Height of care

Partly funded by Ireland's State development agency, the Rural Mountain Health Initiative is getting care to those who need it the most.  BILL CORCORANreports from Lesotho

FLYING OVER the Lesotho kingdom’s vast mountain ranges, it is not hard to understand how they have proved both a blessing and a curse to the Basotho tribe, the inhabitants of the tiny country located within the borders of South Africa.

Inhospitable and barren, the country’s harsh environment has historically led aggressors to look elsewhere when searching for natural resources or a base from which to exert political influence in the region.

While the country’s existence as an independent state owes much to this topography, its inaccessible terrain has also been a contributing factor to its high HIV infection rate.

When mass emigration, a cultural practice of multiple concurrent sexual partnerships, gender and socio-economic inequalities and a lack of resources are added to the mix, Lesotho has become the nation with the third-highest HIV and Aids prevalence rate in the world.

The United Nations says it is at the epicentre of the pandemic, and the latest statistics show that 270,000 adults and children, or 23 per cent of Lesotho’s population, are infected with the disease.

Since the disease was declared a national emergency in 2000, about 50,000 HIV-positive people have been put on antiretroviral (ARVs), a drug combination that slows down the disease’s progress and its damaging effect on the immune system.

And while the roll-out has been considered relatively successful, a lot more needs to be done to stem the infection rate, according to health minister, Dr Mphu Ramatlapeng,

"The major task now is to decentralise all the services to ensure everyone who has to get treatment is on it," she told The Irish Times.

Arguably, the people living in Lesotho’s highlands are in some ways more at risk than their lowland brethren due to factors linked to their mountainous environment. Ever changing weather patterns, the absence of infrastructure and the terrain have all combined to hinder the population’s ability to access basic healthcare, as well as the life-saving ARVs.

The reality for highlanders infected with HIV is that travelling regularly to the capital Maseru for treatment and care is not feasible, as the monthly trip can take more than a week on foot or by horse, the only modes of transport in districts where there are no roads.

However, a new health programme developed and supported by Irish Aid, the Clinton Foundation and the local health department hopes to address this disparity.

The Rural Mountain Health Initiative (RMI), which Ireland’s State development agency has funded to the tune of €12.75 million since 2006, is establishing a network of nine operational clinics that will give everyone in remote mountain districts the opportunity to access healthcare.

Along with primary healthcare services, RMI has recruited 150 foreign nurses, improved the supply of ARVs and HIV education and care, and increased the opportunities for children to receive treatment.

A flying doctors service is also being supported to ensure serious cases can be flown to lowland hospitals for specialist care.

Aside from infrastructure, one of the main challenges facing healthcare provision in mountain communities has been the recruitment of medical professionals to operate the remote clinics.

In the past, the clinics’ isolation and poor living conditions have been stumbling blocks to recruitment, with local doctors and nurses preferring to seek employment abroad.

However, this brain drain has been addressed somewhat by the provision of a hardship payment and proper staff housing and facilities at the clinics, as the developments have aided a positive recruitment drive across the continent.

Dr Fatumak Namuthi (29), from Uganda, a newly-appointed medical practitioner at Lebakeng Clinic in Lesotho’s south east, acknowledges her working environment is challenging, but she explains this is being offset by the RMI and the results it is achieving.

“In winter it is challenging as you can go for a time without food and medicine because of the heavy snow and clouds, which make it difficult for the pilots to get here, but we are having successes.

“Since the clinic was refurbished in 2007 we have put about 400 people on ARVs, which has brought the mortality rate down a lot among the local population. Only about 20 of the people on ARVs have passed away since 2007,” she says.

When one considers the UN estimates there are 62 new HIV infections and about 50 Aids- related deaths per day, the clinic’s achievements are impressive. And it appears the results are being replicated in the other clinics as well.

In total, the RMI has led to 27,000 people receiving counselling and testing for HIV, and 6,000 HIV-positive patients have been enrolled into the programme for care. Of these, 4,000 have been put on antiretroviral treatment.

