Saturday, June 28, 2008

Heading for Embangweni

My photgrapher friend Eileen Hohmuth-Lemonick has arrived and tomorrow morning we're headed to Embangweni Hospital in the rural northern part of Malawi. We are unlikely to have any access to the internet but I will keep writing posts offline and then upload them when I can--probably towards the end of July. If we head into the larger town of Mzuzu before then, I'll look for an internet cafe and send updates from there.

Friday, June 27, 2008

Documenting the Brain Drain in Malawi

26 June

In order to learn more about how and where nurses are trained, I spoke with Jacinta Mtengezo, director of education for the Nurses and Midwives Council of Malawi. The Council is a part of the government and serves as a regulatory body that regulates the training, education and practice of nurses and midwives in Malawi. It also has a mandate is to protect the public from unsafe health care practices.

Nurses who want to leave the country to work must register with the Council, which is where some of the statistics about nurse emigration come from. So for example, 614 nurses (95% of them registered nurses with bachelor's degrees) registered to leave Malawi from 2000 to 2008 so far.

The most common destination: the United Kingdom. From 2000 to 2008, 490 registered nurses and 10 nurse-midwife technicians headed for the U.K. To put that number in context, until fairly recently, Kamuzu College of Nursing—the main source of registered nurses in Malawi—graduated just 60 RNs. KCN's goal is to get that number up to 100 graduates. (Nurse-midwife technicians can also upgrade their credentials with additional education at another school in Blantyre.)

There's just one caveat to the emigration numbers: Registering for emigration is not the same as doing so. When I asked Mtengezo if the Council knows how many nurses actually followed up, she said they didn't, although there are plans to try to get at that number with a survey. Still, there's no question that a fair number of the nurses who registered to leave actually did so.

There is some hope in the numbers. The Council's figures show that the emigration trend is abating. Last year, 23 nurses registered to leave, down from 98 nurses in 2005 and a peak of 111 nurses in 2001.

Here's the raw data, copied from a printout Mtengezo gave me:

Nurses and midwives who migrated to other countries
2000 90
2001 111
2002 90
2003 81
2004 85
2005 98
2006 30
2007 23
2008 6

As for education, there are 15 different institutions that train nurses in Malawi. (That counts the two campuses of the Kamuzu College of Nursing as one institution since only one graduating class comes out of it.) Currently, only Kamuzu College of Nursing is graduating registered nurses with a bachelor's degree. But Mzuzu University is in its second year of a four-year bachelor's program of nursing and will graduate its first degreed RNs in two more years.
Here's the list based on another printout Mtengezo gave me:
1. Ekwendeni College is in the north and trains nurse-midwife technicians.
2. St. Johns College is in the north and trains nurse-midwife technicians
3. St. John of God College is in the north and trains psychiatric nurse technicians.
4. Mzuzu University is in the north and has just started offering the bachelors of science-registered nursing degree. It will graduate its first class in another two years.
5. Kamuzu College of Nursing (with campuses in Lilongwe and Blantyre) offers the bachelor's degree in registered nursing.
6. Malawi College of Health Sciences in Lilongwe (central region) trains community health nurse technicians.
7. Malawi College of Health Sciences in Blantyre trains nurses who want to upgrade their credentials to a bachelor in registered nursing.
8. Malawi College of Health Sciences in Zomba (South region) trains nurse-midwife technicians and offers psychiatry for nurse-midwife technicians.
9. Mulanje College is in the south and trains nurse-midwife technicians.
10. Nkhoma College is in the central region and trains nurse-midwife technicians
11. St. Luke's College is in the south and trains nurse-midwife technicians
12. St. Joseph's College is in the south and trains nurse-midwife technicians
13. Trinity College is in the south and trains nurse-midwife technicians
14. Holy Family College is in the south and trains nurse-midwife technicians
15. Malamulo College is in the south and trains nurse-midwife technicians

Two more training institutions are slated to open. They are Catholic University (on track for opening in 2009) and the Institute of Management for Nursing and Health Sciences (a definitive time for their opening has not yet been set).

More Numbers From Kamuzu Central Hospital

25 June

A picture is developing of how much ground Malawi has lost in health care since the 1980s—post-structural development, post the explosion of the AIDS crisis. Talked with Dr. Peter Kazembe, who runs the Baylor Pediatric AIDS clinic at Kamuzu Central Hospital. He retired from the Ministry of Health but never left medicine.

