Friday, February 1, 2008

Rain, rain glorious rain.

The Chinese are coming, and therefore the Taiwanese are out. The Taiwanese who have been in the country the last 50 odd years have been given 30 days to leave and close their Embassy. The relationship is over. 2000 Chinese are being flown in and the government is USD6 billion better off (so the rumour states). We found this out through the grapevine (the Daily Times, Malawi’s premier daily, has been more preoccupied with people committing suicide after testing HIV positive – a story which appears weekly along with men in Mangochi who have ‘relations’ with goats). First, a friend of ours tried to renew the lease on his house. The landlord had already handed it over to the Chinese, as well as the other 5 houses on the compound. Then there are the ads that go round on the Lilongwe google-group - Taiwanese are selling EVERYTHING – furniture, pets, plant pots. Then we hear of a Chinese restaurant starting up (very welcome – but we’re still suspicious). When a road building project is funded by the EU, Malawian labour is used. For the Chinese they bring their own labour – hence the 2000 – and finding accommodation for 2000 in a small town like Lilongwe is difficult. I’m suspicious: there are certainly a lot of very nice, new, expensive cars driving around with Malawian Government plates at the moment. They weren’t there before Christmas.

Some people say that the Chinese want to irritate the Taiwanese. Others say they want votes from African countries to get them a seat on the UN Security Council. I wonder what else the Chinese are getting out of it? I feel strangely protective towards this little country, and my over-active imagination has kicked in. Just think of Darfur and the Chinese influence there. Two days ago at a steering committee meeting for an international training on community management of acute malnutrition I brought my suspicions up with Tapiwa, the chief government nutritionist. ‘Eee Hazel’ was all she would say, and went back to discussing the more important matter of which snacks to serve on day three of the training.

WFP is not flavour of the month with the Malawian government. Please find attached a recent newspaper article, published by that bastion of journalistic skills, The Nation. It should be pointed out that a mere week later the Nation also reported (on page 2) about how Malawian wives were a disappointment, were getting fat and lazy and forcing their husbands to look elsewhere, usually to the domestic help. Yes, Malawian journalism is something else. Anyway, recently the press hasn’t been very favourable to WFP. Unfortunately, they seem to be getting things rather wrong, so just to set the record straight:

Malawi is maize secure. The harvest last year was very successful and the government was quite right to export maize. Malawi, in fact, became the maize basket of Southern Africa. Problem is, if you eat only maize you become malnourished and end up in either supplementary feeding or therapeutic feeding, which are WFP supported programmes. Hence, there’s still a problem, and food aid for the management of malnutrition is still desperately needed, as are school meals for children every morning, food supplements for people living with HIV and AIDS, and rations for the refugees at Dzaleka refugee camp.

Anyway, none of this has helped our funding situation.

The rain continues to come, down-pour after down-pour. Getting from car to health centre door has become a challenge as the ground turns into mud baths. The constant sweeping which is done around all homes/buildings means that the soil is little better than dust or sand, so when the rains come there is nothing to hold it together.

The BBC is reporting rather different figures for the flood hit areas in the South than our own investigations reveal, although both reports aren’t exactly cheery reading. While many are displaced, there are still only 4 flood-related deaths, and from our sources half of these deaths were caused when two very drunk men decided to cross a crocodile infested, slightly flooded river at 3am one morning after a celebration. The District Commissioner reported these deaths are being entirely flood related, which they’re not. Unfortunately the same District Commission has a tendency to exaggerate pretty much anything that goes on in his district in order to extract money.

For us we can just wait to see how bad the flooding will become, and the indications are that it will be very bad indeed. Already 70,000 people affected in the South. We hear that either this or next weekend the dam at Kariba, Zambia will be opened. That hasn’t happened since 2000/2001 floods, when the whole of the southern African region was denoted as a disaster area. Unfortunately donations aren’t usually received until the tvs show people climbing up trees to avoid being swept away. Here, WFP cannot act unless asked by the government, at which point the EMOP – our emergency operation flood plan – kicks in. UNHCR – the UN refugee organization, which is based on the floor above ours, has already been asked to assist with the flood hit Mozambiquans who have come across the border into Malawi and now need shelter, food and water. If WFP is also asked then – being on the emergency flood roster – I might head down to the South to carry out a rapid nutrition assessment. This is done using a MUAC tape (Mid Upper Arm Circumference), which is a very quick and easy tool to use to assess the nutrition status of individuals. As the government is slightly anti-WFP at present I doubt this will happen. As it is, in the two flood prone districts in the Lower Shire, we scaled up nutrition support through supplementary feeding in January, and the impact of floods on levels of malnutrition won’t be felt for at least a couple of months. At the moment we are preparing for 120,000 individuals to be flood affected, but it could be less, or a lot, lot more.

Last night it started raining at about 5pm and it was still pouring down this morning when I woke up. It’s still raining now. The plants and the insects love it, but the vegetable patch does not. My butternut squash crop has been entirely eaten by a rather gruesome snail, which maybe shows that homemade pesticide mix of chilies, washing powder, soap and water is useless. The basil crop is also looking less than healthy, and Dave – the housekeeper- has temporarily given up cutting the grass with his panga knife because it grows back so quickly. While all the plants expand magically over night, the one plant I was told, in fact guaranteed, would grow as fast as a monkey climbing a banana plant has stayed exactly the same size. Thus the bamboo arch we constructed remains bare.

