Obama? Obama!!

Two sizable river crossings, an ever widening olympic-sized mud hole, and about 15 tortuous kms lies between the 'sugar' highway and nkhate market.  Bicycles are this roads' semi tractor trailers, loaded to the tooth with goods of all imagination.  The occasional galimoto vrooms past, springs long blown by the unimaginable load of goods under goods under goods under people.  Just last week one of the makeshift side-bed extensions on these illegal but long ignored 'matolas' gave way up north and 14 people went the way of gravity at 50 miles an hour to another world. 

Another two river crossings, an almost impassable 3 foot flash flood carved gulch, and about 10 more tortuous kms beyond nkhate lies the small village of makhwila.  Like most of Malawi the people here live off the land, relying on the old barter system for diet diversity and household goods.  In a place where there are no newspapers, little formal education, and the occasional electricity, makhwila is truly a world within a world. 

I paint this isolate description to demonstrate the pervasiveness of what we've done.  "Whats new?" I ask it every week upon arrival.  Last week I heard of the return of cholera with the coming of the rains.  6 deaths in a week as the waters rush over the land flooding latrines, flooding houses, barefoot children playing, touching, and like any child oral fascinations giving way but this time to an easily eliminated but deadly disease where the only medicine is replacing the exact measured amount of fluid excreted.  The epidemics continuation is old news this week for everyone's talking about makhwila's new hotspot.

Introducing makhwilas newest bottle store--the "Obama night club."  Yes even in makhwila, 10 kms from the middle of nowhere, where there are no newspapers, no schools, no television, his election was reason enough for someone to pour everything they had into opening up their very own business.  "Yes we can" it reads in hand painted lettering outside (how could it not?), though somehow the meaning is less clear to me than the already vague mantra of the campaign trail.  Nonetheless, yes you can now buy liquor to your hearts content makhwila. A whole new job market too--on the road I saw a man, dripping with sweat, balancing 4 cartons of 25 carlsbergs each towering 4 ft above his head.  Yes we can...

Flashback:  Through the intermittent fuzz of Blantyre's 98.7 BBC came these now famous chants reaching my ears 10000 miles away from the streets of the Chicago which I know so well.  Inside our little truck emotion around--"We're breaking in now to make a historic report... (a short silence)... All major networks in the United States are now declaring Barack Obama the next president elect of the United States of America. "  From the back seat cries of "Oh thank you, thank you Jesus," and "Jay, is it true? Is it really true?" as I gently slide my sunglasses over my eyes as I struggle to keep it together.  Passing roadside mother and child rushing somewhere, passing man straining to balance bike overloaded with firewood, passing children in tattered school uniforms on their way to school--soon hushed whispers will turn to cries of elation and spread like wildfire across the countryside that one of us--yes one of our very own African brothers--has been chosen and lifted to the highest seat.  Chosen...  And now images of all of my friends there in that great city by the lake amidst the crowds of every nation and race, all celebrating the ushering in of a truly new and distinct era in the world.  And somehow, though the hills of zomba, the vast expanse of flatlands of southern Africa, and a big blue ocean did their best to break us, I felt like I was there, like we were there, like there was now everywhere.

It did take some time for news to spread throughout Malawi, and I was more than honored to become my country's ambassador of good news, at least for a few days.  The reactions varied--shouts of joy, tears of elation, the occasional jaw-dropper after what was initially understood in english was re-confirmed in the mother-tongue.  Before that Tuesday in November I think it was pretty well general knowledge that one of African descent was contesting the highest office in the US of A, but through conversations my sense was often that this arrival to the end contest had somehow been enough; somehow, for lack of better words, it was too good to be true.  I'll never forget that morning when after senator john finished his concession speech one of the nurses spoke in honest expectation "Thats it?  He's not going to contest the results?"  The example set is the beautiful sting of our democracy: Like it or not, the people have spoken.

And now three months later I can attest that Barack has officially gone culturally mainstream.  The airwaves bounce with rhythms and melodies from coco t's "we need bar-aaaaaaack" or some other artists' equally humorous "Bar-ack Obama, Bar-ack Obama, Bar-ack Obama, Hey! Hey!"  And Tanzania's Obama designs have now reached Malawi and I daily feel his stare on the street from the behind of the woman in front, his giant face plastered on the infamous and hot-selling 'obama chitenjes.'   A little eccentric perhaps but certainly an improvement on the old Osama bin Laden chitenjes.  To round out your picture I saw a minibus the other day broadcasting "We (heart) B.O."  Well put.

I would imagine they broadcast images of Kenya in the states on election night.  Take it down a notch or two and that was Malawi also.  We didn't have a national holiday and to my knowledge boys weren't named barack and girls michelle on the day of the results, but there was a feeling in the air, a smile on people's faces, chants of "o-ba-ma, o-ba-ma, o-ba-ma" in the streets of Blantyre.  I recall driving home later that night and seeing for the first time I could ever remember in my travels someone waving an American flag in public, as if for only a day we were all under one flag.  But do people here think there lives will somehow radically change with the coming of the new American president??  Can't speak for all but generally speaking, no.  Sure, perhaps there's some small belief that there may be more aid for Africa or it may be easier for Africans to immigrate to the states, but the aid that trickles down is so intangibly remote and the mere concept of immigration so wildly distant to the common Malawian that it seems the greatest effect of Obama's election has been its very concept.  'Our son' they fondly refer to him here as their Africa has to many for the first time made a splash of cannon-ball proportions in the world pool.  The forgotten continent feels for a time remembered, its far-off leader in daily remembrance.  My 'mwadzuka bwanjis' have been recently replaced by a new eerily near chichewa sounding greeting as I daily fall out of the car to a good morning "Obama?"  "Obama!!" I happily reply.

famines politics starvation

(all information in this informal entry is from one of two sources: 1) "The End of Chidyerano" by Elias Mandala, and 2) yours truly by the experiences of six months (wow))

After seeing about 300 children yesterday morning at Mayaka, I washed, went to the red binder with our severely malnourished children files, and performed my daily search for defaulters (those who were absent from their two week follow-up).  Only three yesterday--surprisingly low for the 160 or so severely malnourished kids at Mayaka.  These mothers are serious about their children's health.  Yet, with the sun still on its way to the top we decided to take a journey into the surrounding villages of Mayaka for these three.  The first turned out to have moved to the central region to find work in the great British tobacco estates there, and the other was found almost 10 km away behind a nearby mountain--too far to travel, especially with her child's edema having subsided.  Giving her three bottles chiponde, a bar of soap, and a kg of beans for graduation from the program, I advised her on the dangers of the common corn-only based diet which had precipitated the macro-nutrient deficiency of kwashiorkor.  "I have no money" was her simple and profound response to the educational barrage.  Of course she wants to feed her child a diversified diet, of course she would buy vegetables and fruits and beans and meat--but the reality is that filling the stomach is done affordably by milled maize in the form of porridge (the malawian staple of thicker 'nsima' or softer 'pala').  I was asking a paraplegic to walk.

