Monica, Ilan, and I left Cape Town early on a Sunday morning heading to Lilongwe, the capitol of Malawi (and after sleeping through my 3:30 am alarm and being woken up by the cab company, I was very thankful to have made it, haha). The purpose of our trip was to conduct a country evaluation of our m2m Malawi program, a new endeavor considering m2m has never a country evaluation before. In fact, having previously lacked an official client tracking system prior to last year, the whole research side of things at m2m is rather new. Even so, the client tracking tools are paper based (we don’t have endless electronic resources here, mind you!), thus there is a lot of client outcome information that is not routinely collected in a central database. Part of our mission was to get out to all the Malawi sites and transfer that information from site logbooks into Excel format so it could be analyzed. The information we sought deals with indicators on the individual level, such as number of visits to m2m, disclosure records, partner status, test dates and CD4 counts, prophylactic medication being taken before, during, and after birth, infant feeding practices, baby test information, etc. – as opposed to the routinely collected site information that just says how many new HIV+ clients enrolled and how many client interactions took place each month. Collecting the logbook information would give us a much more comprehensive view of the effectiveness of m2m programs, as opposed to just analyzing the number of women we see. This would provide the quantitative backbone to the country report; we also wanted to talk with in-country staff about a qualitative piece of the assessment (focus group discussions). The reason the first m2m country evaluation was took place in Malawi was largely because Unicef and the Ministry of Health in Malawi both wanted a report on how the m2m program was doing before providing us further funding.
Carey, who is the m2m Malawi Program Development Manager, met us at the airport and drove us to downtown Lilongwe to check in at our hotel. It’s funny that Lilongwe is the capitol of the country, because it has such a sleepy small town feel. It’s separated into 2 parts, Old Town and New Town, and with a lot of open, green fields in between the two sections, so you just never have the feeling that you’re in an actual city. And if it says anything about the size of the city and industry presence, Lilongwe is not big enough to have a movie theater (not that that’s the most sensitive measurement of connectivity and modernity, but it kind of puts things into perspective at least a little bit). Apparently Lilongwe was made the capitol (as opposed to Blantyre, the bigger, industrial center of Malawi) because it was the birth place of one of the former presidents – go figure! Anyway, we were apparently quite fortunate that the ATM machines were working when we arrived, as Carey said she had been trying for the past 5 days to get money out without finding cash in anywhere. The Kwacha provided a whole new challenge in terms of quick in-head exchange rate calculations, as the rate was 150 Kwacha per dollar – not to mention the fact that that kind of money scale meant you were carrying around huge wads of cash, haha!
Our hotel in Lilongwe was quite nice. I think my favorite part (and a recurring theme throughout, especially given it was rainy season) was having so many beautiful gardens everywhere.
Oddly enough, one of my best friends from home in Montana also happened to be in Lilongwe, temporarily visiting with a Duke research team. Small world! It felt very out of context, but Max and I managed to meet up and hang out on Sunday.
Proof that we did in fact hang out:
We ended the night by sitting in the bar downstairs in my hotel to watch some Africa Cup of Nations matches (that’s the big African soccer tournament, held every two years). It was a fun atmosphere, though it was funny because we were definitely the only white people and I was definitely the only girl. People seemed quite incredulous that we actually liked soccer, with one guy even flat out asking when we sat down. I also tried out some of the local beer, which I found to have an incredibly hilarious name: Kuche Kuche (pronounced coochie coochie, haha!).
Monica, Ilan, and I then spent the next two days working at the m2m Lilongwe office with the country team based there. We were doing a lot of logistical planning about how we were going to get out and collect all the data we needed from the 35 sites spread across the country, in addition to doing the actual data abstraction for all the Lilongwe sites, and also just meeting and debriefing with the in-country team. It’s a small office, with about 6-7 people based there. Everyone was incredibly nice. I also loved being in the office where there were always fresh mango and pineapples available for everyone to enjoy. Ellen (the Country Manager) even brought in a bag of freshly roasted peanuts (still warm) from her brother’s garden – I’ve never had such delicious, fresh peanuts and probably never will again! There was one guy in the office whose job was basically to run errands, make sure the office was in order, get everyone’s lunch, make tea and coffee in the morning, etc., and I must admit I feel somewhat uncomfortable being waited on while at work, but I suppose it’s important to also look on the positive side in terms of how important it is for someone to have a job. Malawi is an incredibly poor nation, but the people are so very, very open, warm, and friendly. I felt much more welcome there than in South Africa, though admittedly South Africa has a particularly complicated history to overcome when it comes to dealing with white people’s presence. Anyway, as an example of just how friendly everyone in Malawi was: once Monica and I were driving around and had to roll down the window to ask for directions. To the nearest man, I said, “Excuse me, we’re looking for…” at which point he cut me off, admonished me, and said “No, no, first, how are you?” Haha I certainly learned my lesson, on top of getting quite the wakeup call as to just how rude Americans can across without meaning to!
