Rugged Roads and Flooding Rains — Daily Hurdles to Global Health Delivery

Some of the winding dirt roads in Neno District, Malawi (Zack DeClerk / Partners In Health)

In early March, the Malawian government issued a severe weather warning for central and southern regions of the country amidst four days of torrential, nonstop rain. The warning quickly became a national emergency as the storm engulfed roads in mud and strong winds caused widespread damage. Impacts were particularly acute across southern Malawi — homes collapsed, bridges washed away, roads caved in, and power supplies crippled. Despite this intense weather, clinicians, procurement teams, and — just as importantly—their drivers were still traveling far each day to ensure community members were able to receive high-quality healthcare.

“But what else can I do? People are waiting for us,” a clinical officer and colleague at Partners in Health (PIH) said to me, shrugging. He and two other clinicians took an ATV from central Neno to Nsambe Health Center, making the slow climb up the rugged, winding dirt road to the top of the mountain ridge. They were dressed in rain gear and anticipated returning much later caked in mud, as they intended to carry out the 131 patient appointments scheduled at the weekly clinic hosted at Nsambe, one of the most remote locations in Neno District.

Then, just days later, Cyclone Idai devastated southern Africa, decimating Mozambique and Zimbabwe and displacing tens of thousands in Malawi after massive flooding destroyed countless homes and ruined precious crops just before harvest. As of March 25, Idai’s death toll reached 750 people, with relief efforts still continuing.

Recovering from one of the worst natural disasters to ever strike the Southern Hemisphere will take years and require massive support to meet basic needs such as food, water, and shelter. But it also highlights another fundamental need, the importance of which I’ve seen firsthand in recent months: safe, reliable transportation.

Rugged Roads

When I first accepted my position as a Global Health Corps fellow with PIH in Neno, Malawi, I was constantly warned: “be ready, the roads are terrible.” In the months since, I’ve seen what a daily challenge that really is. While I had a theoretical understanding of poor road conditions as a hurdle to global health delivery, I had never truly grasped how severely transportation, driver competency, and mud can impact health equity.

Neno District, a remote mountainous district in southwestern Malawi, is home to approximately 175,000 people across 14 catchment areas. From Blantyre, the second-largest city in Malawi, the drive to Neno is about an hour along the M1 highway before the turnoff at Zalewa, where the road becomes unpaved and rocky. From the turnoff, the drive continues for 20–30 minutes, crossing a railroad track and passing Lisungwi Community Hospital, before passing through Lisungwi River (as long as the water is low enough). Immediately after the river, the dirt road gets dramatically steeper, with another 45 minutes of a winding, climbing mountain road. It is a beautiful setting with a breathtaking horizon full of tree-covered mountains, but also a bumpy, wearisome ride requiring skilled maneuvering.

This trip gets even more tiresome during the rainy season,” everyone kept repeating to me, “because of the Lisungwi River crossing.” That crossing isn’t always easy or advisable. When the water is too high and moving swiftly, we have to take a roundabout route, adding at least another hour to the journey.

Road conditions returning to central Neno from Dambe (Elise Mann / Partners In Health).

However in early January, the government completed the construction of a long-awaited bridge over the Lisungwi River, making it possible to take the most direct route to central Neno, no matter how high the water is. I shared in the excitement of my colleagues — each time I drive across this bridge, I’m filled with gratitude. After March’s unanticipated storms, however, there are already concerns about soil erosion affecting the bridge. That’s how quickly road conditions and infrastructure can change in Neno — and our skilled, dedicated transportation team has been dealing with those changes for years.

Rising Costs

In upper Neno, PIH’s transport team manages a fleet of 17 vehicles, four ATVs, and 22 motorbikes. The rocky terrain requires them to change a vehicle’s tires every six months and replace the shocks every three months. The closet fueling station is over an hour away (although one is currently under construction in central Neno — stay tuned!), so the transport team has to closely track fuel and mileage and haul drums of fuel up the mountain when a vehicle runs out.

Transport Officer Mabvuto Chifenthe (Zack DeClerk/Partners In Health)

Transport Officer Mabvuto Chifenthe has been with Abwenzi Pa Za Umoyo (as PIH is known in the local language of Chichewa) since the organization began working in Neno in 2007. PIH had just three vehicles in Neno at that time, and over the years Chifenthe has seen costs rise along with the size of his fleet.

One day, when stopped at a gas station on the M1 highway before the turnoff for the steep mountain road into Neno, I looked at the pump and saw that filling the two 80L tanks in one of our 13 seater cruisers cost 147,568 kwacha (about 200 USD). Our vehicles are constantly carrying teams far distances, facilitating home visits and patient referrals from facilities. The costs of fuel and vehicle maintenance are significant, and limit the delivery of health services.

Distance and Lack of Transportation

Over the past eight months, I’ve made the trip up and down the mountain at least two dozen times, and I’ve traveled within the district for meetings and program activities every two weeks. Beyond work week travel, many of my colleagues travel from Neno to Blantyre to stay with their families over the weekend. While this travel has become normalized, it remains grueling. Then there’s the detail that strikes me most: these roads are difficult by vehicle, let alone when you are traveling by foot. It is easy to see why some community members don’t immediately seek care when our community health workers refer them to health facilities located a day’s walk away from their homes.

Through well-documented public health literature and, more importantly, the personal experiences of those who live far away from formal health care systems, we know that distance and (lack of) transportation are huge barriers to care. For example, the famous “three delays” of maternal health — where a pregnant woman cannot get to a health facility to deliver her baby and access vital services — have proven true again and again during my work here. In a qualitative analysis of 21 community groups aimed at boosting male participation in their wives’ health care across Neno, men consistently identified the need for “help in the construction of bridges and roads in order for women to access antenatal and postnatal care.”

As I was traveling back from a meeting at Dambe Health Center recently, a pregnant woman climbed into the back of the truck to be transferred to Neno District Hospital. The vehicle was very full, with a choppy hour-long ride awaiting us. A colleague kept saying to me, in between his Chichewa conversation with her and his translations to me, “She’s not complaining, but can you imagine what this is like when you don’t feel well?”

Each time I climb into a vehicle, I’m filled with gratitude for the skill our drivers have in navigating the shifting, muddy ground below, helping to ensure that community members have access to health care. As Peter, who has been a driver with PIH for over five years, explained to me, “Of course I’ll keep going up and down the mountains.”

Elise Mann is a 2018–2019 Global Health Corps fellow with Partners In Health where she supports the Community Health Department in Neno District, Malawi. She loves all things related to sunshine and coffee.

Global Health Corps (GHC) is a leadership development organization building the next generation of health equity leaders around the world. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. To learn more, visit our website and connect with us on Twitter/Instagram/Facebook.