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.
Sunday 24 August 2008
Friday 1 August 2008
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.
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.
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