We’ve been home for over a week now, which is surreal. For next year’s interns, I have a few bits of advice:

1. First, making friends is a crucial part of this internship. You’re there for two months; you can’t really make it unless you try to learn the language and get to know the people.
2. Look out for the friendly faces below. People at the hospital helped us get around every day, but these 10 were constant parts of our lives who made us feel like Namitondo was home.

   

   

   

   

   

   

   

   

   

   

3. Knowing a little bit of Chichewa goes a long way toward showing people that you care about being there. The word list/cheat sheet we compiled over the summer is here: Chichewa Word List. (Note: we DEFINITELY didn’t memorize all of these. You can easily get by only knowing the top half of the page.)
4. Malawi is such a young country that its history and politics really effect a lot of everyday life and the healthcare system. If you’re looking for reading material, it might be worth reading up on while you’re there or before you go.
5. Don’t be afraid to a) drink the water, or b) walk around alone in the daytime. Both are safe and will allow you to make the most of your time.

A few weeks ago, I wrote about the pediatric malnutrition we see here and included some detailed stat sheets that UNICEF and the WHO keep on stunting and wasting in Malawi. The statistics, as I talked about then, are shockingly bad: in 2010, the WHO reported that 70.7% of under-5 rural Malawians showed stunted growth (stunting is defined as -2 SD length for age). What I didn’t get into then was my bafflement at how they’d actually gotten those numbers. I’ve lived in rural Malawi for 2 months now, and I’ve seen a baby’s length taken exactly once.

• Current methods at St. Gabriel’s:

• Weight is recorded pretty universally for pediatric patients, because weight and vaccine records have to be sent to the District Health Officer monthly for trend analysis. The hospital has a number of scales available, though the U5 clinics use a chitenje hooked onto a hanging scale.
• The only clinic in the hospital that currently records length is the NRU (Nutrition Rehabilitation Unit), even though the Malawian Ministry of Health included length-for-weight growth charts in their 2012 redesign of the U5 health passports. They have two UNICEF length boards.
• Labor ward is also supposed to measure head circumference at birth, but it’s not done — having seen how hectic that ward can get, I understand why. They have the tape measures and a donated integrated length-weight scale, but they don’t have the time if nurses don’t feel it’s necessary.
• The sign on the bottom right was posted in the lab. Presumably weight isn’t given consistently.

Depending on the progress of the device this year, this could either be a good technology to bring to St. Gabriel’s next year, or a possible site project for next year’s interns: recreating the design using the length board, chitenjes, and scales already here. The crop scales aren’t hard to find, and an easy-to-use fix could go a long way.

On Monday night, Liz and I kept Comfort company during the first few hours of her night shift.

A few things are different at night:

– Thanks to the new solar panels, there’s almost always power at night. However, there are some issues switching back and forth in the evening and morning.

– All patients who come must be admitted. As Liz blogged about, this can create some problems. Apparently some patients know this and, because they want to be admitted, come in at night and then can’t be seen until the following afternoon due to backlog.

– In the pediatrics ward, medications that are supposed to be given at midnight are given at 9PM so that the mothers can sleep. Many mothers sleep on a chitenje under their child’s bed.

– If there are too few nurses during the day, there are even less at night. Roughly 7-8 nurses and 2 clinical officers run the hospital.

– Doctors are “on call” with walkie-talkies. Since all of the doctors are provided housing next to the hospital, range isn’t an issue.

– Female and Labor wards can be significantly busier at night, because women come in from botched abortions (St. Gabriel’s doesn’t do them) or want to come in without their husbands knowing. Something like the SAPHE pad would probably see a significant portion of its use at night here.

From a technological perspective, the shortages and general added confusion in the nighttime reinforce the need for easy-to-use and quick devices. Nurses don’t have the time, particularly for potential-emergency patients who come in at night and need to be diagnosed quickly.

From an observational perspective, we had an exciting night, and I’m glad Comfort invited us!

