That was 15 years ago. Today, clean water in the small communities of El Recuerdo and Agua Zarca is as precious as ever—and still hard to get. There's no turning on the tap over a kitchen sink and letting the gallons gush. Here, many people trudge to a communal source, fill their jugs, and lug the heavy load home again. But seasonal flooding—sometimes hugely destructive and, with climate change, possibly becoming more severe—contaminates many of the area's hand-dug wells, exposing people to waterborne illnesses.
But now, with the help of Oxfam America and its local partner, PROVIDA, the well that Cruz worked so hard to dig on the school grounds in El Recuerdo is pumping enough clean water to satisfy the drinking needs not only of the students but of about 80 families in the surrounding area. The well is one of five "healthy wells" in southern Zacatecoluca province PROVIDA lined, surrounded with a filter, capped to ensure its cleanliness, and outfitted with a pump that sends water to a large tank for chlorination and storage.
"The families in this area are living in extreme poverty, living as subsistence farmers or low paid day laborers in the nearby sugar cane plantations," says Karina Copen, an Oxfam humanitarian program officer. "They face numerous challenges in having to adapt to the increased frequency and intensity of the flooding in their area. With access to a healthy well, they can at least know that in the next flood, they will have a safe source of water for their families and the good health that comes along with it."
Adaptations, such as these healthy wells, are essential for Salvadoran families living in the department of La Paz in the lower region of the Lempa River where seasonal rains, tropical depressions, and hurricanes, make it one of the country's most flood-prone areas.
Coupled with those natural hazards is the fact that communities in the region have significantly less access to improved water sources and sanitation than other parts of the country. The "healthy wells" along with 27 new composting latrines have been a boon to families in the area.
"Kids are getting sick less; families are healthier," says Santos Efrain Coto, one of the local leaders in El Recuerdo. "When they drank contaminated water they got diarrhea and parasites."
The improved wells are based on a model that's new to El Salvador and designed by an organization called Swiss Labour Assistance. Besides having their tops sealed with cement to prevent polluted flood waters from slopping in, the wells are lined with a type of plastic pipe, known as polyvinyl chloride, or PVC, that extends down into the aquifer. Packed around the outside of the lining is a filter of volcanic rock that prevents contamination from seeping through underground.
At the El Recuerdo school one day recently, teacher Ana Elsa Cubias describes how students used to bring their own water from home to drink during the school day. Now, the refurbished well guarantees them a clean supply right on the spot.
"They're drinking water from a protected source and the kids have water right in the classroom," says Cubias.
A short distance from the classrooms sits a large plastic tank, sky blue and able to hold 1,100 liters of water pumped fresh from the well. Chlorinated, the water from the tank flows to two taps standing just outside the gates to the school. They're accessible to whoever is driving or walking by. And to ensure the stored water stays safe for drinking, the water committee arranges to have the tank cleaned every couple of weeks—a task that falls to a child small enough to wiggle inside and scrub the interior walls with a brush and bleach.
"We make sure he bathes before he gets in the tank," adds Coto, the local leader.
In Agua Zarca, a few communities over, Jose Luis Funes Cruze says that before PROVIDA and Oxfam installed the new well, most of the local residents depended on their own backyard wells for drinking water—and that was a problem.
"The household wells take on a lot of rain water and a lot of filthy water when there's flooding," says Cruz, pointing in the direction of the polluted San Antonio River, which spills its banks during big storms. "The things people throw in—there are pigs up river. And the cheese factory is up river."
In the past, when their drinking supply has been contaminated, families in Agua Zarca have had to rely on the government or aid groups to truck in drinking water for them.
But now, with a new communal well their supply of drinking water is much improved.
"We're very grateful—the whole community is—to have that water," says Blanca Lidia Jiménez, who lives close to the well makes about six trips a day to fetch enough water for the seven people in her house. "We don't get sick so much when we drink the water from this well. The little kids would get swollen bellies, but with the new well that problem has been solved."
Still, the situation in Agua Zarca points to the challenges of providing clean water in this area. The community's new well was built on the only land available: next to a cow pasture—an arrangement that could be problematic during the wet season when rain sloshes manure about and allows it to seep into the groundwater.
The deep plastic lining on the well and its volcanic-rock filter help, though, says Guillermo Morán, a professor and researcher at the University of El Salvador's Earth Sciences Institute. He worked with Oxfam America and another of its partners, the Harvard Humanitarian Initiative (HHI), to evaluate the effectiveness of the wells while studying the health practices of families who use them.
The study is an important component of Oxfam's public health work: It promotes accountability and offers a different model for aid groups by linking their work with that of universities.
"We have the field experience and they have the technical expertise," says Miriam Aschkenasy, Oxfam America's public health specialist. "Together we're able to evaluate programs at a higher standard and at one that increases accountability."
In its draft report, HHI said that individuals who live in communities with "healthy wells" were less likely to have diarrhea and reported fewer cases of the illness during the time of the study. But the draft report also revealed that in two of those communities, some people were still using hand-dug wells for their drinking water while other people from places without "healthy wells" were making the trek to a community that had one to fetch their water.
"The study gives us insight in a way we couldn't have anticipated," says Aschkenasy. "It gives us an idea of where to focus in the future. We now know we need to find a way to encourage people who are still relying on the hand-dug wells to use the healthy ones instead. And it gives us great incentive to build more of them."
]]>Tacked to the outside wall of a government office building in Zimbabwe, the warning served notice to all who could read English that Mudzi district is in the throes of a major public health crisis.