Finally, on a kind of aside, I have been really touched by the response to the plea for USD18million. Sometimes I feel that I have lost my way here, have fallen off the desire to follow what I so stringently used to believe were appropriate development techniques along the post-development theory line, in the hope of just achieving anything at all. Theory goes out the window when you’re faced with 15,000 children to feed every month and no food. I never used to be much of a fan of food aid; amazing how things change. Anyway, being forwarded responses from various peoples MPs or DFID enquiry people about the funding of WFP Malawi has been heart warming. Things are still looking grim, we are probably borrowing food from the Tanzania programme at the moment to see us through February, and the constant rain and daily flood alerts don’t help – but it’s good to know that people care, and instead of just saying they care, actually do something. It’s the doing which I am so thankful for. There’s the classic story of the development pornography on TV: the person looks up from reading the paper, says ‘isn’t that truly terrible, someone should really do something’ and then goes back to reading the paper. I am proud that among the people I know it’s not like that.

Friday, November 30, 2007

Waiting for Rain

Waiting for rain is a torturous business. It is officially late and sky watching has become the latest past-time; every morning on the way to work the driver looks up and makes the day’s prognosis: too little cloud, too much sun, not enough shadow, too much brightness. The only thing that makes the rain probable is the heat. Was it really this hot last year?

Today we are told the rains will arrive this week. They said the same thing last week, and the week before. In October and November the fake mango rains tricked the mangos into ripening. The real rains will push the mangos from the trees so that you can’t walk without stepping on fallen fruit. This is the season when a sturdy umbrella becomes the latest accessory, when the windows get closed straight after the rains end to prevent vile flying insects from swarming inside and dying on the floor and the entire country starts to look like a jungle. It’s also the season when flooding destroys livelihoods and homes, and when hunger becomes a real problem – we call this rainy period the lean season. Crime goes up, nutrition rehab. unit (NRU) admissions go up, food prices in the markets go up. This is because as soon as the real rains come everyone plants maize, but this maize won’t be harvested until March, so between now and then there is no food apart from that stored from the previous harvest or from winter cropping. Of course if the diet here wasn’t 97% nsima based – the staple made from maize flour containing 1 of 46 essential nutrients – this problem wouldn’t happen, and if winter cropping (between April and October) was intensified with the use of irrigation, there would be enough maize in reserve to get through the lean season, or if diets were diversified, as they are more so in the Northern region, it wouldn’t be a problem. As it is this is the busy time for us, waiting to see what the rains will bring: good harvest, bad harvest, no harvest.

For the last week I have been in Mangochi, and the experience was a good example of the Ministry of Health at district level. Mangochi has 36 health centres which operate a programme called OTP – Outpatient Theraptic-care Programme. This is a nutrition programme targeting those with severe acute malnutrition (SAM). OTP is part of a bigger programme, CTC – Community Therapeutic Care, which has three programmes operating under it, all complimentary. The first, the NRU (nutrition rehab units) based at hospitals for those with SAM and complications (eg. bad malaria, HIV, TB); then OTP, based at health centres for those with SAM but no complications; then SFP – supplementary feeding programme, for those with moderate acute malnutrition (MAM). Each programme follows on from the next, with SFP working for those discharged from OTP and preventing children even becoming SAM cases. CTC is a relatively new programme, and the OTP programme has been rapidly expanded in the last year to cover about 70% of the health centres in Malawi.

WFP already provides the food for the NRUs, and at every NRU there is also supplementary feeding, which we also provide the food for. We recently agreed to support the CTC programme by providing food for supplementary feeding at everything OTP site. About half these sites already have SFP, but the rest needed to be assessed before they could start the programme.
So last week in Mangochi I turned up to do the assessments. Each health centre has a nurse/widwife or medical assistant (MA) and about 4-12 HSAs – health surveillance assistants, the main implementers of health programmes. So what did we find? Well, at one health centre the MA was drunk at 11.30am, at another all staff were out buying fertilizer coupons (at 10am), at another a very delightful nun and her two HSAs had absolutely no idea about SFP despite being trained in September, then another one had lost all their patient records of the OTP programme as they’d had an accident with some gas cylinder, and didn’t have a register, at another the MA was using syringes to pin notices to a board, and at the worst the HSA asked for money to implement SFP (despite this being part of his job). There were 21 very good health centres, almost always run by a female nurse, with patient records kept in folders and neatly stacked, and clean, organized rooms with no rats. For WFP we can’t risk sending food to a health centre which is unorganized or disinterested. Sending food to a health centre is extremely expensive and food wastage/misuse is common. For example, the HSA who wanted money for this programme apparently had, according to Save the Children, been stealing food from the OTP programme.

