most important message for World Aids Day – she said, “We need to ask ourselves what we are doing to limit the disease. Are we doing enough to prevent the spread of HIV? We know that we can’t afford to treat everybody, because of the failure of donors to deliver on their promises, so increased awareness and advocacy is the affordable option. We can’t afford to think about the implications of the Global Fund decision; we just don’t know what it will mean. I am shocked that world leaders are so easily reneging on their promises. Please – to everyone – we need to do our best to minimise infection – and sustain treatment – our lives depend on it.”

The title of my blog is Positive Thinking because I’m surrounded by remarkable stories of ordinary people all linked together in Zimbabwe by their shared experiences around the HIV AIDS pandemic. I’m struggling to find the positive in this post, but it’s there. In amongst all the international funding idiocy, the bad politics and the broken promises, there are glimmers of hope. The ordinary people of Zimbabwe, so many of them living with HIV, get up and take their tablets and take their kids to school and attend the health clinic – for now – supported by the complex mechanisms that convert cash from the world’s richest countries into life-saving drugs and health messages here in Zimbabwe.  I’m positive because MSF continues to bring some sanity to this international circus. I’m positive because stupid political decisions are always reversible – we can lobby and blog and celebrate the positive lives of our patients in the expectation that sanity will prevail. It’s our moral duty. After all, governments are short-lived, but HIV is for life.

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World AIDS Day II

Supreme respect to our MSF colleagues in Barcelona who, despite going through a tough time, still managed to roll out this initiative, , which celebrates the good in Zimbabwe – an eclectic cultural kaleidoscope of music and commentary that looks forward with hope to an HIV free generation.

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I’ve been on holiday, so blogging wasn’t high on the list of priorities. That’s the excuse; here are one or two thoughts that didn’t involve much effort, but are still relevant.

I blogged about the Jacarandas in ‘Today’ and on Oct 20th Tracy Dunn commented, “…like those jacarandas of my childhood. They are very old now, and I wonder how long Jacarandas live.” Good news Tracy, I was walking along Chinaman again this morning, and some community-minded people are planting tiny Jacaranda saplings, each barely 50cm high, between each of the ancient trees all along Chinaman. A positive contribution for future generations!

This reminded me of a proposal for Zimbabwe tree planting day, which will be in early December this year. We have now opened the new clinic at Caledonia Farm (more about that soon), and I commented to our team about how desolate a place it seems – all the trees have been cut down, and there’s nothing but a lonely isolated clinic on top of a dusty hill. “Let’s plant trees on Zimbabwe tree planting day,” someone said. So plans are still sketchy, but the team’s little private initiative is to plant 50 trees around the perimeter of the new clinic compound. Hopefully in 50 years time, patients of the clinic with a more positive future will be sitting in the shade of Jacarandas planted by the nurses and doctors of MSF in 2011. I’ll keep you updated.

Thinking about special days, it will be World Aids Day soon, an especially poignant day for Zimbabwe. We’re hoping to do something special to note the passing of this day, and the hope for a better future for all people living positively with HIV in Zimbabwe and across the world. Watch this space.

Finally, we went to bed as usual last night. I woke up this morning with an older woman. Happy Birthday, Sarwat; age comes to all of us, and you wear it better than me – stay positive!

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Zimbabwe is a tough country. Even so, life goes on. But sometimes it’s not so easy to keep a positive outlook.

The first time I was really confronted by loss in my humanitarian career was March 1994 in Mostar, Bosnia Herzegovina. There was a small public garden in a sheltered part of the city that had been transformed into a make-shift graveyard – dozens of markers all bearing the date of birth – graves of people in their twenties and thirties – and the date of death, some time in the previous three or four months. The sense of loss was profound. So many young people in such a short period of time.

In the three or four months since I arrived in Zimbabwe, MSF and its team of workers has endured a considerable loss. Just after I arrived, a lab scientist in one of the projects died. Then, a counsellor succumbed to a brief illness and died. Then one of our cleaners died. She had lost her sister only a month before and so had taken in her eight-month old nephew, who was otherwise an orphan. Now their seventy year-old mother is the only care giver for the child, having lost two daughters in two months. One of our drivers lost his brother. Another colleague lost a six month old child. Yet another colleague; his wife and best friend were killed in the same road accident.  I can count three direct employees and at least seven close relatives in the past three months, out of a staff of some three hundred.