Back in the 1980s, when Kazembe was director of the hospital, they had had enough reagents and skilled technicians in the lab that they could do the blood work to diagnose sickle cell anemia—a fairly common condition in this area. Nowadays, he said that is impossible.

Earlier in the day I spoke with Dr. Hadge Juma, the current director of the hospital, and Patricia Nkhoma, a registered nurse-midwife who supervises the surgical department. The main structure of the hospital facility was built in 1977 with 500 beds. Another part of the hospital located about six kilometers away contains the maternity and tuberculosis wards, has 250 beds and was built in the colonial era.
Yesterday the main campus had 970 patients.

More than 70% of hospital admissions are HIV-related Juma said. Twelve people died at the main hospital yesterday. By the time I arrived for a mid-afternoon appointment another 8 people had died. (And in fact, I glanced over at the morgue when I arrived and saw four private vehicles, waiting to claim bodies of relatives and loved ones. Bodies are usually prepared for burial by the families, I'm told. No one has money for embalming.)

Currently there are 202 nurses covering both campuses, Nkhoma said. Of that total, 43 are registered nurses. The complement should be 550 nurses. Since April, 17 nurses have resigned from Kamuzu Central--one to follow her husband overseas and most of the remaining ones left to work for Dae-Yang-Luke, a private hospital run by a Korean church that is opening up near the airport.

(Correction: July 30, 2008. According to Abigail Bonongwe, matron at Dae-Yang-Luke Hospital, only two nurses have come from Kamuzu Central. Indeed, DYL Hospital has made a concerted effort not to recruit nurses from government hospital, targeting those working at NGOs or just graduating from nursing school instead. Also DYL Hospital is not a private hospital but is part of the Christian Health Association of Malawi.)

This internal brain drain—out of the public sector and toward NGOs and private hospitals—is turning out to be every bit as important as the external brain drain.

Wednesday, June 25, 2008

A Visit to the Pediatric Ward

24 June

This is the part I have been avoiding. Went up to Kamuzu Central Hospital during visiting hours this evening. People everywhere. In the hallways. In the courtyard. Visiting family, taking care of them, feeding them with food they brought from home.

Realized at one point I was following my usual New York City subway routine, looking at people's feet so as not to make eye contact. Most people wore shoes, sandals or flip-flops. One young woman walked by in bare feet. Decided to raise my gaze.

Actually a pretty quiet place considering how many people there were. Everyone subdued, hushed, even the children. Didn't notice any particular odor. In fact, I realized it didn't smell like a hospital—didn't have that anesthetic smell that hospitals in the U.S. have.

Went into one treatment room where there were a couple of nurses. Learned there were about 200 babies on the ward that night—with six nurse technicians to watch over them. One nurse said they had no R.N. supervising them that night. Then she quickly reconsidered and said that they did indeed have one RN. The night shift comes on at 4 PM and doesn't leave until 8 AM tomorrow. They get one meal during that time.

Twenty years ago, nurses worked four different shifts to cover a 24-hour period. Sometime in the 1990s, I have been told, the Ministry of Health could no longer afford four shifts and so switched to two shifts. The day shift runs from 7:30 AM to 5 PM (nine and a half hours) and the night shift runs from 4:30 PM to 8:30 the next morning (15 hours).

Would like to nail down the timing of the shift and rationale—was it to meet the demands of the international finance community for structural adjustment? New priorities in government? A result of the burgeoning AIDS epidemic which increased patient loads while at the same time taking a toll on health staff?

Passed by a room with an empty incubator. In a flash I remembered my
mom's stories of how I was born seven weeks premature in wintertime
and spent the first couple weeks of my life in an incubator in a French hospital. Then after two weeks they took me out and placed me in a crib near the radiator because another child needed the incubator and by then I was strong enough to survive.

The main room on the pediatric floor had about 40 cribs lined up along the walls separated one from the other by perhaps a foot and a half of space. A few babies in the beds, most of the rest on the floor with their mothers, aunts or other women eating nsima, a maize-based meal sort of like grits. Family members or friends have to bring food to the hospital for patients. The women stay with the children overnight, sleeping on the floor.

A single junior clinical officer was squeezed behind a table in a corner of the room. A baby scale dominated about half of the table, where he was filling out a form. I asked what the majority of the children were sick with. Malaria, he said. Even though this isn't the rainy season? Yes, if it were rainy season there might be four babies to a bed. Now he was guessing two-to-at-most-three babies to a bed.

