Christmas is coming

There’s been big excitement in Lilongwe in the form of a new ‘direct’ flight to Lilongwe from London. The excitement lasted about a week until the inaugural flight. Not so direct it seems, as it includes a little plane change in Harare. The excitement now focuses on whether any one will pick up on this modest scam which allows a direct plane from Zimbabwe land in London.

So Christmas is approaching. No break for the wicked this year. Wouldn’t want to leave nutrition activities all on their own, especially as the great boss Lazarus is on leave for a month and I am now sole person in charge of nutrition activities in this magnificent country. People starve 365 days in the year you know, and especially over the Christmas season as the rains have come in earnest. Yes, I am SO much fun to be around right now. Anyone want to know about malnourishment? Anyone? Goodness, I’m never going to look at food in the same light again. I imagine if I ever do pop home I’ll end up eating my body weight in ice cream and probably killing myself on a tea drinking overload. I miss milk, milk that doesn’t smell and taste like it’s off.

But it’s all good news. So far have managed to avoid destroying the nutrition programme here. This week has been more than a little stressful with food distribution plans for Jan – Feb to complete. Now, usually this would be the work of the sub office nutrition officer, and we here in the Country Office would consolidate and approve. But ah ha! – not this month, because there are no nutrition officers in the suboffices!!! Why, you may ask? Well, WFP is fairly broke (we actually do spend all our money on food rather than fancy branding apparatus…-I wonder why UNICEF springs to mind). So this month, or rather week, I have been compiling distribution plans for our two programmes: therapeutic feeding and supplementary feeding. The joy of this was that I got to go down to Blantyre suboffice last week and really bond with the excel programme and calculator, and then spend another week on the phone trying to establish why the non food items which are essential to beneficiary screening for both programmes hadn’t turned up in the relevant districts, which meant our food was now sitting around going bad (ahem…UNICEF again I wonder). So, it’s all fun down here in the Southern hemisphere. At least I have a very exciting new umbrella which according to the guy in the market is a genuine umbrella, unlike my last one which he claims was not in fact an actual umbrella.

There’s a lovely little heart warming story though: The MCH (maternal child health) coordinator of a particular district in the South was complaining that health centres in her district couldn’t implement emergency supplementary feeding because the UNICEF consignment of non food items (height boards and MUAC tapes) essential for screening hadn’t turned up. So, after checking with UNICEF in a very sarcastic and skeptical manner, they swore they had been sent. So…the big mystery: where were these essential items? I call back the MCH: ‘Are you sure you didn’t have a delivery from UNICEF in October?’ I enquire – not wanting to accuse her of perhaps getting confused. ‘Absolutely not’ she replies, ‘although we do have some big boxes from UNICEF sitting in the storeroom, which have been there for two months.’ ‘Hm…any reason why they haven’t been opened?’ I ask. ‘Well, we don’t know what’s in them,’ she replies. Three hours later the boxes have been opened, and there are all the non food items, just sitting there. Of course, it’s now nearly Christmas, and the district hospital still hasn’t distributed any of the items to the health centres because they have no petrol for their truck. And in the meantime our food goes bad because emergency supplementary feeding was supposed to start in October. Now, technically we could go over to the district, pick up the items and distribute them. But, first, it is UNICEF who should follow up their own items, and second the district hospital (aka Ministry of Health) has got to start doing something for themselves at some point.

I am looking forward to the return of Lazarus. While the benefits of being current Head of Section are enormous: lots of fun Heads of Sections meetings where we eat candy and talk about the telephone bills, quite bad neck ache from a 2 hour phone conversations with Blantyre suboffice head, and lots of pity from our Deputy Country Director, who came in with two large tins of imported biscuits this morning which I am trying not to eat, I feel a screw up on my part could occur at any point and I’d have no one to blame but myself. On the plus, I have managed to track down – with the help of the Food Aid Monitor down in Thyolo – why 33 bags of our maize meal was transferred to a non-WFP supported health centre without WFP knowledge. This might not seem like a big achievement, but phone lines have been down in the South, and communication is not the easiest even when everything’s running smoothly.

