BUSHUJU, Democratic Republic of Congo -- In this mountaintop village near the hilly eastern border with Rwanda, the vaccination rates are as dismal as the sweeping views are breathtaking.
Measles: 28 percent. Diphtheria, tetanus, whooping cough: 22 percent. Tuberculosis: a mere 16 percent.
The nurse's assistant who is the sole health provider for Bushuju's 4,500 people listed some reasons for the low rates - besides the general postwar chaos and confusion: He was busy. He had trouble telling the drugs apart.
"I was afraid to give the vaccinations," Mugosa Lwendja admitted sheepishly. Heart-breaking words in a country where 20 percent of children die before age 5, most from treatable or preventable diseases.
The picture might soon brighten with help from a Carroll County nonprofit group called IMA World Health. The New Windsor-based association of 12 Protestant relief and development agencies has launched a three-year, $42 million effort financed by the United States to improve basic health care for 7 million people in war-racked eastern Congo.
Though nearly a half-century old, IMA in recent years has expanded its reach globally by gaining the confidence of the American government to take on health in Congo, one of the biggest and most troubled countries on the troubled continent.
IMA knows the terrain. In western Congo, it recently completed a $28 million project, also U.S.-funded, that scored notable successes, such as sharply higher child immunization rates and lower malaria incidence. It did so by boosting an existing if frayed medical infrastructure, relying mostly on local health workers and spending less per capita than many international aid groups.
Both the new program and the old share a key principle that is controversial in aid circles: Patients must pay something for their care. After all, Congo does not have free health care, and the national government has never provided much financial support for its 60 million people.
Charging fees has an up side, organizers of both programs say. Congolese people "have to have a sense of responsibility. If everything is given to you, you care less," said Dr. Leon Kintaudi, the Congolese medical director of the programs.
Critics say the fee-for-service approach is a flaw that will effectively deny health care to many poor people. "Our experience is that even an extremely small symbolic fee can be a barrier for the population," said Dr. Leslie Shanks, a physician working in Congo for Doctors Without Borders.
But Larry Sthreshley, IMA's leader of the new program and a veteran public health expert in Congo, says the argument for generalized free care is flawed. It might be vital in refugee situations or humanitarian disasters, he said, such as during the worst period of the 1998-2003 war in which 4 million Congolese died. But he said he believes Congo's fledgling postwar stability - rising employment, growing business investment - makes that approach wasteful, except for the poorest of the poor. "If I can cover 80 percent of the health needs for 100 percent of the population," he said, "that's a lot better than 100 percent coverage for 25 percent of the population."
One overcast morning, a blaze of colorful skirts and head scarves filled an expansive mud hut. Later, Christians would gather inside to pray. But now, two dozen mothers, their babies snugly strapped to their backs, come seeking a kind of earthly miracle: drugs to help keep their children healthy. It's vaccination day in the village of Nkonko-Tshiela.
This village lies 400 miles southwest of Bushuju. For five years, it was part of Sanru III, IMA's first Congo project and first major foray into on-the-ground development work, which began in 2001. Back then, this village's immunization rates were almost as low as Bushuju's. No longer. Nkonko-Tshiela's rate has eclipsed 97 percent. On this day, mothers looked on as their babies received injections or oral polio vaccine.
The vaccinations occur on a regular basis around this impoverished district. One mother, Claude Kulandi, 25, sold potato leaves at the market so she could afford shots for her 3-month-old son.
"I made a choice between the health of my child and the death of my child," she said bluntly.
"It's dramatic," Nancy Haninger said of the program's impact across this health zone, a community of 90,000 divided among urban areas and small villages.
When Haninger and her husband, Michael, arrived as Presbyterian medical missionaries in 2001, things were bleak. Although a dedicated nurse carried vaccines to outlying areas, often by foot, only about 30 percent of children got them. Drugs often spoiled in the heat.
Women usually gave birth on the dirt floors of huts, often with lethal consequences for them and their babies. Dirty drinking water sickened young and old alike. A paucity of medicine meant that malaria, the area's top killer, met scant resistance when it began bursting the red blood cells of its mosquito-bitten victims.
And the war that started in 1998 - Congo's latest of many sad 20th-century chapters - drew so near that soldiers sometimes attacked villagers.
Sanru III - an abbreviation of the French for "rural health" - could not stop the war, but it brought major health benefits to Nkonko-Tshiela, a subsistence farming village of 11,000, recalled head nurse Mukinayi Mukenge.
It supplied 65 "essential" drugs, such as antibiotics and anti-malarials. It provided a microscope to detect malaria, tuberculosis and intestinal worms. It paid for a bicycle to ferry vaccines quickly to his health center. A solar-charged light replaced a flashlight for nighttime baby deliveries.
One of the most significant investments cost just $400: a construction project to cap a natural spring and channel the water into a pipe. That led to a big drop in diarrhea and related illnesses.
And there were the vaccines. Although the drugs were supplied by UNICEF, the Sanru program created a "cold chain" to keep the medicine refrigerated, trained residents to give the injections and helped develop a volunteer network that urged parents to bring their babies in for shots.
The benefits were subsidized but not free - a big burden for people who earn less than $1 a day. Pregnant women paid 75 cents for four prenatal visits plus anti-malarials, iron and folic acid. New mothers paid a dime so their children could receive five years of growth-monitoring and vaccinations. A visit to the nurse for curative care cost $3, including follow-ups and all medications. Long-lasting, insecticide-treated bed nets, to help fight malaria, cost about $1.