The HIV prevalence in Zimbabwe has gone down in recent years. Some people say the reduction is a testament to improving prevention measures. I’m not so sure – the number of funerals that people in our small MSF staff team have attended in the past three months suggests otherwise. Untreated – AIDS kills. Perhaps that accounts for the reduction in HIV prevalence. And it’s not just AIDS that is the killer – this isn’t a good place to have an accident or get sick. At least half of these deaths were in public hospitals. Healthcare is uncertain in any circumstance, but very much more so here. Back home I would have expected a better outcome in the majority of these cases.

Humanitarian assistance is not an easy job. Don’t think that seeing the world and meeting people as an aid worker is like a pleasant walk in the park. Bosnia was a real shooting war, too close to home, and not fought according to any rules or laws or norms of society. But even though brutal and unregulated and horrific, it wasn’t as lethal or destructive as HIV has been in Zimbabwe. It’s not just the countless direct victims of AIDS, it’s the knock-on effect.  Health workers are dying. The combined effect of the HIV pandemic and the economic crisis means that health workers earn more in neighbouring countries, so as the hospitals become ever more packed with patients, they are depleted of trained staff. Death is ubiquitous. Funerals – a weekly occurrence. MSF treats tens of thousands of HIV patients in Zimbabwe with anti-retroviral therapy – more than 42,000 at the last count – but it’s a drop in the ocean with more than 1,200,000 people in the country living with HIV, the majority receiving no treatment at all.

I ask people how they cope. They say, “Life goes on.”

As I said, Zimbabwe is a tough country.

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It’s daylight, so it’s probably time to get up. I look at the ancient Nokia cell phone that doubles as an alarm clock, and it’s five to six; time to get started. I cancel the alarm before it goes off, switch the phone off and chuck it in the drawer. Washed, dressed, breakfasted, two cups of tea, and I’m out of the door by 6:45. The walk to the office is about two miles – at a leisurely pace it takes just over thirty minutes. It’s an opportunity to think about the day ahead. I know I’ve got two appointments away from the office, and we’re hoping for good news about the negotiations to start clinical HIV services in a new location called Caledonia Farm – but we’ve been hoping for good news for a long time now, so it’s a matter of stoicism and perseverance, rather than a cause of optimism.

The majority of my walk takes me down Josiah Chinamano Avenue – Chinaman to the locals. It is in a central Harare suburb called The Avenues. It was obviously laid out in colonial times with streets running north south – I live in an apartment on Eighth Street – intersected in a grid pattern by wide avenues lined on both sides by jacaranda trees. It’s spring in Zimbabwe, and the jacarandas are in full flower. As I’m walking down Chinaman, I’m suddenly struck by the breathtaking splendour of the view; a violet carpet of fallen jacaranda blooms underfoot and an arched canopy of the most unearthly beauty. In an impulsive move, I whip out my MSF cell phone, and after a bit of fiddling about (I’ve only ever used it as a phone before), I take a snap. I review it on the tiny screen, and it looks OK. I’m sort of pleased with myself – my daughters would be proud of me – multi-tasking with a telephone!

Jacarandas on Chinaman

Jacarandas on Chinaman

Actually, the cell phone priorities are different in Zimbabwe. The one I have is a model previously unknown to me made by the Chinese company, ‘Baobab’. It does all the essential cell phone things like texts and calls and all that, but it also contains two SIMS. This is high on the list of priorities here, because the networks are somewhat unreliable due to factors that include the intermittent electricity supply across the country. As power goes off and on in different neighbourhoods, so do the cell phone transmitters; having access to two networks in one phone doubles my chances of staying in touch.

The early morning tour of the office includes a round of greetings – this is socially an important part of life and just plain good manners in Zimbabwe. I’ve already exchanged greetings with numerous people walking down Chinaman – newspaper boys, phone scratchcard sellers, street vendors setting out their tomatoes and bread rolls and bananas on their pavement stalls; “Hello, how are you?” How was the evening?” How is the morning?” Fine – how are you, too?” Along with the general greetings, staff compare notes on who had electricity last night, and who cooked the evening meal or breakfast or both by candlelight. I like this country – the politeness is genuine. People are truly considerate of each other, and however tough life is, people seem to be able to retain a positive outlook.