I guess its the ultimate question that daily stares at our world in the face: Why are people starving in 2008?

Hunger is no stranger to the Malawian village population.  For centuries it has been a yearly cycle that brings food insecurity to nearly 80% in the months between December and March.  It is these months in which the planting begins for the next harvest, and it is these months in which the the food from the last harvest has run low or for some plain out.  'Njala,' Chichewa for 'hunger,' has no boundaries: it comes and goes when it pleases, staying longer, staying shorter depending on the year.  Some years are worse, some years are better based on the last harvest and concurrent food prices (largely based on that good ol barrel of oil price).  But njala is a cultural staple, even worked into the local language as the second of two annual seasons of weather: masika (dry harvest season), and njala (wet hunger season).  It is deeply woven into the fabric of Malawian village life, and has been for well over 100 years.  

Njala takes a particularly hard effect on children, as food rules in the villages often put them at disadvantage from receiving protein-rich foods reserved for those working in the fields to prepare the next much needed harvest.  It is estimated that at any one time in the Malawian year 2-3% of Malawian children are severely malnourished, which we know if remaining untreated can lead to death (enter chiponde here).  In times of serious njala the world will see these kids on television, certain agencies having bestowed the magic term of 'famine' after having tested a sample population to find over 10% malnourished. The report will carry something about terrible drought often, linking bad weather to starvation. But until that magic mark, all is eerily quiet on the starvation front.  But surely we can't be so calloused to believe that mothers and fathers haven't over the course of history adopted alternate strategies in times of one or two seasons of extreme weather conditions.  Indeed they have, but as the world has crept into sub-saharan africa it has slowly stripped away these local measures of ensuring food security.  The reality in our world is that droughts don't kill: politics kill.  The story of Chickwawa... 

Chickwawa sits at the bottom of Thyolo escarment in the Shire valley.  The river does run through it, flood plains innumerable and marshes galore.  There is a thin strip of habitable land between the mountains and the river and here the population lives, their mud and brick huts, thatched roofs, and fields surrounding.  But in the absence of irrigation the weather reigns supreme, and since time remembered the Malawians of Chickwawa have led adaptable lives to the variable delivery of rains.  Farming below the escarpment the crops are eternally susceptible to excessive flooding, and it is in these times that Chickwawans have taken to the mountains, trooping up and up to the valleys above to find food, even harvesting small amounts of maize and pigeon peas there.  Droughts also are inevitable, and when the rains are inadequate the people gather the opposite way to the drained marshes harvesting sweet potatoes and maize in the newly exposed fertile lands there.  For centuries the adaptability has meant sustenance for Chickwawans, a people that migrated to Malawi as recently as the 10th century.  A famous quote sums from a 19th century Bishop Charles Mackenzie who had "come to teach these people agriculture," but after seeing their work admitted that "I now see that they know far more about it than I do."  It is unsurprising then to find that it is well agreed that people in the rural areas of Malawi view food insecurity as a primarily political problem.  So in order to understand hunger in its correct context we must burrow into the political backdrop, starting first with the two severe famines of the last 150 years.

The planting rains never came in the latter half of the 1862 season, and the absence continued until June 1863.  A food shortage indeed in the village fields, but the devastating starvation far outweighed previous rain shortages.  What happened in Chikwawa in 1862-63 was a result of combination of political events of the time.  It was early in 1860's that the British anti-slave campaign was gaining momentum in eastern Africa, the previous hub for the French colony slave trade.  At the same time, the demand for sugar and cloves produced on French Mascarene and Zanzibar was sky-rocketing, and the combinatorial effect was that slave traders moved out of east africa into subsaharan, especially the Lake Malawi area.  Some of the first reports from David Livingston's epic journey to the area document the horrible atrocities of what was becoming a thriving slave trade.  Overnight raids of villages rained supreme in what became known as an error of terror.  And the consequence was that in the interest of security the people of Chickwawa became markedly less mobile, choosing to remain in the village area instead of wandering into what had become hostile territory.  And so when the rains didn't come, the people were stuck, unable to move to drained marshes to farm as they had done for hundreds of years before.  It took only one season for massive starvation to set in.

The call it "Mwamthota" in the stories of parents abandoning children, parents selling children, skeletons at every turn, neighbors turning against neighbors.  Like the famine of 1862-63, 1922-23 mwamthota was neither preceded by a period of massive rain shortage.  In fact, the drought came immediately preceding many seasons of bumper crop, though the rain shortage did last for two and a half seasons.  But again, Mwamthota was a preeminentely a political event as the British colonizers had recently completed a political overhaul of Malawian society replacing the chiefdom system ('Mbona') with the colonial government.  The old system of village law was sunk and a colonial taxation system established, the colonized ordered to produce cash crops of cotton, sugar, and tobacco (the three top exports of malawi still today, and just as worthless as the economy shows).  With the imposition of the new food market by the British, the old chiefdom system of hunting parties and communal farming fell apart as each man was forced to begin to fend for himself as the taxation system set in.  The world as they knew it for those of Chickwawa was turned on its head.  Whereas in the past times of hunger the people would flock to the chiefdoms and be fed through collective effort, the world had changed in 1922, and Mwamthota was the result. The colonial rulers had not the same fortitude nor the insight to anticipate the disaster that struck, and food distribution attempts were a documented dismal disaster.  To compound the problem, it was the British who had just decades before introduced maize to Malawi, a crop that harvests brilliantly in times of good rain but abysmally in droughts.  Food production was even worse than in drought times past where sorghum and millet faired much better as drought-resistant crops.  The early-warning system of chiefdom times had been destabilized, and effective relief was shirked.