Talked a bit in another room with the father of a nearly two-week old baby being evaluated for a cleft palate. Then visited the orthopedic ward for adult males. Talked with a nurse who was washing her hands with a bar of soap that was—no exaggeration—the size of a vitamin pill—one of those translucent vitamin E capsules. She said there were two nurses on duty in the surgical ward for 56 patients.

Just a little further down the hall noticed a strong odor for the first time—smelled like wet, fermenting straw in a stable. Looked through one of the open indoor windows (used to provide light and ventilation) and saw a man lying on the bed, his leg propped up with a very bad burn down the side of his calf.

Twenty years of living in New York City has taught me how to avert my gaze. I tried to imagine myself in the place of the doctors and nurses here who work here every day. How quickly it would all seem familiar, even normal to have three babies in a crib, moms sleeping on the floor, miniscule bars of soap, no blood for transfusion.

There are a few special people who are motivated by such conditions, who get angry and vow to change things. Most of the rest of us just find it depressing and overwhelming. It's natural to turn away and think the need is so great, there is nothing we can do.

And a lot of time I think the dramatic, darkly lit photographs that we see from the poorest regions of Africa simply reinforce that sense of hopelessness and helplessness. They provide an excuse for doing nothing since nothing seems possible.

It's human nature to long for hope, to respond to places where changes are being made for the good. Not to whitewash or be a Pollyanna but in order to imagine what is possible and what is right. I know I will have to keep looking to get the whole picture—good and bad. The goal is to understand more and more without losing the will to action.

How did the Chicken Cross the Road?
On a bicycle of course. In the car traveling from one appointment to another in the early morning with my very careful and punctual driver Steve, I spotted several men on bicycles with about 20 or more fluffy white chickens dangling upside down from the handlebars.

Most of the chicken I ever get to see comes wrapped in plastic with its skin shorn off in the refrigerated section of the supermarket. But even this landless urbanite knows that live chickens are fairly docile hanging upside down like that. What a practical way to get fresh chickens to market.

Tackling Tough Topics
Spoke with Dorothy Ngoma, executive director of the National Organization of Nurses and Midwives, this morning. After I told her a little more about my project, she laughed, and said, "You don't go for the easy subjects do you?" This is not the first time anyone has pointed this out to me.

I told Ngoma that I wanted to write about nurses in Malawi because nurses are interesting and because they form the backbone of the health care system here. And Malawi is particularly interesting because the government launched a program here three years ago to try to entice nurses to stay here instead of emigrating to England, Ireland, the U.S. and other rich countries. Much of the funding for this program came from the Department for International Development (DFID) of the United Kingdom.

Indeed this is the only program in the world, as far as I can tell, in which donor money has been used to help pay top-ups or extra stipends for nurses and other health care workers in the Ministry of Health. Usually international money will go for building clinics, buying medications or vehicles, paying for consultants or program managers but this is the only example I know of where donor money has gone into salaries of the people who provide health care day in and day out.

Of course, I said, it would be very hard for me as a journalist to go into great detail describing a health system as a health system. Reading, watching or listening to something about health systems sounds too much like homework for most folks. And I have to admit it's not that attractive for me as a story-teller either.

That's where the hard part and the creativity come in. People respond to stories about other people—especially if they are meeting challenges. If I do it right, I can tell stories about nurses in Malawi and still get across a lot of information about the health care system. I'll be able to show why focusing on more than just jobs or buildings in the health care sector is so important, how good roads
can improve maternal mortality rates, why you can't just double the number of nursing students without also paying attention to quality control and so on and so on.

Monday, June 23, 2008

Regarding Visas and Expectations

23 June 2008

Was a little bit concerned when I arrived 10 days ago that the immigration officer gave me an entry visa of just 30 days. I had been told before I left that since I had a US passport there would be no problem about getting a three-month visa at the airport. To be honest, I had envisioned having to spend all day standing in line at a government office in Lilongwe getting an extension.

But the reality was a lot more pleasant. Spent maybe 45 minutes max at the immigration office in Lilongwe this morning, talking to an immigration official filling out the correct form, going to the cashier's window to pay a 5000 kwacha or $33 fee, going back to immigration official, showing him the receipt and getting the extension. (Church workers and NGO employees get a lower rate.) Very easy. So, in fact, there was no problem—just "no problem" in a way different from the one I had envisioned.

