by Naomi Rubin Malawi: the Warm Heart of Africa A. Introduction to the country and region
Malawi is a small landlocked country in South-Central Africa, bordered by Zambia, Tanzania and Mozambique. The country is roughly the size of Nova Scotia, but with a population estimated at about 12.8 million. Of particular beauty in this often drought plagued country is Lake Malawi, which stretches for about 500km along the eastern border of the country. Malawi’s terrain is diverse--from rolling grasslands of the Great Rift Valley to high plateaus of Zomba and Mt. Mulanje, where the hiking is scenic and views go for miles. The capital city is Lilongwe. However, Blantyre is the city with the largest commercial centre.
Hunter-gatherers were the earliest to inhabit the area, but were replaced largely by the Bantu tribes during their migration. In the 16th century the Chewa people founded the area that is now called Malawi. David Livingstone was the first significant Westerner to arrive on the shores of Lake Malawi in 1859, bringing the development of Scottish Presbyterian churches and the establishment of missions.
Malawi, then known as Nayasaland, gained independence from Britain in 1964. Two years later it became a republic with ‘President-for-Life’ Hastings Kumuzu Banda ruling until 1994. With the onset of multiparty democracy, and Malawi’s first full election, Banda’s MCP party was defeated and Bakili Muluzi of the UDF became the first democratically elected president.
Malawi’s economy is based on agriculture with the three main crops being tobacco, tea and sugar. However, Malawi remains one of the world’s 10 poorest countries. The average yearly income for Malawians is US $170. Malawi has the second highest disparity between rich and poor in the world. Domestic investments have been limited and the national debt is reported to be close to US$3 billion. Malawi qualifies for Heavily Indebted Poor Countries debt relief and the country relies heavily on international support and aid from the World Bank, International Monetary Fund (IMF) and various non-governmental organizations (NGOs). The main resources for most families are subsistence crops, such as maize, beans, rice, cassava, tobacco and groundnuts (peanuts).
Malawi has many religious groups, including Presbyterian, Catholic, Jehovah Witness, Pentecostal and a large Muslim and small Hindu population. Religious groups in Malawi exist quite harmoniously, and historically, there has not been religious conflict in the country. The official languages of Malawi are English and Chichewa, with regional languages varying depending on the tribe in the area.
Tourism bills Malawi as the ‘Warm Heart of Africa’, with the Malawian people considered to be among the friendliest you could meet. I would have to attest this to be true. In spite of the incredible hardships of life in Malawi, the people are relaxed, friendly and ready to laugh and share a story.
B. Population Health The average life expectancy in Malawi is 36.5 years, with infant mortality 113/1000. The pandemic of HIV/AIDS has devastated the country; the prevalence of infection overall is reported to be 17% of the adult population, which rises to 30% in urban areas. Almost one million people live with HIV/AIDS in Malawi, and more than 50% of them are women. The most affected age group is young women between the ages of 15-24 years. Over one million children are orphaned due to the loss of their parents from AIDS and it is estimated that over 70% of hospital admissions are HIV-related. Other issues affecting health include poor nutrition and a large rural population with lack of access to basic health care, education, and extreme poverty. Over 90% of the population depends on subsistence agriculture for their livelihood, most earning less than one dollar a day.
C. Health Care System Health care in Malawi is quite basic. The reality is that with the large rural population, most Malawians either cannot afford health care services or they aren’t physically able to travel to health centres. Furthermore, economic restructuring has decreased funding for what little publicly-provided health care is available, such that the health infrastructure is in no way congruent with the health needs of the people. There is a mix of government and privately funded facilities, but these are without any regulatory capacity to ensure quality. Although government funded facilities sometimes provide “free” services, often they implement a “user fee”. Any small fee is still often beyond the means of most Malawians.
D. Disability and Rehabilitation The Kachere Rehabilitation centre was opened 12 years ago, funded entirely by international donations. It is the only rehabilitation centre for all of Malawi and is located in the southern region in the city of Blantyre. Originally it was opened under the name ‘Malawi Against Polio’, (MAP) until Polio was eradicated. Since then, it has opened its doors to those with any diagnosis and needing rehabilitation services. Currently the most common disabilities seen at Kachere are due to stroke, spinal cord injury, amputation due to chronic infection such as osteomeyelitis, and various disabilities related to HIV infections. The referral source is often the acute hospital across the road, called Queen Elizabeth Hospital, or from the community outreach therapists. Kachere provides services free of charge. The centre does generate revenue from some projects for which there are fees charged, such as private physiotherapy service, and rental of equipment to those who can afford it.
