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.