Like wildfire, hot spots of cholera—a waterborne diarrheal disease that can kill quickly if not treated properly-- continued to erupt in late January in this rural northeast region on the border with Mozambique. I heard about the spikes—and the challenge of stopping their spread—at the morning meetings at Kotwa hospital, where aid groups and government health officials gather to coordinate each day’s attack on the disease. Oxfam and its local partner, Single Parents Widow(er)s Support Network, or SPWSnet, are among those responding to the crisis.
Fanning out from the hospital grounds, a small team of nurses, water engineers, and public health promoters hit the road each day, traveling up to two hours to reach the more remote areas where people need everything from clean water to basic information about cholera prevention. And they return each night—sometimes long after dark—to prepare their reports for the next morning.
The news they deliver, along with their statistics, is often unsettling: Reports of people drinking from a stream in which others are washing dirty clothes and dishes; shortages of oral rehydration salts and disinfectant; an ox cart toting a patient who died before reaching a clinic. All of it paints a picture of a country crippled by hyperinflation and failing water and sanitation systems. In Mudzi, less than a third of the households have access to proper latrines, according to one estimate.
Already cholera has sickened close to 85,000 people across Zimbabwe, killing more than 3,900 of them as of Feb. 6. The World Health Organization has called it one of the largest outbreaks ever recorded. And Mudzi, poor and far from central areas of commerce and government activity, has been one of the hardest-hit districts.
Here, in Mudzi, fear of the disease is palpable. Fist bumps have replaced handshakes as people worry that palm-to-palm contact could transmit cholera. Some people are even afraid to eat, though of course they must, one man tells me.
“We are not settled,” says the man, Wonderful Nyatsuto, as he helps a SPWSnet engineer repair a deep well, known as a bore hole, about a mile and a half from his home. About 15 people in his village have contracted the disease, he says, and a third of those have died. Cases of cholera started to erupt when people began fetching their water from a nearby river after the bore hole stopped functioning. Across Mudzi, many of the region’s 600-plus boreholes no longer work and communities are too poor to repair them. But without a supply of clean water, residents face a growing danger from the disease.
“We are trying to maintain the rules they tell us,” Nyatsuto adds. “Boil water. Clean hands before you eat. Clean the toilet.”
Still, in a region where many locals supplement their meager incomes by panning for gold in a network of streams and drink the contaminated water as they labor, people are continuing to get sick.
But getting to a clinic is no easy matter. Functioning ones are few and far between. Some have no medicines. Others have no medical equipment. And so sick people trudge great distances to get the care they need. Roads are rough, sometimes barely more than tracks through the bush, cars are scarce, and fuel is both dear and hard to find—even for aid workers who have access to outside resources to buy what they need. Sometimes, aid groups have to send vehicles all the way back to Harare, the capital, a two-and-a-half hour drive from the Kotwa hospital, to scrounge for a small supply of fuel that they can port back to keep their trucks in Mudzi running.
One day in late January, 49 patients packed a clinic in Makaha, a ward in Mudzi where cases of cholera were suddenly spiking. A series of tents and one dimly lit concrete room served as wards for people stretched out, limp and mostly silent, on cholera cots—beds with large holes cut in the middle beneath which buckets are placed.
Snaking between the tents and the out buildings was a narrow path of mud bricks powdered, here and there, with flecks of white—the remnants of the dried lime-chloride used to disinfect contaminated surfaces. Mixed with water, a jug of it sat at the exit of the clinic, a reminder to all visitors to give their hands a thorough dousing.
As she finished hosing down an empty cot with the chloride solution, a nurse, her face flat with exhaustion, described some of the misery she had witnessed in the last few days. A mother, six months pregnant and very sick with cholera had managed to get herself to the clinic only to lose her baby. The next day, her husband arrived with their five-year-old son whom he had carried more than 16 kilometers from their home in search of help. Weak with cholera, the boy had died en route. And now the husband was gravely ill, too. The nurse was uncertain whether he would survive.
Behind her, on a shelf, stood a plastic barrel—a mini storage tank for the mixture of oral rehydration salts that were helping to keep the clinic’s patients alive. But the barrel had barely two inches of liquid left in it—nowhere near enough to sustain all those who desperately needed the sugar-and-salt mixture. And there was no more solution anywhere else in the clinic. Fortunately, we had a small supply of rehydration packets in our Oxfam truck and immediately gave them to the nurse. But that’s not all she needed. The clinic had just two doses left of ciprofloxacin, an antibiotic used to treat a variety of bacterial infections including severe cases of diarrhea.
Beyond the tents, was the observation area—a patch of dirt in the shade of a large tree. Here, patients waiting to be admitted slumped on the ground and those who had improved continued to rest before making the journey home. Outside the gate to the clinic, family members huddled around small cooking fires, the smoke curling around them. They were preparing food for the patients inside—a kindness that was also a cause of concern to nurses who feared cholera could soon sweep through the family support network.
Compounding the challenge of treating cholera is the widespread hunger many people in Zimbabwe are now confronting in the months leading up to the next harvest. Hunger has left people weak and more vulnerable to the disease.
The World Food Program plans to feed more than five million people in February, the greatest number in a single month since 2002. But because more people need food, the program is reducing ration size so that it can stretch its stocks far enough to accommodate everyone.
For some families, even coming up with the basics to fight cholera—such as sugar for a rehydration solution—can be daunting. Dutchman Matika tells of having to borrow sugar from a neighbor to make his wife the solution when she came down with cholera. As he speaks, two of his young sons listen intently, their hair tinged with orange—a sign of malnutrition. With 11 children and three wives in his household, Matika says mealie meal—a local staple—is in short supply.
“When you walk around, you see it,” says an aid worker about the malnutrition that has followed on the heels of several poor harvests and that’s affecting people most acutely in the interior of the country. “Poppy tummies. That’s one of the very clear indications. It’s mainly in kids. And you get wasting away in adults.”
