When I arrived in Mozambique, it felt like I was in a South American country. It is a tropical paradise and one can feel the influence of the Portuguese that colonized this country long ago. Mozambique is beautiful and rich in history both interesting and tragic, like most African countries that have been colonized. Mozambique is in Southeast Africa and it is bordered by Tanzania to the north and South Africa to the south. The Indian Ocean is its eastern border and the countries of Malawi, Zambia, Zimbabwe and Eswatini border the north to northwest.
The population of Mozambique is about 30 million. It is one of the countries most exposed to climate change with temperatures rising twice as fast in southern Africa as the global average. Economically, Mozambique has many mineral resources, such as coal and rubies, but it remains one of the poorest and most underdeveloped countries in the world.
Natural gas was discovered in 2011, with 150 billion cubic feet of recoverable reserves off the coast of northern Cabo Delgado Province. Once developed, it could make Mozambique one of the largest producers of liquified natural gas in the world. Production by the Total company was scheduled to start in 2022 prior to the pandemic. Between the sporadic terrorist attacks and COVID-19, all that is on hold indefinitely.
Despite its wealth of natural resources, Cabo Delgado is one of the least developed provinces in the country. Since the end of the civil war (1992), this wealth, particularly rubies, has attracted many migrants from Tanzania, Somalia, Senegal, Mali, Eritrea and Pakistan. The local Muslim community has been confronted with a wave of radicalization.
All political issues aside, the people are kind and welcoming. My national staff colleagues speak a gentle, easy to understand Portuguese. Mankua is the local language most commonly spoken by the people in the camps and when I speak to them, I speak through my interpreter as he fluent in Mankua .
Violence erupted in 2017, when an unknown group of armed men attacked civilians in the province of Cabo Delgado. Since then, several attacks have occurred in different cities around the province, displacing huge amounts of the population as they literally run for their lives. Many people have been killed, including children, some who were beheaded in front of their families. There are currently an estimated 800,000 people internally displaced in Cabo Delgado with camps spread throughout the province in the areas that so far, have remained untouched by the violence. In spite of heinous nature of these attacks, the people who have been killed and the sheer number of people displaced, this hardly makes the news. Most of my friends had no idea there was even anything going on in Mozambique.
I had been here just a few weeks when, at the end of March, there was another attack in a city north of here. Many people fled to the bush as the violence began. These attacks are without warning, so no one has time to gather even the most meager possessions or food. They flee on foot and spend days in the bush with no food or water. Eventually, some make it north to the Tanzanian border. Some make it to the shore where they flee in boats and sail further south to Pemba where we have our base.
They arrive terrified, traumatized, dehydrated and hungry. Some of them are injured. All arrive seeking refuge. Our objective is to provide medical assistance, stabilize patients and ensure the ones in critical medical condition get sent to on to a higher level of care. The primary goal is to save lives.
Children are among those who have fled. We cared for one baby with a bullet wound. Pregnant women are also among the wounded and traumatized. One woman who was about seven months pregnant had significant bleeding, probably a placental abruption; her baby had already died. Mothers arrived with day old babies who had been born in the bush after fleeing the terrorists, having birthed in very difficult and unsanitary conditions. Most mothers I saw were in shock, dehydrated and hadn’t eaten for days. Trauma and stress in combination with the food deprivation was enough to keep them from producing an adequate milk supply.
To say that treating people under these circumstances is gut-wrenching, would be an understatement. I really have no words to describe the level of trauma I see daily. Many of the women have experience sexual violence at the hands of the terrorists. Some of the women, now in the camps, experience domestic and sexual violence there as well. The stress, crowded conditions and food scarcity brings out the absolute worst in people.
Caring for the survivors of sexual violence is a big part of my job as it falls under sexual and reproductive health activities (SRH); it is also the least favorite part of my job but probably the most important. Together with the mental health team, we treat and counsel the survivors. The treatment plan for sexual violence survivors is the same in all project and consists of the following: pregnancy test, HIV test, emergency contraception, PEP (post exposure prophylaxis), STI prophylaxis, and vaccination for hepatitis B and tetanus. Men and boys are also seen in the clinic as sexual violence survivors and the same protocols exist for them except of course for pregnancy test and emergency contraception. The survivor has the right to decline any all treatment and testing and some do and only come for mental health services. We facilitate referrals when requested, to local authorities but do not get involved in the legal process aside from providing a health certificate.
There are days when working in the camps becomes overwhelming just due to the sheer volume of patients we see. Babies with complicated malaria, mothers with sepsis due to unclean birthing environments and children with severe dehydration from extreme diarrhea. There was a cholera outbreak which was ending just as I arrived. Now we are heading straight into malaria season.
Malaria is endemic to Mozambique and 100% of the population is at risk for it. Plasmodium falciparum, the deadliest type of malaria (there are 4 types) accounts for 42% of deaths in children under 5 years old in Mozambique. We use Coartem to treat malaria and we ran out about 3 weeks ago. Since then, we have seen a steady increase in complicated malaria among babies and young children.
My interpreter is from the north where the violence first occurred. He fled to the south as well and was able to find a job as a daily worker with us doing interpreting. He speaks Portuguese, English, Mankua and at least 3 other local languages. He shared some photos with me of his time hiding in the bush with his family. He said they went for 3 days without eating. When they came to a stream along the way, they were able to drink but didn’t know how long it would be before their next encounter with water so the women took one of their layers of fabric off and soaked it in the stream and then balled it up to keep it as wet as possible. They stopped periodically to take the fabric and wring it out into the children’s mouths so they were able to stay hydrated. Pure survival.
This is the second time I have worked in a refugee camp, but the first time I am working in mobile clinics. This assignment is much more resource poor than the last. The care we can give is very basic and anything more complicated must be referred to the nearest health center, which is also basic but with a few more resource than what we have, including the ability to treat people on an in-patient basis. The mobile clinics only operate from 9 to 3 Monday through Friday.
Working in an unstable context with the constant threat of violent attacks makes it a little more difficult to completely relax when we are back home after a long day in the field. For this reason, emergency missions are shorter (average 3 months), because they tend to be more stressful. Although we do manage to find reasons to celebrate any chance we get. Birthdays, expat departures, a national holiday are all cause for celebration which consists of gathering around the pool, having a BBQ, playing loud music and dancing.
This week marks the halfway point in my assignment. There is still a great deal of work to accomplish in that time and probably an equal amount of human suffering to witness. As daunting as the prospect is, I think about what Mr. Rogers said his mother told him as a boy about scary things happening, “Look for the helpers. There are always people who are helping.” And I know I can go on because, that’s us! We’re the helpers! We can’t let Mr. Rogers down.
Midwife Without Boundaries 