My parents really liked my last blog post (thanks for reading, Mom + Dad!), so I figured I would follow up. Here are some pictures of the things that you probably wouldn’t see done very often in a lab in the United States: the things that made me do a ‘double take’. On a personal note, happy July 4! We had an American-style feast, and I have to say that mashed potatoes + garlic nali sauce must be the best possible combination of Malawian and American ideals. 

I thought this was smart — they were out of room on the bench, so they dried stain slides on the windowsill. They said there’s minimal risk of contamination because they’ve already stained the slides.

Probably a little less smart. They’d tried to bandage and continue using a pipette when the barrel broke. They must have had a shipment of pipettes after this because they had quite a few extras, and this one had been retired to a half-empty cabinet.

Donated equipment comes to St. Gabe’s from all over the world, so power converters are very important for the hospital. We’ve seen countless blown-out outlets and power strips and a worrying overall disinterest in plug type when people jam things into the wall, but the lab seems to be pretty careful. I’m glad bCPAP comes with the locally-appropriate G type plug and can be modified to use other plug types.

Doom is the name of the most common bug spray here — a name we learned quickly. The bugs are incorrigibly EVERYWHERE here, and I imagine it’s worse in the rainy season. This was the biggest supply cabinet in the main lab.

One of the problems with rotating through donated lab systems is that when one part of one system breaks, the rest can become unusable. This leaves the lab with boxes of system-specific reagents to throw out. There was a box containing CD4 waste tablets in the “Out of Order Machine” cabinet while I was asking them questions about the machines and they immediately started barehandedly tossing the skull-labelled bottles into the trash.

Interestingly, most of the machines in the “Out of Order Machine” closet weren’t actually broken. One needed a part replaced, but a majority of the instruments were operational. They weren’t being used either because (like in the case of the dust-covered ELISA reader) the lab had moved to a different diagnostic method and can’t use two at the same time, or because (like the lab results printers) they were part of a system that had been rendered useless by a single broken part.

“Well-resourced” here is a far cry from “well-resourced” at home. In labs in the States, we’re so thoughtful about so many things — where our waste goes, keeping the bench sterile, preventing workplace risk — here, they have to be thoughtful about different things — not being able to afford much waste, trying to improve throughput, keeping the ants out of the control, how to keep going when the power goes off.

We finally finished working on the back end and manual for DataPall earlier this week! Since the staff trainings are next week, we’ve taken the week to explore the hospital more. On Monday, I got to poke around the hospital lab a bit. I’m pretty sure they thought I was crazy for taking so many pictures, but the technicians were eager to talk to me about what they like and don’t like about some of their equipment.

Before I came here, previous interns told me that St. Gabriel’s has a well-equipped lab for a private hospital of its size. Even still, early on in our time here I was a little surprised to hear in morning report that the hospital was monitoring blood sugar and hemoglobin levels for some of its patients. Two of the most exciting projects that I’ve worked on as part of BTB (yes, I’m biased) are the HemoSpec and its bilirubin analog, and both are based on the need for low-cost point of care blood tests in developing-world settings; I had hoped that St. Gabriel’s would be a good place to see the kind of impact those technologies could have.

I wasn’t disappointed for too long. When I visited the hospital lab this week, I realized that while the lab is indeed fairly well-equipped for a private hospital in terms of what it can test, it has to scramble to make up for what it lacks in how many samples it can test. The hospital has a lot of donated lab equipment, but usually it only has one of a type. Particularly with older machines, the equipment they get often only runs a few samples at a time. Medical wisdom in the States, as far as I know, is that the surer you can be of your diagnosis, the better—therefore, the more tests and the more timepoints, the better. Here, though, real-time patient monitoring is incredibly difficult because of the backlog in the lab. You might only get one shot at getting a patient’s blood sugar level, which doesn’t really tell you much about if your treatment is working.

