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.