Deye mon gen plis gwo mon ke Ayiti!
(Beyond the mountains there are much bigger mountains than in Haiti!)

By Joia Mukherjee, PIH Medical Director

Partners In Health began working in Lesotho in 2006.  Lesotho is a very mountainous and rural country. Only about 10 percent of the 2 million Basotho people live in the capital. The remainder live in small towns in the lowlands or extremely isolated villages in the mountains, where there are no roads, no electricity and no communications. At the time, almost no one in the rural areas of this country where the HIV prevalence is 25% knew their status or was receiving life-saving, highly active antiretroviral therapy (ART).  But since August of 2006 all that has changed in the small villages of Nohana, Bobete and Nkau. 

Wings over Lesotho

On August 22nd we celebrated the first anniversary of beginning HIV treatment in the mountain town of Nohana. This was no small feat and it was no small party!! 

When PIH arrived in Nohana, there was no ART available and no consistent infrastructure to support it. Rural health centers like Nohana are served by the Lesotho Flying Doctor Service (LFDS), an arm of the Ministry of Health, in conjunction with the pilots and logisticians of Mission Aviation Fellowship. Because few medical staff are willing to live in the difficult and isolated environment of the mountain clinics, the LFDS system is based on monthly visits of a medical team to the health center. This system, of course, was designed well before the AIDS pandemic. And many within  LFDS, like Nohana’s amazingly committed and talented chief nurse Me Moso, believe that the system must change to provide care that is available to all, when they need it and even closer to their mountain homes.

Enter Partners In Health (Bo-Mphato Litsebeletsong tsa Bophelo). Nohana, and later Bobete and Nkau were the perfect spots to implement a model of rural HIV/AIDS care that is based in the public sector, integrated with primary health care and connected to the village and household levels by community health workers. Nohana was the first. Village health workers (VHW) were trained and engaged in education, case finding and treatment not only for HIV, but for TB, malnutrition and other problems. Most importantly, they were considered an integral part of the team and paid for their work.

As in many countries in which PIH works, the model of community health workers existed in Lesotho prior to PIH’s arrival, but, also like many places, they were largely uncompensated volunteers. Without pay, these rural people who manage day-to-day survival by tending their land and their animals, were not able to devote the time needed to care for their community members, especially given that clinics are far from some villages, often 8 hours walk or even 10 hours by horseback. In Lesotho in particular, many VHWs had died or become discouraged due to the raging HIV epidemic.

The PIH team of Country Director Dr. Jen Furin and Nohana Clinic Director Dr. Jonas Rigodon had experienced some of these challenges before. Jen’s work in Peru had brought her face to face with the despair of families decimated by MDR-TB and was experienced at implementing treatment as not only a medical intervention, but as an intervention of hope and solidarity. Jonas, as Director of the Thomonde and then Hinche clinics in Haiti, had the experience of using HIV testing and treatment as a “Chwal Batay”—a battle horse to improve all services from the detection and treatment of tuberculosis to the treatment of children with malnutrition. Yet both Jen and Jonas tell me that they were unprepared for what they encountered in the mountains surrounding Nohana. 

The suffering of people—in isolated mountain regions where the HIV prevalence is estimated to be higher than 30 percent--was staggering. The number of orphans, rates of tuberculosis, and the disintegration of families, due to massive migration of men to work in the mines in South Africa, would be daunting to anyone. Yet the Village Health Workers who came forward were remarkable people, they participated in training and walked many hours with patients too ill to support themselves.  They understood, from the beginning, the notion of solidarity. 

 Me Moso gives Dr. Jonas a traditional Basotho hat

Nohana also had, arguably, Lesotho Flying Doctors’ Service’s most dedicated nurse, Me Moso.  After 6 months of working with the PIH team, Me Moso turned down her planned transfer to Maseru (the capital city where her family lives) to stay and work in rural Nohana. It was this stalwart team that began the implementation of integrated HIV services and primary health care in Nohana and its surrounding, remote villages. And in August of 2006, the first patients were initiated on ART. Since the beginning of the program in Nohana more than 3,100 people have been tested for HIV, of whom more than 950 tested positive and 486 patients were started on ART with daily accompaniment by Village Health Workers. 