But all these daily palavers have been compounded by the death of our colleague, Waka. He makes the 6th staff member to die in 2 years. It’s a reminder that while Malawi is a relatively secure and peace loving country, we have one of the highest road traffic accident and HIV rates in the World. Spare a thought for Waka’s wife Rose, and his two little children, Joshua and Will. We are skipping Christmas here this year.

Two months in...and things get tougher

It’s been two months! Last night, over the remnants of what we think is the last bottle of Malawi gin in Malawi (the stockpiles of gin, yoghurt, colgate toothpaste, and ginger beer are now exhausted, and rumour has it there won’t be any more till December), we started swapping stories. It just happens that last night there was a doctor, two dairy farmers, and me - full of tales from my latest trip up north, where in four days I covered just under 2,000km on very, very bad roads, visiting all health centres in Kasungu district, and those bordering Kasungu in Mzimba. More on this later.

So the stories: there has been a push in Malawi (and quite a few other African countries) to incorporate Traditional Birthing Attendants (TBAs) into mainstream medicine, by giving them trainings in the district hospitals, and instructions about referrals, and difficult births. The majority of women still opt to give birth in the presence of a TBA, partly because it’s culture, and partly because those that go to the clinics get treated quite harshly. It’s much nicer to be reassured and soothed by a motherly TBA than told not to make such a fuss by a medical assistant, who is usually a man. Anyway, in Dowa district, when I was asking about a billion questions about TBAs and the frequency of their training, the Maternal Child Health (MCH) coordinator for the district said that trainings happened once the death rate for mothers and children started to increase in the district. Hmm…clearly a case of prevention rather than cure (sarcasm intended). So last night, the doctor was recalling a case of the daughter of a TBA (she was the TBA’s seventh child) turning up at the clinic, having had her mother forget to clamp the umbilical cord, and then waiting for 4 hours while her daughter bled before taking her to the clinic. The daughter died, not unsurprisingly.

On the way back from Dowa our car nearly ran out of petrol. So, at one of the numerous road blocks we stopped to ask the policeman where the nearest petrol pump was. He pointed back up the road, and very kindly directed us to the local black market source, sold in water bottles and looking like vegetable oil. So, having bought a few litres, we then went back through the road block, only to be stopped because the policeman thought we were driving with black market petrol.

Then there is the incident of a health centre in Kasungu called Thupa. It’s 2 hours off the tarmac road, with a large catchment area. The clinic looks a little like a sheep pen, with no door, bat droppings everywhere, holes in the roofs, and expensive drugs lying all over the floor, just waiting to be stepped on. I asked if the maintenance problems had been reported to the DHO (District Health Officer), and while it seems they have, the DHO is waiting for JICA (the Japanese government aid agency) to build a new clinic, which they will do in April. This sort of thing is incredibly frustrating, (sorry for the mass generalization), but sums up a lot about what’s going on here, or at least in the health sector. First, the building should never have gotten into this state if it was maintained. But maintenance here is not the done thing. If something starts falling apart, it won’t be repaired but will be expected to be replaced. Even here at WFP there are 25 cars, but 10 of them have no batteries and so aren’t used. Instead, WFP buys new cars. It’s the same story with furniture, and houses, and bicycles; maintenance just isn’t done. Second, and I don’t know whether this is the result of years of colonialism, then a dictator, and now millions of aid agencies, but initiative is low. There is no question that the medical assistant could fix a door on his clinic, or that the HSA could clean the building, but unless they’re told to do it they won’t. It’s partly because everything is so hierarchical here, and you only do what your boss tells you to and nothing more, but partly also because after years of being told what to do first by colonists, and then by the dictator Banda, drive and initiative has been bashed out of many Malawians. Third, who is (mass generalization I realize) taking responsibility? Why wait for JICA to come and build a health centre which probably won’t be finished until the summer, when the DHO has a budget for repair and building work? Yes, it’s great that JICA has lots of money for buildings and that they have identified a health centre which clearly needs a new (or renovated) facility. But having had JICA say they’ll do the new building, no one bothers to do anything in the meantime.

I’m ranting, I realize, but having seen two really bad cases of oedema at the health centre which should have been picked up by the outreach workers, which will result in the deaths of these two children unless their mothers can take them 35km to the nearest NRU within the day, it makes me fairly furious.