But this year, in Mudzi, there are signs the next harvest may be better. While there is never enough fertilizer to guarantee robust crops, the rains during the current wet season have been unusually plentiful. Where corn and sorghum, millet and ground nuts have been planted, green shoots abound—slivers of hope for the future.
]]>On this day, it seemed highly symbolic: a clean sweep. It was a day which many Zimbabweans were praying would bring them change, after months of political deadlock, an ever-worsening economy, and a humanitarian crisis as the country battled its worst-ever cholera epidemic and serious food shortages.
It was the day Morgan Tsvangirai, the country's main opposition leader, was to take office as the country's prime minister in a new unity government.
Tsvangirai won the first round of last year's presidential elections by a small margin. But he withdrew from the run-off, citing violence against his supporters. In September, though, he agreed to a power-sharing arrangement with Zimbabwe's president, Robert Mugabe. However the deal had been stalled for months amid political disagreements.
While there are skeptics who say the new political arrangement is a sell-out and unlikely to achieve much, many Zimbabweans beg to differ. They view the new political arrangement with optimistic caution. Many told me things couldn't get any worse, and that the formation of a new unity government gave them cause to hope again. They believed it could mark the start of change in their country, which has seen thousands killed from cholera—a curable and preventable disease—and where up to seven million people, more than half the population, are dependent on food aid.
Later in the day, after being officially sworn into office, Zimbabwe's new prime minister addressed thousands of supporters at a packed showground in Harare.
Some attending told me they'd sold household goods—a TV set; an iron; some clothing—to get enough petrol to come to Harare to listen to Tsvangirai address the crowd as the country's new prime minister.
He promised to end political violence and Zimbabwe's culture of impunity; to work for a society where people were no longer living in fear of reprisals or repression for their views. He said Zimbabwe would not be a pseudo democracy, but a functioning democracy, where the rule of law could be re-established.
A second top priority of the new government, he said, was to tackle the humanitarian crisis, to stem the cholera epidemic which has gripped the country, and to ensure that those who needed food got help—regardless of their political or tribal affiliations.
He also promised to appoint a senior cabinet member to coordinate humanitarian efforts; to remove tax duties for humanitarian food aid, and to organize a food summit to try to ensure that in the future, Zimbabweans would not go hungry again.
And he vowed to stabilize the country's economy—characterized by crippling hyperinflation; to get children back to school, hospitals to reopen, and civil servants to return to work.
All music to the ears of the crowd and—possibly good news for international governments that have said they will carefully monitor change in Zimbabwe before making serious commitments of financial help.
The crowds in the stadium cheered, danced and waved flags. Even a reporter from a government-controlled newspaper seemed happy.
"We used to be dead," he said. "Now we are alive. This is the start of change."
]]>The song,"Cholera—Chenjerawo," which translates as "Cholera—Beware," will be played on radio stations across the country every 30 minutes. Performed by a group of musicians calling themselves Artistes for Health, it's the brainchild of some of Zimbabwe's top performers including Tanga Wekwa Sando and Oliver and Sam Mtukudzi who wanted to do something to help stop the rapid spread of the epidemic—the country's largest recorded outbreak. Cholera has now affected every province in Zimbabwe. More than 33,000 suspected cases have been reported and the disease has taken more than 1,600 lives.
The first cholera case was reported in August in a suburb of Harare. This week, at a meeting attended by government ministers, provincial governors, traditional chiefs, health experts, the commander of Zimbabwe's defense forces, diplomats, and the media, the government announced what it called a nationwide blitz to control, cure, and eliminate the disease.
"Information is the greatest tool in fighting this epidemic," declared Dr. Edward Mabhiza, permanent secretary at the Ministry of Health and Child Welfare.
The plan is to recruit as many as 20,000 volunteers to help spread messages about good hygiene. Radio jingles and messages in the papers and on television will be used in the campaign. Pamphlets and posters carrying information on how to prevent cholera are to be distributed everywhere, from beer halls to church entrances, and everyone, from provincial chiefs to soldiers, is being urged to play a part in the national effort.
Theatre groups will be also enlisted. Oxfam is already using drama groups to promote key health messages as it distributes hygiene kits to vulnerable communities across the country.
Using music, theatre, dance and humor, the groups entertain the crowds. But it's entertainment with a message, as the shows also highlight the need for careful hand washing and food hygiene.
Yet even the government, which acknowledges there is still some way to go before it can declare the epidemic under control, concedes that it needs more than educational messages to fight the cholera epidemic.
The country's sewage systems have broken down. Rubbish is no longer collected and piles up rotting on streets. Hyperinflation has caused many health workers to stay away from work, unable to live on their salaries which are paid in rapidly devaluing Zimbabwean dollars. More boreholes need to be drilled to provide clean water sources for communities. And many Zimbabweans are struggling to feed themselves.
There are worries that the epidemic could spike with the approach of the peak season of heavy rains which could spread contamination to shallow wells. There are also concerns about flooding and the movement of infected people within Zimbabwe and to other neighboring countries.
Education, though, can go a long way. And the call for action to mobilize the nation is an important step forward.
]]>2008 was an especially grim year in Zimbabwe—and prospects for the coming year seem little better. The fact that Zimbabweans were celebrating the new year at all might seem surprising. But many people, or at least those with some money living in the cities, were in the mood to party, if only for a night and to forget their worries.
Zimbabwe is gripped by economic collapse. Hyperinflation, the worst in the world, has seen prices skyrocketing, making it hard for many to access food and fuel. Last month, the country's central bank introduced a 10 billion Zimbabwean dollar banknote, but its actual worth, about $10 US dollars on the black market, is rapidly decreasing day by day. Most shops now only accept foreign currency not Zimbabwean notes.