In addition, thousands of patients have visited the clinic for primary care, most of whom had never had access to a clinic that was open, stocked and staffed every day.  In this first year, two additional clinics, in the villages of Bobete and Nkau were also revitalized and have had a similarly profound impact on the community. It was the successes of Nohana in this first year, but also the successes of the PIH-Lesotho Ministry of Health-Clinton Foundation-Mission Aviation Fellowship-Irish Aid collaborative project in these three rural areas that was celebrated on August 22, 2007.

Soccer tournament kicks off anniversary celebration

 Me Moso gives Dr. Jonas a traditional Basotho hat
Me Moso gives Dr. Jonas Rigodon a traditional Basotho hat and blanket

The celebration began the night before with a staff party. The staff of the Nohana clinic—from cleaners to nurses gave toasts and sang. (can put an audio clip here)  The singing was among the most beautiful I have ever heard. Jen told me that in Lesotho, it is impossible to sing the national anthem alone. It requires harmony. What a beautiful metaphor for our work. Both Jen and Jonas received words of real love and gifts from the staff.  Both received the famous Basotho hat and Jonas was given the blanket that is worn as a coat while Jen was presented with a traditional Basotho dress. It was clear by the evening’s activity that the Basotho-American-Haitian team was one. 

The following day started with a massive soccer tournament in which teams from the villages surrounding Nohana had been invited to participate.  The PIH-Clinton gang also fielded a team—led by Drs. Nico and Jonas in the front line as well as Archie, TK, Bokang, Kose, Moses, Malebu, Kala, Paola, Albert, Bob, Jaclyn and others. 

The first round spelled disaster for the PIH-Clinton team, which suffered a 5-0 drubbing.  When I admonished Jonas for the loss he said, “But Joia, they are professionals!” Professional soccer players?? In the mountains of Lesotho?? I had my doubts. But I will have to admit that our opponents did, suspiciously, have their own jerseys and refused the tee-shirts we brought them).  Our loss proved once again, however, that treatment works. Surely many of these “professional” players were our patients. On a historical note, this isn’t the first time a PIH clinical team has lost to patients in soccer. Perhaps our most famous defeat was when the TB doctors from PIH and Tomsk prison lost a soccer match to a team of patients with multidrug-resistant TB.  I am sure they were professionals too!! 

 PIH-Clinton soccer squad
The PIH-Clinton soccer team, minus its secret weapon – the three-woman "12th man"

Back in Lesotho, we fared much better in the second round, winning 3-1.  We deployed a secret weapon in this game—a twelfth position on the field shared by three women,  Dr. Limpho, Dr. Mona and Dr. Joia. While we didn’t score the winning goals, I am quite sure that the twelfth man (or should I say women) razzle-dazzle played a role in the victory!! Goals by Kala Tlali, our driver in Mohahna, and Dr. Nico also helped. And the effect of the entire Nohana clinic team, led by Me’ Malehloko, singing in four-part harmony throughout the match cannot be underestimated!  But I will leave the strategic analysis to the experts. The fact is that the PIH-Clinton team was the happiest consolation game winner in the history of “professional” soccer. It should be noted, that throughout the match Jen quelled her deep desire to play soccer and kept the clinic running!!

Pomp, circumstance, speeches and song

In the afternoon of August 22, the pomp and circumstance began. We heard, from early in the day, the sound of the planes.  All five Mission Aviation Fellowship planes made several trips each bearing our guests—our good friends from Irish Aid, more staff from LFDS, Lesotho’s Permanent Secretary for Health. Then helicopters began to descend on this small mountain village, bringing Congressman Jim McDermott of Seattle (who was at the original NIH-sponsored Models to Implementation Forum in Cange, Haiti, in 2003!), our good friend, former head of the Lesotho Clinton team and now Minister of Health Mphu Ramatlapeng, the US and Irish Ambassadors, and, along with many other dignitaries, the Prime Minister of Lesotho Pakalitha Mosisili.