Wednesday morning we took a car (m2m had 2 vehicles for staff use in Malawi – of course they were the traditional white land cruiser-esque vehicle universally used by NGOs in Africa) and departed Lilongwe at 5 am in order to still put in a full day’s work in Blantyre, about 4 hours south.
It doesn't get much more stereotypical than this, especially with the token Unicef logo
Still, it was a beautiful drive, especially as we watched the sunrise over all the rolling green hills. Since it was in the middle of rainy season, everything was incredibly green.
Beautiful sunrise views:
We stopped for breakfast at a place called Dedza, pretty much right on the border of Malawi and Mozambique, and famous for its pottery.
Malawi is now Africa’s largest tobacco exporter, and some of the other prominent crops we saw were corn, potatoes, rice, bananas, mangoes, etc. I always find it really interesting to stare out the window and learn about a new country through observation. I really enjoy the car time (maybe my tolerance for long car rides also has something to do with growing up in Montana, haha!). Malawi is definitely “real Africa,” (as opposed to Cape Town) if you’ll excuse the stereotype. It was really interesting to watch all the passer-bys dotting the roadsides. There was pretty much a steady stream of road-shoulder traffic – people walking or riding bikes alongside the road, headed to and from their crops, the village, school, etc. Bikes seemed like a great commodity, that’s for sure. And lots of women carrying baskets, bags, water, or huge parcels of firewood on their heads. I honestly don’t know how they do it. I don’t think I could ever carry two dozen pieces of 10 ft long branches on my head, let alone walking up steep roads. It also was not uncommon to see a group of kids out on the road, the oldest looking to be about 7, taking care of siblings of ranging from about age 2 to 5…hard to imagine, but I guess you do what you have to do. There were also tons of roadside stalls with people selling fresh fruit, baskets, meat, what have you. And the landscape itself was quite beautiful – lots of rolling green hills/mountains and little thatched-roof huts dotting the landscape. Going over a few passes, it felt as if we were truly amongst the clouds. Every so often you’d pass through a cluster of very run down buildings (as opposed to villages with just huts) which constituted towns or trading centers. It’s kind of funny because the cell phone carrier in Malawi, Zain, uses hot pink as their company color, and thus any store that sells Zain airtime can paint their building pink (and probably gets a deal if they do so, as it is definitely good advertising). I loved the bright colors – literally it seemed like every other building in these small towns was hot pink, haha!
Some of the roadside scenery:
Driving through the misty clouds, on our way over various passes
Look, it's Mozambique! For a while the road exactly follows the border so when you look out the right car window, it's all Mozambique...too bad it doesn't count to have been to a country even if you've seen it, haha
Driving through the bustling crowds gathered for market day
I suppose it's hard to see, but this is where you would buy your mangoes and goat meat...
Eventually we made it into the Blantyre offices where we met with the staff there and started on the next phase of data abstraction. Once again, everyone was incredibly friendly. Blantyre definitely felt like it had a lot more going on than Lilongwe. We had a ton of work to get done for the Blantyre sites and thus spent most every hour of our time there working. Monica ended up working from the hotel one day, so I had to drive Ilan and I (Ilan, as a Pfizer fellow, wasn’t allowed to drive during his fellowship) to the office, and I must say, it wasn’t exactly comfortable for me to maneuver a huge SUV around the bustling, narrow streets of Blantyre, haha! When we pulled up at the office, we noticed the guy in the car next to ours had a bunch of fish in his trunk.
Max had warned me about not eating fish unless near the lake (Lake Malawi is a few hours away from each of the two main cities), since you don’t know how fresh it is, and I must say, this was definitely living proof to heed his advice! The man was nice enough to offer us a fish, but having not necessarily wanting to keep a fish in the trunk all day (as he seemed quite comfortable with), we politely declined…
On Thursday morning we set out with the Blantyre team to drive south to the next district, Chikwawa, with the idea of working at the Chikwawa hospital for the day. That plan didn’t quite pan out, as upon our arrival we were informed the hospital did not have electricity that day. (Once again, a stark reminder of the things we take for granted, such as hospitals having electricity at all times…) We instead just had to collect all the logbooks and turn around and head straight back to Blantyre. It was still a very interesting drive, however. From Blantyre we had to go over a fairly steep pass which then opened up into the vast, open, flat valley of Chikwawa, which believe me, was HOT (in contrast to the more mountainous regions that don’t suffer from as hot of temperatures due to the elevation).