Once our assessments were made we met with the district nutritionist who seemed to think we were being highly unreasonable not sending food to the bad health centres. She also seemed to think it was unreasonable we were asking her – the coordinator of all nutrition programmes in Mangochi – to monitor the health centres once a month to see if they were getting on okay, and to ensure that they were reporting beneficiary figures accurately and on time (technically part of her job). From our assessments most health centres reported that the district nutritionist monitored them about once a year – not the once a month she is supposed to. The district nutritionist said the health centres were lying. Yes, Mangochi was a joy.
The supplementary feeding programme is essential as it targets women and children in the moderate malnutrition stage, preventing them reaching severe acute malnutrition, which is much harder to treat. Only 3 weeks ago I was in the most northern district of Malawi, Chitipa, at the district hospital. Sitting in the NRU being assessed for admission was what looked like a long-legged baby being carried in its mother’s arms. The baby weighed 12kg, and was 5 years old. If supplementary feeding and anti-retroviral treatment were reaching all those who needed it children like this one wouldn’t exist.

In the last couple of months our house was broken into. The petrol for the police to come to our house and make an inspection had to be paid for by us. A statement was handwritten by us, agreed to by the police, then we had to type it up, print it onto the one sheet of paper the police provided, make 4 copies, return to the police station and pay 500kw (about 2 pounds) to have it stamped. I can see why many people never bother with a police report. Then another colleague died this time from malaria, reminding that this highly treatable illness is a killer in sub-Saharan Africa even amongst the highly educated and well off. For Ennelles the illness was compounded by HIV, and at 26 years old she leaves behind her HIV negative son and a rather large gap on the eight floor of our building. She makes the third colleague to die in the 15 months I’ve been here. Then, after nearly 8 months of waiting the Italian Government have agreed to fund my proposal for 28 nutrition demonstration gardens based on the Low Input Model of permaculture, one per district, based at the nutrition rehabilitation units at the District Hospitals. This is without doubt the most positive thing achieved to date.

Half the time I still think more harm is done than good by this aid game – the aid mentality, the dependence on lunch and travel allowances, the craving for the material uselessness of the West, the attempts to change a country where crime is low and the family unit rules, and where the saying goes that the only reason there has never been a civil war is because the population is so apathetic. The other half I wonder why it seems such an effort and begging process to rectify such a blatant and palpable wrong: that half the world is incredibly rich and half the world is incredibly poor, and that it was only by chance that we were born into the rich half. Even then we still seem able to abuse all that’s on offer, destroy our bodies, turn blindly from those that need help, and feel hard done by when something doesn’t go exactly as we want.

Monday, October 1, 2007

The rainy season seems a long way off

It’s Tuesday evening and I’m hiding from the heat sitting directly under the slightly misshapen and inefficient ceiling fan. It begins to cast shadows as it goes round now, reminding me the mosquitoes are on their way; in just 30 minutes the light will have gone. It’s time to start shutting the windows, bolting the white burglar gates on the doors and spraying Peaceful Sleep on my seemingly highly edible feet and hands. It’s never quiet at night. Sometimes you can hear the hyenas, sometimes just the stray dogs of Area 15, the insects, and the buzzing mosquitoes which seem to be irritatingly gifted at getting inside mosquito nets. They form the company when it’s too hot to sleep and too hot to get up and investigate the ice situation. By the morning the first sound is of Dave, either sweeping our drive, piling up dust and earth which never seems to go anywhere, or the swishing of his panga knife from side to side cutting the grass or hacking down more bits from the mango tree. At just past 6am, Dave’s wife walks down the drive balancing something on her head. Half an hour later the two oldest girls start the walk to school, dressed in their bright blue uniform, carrying their shoes. Just as I leave, at 6.45am, Dave is often leaving too, this time to walk Susie, the youngest child, to school. She only started school this month, and every weekend can now be seen having her hair carefully braided in different styles while sitting on an upturned plastic bin under the papaya trees in the back.

Sitting in Jo’burg airport waiting for the connecting flight to Lilongwe at the beginning of September I wasn’t entirely sure I’d made a good decision to come back here for another year. Arriving at a very hot and dusty Lilongwe airport 3 hours later I was just as unsure. Francis’s eagerness at running inappropriately into the customs bit (just as my case was being searched and my mother’s fruitcake and some vacuum packed cheddar questioned) to grab my case and drag it to the WFP car lead to sleep-deprived uncertainty. His ‘welcome home’ just didn’t sit quite right; home is a deceptive term. It was bye-bye August life and hello Malawi life, with remarkably little being part of both.

The first 7 days of being back I ached with missing, desperately tried to retain my August life, and questioned everything. I wondered when I would wake up and not miss. Then it all stopped. The need for home-contact stopped, the missing stopped, and being here took over: the joys of 25p avocados, fresh peppers and tomatoes from our garden, the sheer cheeriness of people, the lack of complaining, the excitement rendered by an international newspaper, and just the happiness of being in the sunshine, afternoons spent entirely experimenting with the new kitchen blender and a pile of fruit, impromptu aid worker parties every week with old disco music, being barefoot, the insane driving, the strange white girl once again, and Dave’s enormous grin when I walk in the gate of our compound after work every evening.

