They say “when in Rome, do as the Romans do.” This past week, while on a field visit to several of health facilities in the Southern Region district in Malawi, I tried to do just that: eat as Malawians eat.

For the first night, I had a heaping serving of white rice accompanied by three cubes of beef in stew and a few spoonfuls of leafy green rapeseed. The next morning, for breakfast, I had a large portion of rice porridge, two large cups of white rice caramelized in sugar. For lunch, I had two large matanda (pats) of the staple nsima – a thick, maize porridge that is eaten by hand, accompanied again by beef stew and rapeseed. I noticed that I was feeling sluggish and needed  some more vitamin-rich food in my diet. I also noticed that one of my colleagues cleared all three matanda of nsima but left his greens, which I  kindly offered to eat for him. For dinner, I had an entire plate full of chips, the equivalent of at least four deep-fried sliced potatoes. I enjoyed the banana given after the meal and requested a bowl of greens to go with it, in hopes of improving my clogged digestive track. The cycle continued the next day. In my attempt to “do as Malawians do,” I even had a cup of the thick, local, maize beer called Chibiku (also known as Shake Shake). I was extremely skeptical when my co-workers told me how nutritious this fermented liquid porridge was but enjoyed it nonetheless.

By Day 3, I was dehydrated, tired, and sluggish. I skipped breakfast altogether while the others enjoyed the bowl of rice porridge. By lunch time, I did something very unusual; I requested only a bowl of masamba ambiri (lots of cooked green, leafy, spinach-like rapeseed). No carbs. No protein. Just green, leafy goodness. Even with the few words of Chichewa I understand, I gathered that the restaurant patron couldn’t believe that was all I was going to eat. When I asked how much my meal would be – expecting to  pay something similar to the 250 kwacha ($1.50) I’d been paying all week –  her answer astonished me. “How much should you pay for these vegetables? Vegetables?! Ah – you can have them for free.” A meal that I gladly would have paid 1000 kwacha for had no value to her.

The issue of nutrition is something that has struck me here in Malawi. The value of the meal is placed in the starch (nsima, rice, or potatoes), followed by an often fatty protein (beef, chicken, or chambo – tilapia), and possibly accompanied by a small portion of relish such as rapeseed, pumpkin or sweet potato leaves, or beans. But this is not because vitamin-rich vegetables are expensive or unavailable; today I bought three bundles of spinach, six tomatoes, three bell peppers, three onions, two eggplants, and two big carrots for approximately US$2!

A friend named Mya, an agribusiness economist here, had a theory on the lack of value placed on what we know to be “nutritious” meals. He identified four primary categories that he believes contribute to the current diet, and after reflecting on his categories, I’ve expanded below:

1. Income: according to the World Food Program, 40% of Malawians live on under US$1 a day. Poverty affects a majority of Malawians and has a significant impact on the food decisions that people make.
2. Food insecurity: defined as a situation in which food is difficult to get, this is often an issue of money, cost, and proximity to food sources. Malawi is an agricultural economy, with this sector accounting for one-third of GDP and 90% of exports. Additionally, 80% of Malawians live in rural settings where goods farmed are often produced for export rather than for personal use.
3. Knowledge and Education: only 63% of Malawians are able to read and write, highlighting the problem of education. Education is a powerful tool where people can be exposed to the value of a nutritious diet and how to achieve it.
4. Culture: Malawians love nsima; they love large portions of white rice and slices of starchy fried potatoes. These foods are not just something to eat; they are integral parts of the Malawian experience. And as was recently posted on The Malawian Beat, suggesting a change in the diet “means losing some of your cultural identity.”

The importance of knowledge and culture in understanding nutrition is a very thought-provoking notion, particularly in thinking about a way forward. My supervisor insists that “you haven’t eaten today if you haven’t had nsima,” and his perspective was developed from within in this culture. I’ve heard trained nurses and public health specialists insist on the nutritional value of Malawi’s maize-based dishes, despite that my own medical knowledge (albeit limited) suggests the opposite. Simply telling a Malawian that he or she should eat more vegetables because “it’s good for you” may not be enough to shift a mindset based on several generations.

