Malawi has received some vaccine doses under the Covax initiative and priority is being given to healthcare and other front line workers. Daily information on Covid-19 cases and the vaccination programme in Malawi is published by the Ministry of Health on their Twitter feed https://twitter.com/health_malawi

In order to help with the fight against Covid-19 in Malawi, Ripple Africa has:

• run an awareness raising campaign in remote rural lakeside villages to educate people on how they can protect themselves against Covid-19. We produced leaflets in local languages which our staff and fish conservation committee members used to educate others in their communities to ensure that people understood the symptoms of Covid-19, knew what to do if they developed symptoms and understood how to prevent themselves from exposure to the virus. We also employed a public address vehicle to spread the information more widely in the remote rural villages of Nkhata Bay and Nkhotakota Districts.
• provided masks to all of our staff and also to members of our fish conservation committees
• provided buckets and soap at beach landing sites, health centres and market places to facilitate handwashing
• funded the repair of broken boreholes and wells to enable more people to have access to water for handwashing.  So far, we have repaired 440 wells and are hoping to continue this work as there are still more than 400 broken boreholes.  As each borehole is used by over 150 people, this has helped over 65,000 people so far
• raised funds for 13 oxygen concentration machines as there is little access to oxygen in our local hospitals and health centres for those who are suffering from Covid-19

Firstly, the mosquito which carries the malarial parasite is most active at night, so the use of mosquito nets when sleeping can prevent the opportunity for a    malaria-infected mosquito to bite its host. In Malawi, many people have access to mosquito nets; however, not everyone has them, and not everyone is consistent about using them. (We have seen many people using their nets for fishing instead! See our Fish Conservation project to find out more.) In order for mosquito nets to be effective at combating malaria for an entire community, 80% of a community population has to be using them.

Secondly, control of the mosquito population at large can also help prevent the disease. Malawi has recently introduced a scheme where houses are being sprayed with insecticides which are very effective at killing mosquitoes, and last up to 12 months. As with the mosquito nets, however, this residual spraying must take place in at least 80% of homes in an area to be an effective preventative measure to the community at large. People do have access to medication to treat malaria, but often wait until the last minute to seek medical care, especially where a healthcare centre is a great distance from their home. The longer someone waits before seeking treatment, the greater the risk of complications.

Ripple Africa helps fight malaria by ensuring communities have immediate access to healthcare services for quick diagnosis of the disease. Patients presenting with malaria make up the majority of the cases at both the Kachere Health Centre and the Mwaya Dispensary which Ripple Africa supports. In addition, Ripple Africa volunteers drastically increase both facilities’ abilities to cater for more patients.

All healthcare facilities in Malawi such as clinics and hospitals will have a team of nurses (trained in midwifery and nursing), who also diagnose and prescribe. Health Surveillance Assistants (HSAs) have a diverse role, including the management of the community health needs, assisting in clinics, collating all records, and performing VCT (Voluntary Counselling and Testing for HIV/AIDS.)

Despite the huge proportion of people living with HIV/AIDS, there is still a social stigma attached to the disease in Malawi. Culturally, most people in Malawi are still hesitant to talk about HIV/AIDS, and many are too afraid to be tested. Many people feel they will be ostracised from their communities if they are discovered to be HIV positive, and thus continue to live with the disease without treatment, and continue to risk the infection of others.

Fortunately, many people in Malawi have access to free ARVs (antiretroviral drugs), a combination of drugs which considerably prolong the life of a patient living with HIV/AIDS by many years, if not decades. ARVs also significantly reduce the chance of mother-to-child transmission, so mothers who are HIV-positive can give birth to healthy babies without passing the disease on to them. Despite these miracle results, the reality of ARV use in Africa is complicated. However, following an ARV regime is complex and side effects have to be carefully monitored. For many people in Malawi, it is not enough that the ARVs themselves are free. Basic factors such as the cost of the bus fare to get to a clinic for treatment on a weekly basis, and regular access to enough food and water to be taken with the medication can prevent people from taking ARVs consistently or at all. Healthcare resources in Malawi are also extremely limited, so physicians have much less at their disposal to monitor treatment than would be used or recommended elsewhere in the world.