It was also instructive listening in on some of the conversations of the other folks at the immigration office. One Chinese man was finding out about the visa requirements for foreign business investors and workers. Malawi switched its diplomatic relations a few months ago from Taiwan to the People's Republic of China. I haven't seen the masses of Chinese workers that you read about everywhere and that I saw in Lesotho. But that may be coming.

Visited a bit Saturday afternoon with a classmate from Harvard, who had just returned home to her husband and children. Then later that evening with Martha Sommers, an American physician at Embangweni Hospital who has been in Malawi for the past 10 years. Martha had made the four-hour trek to visit with a church group from Oakland and was heading back on Sunday.

Although I am here specifically to learn what Malawians are doing to improve the health care system in Malawi must admit it was great to hear an American accent for a few hours.

I showed Martha my itinerary and she pronounced herself "blown away" by it. Most Americans show up with some kind of printed detailed schedule, she said. That's fine as long as you don't obsess about rigidly following the itinerary. You have to make allowances for life to interfere with your plans. The funny thing was I had thought my schedule was remarkably loose with plenty of open space.

Then we both marveled at how you can create a schedule in the US and stick to it with very minor variations for weeks at a time. And that ease of being able to translate a travel plan from paper to reality in the U.S. lulls Americans into thinking that we have more control than we really do.

Her other, very helpful piece of advice: expect to be embarrassed or confused or caught in an awkward moment. You're navigating two different cultures—the one you brought with you inside your head and the new one you're now surrounded by. Get used to laughing at yourself and chalking things up to experience.

Malawi’s Internal Brain Drain

20 June 2008

Note to self: I have got to talk to the folks at the University of North Carolina about their hiring practices in Malawi. The issue of an internal brain drain in general and UNC in particular keeps coming up again and again in my interviews.

Am told 200 registered nurses work for the UNC research program in Malawi—as opposed to 86 RNs for all of Kamuzu Central Hospital. Just to put that in perspective, until recently, Malawi graduated about 60 registered nurses each year—at government expense. With the new emergency response program, which provides extra money for salary top-ups and training, the new target is 100 new RNs per year.

But what good is having an emergency program to provide nurses the incentives they need to stay in Malawi if they end up leaving the public sector anyway for higher salaries and better hours working for a university or NGO?

There are several different levels of nurses in Malawi. At the top are bachelor-degreed registered nurses, graduates of the University of Malawi in Lilongwe. They’ve spent four years at university after graduating from high school and sitting entrance exams. These are the ones who are most sought after by other countries as well as the NGOs.

Next come the diploma RNs, also called enrolled nurses or nurse-midwife technicians (the newer term). They get about three years training post-high school in nursing and midwifery. They are the backbone of health care in Malawi, providing perhaps 80% of care in the country. Their training does not give them skills that are internationally portable.

After that, it seems there’s a category called auxiliary nurses, sort of like patient aides in the U.S. But this is a bit unclear to me and I need to learn more about what they do exactly and how and where they fit in.

19 June 2008
Daily Routine

Must be getting over jet lag. Awakened at 5 AM by the call to prayer. Dozed a bit. Heard shuffling of feet and a door closing somewhere. By 6 AM hotel staff were mopping the floor of the hallway. Breakfast at 7 AM on the patio. Cool enough you would like something over your shoulders but don’t absolutely need it. And so the day begins.

Have established a different routine in the afternoon, after I’ve completed my interviews.
By 4 PM I close the windows against whatever mosquitoes or other insects might be flying around at dusk (have yet to see a simple window screen anywhere in Lilongwe). Work on notes or read or head to the nearby Internet cafe. Make sure I’m back at the hotel by 5 PM, in other words well before sunset, which is about 5:45 PM. Still a surprise how fast night falls. It’s dark by 6 PM.

Fish out my malaria pills, bottle of Purelle and flashlight. Drop the mosquito netting over the bed, close the curtains and spray the room with DOOM insecticide spray while holding my breath (the can distinctly warns you not to be in the room for at least 30 minutes after spraying), close the door and head to dinner. (Yes, there are still mosquitoes--and the little buggers are very stealthy. They don't whine the way mosquitoes do in the US.) The rest of the evening depends a little on whether there is a power cut or not. A little television, a little reading and then to bed.

