Starting to think of this as my second home. The five-hour trip from Neno was uneventful--best kind. Now to find some lunch.
Will spend the weekend in the capital, greet some new visitors from the U.S. and bid farewell to Eileen, who is heading home with literally thousands of photos on her hard drives. (Eileen wants me to put in that not all of the pictures are good but I've seen many that I liked very much.)
Then it's a little R-and-R at the Lake, where I'll have time to reflect a lot more on my 12-week sojourn in Malawi, followed by game-viewing in Liwonde plus a trip to Zomba to meet more nursing instructors.
As usual, will post more items and photos as time and internet access allow.
Have learned in two places now that at least some rural areas of Malawi are already starting to run out of food. Heard predictions in the north last month that people would start running out of food in mid-August. Spoke with a group of folks from villages surrounding Neno this morning and they said the rains had been poor in this area as well and they also were starting to run out of what they had grown.
Because Malawi depends on subsistence farming, with little to no irrigation, it has a single growing season so there is always a hungry period when crops are first planted in November. August is a bit early for people to start running out of food but there are no predictions of a widespread famine like the one that hit about five years ago.
As for buying maize, the price of 50 kilos, which might feed a family of eight for a week, is now 3500 kwachas (US $23) , compared to 1500 kwachas (US $10) at the same time last year.
That was the sign above a store we passed last week in the car on the way from Mulanje. Wasn’t quick enough to get a picture but just the idea of combining a “fish outlet” and “fashion centre” made me smile. Of course, one of the nurses we met in northern Malawi had a thriving business selling dried fish as well as used clothing from a couple of tables outside her home so perhaps it’s not such a bad idea after all.
In fact, have noticed that many of the nurses who appear to be making a go of things in rural Malawi have some kind of business income beyond their nursing salary or even their locum payments (more on locums in a future post). They often grow maize (both for themselves and for sale) or keep chickens as well.
Not every nurse is necessarily a good farmer or businessperson, of course. But if you’re trying to figure out how to make nursing in rural areas more attractive, it seems you might pay attention to opportunities for creating outside income—and not just pocket change but real income for school fees and the like.
Professional groups like nurses might be a good target audience for micro-credit enterprises—provided, as always, things are done correctly with plenty of education about what it means to borrow money. One idea: loans for fertilizer that make higher crop yields possible.
Which brings up another point: lack of access to affordable credit. I’ve been astonished at the high interest rates in Malawi. If you can get a loan from the bank, the rate is around 25%. Micro-credit and private money-lenders charge a lot more.
I’ve seen a couple of billboards for Blue, the South African financial company, and met a man in Lilongwe who works for them. Their effective interest rate is 50%, he told me. I have been told of a local micro-credit group here in Neno that charges 60% (and apparently doesn’t have many customers.) The loans may be unsecured but at those interest rates, I can’t see how anyone can get ahead.
Want to write more about the trip to Chilimbondo in the Dambe Traditional Authority. We drove for about an hour and a half from Neno on a rocky road ever higher. Went through several areas where there were no villages, but everywhere there were signs of human cultivation: furrowed fields on the hillsides, crops planted in the flood plains of tiny streams, even a few stands of wheat glistening a tender pale green in the sun.
And of course, hillsides dotted with just a few saplings plus the odd mature tree standing as a lonely sentinel on the ridge. I remarked on this to one of my benchmates in the back of the ambulance. Fifteen minutes later he pointed out a thick grove of magnificent tall trees on the side of the hill and told me that it surrounded a cemetery. No one had cut the trees for firewood or burned them to make charcoal out of respect for the dead.
Several times the driver had to slow down almost to a stop to work the ambulance around a boulder or a dip in the road. Before every blind curve, he tapped on the horn a couple times to announce our imminent arrival. And often, in fact, there was a group of children playing or women carrying water, parcels or stacks of firewood. We passed a few bicycles being pushed up the hills or coasted down the other side.
As I was admiring the driver’s skill and the ambulance's brakes, I suddenly remembered the report from a couple weeks ago that a heavily laden truck with 50 people had overturned on a dirt road near Mzimbe, killing at least half the passengers. Then I thought about about the accident we passed on the road to Lilongwe. No point dwelling on the risk—it was out of my hands—and I pushed those thoughts away.
Came to the top of one ridge and suddenly there was a large community of at least 150 or more huts spread out on the slopes below us. We passed through the village and saw oxen—our first in quite a while—along with the usual goats, chickens and, of course, people. Most of the buildings were round mud huts topped with thatch—although every now and then you would see a square one or even a brick structure. Very few homes this far out had roofs made of iron sheets.
Caught myself thinking, as we passed through the village again on the way back, how authentic it all looked. The rondavels capped by thatch, the simple designs painted on a few of the homes. But then, as always with me, that second thought. Did that mean I had been disappointed by the sturdier brick structures I had seen in Embangweni, some with satellite dishes sprouting from their iron sheeted roofs? Would I deny anyone the chance for electricity, running water, better communications, health care and education out of a misplaced loyalty to some artificial ideal of the authentic—whatever that is?
Realize I am projecting my own struggle with what is authentic in my life and my chosen profession onto these sturdy huts. Reminds me of all the bright young people I met in Massachusetts this past year who have become so enthusiastic about global health. One of the biggest attractions—no matter what they may say about justice—seems to be that desire for meaning, to see that you are making a difference every day and not just to take it on faith. Our motivations are always mixed.
