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.

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.

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
income.

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 'ah..Hezil...no,' 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
depressing.'

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.

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.)

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!

A ramble

Today was a very typical day

I went to the bank at lunch time to pay in a cheque from WFP for travel expenses. All the cheque payment slips had run out (this is the biggest branch of the biggest bank in Malawi), so I was advised to use the cash slips. After queuing for 25 minutes in the ‘deposits’ line, behind a couple of tobacco farmers who had turned up with literally a wad of money which needed counting (the biggest note here is 500Kw – the equivalent of two pounds), the man behind the desk said that I couldn’t pay a cheque in without a cheque slip. I explained the situation, and we came to the compromise that I could cash the cheque and pay it into my account in cash. Later that day I went to the cash point. Now, there are technically four cash points at the City Centre branch of the bank, but usually only 2 of them are working. They also close for two one-hour slots in the middle of the day for maintenance. Of course, there was only one cash point working when I turned up. Malawian cash points are really something else. You really have to be prepared to enjoy the experience, otherwise you’ll end up hitting it. First of all, they are incredibly slow. There’s none of that putting the card in and punching out a pin number. Okay, so technically you do just that, but it’s not exactly instantaneous. The cash point I used had a faulty screen, so when you typed in the amount you wanted, you couldn’t actually see anything, so it has to be done by trusting what you type. That, and the fact the bank won’t let you take out more than 40 pounds.

I actually quite like the National Bank. It has a good logo, a large, glassy, clean building a mere 5 minute walk from Kang’ombe House, and friendly security guards by the cashpoints. However it failed to tell me they were charging me for setting up a bank account, or that there are monthly charges for having a cash card (note, only usable for withdrawing money from another National Bank cash point. The whole paying by a card thing here is completely non-existence, unless you are in the nice travel agent, where you can pay for flights by credit card). I admit, I didn’t ask about the charges, but I still think I should have been told. It’s a bit like the doctor when I had malaria. Such a lovely guy, but he completely failed to tell me the side affects of medication, whether it would clash with anything else I’m on, and whether to continue taking my normal prophylaxis.

But really what am I complaining about. It’s not like the banks in the UK are that great either (sorry Holly).

It’s also a novelty (although not a very nice one) for people to die of anaemia. I was quite shocked about this at first…I mean, how can you die from anaemia. Well, 9 months later and it seems that it’s actually one of the commonest causes of death (after malaria, AIDS and needless road accidents). Laz’s uncle, who went in for an operation for a blocked urethra, ended up dying of anaemia. Ntolo’s wife, who had given birth to their first child 5 months ago, died of anaemia three weeks a go, and the mother of someone who works at our sub-office warehouse, also died of anaemia following a car accident. Yes, it’s quite true: a lot of people die around here (especially in the last couple of months). Apparently there isn’t enough blood, and what there is isn’t too good quality, and most of the time transfusions are done far too late. And that’s the whole problem here: late presentation. This refers to nutrition, education, health, even the current government budget – it’s all prepared, or presented, so late that it doesn’t stand a chance.

Please look at the photo accompanying this note. On the whole work can be kept to programme matters, on a so-called higher national level. However, last week I was in Nsanje, in the Lower Shire valley down South. Going into the field means something else from the daily grind; direct contact with beneficiaries and health centre staff, difficult conditions, and the face to face reality which is needed to keep enthusiasm for this job, despite it usually leading to depression when I return. The child in the picture is 8 years old, with severe wasting, marasmus on the arms and legs (stick thin), and a very swollen belly, either from oedema or worms, or a combination or all sorts of other things. The child was found by the outreach workers at the health centre, and was asked to come in to be weighted and measured. That was three weeks ago. The child came in with his 12 year old sister, was advised to go for VCT (voluntary counseling and testing for HIV), and referred to the district hospital Nutrition Rehabilitation Unit. This health offers OTP – outpatient therapeutic care – for malnourished cases which have no complications, but such treatment is futile for such a child; he’s just too sick. Afer the first visit to the health centre the child was not taken to the hospital. This is because the father remarried and the new wife is not interested in his two children from the previous marriage. The next time the child was brought to the health centre by the father. The same advice was given. The health centre even provides transport is the father and child turns up ready to be taken to the hospital. I was seeing the child the third time is was visiting the centre. I was standing the storeroom inspecting the CSB mix and checking ration quantities. I looked over at the queue of children being weighed and this little boy stood out like a hippopotamus in a desert. Visibly, the child is extremely sick. I asked what was going on, and why on earth he wasn’t in the hospital. Maggie, the Programme Assistant for Nutrition at WFP, based in Blantyre sub office explained to the father again that the child would die within days unless he took it to the hospital. She pleaded with him, saying that it was his son, and that there were other fathers in the hospital with their children. Even if he wants to take his daughter with him as well, food is provided by WFP at the hospital for the caretaker and any children brought along too. All the time, I was making ridiculous faces at the children, and he barely had the strength to smile, which is such an odd reaction from the children here – usually they are giggling, or hiding their mouths because they think it is rude to laugh so much in front of the strange white girl. After quite a lot of pleading and begging the health centre staff promised they would get the child to the hospital. In reality, I just don’t know. As Maggie said, if the child stays in the village he will die in the next few days. If he goes to the hospital he can be treated, for even if he has HIV there are paed anti retrovirals in Nsanje district, and the boy can grow to be big and strong, an asset to his father. Children like this break my heart, and make me question the benefits of my sort of job. For personal gratification being in an actual health centre would mean more to me, but then having the opportunity to implement at a nation level has its benefits too, they’re just harder to feel.

