Medicus Mundi Italia | It was a September morning. Maputo, Mozambique. Large crowded rooms, prominent personalities, noises of scientific discussions and hardly working slide shows. A very different view if compared with the expanses of palm trees, dotted by red sand and colorful capulanas in constant movement that we were used to seeing every day.
The MMI´s Country Representative and I, as a health coordinator, were at the National Scientific Days, invited for the first time to discuss two research papers on mobile clinics in the district of Morrumbene. MMI had been working there since 2011, playing a leading role in supporting an integrated system of primary health care for rural communities, in accordance with the Programs of the Ministry of Health and sharing our experience at the national level was an interesting possibility. During the umpteenth coffee break, shortly after attending a presentation about GeneXpert OMNI – a molecular mobile instrument capable of diagnosing tuberculosis in outpatient treatment with minimal laboratory equipment and the same gold standard characteristics of GeneXpert technology – it was impossible to talk about anything else: what if this kind of device was available for the remote communities of the Inhambane Province?
Tuberculosis (TB) is a major public health problem in Mozambique, one of the countries with the highest incidence of TB in the world, as one Mozambican in two hundred develops it every year. Despite being a curable disease, in 2018 the country reported an estimated total of more than 40.000 TB related deaths, accounting for 2,5% of the world TB related deaths. One of the main reasons for such incidence, especially in a rural context, is that only half of the TB cases are actually diagnosed. As we know very well, long distances between communities and health centers, poor preparation of health workers, stigmatization and lack of tools for diagnostic support, unfortunately, explain this gap. But what if the most disadvantaged people could access the best technology?
With this aim in mind, with excitement and determination, we started to sow the seeds of our idea. Less than a year later we were able to buy and use three mobile GeneXperts for the outpatient diagnostic of TB. Edge was the name of the instrument, the most recent model since OMNI was no longer available on the market. Edge has the capacity of detecting TB in one hour with a high degree of sensibility and specificity and showing in which cases the bacteria is resistant to Rifampicine, one of the main drugs used to treat TB. No specific laboratory equipment is required in addition to what is already included in the Edge kit and the disposable protections for the technician that uses the device. Ideally, suspected patients can come to the mobile clinic on the agreed date, be screened and receive bacteriologically confirmed diagnosis and treatment on the same day.
And that was it. We started working in four different districts of the Inhambane Province, applying the TB screening to the mobile clinic routine on the field, as a supplementary service in addition to routine vaccinations, HIV and malnutrition screening, and antenatal care. An extensive project named “Till The End. Community strategies to contrast tuberculosis and HIV in the Inhambane Province” was launched, developing a new strategy which started from the training of laboratory technicians on the use of the device, went through the awareness of communities and health workers at the district level, and culminated with the design of a research project that could validate the effectiveness of such decentralized screening. The first device, unique in Mozambique and called “Gino” (surely our Italian origins could not be disregarded!), was employed for the first time in October in the Morrumbene district. By the end of 2019, we were ready to reach more than 100 rural communities, in collaboration with the National Health System and we were in the position of providing the most disadvantaged groups with the best diagnostic possibilities, with a major focus on those who live far from hospitals and other centralized healthcare services.
Right now, in the COVID era, we are suffering from a lack of interest and motivation on behalf of the local institutions in continuing the fight against this insidious disease, which mainly affects family groups and children. We still don’t know what the negative combination of these two respiratory conditions will be, but we have already managed to detect how difficult it is to guarantee the correct screening of both in a rural context. Health workers are scared, patients are confused and the Government is paralyzed, having to face tough decisions on how to allocate its scarce resources, which will probably not be enough for both emergencies.
“Since long distance travel was prohibited in some areas of China, patients could not go out of their city for health care. Also, in some cities with heavy burden of COVID-19, hospital systems collapsed because of the large number of patients. Because their priority was treating patients with COVID-19, they had no energy to treat other patients, including TB. Laboratory testing of TB was also interrupted” said Hairong Huang, a TB laboratory expert and professor in China.
Keertan Dheda, a TB expert at the University of Cape Town, agrees. “TB services will be impacted at various levels as resources are diverted to COVID-19 and the epidemic ramps up. Many healthcare workers are not happy to put themselves at risk. So, TB diagnosis will be delayed. I would predict a spike in TB incidence, given delayed diagnosis and higher transmission” he said.
Should such circumstances occur in Mozambique – where in addition to large numbers of patients with TB, there are also massive numbers of people living in poverty, with immunosuppressive conditions such as HIV (13% of the population) and malnutrition (41% of U5 children) – the situation would be out of control. However, MMI is keeping on working, supporting the idea that essential health services cannot be put aside, and the struggles of the communities should be treated as a resource, rather than as a problem.
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Author: Carlo Cerini, Medicus Mundi Italy
Contribution by Medicus Mundi Italy to the Annual Report 2019 of the MMI Network
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