For half a century now Malawi has been independent of British rule.  Its been almost 100 years since a major famine, but hunger has not gone away, but rather intensified in its seasonal nature.  The villages of old remain in Chickwawa--even the traditional title of chief continues to be passed--but its clear to all that true political power now rests in a very different place than the big fenced hut in the center of the village.  It was actually a group of Presbyterians that founded a mission outpost in what is now called 'Blantyre' (named after the birthplace of David Livingston in Scotland) in the 1800s under the picturesque Ndirande mountain that has now grown into the largest city in Malawi at 500,000 strong.  The industrial district is by all standards primitive consisting among other small internal industries the two top exporters of carlsberg brewing (denmark) and illovo sugar (owned by a brit).  Other small factories and businesses are growing slowly as many are beginning to make the trek from the village to the city looking for work (though nowhere near the 22 million of Cairo, Egypt).  The import-export economy of the free market is the way of the globalized world, and a game in which malawi--whether it wants or not--will play to the best of its land-locked ability.  But this politically based system based in the powerful business centers has delivered immense repercussions on the very population it aspires to 'develop.'

After the first mission hospital established here, Blantyre has continued to grow.  A massive city in the rolling mountains, it takes much electricity to power the small but growing industry and population.  In the 1970's the decided solution was the building of a series of dams to power the city, and so the Shire was harnessed to power this new global city.  Consequently for the people of Chickwawa, the field-renewing seasonal floods have long since stopped, the marshes have drained (illovo sugars has set up massive sugar plantations in the old marshes), and in the context of a burgeoning population restricting mobility (as I understand from clinic due often to the reality that 2 out of 5 children are expected to die before 5 years of age, so parents overcompensate to have enough children to care for them upon growing old) the old system of adaptability has long since disappeared.  Literally, as I see it everyday, people set in their villages and hope for rain.  And when it doesn't come, food flows from other parts of the country or from mozambique, the high price of diesel and horrible road infrastructure boosting the prices to unaffordable levels. The new powers that be aren't sensed to be responding to the needs of the people. 

I see the cycle of hunger every day in the village.  She arrives with child on back, child in hand holding child, a bag at her side of some small leftovers from a meager breakfast and a used waterbottle she found roadside.  Tired with beads of sweat in the 100 degree heat she has a smile on her face having arrived at her destination.  This mother, like all the rest here today, was born to village parents and at the age of holding a hoe was put to work to cultivate in the fields.  It was then that she was forced to leave school, unable to work and study.  Illiterate and powerless she marries young and begins to produce children for a husband who split his father's fields with two other brothers.  The small field is not enough to support a family of 6, and again this year when the harvest runs out, she hears from her neighbor (who declined to provide support for fear of running low herself) of a clinic down in the valley that distributes chiponde medicine for starvation.  With the father away in town looking for work (and often there contracting HIV), with too little money to afford expensive foods at the nearby market, she has no choice but to pack up all and go down the mountain to seek help.

As I look at mom's little 8 year old helper, I wonder what she dreams of.  Like most 8 year olds she is timid, a big grin and looking away when the tall funny looking azungu speaks to her.  I suppose this child knows her mother's extra-human strength: first to rise, last to sleep, cooking, cultivating, child-rearing, market selling.  But as such a young one does she see her mother forced to maintain dignity in the face of not being able to feed her own children?  Does she see her forgoing her own rations during days of field work to feed the children?  Does she feel the pain of losing a child?  

No child dreams of this life.

Yet the reality is that this is what has waited these young ones for years. By no choice of theirs they lead lives frightfully close to the line of starvation as chance had it they were born in Chickwawa.  Whether you herald its supposed nature or not, the so called "golden age" of communal living is far gone in Malawi while the market remains in its infancy, itself malnourished from the choking of opportunity by four land borders.  Famines don't starve people. Politics starve people.  

So while the government does its best to develop schools and hospitals and roads, some agencies are funding irrigation projects to insert a second growing season in malawi, or donating fertilizer to families who have nutrient-depleted there fields in the scramble for years of food (way to go Egypt).  In the meantime, governments are donating food, others are medically treating malnutrition (chiponde!!), and still others are attempting to genetically engineer cassava to be more resistant to plant viral strains.  But construction equipment breaks down, fertilizer queues are too long for the supply, wars break out and governments renege on agreed donations.  Yes, even in 2008 there is a long way to go to food security, though many agree that even in seven years the country has come a long way.  Individuals and organizations together with governments both foreign and national can work toward a solution to end hunger not just here, but worldwide, so that one day mothers will be able to feed their children as they know how and children will be unhindered to grow to pursuit the fullness of human life.

Adzisiya

'They'll leave' (the goals behind), literally. We all screamed it through the streets of Blantyre, everyone wearing bright red, tearing out of the stadium by all exits. Tonight will be a celebration for the ages as Congo returns empty-handed, having failed to qualify for the world cup and even the African cup which they played so well in two years ago with an impressive fourth place. Instead, one of the smallest and poorest countries in Africa played their hearts out and won a well-deserved spot into the next round of qualifications. 'Malawi Moto' they are called here on the street, and the Flames played amazing today (at least in the second half) defeating Congo 2-1.

Tickets went on sale for the match two days before the last of 6 first round qualifiers. Malawi stood at three wins, two losses--the same as Congo. Egypt had secured the top spot again with only one loss (surprisingly to Malawi earlier in the qualifiers), therefore the two teams were battling for the highly coveted second spot which could have a chance for advancing if theings worked themselves out right in the other groups. I was actually encouraged to buy from some Malawian friends as ticket prices are consistently too high for the bulk of the population to buy and turnout is often low (though today was standing room only).