On top of the economic meltdown, which has seen doctors, teachers, and most government staffers staying away from work because their pay in local Zimbabwean dollars won't even cover their crippling transport costs, there is a serious and worsening humanitarian crisis.
A cholera outbreak in August has now affected more than 30,000 people, and claimed the lives of more than 1,600 people, with cases now being reported across every province in the country.
Cholera is an easily preventable and treatable waterborne disease. But its spread in Zimbabwe is being fuelled by the collapse of health, sanitation, and water services. There are limited medical supplies and many don't have access to clean drinking water or proper sanitation. The onset of heavy rains this month is worsening an already alarming situation.
A second humanitarian crisis, still under-reported, is the worsening malnutrition and food shortages. There have been several years of failed harvests; a serious shortage of seeds and fertilizers; and driving hunger is forcing many to eat seeds instead of planting them for next year's crops.
The UN has warned that around five million people, more than half of the population, will soon rely on food aid.
The country is also facing political deadlock. Efforts to form a power-sharing government between the ZANU-PF party of President Robert Mugabe, who has been in power since 1980, and the opposition Movement for Democratic Change, have stalled.
I got a somber insight into many of the problems the country was facing as I visited Kadoma city in central Zimbabwe, about 112 miles west of the capital, Harare.
Oxfam has been working in the area, drilling wells so that communities can access safe drinking water, distributing hygiene kits, and undertaking health promotion work.
The health authorities have reported nearly a thousand cholera cases since mid November, with 29 deaths. Unofficial statistics put the figure even higher.
Two people had died that day; and I was shown a tent containing the wrapped corpses of seven bodies, several of which had lain there for several days and were swelling. Fuel shortages and rocketing prices meant that there were no vehicles available to take the bodies to the local cemetery.
"Things aren't stabilizing," said one nurse. "They're getting worse. We're seeing more patients every day."
With early access to treatment—intravenous fluids and oral rehydration—patients can recover quickly and be discharged within days.
But a visit to a nearby housing estate—described as a cholera "time bomb" by a senior health official—made clear why the epidemic is sweeping across the country.
The sewage system had broken down, and residents were disposing of human and other waste in the narrow lanes around their homes.
Those images haunted me as I sat in the jazz bar that night. Zimbabweans might have little to celebrate, other than surviving another difficult year; but they are still pinning their hopes that the coming year might bring some change for the better.
]]>On this hot August morning in a small fishing village on Sri Lanka's southern coast, he is probing locals for a full understanding of what well-being means to them. He remains serene as they squabble a bit, call each other liars, and offer up whole new categories no one has mentioned before. When a group of men can't agree on a set of criteria, he announces a tie and allows both points to become part of the findings.
Such is the life of a researcher engaged in the ebb and flow of a study that allows its authors to enter into a direct dialogue with the community they are focusing on. The approach is called participatory action research—a method Weerackody believes in deeply. He is applying it to a piece of research intended to expand the understanding of mental health issues in Sri Lankan communities affected by natural disasters or long-term conflict. Funded partially by Oxfam, the study is part of a large, four-year project conducted by investigators from McGill University. This piece is being carried out by the People's Rural Development Association, McGill's local partner.
"People are never given a chance to participate in the decision-making process," says Weerackody. "And this is what we need"
That lesson became all too clear in an earlier study he had helped to conduct on the impact of the aid system on communities affected by the tsunami. People received goods that weren't relevant to their lives, that were of poor quality, that weren't useful, says Weerackody—all because no one had bothered to consult with the communities themselves.
"It's about attitude and the way the colonial system was established," he adds. That system says decisions should be made by technical experts or politicians. "They think people don't know what they want."
Weerackody thinks otherwise.
"If it is decided by someone else, people don't have any feeling it is part of their lives," he says. And aid agencies have enough experience building roads, community halls, culverts, and the like to know quite well what will happen if beneficiaries aren't involved from the start: As nice as the facilities are, they won't be maintained, says Weerackody.
A relocated fishing village in which he has been conducting research recently offers a case in point. The hillside homes, sturdy but small, now house 55 families formerly living near the sea, and a newly built community center at the top of the hill serves as gathering place for all.
"They have a house but they're not happy," says Weerackody. "That house was not spacious. They can't entertain their relatives. They don't have enough place to sleep. One woman said she can't even make love with her husband. The lesson we learn from the study is you may design houses, but what's needed by development workers is to take into consideration other aspects of well-being."
From a rural community himself, Weerackody, who has been working in participatory development since 1982, says he takes pleasure in meeting with local people to learn about their opinions and needs—an important perspective to understand since so much of the country's population is rural. About 80 percent of Sri Lankans live in rural areas, Weerackody points out. And whenever he's got a free moment, he heads out of Colombo, Sri Lanka's capital and his current home, to visit the village in which he was raised.
"I have a strong belief in community consultation," he says. "Development workers should respect the communities and should win the trust and confidence of communities."
]]>Oxfam visited the densely populated and poor northern province of Zambezia in Mozambique recently to see how PEPFAR and other US agencies work on the ground. At the sites we visited, we found a close level of collaboration between PEPFAR and the Mozambique Ministry of Health. Over the past two years, the Mozambican government has worked to integrate all donors into its national development plans. Donors like PEPFAR have been asked to make some changes in the way they operate. PEPFAR aid to Zambezia province reflects PEPFAR’s ensuing move to integrate AIDS care into the long-term health system. To fight HIV/AIDS in Zambezia, Population Services International (PSI) implements PEPFAR programs ranging from those preventing the transmission of HIV from mothers to babies during pregnancy, to providing HIV counseling and testing, to preventing HIV through theatre and classroom presentations.