If I stand up at my desk I look out on the whole of the city centre, the new bit of Lilongwe built when the old dictator decided that the capital should move from Zomba to here in the 1970s. Part of the joy of being in the tallest building in Lilongwe – a massive 9 floors of non-lift functioning, open stairwell danger – is the view. From the balcony of the Nutrition and HIV room I can stand, apple-eating, and watch the dust rise and fall over the peaceful town, the village of Lilongwe as it’s called. During rainy season we estimate when the clouds will release their rain as they approach, and during marches and demonstrations we can watch from above as crowds sing and celebrate, or promote the latest cause, weaving their way between buildings which shape Malawi. I can’t see the Old Town from here, a vast expanse of dry bush gets in the way through which Kenyetta Drive links the two towns. All I can see beyond Stambic Bank and the UNICEF building is bush; dry, dusty, browning. Below me is Mugabe Crescent. How comforting that Malawi and Zimbabwe are so close that the new road from Blantyre to Mulanje has recently been named or renamed the Robert Mugabe highway. Renaming is common place. Only last week Chilambula Road, off which is Area 15, became Paul Kagame road in honour of the President of Rwanda’s visit. I’m utterly confident that in a month or so the new sign will go down and the road will go back to being Chilambula until the next President comes on a visit. On the crescent below me is a man selling bananas; not the bananas of the UK with their long, yellow, plasticine-perfect sheen, but small, mottled, squashy bananas, which when unpeeled are perfect yellow without a bruise in sight. Under the trees next to him is a Celtel lady, selling phone credit to Celtel users – Malawi’s premier phone network, and also the one which stopped functioning for a month last year when something caught light in the factory and the replacement had to come from South Africa. Also under the trees is a man sitting next to a phone, a rubber-sign maker, and a Nation seller – the newspaper of choice. Occasionally there is a woman who lies in the rubble of a semi-built wall. She is always naked from the waist up, and just lies on the dusty bricks, silent. At the end of the crescent is the PTC – the Peoples Trading Centre – a shop of ultimate Malawian-ness. The same albino sits under an umbrella at the entrance with his hands out. He is an old pro, unlike the little children who run around, dancing in front of your feet, trying to extract money.

Last week dark, heavy clouds approached the building. Lights were being turned on mid-afternoon – an unheard of extravagance. My colleague Inge came in to announce rain. Impossible I thought, this being September. We turned to Osborne, seeking the Malawian viewpoint. ‘No rain’ he said with absolutely conviction, ‘there will be no rain.’ And there wasn’t. Apart from the fake mango-rains of November, the proper rains won’t come till December, suppressing the dust, turning the country green, energetic and puddle-ridden.

I feel a bit like a sorcerer at work at the moment, stretching out my hands moving supplementary feeding sites into alignment over the country. Phase one was completed just before I left (the phasing out of non-Community Therapeutic Care – CTC - sites), and the careful, accurate work of scale-up is now beginning. Scale up in three districts occurs in November. Having picked these three districts for scale-up before the others because I have utmost confidence in their district health office, I got a little nervous a week ago, thinking that maybe I was fooling myself that a scale-up could be carried out smoothly. Down in Nsanje the health centres which will be having supplementary feeding now on a permanent basis have all been tried and test. No worries there then. In Thyolo there is very good NGO support of nutrition activities, and the scale-up only involves 5 centres, so no major concerns there either. But Mzimba, oh dear, what was I thinking? Being sweet talked by the CTC coordinator for the district, and falling for it, now what was going on in my mind? Anyway, instead of the original 5 centres for scale-up, perfectly manageable, and easily oversee-able by me and the district based WFP Food Aid Monitor (FAM), there are now 24 sites. Mzimba is an enormous district, the largest in Malawi, and if not for a difficult chief would be split in two. The district has already put a request into UNICEF for training in supplementary feeding to occur at the end of October. Roger, my ally, the Norwegian nutritionist at UNICEF, let me insert lots of things into the training. Anyway, my concerns over the new CTC sites in Mzimba will be leading to a little visit up there next week. It’s not actually a little visit. The distances are such that it’s going to take at least 3 days to get round every centre, vet them, chat to them, check their food storage capacity and generally be as anal as I can about health centre hygiene.

It’s easy to slip back into Lilongwe-living. I sometimes think of the big glass building in Victoria where I am to start work in September 2008 and imagine that I’ll be dreaming of the sunshine, the big blue open skies with the cartoon clouds, the space of Malawi, the ease, and regret not savouring every moment – because I certainly don’t. My friends who left in September and aren’t returning write wistful emails about the lack of sunshine and the grumpy people in the UK. They complain that the tv is always on, everyone wears black, and no one smiles properly. Malawi is not a paradise land, being wracked with poverty, uncertainly, basic lacks of health and education facilities and unpredictable weather which can launch the entire country into an emergency, yet it’s gentle, forgiving, beautiful.

