We all agree that the dog looks like Tin Tin’s dog, but nobody can remember his name. There is silence while we rack our brains, and suddenly Agnès blurts out ‘MILOU!’ Yes. Milou. In English translations of Tin Tin, he’s Snowy, but since my acquaintance with Tin Tin is based on summers spent in Brittany as a teenager, where my French host family had stacks of Tin Tin books lying around their rambling Breton farmhouse, to me he’s definitely Milou. And to Agnès too, since she’s French.
Milou is not new, evidenced by his dirty white and dishevelled coat, but he doesn’t look like he has been any child’s favourite toy yet either. He is a gift to the Luwingu project from an MSF Water and Sanitation Specialist, Paul Jawor, who has sent over 50 second-hand soft toys to MSF projects around the world. His instructions are always the same: to photograph the creature on location with a variety of exotic backdrops, and finally to award him (or her) to a deserving child. He plans eventually to compile the photos into a series of children’s books. So Milou accompanies us on a weekend away to Lumangwe Falls, a spectacular waterfall about 100km northwest of Luwingu as the crow flies. He swims dangerously close to the 30m drop, gets car sick on the bumpy roads and tries his first nshima, Zambia’s native cuisine. And then he is back on our bookshelf, neglected, and it is time to find that deserving child.
The deserving child I have in mind is Samuel. When I last saw him on 30th March, he was suffering from an ear infection, and he screamed in pain when the clinician looked into his ear with an otoscope. His CD4 count had come back as 479, indicating the need for him to start ARV treatment (children with CD4 of less than 750 should start treatment), however he needs to be initiated at the hospital in Luwingu, and last time Christina couldn’t take him because her mother, Joyce, was not well and unable to watch the remaining children. At this last appointment, Samuel was given Amoxicillin for the ear infection, but I regretted that his referral to the hospital for treatment was delayed by another two weeks.
So today, 13th April, I am determined that Christina will take advantage of a lift from Ipusukilo to Luwingu District Hospital in an MSF vehicle in order to have Samuel assessed for treatment. I accompany her to the consultation room, where she tells Anthony with a shy smile that she frequently feels the baby kicking, and she’s given another month’s supply of the combination pill (TDF/3TC/EFV), which she is taking at 7 o’clock every evening, and which we all hope is pulling up her CD4 count. Since the CD4 count typically only increases by 5 to 7 per month after the onset of treatment, her blood is not re-tested at this stage. She agrees with the suggestion to bring Samuel to Luwingu for assessment, and the two of them are bundled into the MSF vehicle along with another HIV positive mother, her baby and a young, very sickly looking daughter.
Christina is proving to be a perfect patient. To date she has not missed a single appointment, and she seems to be adhering to her treatment without any difficulties. Considering the problems we have faced (and continue to face) with defaulters, it’s gratifying that the first PMTCT (preventing mother to child transmission) patient I was introduced to happens to be this sensible and intelligent woman. Others have cynically pointed out that it may be the curiosity value of a mzungu at each and every visit which keeps bringing her back. Jeanie, less cynically (but quite unrealistically), wants to write me into our defaulter tracing strategy – she suggests that if every patient was given the individual attention that I have given Christina, then they would be less likely to default.
I’m not convinced. Two key elements of Christina’s personal circumstances mean that she was less likely to default from the very beginning, without me even entering the equation. First of all, she can access Ipusukilo rural health centre relatively easily by foot. MSF is supporting six other rural health centres (RHCs) in Luwingu District, and some patients have to walk many hours to reach the closest one. Considering that our PMTCT patients are either pregnant or have young babies, it’s not surprising that long distances on foot are an obstacle to their participation in the programme. Secondly, Christina has a supportive family. Although her husband is absent (ever since I first met her, she has always described him vaguely as being in the Copperbelt visiting relatives), her mother has opted to be her treatment supporter and lives with some of Christina’s siblings close by. We are losing an unacceptably high number of women because their husbands or other family members do not support their participation in the PMTCT programme, but fortunately this is not a situation faced by Christina. I know it’s wrong to stereotype, but I don’t relish the return of her husband in case he turns out to be yet another husband who blames his wife for her HIV status and forbids her to return to the clinic.
We have a number of strategies in place, and some more in the pipeline, to address the issue of women defaulting from the PMTCT programme. In addition to three MSF Counsellors, one per medical team, we also work with a network of Lay Counsellors, such as David Mapulanga, who are based at the MSF-supported RHCs. They are trained in HIV testing and counselling, and often they are the ones to disclose HIV positive test results to pregnant women. They establish a relationship of trust and a culture of confidentiality with the PMTCT clients. In some locations, the Lay Counsellors have established support groups for women enrolled in the programme and other HIV positive community members. New members benefit from emotional support from those who have accepted their status, who may provide the proof they need that an HIV positive woman can give birth to a healthy child, and that being HIV positive doesn’t mean imminent death – that with the correct treatment it’s possible to live a normal, healthy life.