Like so many other countries (excepting perhaps our beloved US of A), when the team plays the country comes to a grinding halt. Even early on saturday mini buses cruised the streets with the red, green, and black of malawi's flag streaming out the windows. Everyone wore red, careful not to be caught with even a hint of blue. Today was to be the biggest match of Malawi's short 50 year history as the team has never been in a position to move beyond the first round of qualifiers. The excitement was certainly in the air, as my disgruntled self was awaken at 6:30 by the horns of excited cars and minibuses.

Our procession left off at 1 for a 3 o'clock kick-off. Red truck--extended cab, shortened bed--took close to 15 in the back alone as we started off for kamuzu stadium. Loud speaker led the chants-- 'Ma-la-wi Mo-to,' 'Chitetzo yao-bwa' chorusing through the streets, walkers chiming in as we passed by. Smiles all around, and the energy was phenomenal. The azungu in the back drew some curiosity, but then again when hasn't a foreigner anywhere in this country. I was doing my very best to follow along.

Having played a bit in the past, I can say that the environment in the stadium was at the very least daunting for the opposition. It was a sea of flowing red, drums beating in rhythm, thousands chanting together in support of their country. Malawi has played well in these qualifiers so hope was overflowing. Congo was a defeatable opponent. Malawi was defeated 1-0 in the last match in Congo on a PK in which the malawian goal-keeper saved twice, but called back on moving to soon, the third time was a charm (corruption??).

3 o'clock passed as I watched some interesting pre-game drama unfold. It turned out that one of the dressed congolese warming up on the field was actually a witch doctor in disguise. I was clued in by some friends and sure enough, his back-pack was the source for strange potions and powders. As he neared the corner flags and goal he was dispersing the bags contents, much to the dismay of keen Malawian observers. Slowly the rumble grew to a roar as fans began to realize what was happening. Within seconds the Malawian army was on the field, escorting the doctor off the pitch. Sporadic fights erupted between coaches, players, security in the ensuing moments, but in the end, thankfully four doctors of their own returned to spray down the goals and corner flags and leaving a little something of their own. Look up juju magic sometime online--interesting stuff.

By 3:30 we were underway, and Malawi looked flat. Unable to hold the middle of the field, they faced wave after wave of Congolese attack through the midfield, to the wings, and back inside for the attempted finish. It was one too many and by the 25th minute the congolese phenomenon Lua Lua put on in the back of the net with a spectacular strike from 25 meters. Things became very quiet, many dismayed to see what was starting to seem another 4 years of disappointment.

But something changed in the second half. Malawi was against the wind, yet their vigor in the attack was simply amazing. It took only twelve minutes to get one on a cross from the right corner flag, and the nation erupted. As play progressed I remember feeling as though the question was no longer if they would win, but by how much. Wave after wave of Flames attack out of the midfield were forcing great saves by the congolese keeper, but alas, with 10 minutes left a header off the near post was followed with a clean strike--GOAL!!! Pure bliss for so many as it was clear Malawi had done it, the 3rd of 4 seeds in their bracket with so little expectation had beaten two giants, and countrymen and women were ecstatic. Rumors had been circulating streetside beforehand of a necessary 3-0 win by malawi by all the analysts to ensure survival, but the spectacular win had erased any misgivings on the future. They had done it, and did it with such wonderful play (really, I was impressed at their play-- GO FLAMES)

With the last whistle fans stormed the field, the gates, in a euphorium beating even that of Egypt's win in the semi-final which I saw in Cairo. Security brought Congo's bus onto the field to escort them out of the country, and the Flames boarded the back of a truck. Thousands ran alongside and they proceeded from kamuzu all the way downtown, closing down streets on the 5 km journey. What a celebration, what a day for this country that left even me with chills with the final whistle. Made me so happy for this deserving country no matter what the future brings. GO FLAMES!!

47.

Its been almost a month. A lot has occurred. We're moving houses, clinics are growing larger, different project people are coming and going. And as each day passes in Malawi I'm slowly learning of life here, internalizing what grips my senses. I should preface to say that the topic is heavy today--but you should know that by no means does it reflect the true nature of my days here, which by and large are filled with smiles, laughs, and good heartedness... but I should write about these thoughts now before I become dulled to it, copingly desensitizing myself to its sting...

Do you know what the life expectancy is in Malawi?

For starters, we should ground ourselves in our own experience: 74 for men and 77 for women in the United States. 1 doctor for 350 people and some argue this is not enough. Hospitals within 10 miles and reliable ambulance services on paved roads (for the most part). A couple of days ago I found the Malawi Ministry of Health website online, complete with a listing of doctors nationwide--a wopping 123 MDs here in the public sector for a population of 13 million Malawians. For those of you burgeoning health professionals, imagine an annual patient load of 35,000. Thats about 100 patients a day, 10 an hour for long days without lunch--and no vacation days. Patient history and physical exam what?

Its absurd the accessibility of health care here in Malawi. Just yesterday on the roadside I came across a sick child, underweight with multiple infections. The sister informed that the child and his mother were both HIV positive. But the clinic for ARVs (anti-retroviral therapy) was 17 km away and ARVs are only given out once a month. This is a four hour walk one way, quite a distance for an already ailing individual. Transport is by bike taxi for 1000 kwacha, exactly one third of a months income. Medical care is not accessible.

So back to the original question: Just how low is the life expectancy here in Malawi?

47.

And those are the government figures--Jeffrey Sachs puts it at less than 40. Shockingly low. Staggeringly low, so low its like a Hollywood movie on the ranks of Hotel Rwanda, or Blood Diamond. Shocking and indigestable as a world so horrible it becomes fictional, leaving us no choice but to resign it only to the ability of the big screen. Surely there is no place where 'over the hill' occurs by the end of high school. There can't possibly exist communities where the 'elders' are you older brothers and sisters. Or is there really a place where people really don't expect to live to see their grandchildren?

In the travelers circuit the 'Lonely Planet' series reigns supreme, and it is here on page 1 that Africa is describe as being so full of vibrant life--the colors here are magnificent from the reds, oranges, greens of clothing to the flowers of the jack o'lantern tree which have just this week bloomed a magnificent bright purple unlike any I have seen before. And its true: when you are out and about through Malawi the youngsters so full of energy are everywhere, giving the entire place a feeling of youth.