Before I left, I thought what defined the HemoSpec was its cheapness: it’s designed to replace the expensive, currently used plastic cuvettes with cheap paper ones. When I got here, though, I realized that “expensive” and “currently used” are oxymoronic. They only use the quicker hemoglobin-only plastic cuvette-based spec when the power is out in the lab or if they have a blood donor. Otherwise, they just run the whole panel every time. That means that a simple quantitative check for anemia could easily take long enough for the patient to decide to give up and go to a traditional healer. Most of the providers here have to rely instead on checking the color of the conjunctiva—red, healthy; pale, anemic. I’ve yet to see them find red conjuctiva. The Hemocue is small enough to fit in a doctor’s bag or a generous white coat pocket; what it stands to offer St. Gabriel’s is not a new metric, but a much more dynamic and therefore useful one.

The problem with reagents is they have to be restocked.

The bilirubin analog is much earlier in the design process, but I think the single-question approach can offer the same benefits on the wards here. One of the design questions our team faced was whether centrifuges were available at hospitals in the developing world, but I was pleased to note that St. Gabriel’s actually has 4, two in the main lab and two in the blood donation room.

On the far right: the Dremofuge

I was even more pleased when I saw the fourth one, stationed in the blood donation room. The technician seemed to especially want to show me how this one worked: a wooden base, plastic shield, and battery pack, looked like a BTB device. I asked him the same question I’d asked about every device in the lab: Do you use it? He emphatically agreed. The one next to it, he said, had a broken brake, and this one worked just as well even when the power was out.

Yes, that’s a floppy disk drive on the bottom.

The device the techs wanted to spend the most time talking to me about, though, was the CD4+ counter. CD4+ counting is very important for HIV/AIDS initiatives, and it’s a known problem in the developing world. Even with all its donation connections, though the hospital still only has one running CD4+ counter, and can only run one sample at a time. In busy times, it’s impossible to keep up with the demand. The outpatient HIV clinic has to rely on counting how many pills the patients have left, which is unreliable and imprecise. They are very envious, they said, of hospitals with machines that can run more than one sample at a time.

In a “well-equipped” lab like this one, BTB can’t provide new diagnostic capabilities. What we can do, though, is make what metrics they have more robust and clinically relevant. It’s not about taking clearer or fancier pictures, it’s about putting the camera in a clinician’s pocket so that it’ll actually get used.

Food and dignity are funny things. Repeated studies have shown that when the incomes of people living in poverty and hunger increase, they don’t actually eat more: instead, they eat ‘tastier’– spending more on fewer calories, increasing the proportion of fat and sugar in their food budgets, decreasing consumption of staples and, in some cases, actually reducing the number of calories they take in overall. [1]

I set out during lunch today with the idea of taking a ‘picture tour’ of the street food in Namitondo for this blog. As I walked down the dusty clay road into the market, my head buzzed thinking about dignity and the need to eat for pleasure, not just sustenance. Little did I know.

[Warning: for only the food tour, just scroll through the pictures.]

I walked from the main intersection by the hospital instead of the way we usually walk from Zitha house and passed a woman selling the biggest bananas I’ve ever seen in this country (the ones on the right are more typical, sweeter and less banana-y than the ones in the US). I saw a stand by a construction site with a plastic tub on the counter; doughnuts, I figured, and stopped to buy one and check a food off my to-capture list. Instead, I was surprised to see these: samusas, Irish potatoes with pepper in a pocket of fried dough. I’d never seen them before, but I really hope I see them again.

I passed a corn seller on the way back to where I thought Daniel’s friend Samson’s family shop was. I’ve tried the corn before, and sadly it’s dry and not as good as it looks: this is one we do better in the States.

I emerged from the covered row of stalls what I would call, in retrospect, “completely lost.” I ducked through an alleyway and zikomo’d past the pair of chitenje-clad knees perched at its end into a familiar but mostly empty clearing. Turned around and saw a group of women selling doughnuts and the round flat fried things Sam had told us were called “Africa cakes.” Perfect.

