Friday, August 29, 2008

Heading to Cape Town

Heading to Cape Town this afternoon to catch up with fellow Nieman Fellow Melanie Gosling. Then it's off to the US after a few days.

Tired but pleased with all I have learned and experienced the past three months. Still processing it all.

Am definitely looking forward to fresh green salads.

Friday, August 15, 2008

Back in Lilongwe

Starting to think of this as my second home. The five-hour trip from Neno was uneventful--best kind. Now to find some lunch.

Heading to Lilongwe

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.

Thursday, August 14, 2008

Running Low on Food in August

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.

Fish Outlet and Fashion Centre

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.

Wednesday, August 13, 2008

More Thoughts From the Road

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.”

Tuesday, August 12, 2008

Rocky Road to Dambe

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.

Sunday, August 10, 2008

Arrival in Neno

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.

Linking the Local and the International Perspective

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.

Heading to Neno

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.

Charcoal and Deforestation

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.

Saturday, August 9, 2008

Filling out the Picture

7 August 2008

When I first came to Malawi, one of the questions that was uppermost in my mind was why nurses leave the country to work in the U.K. or other English-speaking countries or why so many leave the public sector to work for non-government organizations or private hospitals and clinics. But in truth, that's pretty easy to understand. Much of it boils down to better pay, better working conditions (fewer hours, fewer patients, more resources), better housing and more opportunities for their children.

What has been a lot harder to get at is why nurses stay in Malawi, particularly why they stay in the public sector. Catherine Ndolo in Embangweni taught me to look at relationships, at how much the workplace demonstrates that it cares about both its patients and its staff. Others have talked about the opportunity to advance—that they stay with government positions because, after a few years, the Ministry of Health will pay to upgrade their education.

Then in just the past two days I spoke with two nurses—Grant Ngugluwe and Maureen Juma—who had almost diametrically opposed views. Both of them work in Mulanje. Maureen is a nurse tutor at the Mulanje Mission College of Nursing. Grant works in the male ward at the Mulanje Mission Hospital. I talked with each of them separately so it's a little unfair to compare their responses. But they stated their positions so eloquently like that I couldn't help but play one against the other.

Both of them are from the younger generation of Malawians, who have graduated from nursing school in just the past five years. Neither has the sense of caution that I witnessed so often in older nurses—many of whom learned from bitter experience during the Banda era not to rock any boats.

Grant took the more cynical view. When I told him that many nurses told me they stayed because they loved their country—and who would look after their remaining family if everyone left—he told me he wasn't so sure patriotism played such a big role. "Maybe they don't know how to go overseas?" he said. "Much as everyone talks of professional dedication, everyone is looking for better jobs."

He confirmed my suspicion that one way many nurses make the contacts needed to emigrate is by first working for an international NGO. "If you work for an NGO, then you have access to the internet," Grant said. "You also have more access to information in general. You make contact with people in the field."

Then of course there are also friends and classmates who have already made the move abroad.

Grant thought family ties played a stronger role than patriotism in determining whether registered nurses stayed or left. (Nurse midwife technicians—who provide the bulk of Malawi's nursing care—do not have an internationally marketable degree. But it's impressive to see how many upgrade to a bachelor's in registered nursing.)

Maureen Juma, on the other hand, was passionate about the need to serve—and she sounded very sincere to me.

(I've also talked with several nursing students who clearly thought that the patriotic line was a good one and had probably used it for their nursing school interviews. I had to make sure not to smile during some of those interviews—especially when I heard the almost identical phrases coming out of different students' mouths.)

What's particularly interesting to me is to compare the transcript of what Maureen said to the actual recording of her words. Her passion really grabs you through the headphones in a way that the simple transcript doesn't. Comes back to that issue of what each medium does best. Audio is ideal for conveying emotion. Print is an excellent vehicle for giving detailed information—facts, figures and analyses.

One thing Maureen was especially passionate about was how often Europeans and Americans focus on what's missing in Malawi. She says she was particularly struck by this during a recent trip to Norway for advanced training in nursing education. One person very patronizingly started to explain to her what a computer was. "As if we didn't have computers in Malawi," she exclaimed. Another went so far as to ask "if they have cars in your country?"

Her words were coming out so fast by this point in the interview that some of them got a little jumbled up. But the point was clear. A lot of people come to Malawi prepared only to see the worst.

"These people take only bad pictures and they don't know that there's the good side of things," Maureen said. "They think that when you go to Malawi you are going to find people that are dying of hunger, people that are all HIV positive. That's not the news and that's not the situation. Malawi is also a country that has got its own potentials. And it's got things that are good—a lot of them. Apart from having the Lake [Lake Malawi], apart from having the Mountain [Mulanje Massif], we've got people like us who are willing to work in Malawi and stay here for good."

It was a message to the world but also a message to me and to Eileen about what we are doing in Malawi—about making sure we show both the positive and the negative.

I told Maureen I agree that photos and stories from Malawi often emphasize the negative at the expense of the positives that do exist. I've tried on this trip to get a much broader picture—no whitewashing but no unnecessary gloom either. Realize this could be a tough one to pull off. But I'm going to give it my best shot.

Drive to Mulanje

1 August 2008

Eileen and I left Lilongwe at 8 AM with a driver named Godfrey in the vehicle we rented from Sputnik Car Rentals. (Not, I hasten to add, the same Godfrey as the nurse in Embangweni who used to be a driver.)