I jump into the car at about eleven, and exchange small talk with my colleague Philomena and the driver, on the way to our first appointment. This morning we’re meeting with Childline. It’s modelled on the Childline that I’m familiar with in the UK, and they are affiliated to the UK charity, but they’re an independent Zimbabwean organisation, managed by and for Zimbabweans.

Philomena knows the manager of Childline, and they chat about things in general, about a few mutual friends, and about recent meetings. Then we talk about what they’re doing in Harare and across the country. Their main activity is running a helpline for children to call and get some advice or support or just a sympathetic ear. The level of child abuse is alarmingly high; they receive thousands of calls per month. I’m shown the call centre – there are three people on phones, and it’s clear that just as one call ends, the telephonist takes another; it’s non-stop. In addition to the helpline, they also run drop-in centres for children, and this is what is of interest to MSF.

As part of our medical project in Epworth, we offer treatment to victims of sexual violence. This ties in with the theme of medical responses to HIV / AIDS, because if a rape victim is given the correct medication within 72 hours of surviving the attack, their chances of becoming infected with the HIV virus are greatly reduced. In a country with double digit percentage prevalence of HIV, this precautionary prophylaxis is essential. But putting rape survivors in contact with the medical services offered by MSF within 72 hours is a real challenge, and this is where Childline comes in. Through their helpline they have become well known to children and adolescents all across Harare, and especially in Epworth, which is part urban suburb, part encampment, part shantytown. It is an extremely poor neighbourhood, with all the associated social problems.

It is clear that we could probably be of use to each other. Childline have contact with some of the most vulnerable children and young adults in our area, and MSF has the knowledge, expertise and capacity to offer medical support to rape survivors. As the conversation continues, I realise that we have similar approaches. Both organisations share a clear vision of what needs to be done to support the most vulnerable people in society; their clients are our patients and vice versa. We need to collaborate.

But it’s not just the similarities between the two organisations that strike me during the meeting; it’s the differences as well. As we’re getting into the car, I comment on this to Philomena. We’re so lucky in MSF – we are able to turn our full focus onto the patients, because our funding is independent. The manager of Childline has to do the rounds from embassy to UN meeting, talking to representatives of international donors and crafting her projects and reporting formats to fit in with their political agendas or development priorities or the current ‘flavour of the month’ dictated by the foreign policies of the governments that offer the funding. Due to our high profile internationally, and the depth and breadth of individual donor support, and due also to the very principles of MSF, my job doesn’t include doing the rounds in Harare touting for funding.

We chat about which came first; independence of action or financial independence. That’s one for the MSF historians. I know that in the 70s doctors worked for nothing because they sought independence; they reacted against the received wisdom that humanitarian aid was delivered in silence, so the first MSF doctors struggled by whatever means to treat patients and bear witness at the same time. I am very pleased with the results of MSF’s history because, due to our insistence on sticking to our principles in the past, I’m not tied to the agenda of any international funders, and my time is focussed on managing the programme and finding the best angle of approach for our patients.

The next meeting is with an international organisation. It’s a reception for a new head of office, and it’s been in my diary for a couple of weeks since the invitation arrived. I think about my priorities; they do not include meeting with all the representatives and ambassadors and charity executives that will no doubt look on a Friday lunchtime reception as an opportunity for an early weekend. There’s a lot still to do this week, so we decide to cut the meeting and head straight back to the office. Anyway, while we were in the meeting, I received a text that there was news about our planned project on Caledonia Farm. Maybe we’ve finally broken through the bureaucracy and received the OK to set up the new clinic.

Back at the office and the anticipation of good news was again premature. We had originally approached the project, as always, from the perspective on need. This is a settlement of approaching twenty-five thousand people that has no clinic, so our argument was that they needed health services as a priority. The original suggestion was to start as a satellite to Epworth, some three or four miles away, but this wasn’t acceptable. The local council wanted their own dedicated services in a purpose-built clinic, but City authorities were nervous of the interpretation that could come from offering formal healthcare in an informal settlement. The good news is that the local council had agreed to MSF starting clinical services in a temporary building – a pre-fabricated two roomed hut could be in place within a week, so we’re getting quite excited about the prospect of start-up. But still the excitement is premature – another round of phone calls reveals that a temporary structure needs different permits and certificates, so we start the next round of negotiations, which continue until the City offices close for the weekend at five pm.