However, the greatest obstacle to ARV use in Malawi is still the low percentage of people who get tested early, with the majority only confirming that they have the disease once they have progressed to the final stages of AIDS. When people leave their diagnoses and treatment until the very end, their options are very limited and many people turn to traditional medicine, where treatment is often harmful, costly, and of course ineffective.

Ripple Africa volunteers work with many patients who are living with HIV/AIDS and promote HIV/AIDS awareness at schools, clinics, and community level. Ripple Africa has also been involved in public health campaigns to tackle the stigma associated with the disease, and encourage people in the community to get tested.

The majority of the population is heavily reliant upon nsima as the staple of their everyday diet. Nsima is a porridge-like substance made of ground maize or cassava flour which is mixed with water to form a doughy carbohydrate which is then served with different relishes to flavour it, such as potatoes, fish, boiled vegetables, tomato soup, etc. Nsima is eaten all throughout Africa, and is also known as nshima in Zambia, sadza in Zimbabwe, ugali or posho in East Africa, banku or fufu in West Africa, and pap or mieli-meal in South Africa.

As a staple carbohydrate, nsima is popular because it helps Malawians to feel full, and because maize, and particularly cassava, is a dependable crop which grows well in hot climates. While nsima might be a reliable choice for a staple food, it has little nutritional value. Eaten with fish or meat for protein, eggs or oil-based soups for fats, and vegetables for important vitamins and minerals, nsima is part of a balanced diet. However for many Malawians, poverty, food prices, crop failure, poor agricultural skills, a failure to practice crop rotation, a lack of irrigation, fertilisers, pesticides, over-fishing and more all contribute to a lack of access to a variety of foods, and many of the poorest people eat nothing but nsima, or at least not enough relish to make up the nutritional content the body is lacking. As a result, many Malawians are malnourished, and children and pregnant women are particularly vulnerable, where malnourishment not only exacerbates existing health conditions, but can be fatal in its own right.

Undernutrition in women and children remains a persistent public health and development challenge in Malawi. Nearly half the children suffer from chronic undernutrition (stunting) and micronutrient deficiencies, including iron and vitamin A.

According to WHO, almost half of children under five in Malawi are identified as stunted (low height for their age), 4.2% are identified as wasting (low height for their age). Stunting reflects the cumulative effects of undernutrition and infections, even since before birth, and for children who are critically underweight, the risk of infection and death is severely increased. While weight loss can be corrected, the long term effects of malnutrition in the first two years are irreversible.

Anaemia, caused traditionally by a lack of iron in the diet from a shortage of foods such as eggs, red meat, oily fish, beans and pulses, green vegetables, and some fruits, can increase the risk of maternal and child mortality, has a negative impact on the cognitive and physical development of children, and reduces physical performance and the work capacity of individuals and entire populations. Vitamin C, which is found in fruits such as papaya (pawpaw), oranges and lemons, mangoes, and pineapples, can help the body to absorb iron, making it another essential element of a healthy diet. Deficiency in Vitamin A, found in foods such as liver, carrots, broccoli, spinach, and guava fruits can cause night blindness, permanent blindness altogether, maternal mortality, poor outcome of pregnancy and lactation, and a diminished ability to fight infection. Ripple Africa’s Orange-fleshed Sweet Potato project is introducing varieties of sweet potatoes which are higher in Vitamin A into our local area.

Healthcare in Malawi is supported by Ripple Africa volunteers. Our volunteers help fight malnutrition in Malawi by monitoring the weight of babies and children at the Under Fives Clinics run by staff at Kachere and Kande Health Centre on a weekly basis. These clinics help identify children in the community who are at risk, and those identified as critically malnourished join the Malnourished Children’s Project to correct the imbalance. Women and children at the clinics also receive critical supplements, including vitamin A. Ripple Africa’s Tree Planting project, includes fruit trees giving access to nutritious food sources at household level. In addition to being an important source of nutrition, fruit can also be sold to allow families to buy different varieties of food, particularly meat and other products to which they might not otherwise have access.