Thursday, June 19, 2008

My Cell Phone Brain Trust

Practical information on mobile phones and grocery shopping in Lilongwe that might be useful for the growing number of students, volunteers and others who are heading to Malawi.

With a little help from new friends in Malawi and other chums around the world, I am sorting out my cell phone issues. Just one remaining question. Why can't I receive SMS (text messages) from the U.S.? I can send them to US phones but they can't reply. I can send and receive within Malawi and to and from South Africa but only to the US. Frustrating, especially since I will probably not be able to access the Internet very much, if at all, in another week or so. Sorry, Mom and Dad!

Very little documentation about Malawi's mobile networks come with the SIM cards I bought. Celtel is a regional network and Telkom is the national Malawi network—redundancy is a very good survival mechanism I'm learning.

So waitresses and hotel staff have been my incredibly helpful tutors in the finer points of phone management. To add airtime with prepaid cards (700 Malawian Kwachas or US $5 for 500 units) for Celtel you dial *136*PIN from the card, then # and send; for Telkom it's *111*PIN from card, then # and send. To check airtime on Celtel is *137# and for Telkom it is #123#.

For a while there, text messaging wasn't working too well within Malawi either. But a very nice clerk at the Celtel shop realized the phone number for the message center hadn't been entered properly and she entered it for me. (The documentation rather unhelpfully suggests you call your provider for this number.) Sure enough, messages went through much more reliably after that.

But still no texts from the US. I sent an e-mail to Nieman Fellows around the world asking for ideas. That's when I learned I could send and receive to South Africa.
Piecing together what I learned from those emails and from Muhammad from Minnesota at dinner last night, it looks like international texting is an extra service you have to pay for in the US and it is expensive. Sounds plausible but if I were in the US, I would call to my service provider to verify that. Strange to think that Malawi is ahead of the US in this area of telecommunications!

Depending on which network you're calling, phone calls are about 50 cents a minute. Texts are 10 cents per message. So far Celtel seems to give you more options. I have also verified that actual phone calls from the US do come through—although that is sure to be expensive and useful only for extreme emergency. I've heard that there is a Malawi long-distance calling service but I haven't looked into that.

Things You Can Buy at ShopRite in Lilongwe
The Shop-Rite in Lilongwe is quite a find. If you happen to forget a toothbrush, you can buy one here. Also Colgate, Aquafresh, Mentadent, Macleans and Dentazyme toothpaste. But not Crest for some reason, at least not today.

Here is a sample of some of the other things you can buy: two-liter bottles of water, the ever-present Coca-Cola, ice cream, whole roasted chickens, various cuts of meat, fresh fruits and vegetables, powdered soup, canned spaghetti, Gillette shaving cream, lint brushes, hair brushes, nail brushes, bike pumps, hand pumps for car tires, small suitcases, Huggies, Pampers and Jolly Tots nappies, Johnson's Baby Powder, various kinds of shampoo (including Head and Shoulders and Pantene), towels paper napkins, plates, pots, pans and electric kettles, shoe laces, large Citronella candles, spray cans of Doom and Raid (insecticides, useful for spraying the inside of your tent or budget hotel room against mosquitoes—but remember to stay out for at least 30 minutes), a few AA, C and D batteries.

A small selection of candy: Safari nuts (salted peanuts with or without raisins), Snickers Bars and Chips Ahoy cookies.

Wednesday, June 18, 2008

"No Food for Lazy Man"

Malnourishment continues to be a big problem in Malawi. But the idea that too many people are idle also seems widespread.

Saw this message--"No food for lazy man"--traced in the dust on the back of a bus in Lilongwe.

I apologize if the writing is unclear. This is my first attempt at uploading a photo from an Internet cafe. Jpeg may be too small.

Differing View on Community Health Workers

17 June 2008

Good interview today with Martha Kwataine, executive director of the Malawi Health Equity Network (MHEN). Despite recovering from a bout of malaria last week (for which she has received treatment), Kwataine was very passionate about the need for civic organizations, like hers, to hold government accountable. An umbrella group for health service organizations, advocacy groups and others, MHEN (pronounced May-hen) nearly folded in 2004, she says, because of "governance issues."

Trained as an economist, Kwataine has been rebuilding the group ever since she came on board two years ago and has garnered 68 million Malawian kwachas in funding from six international organizations, including Oxfam, Cortaid (an Irish group) and the Canadian government.