 

I walked up to them and stood while I tried to decide what to get. Before I could ask for anything, though, one of the women stood up and started gesturing and speaking in rapid-fire Chichewa. I stuttered and my face contorted with discomfort and confusion; luckily this is a pretty everyday occurrence and by now I’ve learned some of the words: “…Ndikuphunzila Chichewa… pangono pangono.” I’m learning Chichewa… slowly, slowly.

She kept speaking, but she slowed down some. Didn’t really help. “PANGONO pangono.” She stopped and smiled. I looked at my watch and realized that I wasn’t just going to buy something from these women and leave. “Muli bwanji?” she asked. “How are you?” Chichewa 101, I had this one down: “Ndili bwino, kaya inu?” Got the accent sort of right, and everything. She smiled at me again, and I tried to give them a sense of my skill level by greeting the woman to her right with the afternoon greeting.

I asked how much the food on the far right cost while a woman on the next stoop over asked loudly about the azungu. 10 kwacha. I began to sit down on the dust on the far right, but the woman closest to me stopped me and arranged some pieces of wood. I sat cross-legged in my blue jeans, smiled at the women, looked around for a bit, and then remembered that I was supposed to be trying the food and pulled a K10 coin out of my pocket.

I still have no idea what it was that I ate. Bottom left picture. Looks like a beignet but I was surprised to find that was salt on top of it. Crispy, smoky, slight fishy flavor. She pointed: “chinangwa.”

For the next few minutes we exchanged halting small talk and they pointed out the names of the other foods they were selling.  They still occasionally raced ahead of my Chichewa abilities, but I pulled out my early-00’s style Nokia cell phone and saved a message to myself with all the words. From left to right above: chinangwa, batatas (soft, sweet, smoke-infused Irish potatoes cooked like the corn), tumbuwa (“Africa cakes”, a rough fried corn meal round), and mandaz (oval doughnuts that taste like the oil they use here; we were told it’s a cheap vegetable oil that would usually be used for mechanical purposes but it tastes good to me.)

Then the kids came, 20 or so in primary school uniforms crowding around our stoop to look at me. I’ve gotten accustomed to it from walking around the village or to and from the hospital, but to be honest it still makes me incredibly uncomfortable to be the focus of so many kids shouting “azungu” and thinking of my presence as a spectacle. The women tried to teach me how to shoo them but I stumbled over the words. The pained look came back to my face. The kids giggled amongst themselves, “azungu”.

I looked up at Catherine next to me and figured it was worth a try. “Zinalanga Hannah… No azungu” My name is Hannah, not azungu. I repeated it like a plea.

She and the other women took my cause. I know it sounds cheesy, but I almost wanted to cry when they loudly repeated that to the gathered kids and admonished them for treating me like a spectacle. I couldn’t understand most of it, but I looked up when I realized that I thought they said a word I recognized: “zanga,” friend.

I thanked them as profusely as I could in broken Chichewa (there are three common ways to thank someone in Chichewa, we elicited a lot of giggles figuring them out in the first few weeks here).  Catherine smiled and answered her phone; I heard her say something about “zanga Hannah,” and for once I’m certain she said “zanga” and not “azungu.”

The kids didn’t go away, though the older ones left and later kids in torn clothes came carrying younger siblings to come see. Instead, a crowd of primary school kids and one of their teachers helped me talk to Catherine and her friends. I ate a batata, they eagerly watched me write down Chichewa words that I’ll probably never need to use, for “up” and “down” and “arm” and “shoes.” A few brave older kids jumped out and tried their English on me. We were back to the feeling of hanging out, albeit with a few more people. Catherine moved over so I could sit on the stoop, and some of the kids bought snacks. At some point the kids taught me the word for “camera” and I let them commandeer mine until the game ended, as all games of 20-kids-play-with-one-toy must, with it dropping into the dust.

We sat for a while longer, until I looked at my watch and the woman who’d originally stood up and gesticulated at me asked if I had to go. I said goodbye and “zikomo cuambiri, cuambiri, cuambiri,” for which a kid named Useful jokingly mimicked me as they followed me out of the square to get one of the fanta and coke freeze-pops people eat by the side of the road.

