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Reporter's Notebook: A Clinic's Strains in Mozambique

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MAPUTO, Mozambique | Heard much about Mozambique in the last 35 years?

It's a country that doesn't get much attention in the United States. It's a big place, roughly the size of Pakistan, and sparsely populated by some 23 million people. It's among the poorest countries in the world with a per capita GDP of about $500 per year (compared to about $44,000 a year per American). That's poor.

Mozambique played a role in the final chapters of the Cold War in Africa, after a liberalizing Portugal abruptly left following almost 500 years of colonial rule. As in many African countries, a Marxist liberation movement fought to pull Mozambique out of Western European hands and into Moscow's orbit. Seventeen years of civil war followed between right- and left-wing armies. After it was clear the forces of the Mozambique Liberation Front, or FRELIMO, was going to prevail politically and militarily, the Mozambican National Resistance, or RENAMO, fought a long campaign of sporadic attacks and economic sabotage before coming in from the bush and joining parliament as the opposition.

Now stable and peaceful, Mozambique is what is called an HBLI, or heavily burdened, low income country. The burden is disease, and Mozambique is so poor it can only spend a relative pittance per citizen on health care, and HIV and AIDS burn through national resources.

The other day we visited a large and busy clinic run by the Mozambican government with a strong assist from Medecins Sans Frontieres, the international medical NGO.

The pharmacist there showed me empty pallets and the dwindling stocks of life-saving anti-retroviral drugs, or ARVs, on hand for the hundreds of patients who come to the dispensary every day. The clinic had just been forced to cut back the allotment per patient from a month's worth of pills to just seven days. They had also informed the parents of HIV-positive children on the day of our visit that they would not be dispensing ARVs to children until the supply picture improves. It was, in microcosm, an illustration of the success, and burden of the success of managing AIDS as a chronic disease in sub-Saharan Africa.

It wasn't all that long ago that AIDS was more like a death sentence. Contract the virus, get progressively ill, and die ... that was what awaited almost everyone who got the dreaded news that they were HIV-positive. The new drug therapies were expensive, the medical infrastructures of many of the worst-effected countries were almost non-existent, and Africans were dying at a breathtaking pace.

Then ARVs advanced in effectiveness and steadily dropped in toxicity and price. The Bush administration introduced the President's Emergency Program for Aids Relief, known as PEPFAR, and made strong interventions in infrastructure, education and treatment. In the course of a few years, AIDS sufferers in sub-Saharan Africa reached by drug therapy moved from a few tens of thousands to a million. Today, 5 million people in countries like Mozambique are kept alive by ARVs.

Fully half of those people are kept alive by the U.S. taxpayer. It's a stunning result, a costly commitment, and a quandary about which all countries of the world are going to have to have some serious and challenging discussions.

Here's what I mean: When a government, NGO, church or other institution encounters a dying person and gives them a drug that can keep them alive for decades to come, it creates a standing obligation. Add in the new infections likely to come online in the coming years, and policymakers have created a cost that really only heads in one direction: up.

The Obama administration has made clear its intention to plateau spending on ARV support, putting any added spending into what's called capacity building (that is, helping create the ability for countries to better manage their own health care) and support for women and infant health (having found that you get significant payback from that kind of spending, in longer and healthier lives).

The U.S. is sticking with its existing commitment to ARVs, but is looking for help from the rest of the world. The U.S. made a strong, unilateral gesture with dramatic consequences for countries like Mozambique, but the day may come when governments and other institutions may have to tell a newly diagnosed AIDS sufferer, "Sorry. We are going to continue keeping those already treated alive. There are no drugs for you."

As it is, the rapid ramp-up of treatment in Mozambique is outstripping the ability of the government and other institutions to treat all the infected, instead making them wait until the viral load increases to the point when they can no longer wait to begin treatment.

There's daunting math that accompanies these decisions for caregivers and patients alike. Consider this: the simple decision to give the drugs on a weekly rather than monthly basis means an individual patient has to visit the clinic four times a month, rather than once a month. That represents something much more than an inconvenience for patients in a country like Mozambique.

On the day we visited, the courtyard and passageways of the clinic in the capital were jammed with people waiting quietly for their screening and their drugs. An already inadequate facility, straining to keep up with malaria, tuberculosis, parasitic diseases and other illnesses must now voluntarily give themselves the added burden of quadrupling the visits of ARV recipients. People living on the edge of destitution must wait for hours in a crowded facility, often missing a day of work, shelling out precious cash for rides on dangerously overcrowded buses.

The clinicians we spoke to surveyed the waiting crowds and predicted that some will simply not come as often, skipping their meds or trying to stretch the doses over longer periods, reducing the effectiveness of the medication and eventually encouraging immunity to the drugs. People who are forced to make the choice to divert precious cash to acquiring their drugs may be pushed closer to food insecurity. These drugs must be taken with adequate food. They are literally nauseating on an empty stomach... and stomachs are often empty in a place like Maputo.

Outside the capital, where the sprawl of an African city gives way to farmland, I met a woman of about 40, Leonore. Her story is pretty common: her husband left home for most of every year to work in South African mines. He came back from the worker's hostels with an HIV infection he passed on to his wife. He was never tested, denied he was sick and died.

Leonore began to lose weight, and lose the strength needed for work. She got tested, got on ARVs, and today says she feels pretty good. She's already seeing the supply problems in the clinic she visits for her drugs. She can no longer get more than a week's worth of medicine at a time. I asked if there was anyone in the area who is also on ARVs, someone she might alternate the long, slow, bus trip with ... and her answer was not surprising. Though she is open about her status, no one else in the area will admit to being HIV-positive. It's a conversation she simply cannot have with her neighbors. So in a few days she'll walk from her handmade home, on a sandy footpath through scrubby brush, to wait for the bus again.

Leonore is proud to be able to continue to support her family. She is willing to do what she has to in order to stay healthy. You can only hope Mozambique's and the world's problems don't land too heavily on her slender shoulders, and defeat her.

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