Yet, as you may imagine there is more to Africa than the passing safari of a couple week visit. Each coin has two sides, each year a balance of seasons, and I must write now of my glimpse of this other side of life here in Malawi as it occurred three weeks ago....


"Jay, she is waiting for you," the nurse informed me. What for I couldn't imagine as I had just finished giving my condolensces and was struggling to return to the height board myself. The child had died a week earlier of dehydration secondary to copious diarrhea (probably rotavirus--the number one cause of child mortality worldwide for which we have a vaccine but pharm companies have decided its not profitable enough to make it), the first in well over a thousand children treated in my clinics. "Its customary to give whatever small thing you are able" said the nurse and so I reached in my pocket and away went mom with Kwacha at the death of one of her firstborn twins. She left, her chest empty of the weight of the deceased little one, brother on back void of sister, and the notion of a material value of a life sent shivers down my spine. I marked 'death' in its appropriate column.

We load the car and drive away, Roger asking for "Tikondane," or "Love each other" before we even hit the road, and I obey, never missing an opportunity to listen to the sweetness of reggae. The slow pretty part fills the car, windows down and the sun beating, but before rasta man can drop his beat Roger reaches in a flash and shuts it off. In the same instant the green branches of the pear tree spread perpendicular across the rutted out road greets my eyes, and its clear that we are entering into a funeral zone. Just 50 yards ahead of the beginning lies the end's matching branch signals, but until then we idle ever so slowly in silence. Through the trees to left we catch glimpses of a large crowd in excess of 200. They surround the house of the deceased, paying their last respects, some choosing a final viewing. And then "Love each other, people of Africa, poor and rich..." returns as quickly as it disappears. "Funeral!" I foolishly yell 10 minutes later for what turns out to be a downed tree as we approach closer--we laugh as I jumped the gun, but hey, we really do pass at least two a day.

I'm happy to be back on the tarmack to home for there is much to do before dinner. By my best estimates we should arrive back in a decent time today which is pleasing for two reasons--Linda can catch her minibus and I can catch the day shift nurses at the hospital before they leave. Linda is off to Mulanje for the funeral of her aunt whose sudden passing yesterday has left a sullen atmosphere amongst the team today. The highly treatable "high-five" has robbed yet another of unknown years, and I'm speechless for in only two months time here the reality of this great global tragedy hits really close to home--again. The story goes that the husband has been quite sick for some time, his condition known and being treated accordingly. After contracting the wife's condition became known but she remained healthy for quite some time. However, in only one month's time her condition degraded precipitously, too fast for the overstretched and primitive health system here to catch her invisible CD4 descent. Therefore, by the time she was started on ARVs it was already too late. The toll that this disease continues to take on married women is appalling...

Almost four weeks ago a one year old child was brought to Chiponde clinic at Chickweo with grade 2 hydrocephaly. When questioned the mother related that she had not sought medical advice and, having never been to school and unable to read or write, in fact was surprised to learn of the potentially fatal consequences of the abnormality. After some coercion they relented to take the long trip to Blantyre--a place she had never been before--to seek help at Queen's Hospital. So back in Blantyre now I'm off to check on them again, curious as to their care and progress on the shunting schedule.

I've been to Queens many times in the last couple months, and at first I thought the ceremonious singing was part of some religious function at the hospital. Choruses echo through the walls of the place and beautiful, peaceful to the ears. But today as I walk towards the pediatrics wards I realize I'm now squarely behind the mysterious voices, and this 50-strong procession of gospel trails a sheet-pulled stretcher. I learn of this tradition at queens, where the entire temporary ward family assembles together to raise up the family of the newly deceased in their time of great suffering. The procession moves through the halls, offering soft melodic expressions of condolence. Tradition happened twice more over the next hour.

Sure--people die in hospitals, but hospitals should not be places that people go to die. What happens all too often at Queens is that by the time someone makes it to Queens, the condition is beyond recoverable. Early intervention makes all the difference in the big 4--malaria, HIV, tuberculosis, and malnutrition--but early diagnosis and transport are difficult. Here in Malawi hospitals aren't the last beacon of hope we so often conceputalize at home. In fact, they have historically been a place of dread and despair, as we meet mothers who only by persuasion allow us to transport them to the hospital for their child's dangerously high fever or unresponsiveness.

Its all a lot to take in after two years in medical school in the United States learning about all the amazing remedies we have available to treat these horrible diseases. Of all of the big 4 mentioned before, every single one of them is highly treatable. But what we as a global society struggle with is providing the access needed within the structures constructed. And there are places and the people within that suffer the consequences. We are on the front lines here in western power carved-up Africa, in this landlocked, economy-less Malawi, where--as I experienced last week--a child perished as the local health center had run out of Malaria medication.

On the way home the phone rings and its Victor from the Chiponde team. He has just received word that his sister has died in Zimbabwe. The details are sketchy, but she had been sick for some time previously. He's requesting some time away from work to travel back to Mozambique to be with his family. For the third time I offer my condolences in one day, feeling now more than ever the weight of the inequalities in this world. "Pitani Bwino," go well my friend.

The sun is setting on this long day, and as their are no landfills here in Blantyre, the smoke from trash fires turns the evening sky a deep red. Traffic is worst now as minibus vans transport working people from the city center to the ring of communities outside. They stop anywhere and everywhere, their competition having driven the public bus system out of service. With its elimination, the transport price has risen again drastically, the competition eliminated and replaced by giant minibus unions. I'm stuck behind one now, careful to keep my distance at the distinct possibility of no brake lights. We're cruising through the streets of Blantyre, and tonight I can't help but notice the plethora of the furniture/coffin shops that line the streets. "Alipo Coffin makers," "God's trust furniture and coffin maker," "hallelujah coffin shop" pass by. At the beckoning of the west, Malawi has been thrown into a game of global economies--a game it knew nothing about. Supply and demand rule the day, and coffins are no exception. Here is a sector of true competition in Malawi, everyone wanting a piece of the economic prize in this sector. Fortunately, in the midst of this life and death reality I have tried to describe, I experience everyday the hope that can be given from a concerned few. Project Peanut Butter is doing amazing things here for child health as I watch every day the weight increases in starving children, the disappearance of edema in nutrient deficient children, and its striking how together we can work towards solutions, that all may have the ability to enjoy the true fullness and beauty of life.