Driving to Chikwawa (roadside stalls like this were quite common everywhere we drove)
The vast Chikwawa valley
Chikwawa District Hospital
Maternal health signs...too bad I definitely cannot read Chichewa (good morning - mwadzuka bwanji - and thank you - zikomo - were unfortunately as far as I got)
Wezi (the Blantyre Regional Manager) taught us a lot about Malawi on the drive. This photo is of Wezi and Ilan.
Apparently, it being rainy season, food is relatively plentiful this time of year and people probably eat 2-3 meals a day. During dry season, however, most people only eat once a day. Food security is a big deal in Malawi because there are essentially no storage/preservation systems so they have to eat the crops while they are producing. I also found it incredibly interesting to hear her say that, despite the fact that cows are ubiquitous, nobody eats beef. Apparently the cows are purely for status and therefore people would never kill them (and I didn’t get the impression they even use them for dairy that much). She said the only way you would see beef being sold is if the cow had a disease and had to be killed or if it was mauled by a crocodile. I just found it very counter-intuitive that for a population that has such food security issues, they don’t utilize one of their main forms of livestock. Wezi also described a typical day in the life of a Malawian woman: get up with the crack of dawn and head out to the fields (your crops probably not being located right next to your hut, but rather up in the hills, etc.) to work for the morning, then buy the firewood and carry it back to the hut, then go out and fetch water (also a very arduous task), then be expected to make a big meal for your husband. The husband would probably have spent the day perhaps working in the fields and also perhaps trying to sell stuff at market. Obviously, it sounds like a very difficult life. When we drove past people selling what looked like dollhouses made of branches, Wezi said the houses were for pigeons which people just like to keep, with no real purpose to having them other than it’s just nice to have something, like having a flower garden. I found it interesting to see that people who struggle with day to day subsistence still sometimes just want something nice to call their own – yet another reminder to me that I sure take a lot of things, including my possessions, for granted.
As we crossed the large Shire river in Chikwawa, Wezi informed us that it was full of myriad crocodiles. Despite this, people bathe, wash clothes, etc. though she admitted occasionally children get snatched – yikes!
The actual data abstraction process was definitely a bit tedious, but it had to be done and there was literally no alternative to accessing the information required before being able to undertake the fun data analysis part of things. And despite it being tedious work, I still found it interesting to read about what was going on in these women’s lives. Looking over countless client records, I was naively a bit surprised by how many HIV+ women had HIV- partners. It’s easy to assume everyone who is HIV+ has an HIV+ partner, but that’s definitely not the case. It’s quite common to have discordant couples (I think around 20%?), and in those scenarios it’s obviously even more important to practice safe sex and be aware of one’s status. I think what surprised me the most is that I always stereotypically thought of the man in the relationship as being the one who is unfaithful and subsequently contracts HIV and passes it onto his wife. Monica explained to me, however, that it is a quite common infection cycle for young women to be infected before marriage, and then marry an older HIV- man, who eventually becomes infected himself.
Also going through the logbooks, it was interesting for me to compare the treatment and care scenario in Malawi to that in South Africa. I’ve spent a lot of time with South African logbooks data, and most every woman here delivers in a facility and there are much more ARVs available (for instance national protocol has most women taking two different prophylactic drugs before and after birth, as opposed to only one). However, the situation in Malawi is not as advanced, in the sense that it is a much more rural, poor country. This means that a lot more women deliver with traditional birth attendants outside of the facility. Getting to a facility means a day’s walk for many women, so it is much more difficult for them to receive antenatal care in general. In addition, Malawi has only just introduced dual prophylaxis and we are only beginning to see evidence of its use at the facilities where our sites are based. Also, going through the logbooks, it was really common to see a few pages in a row where every woman would be missing an important drug and the comments section would say there was a stock-out. It just really puts things in perspective when you see how different life could be, as opposed to living in the U.S. where everyone obviously delivers in a facility and has access to any drug they want at any time and doesn’t have to worry about getting transport to the health facility.
Well, we somehow managed to finish up all the Blantyre work in time to depart the city mid afternoon on Friday, leaving us enough time to get to our next destination before Friday sundown. The drive from Blantyre to Mangochi, located on the southern end of Lake Malawi, was also very beautiful, especially in the evening light.