Sixteen percent of the adult population of Mozambique is HIV positive. In some areas, infection rates are as high as 20 percent. In 2000, only 1,000 Mozambicans were on anti-retroviral therapy. PEPFAR programs have increased those numbers to nearly 160,000. PEPFAR funds have also financed care and support for about 800,000 people living with HIV and their families.
Development experts worry that PEPFAR may not be the kind of program that leads to long-term health and development. PEPFAR is often criticized as the textbook "vertical fund," which bypasses the government and creates a parallel health care system. Critics of these so-called vertical funds have pointed out that foreign aid donors sometimes pour all of their health funding into treatment of one disease. This can have the unintended result of neglecting basic care for the general population and hiring away health care workers from general medicine clinics to HIV clinics, leaving the general medicine clinics understaffed.
Donor resources for HIV have outpaced support for basic health care for all Mozambicans. In 2007, only 3 percent of US foreign aid to Mozambique was for child and maternal health, while 61 percent went to HIV/AIDS. But more people in Mozambique are affected by child and maternal mortality than by HIV, since 15 percent of Mozambican children do not reach their fifth birthday and the mother dies in one out of every 100 births in Mozambique.
In the small town of Maganja da Costa, there is a PSI building next to the government health clinic that used to offer free counseling and testing to people who suspect they have HIV. The building bears a freshly painted sign. The sign used to read "HIV Counseling and Testing," and now it reads "Health Testing Center." At the request of the Mozambique Ministry of Health, PSI has expanded services offered there to include cancer, diabetes, and tuberculosis screenings. The change is a result of a recent Ministry of Health policy of integrating stand-alone HIV "day clinics" into the general health system, including centers funded by donors. Integrating these HIV day clinics into the general health system reduces the stigma attached to getting tested, since it's no longer obvious that if you walk into that building, you are there to test for HIV and HIV only. Making the building a generic testing facility, and not just an HIV one, provides new testing capacity for the government health clinic.
PEPFAR is also working to integrate health care workers into government clinics, rather than hiring away the best staff for separate clinics. PSI has implemented this change on the front lines: its nurses are embedded within government clinics, wearing the same uniforms as government employees and providing the same services.
In the district hospital in urban Quelimane, PEPFAR's contributions to basic health are also on display. There, PSI uses PEPFAR money to fund two nurses and a physician's aide—a big addition to the original staff of eight. PSI also renovated the maternity ward, and Columbia University (using PEPFAR funds) transports blood samples to the lab, which is hours away. Support like this from PEPFAR makes it easier for the clinic to serve the more than 260,000 people depending on it for all their health care needs.
"PEPFAR support actually benefits other areas in the clinic. We now have pre-counseling in addition to testing, which we didn't have before, and we can now test for other sexually transmitted diseases as part of antenatal care because we have additional money for other testing." — Director of Government Clinic, Maganja da Costa
When we arrived in one town, PSI insisted that our first destination be the government clinic, where we asked the clinic's director for permission to visit. Visitors can be disruptive, preventing doctors, nurses, and health workers from seeing patients. Asking permission also reminds visitors and nongovernmental organizations that this is the government's clinic and that even though PSI may have outside money, its role is to help the government of Mozambique provide health care and not the other way around.
While we heard concerns from international donors based in Maputo that PEPFAR is not fully integrated into the Mozambique Ministry of Health and National AIDS Council, the experience of health care workers in the field appeared to be one of close collaboration and integration. The change is due to two key innovations:
PEPFAR's evolving role in Mozambique is a model for other PEPFAR focus countries, particularly the countries that have only just begun to hold donors like PEPFAR accountable to their national health priorities.
]]>There, on the shore behind what's left of a half-constructed mansion, the chug-chug-chug of a diesel pump holds the promise of clean water for 11,042 people at Buhimba camp. They are just some of more than one million villagers forced to flee their homes as conflict has swept across the eastern provinces of that vast country. A short distance away, a second pump, submerged deep in the lake, provides water for an additional 18,016 people in two other camps known as Mugunga I and II.
Without clean water, without decent sanitation, and without the public health outreach that helps people understand the link between the two, waterborne diseases could ripple through theses camps with devastating consequences. That's what Oxfam, together with its local partner, Action Santé Femme, or ASAF, was determined to prevent when it helped establish the water systems for these three camps—and a fourth, Bulengo—outside Goma, the capital of North Kivu province. Through a network of rigid plastic pipes, storage tanks, and outdoor faucets, water from Lake Kivu now gushes into the jerry cans of thousands of families with the turn of a tap.
At the top of a short but steep hill at Buhimba, where two massive water storage tanks frame the sprawling camp below, Helene Kanyere Ndakas stands ready with a notebook in hand. She is the manager of this storage station—and knows better than almost anybody the importance of making sure the system runs smoothly.
What gives her that special knowledge?
Ndakas herself relies on the water that flows from it. She and her family are among the thousands of people who are now making their homes temporarily at Buhimba.
Flipping her notebook open, Ndakas points to the careful records she keeps each time she opens the valves to refill the tanks with lake water. And she notes the amount of chlorine that goes in to guarantee its cleanliness. Hired by Oxfam, Ndakas is on water duty from 6am to 4pm each day—a job she takes very seriously.
"People are depending on her," says Charles Mampasu, an Oxfam program manager in Goma. "And they're happy with her job."
In a place where there was little or no infrastructure to support a water system, supplying tens of thousands of people with clean water on an emergency basis has been no small feat. And making sure they continue to have access to it when Oxfam moves on to its next project is one of the organization's central concerns. That's why Oxfam is working hand-in-hand with ASAF to help it build its ability to handle the water system on its own, particularly in Mugunga camps.