In the immediate area in which Ripple Africa works, villages are very well set up with community boreholes. However, where a borehole does not exist, many people collect water from exposed sources which can contribute to a number of waterborne diseases. Most Malawians still have to make a daily trip to their water sources once or twice a day, and how water is stored and used will also have an impact on how safe it remains to drink.

For those who do access water from open sources, proximity to household latrines inevitably affects the safety of that source. In rural areas, the majority of people use unimproved pit latrines (outdoor pit toilets which are simply dug into the soil and have not been reinforced with construction materials.) Only the minority of rural families use improved latrines, or drop toilets, which have been reinforced with materials such as cement. Flushing toilets do exist where there is formal plumbing, such as in the cities; however, the national average of people with access to improved latrines shows little difference between rural and urban areas.

In the rainy season, household waste from an unimproved latrine can easily wash into water sources, leading to waterborne diseases such as cholera, dysentery, typhoid fever, gastroenteritis, botulism, severe diarrhoea, and more. Open wells are also a breeding ground for mosquitoes which lead to malaria. Waste and garbage disposal is also a problem in Malawi, with no national refuse system. At household level, waste disposal is by rubbish pit and burning of waste. Despite a lack of sanitation, only 66% of families in the district have soap for washing their hands after they use the toilet or handle rubbish.

Ripple Africa is helping to improve healthcare in Malawi by improving access to safe water and proper sanitation at community level by installing and maintaining boreholes and building improved latrines in our schools and healthcare facilities. Ripple Africa is always looking for donors who can help raise money for additional toilet and boreholes in these facilities, please contact us if you can help!

In Malawi, midwifery is not considered a separate discipline from nursing, and nursing students undertake a year’s midwifery training as part of their overall skill set, although this is not compulsory. According to the Impact Evaluation of the Sector-Wide Approach in Malawi published in 2010, 79% of nurse/midwives had midwifery skills, and could be counted as a SBA. While the value of giving birth with a professionally trained nurse/midwife was self-evident, passing a law without increasing access to medical facilities meant that women often have to walk for hours, if not days, to get to the nearest health centre. According to WHO, 87% of all births in Malawi take place in rural areas, compared to 13% in urban areas where most health centres and hospitals are concentrated.

Malawian women in rural areas have to make the difficult journey to their nearest health centre, many while in labour, and others journey to a health centre weeks in advance and camp outside the facility until they start labour. Most health centres have just one room for delivery, and are staffed by a single nurse/midwife with no one to relieve them. Understaffed, lacking critical resources, and oversubscribed, these health centres often struggle to cope, and in the event of complications many still lack the medical facilities to handle emergency situations, including C-sections.

Motherhood in Malawi is obviously a dangerous undertaking; however, having a traditionally large family is still an important part of Malawian culture. For many women, however, the use of birth control is becoming more prevalent, and women are beginning to have more control over their own family planning. Common methods of contraception in Malawi include condoms, birth control pills, Depo-Provera, IUCD, Norplant, and sterilisation. Malawian culture is still very male-dominated, and many women feel they have little right to make family decisions (including about contraception and family planning) without the permission of their husband. For men, large families are seen as a status of wealth, power, and fertility. Gender inequality still presents the greatest difficulty in women accessing contraception in Malawi. As things change, however, and women have greater access to education, conscious family planning is slowly becoming more common, but it is still not the norm. Ripple Africa sees many of the brightest female students drop out of school at an early age due to teenage pregnancy, which could have been prevented by the use of birth control. Our Family Planning and Sexual Health project is working with local community groups, schools and couples to educate people about the benefits of limiting their family size, for their own benefit and to ensure that there will be sufficient natural resources left in Malawi for future generations.