Almost as soon as we left Lilongwe, you could see the vegetation changing. More water, more fertile. We stopped in Dedza to see the pottery factory there. Nothing earth-shattering but good quality nonetheless and a nice-looking guesthouse. Actually liked the tiles in the women's restroom the best.

Then we worked our way south on the M1. There are people along the highway practically the whole way—bicycles, pedestrians, the occasional ox cart—although the ox carts became fewer and fewer the farther south we went.

Asked Godfrey about the lack of oxen compared to the north and he said that after the arrival of multi-party elections in 1994, there was kind of a free-for-all in which many people thought democracy was the freedom to do or to take whatever you wanted. As a result lots of cattle were stolen in the south and they've never really recovered. That would be a good story to check into further but alas I don't have the time and it really doesn't have much to do with my project on nurses.

Anyway, there were plenty of trucks, minibuses and pickups packed with folks sitting in the bed on the road. Just so much humanity. Plus chickens, goats, cattle and the like.
We stopped in Blantyre to pick up a few snacks for lunch. Still don't quite have the hang of making lunch ahead of time for the trip. Sandwiches or the like. Haven't really found cold cuts or lunch meats. Godfrey stopped at a supermarket in an area crawling with street kids and others who started begging before we were even able to get out of the car. Lost my appetite right then and there.

We drove through Blantyre. Saw the Queen Elizabeth Hospital and the College of Medicine from a distance. Could see new construction at the College. Billboards from various donors announcing their participation in funding this building or that.

At Limbe, we took the slightly longer route in order to go through the tea plantations. Beautiful light green, rolling hills. Godfrey pulled off in one area so we could stroll a bit between the tea bushes and get some photos. Later we saw some of the shacks that the workers lived in. Although they were stucco, it reminded me of sharecropper-cabins I had seen in Mississippi when I was a kid in the 1970s. Long blocks divided into living quarters for different families.

At any rate, we made it to Mulanje about 4:30 PM. A good day's travel. Glad I wasn't driving.

Practical Notes on Photo Releases

1 August, 2008

Web publishers need to pay more attention to getting formal permission to publish someone's likeness on the Internet. It may cut down a bit on spontaneity and it can be a hassle to manage the information but it's the right thing to do.

The Berkman Center for Internet and Society has just put out a legal guide especially geared to citizen journalists or participatory media. Although the guide is clear and well-written, you can tell it was put together by lawyers in academia and not by practicing journalists. No one would be able to follow all those rules and still meet a tight deadline.

That's too bad because there are a number of legal issues that you should be aware of when publishing on the Web or for a traditional media outlet. Still, the Berkman guide is a good starting place and you shouldn't be put off by its comprehensiveness.

One issue that I have focused a lot on in the past seven weeks in Malawi is getting written permission to publish a person's photograph—whether in print, broadcast or electronic format.

The principle is pretty simple to understand. It's one thing to take someone's photo for your own personal use. It's quite another to publish it.

You should have that person's permission to publish their likeness. How you prove that you received such an okay varies a lot from implied consent (the subject didn't try to block what was obviously a camera taking their photo) to spoken agreement to written consent.

There are also different standards based on the level of privacy one might expect in any given context. Then there's the issue of whether you are photographing a public personality or a private citizen.

In public places like the streets of Manhattan, there is not a reasonable expectation of privacy and so permission is implied. That's why you don't have to get even spoken agreement from all the folks featured in a crowd scene at a football game, for example, or at a demonstration.

In places like hospitals, where I have spent a lot of my career, there is an obvious expectation of privacy. And so, ideally, the highest standard—written permission for the publication of photographs—should apply.

But that's not always the practice. One thing I learned while on my Nieman fellowship is how often the implied consent rule is used—such as when a patient is transferred to an ambulance after a car accident. (The video or still camera was obvious and no one tried to stop the shot.)

For my Malawi project, however, I resolved to get written permission for the use of people's likenesses in most cases and only occasionally rely on verbal or even implied consent. I see no reason to use one standard in the U.S. and a different one in Malawi.

Plus, since the consent form includes the use that will be made of the photograph, it provides reassurance to the subjects that their image won't be used to illustrate an entirely different theme. One story I heard from more than one person was about unnamed journalists taking pictures under one guise—such as work in a hospital—and then using them to illustrate a story on HIV, accompanied by a caption that said declared that everyone in the photo was infected with the AIDS virus. Whether that's a true story or not I don't know, but it sounds plausible.

Another benefit of getting written consent is that you get people to write their own names, making sure to get the correct spelling. Plus you can write good caption information for the photos right on the consent form.

In retrospect, I should have realized that a lot of the patients would be illiterate. Ended up using X's and thumbprints in most of those cases. Fortunately, the idea of giving written consent for operations is becoming more widespread in Malawi and so people understood the concept—even in translation.

Anyway, you don't have to go crazy with these consent forms. In my opinion, long consent forms tend to obfuscate rather than to clarify what you're trying to do. Here's the central wording for my form:

"I hereby consent to the use of my photograph, video footage and name to illustrate any articles by Christine Gorman—whether in print or electronic format—concerning the subject of ________________________________________________."

That's followed by spaces for the printed name, signature, the date, address and contact information (telephone or email).

I use a separate consent for children, which requires a guardian's signature.

NB: Check out Andrew Quinn's experience with consent forms in Kenya.