A classic example of why nutrition education just isn’t working: when I asked why women don’t feed their children an egg every couple of days (very cheap, and nearly everyone has a chicken), Maggie said that traditional belief linked eating eggs to epilepsy, and so no one in the villages eat them. So there goes another easy to eat food, rich in protein, which no one will touch. It takes generations to change culture.

The return

During pre-departure training one big tip given to everyone was to go away from their overseas placements for a week or so after about 6 months in order to achieve the feeling of ‘coming home’ when returning. It’s a good trick, and it does work, but right now if one more person comes into the office and gives me a hug with a sad, suitably appropriate look, and a ‘I’m so sorry’ comment, I think I am going to crack. I knew before I left that WFP – the good bits of WFP – really are something else. Never have I worked with people I like more, where really everyone has a good soul. Even the security guard on the fourth floor, who I usually avoid, dealt well with a sarcastic reply to his ‘how was the holiday?’. ‘As well as a funeral could go’ I scowled back, and he seemed genuinely nice about it. Saying that, never before have I worked in an organization where family comes first. I don’t think my September 2008 awaiting job in London would look too kindly on me nipping out for a couple of hours to visit my cousin’s daughter in hospital. But I like it. We still get the job done (on the whole), and when Nell walked into our nutrition office this morning to find Laz, Osborne and me having a good chuckle, Laz beamed at her with a ‘welcome to our office.’ These are the things to treasure, especially when I am experiencing post-funeral blues.

On the plane back I got to thinking about the added value of being here. There’s got to be something right, something other than resume related? When I was in Addis I never really thought about added values, it was just as it was, a life. I remember sitting in City Bakery in Addis with my friend Ute thrashing out these issues: will anyone understand this type of work? why should we expect our friends back home to be interested in the minute details of our daily lives and jobs? is it worth the mental isolation if we think what we’re doing is important? will the transience of relationships which are formed have longer term effects? are we missing out on what I sometimes think of as a ‘normal’ life? In Addis I never considered myself to be treading water or putting my life on hold. I was living there. It was a life. I was happy to just be. But here in Lilongwe it’s different. I don’t know if it’s because of the length of time I’ll be here for, or because it is just such a small place, but the feeling of being on hold, of wanting my London life back keeps creeping up on me. When I went back home last week I thought I’d go mad with all exciting food, and decent newspapers. In reality, I didn’t want any of it. What was more surprising was that I didn’t want to talk about my job. My job and my life here are so intertwined that I don’t differentiate. But at home, on the only one occasions someone asked about the job specifics, I didn’t want to talk about it. On the one hand it would be part reeling off statistics and the logistical problems of getting food to 50,000 malnourished children, dumbing it down a little and not using acronyms. On the other hand I could go down the sob story route, about the late presenting quash cases and the use of Fanta in weaning children. Or again, it could be about the frustrations of trying to get things moving quickly when working for an international organsation, how problems repeat offend, how the sheer brick-wall feeling occurs so often that it wears you down, how the physical exhaustion of spending 9 hours in a car 3 days a week wandering around rural health centres can sometimes lead to tears for absolutely no reason. In Malawi I’ll talk about my job until the cows come home. Even to the taxi driver I’ll be expanding on the 6 food groups and the evils of Fanta. But in the UK, I really don’t think anyone is actually particularly interested after the initial and highly superficial introduction. And really, why should they be?

The ever brilliant Roger McGough has some good things to say on this. I’m not in to quoting poetry, but his entire book ‘Blazing Fruit’ could be inserted about now.