Lake Malawi stretches almost the entire length of Malawi, serving as the Eastern border between it and Mozambique. It is also the very bottom of the Great Rift Valley. The fishing industry is very important for the Malawian people. I read on our map that there are more species of fish in Lake Malawi than in all the freshwater lakes in North America and Europe combined, which is rather hard to believe! Apparently Malawi is the source of many of the tropical fish you see in aquariums. We ended up staying Friday and Saturday night at a very fancy lakeshore resort (oh, the things that are wrong with the NGO world sometimes…) which was truly gorgeous. And finally, dining on the lakeshore, I felt I was close enough to safely eat the fish, haha! The most common fish in Malawi is called Chambo, which is tilapia-like, and definitely very tasty.
Saturday and Sunday were also mostly spent working, but I must say, it really doesn’t feel quite like work when you are sitting poolside with your laptop and having beautiful lake views! We also managed to get a bit of recreation in during our breaks – Monica and I played a lot of ping pong (during which she beat me every time), tried our hand at tennis in sandals with flat balls and very old racquets, and also attempted some paddle boating. I had never quite seen a paddle boat like this one – basically it looked like a large tricycle and had no bottom. I’ll admit, the bottomless boat concept caused me to internally freak out a little bit during our adventure, as you’re not supposed to swim in Lake Malawi otherwise you might contract a nasty parasite called shista. I don’t really know the details of it, but all I did know is that I certainly did not want to fall in! As it turned out, our paddle boating had to be cut short because the distance between the paddles and the seat turned out to be made for someone of miniature size, resulting in a knees-up-to-ears phenomenon which didn’t allow for much momentum gain, haha.
View from the paddle boat
I'm amazed we managed to get out that far, considering this was our means of transportation:
It being rainy season, it rained almost every afternoon. We’re talking RAIN here, African downpour style. It was never cold though, and I found the big storms to be quite refreshing. Anyway, it was very nice to sit on the beach and watch the sunset after the air had cleared. Sunday I managed to wake up early for sunrise and enjoyed walking along the beach and watching some early-morning fishermen head out. I also just loved the grounds of the place we were staying at, as there were endless beautiful gardens and trees to marvel at, as well as lots of cute lizards and a few monkeys.
Pool and grounds at Club Makokola (the Lake Malawi resort), after a dounpour
Private chalets!
Quite the rooms!
Club Makokola greenery - very lush!
Look, a tree growing on top of a tree! I had never seen this before, but Monica explained the vine-y looking tree is a strangler fig, which eventually kills the tree underneath - too bad!
Another strangler fig, this time growing on top of a giant baobob - quite a spectacular display!
Monkeys!
Sunset underneath the palm trees
Catching sunrise, as the fishermen head out
Sunday we checked out and headed to another hotel down the road which was much cheaper (it didn’t have availability originally, so that’s why we had to stay at the nicer place at first, in defense of our spending practices). It wasn’t really anything to write home about, though for some very odd reason they did have a few camels, so I got to see my first live camel – they are much taller than I had ever imagined!
Since it was a pretty dumpy place, and didn’t have a good working area, nor terribly consistent electricity (at least I’ve learned my lesson about African travel – always have a headlamp and roll of toilet paper with you at all times, haha!) we actually checked out Monday morning and headed back to Club Makokola where, since the place was practically empty, they upgraded us so we each had our own chalet – very, very nice!
We spent Monday working with the Mangochi District Manager, named Blessing. (I love the inspirational names in Malawi – Wisdom, Precious, Blessing, etc…though Carey and I also noticed one woman in our logbooks named Funny, which I’m not sure is inspirational or not. Funny, however, seems better than the Nopassport I ran across in one of our South African logbooks once!) Blessing was incredibly nice, of course. In the afternoon he took us to Mangochi District Hospital to meet with the Mentor Mothers there. It’s always so interesting to talk to Mentor Mothers. Once again, the context there was quite different from the sites in South Africa I’ve been to. In the Mangochi area in particular there was a large Muslim population (apparently a lot of Arab traders came into the area due to the lake), and polygamy was also quite prevalent. It was just really interesting to hear about the women talk about the challenges of disclosure (disclosure obviously playing a huge role in prevention) in a polygamous relationship. Often in those scenarios women don’t want to disclose because they’re afraid their husbands and the other wives will shun them – but obviously it’s a terrible scenario for letting the virus spread throughout more and more people. So many challenges to fighting HIV…
Monica, Blessing, Mentor Mothers, and me at Mangochi District Hospital
Mangochi District Hopsital is obviously a whole other world compared to what women in the U.S. experience. For instance, you probably wouldn’t be weighing your baby from a tree (what those women are gathered to do)
Nor would the antenatal waiting room be outside, where you have to wait all day long, downpour or not...