Some major decisions have been taken this month, not least which swimming pool to frequent for the next year. Last year in a desperate attempt to find anything vaguely familiar Anna and I signed up to the British High Commission and its clean, non-pestering, carrot-cake offering swimming pool. This year I am branching out and abandoning my roots. The BHC pool is a twenty five minute bike ride on a Sunday morning, and off-limits on a Friday afternoon – our half day. A mere 10 minutes away is the Portuguese pool, three times the size, not quite as clean, with tiles coming away from the walls and a not-quite-right smell, complete with overly attentive Mozambiquan staff. But hey, it’s ten minutes, which in this heat is about all I can take on a bike before I melt and turn into a squashed tomatoe look-a-like. Plus, it’s rather conveniently located just past Foodzone, the Indian supermarket open on Sundays, and – at the moment – selling coke light and nutella. So, Sundays have taken on a good look: an early morning swim and then studying for the rest of the day, trying to focus on health economics and epidemiology and not thinking about the exams at the British Council in June.

It’s a nice sort of life.

Wednesday, August 1, 2007

One year down

Two months ago my colleague's wife died. She was 28, had given birth to
their first child in January, and died of anaemia. She was not an
uneducated village woman, but degree holding, smart, funny, and
overjoyed with her new daughter. Up until this year I had never heard of
anyone dying of anaemia, yet here it seems that everyone dies from it.
Iron deficiency is the main cause of anaemia in developing countries,
and there are as many as 56% of pregnant women who are iron deficient in
this part of the World.

Iron deficiency reduces work capacity, and therefore reduces development
potential, increases susceptibility to infections like measles and
malaria, increases the risk of maternal mortality by six times, and
leads to suboptimal mental development. In the West we don't even think
about it.

Not that I've checked, but I imagine UK flour and bread is fortified
with iron, as in many developed countries the governments have ensured
that iron deficiency won't halt a country, like it has here. Iron isn't
the only micronutrient halting the progress of Malawi: iodine, vitamin
A, niacin, thiamin and vit C play their part too. At least here all salt
must be iodised by law - but the storage of salt in the sun means that
most of the time the iodine has evaporated before it enters the body, or
it comes over the border from Mozambique, where iodizing salt isn't
enforced. The economic implications of malnutrition are staggering:
populations working at 50% capacity, high infection rates due to poor
immune systems leading to costly medication, high maternal mortality
rates, and in a country with a high HIV rate like Malawi a good diet can
drastically halt the transition of HIV to AIDS by decades, and
complement Anti-retroviral Therapy, making ARVs more effective and
reducing the side-effects (fortified supplementary food to ART
beneficiaries is another WFP programme). Food fortification is the
cheapest, most extraordinarily successful way of improving the health of
populations, and this should be a right, not a priviledge.

The only reason this is coming up now in an email after nearly a year of
being here is that I've just finished a week long training on nutrition
needs in emergencies. This is the last of a batch of WFP trainings, and
focused on ration content, ration size, and meeting the nutritional
needs of the most vulnerable during crises. As ever by the end of the
training I fail to understand the attitude to food in the UK. Certainly
since September I've seen my fair share of children with severe wasting
and stunting and some horrific kwashiorkor cases, where the child's face
is so swollen with fluid that they can't see. Yet despite this, and the
previous trainings from WFP on nutrition, this latest course has struck
home much more intensely the very basic nature of development that we're
dealing with. Food is so fundamental, so essential, and totally
devastating when lacking. In the UK there is just so much; you can
choose between different types of bananas and apples, a multitude of
breakfast cereals, a plethora of biscuits, and yet still people are
unhappy with their relationship to food. There are such enormous
advantages in the UK, and such basic lacks here. And yes, it is utterly
pointless going on about Western guilt mentality, but does anyone
realize how lucky they are for more than a fleeting 10 seconds when
walking down the aisle of Sainsburys? I struggle with this enormously
because I complain just as much about the lack of yoghurt, cheese, fish
and jam here, and wish there were more regular food supplies in the
shop, or at least more exciting cooking ingredients. 95% of this country
spend 97% of their income on food. In the UK it's something like 12% of

If I ever write a book about here it will be on the drivers, one chapter
on each of them. There's Pashani, my favourite, who is always on time
(not Malawian time), always asks about my sister in China, and starts
every sentence with ',' and gets particularly passionate
about my lack of a brother. Pashani is the driver who recently prevented
us ending upside down in a ditch when we had a blow-out tyre while
driving at speed on a deserted bit of the M1 in the North. Joyce, the
only female driver, is extremely intimidating with 4 children (by three
different men), and 6 nieces and nephews she also looks after. She is
vast, with rapidly revolving hair styles, and you don't want to cross
her. The drivers are never just drivers: they all have about 10 acres of
land under cultivation, one has a mini-bus, and Hastings sells his soya
to Unilever. When it comes to unknown territory they are all fearless:
never tell a WFP driver that perhaps the road isn't too good, as they
will always want to try it out. This has resulted in me getting stuck on numerous occasions, watching from the sidelines as a gleeful driver dons overalls and tries to yank
the vehicle out of a mud-bank.