So now I have two lives, and while Malawi rubs me up the wrong way more than I could ever imagine there are many things to value too. Post funeral it feels that while death here is so much more common place than in the UK, it seems to mean so much more. I don’t mean to be derisory, but here there is such a dignity to death. Old members of the family are looked after and treasured, not put in nursing homes or farmed out to other paying establishments. There is something quiet, discreet, and meaningful about the way death is treated. I’m not saying that this isn’t the way in the UK, but it certainly feels different here. Maybe it’s the knowledge that here, with the increased religious conviction, there is a confidence that the dead are passing on to somewhere better. What is more reassuring than that?

So coming back to Malawi is a good thing. Good in that it is my home, for now at least. Good that when the taxi came through the gate of 194, Area 15, Dave beamed and clapped his hands. Good that the dresses I bought for Dave’s girls fit. Good that the house still feels the same. When something so permanent in your life goes you think that everything will change. But it doesn’t, and the daily rigours of distribution plans, endless meetings, field monitoring and random chat take over.

Break in at Kan'gombe building .... beware of furry creatures ...

...and this is a reason why it's good to be here - an email waiting in the work inbox this morning:


All,

The Common Room "tea time" group feels obligated to inform all CO and LLSO staff members that last night there was a furry intruder on the premises.

Shocking but true ... members were confronted by this fluffy beast that accused all WFP staff members of spending too much time sitting and looking solely at their computer terminals. This funny bunny ... guarded closely by a group of chickens (members were amazed that they could actually talk - and be fully bilingual as well ....) wanted WFP staff to prepare for the long weekend ahead by allowing them - today - the opportunity to look away from their monitors and exercise their necks ..... consequently .... a plot was hatched (excuse the pun - ramifications of psychological trauma).

It seems that the chickens were not just sauve bodyguards but .... producers of delecious chocolate eggs ...... and the bunny .... being apparently a very democratic creature ... mandated that each staff member should be awarded two chocolate eggs ..... IF they can find them.

So ..... please, do not shoot the messengers ....... but ..... the bunny has hidden chocolate eggs within your office ..... I guess these furry creatures were serious about taking the time to look away from your terminal!

Good luck!

The Common Room tea time group

Dum dum de dum

On Saturday our house keeper, Dave, got married. I did find this a little surprising considering that when we arrived in the house last September Dave introduced us to his wife and three children. Seems it was never actually official.

Well, now it is, and Dave is sporting the proud wedding band of a married man.

It's been seven months!

This was going to be a bit of a long, and no doubt tedious, email about the frustrations of trying to do anything in Malawi; about how it feels like treading water with all these development projects liberally scattered all over the place, when in reality these step by step programmes are not going to lead to Malawi developing. Sure, they may help some people, but ultimately they aren’t going to do much in the long term. One school by one school does not equal a South Korea. But, this isn’t going to one of those emails.

Yesterday afternoon I got a little over excited about a meeting at Ministry of Health. It was me, the chief nutritionist at UNICEF, the three from the MoH nutrition team and someone from Valid International. We were there to get a preview on the report a consultant has written on the new nutrition programme for the country, and we chosen few are, or will be, key players in how nutrition activities are shaped in Malawi in the next year. MoH are introducing something called CTC – Community Therapeutic Care, which is a complete package of nutrition including nutrition rehab. units, supplementary feeding and outpatient therapeutic care. It’s pretty exciting stuff, as we’re rolling this programme out from June. WFP wise, we’re scaling back our normal programmes where CTC won’t be implemented, but will scale up where it is. Scary stuff, and my baby – my first all district project! Anyway, there we were discussing reporting methods. In my mind, why introduce a massive new programme which needs good reporting structures when the current reporting structures for nutrition activities don’t work? MoH were suggesting we use the same structures, with a focal person for reporting in each district. Great idea, but it’s what we currently do, and it hasn’t worked for three years. For February I received only 68% of NRU reports, despite calling each focal person in each district. Without complete reports I don’t know if the food is running out, what the total NRU admissions are for the country, what the malnourishment trends are for the month – things we kind of need to know in order to send the correct quantity of food. Anyway, I hitched a lift back to WFP after the meeting with Stanley, from UNICEF. I admit to being quite psyched about CTC, as if it works it’s a really brilliant programme. The trial districts which have it are doing so well. But as Stanley pointed out after an outburst of my youthful enthusiasm, a programme which is so resource heavy is not sustainable, and if it’s not sustainable, then what’s the point?