Among the things I want to remember: Kwataine became rather agitated when I asked her about community health workers, basically lay people who have gone through six to eight weeks of training primarily in preventive care. Community health workers are perhaps best known in the US as a centerpiece of the Partners in Health model for delivering health care in rural areas of Haiti, Rwanda and Peru.

But Kwataine clearly saw community health workers as a fig leaf used by governments to dodge their obligations to provide good accessible health care. Take that, Paul Farmer!
I suggested to her that no one expected community health workers to do it all, but that they could be useful in extending the reach of more highly qualified nurses, clinical officers and physicians but Kwataine was having none of it. "You cannot replace a nurse with a community health worker," Kwataine says.

And, of course, that's a point on which the proponents of community health workers would wholeheartedly agree. But what happens if the community workers are promoted in the absence of more qualified professionals? That's the realistic fear that Kwataine is describing. Will be interesting to see once I begin traveling around the country if this point of view is widely shared.

16 June 2008
Who Says Journalists Should Be Lone Wolves?

Power cut tonight, just about 6:40 PM. This is why I carry a flashlight (or torch) with me at all times. Am typing by candlelight tonight. (Yes, it is that dark at 6:40 PM.)
You can hear the generator at the restaurant next door. The hotel staff has placed candles on the floor in the hallway.

Hardly had a chance to finish the last sentence when the lights came back on. The generators have fallen silent. Went outside to peek and sure enough the candles are already out. I return to my room and snuff mine as well.

Very productive day today, setting up appointments. I showed Kondwani the list of names I had gleaned from the Internet and sources in the U.S. He told me about others I wouldn't have known about, then introduced me to staff at the Ministry of Health, the Churches Hospital Association of Malawi, the Council of Nurses and Midwives, the National Organization of Nurses and Midwives (the first is a government agency and the second is a kind of trade union), the University of Malawi College of Nursing and finally the Malawi Health Equity Network (a civil society group). K also introduced me to a driver I can hire as I follow up on all these appointments over the next two weeks.
Was even able to talk with Diana Jere, principal of the University of Malawi College of Nursing, and Evelyn Chilemba, dean of faculty, for a good 45 minutes. Great overview from both of them.

What a great introduction to a country and how grateful I am to Kondwani for smoothing the way. Makes me question once again why journalists strive so often to be lone wolves, always working on our own. Oh, I know the reasons well enough—fear of being scooped, worry that someone else will get the credit for all the legwork you have done. Sharing all your sources is the fastest route to no longer being indispensible. (Just ask any consultants or corporate headhunters you know whether they would be willing to share their Rolodex—that's their bread and butter.) It takes time to build trust and find compatible working styles.

And yet, and yet. As journalists tackle more and more complex topics, like global health, that cross more and more borders, cooperation and collaboration makes an increasing amount of sense. And not just with other journalists but with the folks we previously called sources as well. All ideas to develop at a later date. Right now I need to type up my notes from today's interviews.

15 June 2008
A Study in Contrasts

Celebrations of Malawi's win yesterday were still continuing this morning outside the hotel. One young man kept saying the same Chichewa phrase, which even this mazungu could understand: "Malawi 1, Egypt 0."

Perhaps even more important than the Egyptian team having been the defending champion of the African Cup of Nations, is the fact that the Malawian coach, Kinnah Phiri, is Malawian. Previously, I've been assured, Malawi always looked to expatriates to coach their football (soccer) teams—often with less than stellar results. Now a Malawian had proven that Malawians are indeed up to the job.

The rest of the morning was spent in church (my choice) although the only service available in English by the time we got going was at the Lilongwe Pentecostal church—a first for this Presbyterian. Lots of great praise hymns. The minister took a verse from Zechariah chapter 4 as his main text: " 'Not by might nor by power, but My Spirit,' says the Lord of hosts." (I just looked up the reference in the Gideon Bible in my hotel room.) But there were contributions from Ephesians, a word about men loving their wives as Christ loved the church and women being submissive to their husbands and a long, funny story about how hard it is to be a Christian when British Airways loses your luggage for more than a week.

Then we took a quick tour of former President Banda's mausoleum, the war memorial commemorating Malawians who died in World Wars I and II and other conflicts and the Capital City where the government and most of the international agencies and banks are headquartered. At one point we drove through a poorer neighborhood.

