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Nkhani November 2003

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Nkhani Newsletter - November 2003

Médécins sans Frontières

MSF has always been first when there's trouble. They have done it again in Chiradzulu, pioneering the treatment with ante-retroviral drugs (ARVs) of people with HIV. It is one of six places in the world where they challenge the accepted view that ARVs can be used only where there is adequate education and good health services.

ARVs are often seen as irrelevant in African rural countries - too costly, too complex, too demanding in supervision, too likely to lead to drop-outs and drug resistance. Three years' experience at Chiradzulu and elsewhere has shown:

• the cost per person falling from £12,500 p.a. to £164
• a likely fall to £118 under deals just announced by the Clinton Foundation
• a regime - 2 sets of pills a day - simpler than that successfully used for TB
• a dropout rate of 2 out of 302; in a shantytown near Cape Town there were none in the first 3000 treated
• patients need to be hospitalised only for the first few weeks when side-effects are likely
• silence and stigma disappear when people have hope
• treated patients become evangelists.

Fred Minandi of Chiradzulu says:I became ill in 1997. I am one of the first to have free ARVs in Malawi. People say Africans cannot take pills properly because they can't tell the time. Maybe I don't have a watch but I can tell you that since I began my drugs in August last year, I have never forgotten a single dose. I knew I was HIV+ but I never wanted to admit it. My neighbours saw me get weaker day by day. Of course they knew what was wrong but no one asked questions. One by one they just stopped coming to see me. That is why my country is dying in silence.

Now I work in my field, I have returned to my church and I can feed my family. Over the last two years, I harvested only two bags of maize because I was so weak. This year, alone, I harvested 10. I feel I have a future. Someone who has AIDS frightens everyone because people see their own death in his eyes. But once you are being treated, you feel better, you look better and people don't reject you any more. People tell you that treatment is too expensive and that a country like Malawi should work only on prevention. Does that mean that all my friends in the People Living With AIDS group, and I myself, must die? It is too late for us to talk about prevention, but I consider my life to be important, not just to me, but to my family and the whole country.

Providing affordable treatment will encourage many more to face their HIV+ status. This will allow the silence to be broken. My friends in the PLWA group have been trained as counsellors. We have been able to convince many people to take the test because they know they will be treated if they are positive.

I appeal to drug companies to reduce the price of their drugs and to governments to support treatment so that we can reach our goals. (Note: at present only the élites - 1 in 400 of Africa's 30 million with HIV - have access to ARVs.)

Why people still starve

"Families starve because families lack money. In most cases it's that simple." That is the conclusion of Barry Bearak, a New York Times staff reporter sent to find out why thousands died a hunger-related death in 2002. He focussed on one family where father, daughter and three grandchildren had died. They had received their starter-pack of maize, fertilizer and beans. Thinking to outsmart the experts, they spread the fertilizer over all their land instead of the intended quarter acre. It did no good. And the beans? They had been unable to resist: they had eaten them.

Barry writes: Adilesi and her daughter shared with me their "ingenious trick", something every human being ought to know. If I were ever so hungry I could no longer work, they advised me, there was a way for a determined mind to outfox a hollow stomach. "Tie some cloth tightly around your waist right at your navel," Lufinenti said. "Make it as tight as you can. For a few hours, you can fool your belly into thinking that it?s full."

Selling an ox-cart

Kennedy Njewa, a young farmer, sold his ox-cart. It was a very big deal. It had taken years to save up for the battered old carrier. Why? Two months earlier his 13-year-old sister Marghareda had come top of her class in the national exams and so become eligible to attend one of Malawi's elite boarding schools. It would cost £60 a year and the village had no money. So Kennedy didn?t hesitate. He sold the cart. It raised about £35, enough to pay for two terms.

The prime cause of the hunger was a vicious unseasonable drought in 2001. But the hand of man was also involved. The government had not responded to early warnings. Meanwhile, the IMF had pressed it to sell the 200,000 tons in the national grain reserves to save a few million pounds in storage costs. Malawi 2002 did not look remotely like Ethiopia in 1984. There were no migrations of people and no field hospitals full of twig-thin babes for the TV cameras to linger over. Yet the local Malawian churches with their ears to the ground were pretty sure that up to 10,000 had died already. This was a hidden famine, affecting only the poorest of the poor. There was still food in the markets in towns. The hunger was happening out of sight, in the remoter villages."More children die of moderate malnourishment than severe," said the nutritionist. "They die of measles, chest infections, diarrhoea. We tested all the malnourished children and found that 10% were HIV positive." Gumbi was perhaps the saddest village I had ever been to. It had no life, no energy, no hope.

In November I returned to Gumbi again. In the evening Kennedy came round. His one dream was to learn English and to expand his and the village?s horizons. He regretted deeply that he had never been to secondary school. He had the only book in the village. It was a tatty, precious English-Chichewa dictionary that he had read cover to cover. "It?s hard," he said. "I need a grammar book." His hopes are invested in his younger sister, Marghareda. The young girl was too shy to speak. "She is very intelligent. She will learn. If this village is to change, then we need education," said Kennedy. "Without it we cannot survive in these days. If we do not have education, then we will be like slaves."

In May 2003, almost a year to the day after the first visit, I return to Malawi for the fourth and last time. Food aid is at last getting through. But the very poor are still in trouble. More than 2,000 from the 67 villages around the feeding centre, Sister Modesta says, are still clinically malnourished. But the harvest looks good, for the first time in two years.