Edward, the youngest driver at 28, is a bit cool. He wears bright
striped shirts with white collars and cuffs, and has a thing for Nelly
Furtado. He always beams with bashful pride when you comment on his
choice of shirt. We were in Ntchisi one day going round health centres
with the District Nutritionist, Albert, who is also 28. The journey
started off from the boma in silence, then Nelly Furtado came on the
tape and Edward turned it up and said to Albert that this was a really
hip song. Albert nodded in a kind of cool, understanding way. This broke
the ice. After rewinding and listening to the song another three times,
Edward offered Albert his newspaper in an off-hand, not really offering
sort of fashion. It was brilliant. By the end of the trip they were firm
friends, talking about women, football, the crazy politicians in the
country, and Nelly Furtado. I really love these trips, sitting in the
back of the pickup, getting my spine contracted with every bump, and
waving back to the children walking along the side of the road.
This last month I have been spending a lot of time with the drivers due
to a two week evaluation of the emergency supplementary feeding
programme: a week in the Central and Northern region, and a week down
South with Roger, the Norwegian nutritionist at UNICEF, where we crammed
five districts into five days. The last evening of the mission was spent
playing snooker at the local bar in Phalombe (a relatively new District,
still connected to the main road by a 1.5 hour dirt-track journey) where
I teamed up with the very drunk District Nursing Officer (DNO) and beat
Roger and his partner - an even drunker District Head of Police. Only on
trips with Roger can I enter a local bar, and even then you can see all
the drunken men looking slightly uncomfortable as they stagger to stand
up in shock as two muzungos
(foreigners) arrive. Still, my snooker playing has improved immeasurably
after some handy tips from the DNO. These trips are exhausting, both in
the planning and the execution: 6am to 6pm most days, extremely bad
roads, mice-infested accommodation and health centre after health centre
where either the staff have decided not to show up at work that day, or
where syringes litter the floor and no one seems to care. There are, of
course, exceptions, and some of the Health Surveillance Assistants
(HSAs) I interviewed were inspiring and hugely committed to improving
their knowledge about effective nutrition interventions. One health
centre in Ntchisi has the most beautiful nutrition education garden,
which the health centre staff maintain and fund themselves. As most of
them earn $80 a month, their dedication is quite spectacular.
When planning the methodology for the programme evaluation I wanted more
than anything to interview beneficiaries to find out whether they knew
why they were receiving food. Interviewing beneficiaries is a first for
me, and certainly a first for this programme - which hadn't been
evaluated before.

Unusually at one health centre in Phalombe a father - not a mother - was
there with his daughter. At the end of my questions he asked what was
the point of supplementary feeding if his daughter (aged 2.5 years)
weighed 8.2 kg at the beginning of the programme and weighed 8.2kg now?
I was a bit lost for words; how do you tell a father than 90% of
non-responders are HIV positive? Nearly 1 in 3 malnourished children are
HIV positive and nearly all non-responders. HIV is everywhere, not least
on the M1 just outside Blantyre where there is an enormous sign stating:
'AIDS is real, It is not witchcraft.'

At Ndamera Health Centre in Nsanje the HSA replied to my question about
how we could solve malnutrition long term without food aid by saying:
'A thing seen by my eyes can be remembered, but a thing done my by hands
becomes part of me,' and while he was referring to nutrition education
and kitchen gardens, for me this rings true in so many ways concerning
my time here so far.

This first year is coming to an end now, and there are so many lessons
learnt about the realities of being an aid worker, and so much more to
learn (my Chichewa can still be classified as basic). Sorry Chris for
abusing your email, but you put things much better than I ever could, so
please forgive the quote: 'Partly, your work becomes just that - not
saving lives, not exciting-every-day tasks with your merry gang of
superhero colleague-friends, but work, a job which you do, desensitised
to its real meaning; knowing the world is far more populated by number
crunchers than by development zealots, and knowing this isn't an all-bad
thing... and when you do think about it, you're making it so that people
can move up from a miserable to a meagre existence, and it's rather

This is something we talk about a lot here, especially when it comes to
relating this life with the one back in the UK. We get asked how life is
in 'Africa?' and have to resist the temptation of saying that we have no
idea what it's like in the northern countries, or over in the west.
There is no saving of millions of lives going on, no Mother Teresa mass
acts. Instead there is a normal job, and lots of valuable work done from
the number crunching side as well as the not-strictly-number-crunching
side: writing monthly NRU admissions analyses, composing programme
evaluations, writing the bi-monthly country nutrition food distribution
plans, the dreaded Monthly Consolidated Output Report, disseminating
ideas about food diversification, constant monitoring of the programmes,
exasperation at the Ministry of Health, and really countless, endless
meetings where the agenda isn't followed and you leave not having a clue
about what was achieved or the next step. But these things contribute to
so-called development: tiny chippings away at the gruesome poverty which
doesn't seem so gruesome anymore, a worry in itself.

