Malawi, January 28, 2018
By Cliff Kawanga
At the height of hunger crisis few years ago, a lot of people cried for support.
Despite a lot of cassava or sweet potatoes in their household, some of them still lined up to receive free maize that the government was distributing. In a year when maize had failed, the farmers indeed had cassava and sweet potatoes as options. It is not quite surprising that in Malawi, food is nsima and those who claimed to have no food actually meant they had no maize from which fl would be made.
The many interventions in Malawi – which have lessened the burden of HIV and Aids – are founded on the availability and uptake of life-prolonging drugs.
An important aspect of such interventions is nutrition which, according to Dream Programme, should be embraced by all the stakeholders in the health sector as well as traditional leaders and the communities.
Dream Programme’s Country Coordinator Roberto Lunghi said nutrition is a key component in addressing the challenges in the health sector.
“This is where we should start from. We need to impart this knowledge about nutrition and we believe every stakeholder will play a role moving forward,” said Lunghi on the sidelines of nutrition training organised by Dream Programme in Blantyre last week. The training attracted participants from Dream Programme centres across the country and district health facilities.
Dream’s National Nutritional Coordinator Dyna Tembo said there is need to look at the nutrition side in the course of implementing other activities.
“Eating well is key to maintaining strength, energy and a healthy immune system. In addition, because HIV can lead to immune suppression, food safety and proper hygiene are concerns when it comes to preventing infections. This is the reason we gathered here to share the emerging issues based on the evidence from the communities in which we work,” Tembo said.
She emphasised that although focussing on the right food quantities is very important, food safety is crucial.
“You cannot talk about nutrition while ignoring hygiene. We urge our clients to follow the few basic safety rules when preparing and eating meals,” Tembo said.
She said the knowledge the participants acquired is key in meeting some of the targets set.
“Expert clients play a very important role because they are in direct communication with the patients. They follow up on patients and visit their homes when they miss appointments.
“Most importantly, the expert clients are involved in homecare. For patients who have problems with drug adherence or have poor nutrition conditions, the expert clients go to their homes, spend time with them to learn how they prepare their food, to see the hygienic conditions in the homes and then teach them on the correct ways of food preparation,” Tembo said.
One of the participants was Dowa’s Assistant District Nutrition Coordinator Precious Mlotha who said patients’ nutritional needs are assessed before meeting the doctors. “What we are doing in Dowa is quite remarkable. Regardless of the type of disease one is suffering from, we believe assessing the nutritional needs will go a long way in promoting healthy living in the communities,” he said.
He said that people might have a lot to eat but there is knowledge gap which they want to fill.
“We have learnt a lot and if we work together, we will soon count the benefi Everyone should own the initiative. In the past, the communities were at the receiving end but now they are actively involved,” he said adding that addressing nutritional needs is not the responsibility of the hospitals alone.
Another coordinator from Mangochi’s Kapire Dream Centre Alexander Mbewe said every food is important but there is need to consume the right quantities.
“Food helps the body to function properly. It is an important aspect in HIV/Aids because it protects the clients from HIV/Aids complications or opportunistic diseases,” he said. He said it was encouraging that most people appreciate the importance of good nutrition. “Few years ago there was a misconception that some diseases like diabetes or hypertension were for the rich only. This is slowly changing because people now understand that everyone can suffer from these diseases and good nutrition has proved to promote healthy living,” he said.
At the time the Dream Programme started in Malawi, the focus was on Drug Resource Enhancement Against Aids and Malnutrition with the aim of pulling resources together and enhance the fi against HIV and Aids.
After years of feedback from clients and efforts by the Dream Programme to do more, it was suggested that the neglected diseases, including non- communicable diseases, would erode the gains made in HIV and Aids interventions.
Dream now bears a wider meaning, Disease Relief Through Excellent and Advanced Means (Dream 2.0). With Dream 2.0, there is more focus on obesity which leads to cardiovascular diseases.
“Over-nutrition is as important as under-nutrition which poses the great threat to an individual’s health yet it is usually overlooked. So the training also focused more on over-nutrition,” Tembo concluded.
On a warm summer’s day, Ak. is seen leaving his neighbourhood smiling and greeting everyone he knows: “I am going to school! Hooray! I am going to boarding school!”.
Ivy and Maureen went to pick him up early in the morning to take him to a residential school that an Italian family has provide for Ak.
