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.