Last month, I was in Zambia, a country especially close to my heart. I was born in Zambia and lived there through the end of high school. We didn’t live in Lusaka—we lived in the “bush,” as it is still called, 350 miles from the Copperbelt in the Northwest province. Although many things have changed over the years, what impresses me most when I go back is how much hasn’t changed. Village life seems much as I remember it as a child. Many people live without running water and electricity; they have to walk miles to the nearest health clinic, school, or store. During the rainy season, which can be anywhere from  three to six months a year, many of the roads are completely impassable. We visited during the dry season, and even then the drive from village to village was slow-going.

Today, Zambia ranks 164 out of the 182 countries on the UNDP Human Development Index. This is reflected in its health statistics:

• Zambian women have a one in 38 lifetime risk of dying from pregnancy-related causes.
• One in six Zambian adults is living with HIV.
• Zambia has fewer than three nurses, midwives, or doctors for every 1,000 people.

On this recent trip, Namoonga Winnie Hamoonga, IntraHealth program manager in Zambia, and I and several other colleagues were assessing the quality of voluntary HIV counseling and testing services provided by lay counselors in the rural southern province. Toward the end of a long day of driving, we met up with Sam, the local HIV counselor. Sam has had only a couple of weeks of training on HIV counseling and rapid testing, and this is all he is expected to do. But the shortage of health workers is so pressing, and the needs are so great, when we found him in the clinic at 4 p.m., he was doing his best to attend to a stream of patients with a wide array of health concerns.

Among these patients was a young mother with a little boy about two or three years old. The boy had a high fever and was convulsing; he was incessantly crying. Ernest, the district coordinator who was with us, examined the child and diagnosed him with cerebral malaria. The clinic did not have the drugs to treat him, and there was no other transportation available. So we bundled up the child along with his mother and another relative and took them immediately back to the nearest district health center, which was an hour’s drive away. When we got there, no one was in the health center, so we had to go door to door to find someone to open the health center and ensure the child got the care he needed. I was relieved to hear later in the trip that the boy had recovered. 

The next day, we visited the Namwala District to talk to community leaders there about the importance of HIV counseling and testing and preventing mother-to-child transmission of HIV. First, we met with the chief of the area under a shady tree outside his “palace.” Then it was on to the real action—songs and speeches about HIV from the local community in an open grassy area. The crowd, mostly women, sat on the ground. A few seats were available for the guests of honor, and a spot in the shade was reserved for the village headmen. Amidst it all, a hen and her chicks clucked and pecked.  

When the performances wrapped up, the local chief stood up. First, he thanked the district health representative and IntraHealth for the work we are doing together, and then he launched into an impassioned plea for HIV treatment services for his community of 20,000 people. He pointed out that the nearest place to get antiretroviral medications is a 100 miles away—a very long way to travel for villagers who are living with HIV when there is little to no public transportation. The district has planned to provide two vehicles with mobile health care services, but they will not reach the particular village we visited.

The chief speech’s really touched a chord with me and made even more clear the challenges we have before us. Even as we expand the reach of a basic health system with lay people and community health workers, we have to recognize the tremendous need and daunting conditions these health workers face every day: lines out the door, clinics that don’t have the appropriate medications, a lack of adequate support and training and a functioning referral system, roads that make travel grueling or impossible, and as one health officer pointed out to me—even black mamba snakes. Particularly for our lay HIV counselors in Zambia, as the chief pointed out, it is very difficult to encourage people to agree to an HIV test if they know they won’t be able get treatment if they need it.

After we left the village, we went into Lusaka to meet with staff from the United States Centers for Disease Control and Prevention to discuss how we can best support the Ministry of Health to extend mobile HIV treatment services into this district and reach this village. It’s a work in progress, but one I dearly hope we can successfully accomplish. I left Zambia with many of the same thoughts I had when I arrived this time: so much hasn’t changed, and there is still so much to do.