clinic

Ramsey's upshift as we turn off the tarmak before Zomba stirs me from my morning auto twilight zone. Going on an hour and a half in the car since 5:30 and even my new thermos of instant coffee can't keep me from dozing off as the Craig David cassette plays in the background--over and over and over again. But there will be no sleeping from here on out as we enter roll-bar, white-knuckle malawi. Tarmak gives way to dirt, rock, and the occasional boulder exposed by years of trucks and rainfall run-off. This is the infamous short-cut to Mayaka, rumored to save us a half hour on our travel time, but surely promising to cost us in suspension repair and general joint health. Hang on tight as we race over washboards, roll through washed out riverbeds, and pass through narrow markets. My door is shaking vigorously and making a wierd noise. I think its going fall off.

Mayaka trading center opens today, site #14 for us. Some general specs...
Catchment area population: 57,000
Catchment villages: 111
Health facilities: 1 Catholic mission health center, 14 health outposts
Health Surveillance Assistants: 51
Previous malnutrition therapy: none

I understand this information probably doesn't mean much, so let me provide a context. The HSA number best reflects the population size of a catchment, and I'd guestimate our average HSA number lies somewhere between 15-20. So at 51 HSAs this is a absolutely massive site. As HSAs help us run clinic at the various sites, we always have an initial training which took place at Mayaka last week. I'll be sure to write more on HSAs later, but suffice to say that each HSA represents somewhere between 2-3 villages, where they are responsible for that area's health. As a general rule throughout all clinic site, our patient load results almost solely from HSAs returning to their villages as the only trained health worker and refering potentially malnourished children to chiponde clinic. So when asked last week how many children they thought would come to chiponde clinic if all the HSAs were referring, they answered "13,000," which is quite humurous as we can screen absolutely no more than probably 500-1000 in a day. Mayaka is big.

We've come to Mayaka out of need, referred there by the public nutrition coordinator for the Zomba district for which Mayaka is a part of. I remember vividly the smile on the sister's face upon our first site visit a month ago when informing about our potential for treating malnutrition. But 13,000 is a bit much for our abilities, and we are coming to Mayaka today under the pretense that we should start first with patients from mayaka trading center proper, the so-to-speak capital of the catchment. I'm anxious to see who turns out, and in what numbers...

The children run alongside the car, anxious to find what foreigners this white nissan carries and to what objective they aspire to. News spreads quickly that 'chiponde clinic' has come to Mayaka, and the rumor that a truck full of peanut butter medicine has arrived causes quite the stir in this impoverished area. We have intentionally paired chiponde clinic with Mayaka's general under-5 clinic, and thus its 7:30 and the HSAs have already begun to assemble. 'Matzuka bwanji's' copiously ensue as we fall out of the car, anxious to stretch our legs and open this new site. 15 handshakes of the HSAs and nurses and we're off to the sanctuary, where it turns out we will host clinic in a side classroom. Entering say I, "We'll need a table, a couple of chairs and two benches," to the Senior HSA. "The chairs and benches I can get for you, but the tables are all tied up in the health center I'm afraid," he replies. We'll have to commission a table to be made by a local carpenter after clinic--note to self in ink on the forearm.

I exit the dark room to quite a sight--at least two hundred mothers have now in 10 minutes assembled outside the room on the dirt in front of the cathedral. Dressed brightly in their beautifully print-patterned chitengis of purples, blues, reds, greens, they have come from near and far--for some as much as 4 hours walk starting from the darkness of the early morning. They come with their babies wrapped in cloth and tied neatly and tightly to their backs, legs poking out either side of amai, head above the frameless, logo-less backpack resting on mom's warm back. They've come for screening and now our nurses are assembling in front, about to give their daily morning program that precedes chiponde clinic.

"Azmaya, Azmaya, matzuka bwanji" they begin and the attention now turns to the newcomers, and the limits of my Chichewa are quickly reached as introductions ensue. Lydia then Chrissy then Ramsey, and they are looking at me now expectedly with a smile. Its my cue to force out "Dzeeena laaanga dee-na Jay" with a wave of the hand. Some confusion for a couple of seconds, and one of the nurses explains that my name is Jay and what they heard was supposedly Chichewa. Laughs around and then just like that with a couple of spotty claps this 200 strong female chorus bursts into song, so strong, so loud, so beautiful like for ten minutes the music had held its breath till it no longer could and burst in what seemed so natural. We are new here but though the site changes the songs do not, and I recognize the tune of this one. With the sun low but bright, the harmonies are immensely calming to me in anticipation of the madness of clinic that will soon ensue.

What begins now is one of the neatest parts of clinic. Some of the nurses have been working within the project for several years now, and during this time they have developed wonderful ways to teach mothers about malnutrition, one of which involves song. What they have done is changed the words of traditional Malawian songs to lyrics that are instructive regarding chiponde clinic. I've noticed in my small time here that music is truly pervading, from the choruses ringing from buses in the streets of blantyre to the 24 hours of music that resonates from the bar below us. So the mothers return home not only with Chiponde, but also with songs such as this...

Chiponde, Chiponde (Peanut Butter, Peanut Butter)
Chiponde ndi mankhwala (Peanut Butter is medicine)

Mwana akutupa (The child swells)
Tiyetse chiponde (Feed Chiponde)

Scalo ika tsika (The child loses weight)
Tiyetse chiponde (Feed Chiponde)

Following the music and before the clinic screening begins, there is a time of general health advising by the nurses, ranging from family planning to HIV to nutrition education. For some mothers, many of whom remain illiterate, this may be one of the few opportunities to instruct them on these pressing health issues as clinics are distant and the literature from HSA is useless.