In the case of defaulters, if a woman fails to turn up to an appointment, her name will appear on a list of defaulters, and it is the responsibility of the Lay Counsellor to track her down, find out her reasons for missing the appointment, and, if appropriate, counsel her to come back. If it is the husband or family who are proving to be the obstacle, then the Lay Counsellor can use the home visit to try and educate them on the importance of the woman’s commitment to the PMTCT programme, and the benefits of voluntary counselling and testing (VCT) for all sexually active individuals. Until recently, the Lay Counsellors have complained of the difficulty of reaching all the defaulters on their lists, since many of the clients live so far from the RHCs. For this reason, we have provided them with bicycles. While we do expect increased mobility of the Lay Counsellors to have a positive impact on the defaulter tracing, we cannot pretend it is a magic bullet – after all, it does not provide a solution to the lack of transport options available to the women themselves.
The issue of distance from the RHCs has been a concern since the early days of the project, not only for the women enrolled in the PMTCT programme, but for all women needing to access the sexual and reproductive health services on offer – including antenatal and postnatal consultations, family planning and safe deliveries. Most women in Luwingu do not plan to deliver in a health facility, because of distance but also because for such a long time the RHCs in this district have been without qualified medical staff. When MSF arrived in Luwingu in May 2010, there was only one qualified medical staff working in one out of eight of the RHCs in the district. In the early months of the project, MSF lobbied the Ministry of Health to allocate qualified staff to these centres, which resulted in at least one Nurse being posted to seven of the eight RHCs. The presence of qualified staff meant that we could start to encourage pregnant women to come and deliver at the centres, instead of in their homes. However, without confronting the issue of distance, this was an unrealistic expectation.
In January of this year, we started to pilot test the ‘Zambulance’ (photo below), a bicycle ambulance trailer. We donated eight of them, 700 USD a piece, to eight villages each between 15 and 25 kilometres from the nearest RHC, with the objective of transporting labouring women to the closest RHC. The Zambulances, which were donated to community ‘SMAGs’ (Safe Motherhood Action Groups), are having modest success (so far we know of 34 referrals), and we are currently considering whether or not to purchase more of them. Unfortunately, however, there are many thousands of women in Luwingu District whose homes are unreachable by Zambulance – either because of the distance or the condition of the road.
Which leads me to one of the strategies in our project pipeline: to establish a ‘Mothers’ Waiting Shelter’ at each of the RHCs. I remember a Midwife colleague of mine describing these to me last year in Haiti, but having never worked in a project which involved encouraging rural women to deliver their babies in health facilities, I failed to grasp the significance of what she was saying. A Mothers’ Waiting Shelter is a place where women who are in the last two to four weeks of their pregnancy can come and stay until they deliver, thereby ensuring that they will deliver with a health personnel in attendance. Certain women require a higher level of care during their delivery (for example if they have had complications during previous deliveries), so if they come to the shelter in good time, then they can be transferred to Luwingu District Hospital. During my time in Luwingu, I hope to see the impact that such a shelter can have in terms of the number of women choosing to deliver at health facilities rather than at home.
As for Christina, she plans to deliver at Ipusukilo RHC, just as she did for her previous three children. Although these were not in the presence of a qualified health staff (there was a ‘CDE’ in attendance, which stands for Classified Daily Employee, not medically trained but the stalwarts of the RHCs before the Ministry of Health posted qualified staff), she was still satisfied with the service she received. Her delivery will, more than likely, take place when MSF’s team is not at Ipusukilo (since this RHC is only 15 kilometres from Luwingu, we only visit on a fortnightly basis). This means that it will be the Ministry of Health Nurse or Clinical Officer (Ipusukilo is the only RHC in Luwingu with a Clinical Officer) who will be in attendance at her delivery. They have been trained on what to do if an HIV positive woman comes there to deliver; in Christina’s case, this will mean administering Nevirapine syrup to the infant as early as possible after delivery (and daily for six weeks afterwards), and ensuring that Christina continues taking her medication as normal. Christina also knows that the baby will need medication when he or she arrives. The delivery is the most dangerous time for the baby in terms of exposure to HIV, so it essential to get this part right.
Despite doing everything right, Christina is naturally worried about transmitting the virus to her unborn baby; but before he or she (she’s hoping for a she) arrives, her focus is on Samuel. When I present him with Milou before we set off for the hospital, he accepts him warily. By the time we arrive, however, he is clasping hold of him tightly, as if he never wants to let him out of his sight. While a man at the hospital starts to ask Christina questions, neatly filling out the first of what I imagine will be dozens of papers about Samuel’s health over the next few years, I am for the first time ever witnessing him behave like a child. I’m not attributing this to Milou, or to myself, I’m just delighted to finally see him smile and giggle, turn round and round in circles, jump up and down, organize empty pill boxes on the window sill and then knock them all down, and just generally entertain himself. Unfortunately, these moments are short-lived, since Samuel needs to have blood taken for a series of tests that are required before he can be initiated on treatment. While the handsome Laboratory Supervisor, Mr Bwalya, breaks out into a sweat trying to locate a vein on his chubby hand, Samuel is once again screaming and crying, this time repeating over and over ‘Nakana! Nakana!’, which Mr Bwalya wearily translates as ‘I don’t want’ in Bemba.
On the same day I am privileged enough to see Samuel enjoying carefree, childish moments, I also realize that it is the first day I have seen Christina looking really, noticeably pregnant. In fact, she is now enormous, invigorated and blooming. Today she has brought me a bucket of groundnuts from her own harvest, and as she picks at them and tosses the shells over her shoulder, I wish I had the words in Bemba to tell her how beautiful she looks.