Flying by in the car, I tried to take it all in. Mud huts and squat brick homes. Shiny glass and concrete buildings. Chickens and goats. Mercedes Benzes, Land Rovers and reconditioned cars from Dubai. And everywhere people. Standing, walking, sitting, talking. A child with a stick watching after four goats by the edge of the tarmac. People walking home from church. Two men in suits walking side by side, one carrying a Bible, the other had a wooden lectern over his shoulder.

Lunch was out of town at a Malawian cultural center on the border of a river or was it a small lake? A well-dressed man and woman left rather quickly after we arrived. Did our presence offend? Was she not his wife? Were they just tired of waiting for their food? None of the above? Who knows? I was reminded of small communities I have visited in Texas, New Mexico and Missouri where everyone notices and remarks on other people's comings and goings. I come from an island with 2 million people in a city of 8 million or so. We often rely on our anonymity and the freedom we think it gives us and yet just last week I ran into three different people I knew running some last-minute errands on Broadway. Last week. Was it really only last week?

Saturday, June 14, 2008

Arrival in Lilongwe

13 June 2008

Given that I have been planning this trip for months, I should not be surprised to finally be in Lilongwe. And yet I am. Thirty-six hours ago I was bearing up under an unusually early heat wave in Manhattan. Today I arrived to the cool breezes of a southern hemisphere winter. In those same 36 hours I also traveled from one of the richest countries in the world to one of the poorest.

But there is no shortage of hospitality here. My friend Kondwani came to pick me up at the airport, gave me a quick orientation to the city, then deposited me at the hotel to rest up a bit.

First adventure on my own: trying to buy a cell phone. Stumped already. Found a shop that would sell me a cell phone but not the SIM card that would make it work. Nor could they offer the prepaid minutes that you need to use the network. So have put that task off until tomorrow.

Second adventure. Returned from a foray to the local Internet Café to discover that the front door of the hotel was closed and locked tight. Tried all three of the keys I had been given. No go.

The sun was low in the sky and throngs of people were streaming along the streets, headed home. I walked over to the right side of the building and searched for another entrance. Came to a courtyard and spoke with the security guard, who pointed me to the back stairs, which are used after hours. Climbed the steps and headed to my room. So, I didn't have to spend my first night on the streets of Lilongwe after all!

Got back to my room and read the information brochure that explained about the front door. The back door gets locked after 10 PM. Doubt I will be out that late.

Talked at dinner with two young women from the Netherlands who are just finishing up a 13-week internship in midwifery. The brunette said Malawi had stolen her heart and already she was thinking about how to get back again in February. That's the peak month for delivering babies, she said. Funny, I replied, isn't that also the peak season for malaria? Poor choice of words. Not funny at all. The rains begin in November, followed by babies and malaria. More pregnant women, new mothers and kids under the age of fiver die of malaria than any other single group.

14 June
A Day to Cheer

First full day in Malawi. Successfully bought a cell phone, SIM card and some airtime in the morning. After lunch, Kondwani and his friend Augustine took me on a tour of Malangalanga Market.

Just about everything was on sale: socks, stuffed animals, fresh fish from Lake Malawi, t-shirts, pots and pans, hoes with strong wooden handles and pipes for the solar heating of water. We stuck to the main roads and it was not a place I would travel on my own—especially after just 24 hours in a new country. One small section felt a little like Bryant Park in the 1980s. I know I missed a lot but I was also paying close attention to where I put my feet and kept a wary eye on the cars pushing their way through the crowds.

The market is spread out between and surrounds two large mosques. Everywhere we walked we could hear the big soccer game (or football as most of the world knows it) between Malawi and Egypt. People were clearly in a partying mood, which turned into a giant celebration later that afternoon when Malawi beat Egypt in the final minutes of the game 1 to 0.

Now back in my hotel room, I can hear the horns of passing cars tooting to each other in victory greetings mixed in with the call to evening prayers.

Wednesday, June 11, 2008

Heading to Malawi

I start traveling today. Hope to be in Malawi by the end of the week.

Will blog as much as possible while I am there. My guess is that I will be uploading several days' worth of batches at a time as I find Internet connections.

So keep an eye on this space in your favorite browser or RSS reader. Read more about the project: At Work with Malawi's Nurses.