Kachere is a 40 bed inpatient facility for adults. There are 2 Physiotherapists, 4 Rehabilitation Technicians, and one OT. The centre also has a school and training program, whose goal is to meet the huge demand for services by increasing the number of trained rehabilitation workers. The Rehab Technician program is 2 years and essentially trains the graduate with basic skills to function as a PT/OT/SLP combined. There is no Physiotherapy school in Malawi. To become trained one must travel to another country such as Tanzania to become certified with what would be the Canadian equivalent of a diploma.
Kachere is now in the process of upgrading its program in order to certify the graduates with a diploma equivalent, with their long term goal to be able to provide a BScPT program in the future.
E. Personal Experience In April 2005 I had the privilege and opportunity to go to Malawi to volunteer for 3 months. A friend of mine had volunteered for 2 years as a physiotherapist with VSO at Kachere from 1999-2001. She continues to be in close contact with the staff at Kachere, and it was through her that I made contact by email to the director, and arranged my work term. My friend also had contact with an orthopedic surgeon who had helped establish a pediatric orthopedic facility, through CURE International. As my work in Canada is primarily pediatric based, I had hoped to do some similar work in Malawi. It was arranged that I would work at Kachere in the mornings and next door at CURE in the afternoons.
I was responsible for my air fare, accommodation and expenses. For my first week I stayed in a guesthouse, which was about $10/night. But soon I had met several other volunteers--many Canadians--and one who had an extra room in her house which she offered out to me. As Malawi is so heavily dependent on foreign aid, there are a lot of expatriates about: teachers, health care workers, volunteers in orphanages and many other NGOs.
At Kachere, my role was to simply be an extra pair of hands. To work alongside, exchange knowledge and skills, but mostly help decrease the numbers on the incredibly long wait list. My caseload varied from spinal cord injuries, stroke, acute neurologic disorders of unknown diagnosis and HIV related neuropathy. The gym was quite a large, bright and cheery place; patients came and went with their caregivers, and therapists worked side by side. Equipment was very basic, but functional. The day started at 7:30 and ended at 5pm with a break between 12pm-1:30pm. Although the therapists not have the letters B.Sc.PT next to their names, I can say with confidence that they had received excellent training, and I noticed no difference from their work to that which I might see here in Canada. Unfortunately, the biggest difference was in their salary--some earning only $20-$40 a month.
CURE International is a faith-based non-profit organization which establishes pediatric facilities in developing countries. Its mission is to provide free surgeries to all children who require it and otherwise could not afford it. At the time I was there, the surgeons were all from the UK, coming for 6 month to 1-2 year terms. There was also one PT from the USA, who provided private outpatient physiotherapy, which generated income for the facility. A portion of her fees for service went directly back into supporting the surgeries for the children.
During my afternoons at CURE I worked alongside Janet, the one Malawian Rehab Technician (PT) who saw all the inpatients (66 beds) and taught children how to use crutches, canes, ambulate with new prostheses, perform exercise programs and stretch burns. Chronic osteomyelitis due to poor wound healing was one of the major problems leading to amputation. Burns were also very common due to children playing too close to the cooking fire. Simultaneously, Janet ran the club foot clinic, which was incredibly busy. She would work her way steadily through the long line of women whose babies were waiting for serial casting based on the Ponsetti Protocol.
CURE also had 6 inpatient beds for adults, recovering from total hip or knee replacements, or other orthopedic surgeries. These surgeries were all privately paid for by the patients, wealthy Malawians, and these funds also generated income for the pediatric unit. At both CURE and Kachere, I felt like I was often the one doing all of the learning: learning how to be more creative when supplies are limited or non-existent; wondering how people can continue to be so friendly, and smile so readily when life is desperate and incredibly hard; and discovering with heightened understanding, (in spite of having volunteered in rural India and traveled previously in Africa), the extent to which HIV/AIDS is devastating families and communities in Malawi.
I’m not so naïve to think that three months was enough time to really make a dent in anyone’s wait list, especially one as incredibly large as the one that exists in Malawi. I can only hope that it was helpful in some small way. I was happy to be involved in the Dalhousie-Malawi project (November 2006) which was profiled in the IHD newsletter Dispatches, Spring 2007. Through partnerships with Dalhousie University, and health care facilities in Halifax, we hope to continue to support our Malawian colleagues, and build capacity through this North-South exchange.