He still cannot believe it. Up until last year he couldn’t go to school, he didn’t have anything to eat, he didn’t have money to pay for transport to the DREAM center…
He is one of the many teenagers currently being treated at DREAM centers. For over a year now Ivy and Maureen had been noticing that his treatment was no longer effective, that he wasn’t taking his medication properly and didn’t attend his check-ups, so they decided to investigate the situation.
Fatherless and abandoned by his mother who suffered from severe mental illnesses, he lived for a period with his aunt up until he was accused of being a child-witchdoctor and of causing his father’s death, and was sent away. He became one of the many street children that roam the urban centers of Malawi. Many attempts to have him live with a few relatives were made with the help of the DREAM operators, but after a few months he would again be sent away, suspected of being the reason behind the family’s ills, scarce rain, diseases or economic problems. He was told: “it would be best if you died and ended up in the cemetery with your father”.
Maureen, one of the coordinators of the DREAM center in Blantyre who never ceased to look for solutions, managed to get help from sister Matilde: she gives him something to eat at the end of the lessons, sometimes accompanying him to his check-ups and helping him with his medication.
Teenagers are amongst the most difficult patients. After an initial success during their childhood, therapy often stops being effective due to scarce adherence.
Almost a thousand teenagers are being treated in the DREAM centers in Malawi. Many are orphans, but even having a careful and supportive family doesn’t make persuading them to regularly attend therapy any easier.
Adolescence is a difficult age under every aspect. You become aware of yourself and you begin planning your future, which isn’t easy when your life has been scarred by AIDS since birth. Many questions pile up in the teens’ minds. How will my life be? Will I be able to marry, have children? Why should I bother studying if I am sick? Will I have to do therapy for the rest of my life? These are complicated matters even for an adult, and can be daunting for a teenager, especially when lacking emotional and social stability.
This is often hard for parents or relatives, who do not know how to talk with their children about their disease. Mothers usually feel guilty of having transmitted the virus to their children and, due to ignorance or a feeling of inadequacy, avoid a serious conversation where they explain why daily therapy is necessary.
It is easier dealing with children, as a simple excuse can suffice such as “…this medication is for the anemia…” or “…to prevent malaria…”. With teens it is harder.
Oftentimes the teens find out about their condition by chance, it could be from a classmate who notices the regular and frequent absences due to the medication and begins teasing them.
In countries where HIV is endemic, adherence to treatment remains an open challenge for all teens. For this reason the DREAM centers in Malawi have begun addressing the seropositive teens’ situation directly to offer them better support.
Following a few lessons with personnel about the various aspects of adolescence, a specific analysis of all patients aged 10 to 17 was carried out. An investigation followed, verifying if each teen had been informed of their situation and if so, how. Subsequent meetings were organized to help and educate the parents or legal guardians on how to talk to their children about the diagnosis.
For example explaining that universal access to treatment was not available during the pregnancy and stressing how the parents have always looked after the children, taking them to the hospital for treatment and helping them grow, contributed to reestablishing trust between adults and teens.
For the most complex cases, showing an increase in viral load after years of good health following the therapy, the decision was to carry out a targeted intervention with the assistance of an activist as a reference point, with frequent visits to the home put in place in support of the whole family.
Next, the “Saturdays for teens” began. Part of the health personnel of the DREAM centers volunteered to dedicate the last Saturday of each month to the inauguration of the center, creating a special day of activities for the teenagers. This has a very positive impact on them as they no longer have to skip school (there are no lessons on a Saturday), and being surrounded by their peers makes them feel at home.
On a Saturday the situation is completely different: hundreds of boys and girls “seize” the centers. From very early in the morning until closing hours kids can be seen playing chess, soccer, talking amongst each other, snacking together and participating in health education meetings organized by the personnel.
Feeling part of a group is very important at this age. It can give strength, courage, enthusiasm and will to live. Sometimes older kids who were once teenagers of DREAM are invited on a Saturday. Their story is an example of success, both socially and therapeutically. Kids such as G and F who have recently married, with G now working as an electrician in an important company of the country.
The more “Saturdays for teens” organized, the more boys and girls started coming back to the center, even when they didn’t have medical checkups. They realized they weren’t alone in the challenge against the virus, while making friends along the way. The group also helped take care of children coming from impoverished social situations such as Ak.