A tour through Mugunga I shows how important a steady supply of clean water can be—especially when people are struggling with such harsh living conditions. Built on fields of sharp volcanic rocks, the shelters many people now call home are not even tall enough in which to stand. Made from grasses and dried banana leaves flung over a frame of saplings and topped with a plastic sheet, the huts offer only minimal protection from the elements. To keep warm—and to drive the bugs out—many people cook on small wood fires inside their huts, the smoke curling into their lungs and out through the cracks in the shelter walls.
At the health clinic, the nurse on duty reports that respiratory infections are among the most common medical problems he sees. About 150 people a day flock to the clinic with a host of ailments that also include malaria, tuberculosis, and diarrhea. The latter is what the clean water—and scores of latrines that Oxfam has also installed—help to fight.
Snaking across the rocks, over roots, and through the mud, a network of wide black plastic pipes carries the water from Lake Kivu. It's replacing a temporary supply that another agency had been trucking in daily and storing in two plump water bladders—they look like giant egg yokes when full—at a cost of $3,500 a week. Nearby, the water blasts from faucets when kids turn on the taps to fill plastic jugs before lugging them home.
The water jug of choice for many kids has a familiar look: it's the container that once carried their family's allotment of cooking oil, doled out during the regular food distributions that displaced people have no choice but to depend on. Here at Mugunga, nothing goes to waste—not the jugs, and not the precious water they carry.
]]>Byakupita Wabinwa, president of the management committee that oversees the Kabimba health clinic, is standing below the sign. He is a small and serious man with a serious problem—one that plagues not only his community but that crops up frequently in this region of Democratic Republic of Congo: cholera.
Here, in the eastern provinces where years of conflict have taken a toll on social services, outbreaks of the waterborne disease are just one of the consequences of underinvestment in everything from roads, to health clinics, to clean water.
Sometimes, if maintenance of the simple delivery system has been lax, the water at this clinic doesn't run at all. That's why an enormous black cylinder is lying on its side in the clinic's front yard. It's a storage tank, waiting for installation as part of Oxfam's program to help ensure the clinic has a reliable reserve of water as well as decent sanitation facilities. In the back of the yard, a pair of pit latrines and two bathing stalls are under construction. And nearby, deep in the ground, lies the newly dug "placenta pit"—the local solution for disposing of hazardous medical wastes including afterbirth from the maternity ward.
Though it has no doctor and just five nurses, this is a busy place—serving an area with nearly 14,000 people. About 75 make their way here each week—some walking two hours down from the mountains—to receive treatment for malaria, to get tested for tuberculosis, to fight the cholera that erupts from time to time, especially during the rainy season.
Tacked to the door of one of the buildings is a sign, warning with explicit detail in Swahili, about the symptoms of cholera. It urges those who've got them to head for the nearest health clinic as soon as possible.
On this day, there are no cholera sufferers at the Kabimba clinic. But sometimes, during outbreaks, as many as 20 people a week come for treatment, though there is hardly the space for them. People lug their own bedding with them and spread it on the floor. A small building—about 30 feet long by 15 feet wide—serves as a quarantine area.
"But how can you put 20 people in that building and keep them healthy?" asks Wabinwa.
Inside, the walls are grimy with stains and the ceiling is collapsing. Of the original 10 cholera beds—mattresses with holes in the center beneath which buckets can be placed—only three remain. The plastic covering on one of the mattresses has pulled away, exposing the foam around the hole and leaving it like a sponge to sop up germs. A rickety wooden rack serves as a post for the intravenous drip.
As primitive and ill-supplied as the Kabimba clinic is by western standards, Trish Morrow, Oxfam's public health team leader for rural villages around Uvira, assures visitors that it's better than many that serve some of Congo's 62 million people, vast numbers of whom live in poverty. Few have the resources to pay for much medical care at all, but many live at risk of contracting serious diseases—like cholera—to which that poverty, with cruel irony, exposes them.
Nowhere is that more clear, perhaps, than along the stretch of land between the Mulongwe and Kavimvira rivers just outside of Uvira, South Kivu province.
It's there, between those two central sources of water, that the greatest number of cholera cases in the area erupt, says Jill Markvorsen, Oxfam's program manager for Uvira. During the first week of January, an outbreak almost reached epidemic proportions. At the cholera clinic in Uvira, workers charted 64 cases of the disease&mdasdh;one shy of the number that would have triggered the implementation of Uvira health zone's cholera contingency plan. Instead, officials, staffers from Oxfam and other aid groups, and volunteers from the Red Cross managed the flare-up by chlorinating water sources, making public health announcements on the radio, and providing information to people about measures they could take to improve hygiene and sanitation.
A few months later, in mid-March, both banks of the Mulongwe River are teeming with activity. Not far from one edge, a bare-bottomed boy dashes behind a bush and squats to relieve himself. Pigs root in a heap of rubbish that inches, black and slippery with mud, almost into the water. It rushes by filled with silt. Men wash their clothes. Others drive trucks and cars into the shallows to rinse off the dust and dirt. Up stream, a market crowded with people hugs the bank.
For those who have no other source, the Mulongwe River also serves as their supply for drinking water. It's no wonder then that cholera, caused by ingesting water or food contaminated by the bacterium vibrio cholerae, is one of the ugly facts of life for people living in this war-torn region.
At the Uvira cholera clinic, Oxfam helped to install a large tank that stores a backup supply of water—collected from the roof during rainstorms and precious for its relative purity. Two large rooms—one for men and the other for women—serve as sick wards. Simple beds—wood frames with sheets of rugged plastic stretched taut across and cut in the center with a hole—are scattered about the rooms. Others are piled outside.