It’s dark by the time I get home. Time enough to rattle out a record of the day on the computer and while it’s on, I hook up the cell phone that took the picture of the jacarandas. I can see from the results that, as a camera, it’s only really good for making phone calls. Oh well, I’d better not get too boastful about my mastery of technology!

The two SIM Chinese phone is on the bedside table – great for staying in touch 24-7, but now I know it’s no good as a camera. I get my old faithful Nokia out of the drawer, switch it on and set the alarm. It beeps immediately – there’s a text. It’s my emergency means of contact with home – a UK mobile that’s cheap to receive texts – how exciting – a text from the family, perhaps. I switch the light back on, find my glasses and display the text. It seems that O2 are offering me a special deal on tickets for the Olympics if I top up regularly – no thanks!

It’s been a funny sort of day – room for optimism, a chance to meet people, some small excitement and a little disappointment. Sadly, as a manager in MSF, it’s not always about meeting the patients and seeing the direct benefit every day, but it’s still gratifying that I’m working for an organisation that places the vast majority of its volunteers on the front line in the clinics and hospitals and facing patients in need every day. I believe in what we do, I relish the independence that MSF enjoys, and the role that I have ensures that the MSF doctors and nurses do exactly what we promise our supporters. I’m very happy to be working for an organisation in which I can believe.

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My name is Paul Foreman and I want to blog about the people of Zimbabwe.  I’m head of mission, so I spend much of my time close to government officials and sitting in meetings, but nevertheless there are extraordinary people all around – it is the contact with the ordinary people in our programmes, even if less frequent than I would like, that fuels the spirit and keeps the mind alert through too many complex negotiations and management meetings.

There are various stories about why MSF built a new clinic in Overspill, Epworth, and really they’re not all that relevant. The love in Zimbabwe for literal nomenclature says it all; a place that is officially named Overspill has a clear origin and purpose, and there was no clinic. Epworth is referred to as a ‘peri-urban’ suburb of Harare – implying (I assume) that it’s peripheral. That’s certainly true – it has grown out of the rocky hills about 15 km to the south-east of downtown Harare. Population of somewhere between 165,000 (the 2002 census figure ) and 420,000 – the upper estimate from some local officials who maybe have a vested interest in talking up the numbers, it is a cheap dormitory town where 10 dollars (US) per month will rent a room. The population of Epworth is mostly transitory – migrants from rural areas that seek employment in the city, or who are passing through, or who favour a residence with no official address, no street names, no house numbers.  Epworth is a tough neighbourhood.

We’re not really renowned for our construction skills – MSF is an organisation of doctors. You don’t automatically identify MSF with great building projects. I’ve built many a temporary structure in my nearly ten years with MSF, but as an emergency organisation we generally leave the long-term development to other organisations and just get on with the medicine. However here in Epworth, we’re providing an emergency intervention that has all the hallmarks of a long-term project, and it wouldn’t work any other way. Poverty – migrant population – recent urban shanty-town – large numbers of young men taking advantage of the anonymity of an as yet ill-defined cityscape – this is fertile ground for HIV infection.

We’ve been working in Domboramwari Polyclinic since 2006, we have 12,000 + registered HIV positive patients in Epworth, more than 9,000 of whom are on Anti-Retroviral Therapy (ART). Domboramwari is the Shona word of ‘footprint of God’, referring to one of the many huge granite outcrops that litter the landscape on which (so it is said) the faithful can see the footprint of God. However, the locals aren’t necessarily so hot on all that, so they just call it ‘Dombo’.

So Epworth became overcrowded – the urban sprawl went beyond recognised boundaries – a new ward of the suburb is born out of necessity – call it Overspill. Although part of the same suburb, it’s almost 5 km away, so it needed a clinic of its own. And the polyclinic was getting so congested that we could hardly see how we were going to cope with the ever-increasing numbers – on a busy day up to 600 patients queuing at Dombo Polyclinic for HIV testing, ART prescriptions, treatment for infections associated with HIV, lab tests, ante-natal care, psychosocial counselling, and many more therapies. So a new clinic would serve at least two purposes; along with the benefit of delivering good quality medicine in a good quality structure, it would relieve congestion at the Polyclinic and it would decentralise treatment – one of the planks of a country-wide strategy to roll out HIV treatment in Zimbabwe. Put this way, it seems quite rational for MSF to build a brand new clinic in Overspill. But as I have said, there are many stories about who said what, how different parties influenced the decision, and why MSF proposed, designed, funded and in fairly quick time built the fabulous new health clinic at Overspill.