I met one of the sacred district nutritionists last week; there are only 7 of them, despite there being 28 districts. There are these new posters from the Ministry of Health which show the six food groups. We are trying to get them actually put up on walls in the district hospitals, rather than sitting in cupboards of the MCHs office. Anyway, turns out this district nutritionist has been very pro active on the poster front. He has been advising people to eat one of the six food groups each day (ie, carbohydrates one day, protein the next day, fibre the next etc), and then on the seventh day you can eat maize. Very inventive don’t you think, and utterly, utterly misguided.

Anyway, enough moaning. Although I will add that I visited a traditional healer a few weeks ago, and thought he was pretty convincing until he said that he learnt his trade in a dream, and when he diagnoses someone, by connecting with the spirit world, only his wife can translate for him. I wonder if the wife gains these translation skills after marriage, or if it is a pre-requisite? I then went back to the office, bursting with skepticism, to discover that my boss is a complete believer in traditional healers and the spirit world. He claims to have been affected by spirits, and seen them. Lazarus and I have these nice, silly discussions. He thinks I’m far too rational, but then I do believe that as he is a nutritionist he should perhaps stop drinking three bottles of fanta a day, and only eating highly fatty foods like samosas. Of course, he thinks this is very funny, particularly when I point out how many false teeth he has. But then, I really could have everything wrong; the brainwashing of the West, as Laz calls it.

But, there are some great things going on too, like the increase of Baby Friendly Hospitals. In Nchisi district there was a big sign painted in enormous black letters saying ‘Coming Soon…Baby Friendly Hospital.’ Now they’ve painted over the ‘coming soon’ bit, as they have official status. Being a Baby Friendly Hospital means that they promote exclusive breast feeding for the first six month, not dependent on HIV status, as naverapine is given out anyway. It also means that fanta is banned, as is coke and cherry plum. Before a Baby Friendly Status, babies are often weaned onto fanta, water or tea, which is heartbreaking. No wonder the baby becomes malnourished.

I have been in Kasungu district for the last 5 days, going round every single health centre assessing them for potential implementation of supplementary feeding. The aim is that this will prevent the children getting to severe acute malnourishment (SAM) stage, when they need to be admitted to an NRU. It was a great trip, partly because I am really amazed at the push for free health care here. Government clinics, which make up the majority of health clinics in a district, provide free care to anyone. Okay, so the drugs they offer are limited, but antiretrovirals are free, therapeutic foods are free, and referrals are made for more severe cases. I think this is quite astounding, and while there is a long way to go on the health care front, the idea is there. The DHO at Kasungu also agreed to give me space for a garden by the district hospital NRU, for nutrition education along the Low-Imput model lines, which is fab. I’m having dreams of a model garden, based around the 6 essential food groups. Of course, it’s more likely to be a bit of mud with some chickens and maize, but the DHO is a really inspirational guy and I have high hopes for this garden.

But, the whole real-job thing is a scary business. What if I misheard the name of the hospital and have now sent 2MT of corn-soya blend somewhere totally random? What if I’ve miscalculated the quantity of food for Kasungu district? What if I’ve been targeting the wrong traditional authorities for additional food because I misread the email? Just now a nurse from Kamuzu Central Hospital in Lilongwe called up saying they had run out of food and have a nutrition clinic tomorrow and no food to distribute. Help! So, a call to logistics, then a call to the warehouse, then back to logistics, then back to the nurse. Food will turn up they claim, but according to Laz they often lie over in logistics, because the cost of transporting a few tones of food is so much it isn’t worth it until there are other hospitals/clinics in the area which also need food.

Anyway, I am hugely looking forward to having my housemate back. She is in South Africa this week at a conference. We have another flea infestation in our house, and at least when Anna's around they bite her and not me. Our dog is pregnant, which I don’t think was planned. We have put her on a diet of supplements. Our sunflowers are now about a metre tall, and I am looking forward to the rains more than I can say; it is baking, and we are running at 5.15am because by 6am it is too hot to be doing anything other than very slow walking.