Being together as part of a group and having a family who embraces you leads to new perspectives and opportunities to make new friends, such as T and R. They both had long hoped to take a trip and see all the animals roaming the Malawian Savannah. And just like that…chipping in for a few months to pay for the transport fees to the Chickwawa wildlife reserve in the south of the country…preparing sandwiches for lunch…a little help in obtaining preferential access to the reserve and…on 4th November 2017, 75 kids took a trip to discover their country, which tomorrow will surely be a better place, also thanks to their contribution in building a more humane and inclusive society.
Women around Phalombe district have been told the importance of going for screening for cervical cancer, which is one of the deadliest diseases in the world.
A week long campaign has been launched in the district and is expected to run from 6th to 10th November 2017 with support from Disease Relief through Excellent and Advanced Means (DREAM).
The organization’s National Coordinator for Cervical Cancer Dr Hawa Mamary Sangare told Malawi24 on Saturday during the launch at Nazombe Primary School ground that it is important for women to go for screening since cervical cancer is a dangerous diseases.
“It is alarming in all the districts here in Malawi, we saw that there is need to go step by step and here in Phalombe we are helping the district health office to screen women,” she said.
Meanwhile, Phalombe District Health Officer (DHO) Ketwin Kondowe has said they are expecting to screen many women during the campaign.
“We are very optimistic that more women during the campaign will be screened in all the eight centres we have put in place.
“Cervical cancer kills but if the woman is screened earlier and she has signs and symptoms of it then she can be helped in time,” said Kondowe.
Meanwhile, Senior Chief Nazombe has commended DREAM for the initiative saying this will help women not only from his area but most parts of the district to know their health status.
“Let me thank DREAM for coming up with this initiative on screening cervical cancer, our women here will really be helped,” she told this publication.
Nazombe then asked women to flock to the centres in large numbers during or after the campaign since this is very vital to their daily lives.
In Phalombe the campaign will be done in centres within three Traditional Authorities namely; Nkhulambe, Jenala and Nazombe. Women in the reproductive age group of 15-45 are those expected to go for screening in the selected health centres. DREAM is a global health care which aims to lessen non-communicable and communicable diseases.
The role of Laboratory diagnostics in HIV and Co-Morbidities Management in the Era of Global 90-90-90
Over the course of August the first open day of the DREAM center “Elard Alumando” took place in Mandala, Blantyre. Malawi’s Minister of Health Atupele Muluzi was present, as well as many partners and collaborators of the DREAM Program in Malawi.
The day was an occasion to demonstrate to all of the stakeholders of the DREAM Program its main activities and the available resources (both in terms of equipment and human resources) which it can provide for the country and its partners, as well as the results that the Program wishes to achieve in the near future.
For years now DREAM has operated in Malawi, especially in the fight against HIV/AIDS, and has recently broadened its scope to other diseases such as cardiovascular diseases, cervical cancer, diagnose and treatment of tuberculosis, hepatitises and other non-communicable diseases.
With the August event the wish was to show how the Program can contribute to the effort that the whole country is undergoing to improve the health of its citizens. At the same time, the event was an occasion to inform the participants and create a public debate on a few particular topics such as the role of the laboratories in the 90-90-90 strategy, the topic of resistances to HIV and the role of the laboratories in the treatment of hepatitis.
Over the course of its 12-year activity in Malawi, DREAM has contributed in various ways to the fight against AIDS, but one of its fundamental contributions was the development of a network of molecular biology laboratories. Therefore central to the event was the topic of diagnostics and their role in facing the existing challenges. For this reason, all of the guests showed great interest during the visit to the laboratory, led by its manager Dr. Richard Luhanga.
In one of his first official visits to the healthcare facilities of the country, the newly-appointed Minister of Health showed particular interest in the fact that the event, which took place in a health center and not in a conference room, allowed for a humane interaction with the staff of the program. Therefore not only the healthcare personnel such as lab technicians, doctors and nurses, but also the patients and the expert clients, beating heart of DREAM’s activities. In his speech he also mentioned the will of the country to stay ahead in the innovation sector, and do so together with partners such as the Community of Sant’Egidio and the DREAM Program.
Furthermore the event was a precious occasion to strengthen the relations with the main organisations active in the health sector such as UNAIDS, UNICEF, the CDC, the Clinton Health Access Initiative and the national cooperations of various countries.
On 19 June 2017 at the “Giovanni Paolo II” Nutritional Center the first Community Vegetable Garden opened, promoted by the Community of Sant’Egidio in collaboration with Slow Food.
The project was made possible through the Sichem and Efraim Communities of Olgiate Olona, a town in the Italian municipality of Varese, which organized on 29 April a master class for charity: “4000 meatballs for Malawi”, together with a Malawian biologist from DREAM.