Tuesday, June 10, 2008

Wanted: A Better Metaphor for "Health Systems"

Finding the right metaphor to describe a complex issue is often one of the hardest--and most creative--tasks facing any journalist. Say the words "brain drain" and you feel like you already have an idea of what the issues are--rich countries poaching nurses and doctors from poor countries.* But say the words "health system" and most of us draw a blank about what the phrase means or why it's important.

I know that's the case for me. I started my Malawi project thinking it was about the "brain drain" of nurses. But interviews with Michael Clemens, Fitzhugh Mullan and others convinced me that was only a piece of the puzzle. I needed to widen my focus from what rich countries were doing to lure nurses away to conditions within Malawi that pushed them to leave.

It's about more than just money. You have to look at the state of the entire health system--from conditions in the hospital to how long it takes patients to travel to a clinic (or for a health worker to come to them) to medical opportunities for professional development to individual workers' own hopes and dreams for their children's future.

Ruth Levine of the Center for Global Development suggests the metaphor of the human body to describe a "health system" and likens the physical infrastructure to the bones, the workforce to the muscles, the supply chain to the circulatory system, etc.

Bill Hsiao of Harvard told the Nieman global health fellows his working metaphor is a car. It needs to have enough money (gas in the tank) to run but your basic Tata Nano can get you from point A to B in India for a lot less than a Rolls Royce.

Following up on the automotive metaphors, others have likened health systems to the network of highways that crisscross any major developed country. Imagine trying to move a truck full of lettuce from California to North Dakota on dirt roads vs. six-lane highways and you get the picture. In one case, the produce spoils before reaching its destination. In the other, it seems perfectly unremarkable that you can mix a salad year round.

Don't think we have hit on the right metaphor yet. (Metaphors that need a lot of explanation kind of defeat the purpose.) But more and more of us are working on it.

If you have any suggestions for metaphors to describe health systems, please post them in the comments below.

* More recently, folks like William Easterly have pointed to another view--health workers emigrating to make their lives better and maybe send some cash home in the bargain.

Monday, June 9, 2008

Share What You Know

It has worked wonders for my Malawi project. Last week I received an email from a PhD student in England who is writing a thesis on the experiences of Malawian nurses in the UK, South Africa and Malawi. Talk about an exact match! We've already started comparing notes. She found me because I posted my field project proposal on the web and have been blogging about this trip for the past several months.

And that is just the point. I've spent the past year unlearning some (not all) of my training as journalist. The idea that you have to hoard all the information you have until publication date is not only old-fashioned, it actually keeps you from finding important new contacts. Or should I say, it keeps them from finding you?

Note this probably doesn't work if you are on a tight deadline or are trying to expose wrongdoing at the Walter Reed Medical Center. And all the old rules of contacting known experts and sources, conducting literature and databases searches and following up, double-checking and verifying still apply.

What this means is that we're breaking the "tyranny of the now" that has gripped news-gathering for decades. No longer do stories appear just once and then quickly get displaced by some other news-breaking event. (That's a weakness of traditional news gathering that has been exploited by spin doctors who release bad news on Friday afternoons after the markets close when fewer people are paying attention.)

We're going to have to change some of our ideas about news hooks and exclusivity. People will read/view/use the final product because it provides an overarching framework by which to make sense of complicated issues and all the twists and turns in the report-as-you-learn it model.

In the long run, I think we will see that collaborative story-telling and news-gathering is better than traditional methods at keeping tabs on issues that unfold over longer periods of time, such as global climate disruption or the migration of health workers. But as anyone who has ever served on a committee knows, collaboration takes a lot of effort to work.

Related posts:
At Work With Malawi's Nurses
What Do Patents and Peanut Butter Have To Do With Each Other?

Monday, June 2, 2008

Nine Days to Malawi

Still no sight of the free-standing mosquito net I ordered more than two weeks ago. Travmed, the mail-order company I used, says the manufacturer of the Indoor Travel Tent is going out of business. (In that case, you would think Travmed would take the item off their web site, which they haven't as of this morning.) In any case, I've ordered a replacement.

I get my second hepatitis B shot later this week. Now I'm sorting through the clothes, toiletries, notebooks and rechargeable batteries to figure how much I can lug.

I've organized the Malawi trip a little like a long-distance hike with resupply from friends and fellow travellers who will be coming from the U.S. at various intervals. But also hope to help the Malawian economy by buying local whenever I can. Can't wait.