I have recently returned from a visit to Amref Health Africa’s programmes in South Omo.
I must confess that at one point during the visit I was quite convinced that before we try to reconnect anyone with their health systems, we must find someone to reconnect Amref with its marbles, for I was sure we had gone and lost them!
South Omo is one of the zones of Ethiopia’s Southern Nations, Nationalities and Peoples Region in the south-west of the country. It takes two days by road (a lot of it good road, a lot of it bad) to the zonal capital Jinka from the country’s capital Addis Ababa. Dutch photographer Ruud Taal, our driver Asnake and I arrive in Jinka on a Sunday afternoon to find Amref staff in the office. Mequanent Fente, Programme Manager for South Ari and Malle, explains that they have four training sessions the following week and must work long hours to meet their targets.
Amref has been working since July 2007 in the remote and underserved Selamago, Benna-Tsemay, South Ari and Malle districts of South Omo to support the Ethiopian government in developing a health delivery system for the nomadic communities living there. The vast region’s only hospital serves a population of nearly half a million people in a zone of over 22,000 square kilometres and the nearest operating theatre is 400km away. South Omo also faces a severe shortage of health workers. Most people do not have access to transport and the nomadic communities in particular find it difficult to seek out health care.
Every day we rise early for our visits to the projects – it takes hours to get to any of the sites on rough, narrow roads, sometimes on no roads at all. The journey to the mountainous Malle District in particular I will not forget in a long time. At first the ascent is gradual, but after a while the road begins to climb more steeply. It is a narrow road, carved out of the side of the mountain mostly through the efforts of the local people. As the vehicle crawls around sharp, hair-raising bends. I catch myself holding my breath and clinging onto the seat, instinctively moving away from the door of the vehicle, lest I cause it to tumble over the precipice on my side. Inside the vehicle there is silence; the only sound is the groaning of the Toyota Landcruiser as it bears us up the mountain.
I am suddenly struck by hysterics. It starts with a nervous giggle that quickly builds up into high-pitched laughter that has my companions looking askance at me. But I am way past caring – a mixture of unexplainable emotions has taken over. As the vehicle slowly makes its way up the steep, rocky incline, I fear it may give it all up and move in reverse back down the mountain. Why does Amref do this, I ask myself? Are we all crazy? Why would anyone in his right mind want to come and work in a place like this, in conditions like this? Why does Mequinent risk breaking his bones travelling this so-called road to reach people who are not even his friends or relatives? They don’t even speak his language!
As I ponder this, my mind calls up images of other Amref staff who do strange things in the name of work – such as Caidah Ngubane, who spends most of her waking hours with beaded and gourded spirit-possessed traditional healers, talking about TB and HIV; or John Muiruri, whose specialty is red-eyed, glue-sniffing, often knife-wielding street children. Why can’t Amref simply find some nice, safe villages outside Dar or Kampala where we can lay pipes and jab babies?
I explain my thoughts to the others in the car, and infect them with the hysteria. But our merriment dies abruptly when Asnake somehow gets us to the top of the mountain and round another narrow bend, where we are suddenly confronted by a steep, almost vertical decline that is much better suited to skydiving than driving to work. I desperately wish we could go back the way we have come, but there is no space in the road to turn the car around. As Asnake begins the descent, I screw my eyes tight, dig my fingers into the seat and knock frantically on Heaven’s door.
I have had some hair-raising experiences in the course of Amref duty. I have been tossed about in a tiny, manually navigated plane that was completely at the mercy of the elements – and didn’t those elements let us know it! I have visited the remote Tali Payam in Southern Sudan’s Terekeka County where snakes and scorpions reign supreme. I have even been threatened with abduction at gunpoint by intoxicated militiamen in Somalia unless money changed hands (it did, after intense negotiations with Amref staff).
But I have never been as petrified as I was going down the mountain that day. Not only was it steep and rocky, the narrow strip of so-called road was suspended between a high wall of rock on one side, and a sheer drop into nothingness on the other. Any small mistake could send us all flying into that nothingness. Even as I pleaded with God for safety, I began to plan in my mind how, once I emerged from the carwreck, I would negotiate with the locals for a donkey to take me back to Jinka.