This pilot garden in the area of Machinjiri represents a concrete and sustainable solution for aiding the families affected by the economic challenges and food emergency.
This new adventure began with a 2-day training course held by two representatives of Slow Food in Malawi. 15 people participated of whom all, by cultivating the land, will be able to support their families and improve their living conditions.
On the first day of the course theoretical elements were covered, while on the next day the ground for planting was prepared.
The partnership between the Community of Sant’Egidio and Slow Food will allow to reach this goal of social value in a “Good, Clean and Right” way: slogan of the Slow Food association, which has been active in Africa for years now, working towards the development of food gardens through the “10,000 gardens in Africa” campaign.
Particular attention will be given to maintaining the biodiversity of the crops, giving value to the local species of fruit and vegetable and avoiding the monocolture of maize, partly responsible for the food crisis, as it requires a lot of water to grow.
Furthermore no chemical pesticides or GMO seeds will be used, but instead natural methods of fertilization and safeguard of the local plants and seeds, which are selected through the expertise and knowledge of the local farmers.
The team, composed of people who all led different lives and experiences and start now as farmers, began working with enthusiasm and unity of purpose.
The name selected for this garden is: “Mbeu kwa Ufulu”, which means “Seeds of Freedom”.
Freedom from pesticides and GMO seeds, freedom for the men and women of this marvelous country, stricken by hunger and hopelessness.
Seeds of freedom in view of a better future beginning from an invaluable treasure: the African continent and its people.
Between 20 and 27 April a campaign for the prevention and treatment of cervical cancer took place in the district of Blantyre, Malawi. The event received widespread support by the media and the local population.
We met with Dr. Hawa so as to learn how the initiative unfolded and ask her to explain its results and the coming challenges for the future.
Cervical cancer is very common in Africa, particularly amongst HIV-positive women. It can be prevented through vaccinations (routine in western countries, but not yet implemented in developing countries due to associated costs) and is easily cured if diagnosed in time through a simple screening process.
Q: Good morning, could you briefly introduce yourself and tell us about your role in the Dream Program of the Community of Sant’Egidio?
A: My name is Sangarè Hawa Mamary, I am a doctor and have been working with the DREAM program in Malawi since 2010 at the Elard Alumando Center in Blantyre.
My work at DREAM consists of various activities: I visit and treat the HIV-positive patients and in particular I manage the vertical prevention program to impede the mother to child transmission of the HIV virus (PMTCT). I dedicate myself to pregnant women and their children born in the program, which are all essentially HIV-negative, but whom we follow until their second year of age.
Furthermore I monitor and supervise the district’s healthcare facilities where DREAM supports and collaborates with the Ministry of Health on matters such as HIV and early child diagnostics.
Another aspect of my job is training the activists (Expert Clients). They are patients we select and train in order to follow the newly arrived women who enter the program through Home Care and a detailed health and food education program.
I am also DREAM’s National Manager of the health programs for women and particularly for the prevention and treatment of female cancer. In our center we carry out cervical cancer screenings through a visual inspection of the cervix, using acetic acid (VIA).
Q: How widespread is cervical cancer in Malawi and what are the possibilities of treatment and prevention?
A: Cervical cancer in Malawi represents 45% of all types present. In 2010 the HPV Center of the World Health Organization estimated that every year in Malawi 3684 women develop cervical cancer and, due to the lack of efficient programs, many die. Unfortunately the diagnostic and treatment centers are scarce and present only in the main cities.
Q: What are DREAM’s efforts in fighting cervical cancer in Malawi?
A: Our program is mainly based around prevention and treatment. We work together with partners such as the Ministry of Health and use the SVA – single visit approach through the VIA (visual inspection of the cervix) and immediate cryotherapy when needed. This is an efficient and practical method approved by Malawi’s Ministry of Health and many African countries. Furthermore DREAM, in collaboration with Norwegian Church Aids, supports the National Health Service by training medical personnel, supervising and supplying materials and devices required by cryotherapy in the districts of Mangochi and Balaka.
Q: When and why did you begin working on the prevention and treatment of female cancer?
A: We started the program in February 2016. This idea came to be together with the new approach of the DREAM program which in 2016 became DREAM 2.0.
The idea is to consider the global health of our patients. We immediately noticed the high prevalence of cervical cancer amongst HIV-positive women and realized that the existing services were not able to reach every woman.