Interestingly, Malawi has a woman vice president who is doing a lot to try and further maternal health in Malawi. (And FYI, people seem quite pleased with the current president, who has made significant strides in boosting the economy – that’s always pleasant to hear, as opposed to the all too frequent stories of African leaders doing more harm than good.) Carey and Ellen even had a meeting with her about m2m just the other week! Anyway, one of the strategies the government has employed in order to get more women to deliver in facilities was to sell the idea to local chiefs, who subsequently made rules that if a woman does not deliver in a facility than her family owes him a certain number of cows/goats, etc. I found that to be an extremely innovative and interesting approach to reversing certain cultural norms, and apparently it is quite effective.
Tuesday morning we finished up our last little bit of work in Mangochi before bidding a sad farewell to the lovely Club Makokola and heading back to Lilongwe. We were trying to get Ilan on a 1pm flight back to Cape Town, but our timing wasn’t quite there. The mountain passes and winding roads, coupled with numerous speed traps, made the drive much longer than anticipated. Monica even got a speeding ticket! (Gotta love it when you get pulled over and the police officer says “show me your license before I arrest you”…I’m not sure if those are the types of things I would joke about in that context, haha!) We eventually did make it back to Lilongwe, but not in time for Ilan’s flight, so he was stuck with us until Thursday since there aren’t daily flights.
More roadside scenery on the way back to Lilongwe
I just found this sort of funny, having a sign about a business and computing school with a goat sitting under it
Cute kid!
Just one example of a bright pink Zain building...now picture literally half the buildings in Malawi being this color, haha
And eventually we reach Old Town Lilongwe
This is sort of a random picture, but I couldn’t help but marvel at how out of context the Chinese pagoda seemed, planted in the middle of a field in Lilongwe. (Also, this is in the middle of New Town Lilongwe, directly across the street from our hotel - see what I mean by it not exactly feeling like a capitol city?)
But then again, the Chinese are certainly making their mark on Africa these days, which is a whole other issue…
Back in Lilongwe, with data collection complete, and cash once again to our name (there is no place to get cash outside of Lilongwe or Blantyre), we settled in for more work, this time on the actual data analysis and presentation part of things. Fortunately, we managed to justify working outside in another beautiful garden upon our return to Lilongwe on Tuesday afternoon.
Wednesday all day was spent in the Lilongwe office working on the report. (No phone lines for 3 days due to a huge lightning strike in the area, but at least the internet was working!) At one point a Unicef person stopped by, apparently a bit surprised to hear that m2m had a team working in-country on the evaluation project. This was a little bit odd, as a concept paper on the evaluation and our planned presence was circulated between the Ministry and Unicef months in advance. It was an interesting lesson in politics, and, as Monica put it, how “process is often more important than content” in many African political scenarios – essentially Unicef and the Ministry were not that pleased that we didn’t follow formalities and notify them upon our arrival and keep them more up to date on our plans. We had to schedule a last-minute meeting with them for Thursday morning before our flight to talk about the evaluation. I was very happy for the opportunity to tag along, where we met with the head of the Malawi Department of HIV and AIDS.
Unfortunately the Ministry and Unicef were a little wary of the fact that we were conducting an internal evaluation (despite not giving us funds for an external evaluation, nor raising this concern when the concept paper was circulated months ago), so we might have to do a bit of backtracking to accommodate external evaluators in the qualitative aspect of the evaluation. Well, as I said, definitely an interesting lesson in politics and formalities…
Our last night in Lilongwe, Monica and I met up with a friend of Alisha’s (Alisha works with us in the m2m office, but previously had spent 3 years living in Lilongwe) for a fantastic dinner. We went to a little Ethiopian restaurant, which was essentially just a room in a person’s house, and we were the only customers, so it felt quite intimate. I had never had authentic Ethiopian food before, but it was very delicious. Definitely something to take advantage of more often, if possible!
The rest of the trip back to Cape Town was pretty uneventful. Having learned our lesson with Ilan, we left quite early for the airport, which turned out to be a good thing because the President was flying in that same afternoon (from the African Union meeting, where he was elected to be the next head of the AU) so that meant there were going to be huge delays, lots of security, etc.
Evidence of the President's impending arrival - it's not often you see a red carpet on the runway!
To avoid all of this mess, our flight took off about 30 min. early, which was great…though I’m not sure how that would have worked for passengers who had not happened to show up to the airport very early. Oh well, it worked out!
It’s nice to be back in Cape Town and have a more normal pace of life (i.e. much fewer 5am mornings…), but the trip was an incredible experience and I’m very grateful for having had the opportunity to take part in it. And I can definitely say I recommend Malawi to any future visitors!
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