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.
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.
