Condoms remain some of the most effective and affordable tools for combating the transmission of HIV, the spread of sexually transmitted infections and the instances of unintended pregnancy. But how do condoms get to people who live in some of the hardest-to-reach corners of the world?
Tanzania-based photographer Sala Lewis traveled with global health organization Pathfinder International to document the Tuungane program in Tanzania, which brings condoms from the urban center of Kigoma to the small villages around the Mahale National Park. Project staff travel to the field at least once every two weeks, delivering what ever supplies are needed — contraception, anti-malaria drugs or even a new radio.
PREPARING FOR THE JOURNEY
Dr. Ernest Athumani (left) and Petro Masolwa (right), work at Tuungane project headquarters in Kigoma, Tanzania. Here, they pose with four boxes of 90 female condoms at the main office, though they took only two on the trip. Between 1,000 and 1,500 male condoms and 50 female condoms are typically distributed to rural communities each month. (The project took more female condoms on this journey to help the ministry.) Almost 6 percent of the Tanzanian population is HIV positive, with more than half of infections occurring in women.
APPROACHING THE FERRY
After a three- to five-hour drive from Kigoma along dirt roads, the condoms arrive by truck to a ferry to cross the Malagarasi River. The ferry ride takes less than 10 minutes.
ABOARD THE FERRY
An old ferry carries the condoms across the river, after which the truck driver will continue the journey. The villages served by the Tuungane project are some of the most difficult to access in Tanzania, a country with phenomenal wildlife and national resources, and a growing economy. The Mahale National Park, which is near the villages, is home to most of the remaining chimpanzee population in Tanzania. Lake Tanganyika, against which many of the Tuungane project villages sit, holds nearly one-fifth of the world's fresh water and has more than 300 species of fish. Although Tanzania is resource-rich, it faces serious health challenges: HIV-positive patients occupy 50 percent of hospital beds, and a woman has a 1 in 24 lifetime risk of dying in childbirth.
BACK ON THE ROAD
After the ferry, the driver transports the condoms, Dr. Athumani, Masolwa and the other project workers another two hours over rural dirt roads to a simple port. Lake Tanganyika is the primary means of transit, but the lake route would take between 16 and 20 hours — the lake is large and the boats slow, and the weather can change quickly and delay transport.
LOADING THE SPEEDBOAT
Msafiri Nzunuri, the Tuungane governance lead, lives in the park headquarters and works with people at the village level to strengthen involvement in running local government and increasing participation in project activities. (Currently, 66 percent of community members have no say in village government decisions.) He loads the condoms onto a speedboat in order to deliver them to the lakeside villages. From the road where the truck dropped the boxes, it's a 10-minute walk to the beach, carrying the boxes by hand. Once the project employees and shore workers load the goods, timing is a gamble — this particular boat trip took three and a half hours in the pitch dark before the team had to camp for the night. Then a storm hit, and they were stuck for two days in rural huts in Mahale National Park. "These condoms symbolize how difficult it is for resources to reach communities in need," Linda Suttenfield, Pathfinder's director of communications, said. "And conversely how difficult it is for a woman who is experiencing an obstetric emergency and needs a higher level of care to get that care. If there's a condition like no boat or storm conditions that prohibit you from going out on the lake, you're unable to get the care you need. And you may die."
LOADING THE SPEEDBOAT, PART TWO
After the storm clears, project employees and local workers carry boxes of condoms onto the boat at the loading beach, from which it's typically another seven hours to the villages. This team was lucky they had speedboats (a rare occurrence), as this cut down the travel time to the southernmost village of Kalya. Typically, the team visits multiple villages along the lakes, bringing doctors such as Dr. Athumani to the villages to provide training and support to health workers along with goods. "On our way back from this trip, we got off at one landing spot, and we still had a box of condoms with us," Suttenfield said. "People were coming over to the box asking the doctor for condoms right then and there."
ARRIVING AT THE VILLAGE
A villager carries the condoms to their final destination in the village of Kalya, the southernmost village served by the project with a population of about 10,000. There are no roads and no phones in Kalya, and it's 16 to 20 hours by boat to the nearest urban center — a trek that becomes necessary in the event of a serious medical emergency and costs about $18 USD. Households in Kalya bring in an average of $92 USD per year and are about 30 percent larger than they are in the rest of Tanzania, with women giving birth to an average of seven children. Forty percent of women in the Mahale region of Western Tanzania, where these villages are located, want to delay or prevent pregnancy but lack access to contraception.
INSIDE THE CLINIC
After a 10-minute walk from the beach, the condoms finally arrive the clinic in Kalya. The clinic is in a distressed building and primarily serves women and children. Contraceptives are in high demand, as are basic medications like anti-malarial drugs which, given the remote nature of the clinic, are prone to running out. Only three staff members work at this clinic — an assistant medical officer who can perform emergency surgery, a nurse midwife and a health officer who is responsible for overseeing general public health issues, including immunizations, hygiene, sanitation and national health campaigns. The clinic sees 100 patients every day.
DELIVERING THE CONDOMS BY BICYCLE
Two Population Health and Environment Agents, Patrick Aguda, 38, and Ashula Rashidi, 29, volunteering with the project set out to make house calls, where they talk to their neighbors about family planning, the environment and health care. They deliver condoms to individual residences and also let community members know they can get additional supplies at the clinic.
MAKING HOUSE CALLS
Aguda (far right) and Rashidi (middle right), who have volunteered with the program for the past year, sit down with Zainabu John (middle left) and her husband Peter Msafiri (far left) in their village. So far, the project has 19 community health workers, four in Kalya. Each volunteer serves more than 250 clients — a number they hope to bring down to 100 as they train more staff.
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Disclosure: Jill worked with Pathfinder International on a consulting project in 2013.
Photo credit: Sala Lewis and Maren Vespia