Reaching the Last Mile: The Trachoma Investigators of Mozambique

A child receives antibiotics for trachoma during a campaign in Mozambique. Many Mozambicans are no longer at risk for the NTD and the country is working to eliminate the disease. Photo credit: RTI International/Damien Schumann.

A small boat slips through narrow channels off Mozambique’s Zambezi River, carrying a special team of investigators.

They don’t have badges or uniforms — but they are certainly on a mission.

The team is part of a global effort to investigate why some geographic areas are falling behind in the fight against neglected tropical diseases (NTDs) and to design solutions to ensure every affected community can eliminate these diseases.

USAID’s Act to End Neglected Tropical Diseases | East (Act | East) program, led by RTI International, supports Mozambique’s Ministry of Health to eliminate trachoma, an NTD that can cause permanent blindness. Despite continued rounds of treatment, rates of trachoma remain high in Chinde district, a result that contradicts progress demonstrated in many communities within Mozambique and around the world.

“We launched an investigation in collaboration with the Ministry of Health, not just from our desks in Maputo, but in Chinde itself,” said Dr. Mawo Fall, Act | East lead in Mozambique. “As trachoma elimination edges closer in Mozambique, we need to understand how we can better reach the most remote and vulnerable communities, like Chinde, so no one is left behind.”

Crocodiles, Hippos, and NTDs

The Ministry of Health investigation teams supported by Act | East, started by examining community, district, and provincial data to zero in on potential problems and gaps.

Next, it was time to make the journey to Chinde.

A port city on the Indian Ocean in central Mozambique, just reaching Chinde itself is a trek. Travelling there from Mozambique’s capital city of Maputo requires a three-hour plane ride, five-hour drive, two-hour boat ride, and another 45-minute drive.

And that is just the beginning.

Many parts of the wider district are extremely hard to access, requiring four-wheel vehicles to navigate tough terrain and small boats to navigate narrow water channels. In the boats, teams contend with crocodiles, hippos, and other hazards — often taking the really long way around to avoid danger and safely reach remote communities.

Once there, the investigation team worked to identify challenges and to determine how treatment campaigns could be improved. No matter how difficult locales are to get to, the teams visited communities where trachoma prevalence remains high, interviewing key people at all levels of the NTD response — from provincial medical chiefs to local leaders to the trained volunteers who distribute the antibiotics during treatment campaigns.

They discovered that some communities were even more isolated and remote than anticipated. Supervisors, who play a key role in ensuring the quality and effectiveness of treatment campaigns, were struggling to reach these communities due to intense logistical obstacles. They also found that access to safe and clean water, sanitation and hygiene services were limited in many of these communities.

Once the investigation was complete, the team worked to rapidly respond to findings in time for the next round of treatment, which was scheduled a couple of months later.

“We had to make sure that what we have found in the investigation was quickly reflected in reality,” said Dr. Marilia Massangaie, Director of NTDs at Mozambique’s Ministry of Health. “For the next treatment campaign, we allocated additional resources for more pre-planning, more volunteers and supervisors, more boats and motorcycles, and more intensive social mobilization, and more extensive training for community drug distributors.”

Beyond Chinde, the Ministry of Health is debriefing with each level of Mozambique’s NTD response, including all NTD focal points across the country.

“Findings from the investigation must ensure not only that Chinde’s next treatment campaign is as successful as possible, but that other districts facing similar challenges can be more effective at reaching hard-to-reach and vulnerable communities,” said Dr. Massangaie.

Mawo Fall points at a group of hippos during the supervision of trachoma surveys. Some areas in Mozambique are only accessible by water — making hippos just one of the challenges faced in reaching communities. Photo courtesy of Mawo Fall.

A rapid and systematic approach to investigation

The investigation in Chinde is part of a wider effort to achieve global targets for trachoma elimination, often in extremely challenging environments.

Sometimes, the reasons for slow progress are abundantly clear or even anticipated due to known variables like tough logistics. Other times, it takes an intense amount of sleuthing to decipher why a specific community has not seen the reduction in disease that was expected.

Act | East has taken a rapid and systematic approach to these investigations, working closely with ministries of health to investigate issues in districts that — based on various surveys — seemingly are unable to meet programmatic target thresholds, and therefore may require a different approach.

Like in Chinde, this investigative work is rapid, often beginning within 48 hours of receiving results, with the clock ticking to make changes before the next round of treatment; it’s collaborative, with Act | East working closely with ministries of health, the World Health Organization, and other partners; and it’s data-driven, often using a gender equity and social inclusion lens to ensure we understand who is being missed and why.

Even without cool badges and uniforms, and despite the crocodiles and hippos, Mozambique’s trachoma investigators who doggedly reach remote villages and communities in districts such as Chinde are a critical part of the global mission to eliminate NTDs like trachoma once and for all.

The Act | East Door to Door, Community by Community series (#DoortoDoorForNTDs) features the stories of health workers, volunteers, and others on the frontlines who are forging ahead — during a pandemic, no less — to safely eliminate neglected tropical diseases. Thanks to the commitment and tenacity of NTD fighters like the trachoma investigators of Mozambique, communities and countries are edging closer to NTD control and elimination goals. Contributions from Mawo Fall, Sabrina Eyob, Laura Cane.

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