This isn’t a picture-perfect story. Once we were further down the road, some of the school kids resumed following me with the typical “azungu, you give me money.” I still walked out of there not knowing all of their names and not remembering all of the Chichewa they’d tried to teach me, and I’m still leaving here in less than three weeks to return to a country most Malawians seem to think of as some untold paradise.

But what made me feel so welcome was that they knew that: they asked me when I was leaving and where I was from, they accepted that mediocre may be about as good as my Chichewa will ever get. For an hour or two, these women pulled me down from my ivory tower thinking about dignity. I always worry that it might seem disrespectful to be spending so little time here and still think that we can do something sustainable, but with that hour and shared food I felt more relaxed and at ease than I have in weeks. We all could acknowledge our shortcomings and keep trying anyway. In the face of the overwhelming, it seemed like the most vital thing in the world to be able to sit on a stoop eating unhealthy street food and laughing at yourself.

All right, enough with the talking, back to the food:

No interest in trying the street meat, but these stalls always provide an interesting look at the internal bone structure of common farm animals.

The famous street chips. They’re K100, but for an extra K50 they will put in cabbage and tomatoes. These were a little salty for my taste, but Dr. RRK and Dr. Oden both said they love them and we’ll probably give it another try before we leave.

One day close to the beginning of our time here, we were curious enough about the sticks kids were chewing by the street to buy one of these 8-foot poles of sugarcane (zimbe) for K80. They’re really hard to eat and extremely sweet, but it was definitely worth the adventure of trying them. I think this was one of the first times we went into Namitondo.

This last picture is totally cheating because it’s not even remotely street food, but we’re always amused to see that the sweet rolls at bakeries all over the country are named “Obama rolls.” MK told us that they used to be called “Osama rolls,” and that they changed the name in summer 2011. The baker is Aaron, who started a conversation with us one Saturday while we were drinking Fanta on the general store porch, heard that we were from the US, and immediately asked if we knew (former BTB intern) Elizabeth Nesbit.

[1] I pulled these sources from the book Poor Economics by MIT professors Abhijit V. Banerjee and Esther Duflo: Shankar Subramanian and Angus Deaton, “The Demand for Food and Calories,” Journal of Political Economy 104 (1) (1996): 133-162; Robert Jensen and Nolan Miller, “Giffen Behavior and Subsistence Consumption,” American Economic Review 98 (4) (2008): 1553-1577; Angus Deaton and Jean Dreze, “Food and Nutrition in India: Facts and Interpretations,” Economics and Political Weekly 44 (7) (2009): 42-65. They also cite a passage from George Orwell’s The Road to Wigan Pier that was really helpful and is on the reading list for when I get home.

It seems like transportation is a hot topic around BTB this week, with Katharine posting about shipping Pumani units and Emily posting a picture of the inside of an Ethiopian ambulance! While easy transportation is an important design criteria for devices that will end up in overseas hospitals (like bCPAP or IV Drip), it can be one of the make-or-break features of a technology like morphine dosing clips that ends up in a patient’s hands.

Bikes are probably the most common mode of transportation other than walking that we see in the villages. Farmers bring their crops to market on bikes, salesmen carry their wares, parents ferry their children to school, and mothers carry a seemingly impossible number of children on their backs and laps to and from the market. The bike taxi bays are always full outside the front gates of the hospital and at the corner of the main road in Namitete, and a 15-minute ride is 300 kwacha.

In terms of carrying home technologies, bikes are tricky. Most bikes here have a flat rectangular platform above the back wheel (on the bike taxis, it’s covered by a cushion to make the seat) on which people carry bags and/or family members. Few people other than school age children seem to have backpacks, and, at upwards of 500 kwacha, the drawstring sport bags in Namitete would probably be too expensive a purchase for most patients to justify. Any technology that goes home with a patient who’s walking or biking, then, needs to be able to be secured to one of those bike platforms. Luckily, however, the platforms are stable enough that St. Gabe’s can fairly easily send patients home with commercial water bottles. Anything more delicate than that, like the thin-walled invertabottle, won’t really work.