Having been counting the days till I go to the UK for a month's home
leave, I'm now not so sure. There is so much I've learnt this year and
so much I have grown to love. The humour here is fantastic with comments
about breasts the size of pawpaws (during a breast milk lecture), a
comparison of women and cows ('but we are all animals after all' shouted
one guy) and when the facilitator of a recent workshop on the
Accelerated Child Survival Strategy said that Malawi was a very
peaceful, stable country, three people from the Ministry of Health
heartily chorused, 'at least we've achieved something in 50 years.' Even
this is incomparable to the hysterically funny Advanced Security in the
Field training, after which I can now identify different land mines and
how to cope in a hostage situation. The training was conducted by an
Angolan former Army general, who had a map of Angola tattooed on his
bulging bicep, and had difficulty controlling a bunch of WFP staff who
found innuendos in everything he said in his heavily accented speech. My
car maintenance skills have improved beyond belief (fan belt /tire
changing in the dark/jump starting a battery), and I could write a
recipe book on 101 things to do with a squash or pumpkin. Lilongwe is a
small, pretty, fairly planned out town, with five shops, seven
restaurants, and the famous Chameleon which plays jazz on Sunday
afternoons and 80s disco music on Friday nights. There's not much else.
Every international is on the Lilongwe google group (it really is that
small), and in the course of two months you'll see the entire muzungu
population at the Thursday night film showing, held on a projector at my
friend Matt's house. It's a content life, wholesome, immaterial, all
ages mixing together, but slightly dull. I like the simplicity and the
values but hate the lack of anything to do and the cliquey muzungu
groups. While this is an isolating experience in many respects, and
there have been some very difficult, frustrating, gloomy times, I feel I
know Malawi from Chitipa to Nsanje by the position of over 500 health
centres, by the dirt-road shortcuts, and by the shapes of the mountains,
and for all the faults of WFP it really is my family.

So to finish with a saying from Ntolo in our M&E unit, which he says
when I scream at yet another driver overtaking up a hill/round a bend
and nearly hitting us head on: 'TIA':
This Is Africa.

I'm back in the UK this Wednesday.

Monday, June 11, 2007

School Feeding photos (from Ntcheu)

While this might look like an ad. for a WFP catalogue, this is in fact mouldy Corn-Soya Blend (CSB), which had to be destroyed.

A good example of food diversity...lovely yummy fruit.

A finger print from a school feeding recipient, as she picks up her take-home ration.

Taking the rations home.

Nell's nocturnal visitor (a story from the sticks, direct from the horse's mouth)

‘On Tuesday night I went out to eat dinner with my neighbours. I was out until around 9.30pm, which is a late night for me in Ntcheu. I should note here that it has been getting cold at night, and so therefore I have not been opening the windows, or leaving the doors open for any length of time, other than to enter or leave the house.

Upon returning to my house I made tea for my night watchman, Earnest. We had a disagreement since I told him I would be deducting money from his wages if he continued to come after dark. Despite this we said good night on good terms, and I slept peacefully at 10pm.

At 10.55pm I was awoken by loud noises coming from the kitchen. There was a crashing of pots and pans as they fell to the floor. My thought was that intruders must have entered the house. I was terrified. Somehow I summoned the courage to pull on some clothes and grab my keys. Then I made a run for the door. Upon leaving my bed room (it was dark) I felt something slap me in the face. I kept running and realized that there was some kind of large bird circulating in the hall. I saw that it was an owl. I fumbled with the lock and the bugler bars until I escaped from the house and shouted for my night watchman, Earnest. He was no where to be found. I shouted and shouted but he didn’t come. I did not know what to do, but I was not ready to confront the creature alone. I called for my neighbours and they came together not believing that an owl could be inside my house. We put jumpers and blankets around our heads to protect them from the bird’s attack. My neighbours approached the bird with a broom and a mop. Thankfully it panicked and flew through the open door. All of us were terrified.

My neighbours told me that owls in Malawi are associated with witch craft. None of us could explain how or why the owl had entered the house. Some suggest that it may be linked to the disgruntled watchman, and that the watchman transformed himself into an owl. In fact, nearly everyone in Ntcheu believes that the owl was an evil presence, and was the watchman in another form. Many people have come up to me to express their regret at the evil owl. The watchman later denied all knowledge of the incident. He claimed to have been present the whole time, but we can safely say he was not… in his human form.’

(Nell works for WFP as a Food Aid Monitor in Ntcheu district, two hours by car from Lilongwe, and two hours from Blantyre. This weekend she escaped up to Lilongwe, fleeing the owl and the disgruntled night watchman.)

Monday, June 4, 2007

9 months in.

I was extremely tempted to scrap the below email, carefully written on Saturday, and write about the mountain we climbed yesterday. It is a beautiful mountain, called Mphunzi, and like all the mountains in Malawi is a very funny shape, mainly rock, sitting just behind a CCAP Mission church and health clinic (which does supplementary feeding). It was a straight up the side kind of hike, a break at the top for fruitcake, and a rather scary descent before the trip back to Lilongwe on Ali’s Djibouti 10-seater overland truck.

Anyway, this is not going to be about the mountain, or the rock paintings that were up there.

This last month I was back in the field to my old haunts in the Lower Shire (shir-e): Nsanje and Chikwawa. I realize that being ‘in the field’ is a little odd as an expression, especially as it refers to anything outside Lilongwe. But for the Lower Shire it holds some truth; halfway between Blantyre and Nsanje the tar road stops and the driver announces with a smirk ‘now we’re really in the field.’