A month in

How time flies when you're having fun, and how it drags when you're waiting for your water to be reconnected. In this instance I think I can blame ‘African bureaucracy’ for turning up one day while I was in Dedza, monitoring food distributions at a health facility for the malnourished, and disconnecting it. Still not entirely sure why, but being the harbourer of a blaming tendency, I go with the previous tenants. Then comes the tricky business of trying to get it reconnected. All bits paid, yes, but it doesn’t result in a reconnection despite a ‘reconnection’ fee being paid.

So beside water problems, a house infested with fleas (now killed thanks to the magic powers of DyFlea – they also sell DyRoach and DyAnt) which I blame entirely on the two dogs we seem to have adopted, the sacking of the night guard, which actually occurred twice due to some misunderstandings, and a bout of fever and accompanying sidekicks, what’s been going on?

First the job. For anyone who says the UN wastes money please come and have a look at WFP. Not a model agency by any means, but with overheads of just 7%, a fairly run-down office like ours (the VSO office is much nicer), and staff members even buying their own notepads, this place is pretty impressive. For an entire country’s nutrition programme there are just two of us, the boss – Lazarus – and me, and considering there are over 90 Nutrition Rehabilitation Units (NRUs) in the country, about double that for the supplementary feeding programme (SFP), and the Community Therapeutic Care (CTC) programme to implement, it’s a bit busy. Plus, it’s a bit acronym friendly. Entire sentences can be formed with a verb and a list of acronyms, which makes conversation with anyone out of WFP little difficult.

Not that there is anyone out of WFP. With working hours of 7.15am to 5.15pm, and Anna, my housemate and fellow VSO, and I running at 5.30 in the morning, our lives so far revolve around WFP, the British High Commission (which has a lovely swimming pool and very cheap carrot cake), and five shops the combination of which means we can usually find the food we are looking for – with some notable exceptions being herbal teabags, nutella, normal chocolate and pork.

It's been a good start, perhaps far too good, so I dread what is to come...

Beginnings...

Second day in the office and I'm already off to Mangochi for a conference on Friday morning on nutrition with my boss. Takes about 4 hours to drive down there, hence we're leaving today. Laz has said we can pop into some NRUs on the way down. All go here. Got A LOT to learn on nutrition - interesting as I'm the assistant nutrition programme officer. Hmm...how misleading job titles are. Had some training all morning yesterday on the NRU (nutrition rehabilitation units), for therapeutic and supplementary feeding. Or rather, I watched some training of people who are going out measuring how malnourished people are. Interesting stuff about the middle upper arm circumference measurements (MUAC), and length rather than height of those under 2years. I have a lot to learn. A couple of things about being in the WFP, or rather, being in the wider UN: everything is in acronyms, we get some rather large radio things with our own signal - complete with manual about how the radio could save our lives, a 24 hour private police type call-out number, and a snazzy ID card.

Our house is getting in shape. After a rather dismal arrival, with the shock of forced adoption of two dogs (who we now love), a really awful brown sitting room, and the need to sack the nightguard, everything is getting there. Pagono pagono as they say here - little by little. So, our friendly neighbours, Heather and Floris, took us 'shopping' last Saturday to buy masses of fabric to cover the sofas, and also helped us with the hunt for a mirror (still looking). Seems the 'shops' here stock pile, so there's either 5 shelves of toothpaste, or absolutely none. It's taking a bit of time to get used to Dave, our garden/house/washing man, who lives attached to the house with his wife and three children. Anna and I had been looking forward to getting stuck into the garden as a time occupant, but it seems Dave just does everything. I merely mentioned how nice it would be to have a flower bed around the front of the house, and when I got back that evening, it was done. Because of such lofty and not necessarily genuine wonderings, we now have many many flower beds, marked out in brick. Still, this morning we thought Dave may be cross with us for the sacking of the night guard (his friend) - which was did last night, and had to recover from with some Malawian gin (very famous stuff, and affordable at four pounds a bottle). The night guard nearly cried, so we were quite tempted just to keep him on. But no. Stand firm. Questions now pop into my head as I try to fall asleep at 9pm (have to get up at 5.30am these days) that the nightguard (we don't even know his name) may try to torch the house while we sleep.

Still, there are some positives; meat is unbelievably cheap (50p for two steaks), whereas a bunch of carrots costs about four pounds.