We climbed FOUR more mountains. I later learnt that they are part of the East African Chain of Mountains that run from Ethiopia to Tanzania. Just when my heart was about to give way, Mequinent announced our arrival in Malle. And it was here in the remote, neglected villages of South Omo that I found the answers to my questions. My fear and apprehension vanished as I watched the people of Balla Kebele carrying stones, wood, sand and water for the construction of a health post. Despite the heat and the weakening effects of hunger due to drought, the men and women worked hard.
“We are very eager to finish this building so that we can have health services near to us,” said Singe Shirrshe, Chairman of the Kebele. “Right now if somebody gets sick, we have to travel very far to get treatment. Malaria and pneumonia are very common. Children get sick with diarrhoea and skin diseases because we have no clean water, and our women die when giving birth because there is no one to help them. We are really grateful to Amref because they are helping us to solve this problem. Once the health post is complete, we will be very happy.”
This, I remember, is the reason we do what we do – to ensure that people have access to good health, no matter who they are or where they live. It is their right. It’s a Herculean task, but Amref staff have rolled up their sleeves and are getting on with it. In Gura Kebele, home to the Bodi community, Project Assistant Ephraim Yifru uses a wooden peg to pin a picture poster to a tree trunk and proceeds to teach a group of villagers about the importance of keeping their bodies and environment clean. Gia Biobersha, a Pastoralist Health Extension Worker from the community, translates. Gia has been trained by Amref to diagnose and treat common illnesses such as malaria and diarrhea, and to provide health education at household level. He sends patients who are very ill to the Hanna Health Centre for treatment.
The Bodi are famous for their New Year festival, the highlight of which is a pageant held to choose the fattest man in the community. Contestants feed on milk and blood for at least three months before the competition and do no work in order to fatten up. On the material day, champions from each village face off in the nude to select the winner. The lucky man is awarded five or six girls of his choice. But the pomp and festivity of the New Year belie the grim reality of illness and poverty in the villages. In one tiny hut, a mother nurses her sick baby. Bodi tradition prohibits a sick child from leaving his mother’s hut, not even to get treatment. Ephraim and Gia squeeze through the tiny doorway, shoo out a couple of goats and join the mother on the floor to examine the baby, who is weak and severely dehydrated.
Outside, a tiny pot of grass and water is boiling; the mixture was being given to the baby to make him vomit the ‘dirt’ from his stomach. Ephraim gives the baby a dose of antibiotics and painkillers. Gia makes a solution of water and oral rehydration salts and instructs the mother to keep giving it to the baby. He will keep a close eye on the child.
Two huts away, another sick baby lies on the floor. He too is given a drink of rehydration salts. Without Amref’s intervention, these two babies could easily be among the 5.5million African children under five who die every year. Many of the causes of these deaths are easily preventable, as Moyon Giltoi, 27, has learnt from Ephraim’s lesson under the tree. Moyon has three children who fall ill often, especially during the rainy season. “I have learnt that if I give my babies dirty water to drink, they will get diarrhoea, so I have to boil it before they drink it. I have also learnt how to protect them from measles by having them vaccinated. I am very happy to learn these things because sometimes we have many sick children in the village and yet that does not have to be the case. We can do something about it.”
In the neighbouring Moyzo village, Amref has catalysed a process to get the conservative Mursi community to stop the cultural practice of lip lengthening. Women in the community traditionally have their lower incisors removed and lower lips pierced and stretched until they are hanging way below their chins, putting them at risk of infection and denying them the use of their lower lips. At a meeting organised by Amref and the Department of Women’s Affairs in June this year, community leaders agreed to stop lip piercing but insisted that they would continue to pull out the incisors as it was the only way they could feed sick people who were unable to eat.
“Getting them to agree to change the practice was a very big accomplishment. It takes time to change attitude and behaviour, particularly if has to do with culture. But we always listen to the community - so that decisions are made based on their needs and priorities,” says Ibrahim.