Nsanje is little more than a one-street-wonder, positioned by the enormous River Shire, which floods with depressing regularity, stuck at the bottom of a basin that makes up the Lower Shire, a mere 30m above sea level. It really is as if Nsanje and Chikwawa were dropped off the side of the great cliffs of Blantyre. In Nsanje there are a few NGO district offices, the District Assemblies building, District Hospital, District Education Office etc. In fact there are more buildings declaring it a District capital than there are people. This district has the highest rate of malnutrition in the country, the highest temperatures, highest humidity, highest percentage of malarial mosquitoes, prone to famine and drought and lacks a proper road to connect it to the rest of the country. If something goes wrong in the country, it will probably happen in Nsanje.

However, the town has another, more positive, claim to fame: it’s Port – the President’s vision of the future, but as yet no more than a signpost, and an official looking building with a guard situated on the banks of the Shire. On the strength of the promise of the Port a baker arrived in December 2006, and Mr Singh is a bit of a legend among people who go to Nsanje. My two friends who live down there, VSO doctors, (the only doctors in the district) have had their lives revolutionized by him. Now not only can bread be bought, but raisons and peanuts, and the odd beef sausage. Considering you can’t buy eggs all the time, Mr Singh and his little raison buns are a bit of a miracle.

The point of the Mission to Nsanje was to investigate the possibility of changing the way we do food distributions for the nutrition programme. At the moment WFP delivers directly to health centres on a bi-monthly basis. This is extremely expensive because the tonnage for Assistance to Malnourished Groups (AMG) activities is small, and only 3tonne trucks are needed. In April this year the trucking company refused to take the food for AMG activities, saying that the quantities were ridiculous and they’d rather be sacked so they could go and haul tobacco around the country. It was a bit of a disaster for us and put our critical food distributions behind by a month. Understandably we won’t be using this truck fleet again. For 4 months of the year when the rains come to Nsanje the roads also vanish, making deliveries near to impossible. Yes, of course we pre-position for the rainy season, and send food for 3 month periods, but it’s still a challenge. I had heard that the RUTF (ready to use therapeutic food) supplied by an NGO for the OTP (out patient therapeutic care programme) was being delivered to this Nsanje district hospital, and then Ministry of Health was distributing to health centre themselves. So, I thought maybe we should look into this, as perhaps MoH could do the same with out food, especially considering a possible phase out of WFP in the next 10-15 years.

The first evening down there I had dinner with Isobel and Berndt, the two doctors. Isobel has just been made DMO – District Medical Officer, and responsible for all clinical medicine in the district. Typically, as is happening in Lilongwe at the moment, the power cut for three hours (6-9pm), so we fried eggs on a fire outside, with mosquitoes sticking to our sweat from the 30 degree heat. These two do an extraordinary job, especially considering the lack of resources in Nsanje. Isobel does everything from surgery to district level policy and staff supervision. The stories they tell are enough to make you never want to need very basic health care, not only in Nsanje, but also in the rest of Malawi, and chatting with them is always a bit of a horror story.

Of course, no visit to a district would be complete without checking on the WFP supported NRU (nutrition rehab unit). The NRU in Nsanje is attached to the paediatric ward, and the smell wafting up the corridor as we approached was not very nice. This NRU had been highlighted at the last TNP (Targeted Nutrition Programme) meeting, which is a monthly meeting of the key stakeholders in nutrition in the country (usually about 10 of us). Nsanje NRU had been reporting a death rate well above the SPHERE standards we should be meeting. Because of this, the supporting NGO – Concern World Wide – have been doing a careful supervision of the NRU for the last month, and while the death rate has decreased from 65% to 30%, it’s still way above government and SPHERE standards. One child I had been discussing with Isobel the previous evening had a 25% chance of survival. It was a re-admission, with severe wasting and quashiokor, and had gone into spasms in the arms. The main problem was that the child will have been like this for at least at least two weeks. And here’s the main problem with everything health related: late presentation.

So the conclusions of the mission?: next year the MoH could probably take over a third of our deliveries to health centres, especially the difficult to reach ones, providing we do a needs assessment next December and they put the cost implications in their District Implementation Programme (the famous DIP). Moderate cost reduction for us, capacity building for MoH in Nsanje, and with any luck better, and more timely food distributions in AMG activities.

There’s been a lot of traveling this month. On Friday I returned from a really fantastically motivating conference, where we were coming up with a national communication strategy for Accelerated Child Survival and Development. About 20 of us, mainly from Unicef with District representation, spent 4 days in a beach resort in Mangochi thrashing out ideas and slogans, key messages and prioritizing high impact interventions at national and district level. It was exhausting, but so good to be part of something broader than just food aid. I came back from the four hour drive from Mangochi bouncing into our house telling Anna, my housemate, that I want to work for Unicef – despite having spent the last six months slandering their every move.

Anyway, it’s the weekend now and it’s time to close. I am half way through painting the kitchen cupboards blue, as far removed from their prison-like dark grey as possible, and I have a rehearsal to get to for the concert in two weeks time. If any of you know the Poulenc oboe sonata or Grovlez sarabande then you can empathise with my fears of a complete screw up on the night in question. Have a good month!