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.
Wednesday, May 23, 2007
Monday, May 21, 2007
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.
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.
Thursday, May 10, 2007
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.
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.
Wednesday, April 4, 2007
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
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
Monday, April 2, 2007
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.
Thursday, March 29, 2007
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.
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.
Wednesday, March 28, 2007
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.
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