When I first saw the list, I knew it would be an adventure. Thirty health centers had been randomly selected from within the North Gondar area. Some were easy to travel to, some were impossibly remote, but they all needed to be visited in person. Some seemed to exist only on the list itself, as maps of the area tended to be old or incomplete. An initial search of several paper and internet based maps held location clues for only half of the centers.
Adino (the SCOPE/FLAME project manager) and I planned trips and mapped routes. Some clinics were located in a mid-sized town or right on a paved road. Most required bumpy rides in the dirt, battling the mud during the rainy season and the choking dust after the rains ceased. I remember on one early visit, a rutted dirt road leading to the health center wound through a maze of dense village homes- many so close I wasn’t sure the car could pass. As the driver expertly
threaded our way through, we had to stop several times to allow clothes lines spanning the road to be lifted. It was clear that cars had been scarce here.
Still, there was one section on “the list” that worried me. The Woredas (districts) of East and West Belessa seemed to be a black hole of information. I could locate only one of the six places we needed to visit on any map. Adino worked the phones, calling contacts in the Ministry of Health, gathering information on the locations of health centers and the road conditions nearby. Google earth showed no evidence of paved roads anywhere in the Belessa area. It was arid, sparsely populated, and seemed almost impossible to access. If the goal of the FLAME study was to test whether the SCOPE intervention worked in more rural areas, farther from Gondar, we had certainly found an extreme example.
After only 30 minutes on a paved road leading out of Gondar, we turned onto a dusty, single dirt lane heading into the eastern hills of Belessa. The rainy season ended in September, and the wild brush and planted fields alike were beginning to fade from a vibrant green to a parched beige. The ever-present child animal herders, with their goats, sheep, and cattle charges, scattered from the road as the driver tapped his horn to warn them. Usually this space belonged to the livestock.
We chugged up the side of an imposing hill, bare except for the low brush and lonely huts every few kilometers. It was noticeably hotter than Gondar, and the growing intensity of the sun reminded me how close we were to the equator. Emerging past the apex of the hill we caught our first glimpse of the wide, flat valley hosting the town of Arbaya, the capital of west Belessa.
We quickly gathered the data we needed from the health center in Arbaya and confirmed our directions to Jandeb, the next site on the list. However, outside of Arbaya, the conditions quickly worsened. We were the only car on the rocky, sloping terrain. We picked up locals to help us discern the road’s boundaries- the dirt spread
in all directions, and an unexpected turn in the barely discernible road could go unnoticed. We crossed rivers and chugged up hillsides, getting out to push the tired vehicle every now and then. After many miles, we were faced with an incline the car could not handle, and we set off to complete the journey on foot.
In the tiny village of Jandeb, small clusters of huts clung to the side of a hill, and livestock wandered freely. The small health
center was open for business, and a midwife helped us gather the data we needed. Despite the remoteness, the health center seemed fairly well supplied with the medicines and tools needed to tend to normal deliveries and provide basic medical care. Again, I was awed both by the difficulty of the terrain surrounding the clinic, as well as the strength and endurance of the local residents. Several times on our hike we were easily passed by women and children carrying unfathomably large loads, chatting as they navigated the rocky path in thin plastic shoes.
At the health center, the midwife motioned to a long building constructed out of mud and sticks. It was where the health center staff lived, since there was no housing available in the tiny village itself.
“Is it difficult to live in such a remote place?” I asked the midwife. I knew that health care workers typically trained in cities and were then placed wherever they were needed.
“Oh yes,” he sighed, “most people do not stay here for long.”
On the way back to Arbaya, I thought about the effect that this high turnover must have on the people’s trust of their health care providers. I had just read a research article showing that trust in one’s midwife, and confidence that the midwife will act with professionalism and respect, is one of the biggest factors drawing Ethiopian pregnant women to give birth in safer places like the clinic in Jandeb. But how could the women trust a clinic when the staff was constantly changing?
I thought about the people in Jandeb who didn’t change. Local, trusted women, called Health Development Army members, liaised with the health center to make sure health messages reached the people. And priests- priests are the bedrock of society in places like these. As Dr. Getahun keeps reminding me, “rural people are very, very strong. And very, very religious.” Local Priests, or Soul Fathers, as they are called here, are the first ones called upon when a family has a need. They are trusted confidantes and respected advisors. And they invest long-term in the areas where they are based.
The clinic in Jandeb stands ready to serve, but the connection to the community may be hard to maintain with the high turnover of staff. In such remote locations, I believe it is even more important to connect quality health care to that which is permanent and trusted in the community. SCOPE trains Health Development Army members and Priests to work together to seek out pregnant women and provide advice and support, bridging their way to the health center. The people who live in rural areas are truly very strong. And they deserve to have a strong connection to, and strong trust in, the health care services that may mean the difference between life and death.
The SCOPE team completed three assessments in Belessa on that trip, though several more remote clinics still need to be visited. We’ll be back to Belessa soon, along with nearly every other Woreda in the North Gondar zone- no matter how remote.