The wards are empty on this mid-March day—a good sign.
Morrow, the public health team leader, says that the medical staff in Uvira has been trained well to provide patients with good care. Though there is not so much it can do to prevent people from contracting a disease that's so closely linked to the lack of public services—like potable water—the staff has been successful, says Morrow, in stemming the tide of cholera deaths.
And in a place where basic precautions take on ominous importance, blue buckets filled with a mixture of water and a heavy dose of chlorine dot the perimeter of the clinic's yard. All visitors are advised to scrub their hands with that solution before they leave. Most do—and duck out smelling like a swimming pool in the western world, but grateful for it.
]]>These community organizations are the leaders in an epic struggle against HIV and AIDS in South Africa. They are doing what the government cannot seem to do: deliver essential services that directly benefit the millions of people in the country infected and affected by HIV/AIDS.
"If the government of South Africa wants to address HIV issues, then it needs to strengthen community-based organizations," says Gerard Payne, who works for the AIDS Consortium, a national organization that supports thousands of community groups. He says that the HIV/AIDS crisis is the most significant challenge facing South Africa since the transition from apartheid.
The scale of the problem requires a local, grassroots response, and community organizations are doing their best to deliver it. Many are overcommitted and underfunded. "Whether it is through financial resources, whether it is through training, we need to strengthen them, so we can reduce the rate of HIV in this country," Payne says.
Payne has just been to visit one such community organization, where he stood in the dusty courtyard outside a two-room cinderblock house in South Africa's North West province as a dozen high-energy toddlers played and ran around him. Four of the organization's home-based care givers prepared to make their rounds, visiting patients in their homes to help cook, clean, and remind them to take their medication.
Payne's job at the AIDS Consortium is affiliate coordinator, so he visits the community-based organizations, assesses their needs and capabilities, and recommends a course of action to train the staff. Many must learn and implement procedures for raising and managing money, and develop a strategic vision for what the organization can be and where it can go. This helps the community organizations get past simply reacting to the HIV/AIDS crisis and working towards measures that will help improve the situation.
One example is in the care of orphans and vulnerable children in the community. The government of South Africa estimated last year that there are 1.5 million children under 17 directly affected by HIV: one or both parents are dead, or they are living with the virus themselves. With so many children now in need of a place to live, or at least hang out after school, get a meal, and stay out of trouble, it is the community organizations that are struggling to meet this need, many of them without specialized training or adequate funds. "They may be running a program, but have no idea how to really do it properly," Payne says. "So we will help them get training so they can provide counseling and other services that will help the children. We help them get to a level where they have good infrastructure and are rendering quality services." This can include a curriculum to teach "life skills" to young people so they can learn how to prevent HIV.
Another essential area where community groups can make a big difference is in helping people living with HIV and AIDS to understand what treatment is available and how to get it—a basic level of knowledge known as "treatment literacy." This is particularly helpful for women, who for reasons related to poverty and discrimination may be unable to get to a clinic or hospital—their families may not give them time, they may not have money to pay for transportation, or they may just simply not know that they are HIV positive and need medication.
Gerard Payne says that even if a patient can get to a hospital, he or she still may not understand what they need to do to stay alive. "Patients go there, the staff does a CD-4 count and gives them some medication, but they do not explain anything," Payne says. "Our objective is to educate organizations how to help patients understand the different treatments needed, and their rights to access treatment."
He adds that educating people about their right to treatment is a big step for many groups that are accustomed to delivering food and other care. "Community-based organizations respond to needs: if someone is sick, they go to them once or twice a week and take care of them," he explains. "We are saying they need to take it a step further. That patient is eventually going to get really ill, so they need to understand what care is available, where to access it, and that they must adhere to the treatment."
Seeing organizations grow and become more effective is one of the things that keeps Payne engaged in his work. "Last year I had one affiliate with no money, so I helped them get financial management systems in place," Payne says. "The first 1,000 rand [US $125] they raised was due to the fact that we showed them how to open up a bank account and write some letters to raise money."
"The joy and satisfaction I get comes when someone tells me that the work we do is making a difference," Payne says.
Payne says that South Africa is at a crucial stage in its history. "We have come a long was as a country, and struggled through many hardships," he says. "We are now in a different kind of struggle, and I want to be able to feel that I am contributing in the struggle against HIV."
]]>"Having secured an arrangement with government units to provide relief in remote areas, Oxfam's five relief teams are putting all of our resources into helping people stranded in rural areas away from the epicenter," said John Sayer, director general of Oxfam Hong Kong.
Oxfam has now committed more than $3.2 million to an initial effort that has commanded response from around the world as headlines continue to bear bad news: A week after the 7.9 magnitude quake struck, Reuters is reporting that 34,000 have died and 30,000 others remain missing; 4.8 million people have lost their homes; and Sichuan Province alone is facing $9.6 billion in economic losses. Hundreds of aftershocks and heavy rain have brought further devastation, including landslides that have reportedly killed 158 relief workers struggling to repair roads in recent days.
"Oxfam is teaming up with medical and hygiene professionals and working in and around the city of Mianyang to prevent an epidemic from starting," said Sayer. Oxfam is also carrying out disease monitoring, control, and prevention in Guangyuan and Zhenzhong.
The organization is concentrating on securing an adequate supply of drinking water for survivors as well as helping to provide safe sanitation services, and carrying out public health education.
Oxfam's first shipment of goods reached Dujiangyin and Guangyuan on Monday. A second shipment is due to reach Qingchuan on Tuesday.
Among the health-related goods Oxfam is sending into the region are portable toilets, intestinal drugs, first aid materials, face masks, and sanitary supplies for women. It has also provided clothing and high-energy biscuits.