But now for a few horror tales from Lilongwe. Last week an ICU nurse newly arrived from London found a dead body on the floor of Kamuzu Central Hospital. Welcome to the health facilities in Malawi. I realize this sounds very negative, especially when one of things which I think is so great in Malawi is the idea behind the health system. At any government hospital or clinic free health care is provided to anyone. And it’s true, if you have malaria, or need contraceptives, or antibiotics, you can get them for free in even the most remote facility. The same certainly can’t be said of many sub-Saharan African countries. The problem comes with the lack of drug diversity. For example, an epileptic can technically get free treatment to control fitting, but in reality there is no medication. Similarly, anti-retrovirals are free – a really positive step towards preventing HIV transforming into AIDS, as is neverapine (for prevention of mother to child infection), thanks to a generous donation from the Global Fund. But ARVs for paediatrics are still quite rare and the donation was only supposed to last for three years thereby giving the National Aids Commission enough time to source new funding. But of course, this hasn’t happened yet.

A bit of background information: In Malawi there are government hospitals and CHAM hospitals. CHAMs are any hospitals which are remotely religious; Anglican, Catholic, Presbyterian. The central Christian Hospital Association of Malawi (CHAM) doesn’t have any power over these autonomous hospitals, but there are general similarities: clean wards, a doctor per hospital – which certainly doesn’t happen in the government facilities – and lots of qualified nurses. You can always tell a CHAM before you enter a building because they have beautiful gardens and the smell of unwashed flesh doesn’t meet you as soon as you step inside the compound gate. My favourite two hospitals in the whole of Malawi are CHAMs – one called Kapiri in Mchinji, run by Taiwanese nuns, where the staff beam with happiness, and the Livingstonia Mission hospital, one of the oldest hospitals in Malawi. It has a beautiful nutrition education garden based on the six food groups and a very charismatic and enormous wooden cross wearing administrator.

Like other sectors the health system works in a decentralized way, with the district being the top of the pyramid. Per district there is one district hospital, which has a doctor, maybe a rural health centre with a maternity ward, and then lots of health centres and health posts for outreach work. No where except the district hospital will have a doctor and while there may be a poorly qualified clinical officer dotted around the place (a 3 year course) who will do whatever surgery he thinks he’s up to (butchery springs to mind), the likelihood of someone in a village ever seeing a doctor in their lifetime is extremely slim. At the district hospital will be a whole lot of acronyms – the DHO (District Health Officer – rarely a doctor), the DMO (District Medical Officer), DNO (District Nursing Officer), MCH Coordinator (Maternal Child Health) and in 8 of the 28 districts a District Nutritionist, and that’s it, apart from the odd volunteer doctor from overseas. Okay, so in reality a couple of district hospitals don’t have any doctors apart from overseas volunteers. Thyolo district hospital is nearly run by Medicin Sans Frontieres, and the only doctors in Nsanje DH are supplied by VSO.

At CHAM facilities there will be a doctor, nurses, maybe a nun or two, and enough money to feed their patients vaguely nutritious food and change the bed sheets every week. The problem is that CHAMs charge, not much at all, but enough for most people not to be able to go.

But now onto other things. At the moment the rains have stopped, and with this comes the end of the lean season and the beginning of the summer harvests. According to new government statistics if the harvests of the summer crop go well Malawi has 50% more maize than it needs, and just two weeks a go the ban on exporting maize has been lifted. While this is really fantastic news there begs the questions why we are still supplying food to over 250 health centres for supplementary feeding and 96 NRUs?