Must be coming to the end of the trip. All these ruminations. Well, that’s normal, I guess. This is the time to reflect before I start collating the interviews, the impressions, the memories I have gathered and buckling down to write. Or in the immortal more direct words of Andrew Quinn, one my compatriots in Nieman fellowship, “I am learning a great deal. But is it going to translate into copy? Sheeeeez.”
Just back from three hours on bumpy, dusty roads into the hills right on the border with Mozambique. What a blast and am I ever glad I don’t have to do that every day! We packed into the back of an ambulance with Matilda Nyambo and her team from Neno District Hospital and climbed up a rocky, dusty road to the hillside village of Chilimbonde in the Dambe Traditional Authority. (More on Neno and the Ministry of Health's partnership with two international organizations in a future post.)
We followed the ridge most of the way and so had a good view of Mozambique to one side of the vehicle and Malawi to the other. In fact, because the road forms the border for part of the way, I was riding in Malawi on the way out and came back through Mozambique!
Seems every nurse who goes on a mobile clinic is part actress—and Matilda is no exception. I enjoyed watching her engage the group of 100-plus women and children and listen to them laugh at some of her pantomines.
Of course every good act needs an opener; there was singing and a lecture on the use of bed nets to prevent the transmission of malaria. Because the bednets are donated they can only be given to mothers with children under the age of a year. And yet, everyone seems to want them.
And so another odd complication. When the bednets were for sale, anyone could buy them but no one could afford them. Now that they’re free, they are limited to pregnant women and mothers with children under the age of one.
(For a while they were given to pregnant women and those with children under the age of five—the highest risk groups—but everywhere I’ve been in Malawi, I’m told the target now is pregnant women and kids under the age of one.)
But a number of people on the ground are trying to get bed nets for everyone--including adults with HIV, who seem particularly vulnerable to malaria.
NB: In the original version of this post, I said we had traveled to the village of Dambe. I learned afterwards that we traveled to Chilimbondo, which is in the Dambe Traditional Authority. We did not go to the village of Dambe, which is the chief's headquarters.
Have arrived safely at the PIH facility in Neno after about 45 minutes on a tarmac road and about an hour on a dirt road. I'm becoming quite the connoisseur of dirt roads. This one is more rocky as we climb the side of several hills whereas most of the others we have been on are more sandy.
The caps lock key on my laptop seems to have inverted itself somehow on the ride. So when the green light is depressed, I get normal upper and lower case but when it's out, THE LETTERS ARE ALL UPPER CASE. (Seems to have something to do with the "num lock" key. ) But other than that, we and our equipment seem to have survived the journey.
The other big news is that there is wifi in the guest house--the fastest connection we've yet had in Malawi--so I'll be able to post items throughout the week. Alas, no Celtel mobile service but Malawi Telekom is supposed to work.
8 August
Arrived in Blantyre this morning. Spent this afternoon talking with Tulipoka Soko, the chief nursing officer at Queen Elizabeth Central Hospital, and some of her colleagues.
I had tried to make arrangements from the U.S. to talk with nursing staff at QECH but hadn’t gotten anywhere. But when I showed up on Tuesday to set up the interview for today, Mrs. Soko was quite open and willing to talk. Some things you just can’t plan ahead.
This brings up another point. I have tried not to rely too much on expatriates in doing my reporting in Malawi. It’s not that I have anything against expatriates and indeed you have to talk to some international folks to get a good picture. But you can’t leave out the people who are working locally, in government, in hospitals, in local civic organizations. And even within Malawi, you certainly don’t want to talk only to people at the highest levels.
This is often harder than you might think. For one thing, expatriates often come at things from familiar perspectives, so it’s usually easier to get a good grasp on what they are saying. And expatriates are often easier to contact from the U.S. So there’s a built-in bias towards folks who have more access to international communications.
But by being here in Malawi, and spending nearly three months here, I have been able to meet lots of people—like Mrs. Soko—who are quite open about their experience, the joys and challenges of where they work.
That doesn’t mean you have a magic crystal ball and everything suddenly becomes clear. (Would love to spend more time at QECH to delve deeper into the daily experience of patients and ward nurses, for example.) But it certainly gives a better picture than if you limit yourself entirely to those with an international perspective and status.
The driver from Partners in Health is going to pick us up at noon. Once again, I think we will be beyond the reach of the Internet for a while and possibly even of text messaging. But by the end of the week, we should be back in Lilongwe and have internet access.
Although my primary focus in Malawi is nurses and the health system, I can’t help but notice other issues—like deforestation. Many of the hills that I have seen in southern Malawi have been stripped bare of trees to feed the need for charcoal.
Even the forest preserves around Mulanje Massif are starting to show the effects. A new road from Blantyre to Mulanje has opened up—which cut the trip to less than an hour by car. But that has also meant charcoal sellers can easily bike their way up to Blantyre from Mulanje. The photo above is of a charcoal seller who has wrapped his wares in plastic so as not to get in trouble with the forest rangers.
The economics of the issue are compelling. Charcoal is less expensive for cooking than electricity. Charcoal in the rural areas may cost 300 to 400 MK for one of these huge bags but 800 MK in town and that could last you a month. So what happens when all the trees are gone? When you’re trying to make it to the end of the day alive, tomorrow is a luxury.
