Where is the last mile? Is it where concrete ends, and dirt begins? Where the buses stop and motos go? Where women walk miles with babes in arms tucked into multi coloured wax cloths? I had the opportunity to reflect on this term that we bandy about in our work in NTD prevention as my colleagues and I bounced through miles of rainwater inundated mud roads in Northern Democratic Republic of Congo.
We were en route to Boto, a district in Sud Ubangi, a northern province in Democratic Republic of Congo (DRC). The district health administrators had organized a training for TT case finders - men and women, who would be equipped with the skills needed to find community members with suspected trachomatous trichiasis (TT). TT is that stage of the infectious eye disease where the eyelashes can turn inwards due to repeated infections and rub against the eyeball, causing intense pain and irritation.
The newly minted TT case finders, mostly men, worked in pairs and walked up and down the main thoroughfare of their assigned villages, requesting household members to participate in the case finding.
We pulled into the Boto district health office, ending a 2-hour journey that started in a land cruiser, continued by foot to traverse a wooden bridge in mid repair and ended by moto.
James Bigo, the district medical officer, greeted us and hosted a lively exchange of feedback with three TSOs or techniciens sante oculaires, the supervisors of the case finders in the district. As I listened in, marvelling at the level of detail and the intensity of the discussions, I couldn’t help but notice that Ms. Madame Valentine Debokosemodeawi, one of three TSOs was one of only a handful of women implicated in the NTD interventions. Tall and with high cheekbones, Valentine exuded a quiet earnestness that was at once familiar and comforting. I spoke to her for a few minutes to better understand what motivated her to do her work. Originally from the province of Sud Ubangi, Valentine is trained as an ophthalmic surgical nurse and is also capable of performing surgeries such as appendicitis and caesarean operations. She completed her education and training in 2005 and has been assisting and performing surgeries for over 11 years. She now works closely with Dr. Jacques Dawili, the district medical officer for Bwamanda, an ophthalmic surgeon, a soon to be TT surgery national trainer and all-round super star.
Valentine attended the very first training for TT surgery in 2020 and is keen to support the TT services scale up. Maybe one day I too can perform TT surgery, she said wistfully, knowing that in DRC, only medical doctors with surgical training are allowed to perform such operations.
James, the Boto district medical officer, invited us to his home for refreshments before we headed back to Bwamanda, a neighbouring district. Set a few miles down the road from the health centre, his house was likely built by the Belgians and may have served as a missionary guesthouse in colonial times. A beautiful, if weatherworn, brick home greeted us and James’ sister served us some delicious fried meats.
As I sat down to partake in the shared meal, I looked around and took in the scenery - a group of hardworking, dedicated individuals breaking bread after a long day of training and honest public health work. A larger-than-life yet deeply sensitive and committed medical officer inviting friends and strangers alike to his home, a conscientious nurse eager to do more for her community, and road weary travellers from Kinshasa, Cambridge and Atlanta entranced by the work, the people and the hospitality. I cherish such moments where everything that I do suddenly clicks together and makes sense and the light at the end of the tunnel grows just a shade brighter.
So, I ask again, what and where is the last mile? Is it where people like Valentine and James and Jacques do the work that they do to advance public health? Where people like my CBM colleague, Dr Safari Mwandulo, bat nary an eyelid to trudge through storm waters to ensure that supplies are delivered in time? Where people like Mbwase Mbamba, a case finder, do the everyday shoe leather epidemiology that advances the health outcomes of his community?
How can this be the last mile? Isn’t this the first, and every mile?