This past month I have been conducting a mid-term assessment of the emergency supplementary feeding programme. This programme started in November, and is supposed to run until June, thereby covering the lean season and any hiccups with harvest. In October I assessed health centres for their suitability in implementing supplementary feeding along with a Norwegian nutritionist from UNICEF. We targeted only those districts which showed up as red on the Malawi Vulnerable Assessment Map – districts which are supposed to be most food insecure. This left us implementing the programme in four districts in the Central region and five districts in the Southern region. Emergency supplementary feeding is aimed at tackling only those with moderate malnourishment. The programme has very strict criteria. For under 5 year children admission is only by a MUAC (mid upper arm circumference) of under 12cm, or a weight for height ratio of under 80%. Of course if the children has oedema, due to severe protein deficiency, and therefore has swollen arms, they won’t meet the MUAC criteria. BUT, in these cases the child should be referred for an NRU. Supplementary feeding is not going to help a child with oedema – they need specific therapeutic milks. For pregnant and lactating women admission criteria is only with a MUAC of under 22cm. MUAC is a very useful tool for rapid nutrition assessments. A few weeks a go UNHCR were reporting severe malnourishment in the refugee camp in the South, especially of newly admitted refugees, mostly from Ethiopia, Burundi and Eritrea. My boss, the great Lazarus, went down and conducted a rapid nutrition assessment using MUAC, and for the most part it was highly accurate. Anyway, back to supplementary feeding. UNICEF released money for training of health surveillance assistants (usually 5 in each rural health facility) and the nurse/midwife (usually one per health facility) in November. Trainings of supplementary feeding implementation (admission/discharge criteria, how to distribute food, ration size etc) were done in December, and food was also delivered in December. Ah…that was the month of the maniac distribution plan...happy memories. We had reports in January that some centres had run out of food. This was concerning as the distribution plans are based on two months worth of food. The district based WFP food aid monitors did a bit of checking and discovered that admission criteria were not being followed. So, come mid term assessment and I head up to Kasungu, the district with the most health centres in this programme – a whopping 18 facilities. After many attempts of trying to be charming over the phone to Wales Kazonde, the district MCH coordinator, and therefore technically person-in-charge of this programme, he agreed to accompany me on the entire trip. All WFP nutrition programmes are implemented in conjunction with Ministry of Health. In fact everything we do must be on their request. For example, if a health centre needs more MUAC tapes they must write to requet from UNICEF, as UNICEF is not allowed to give directly. This is essential for government capacity building, and for when we pull out, but most of the time it just makes programmes run less efficiently, and is incredibly irritating.

So the results for Kasungu: 3 out of 18 health centres were implementing the programme properly using the correct admission criteria. One centre had no registers on site. We were told the HSA had gone to an outreach clinic and taken the registers with him. So off we went to find him. Once at the clinic - a horrific 45 drive from the health centre on the dire-est of all dire roads, we were told he had gone back to the clinic. So we returned to the clinic, and of course he wasn’t there. The general consensus was that he was with his girlfriend. It was only 2.30pm. The other centres were admitting perfectly healthy children and seemed to be carrying out a type of general food aid to vast numbers of people – up to 1000 in one case. So, no wonder the food ran out. But this makes me wonder, why could three health centres implement properly and the rest not. After explaining the intentions of the programme and the criteria to one nurse she looked so sad I asked her why. Shame she said, shame at getting it so wrong. But whose fault is it? MoH, the MCH coordinator, us for believing MoH would conduct suitable raining, UNICEF for not following through on the use of their non food items? So when you read statistics of how many thousands of people WFP are feeding think about whether they are the right people. I really think our Country Director hasn’t got a clue about what’s going on in the field. My note for record on this mid-term assessment fuelled a panic with him, where as surely he should be more worried about the lack of any food getting to schools for the school feeding programme in the next two months due to a problem with the out put reporting system, or the fact that for emergency school feeding only 4 out of 123 schools in Nsanje have received their high energy biscuits, and even then the reports are that the staff are stealing the rations?

But things continue as normal in Lilongwe. This past month has included an entire week off work, flat on my back, with a three day fever thanks to some hideous biting insect, although it wasn’t malaria this time (wish it had been – easier to cure). And of course when all you want to do is eat lots of fruit and veg and drink gallons of fruit juice, the supermarket – which actually stocked some exciting broccoli, cauliflower and plums the previous week - decided to be out of everything except the bog-standard tomatoes, onions and cucumber. It was not a good week. However, I did learn to make gnocchi from scratch the following week, which was rather thrilling.

So with all this you might wonder why I have decided to stay for a further year. I may end up regretting this, especially as the last month has proved how basic facilities in Malawi are. A volunteer doctor at Kamuzu had a needle stick injury a few weeks back and had to have the HIV post exposure kit couriered over from the UK as the doctor we are recommended to see didn’t have enough medication. But there are times, especially in the field, when you are driving down a dirt track at about 5pm, with the sun incredibly low and those long, beautiful shadows, and the driver is playing his favourite Enriques Englesias tape, and you’ve finished the job and are heading home. All you can see for miles and miles is funny peak after funny peak, and lots of smiling, laughing children playing on the side of the road, and everything seems right in the world.

It's a small world

Isn’t the world a small place? By a set of very odd coincidences last night I had dinner with a guy my sister’s LSE friend Kasia met in Prague two years a go. Kasia met him for all of two hours in a hostel, and low and behold, two years later I also got to meet him for two hours (see how desperate I am for new company?). He’s a newly qualified medic who has been here experiencing African medicine first hand for two weeks labouring in Kamuzu Central Hospital – where you go to die (quite seriously). His impressions of Malawi remind me of what it was like when I first arrived, a whole 7 months ago: all the smiling, non-crying children, the endless people walking along the side of the road, the beautiful mountains and the bad food.