We also occasionally see motorcycles (in fact, the “community care appointment” button in DataPall is a motorcycle icon, because Alex is known for using his motorcycle to the villages to save gas.)

In trading centers we see these huge flatbed trucks carrying both crops and big groups of people. Judging by the soda sellers who strap on gravity-defying 5-crate pyramids of glass bottles, I think the bike platforms are strong enough that weight is an inconsequential constraint if shape is right (though not for patients walking). In these crowded trucks, though, size become a critical concern: the bed of that truck is filled, wall-to-wall, with people and their bags.

The other way people travel between major centers cheaply is minibusses. They’re prone to functional errors and they make that flatbed truck above look veritably deserted. For patients travelling on this public transport, space is at a premium and sharp edges must be hugely problematic.

(Don’t worry, Mom: they’re expressly forbidden by BTB. When we need to travel into Lilongwe we find a car.)

Once they make it off of a big road and get closer to their village, robustness really comes to the test: transportation that is designed to work for 50kg bags of maize won’t necessarily accomodate a fragile device. Daniel wrote about a patient at Queen’s who doctors thought about sending home to her village. There were clearly bigger obstacles to her care than transportation (namely: supply of oxygen, caretaker capabilities, advancement of illness), but it bears thinking about: even if a local hospital had enough oxygen tanks to give a supply to her family, how would they have gotten it there? Anything designed to go home with patients in this kind of setting should pass a modified kind of high school physics egg drop test: roll it down a gravel stretch of the outer loop on a skateboard, and see how it holds up. That’s what the roads feel like once you get off the asphalt.

“Easy to transport” isn’t exactly the easiest thing to ensure when you’re building a device that needs more features and more functions. It’s a shame, though, when the barrier to use for an otherwise-promising technology is something as simple as getting it home from the hospital.

Sorry I haven’t posted all week! I lost my dongle and spent the weekend reading Game of Thrones instead. Last week, we visited Queen Elizabeth Central Hospital with Sam and Ariel. Even after the week spent visiting district hospitals, Queen’s felt strikingly big and astoundingly full.

Queens’ neonatal record storage unit has a ginormous task to manage. Ariel’s blog this week has more on record keeping, but  I was amused to see the ubiquitous Chiponde boxes repurposed.

They were cleaning the infamous diarrhea bay when we came by, so we didn’t really get to see it. Mixed feelings on that one.

I realized that I’ve never seen a pediatrics ward that wasn’t at least slightly decorated — QECH is no exception. This scene decorates one of the labyrinth windowed hallways that lead everywhere at Queen’s. This was the first hospital we’d seen with completely indoor halls; at St. Gabriel’s everything is open.

There was even a playground near Sam and Ariel’s office. We passed a few of these in the small courtyards created by the hallways, along with clotheslines and empty spots of grass where guardians slept and waited.

As a central hospital and the site of Malawi’s only medical school, Queen’s hosts much more research than St. Gabriel’s. At the sight of the sticker on this stethoscope, I remembered how Dr. Dube mentioned this when she spoke with our GLHT 360 class last spring. QECH is occasionally able to expand their diagnostic capacities by participating in international research. In order to participate in the BTB CPAP study, for example, they needed to be able to reliably, accurately, and precisely measure infants’ birth weights. To make that feasible and ensure good data, BTB provides participating hospitals with a locally-compatible and accurate scale.

I took this picture quickly as we were leaving, but it’s the image I think will stick with me most from our day touring Queen’s. We walked in through the front entrance you see from the top photo, and the first thought that popped into my mind was, “Wow, this looks like the emergency waiting room at Ben Taub.” Queen Elizabeth seems unarguably to be the vanguard of public medical care in this country. We, donors and governments and taxpayer dollars from wealthier countries, remake these hospitals in our own gleaming image. But what happens next, when we’ve transferred the same shortcomings onto a system that already comes up so short?