I arrived in Zimbabwe a couple of months ago – when the Overspill clinic had already been completed, and it was being furnished, equipped and made ready for work. As I said, I’ve been around with MSF, having worked in countries in Africa, the Middle East and Central Asia as Head of Mission. Zimbabwe is a new challenge; one that we’re still adapting to in MSF. HIV is an emergency in Zimbabwe, but it’s an emergency that needs a lifelong solution.  By establishing mass treatment programmes, MSF has built on an approach that establishes the right to free treatment for HIV with ART. Now we need to demonstrate that the new approach works across the whole country. So Epworth has to evolve from a centralised programme, where the MSF expertise underwrites free access to HIV care. The evolution has to take into account the ongoing need for ART for thousands of existing patients and the need to diagnose and initiate new HIV patients into the ART treatment programme, but using progressively less technical methods and fewer resources. Otherwise, we’re creating an insurmountable challenge in the long term for MSF.

An opening ceremony for Overspill Clinic was meticulously planned. The Minister himself would cut the ribbon and unveil a plaque. So there was lots of tension; whilst it was potentially a good PR opportunity for MSF in Zimbabwe and a chance to promote strong health messages, the whole event would hinge on our ability to bring order out of chaos. It was a bit nerve-jangling for me because however many good speeches have been previously made and senior officials met and complex public events planned, it only takes one mistake to spoil the party.

Opening ceremony

The opening ceremony

The day came, and the running order was established. All foreseen disasters would be avoided, and unforeseen ones would hopefully not occur. The minister was fashionably late – about 45 minutes – but put everyone at ease fairly quickly by making it clear that he wasn’t in a rush and so the programme wouldn’t have to be cut. We gave the minister a tour of the clinic, and he was extremely engaged in the details of our programme. He asked technical questions, and our doctors excelled themselves in their answers. The minister, a doctor himself by profession, dispensed ARVs to some of the patients before making his way to the stage for the speeches.

Our theme for the opening was ‘positive living’.  We promote living positively as a means of breaking the taboo and reducing the stigma around HIV. It’s a disease that’s still discussed in hushed tones in certain circumstances; having public figures being tested and singing about HIV on stage and having government ministers dispensing medication all goes towards de-stigmatising HIV. So in this vein, we asked one of our patients – the star of the day, in my eyes – to make a public statement about living positively.
His name is Adam Black. We explained to him that there would be at least two hundred people there and that he would be asked to tell his story to the minister and assembled audience. He was willing; enthusiastic, even.  I met Adam earlier, and he explained his presentation to me. He seemed quietly confident, and he’d even brought along one or two props in his pocket – a true artist – fully prepared for an audio-visual performance. In fact the crowd was nearer a thousand, and I was worried that our speakers would be intimidated by the event. Adam stood in front of the microphone.

He took a small rock from his pocket and held it up.

Adam holds up the flower

Adam Black holds up the flower

“When I first had HIV,” he said, “my heart turned to stone. I was too sick to walk – my wife left home – I was sure I was going to die.”

“I tested positive 2 ½ years ago, and I had stone in my heart. But then MSF put me on ART and I felt better – I moved from my bed to a wheelchair to my feet, and then back to work. My wife came back – she tested – and now we’re living positively together. My CD4 count (I’m not going to explain the technicalities – just be impressed by Adam’s knowledge! – PF) went from 170 to more than 550; I went back to work and the stone left my heart.”

Adam now dramatically casts the stone aside and pulls a red and white flower from his pocket.

“This colourful flower represents my life now – beautiful and varied. I’m member of different support groups, and I tell my fellow citizens now to go and get tested…” And then a white flower emerges from the same pocket, “…and this flower is MSF – it saved my life, and it’s pure and good and clean.”

It’s a tough act to follow! Living up to Adam’s image of MSF isn’t going to be easy. But he’s a natural guy, and his story is his own, visual effects included. And it’s a story that came from his now not stony heart!

Thanks Adam – you’ve given me this month’s motivation for another round of management meetings!

Posted in Head of mission, HIV/AIDS, Uncategorized, Zimbabwe | Tagged , , , , , | 8 Comments