Breaking down in Mozambique

Three weeks ago my mother's worst nightmare came true: braking down 100km from anywhere in rural Africa. However, unlike in her dream where a man comes out and kills us all, a very nice NGO car stopped, temporarily fixed the car, gave us the name of an engineer and a man who spoke English, and helped us back to the town we had come from. If anyone feels like donating to ADRA, they are the wonderful NGO which saved us. If anyone is passing through Mocuba and needs the name of an engineer let me know.


After a two day drive from Malawi, we finally reached the Ilha de Mocambique, in undeveloped and rarely visited Northern Mozambique. This is the island which gave Mozambique it's name, and would have been extremely beautiful aboout 300 years ago. It's 600m x 2km, and yet squeezes on 7000 people.







The Island is currently a UNESCO World Heritage Site, and so protected from any mass developments. The plans at the moment are to restore it to former Portuguese glory. Everything is there, structurally, but the extent of lack of care, and the number of people living from this tiny space has taken its toll. We stayed in a restored house, which is owned by the Italian architect Gabriele (www.mozambiqueguesthouse.com). He is part of the rehabilitation of the Island, and if he has his way, the Island won't be ruined. Give it ten years he says, and come back and see a transformation.

The Development Set

There’s a wonderful poem at the beginning of Lords of Poverty which starts:
The Development Set is bright and noble,
Our thoughts are deep and our vision global;
Although we move with the better classes,
Our thoughts are always with the masses.

In Sheraton hotels in scattered nations,
We damn multinational corporations;
Injustice seems so easy to protest,
In such seething hotbeds of social rest.

Last week I received a letter from my friend. She wrote that it felt like I was in a parallel universe and how on Tuesdays we used to sit after our International Institutions lecture having a very un-nutritious lunch of a caramel square talking of those people who work in deprived areas of Africa, and now how it seems I’ve temporarily become one. It’s as if the ‘big dream’ is being carried out, and yet it doesn’t in the least bit feel like that.

A few days ago I was at a rural hospital, and while I was waiting for the keys to the storeroom so I could check up on WFP food I was sitting in the NRU chatting to the homecraft worker. As I was there it began pouring with rain, with the wind pushing the rain into our open concrete square and through the windowless window frames. A woman walked in with her 13 month-old grand-daughter who had been referred to the NRU from their local health centre. The grandmother had walked for 4 hours with the girl, as the mother was at home with her 1 month old baby. The little girl had 3plus oedema, the symptom of quash. In malnourishment terms there are two illnesses we see, quashiokor and marasmus. Marasmus is what you see on tv, the stick like arms, alien looking head and general wasting which comes from starvation. Quash presents itself in fluid retention, so the child has swollen feet, arms and a moon-like head, often with very fair hair. Unlike most of sub-Saharan Africa here in Malawi quash is the most common form malnutrition takes, and it’s the hardest to cure. The girl who showed up with her grandmother at Alinafe in Nkhotakota district was a typical example. Her mother had initially taken her to the traditional healer, because a chubby looking child doesn’t equate with malnourishment for these rural women. The traditional healer gave the mother some medicine for the child, believing that she has either been cursed or that the husband was cheating. That medicine made the child’s legs purple. So the mother waited 4 days before taking the child to the health centre, who refered her to Alinafe. It’s not good enough that the child will probably recover, providing that there are no complications. The damage has been done to the child’s cognitive and physical development. She’s not unique by any stretch of the imagination, so when you consider that thousands of children suffer from malnutrition and what this does to their cognitive capacity, is it any wonder that countries develop at different rates? And think about all those children with quash who aren’t taken to the health centre, or who aren’t picked up by the HSAs – the outreach health surveillance assistance on their insane 50km bicycle catchment areas.

So what are the developments? I admit, WFP is not a development agency. It is a humanitarian aid agency which primarily works in emergencies, with a few development programmes such as school feeding. And yes, by looking at the facts in my programme alone we are proving food to 96 NRUs, 250 supplementary feeding centres every month, which equals about 30 children per NRU and 350 per supplementary centre, and this is half the size of the school feeding programme. In NRUs we also provide fortified foods to the caretakers to reduce the abscondee rate, and support nutrition education and low-input gardens to provide the caretakers with information about how malnutrition can be prevented. But is any of it working. The malnutrition rate is decreaing so far this year when compared with last year, but surely that’s only because the emergency is ending and the crop stores are better? Sometimes, when I’m in the office filling out a procurement form for ink and ink pads for the stamps the health centres need to complete their waybills I really wonder if this is it: hospitals which need signs on every wall saying not to wean babies onto Fanta or tea, and hospital workers who can’t keep a food storeroom clean and don’t seem to understand that the food we send should be treated like medicine, and not left to be eaten by rats or ruined by piling it up against damp walls. So I suppose what I’m trying to say is does any of this make a difference?