One of these patients is Moshoeshoe Matlali (27), who has been attending RMI’s Bobete clinic in central Lesotho for the past few months to receive treatment for TB, a disease that thrives in people infected by HIV.

“Before I came here I could not walk, but now I can go into the fields to work, which is a major task for us because we need to grow our own food to survive. At the clinic I get my medicine and they teach me how to live a healthy life. So I am looking forward to getting better,” he explains.

Irish Aid’s head of development in Lesotho, Pat Curran, says the RMI’s roll-out has gone extremely well to date, with seven of the nine clinics nearly fully refurbished and operational. The next major step, he concludes, is to hand the programme over to the government. “We think it has gone very well in the fours years since we began rolling out the RMI, as we have seven of the nine clinics running, and the contribution they are making to their surrounding communities is impressive, especially given the remoteness of the sites.

“So it is particularly satisfying to be at the stage where we can hand the programme over to the Lesotho government, for the interest of sustainability,” he says.

Despite the progress made, many challenges relating to HIV remain, says health minister Ramatlapeng, with the most pressing revolving around the question: how do you change long-held local cultural practices?

“If anyone can come up with a formula to interest men in HIV and healthcare as a whole, they would probably get a Nobel Prize,” she laments before adding, “Aids will continue to be a problem for a long time partners. It is a way of life we are not proud of, but it has been here for a long time. We have to see it for what it is and change it.”

‘Stigma [of HIV] is the biggest killer in Lesotho’

Among Lesotho’s Basotho tribe the fear of being stigmatised by one’s community for having contracted HIV has been directly responsible for tens of thousands of deaths since the disease first took hold in the country.

In a kingdom where a community’s generosity can be crucial to survival given the high levels of poverty, many people with the deadly virus refuse to acknowledge their illness, fearing they will be ostracised and shunned by family, friends and neighbours.

Despite the widespread availability of the antiretroviral drugs that can save their lives, HIV many sufferers ignore the virus’s symptoms until it is too late, and all that is left is a slow and painful death.

Mamaleshoae Nkhahle is one of a small group of 50 HIV-positive men and women in Lesotho who have decided to buck this trend of denial. She has refused to be overcome by the fear of going public about her illness, and has dedicated herself to breaking the aura of shame that clings to the disease.

Known as an expert patient with HIV, Nkhahle works with the medical staff at Likotsi health clinic in Lesotho’s capital Maseru trying to reduce the stigma and anxiety felt by recently-diagnosed patients by talking openly about her own experiences.

“Stigma is the biggest killer in Lesotho, as the ARVs will save your life. You must be willing to accept the situation you are in. If people talk about HIV and tell their kids about it, then fewer people will become infected.

“I tell them my CD4 count was 39 before I went on ART and TB treatment and now it is 730. They look at me and see that I am not close to dying, and get hope from that. The people who have most difficulties with accepting the disease are men, as they do not want to listen,” she says.

The mother of four shrugs off any bravery accolades that come her way for confronting the disease head on, insisting she has no choice but to face her predicament because she has children to look after.

Nkhahle’s husband died nine years ago after a long illness, but it was only at the end of his life he found out he was HIV positive. A few years later she too became sick, and after going to a clinic for testing Nkhahle was told she had contracted the virus.

“I was convinced that facing the disease was the best way to have a better life. I received counselling, and then told my family I was sick. I brought my children for counselling so they could understand my situation. At first I feared if people found out I would be a laughing stock, and shunned by my peers. But once they were told about it, and how many other people were infected by it, they understood. They are now positive towards me,” she says.

Nkhahle gets a small payment from Irish Aid for the work she does. “I had to stop working in the textile factories even though I have a family to look after because the disease makes you weak. I get around R800 [€71] a month for the expert patient work I do, but I am afraid if the money stops I will not have anything.”

Bill Corcoran in Maseru