Following this session, chaos begins. The mothers rise one by one from the dirt and begin jockeying for position in the line that leads to the beginning of screening at the scale. As the 'managers' of families as large as 10, these women have much to do each day from retrieving water, visiting the market, cooking, and therefore their time is precious. The sooner they can return home, the better. They swarm towards clinic, but luckily today we are working inside, which allows some control of the flow at the door. A HSA lets mothers in by groups of ten, and they move from the scale to the MUAC station to the height board, where I am stationed. The height measurement fills out the data, and a quick check of edema and weight-height status will end the screening process. "Mwana ali bwino"'s (the child is well) are exhaustive today as over 300 come through the screening process. I give two colored kinds of cards: green for the moderately malnourished, and orange for severely malnourished. 20 oranges and 5 greens are gone from my pile by noon, on world record pace. In another hour we find several more, ending finally with a grand total of 25 orange and 10 green. So about one in ten children are malnourished in our screening today here in Mayaka, many of the mothers having seen the crowd on the way to the market and having stopped through to have their fat healthy babies screened. Yet 25 is the new record for me here at clinic, and this is only the first day. Friday's will be long days indeed.

If a mother is given a green or orange card, they are taken to the nurses where they are advised on the particulars of chiponde--its ingredients, its dosing, the next scheduled appointment time, ect. This part takes some time to explain that dad is not supposed to eat chiponde, that chiponde should not be used as a tasty sweetner in porridge, that the oil should not be poured off and used for cooking... The nurses are wonderful at establishing the project's wonderful track record of adherence.

Subconsciously the quiet causes me to glance over my left shoulder, and I am pleased to see the last mother and child. My back is stiff, my mouth parched from lifting so many children onto the height board over the course of 5 hours. My ears are ringing from little ones screaming, afraid of the azungu health man and what he's gonna do when he puts me on the table ('Mugona mwana' we say, telling the child to sleep, which may or may not add to the sense of terror). My clothes are damp still from the little one whose fear materialized though the excretion system. I rise with my height board compadre and we smile, shake hands, and exit the room. And its always a beautiful site to see Ramsey distributing the Chiponde by the truck, Chrissy and Lydia feeding the malnourished children their first chiponde (the last step before the mothers leave). They are checking to make sure that the child indeed is eating, aware that if the appetite is poor, it is better to make our way to the hospital. But today they are all eating praise god, evident from the mess of peanut butter which for this one in front of me somehow made it into the lightly colored, sparse, and easily pluckable hair of this kwashiorkor child. Next week his edema should be gone if he is fed appropriately, and by all indications his appetite could consume the 12 bottles of chiponde in the next two hours. Mom takes the bottle and tightens the lid, child reaching for chiponde and here it comes, the first sobs of anger that chiponde time is over. I think he likes it.

What a day. If it wasn't friday I'd say pack it up and lets do it again tomorrow. But its been a long week of this, and we've got another two hour drive back to blantyre. There's a peace core guy trying to hitch a ride. Dropping him in Zomba on our way, we stop for a couple of cold cokes, and I return to my auto twilight zone as the sun falls slowly. What a day.

10/25

"Weight height z severe. Edema positive. Enroll in 10/25."


I wrote it 19 times between 7 and 11 on thursday morning. By far it was the most we had enrolled for any of the clinics yet. Ntaja, a q-14 days site, seemed slow as we pulled up shortly after seven. Only a handful of mothers sat waiting under the big tree outside Ntaja general clinic with a couple of HSAs lingering nearby. Yet the line for screening seemed to grow each and every time as I glimpsed up periodically from my station #3 post. All in all around 70 mothers and their children attended clinic on advice from their village HSA, 19 of which were--by our admission criteria--"severely" malnourished and another 15 who were "moderates."


"The harvest was bad this year man. Too much rain. Things will be hard this year."


Robert is the "Senior HSA," as they call him, which in the medical hierarchy of Malawi places him as the leader of 24 HSAs assigned to the Ntaja catchment, part of the greater Machinga district, and reporting only to the clinician assistant. He is the voice of the HSAs, and the commanding voice of the communities which he represents. And across Ntaja he reports that early rainy season flooding severely damaged much of the crops, yielding a substantially low harvest, and little surplus. Therefore many subsistence farmers have food enough starting from March, but beginning to run low even now, forcing many to make the annual switch from two meals a day to one meal a day 4 months early. And to further compound an already huge problem, low surpluses mean high food prices. In front of me I have today's "The Nation," which is reporting that the average 50kg maize bag is running 3500 kwacha (140 kwacha to the dollar), and in a country where the average monthly salary is 3000 kwacha, this spells problems...


All this goes to say that we may be distributing more of an already substantial amount of chiponde this year. The factory operation here in blantyre (termed project peanut butter) will certainly be busy producing its prized product--locally produced Chiponde RUTF (for severe malnutrition) and now its recently operationally implemented Soya Chiponde RUTF (for moderate malnutrition). This factory operation I can describe in detail later, but suffice to say that it produces somewhere close to 1 ton of chiponde every week. So whats the big deal with this local production you may ask...


1) Originally, a company in france called nutriset was behind the production of RUTF for global malnutrition. Together with the good doctor here in Malawi, a way was pioneered forward to produce Chiponde RUTF, which has become now the standard of care for outpatient malnutrition therapy. This Chiponde was produced in france and shipped to Malawi at a cost. Local production avoids this cost, and guarantees the presence of chiponde when needed (insofar as local ingredients are available).


2) Local production ensures that the ingredients used for production of Chiponde RUTF are from Malawi (excepting milk powder and the vitamin/mineral mix--more on this later), pouring financial resources back into the Malawian economy while producing therapy for Malawi. As Chiponde is 25% peanut paste, 25% oil, 25% sugar, 25% milk, this means that project peanut butter has contracts with local peanut paste producers, sugar companies, and oil companies.


3) Local production means local jobs. Altogether the project now employs close to 30 employees for the production and distribution of Chiponde RUTF. Last week's employee cookout was a blast. (I thought Americans liked meat. I was busting with steak, sausage, and chicken when a night when a bucket of goat meat was brought out. Long night indeed...)