[Happy Fathers’ Day! My dad is the only 50-something-year-old guy I know who cares enough about pediatric nutrition to stand and carefully examine the baby food aisle every time we go to the grocery store. In his honor, I’ve been taking some pictures and notes on pediatric food options here.]

During our first week here, my mother asked me what I was eating. I dodged the question. Luckily, we’ve since figured out where to get food other than rice, bread, peanut butter, and nsima, but finding nutritious food sources is still an issue for many people, particularly children, in the outlying areas.

Growth faltering is a delay in the onset of the childhood growth phase (measured by height for age) at the end of the breastfeeding period. Growth faltering is worst around 18-24 months, and if you haven’t intervened by then, you may have lost the opportunity. [1]

WHO statistics indicate that in 2010, 70.7% of rural Malawian children under

the age of 5 showed stunted growth– meaning that they were two or more standard

deviations below the reference for height by age. [2]

The potential irreversible damages of poor fetal growth or stunting during the first two years of life are marked by shorter adult height, decreased offspring birth weight, lower attained schooling, and reduced adult income. In the US, the government prevents this by providing formula for children under 2 whose parents can’t afford it. [1] Here, where kids aren’t yet in school, there’s no good way to distribute to that crucial age range.

Kwashiorkor is caused by sudden food deprivation. It’s more lethal than marasmus because it opens children

up to infections and tends to occur in older children. Markers are pale sparse hair, enlarged liver, wasted muscles,

oedema, moon face, poor appetite, pale skin, and apathy. [3]

Other than the obvious (breastfeeding), the food options for children under 2 in the village are pretty minimal. In stores in Lilongwe, we saw a fair assortment, though it appears that Nestle dominates the market. In the village mart, Jey Jey, the two infant food shelves hold three flavors of Nestle baby cereal and a few cans of Nestle starter formula. Children of the relatively well off (workers at the hospitals, at nearby Namitete Technical College, at the furniture factory) can afford the Nestle. Children in the villages eat almost solely maize.

Some of the hospitals that we saw this week were “baby-friendly hospitals,” meaning that they strongly encourage breast feeding. There’s not really the same stigma about public breastfeeding that there is in the States–mothers nurse their babies everywhere. [4]

The formula costs 1,570MK (Malawi Kwacha) and the baby cereal is 1,320MK; by today’s exchange rate

that’s about $9.40 USD and $7.90 USD, respectively. In 2011, 74% of this country’s population lived below

the international poverty line ($1.25/day) and the average Malawian woman had 6 live births in a lifetime. [5]

We see the signs of malnutrition everywhere. During our first week here I remarked that I enjoyed being average height here. While my 5’2” stature is probably genetic [6], for many Malawians it’s the result of inadequate nutrition. We see kids with textbook kwashiorkor every time we go play with the local kids. It’s very hard to guess children’s ages because kids are much smaller here than they are in the US. Our second day in morning report, the pediatrics ward nurse reported an overnight death due to “anemia and hypoglycemia.”

The traditional diet relies heavily on different permutations of maize. Nsima, on the far right, is such a staple of the diet that,

as Sister Justa puts it, “in the villages, if the children take food but they do not take nsima, they think like they have not taken

anything at all.”

Like most progress indicators in Malawi, the malnutrition problem hasn’t gone without significant global aid efforts. The HIV/AIDS clinic at St. Gabriel’s gives out packets of Chiponde, a fortified peanut butter paste also known as Plumpy’nut, to all pediatric patients who have a BMI below about 16. [7] Other efforts in the country have been successful in reaching a 96% Vitamin A supplementation rate and 50% iodized salt consumption. [4]

Chiponde boxes and sachets at the HIV clinic.

There are still huge discrepancies between urban and rural nutrition access, though, and this issue is linked far too closely to poverty to be an easy fix. Instead, as with most of the seemingly impossible challenges here, I’m trying to see malnutrition through the quote my dad puts at the end his talk: “It is not incumbent upon you to finish the task. Yet, you are not free to desist from it.” [8] We can’t do everything. But maybe with consistent and diligent effort, we can do something.