Villagers said it has been worth every penny. "Now we have babies in good condition; now disease is down because of the center," said the village's 74-year-old chief, Maurice Nkonko.
But the gains are fragile, and some have been lost since federal funding for Sanru III ended last year. The funding cut was rooted in geopolitics and the global fight against terrorism. The U.S. Agency for International Development decided to shift new spending to eastern Congo, hardest hit by the 1998-2003 war. The move was part of a post-9/11 policy aimed at shoring up fragile areas seen as potential terrorist havens.
In Nkonko-Tshiela, the effects of the shift were felt immediately in May 2006. That is when Mukenge, the head nurse, said the supply of drugs stopped flowing, forcing him to buy more expensive and less reliable drugs from roadside "pharmacists" in a nearby city. He had to double the charge for Fansidar, a common malaria drug that's generally effective in this area, from 10 cents to 20 cents.
It was not good news for Remi Tshinkunku, 50, a villager whose life Mukenge probably saved three years ago when he was near death from malaria. He said he thinks he has malaria again, and several of his six children show symptoms. But he has no money. "Because drugs are very expensive, I will wait to die," Tshinkunku said with a nervous laugh.
"If there is no money," said Mukenge, who had walked over to the man's hut, "they can give chickens."
Tshinkunku shook his head. His family had no chickens to give.
If Tshinkunku is willing to go into hock, his name will join other debtors on a long list that Mukenge keeps in his office. The nurse's generosity, while laudable, has a damaging ripple effect: The less money he takes in, the fewer supplies he can buy.
And because the Congolese government does not pay nurses or many other civil servants a salary, Mukenge must provide for his family on any profit the clinic makes. Most months, he takes home less than $10.
This health zone is fortunate. It has been included in the new IMA program, called Project AXxes, so the drought of discounted drugs recently ended. Though the first container-load of AXxes drugs will not reach Congo until later this month, some pharmaceuticals have been air-freighted into the country, and the Presbyterian Church (USA) has provided additional drugs.
But, for two dozen other western health zones with a combined population of 3 million, no relief is in sight. Some benefits will live on, such as the community volunteer program, the knowledge gained from training and the water systems.
The final evaluation of Sanru III, written by an IMA evaluation team for the U.S. government, stressed that point: "Financial self-sufficiency will take some years to materialize. In other words, most gains made under Sanru III will be erased including in the more mature zones in Western Congo if adequate follow-up operations are not promptly implemented."
Meanwhile, in alpine Bushuju, villagers await the start of the new project with great hope.
At the height of the war fueled by ethnic divisions and a scramble for control of the region's diamonds and other natural riches, thousands died in this health zone. Villagers fled marauding soldiers, enduring months in unhealthy conditions with no access to medicine. Fields went untended, depleting food supplies.
Amid the chaos, most of the Congolese civilians who died succumbed to disease or hunger, not to bullets or machetes. Because rape was such a common weapon of war, the east has seen a spike in HIV rates, and scores of women suffered ghastly physical injuries.
Dr. Alexis Kashobo, one of two doctors for 130,000 people in the wider health zone, said the war's lingering effects include poverty, HIV-AIDS and high rates of mortality and malnutrition.
The lush soil and reliable rains in this hilly region should help speed the economic recovery. But in another blow, farmers said, a plant virus has attacked cassava crops, the agricultural staple.
And so the dying has continued. Mawazo Dogale lost her 9-month-old son, Jean-Claude, to malaria in April. He had been an energetic, strong baby, she said, until he grew feverish. The doctor said she waited too long to take him the seven miles to the hospital in Lemera, a large town down the mountain from Bushuju.
Dogale, 25, said she hoped peace would improve her life. "But now there are problems of health and hunger," she said at the hospital. Next to her lay her 6-month-old daughter, now sick with malaria.
Lemera's hospital charges $4 for an uncomplicated birth. To make sure the family pays, mother and baby are held under virtual house arrest, sometimes for months. Despite that, the hospital is poorly equipped after being looted in the war, and it brings in so little money that its two doctors barely manage a living.
Project AXxes will keep what worked best under Sanru III, such as the vaccinations, but will spend twice as much per health zone, according to Sthreshley, IMA's project leader. Counting outside funding, the average annual expenditure per person under AXxes will be $2.15.
That is a fraction of what some European humanitarian groups have been spending in eastern Congo, but Sthreshley predicted that AXxes will achieve at least as much. He pointed to its reliance on dedicated, culturally aware Congolese staff, with fewer well-paid Americans or Europeans. Another factor is the emphasis on low-cost preventive measures rather than cures.
As with Sanru III, patients will be required to pay, but the fees will be more heavily subsidized than before.
AXxes will also help villagers generate more income - such as with market gardens - to make it easier for residents to pay for their care.
And a revamped credit system will, if all goes as planned, enable clinics such as Bushuju's to continue obtaining essential medicines from drug depots even after AXxes comes to an end.
As Kintaudi, the Congolese medical director, put it, the program is built on the idea that "the day we pull out, they will have something to go on."
Even so, Derstine of IMA said those refinements might fall short, given the project's three-year projected life. Unless the U.S. extends AXxes, more money will be required from the World Bank or other sources.
"In eastern Congo," he said, "you're not going to be able to achieve sustainable objectives in three years."