The 'fortified' portion of Chiponde is produced by nutriset in france, and as a specialized ingredient, this portion of chiponde must be outsourced. Likewise, milk is purchased from outside malawi from places including south africa and germany as Malawi as of yet contains no endogenous milk-producing industry. As you might imagine, at 25% ingredient load, the purchase, import, and transport of this particular ingredient runs a steep cost, and consumes a correspondingly unequal portion of the total cost of producing chiponde.


So all the more reason for research to find a cheaper solution with equivalent nutritional and caloric value. Insofar as milk proteins are crucial to development, milk is an absolutely essential ingredient. But insofar as milk is the most expensive ingredient, it severely limits its production (by those good ole bottom lines). And like any enterprise in this world, project peanut butter (and MSF and Clinton Foundation and any other NGO that buys and distributes chiponde from project peanut butter) runs a bottom line, but as we sell at cost of production, the amount of chiponde produced is directly dependant on the cost of its ingredients. Without an existent production or plausible future of a milk industry here in Malawi (or most other developing nations for that matter), it became evident that a product with equivalent calories and nutrients with less milk content and equal therapeutic value would greatly enhance the fight against childhood malnutrition.

Every evening after clinic I swing by the Chiponde factory to load up on small mountains of boxes of RUTF labeled "1" and "2." We (myself and El, a Wash U med student) are running a controlled, randmomized, double-blinded trial to determine if the new 10% milk RUTF is therapeutically equivalent to the 25% milk RUTF now being operationally distributed. The unaccounted 15% in the new RUTF formulation is actually soya, a crop produced and supplied here in Malawi. However, though the caloric value and micronutrient percentages are statistically equivalent in the two formulations, one must never assume hypothesized outcomes.

Hence, once a child is identified as severely malnourished, the mother is informed as to the study. If agreeing to participate in the study, an informed consent (the study as been approved by the Wash U and U of Malawi med schools) is signed or stamped (many women can't write their own names) and the mother selects one of many brown envelopes which contain a code for food. Once this randomization process is complete, the mother gathers the corresponding food--either a "1" or a "2"--and its correct dosage, and is advised as to appropriate feeding techniques before leaving.

Neither myself or El is aware of the identity of 1's or 2's, really!! Every two weeks the mother's return with their children and we track the progress of the child. 2500 of these enrollees will be tracked over the course of 8 weeks to complete our study and allow us to analyze to find the results (we have in four weeks already almost 300!). But most importantly, until then we will be periodically entering the new data and analyzing to ensure no therapeutic failure of any food type.

So we're simultaneously feeding kids and searching for better food--they are somehow inextricable from each other. The service informs the research and the research informs the service. The implications are great either way the results turn out, for we could find how (or how not) to effectively double the output of chiponde.

Nkhate Market

Today is an oddity. Weekends included, the water shuts off here in Blantyre almost precisely at seven every morning, returning at its evening counterpart for some hours, giving us just enough time for some showers and a quick restock of our supply in 50 gallons containers. Yet today it wasn't the liquid but the usually reliable power that cut out, leaving us dark but delighted to take afternoon showers after another dusty morning in the dry season. Today, Monday, brought us to our every week sites of nkhate market and makwila in chickwawa district--one district and 3000 feet below blantyre. Though I may prefer two-wheeled man-powered transportation, I'll be the first to admit that its quite a spectacular drive. 10 minutes south of blantyre the road begins to drop precipitously, switchbacks included, as the mts of blantyre give way to the tschire valley below carrying its namesake for hundreds of miles through the lowlands of subsaharan africa, connecting with the zambezi in mozambique before spilling into the indian ocean. They say that on a clear day you can see mozambique from one of the turns--the third of three distant mountain ranges.

On reaching the bottom we quickly take a sharp left back to the west, leaving the lone malawian highway in the south, bisecting the country east and west. In fact its referred to as the 'tarmack' for its actually concrete, unlike the rest of the dirt roads in the south. Even I have been surprised at how undeveloped the basic infrastructure of the country actually is. The road is often packed with traffic not of the motor kind, but those on foot or fortunate enough to have purchased a chinese bike carrying sugar cane, pvc pipe, grasses, even bricks are transported. As we barrel down this one lane dirt path at 40kms an hour these transporters ditch right and left into the fields to avoid our machine. A bridge over the tshire is as good as it gets--thereafter are a series of smaller rivers to be forded, rutted roads left over from washed out rainy seasons past, and boulder obstacle courses. What I'm trying to convey is how far removed a place like nkhate is from the world of globally traded goods. Just to get to the tarmak is a days walk, and blantyre and nsanje from there is a minibus ride costing you your monthly wage. And it means that you live off of what you and your neighbors produce and what you can sell or trade at the market. Being strapped brings a whole new meaning... Are the children going to be able to eat this year? (In Chichewa they describe the two seasons as the current 'masika' (harvest) and the coming 'njala' (hunger).)

As you might imagine, nkhate has no medical facilities. The binder with charts we keep is labeled 'nkhate market,' for we literally hold clinic next to the basket and mat weavers every monday on the side of the market. Its the most logical place in a 10km radius to hold clinic, where all can meet in a central location. Most mothers are there to do business or buy food anyways, so we often pull interested passer-byers. But the bulk of our population at clinic are referred by governmental 'health surveillance assistants,' or HSAs as they are known. Assigned to 2-3 villages each and armed with a MUAC tape and a bike, they refer kids under 12.5 cm to our clinic on monday morning. By disseminating through their communities the info in chiponde clinic and performing initial screenings, these HSAs are positively the fuel that powers our whole project, and for this they are thanked copiously and fairly compensated.

Today we had 30-40 women with their 6month - 5 year olds that came to be screened, of which we treated about 10. I understand this number could as much as triple or quadruple in the hungry season--which I also understand is approaching by as much as 3 to 4 months earlier than normal this year, due to a variety of factors I should write on later. But suffice to say, there is a general feeling of unease regarding the time at which the family's surplus begins to run low this year. So we are now getting the hang of things around here before they get completely crazy...

I'm off to Namindanje tomorrow for the weekly overnight. We are way up in the northeast part of central region--too far to return to blantyre. I realize now that I haven't written at all about what I had planned, but for next time I'll write about the study--yeah I am doing research here I promise:> mugano bwino to you all--sleep well. I know I shall myself.

Jay