Before the ceremonies began, there was some time for mingling and seeing the new facility at Nohana.  Lesotho’s Secretary General of Health spoke to Drs. Nico Lesia and Limpho Ramangoaela our Basotho doctors (see Paul’s notes from Lesotho) and said, “ Thank you for returning to serve your people and your country, we aim to find more people with your spirit and commitment. Will you help us find them?” The Secretary General gave them his personal cell phone number and encouraged Nico and Limpho to work with him on recruiting others to come home. When he asked how their experience was, Limpho replied, “Work is so much more meaningful when you serve others and serving others is so much more meaningful when you are in your own country, with your own language and your own culture.”   

A crowd of more than 2,500 people had assembled at the Nohana health center to celebrate this day and to welcome these distinguished visitors. Many of those in attendance were themselves patients and Village Health Workers, all of whom had invested much in the last year in the notion that health and solidarity can build community. The ceremonies started with a prayer by Father Francis of Nohana. Father Francis reminded the attendees that health has physical, spiritual and mental dimensions and that building a community through the provision of health care addresses all those aspects of health and is truly God’s work. He remarked on the labor of love that is performed daily by the staff—from those who clean the grounds, to the VHWs who accompany patients to the doctors and nurses who serve Nohana. 

 Village Health Workers singing
Village Health Workers singing during PIH-Lesotho's anniversary celebration.

Several dignitaries spoke about the amazing progress that has been made in Nohana, including Paddy Fey, the Irish Ambassador to Lesotho, who delivered his address in beautifully spoken Sesotho.  Congressman Jim McDermott said in his work to support the Global Fund and the Millenium Challenge Corporation he never imagined what this money could do for rural Lesotho. A group of Village Health Workers sang a song thanking Dr. Jonasi and Dr. Geneva (PIH Country Director Jen Furin’s new name). (Click here for the lyrics of their song.) They were followed by Paul Farmer, who praised the leadership of Jen Furin and Nohana Clinic Director Jonas Rigodon. Paul also remarked on the amazing solidarity of the team that has been built in Nohana in just one year. Two patients testified to the gathered crowd how their lives have been changed not only by the availability of antiretroviral therapy but by the caring, concern and friendship of the whole team. 

Me Moso gives Dr. Jonas a traditional Basotho hat 
Village Health Worker speaking at Nohana anniversary celebration

Speaking on behalf of her colleagues and the community, a Village Health Worker addressed many of her remarks specifically to the Prime Minister as she proudly declared, “Mr. Prime Minister, we appreciate that you have come here to honor our work.  And I want to tell you, on behalf of the Village Health Workers, that we are not opposed to hard work. We love our country and our people. We will walk through these mountains until the soles of our shoes are finished. But we need to be paid. When PIH came, they realized the merits of our work, they included us in the plan and paid us for our labor. The program you see today is our work. When we come to clinic, it is a sharing experience.  Please, Mr. Prime Minister, tell your government that Village Health Workers must be paid if we are to change the situation [with HIV] in our country.  We don’t need to be wealthy, just respected.  And if you are committed to this work you will bring us telecommunications and infrastructure. If we had cell phones, we could help so many more people who suffer in isolation. And if there were roads, our burden would be lighter.” By this time, the entire crowd was on their feet cheering the words of their community member, colleague and friend as she respectfully but boldly addressed the Prime Minister of Lesotho, who was visiting Nohana for the first time. 

A parade of Basotho horsemen on beautifully decorated horses came down from the mountains and bowed before the Prime Minister. And when he spoke, it was clear that the work, the ceremony and the words of the patients and VHW had profoundly moved him.

 “What I see here is remarkable commitment,” Prime Minister Mosisili said. “The parliament is very interested in the issue of health and delivering health to the rural areas. However, it is difficult to imagine how this can be done.  Today, I see. I see the role of people themselves in delivering their community back to health. Yes, you must be paid, all of you Village Health Workers who serve your fellow countrymen. You have my promise that I will work for your just compensation.”  The crowd was visibly stunned by the direct response of the Prime Minister to this local health worker’s words. The Prime Minister closed the ceremonies stating that Nohana was a model of hope of what can be done in Leostho.

When the day ended, an exhausted PIH team watched the stars as they appeared in Nohana’s jet black sky. The same stars were there one year ago. But now the earth has changed.

[published September 2007]