The chief in Gumbi is hardly recognisable. Instead of the downcast peasant farmer of last year, there is an upright, beaming man - if barefoot and raggedly clothed - who looks six inches taller and 10 years younger. He tells what has happened. The rains came just after I left in December and the farmers had managed to plant their crops. Elsewhere in Malawi there had been floods and thousands had lost their crops, but Gumbi, the unlucky village, had escaped. Now they are expecting a reasonable harvest. Any day now, he would give the signal and the whole village would head for the fields to gather the crops.

The village itself looks different. Outside every house is a large compost heap. "We have learned we must not be too dependent on fertiliser. We are learning what we can do for ourselves," says one man. Justin has lost a tooth, but he is smiling. "We are learning not to be dependent on one crop, and that we can use other areas to grow crops. All of us now use compost heaps and manure. And we are working together."

We head to the edge of Gumbi where a seasonal river trickles through a large wetland. More than 60 people have constructed a paddyfield, and now an acre of rice is growing. It will be shared between those who worked the land and the neediest in the village, says Kennedy. The plan is to construct a small earth dam across the river and eventually turn the whole area of more than 100 acres into a place where winter crops could be grown communally with five other villages.

"We know it will work," says one of the villagers. "Three thousand people could benefit. It would mean the end of the hungry season. But we do not know how to go about it. We have the labour but we need advice on how to construct it and pay for it."

"Last year was the year of funerals. We nearly died as a village. This is the year we learn," says Kennedy. "We are learning not to be dependent on maize and fertilizer, but we also know that we must work together more. We need to find new ways to get skills. That is why I sold the ox-cart for Marghareda. She and the other children are our future. We must start by believing we can make things better."

The new government budget

Civil society has not left this unchallenged. The Malawi Economic Justice Network analyzed the government budget ruthlessly at a Post-Budget Breakfast. There was a deficit of £100 million to meet, yet:

• The Foreign Affairs budget is up by 50%
• Presidential houses & offices up 64%
• National Intelligence increased by 164%

At the same time half the pro-poor expenditures are down:

• Primary teaching materials reduced by 31%
• Police training down by 34%
• Water development reduced by 65%
• Small-scale fish farming down by a massive 91%

MEJN's recommendations are modest. They call for: "The reallocation of some resources from State Residences, Office of President and National Intelligence to pro-poor activities."

The IMF is now resuming aid to Malawi but warns: "Keep to your promise of fiscal discipline and cut foreign travel!" Civil society leaders have asked government not to use these new resources to get itself re-elected in May 2004.

From the hospitals

St. Peter's Likoma Island is celebrating its first baby treated with nevirapine, now six months old, says Dr. Pam Douglas. £2 worth given to both mother and baby at the time of birth will prevent up to 50% of the babies contracting HIV from an infected mother, even with breast-feeding. Half the mothers come from the Mozambican lakeshore where there are no medical services.

St. Anne's Nkhotakota has been the first hospital in Malawi ever to provide proper palliative care for those who would otherwise die painfully. Dr Tim Wiggin and the World Medical Fund planned to extend this to everyone living in Nkhotakota District. The Princess Diana Fund was hoping to provide the resources. Sadly, the threat of legal action by Franklin Mint of the USA on a copyright issue forced the fund to suspend all grants three days before they could ratify the decision.

St. Luke's Nursing School celebrates the passing-out of their first 34 male nurse graduates, though an administrative hiccup in government meant that they had to wait for six months before starting their midwifery training.

Dr. Elly Holtrust, retired but still working, says of St. Martin's, Malindi: "A spotlessly clean hospital, a highly competent matron and an excellent, really dedicated staff. Three babies are born every day and DFID has just given a grant to renovate the labour ward." Professor Paul Fenton (College of Medicine Blantyre 1986-2000) wrote in Anaesthesia News after a recent visit to Malawi: "Missionaries and eccentrics keep the health service in Malawi going today." MACS will gladly forward to these four brave hospitals any help you are able to give. It will mean lives saved.

Malawi Against Physical Disability

"I sat this afternoon in a clean theatre with a dedicated and enthusiastic team, transferring a fibular graft into a massive tibial defect. MAP is doing exactly the job it set out to do in 1979, finding and treating disabled people in remote rural areas. I am just back from Nkhotakota where we saw 112 patients in a day. They come from miles around and just sit on the grass patiently awaiting our arrival. A hot and sweaty day but the cold beer afterwards on the beach tastes all the better!"

For an email update of Malawi Orthopaedic News contact Chris Lavy

We celebrate the lives of...

Maxwell Zingani, literature secretary, interpreter and stewardship adviser at Malosa throughout the 60s and 70s and then a dedicated voluntary priest, farmer & missionary to the area between Monkey Bay & Mua. Please pray for Rhoda and family.

Olive Price Fellow pilgrims of 1989 recall her (with severe leg ulcers "to be kept dry") crossing the Shire River to Matope in a leaky canoe. On her return, she sold her house in the UK and divided the proceeds between various church projects in Africa that she had seen. She died recently at 98, the darling of her nursing home at Herne.

Mel Crofton died in June after an 18-month battle with leukaemia. He began in 1956 as ADC Fort Johnston in Nyasaland, ending after 16 years as Secretary to the President and Cabinet of Malawi. He then picked up his earlier career as an engineer and travelled the world with TETOC (Technical Training for Overseas Countries), advising on the technical training of the young. Our hearts go out to Brigid and their family.

In brief

Church leaders are lining up to advise the public prior to the 2004 elections, as happened in 1994. Bishop Tengatenga is playing a prominent part, supported by Mgr. Boniface Tamani (Chairman of PAC, the Public Affairs Committee) and leading ministers from Blantyre and Livingstonia CCAP. Expect to hear more. The Electoral Commission has warned faith groups not to take sides in the run-up to the elections.