Where Does the Money Go?

The AIDS clinic in rural Mangunde nears completion

SOFALA PROVINCE—In 2004, Mozambique’s health ministry spent $50 million to fight AIDS. The United States dropped $27 million last year and will donate $48 million more in 2005. From the passenger seat of a pickup truck bumping along a teeth-grinding road in one of the most infected parts of the country, Aurelio Gomes has just one question: Where is the money?

“It is a big joke, as you can see,” he says, gesturing at the potholed dirt and flat plains dotted with cane houses. “There is no money here.” It’s a frequent refrain from Gomes, one of the most embittered yet proactive people I met in Mozambique. For the Mozambican doctor who resembles the aging Muhammad Ali, the desire to treat HIV/AIDS quickly has meant abandoning the international donors he sees as a patronage network and bureaucratic nightmare. After butting against that wall too long, Gomes struck out on his own. 

“Don’t say you give money to Mozambique,” he chastises the international community of his imagination. “You give money to the government of Mozambique.” Whether they work together or not, Gomes believes foreign donors like the United States and the government are not working for the country.

After spending countless hours trying to get money from these groups, Gomes hooked up with a Franciscan organization that was starting clinics in central Mozambique. He’s worked in health and development for years, but he says top officials won’t meet with him. He didn’t get money from President Bush’s giant new global AIDS initiative; he got it from the National Institutes of Health, an organization that never saw his face. After more months of battling the government, he just got permission to start treating AIDS patients with antiretroviral drugs, the cocktails that can prolong the lives of people with the disease.

Gomes’ four clinics are, literally, in the middle of nowhere. “People don’t like to live close together or near the road,” Gomes says as we bounce through the landscape, pink and purple clouds swirling overhead. Roadside stalls offer nuts, oil, and tall bags full of homemade charcoal topped with straw. We pass men on bikes with live goats strapped to the seats. Burning piles of cut grass along the side of the road obscure the route. A formal economic system barely exists. Unemployment may be 80 percent.

The African sunset takes nearly two hours to play out, but it is dark when we arrive at the first clinic, in Mangunde, more than four hours’ drive from Beira. The next morning I see that it would be an exaggeration to call Mangunde a town. It’s a school, a farm, and a three-building, one-story hospital, all run by the Franciscans. If it weren’t for them, Mangunde would be just another dusty intersection. But Gomes’ work is bearing fruit. The clinic now sees 2,000 people each month, and the nuns are putting the finishing touches on a new building designed to treat AIDS patients.

Dr. Aurelio Gomes and a Franciscan nun discuss construction of a clinic for AIDS patients in rural Mangunde

These clinics will get ARVs from the Community of Sant’Egidio, a Catholic lay group based in Rome and affiliated with the Vatican. Sant’Egidio helped set up the 1992 peace agreement that ended 17 years of civil war in Mozambique, so it has a special status for some Mozambicans. That status allowed them to establish the country’s first ARV clinics as well as the first public diagnostic labs in sub-Saharan Africa. Now they run 13 clinics and have 3,900 people on ARVs, about half the country’s total. Sant’Egidio says that by plunging ahead it dragged the country to the realization that it could treat AIDS on a large scale. Like Gomes, they operate with the government’s consent, but outside its structures, a position in which the group takes pride.

“The word ‘emergency’ can accord with the word ‘quality,’ ” Stefano Capparucci told me the day before I embarked on my journey with Gomes. Capparucci, who, with his round glasses, cigarettes, and flannel shirt looks like a shop teacher, is one of a rotating group of Italian medical volunteers who spend a month at a time in the country. He showed me around a Sant’Egidio AIDS hospital in Manga Chingussura, a slum outside Beira. The one-story building held several small exam rooms, an ice-cold pharmacy, and computers logged onto a database linked to clinics all over the country; as blood samples, patients, and drugs shuttle among hospitals and labs, the computers keep efficient track of the system.

Patients lined up to meet with doctors and get supplies of ARVs, as well as antibiotics and TB drugs. Sant’Egidio also provides its patients with food: sugar, flour, oil, beans, and, for nursing mothers, formula and a filter that makes water safe to mix it with. It’s what Capparucci calls the “golden standard,” treatment equal to Western norms. “We could do the minimum, but it’s not our philosophy,” he said. “We hope in the future we will be here to do the golden standard for everybody.” Sant’Egidio’s drug regimen costs $300 per person per year, almost half the cost of the cheapest drugs the U.S. government buys to treat AIDS patients overseas. Add in care and lab tests, and treating an AIDS patient costs them $700 a year.

Sant’Egidio also trains Mozambican volunteers to work in their communities, educating people about AIDS and bringing sick people to the clinics. Most are HIV-positive women who Sant’Egidio has restored to life with ARVs. As we walked past an open-air, metal-roofed waiting area, one volunteer whose daughter died of AIDS read aloud to the group, translating a Portuguese text on health and hygiene into the local language. She was an older woman, full of enthusiasm. “Oh, how I love this grandmother,” Stefano beamed. The feeling was mutual. The volunteers ran to greet Stefano when we arrived, and kissed me hello, thinking I was also Sant’Egidio.

Not everyone is so magnanimous. “They are scaling up quickly with lots of mistakes,” says Dr. Eduardo Matediane, an obstetrician who helped start an AIDS clinic at the government’s central hospital in Beira. “If you scale up quickly, quality will go down.” Treatment is all well and good, he said, but patients need to be monitored and programs developed so they can be sustained. The central hospital gives extensive counseling to patients before they start ARVs. Some patients come into the clinic every day for the first six weeks of treatment to deal with side effects and make sure they stick to the pills. Sant’Egidio did not participate in efforts to coordinate a nationwide approach to the disease and doesn’t always work with other groups. The fact that volunteers come and go each month means that lines of command and communication are often unclear to outsiders. “Sant’Egidio doesn’t get it,” says Wendy Johnson, the Mozambique field director for Health Alliance International, a U.S. group working with the Mozambican government.

To Gomes, the government symbolizes inefficiency. Once private money is spent, the government swoops in and declares it a success. ” ‘We give you permission to do treatment, so we can take credit,’ ” he says mockingly. “I say bullshit.” Gomes wonders why so much money has come in to the government plan and yet so many patients are being treated by Sant’Egidio. Johnson and others say that for the impoverished health system to ever stand alone, investment should go through the government, even if that takes longer. “We’re not in competition to try to see who can treat the greatest number of AIDS people in the shortest period of time,” Johnson says, puzzled at Sant’Egidio’s approach. The AIDS epidemic will probably get much worse before it gets better, which is why she thinks investment is important to improve conditions in health, transportation, and other sectors. “We’re all in this together.”