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Story Publication logo August 26, 2013

A View of Life on the Brink in Rural Malawi

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Malawi
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Access to Health Care in Malawi: User Fees, Politics, and Historical Memory

While the debate over health user fees has been raging in international development circles for...

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This picture, taken during the reign of President Hastings Kamuzu Banda (who ruled from independence in 1964 until the first multiparty elections in 1994), shows the ideal of agricultural plenty. The silos are used to store a family’s maize, Malawi’s staple crop. From one May harvest to the next, this store of maize is drawn down to feed the family. Here the government shows a family with a bountiful harvest at its time of plenty, but for many in Malawi, this level of security is not easy to come by, or to maintain. The pictures that follow were taken in July 2013, along the dirt road that leads from the hills of Nsambe to the nearest government hospital, 13 miles away in Neno. Image by DM Arnall. Malawi, year unknown.
During the dry season (May-October), farmers in the highlands of Malawi use the rich, damp soils in the valleys between hills to cultivate Irish potatoes and other crops. If the harvest is good, a family can use these foodstuffs to ward off malnourishment during the hunger season (January-March) before the annual maize harvest is ready. But in years like 2013, when cold nights have frostbitten the leaves, the yield has been pitiful. Farmers are already worried about a particularly brutal hunger season come January. Image by Luke Messac. Malawi, 2013.
Shortly after the harvest each May, small-time traders will offer to buy maize from farmers in exchange for much-needed cash to buy clothes, pay school fees, and purchase other basic goods. Often the traders will simply store the maize close by and sell it back to the very same people when hunger season arrives in January at markups of 100 percent or more. On this sign, a trader offers to buy maize for 100 Malawian kwacha (approximately $0.30) per kilogram, or 2,000 kwacha for a tin pail (about 20 kilograms). The government has tried to discourage smallholder farmers from selling crops like maize that are intended for consumption, but villagers in need of cash have continued to turn to the practice. Image by Luke Messac. Malawi, 2013.
In an effort to find income beyond bare subsistence, some rural Malawians cut down trees to sell by the side of the road. Here, in rural Neno district in southern Malawi, villagers sell ironwood, which is commonly used to make charcoal. Professor Wapumuluka Mulwafu, an environmental historian at Chancellor College in Malawi, explains that deforestation has led to topsoil runoff and siltation of rivers and valleys, which renders farmland less viable. But in times of struggle, the need to eat overwhelms such long-term considerations. Image by Luke Messac. Malawi, 2013.
Charcoal is the primary energy source in rural Malawi. Specialists in villages make charcoal by slowly burning wood buried underneath the ground. The near-absence of oxygen helps make good charcoal. After a few days, when the charcoal is ready, it is broken into pieces and sold in bags by the side of the road. The sale of charcoal is illegal in Malawi, but the law is very loosely enforced. Without subsidies for kerosene or other less environmentally harmful energy sources, Malawian peasants have no other choice. Image by Luke Messac. Malawi, 2013.
Villages of thatched-roof huts are found every few kilometers along the road from the mountain villages near Nsambe to the government hospital in Neno. Transport options are scarce here. Bicycles are a common mode of transport, for those who can afford to buy or rent them. Many elderly Malawians in Thindi report having lived and farmed in this area their whole lives. Image by Luke Messac. Malawi, 2013.
A buckled bridge on the road to Neno. Broken for the past six years, this ruin still serves as the the easiest route for locals to cross the river below. Image by Luke Messac. Malawi, 2013.
The Mufelanji clinic is a private establishment just off the road about a mile from the government hospital in Neno. Though it remains open, the clinic has not been heavily frequented since Neno hospital was rebuilt in 2007. Yet the name Mufelanji is illustrative of the goading that private doctors do when asking patients to trade scarce funds for the chance at a cure. Mufelanji Chipatala, translated directly, means “The why-should-you-die hospital.” Image by Luke Messac. Malawi, 2013.
The government hospital in Neno underwent massive renovations in 2007. The two-story structure behind the current outpatient department was entirely new. Today new maternity and gynecology wards are under construction. The hospital is commonly known as “Clinton’s,” as it was built with money raised by former President Bill Clinton’s foundation. Since 2007 Partners In Health, a Boston-based NGO, has provided financial support and staff to the hospital and other health activities in the district. Image by Luke Messac. Malawi, 2013.
People gather in anticipation of a campaign rally in Neno featuring Peter Mutharika, former law professor at Washington University in St. Louis and younger brother of the late former president Bingu wa Mutharika. Peter Mutharika is a likely candidate for president in the May 2014 elections. A particularly fawning news report claimed that the president’s willingness to “brave” the rock-strewn dirt road to Neno was a “symbol of humility.” The rally drew a large crowd, but not all interviewed after the rally said they would vote for Mutharika. His late brother remains popular with many for a fertilizer subsidy that helped boost maize production, but late in his rule shortages of fuel and foreign exchange sparked protests in urban areas. Image by Luke Messac. Malawi, 2013.
Though it is one of Malawi’s poorest and most remote districts, Neno is no stranger to foreign investment. This clearing will soon be the site of a rail line carrying coal from nearby Mozambique to the coast. In return for the concession of land for the rail line, the Australian mining company Vale agreed to pay the Government of Malawi $8 million per year. In recent months, local authorities in Neno have expressed concerns that MotaEngil, the Portuguese company contracted by Vale to build the railroad, is not employing enough Malawian workers and has not followed through on a pledge to build a health center. Image by Luke Messac. Malawi, 2013.
This final picture is not along the road from Nsambe to Neno, but will have much to do with the area's future. Pictured here is the coal basin in Moatize, three hours' drive away in neighboring Mozambique. Geologists believe this basin, discovered in 2008, has enough coal to fire all the coal plants in the United States for 25 years. The mining company Vale is now working to build enough rail lines to ship mountains of mined coal to the coast for export. One of the planned rail lines will run through Neno District in Malawi. Image by Luke Messac. Mozambique, 2013.

To better understand the importance of free public health care facilities in rural Malawi, it helps to see how precarious life there can be. These photos, taken along the well-trod path from the mountain villages of Nsambe to the nearest government hospital over 13 miles away in Neno, show the lengths to which people must go to eke out a living in rural Malawi.

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