Five villages in Gansu Province will also be getting a delivery of aid that will include tents, flour, oil, blankets, and milk powder. The goods will help meet the needs of 3,000 people in Wudu County.
Oxfam, which has more than 20 years experience working in mainland China, is now working alongside the Civil Affairs Department, the Poverty Alleviation and Development Office, several mainland-based aid groups, medical schools, and a variety of volunteer groups.
Additionally, the organization is preparing to reach remote areas of Aba Tibetan and Qiang Autonomous Prefecture.
]]>Oxfam has committed $1.55 million to this initial response. It is also preparing for longer-term projects such as helping to rebuild damaged infrastructure.
Oxfam colleagues based in the neighboring province of Yunnan are now traveling to Wenchuan County in Sichuan, the epicenter of the 7.8-magnitude quake, for assessment and coordination of the relief work. The organization is also planning to provide assistance in Gansu Province where it had been working on development projects prior to the disaster.
Based on our communication with local organizations in the affected areas, our initial assessment is that earthquake survivors need clean water, food, medicine, clothing, and blankets. We also anticipate that there will be a huge need for rehabilitation and reconstruction assistance. Damage to infrastructure and other facilities is significant and Oxfam expects it will take months for the region to recover.
"This is the worst earthquake in 30 years, with a huge impact on people's livelihoods," said John Sayer, director general of Oxfam Hong Kong. "With over 20 years of experience working in China on long-term development work and emergency relief, Oxfam Hong Kong is determined to help as quickly as possible, to guarantee people's safety in the short term, and in the end, as a long-term goal, to improve their livelihoods."
]]>Mogale, 37, is open about her status: she has been HIV positive for two years, and she is living with it. After all, she is doing better now and hopes the worst is behind her. "Now I am really fit compared to when I was sick—I can go a long distance walking now," she says. She regularly walks about one and a half miles to the headquarters of Pholo Modi Wa Sechaba, a community organization where she is part of a support group for people living with HIV/AIDS in her village of Welgavel.
Pholo Modi Wa Sechaba helped get Mogale out of bed and back on her feet. The organization sent a home-based care worker to nurse her, help her get to the hospital for treatment, teach her how to take her antiretroviral medication and manage her diet, and file for a government support grant—a source of money for disabled people.
Pholo Modi Wa Sechaba—meaning "health is the root of the nation" in Setswana, the local language—has about 21 caregivers serving 240 patients in four villages. They ensure that patients are taking their medication; they cook and clean, and disinfect and dress wounds from the many infections that bedevil those with an immune system compromised by HIV. In some cases they deliver food parcels to help families survive.
Pholo Modi Wa Sechaba is just one of thousands of local community based organizations helping the roughly 5.5 million people living with HIV/AIDS in South Africa. They are on the front line of the struggle, and play an essential role in providing services. "Community-based organizations are key in the fight against HIV/AIDS," says Gerard Payne the affiliate coordinator at the AIDS Consortium, an umbrella organization for the thousands of such community groups around South Africa. "Without them the fight against HIV and AIDS is a mere media campaign. They provide essential services in the community, they speak the language, and they understand the cultural issues in the communities."
Oxfam America is working with the AIDS Consortium to provide training and other support to community based organizations like Pholo Modi Wa Sechaba in South Africa's North West Province, one of the poorest areas of the country, with a high incidence of HIV/AIDS. The AIDS Consortium is working with 47 local community based organizations in the North West, and with funding from Oxfam it can expand its efforts to some of the 150 others struggling against HIV/AIDS in the province.
Pholo Mode Wa Sechaba helps patients get tested for HIV and, when patients test positive, counsels them on their treatment options and on how to "live positively." In addition to its home-based care program, it has a daycare for young children and an after-school program for orphans and others who need a place to do their homework and learn valuable life skills including how to prevent HIV.
Learning that you are HIV positive forces you to think about everything differently. Just having to share your status with your family is enough of a crisis for many newly diagnosed people. They then must struggle with how to live with what may at first seem a death sentence, how to make ends meet if they are too ill to work, how to endure the side effects of the medication, and how to manage the stigma of being HIV positive.
South Africa's health care system, while free, is overburdened and does not provide adequate social support for people living with HIV/AIDS. They can be tested, learn the result, and get a CD4 count (a measure of the blood cells that support their immune system). Many get free antiretroviral medication. But then they are really on their own—and if they lack a support system of family and friends, as many do in communities already ravaged by the disease, these patients are in crisis.
Pholo Modi Wa Sechaba helped Maria Mogale with these struggles, and helped her understand her treatment options. These are the most important lessons the organization teaches people in the community, particularly valuable to women who are sometimes excluded from health care options owing to poverty and discrimination—a violation of their right to health care. Family members may insist on traditional medicine, which frequently delays treatment, and can often hasten death.
Mogale learned this from Pholo Modi Wa Sechaba: "If people are sick, they need to go to the hospital, and not just stay at home and say they are bewitched," she says at her home, a three-room house made of metal sheets outside Welgavel. "I tell people, 'AIDS is there, but you can get better.'" She smiles as she speaks.
Mogale is a strong, positive example for members of her community—and this strength, tragically, is also a good example within her own family. Her daughter Portia, 18, learned she was HIV positive two months ago, and her 60-year-old mother Priscilla, who lives nearby, is also in treatment. Both are now thinking about their lives differently as well, and look to Mogale for advice on how to live and think about their future. Portia is in her second to last year of high school and is considering higher education, even as she is still learning what it means to be HIV positive.
For Maria Mogale, her future may involve helping others on a more formal basis: she wants to work with Pholo Modi Wa Sechaba. "I want to become a caregiver, and teach others what I have learned."
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