What I fear becoming is one of those development people who complain all the time and outside work only talk about where to buy such and such. I see myself doing it a lot. Conversation often revolves around the latest import of really fantastic cheese, or whether or not there’s the nice yoghurt this week. This isn’t what it should be about, but I suppose in an effort to blank out the work shallow-ness comes to the surface. It’s so easy to walk through an NRU and not take in what is actually there, and most of the time that’s what happens – it just looks so normal now.

In order to keep sane things are done in baby steps, one person by one person, one drop of water to make up the ocean, and all those other analogies. But ultimately what good is it doing? As the poem ends:

Enough of these verses -- on with the mission!
Our task is as broad as the human condition!
Just parry to God the biblical promise is true:
The poor ye shall always have with you...

Press Release: WFP REACHES BENEFICIARIES DESPITE LOGISTICAL OBSTACLES

LILONGWE – Due to generous donor support, the United Nations World Food Programme (WFP) is confident that it will be able to successfully scale up its operations and deliver vital food aid supplies during this lean season to 1.3 million Malawians (including pupils benefiting from the school feeding programme) in need of assistance in the coming months despite the deteriorating state of much of the country’s infrastructure.

Recent heavy rains have damaged numerous roads and bridges, leaving many vulnerable communities in danger of being completely cut off. However, thanks to substantial contributions from a number of donors and a remarkable logistics effort, WFP believes that it will still be able to reach all of its targeted beneficiaries.

“While the heavy rains are welcome in terms of the forthcoming harvest, they have made WFP’s life much harder by hampering access to many rural communities that urgently need our help,” said Dom Scalpelli, WFP Country Director in Malawi. “But WFP’s logistics unit is working non-stop to overcome all the infrastructure problems to ensure that all those in need of our assistance receive sufficient food supplies.”

During the lean season between January and March, WFP intends to distribute an average of 14,000 tons of food per month to around 1.3 million beneficiaries, including families affected by drought, floods and HIV/AIDS. However, it is becoming increasingly difficult to transport food aid to some parts of the country due to the devastating impact of recent downpours.

WFP road and bridge assessments indicate that parts of Chikwawa, Ntcheu, Nsanje, Phalombe, Salima and Thyolo are now extremely difficult to reach. In addition, an average of 10 trucks per day are currently getting stuck in the mud, forcing transporters to hire tractors to pull their vehicles out of the mud.

While these obstacles are certainly hindering operations, WFP is continuing to deliver food to people across the country, even in the most remote areas. Along with pre-positioning food supplies in temporary storage facilities in some of the worst-affected districts like Nsanje and Chikwawa, WFP has also been relying on a fleet of small powerful 6 ton trucks donated by the Norwegian government.




“We knew that some areas would be inaccessible after the rains so we stockpiled food aid in these districts before the rains intensified so that vulnerable people would still get aid,” said Scapelli. “We have also managed to reach many people in other areas thanks to our own fleet of trucks. We are very grateful to the Norwegians because without these tough trucks, many of our beneficiaries would have been left with little or no hope of assistance.”

WFP is also extremely thankful for the contributions from other donors, including Denmark, DFID, the European Union, Germany, Iceland, Ireland, Japan, TNT (a multinational logistics company) and the United States. In addition, the government of Malawi recently donated 10,000 tons from the country’s Strategic Grain Reserves.

“Millions of Malawians have received food assistance over the past few years – and will continue to receive food assistance until the end of 2007 – thanks to the ongoing support of our donors,” said Scapelli. “Donors seldom get the credit they deserve but without their contributions, large numbers of Malawians would be facing an even harsher lean season.”

Most donations are used to procure food in Malawi so boosting the local economy and strengthening local markets. Since 2001, WFP has bought 140,000 tons of cereals, pulses, Likuni Phala and sugar in Malawi, ploughing over US$33 million into the economy.

Nevertheless, WFP Malawi still requires additional contributions to fund its operations, with another US$24 million needed until the end of the year to meet its current shortfall for the regional protracted relief and recovery operation activities.