Q: How did the idea of dedicating a special week to this campaign come to be?
A: The idea of the Campaign is the result of having participated in a meeting discussing the implementation of screening tests in the district of Blantyre. During the encounter it turned out that most of the rural health centers were not able to carry out screenings. For this reason we asked various partners to work with us in the district of Blantyre and we organized mobile clinics to carry out screenings in the rural areas.
Q: Who collaborated in planning the week?
A: The list is very long. First of all we met several times with the District Health Officer (DHO) of Blantyre, the various managers of the different health sectors, the village chiefs and the Traditional Authorities of the local area, as well as the personnel of the rural health centers. Their agreement and cooperation was necessary for the success of the event.
Q: What was the week’s schedule?
A: The opening ceremony took place on 19 April at the Health Center of Chileka. The next day we began the screening activities which lasted up until 27 April. The intervention was always preceded by health education lessons in order to explain the importance of periodically undergoing prevention and favor the spread of this message.
After the lessons the screening was carried out.
We operated at 9 sites: Chikowa, Dziwe, Chileka, Chimembe, South Lunzu Machinjiri, Lirangwe, Makhata, Lundu and Ndeka. All HIV-positive women found were directed to the two reference sites for treatment, the Queen Elizabeth hospital and the DREAM Center Elard Alumando.
Q: What was the fixed goal and how many women were examined?
A: Our goal was to reach 1500 women over the course of the campaign. Actually during this week 2731 women underwent screening tests (182% more than our initial predictions), with 52 resulting positive to the VIA test (2%) and treated with cryotherapy, while 10 women showed signs of stage 2 or 3 cancer and were directed to surgical treatment (0,3%).
Q: Why do you think that health education and this campaign are important?
A: Health education and the campaign we carried out are important because they raise awareness in the community to the health risks. They allow, thanks to an early diagnosis, to intervene on the disease before it manifests through its symptoms and becomes hard to treat. This is particularly important in countries with limited resources such as Malawi.
Furthermore it helps the people change their lifestyle and avoid a risky behavior. Over the course of the campaign we realized that many people never underwent a screening test due to the lack of information on how this type of cancer develops and how it can be treated.
Q: What were the people’s reactions and comments?
A: The women were happy and grateful for the occasion. Due to the high demand we raised, we decided to offer two more days of screening at the DREAM Center Elard Alumando. On the last day of the campaign every site was full of women. We received requests to repeat the event and many women will come over the next few weeks to our center to benefit from the prevention routine that we offer twice a week.
Q: How did the health institutions and the donors react?
A: The District Health Officer welcomed the campaign with enthusiasm and a few news outlets publicized the event free of charge. The red cross offered its tents for the duration of the activity. Total Malawi supported us on the purchase of a few materials required for screening.
Q: What are your plans for the future and how do you intend on moving forward with the project?
A: This year we managed to cover 9 areas and reach many women, and many more will continue to visit us over the next few months.
Next February (as is known, 4 February is World Cancer Day) we plan to repeat the mass screening process in more rural areas. Furthermore we would like the next campaign to last 4 weeks.
It is also fundamental to build other centers that are able to autonomously carry out the VIA. It is useful to equip mobile clinics in order to reach the most remote rural areas and it is important to provide the population with quality health services. One of our dreams is also to administer the HPV vaccine to teenagers. To fulfill our plans we must trust in an increased support on behalf of companies, non-governmental organizations and provate donors. Naturally we will continue, as always, to carry out routine screenings to whoever visits our centers.
Q: What were the main challenges in realizing this activity?
A: I would say that the first challenge was to raise awareness amongst women, especially in the rural areas. It was a success anyways, and in some cases we carried on with the activities until late due to the high number of patients present.
Another problem was the short duration of the campaign. It attracted many women that wanted to undergo screening, and with adeguate resources we could have extended its duration.
Notwithstanding this we demonstrated how it is possible to achieve much more. In just seven days we visited 52% of the total number of women visited in Blantyre over the course of 2016.
Q: Thank you, would you like to add anything else to this interview?
A: Yes, I would. In particular on behalf of all the women who live in rural areas I would like to thank the Community of Sant’Egidio for having made this campaign possible and having amplified DREAM’s coverage also to the prevention of cancer in women. I would like to thank as well the various news outlets for their role in encouraging and mobilizing the women. I am also grateful to the public health institutions and all the donors and operators that supported our activities. And also thank you for this interview.