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.
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.
“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!