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!
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!
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