[1]: GLHT 201 Lecture notes 9/6/12, that time my dad came to talk about global malnutrition. See, dad, I wasn’t just doodling!

[2]: Unfortunately, statistics like these are often inaccurate in low-resource settings. Expect an upcoming post about stunting metrics problems and BTB’s attempts to answer them.

[3]: Had to pull this part from the powerpoint. Okay, I may have been doodling a little bit.

[4]: We don’t have very many baby-friendly hospitals in the US because of the prevalence of formula.

[5]: UNICEF. Unfortunately, they didn’t have these statistics split urban/rural, but for the two friends of mine I know are wondering (you know who you are), check out the UN report on rural gender employment inequality.

[6]: Hi dad.

[7]: Plumpy’nut is its own very google-able story. It appears to be seeing some success in Malawi, but the outlook for a more global scaleup remains unclear.

[8]: Rabbi Tarfon: Ethics of the Fathers, Pirke Avot, Chap 2: verse 21

Hello from Blantyre! We went up and down the countryside collecting data with the bCPAP team this week, which means that we got to see quite a few new hospitals and even more road. On the way, I thought about what I posted last week about poor malaria net and ARV usage. Why does ORS seem to have such better adherence than malaria nets? What is different about the technologies? What was the difference in the implementation strategy?

The Malawian highways are dotted with billboards. People lean against them in the trading centers and little kids climb on them in the mountains. It seems that the vast majority are pretty evenly split between telephone/internet companies (Airtel and TNM), beer, and internationally-funded health-related advertisements.

In particular in the healthcare sector, we see Thanzi-brand ORS advertisements all over. In the south part of the country, too, we started to see billboards and painted buildings for Chishango brand condoms (though their scarcity in the North might be an artifact of our being so close to St. Gabriel’s—the immediate surroundings are markedly Catholic.)

A major difference for implementation is that unlike malaria, for which many people feel they need to see a health care provider, HIV/AIDS transmission and dehydration prevention are thought of as issues for which people should take personal responsibility.

Because it was heavily subsidized by USAID until 2012, Thanzi was very cheap and widely available. Now a cheaper, Kenyan-produced brand has taken much of the market, but since the technology is still effective even when produced more cheaply (as far as I can tell, the biggest difference for the end-user is that Thanzi includes small pictorial instruction cards). The initiative behind Thanzi’s marketing, PSI, made ORS a standard part of patient care and worked with the Malawian government to work it in to the massive HSA program. Because the market was so well-primed by PSI from 1990-2012, there doesn’t seem to be a dip in ORS use with the change in companies. Thanzi ads are still up everywhere and I see ORS very widely available at grocery stores and for free at the hospitals.

Interestingly, PSI is also behind Chishango condoms. Though stigma clearly makes it slightly more complicated to paste “Chishango” across every building, the condoms are very widely available. In the cities, Aqua Pure water bottles carry a red ribbon and the statement “Aqua Pure Cares. Love Life. Avoid HIV/Aids.” Though I don’t necessarily agree that we can place the entire onus for prevention on individuals’ safe sex habits (other transmission risks like occupational hazards are often overlooked), conversations with people here have shown us that sexual safety tends to be considered a personal matter.  [2]

PSI has had less success, from what I can see, with its malaria nets and water purification systems. I think there’s less of an interested market because Malawians don’t think they’re as necessary. With HIV transmission prevention and dehydration prevention, PSI has been effective because they have either found ways to build a cultural concept of personal responsibility and importance or built on what was already there. [3]

[1] Gates Foundation Case Study on ORS in Malawi.

[2] This climate is sadly often observed in the breach—in discussion of times when personal agency is negated. I have heard it said, though I can’t find it specifically online, that roughly one in four Malawian women’s first sexual experience is forced.

[3] USAID evaluation, Sept. 2004.