FAO/WFP Flood Impact Assessment, Lower Shire

Two women assessing their replanted maize crop, Nsanje District.

Legend has it that God intended Malawians to live on the plateau of Malawi, but to work and harvest from the rich soils of the Lower Shire (pronounced Shir-ee). Of course, fast forward a few thousand years and things haven’t quite worked out as God intended: a large number of unfortunate souls live in a basin well below the rest of Malawi in intense humidity and horrendous average daily temperatures of 42 degrees. Oh yes, God was certainly right about one thing – the soil is incredibly fertile, as the sugar plantation owners know, but there’s always a catch – in this case the humidity, floods and drought. Welcome to Nsanje and Chikwawa Districts which make up the Lower Shire. It’s a little cruel, in my opinion, that from the bottom of the basin the soaring ridge of the plateau is visible so that every time you look up you are reminded that not everywhere is already 36 degrees at 7am.

Having heard the legend, last week I was fortunate enough to travel to Nsanje and Chikwawa for a week to conduct a flood impact assessment as part of the joint WFP-FAO (Food and Agriculture Organisation – another UN body) mission team. Actually, the ‘team’ was made up of me and Chester, a FAO guy and previous Chikwawa District Crops Officer, and the ever important driver who managed to only get us stuck once. In November some flash floods hit the Lower Shire – quite normal for that time of year, and quite expected. BUT, come January, no one was expecting more floods. At WFP these floods have been disastrous, as transporters carrying food for the Jan-Feb distributions have become stuck in an area called the East Bank, along the River Shire.

According to Ministry of Agriculture assessments huge numbers of hectares had been totally destroyed by the January floods. Unfortunately the very lovely Ministry of Agriculture have a few ulterior motives when reporting crop damage, so we were there to do our own assessment. Unlike in the health sector, where Malawi’s 28 districts are divided into Traditional Authorities (TAs), in agriculture the districts are divided on geographical, not political lines, which results in about 5 or 6 EPA (Extention Planning Areas) per district. We spent a lot of time wandering around fields of half flooded maize, and looking at sand covered rice crops. Why oh why, we pleaded, had these people been advised to plant maize after the first rains?? Why not cassava, rice or sweet potato, which are much more resistant to flooding? At one spot we cowered under a tiny tree for shade and looked out on a field of maize which now looks like a beach. Gradually the whole village came over to us and explained that floods had never happened before in the area since 1997, and that they were 100% reliant on the maize they had planted for food. Luckily most other areas weren’t so dependent on their summer crop (it’s summer here!) and could get by on winter harvests, so there’s no need for food aid. Food aid, in my opinion, can be a hugely dangerous thing.

One night I found myself in a snazzy motel in a place called Nchalo, half way between Chikwawa and Nsanje, with ‘you want regret’ under its sign. Nchalo is your typical Malawian town, strung along a main road with a PTC shop, petrol pump and a whole host of little run-down shops selling very randoms things from bicycle tires to goats (Chester actually bought a goat on the way back). There I sat in a bar drinking a ginger ale next to a guy slowly getting drunk on green Calsberg who asked the same question ever 10 minutes or so. Behind the barman’s head was a novelty item: a television with DSTv disk, flashing scenes of As Time Goes By. It had taken some persuasion and the agreement of the entire bar to change the channel to BBC Prime, but the explanation that it would remind me of home made everyone very agreeable. Of course, there followed 100 questions: where was home, what was I doing in the Lower Shire, how long had I been here, which football team do I support??? They were, for the most part, half drunk, and so ecstatic to oblige a white girl who for some bizarre reason was spending a night down in the Lower Shire. So, we sat in the bar till 10pm, by which time the temperature had dropped to a sleep-able 30 degrees.

I wouldn’t want to live in the Lower Shire, although an awful lot of people do. Illovo, the sugar company, has a huge plantation there, and about 30kms of the M1 road travels alongside the sugar cane. Of course, those 30km takes nearly an hour to drive as the road is so bad as to make you feel that your spine is being compacted on every single bump. Nsanje, the last town on the M1, or the first – depending on your viewpoint – promises the exciting Nsanje Port on the Shire River when you enter the town. Unfortunately this hasn’t been built yet, and comments go that why not build a proper road before building a port. At least the promise of the port has brought a baker to the town.

According to my colleagues, I can now say I have seen Malawi. I have traveled the whole of the M1, from the most Southern tip in Nsanje to the most northerly point in Chitipa, covering 24 of the 28 districts. What can I say? Half the time I want to stay for ever in this beautiful, friendly, well meaning country, and the rest of the time I desperately want to come home.