Mathewos Melese is the officer in charge of the government’s Salamago Health Office, which is in charge of Gura, Moyzo and several other kebeles, some as far as 65km away. Though the centre has been open for three years, Mathewos and his staff have not been able to reach all the people in its jurisdiction. Amref has trained nurses and extension workers based at the health office, provided medical equipment for five health posts and is assisting the government to construct more health posts. “Before Amref came most of the distant kebeles did not get any services because of lack of resources,” observes Mathewos. “Now with more trained staff and the availability of transport we are able to reach many people with essential services like immunisation and family planning. We are also able to refer serious cases such as obstructed labour and very sick children to Jinka using the Amref vehicle. Over this one year that we have been working together, there has been a lot of awareness created among the people, and they now ask us for the services. In fact, immunisation coverage has risen from 15 per cent before Amref came here last year, to 89 per cent this year.”
To reach the remote communities in South Omo with relevant and quality services, Amref lays emphasis on training of health workers in government facilities and in the communities in order to bring communities and . So far, Amref has trained 28 nurses on TB, reproductive health, sexually transmitted illnesses and malaria case management, and has provided refresher training for 132 health extension workers (HEWs); 45 of the HEWs have been equipped with skills to train other community health workers. In Limogento, the capital of Malle District, Amref is holding a one-week course on maternal and child health for 31 government health centre supervisors and health extension workers.
For Petros Wolachire, a Health Extension Worker stationed at the Balla Health Post, the course has been an eye-opener. “I have learnt that for children to be healthy, we must begin to look after them during the mother’s pregnancy, and then through breastfeeding, immunisation, hygiene and nutrition. In Balla, anaemia in mothers is common, but this can be prevented through proper nutrition. In fact, many of the health problems for mothers and children are due to lack of awareness. With the tools and training I have received I will be able to go out to the community and teach them effectively about improving health and preventing common illnesses at home.”
In Disishish Kebele, Fantaye Zenebe, a health extension worker, is putting her community education skills to work. Surrounded by a group of giggling villagers under a huge tree, Zenebe demonstrates the use of a condom using a wooden penile model. Despite the mirth, the mixed group of women, men and children listens keenly as Fantaye uses a picture book to teach them about HIV transmission and prevention. “I have been working as a health extension worker for three years, but I used to find it challenging to talk about health issues in the community,” says Fantaye.
“Now the training I received from Amref has given me a lot of confidence and improved my working skills. I have managed to create a lot of awareness. People are able to talk about HIV openly. They are digging pit latrines, pregnant women are going for antenatal care and mothers are getting their children immunised. Some community members have even volunteered to help spread the messages of health.” One such volunteer is Nigist Nigastu, 38, who is keen to teach other villagers about family planning.
Fantaye has been training her. The mother of six says all her children are very bright, but she and her preacher husband cannot afford to send them all to school. “My second child is in university. It is very expensive to maintain him there because we have to pay fees and accommodation, so there is not enough money left for the other children. I do not want other families to go through what we are going through, so I want to tell them about family planning. I have had my tubes cut so that I do not have any more children. Fantaye taught me about family planning and now she is teaching me so that I can be able to talk to people just like she does.” Nigist’s enthusiasm is an uplifting endorsement of Amref’s work and a reflection of the change that is already taking place in communities in South Omo after just one year.
The difference that their work makes to the lives of the communities is what drives the hardworking staff in South Omo. “We too were apprehensive at the beginning,” Anteneh Girma, Programme Manager for Salamago and Benna-Tsemay tells me in his quiet manner after I narrate my experiences on the road. “But we gain more courage daily from the positive results we get. When we make a difference, it is very satisfying. When we see how enthusiastic the communities are, we keep going back. In the end, it’s improving the health of the people that really matters.” Indeed it is.
Needless to say, I quickly realised that it is I who (temporarily) lost my marbles on that treacherous road to Malle. In the end, I came away from South Omo with a deep respect for the dedicated Amref staff who work there and in all other Amref projects across Africa to ensure that people can enjoy good health. Even for the people living in these remote communities Amref can help ensure that they are not forgotten and that they can be truly part of the health system. And every day, Amref learns new lessons that will benefit other remote and forgotten communities in other parts of Africa.