This experience is not unique to Malawi. When I spent six months in Senegal, I remember desperately seeking fresh fruit and vegetables. In Kenya last summer, I could never finish the portions of meat and carbs that comprised every meal. And when I was in Nigeria last November, I constantly requested extra portions of vegetables to accompany the filling portions of yam-based fufu, meat, stew, and fried plantain I ate frequently.

And it’s not unique to just nutrition either. My experience in HIV prevention, treatment, and care over the past eight years has revealed that what may appear to be simple solutions – such as using a condom to minimize transmission or taking antiretroviral medications to slow the progression of the disease – sometimes challenge common cultural practices and beliefs. I can’t say for certain yet but these may be some of the challenges contributing to high incidence and illness from HIV in Malawi.

I have always been a strong proponent of the importance of cultural competency in health policy and programming, an idea that I was surprised to find little support for during my time at the Harvard School of Public Health. But my lesson in “the value of masamba” reminded me that policies and programs that do not resonate within a culture will never be successful on the scale needed to lead to improvements in health and well-being. In tackling the problem of nutrition, HIV, and health more broadly in Malawi or any community, we have to remember that focusing on money and accessibility is not enough. Problems of health and development are also rooted in culture, and knowledge that has been passed down as a result of shared beliefs, values, and experiences. Until more initiatives understand this and encourage solutions from within the culture, I’m not convinced that we’ll see sustainable and promising improvements.

Launched in September at Michigan Technological University (MTU) with the Michigan Organization of Residence Halls Associations (MORHA).

Charity:Water and SCOUT BANANA believe that access to clean water is a basic human right, and this year, 2007, we are doing something about it. Charity:Water was founded in 2006 and since has provided people with clean drinking water through construction and rehabilitation projects on wells. Through on-the-ground organizations Charity:Water has built 158 wells in five African countries that will give close to 100,000 people clean drinking water. SCOUT BANANA is an organization dedicated to providing access to basic health care. Access to clean water is extremely important to being and staying healthy as 80% of all sickness is due to unsafe water. In Michigan, we take for granted that we are surrounded by the world’s largest source of freshwater. The Great Lakes hold enough water for each of the 300 million people of the US to have 19 million gallons of water. Between 2000 and 2004, Michigan increased its water use by 1 billion gallons per day (gpd), to almost 11 billion gpd, or 4 trillion gallons per year, with 81% being withdrawn by power plants. This is enough to cover the entire land area of Michigan with 4 inches of water. 89% of water withdrawn in Michigan comes from Great Lakes sources. The remaining 11% comes from inland surface and groundwater sources (DEQ 2004 Report). There is a term in water management known as “unaccounted for” water. This is treated water that leaks from faulty pipes and is completely wasted. This water, ready for usage, that leaks from pipes every year in Detroit alone would be enough to give every person in the combined countries of the Central African Republic, Ethiopia, Liberia, Malawi, and Uganda with 297 gallons of treated water. (www.uswaternews.com, August 2002). In Africa just $20 can give a person clean water for 20 years. The estimated cost of the leak is $23 million worth of water that never reaches homes and businesses, this could provide over one million people with the clean water they so desperately need.

Charity:Water Facts
• Over 1.1 billion people on the planet do not have access to clean drinking water.
• 42,000 people will die this week from disease related to poor drinking water. 90 percent of them will be children under age 5.
• A child dies from unsafe water every 15 seconds.
• 80 percent of all sickness on the planet is caused by unsafe water and lack of basic sanitation. It kills 2.2 million people every year. That’s more than all forms of violence, including war.
• Millions of women in developing countries walk 3 miles every day, to get water is likely to make them sick.

Bobi, Uganda
The first six wells built and rehabilitated by Charity:Water were in the war-torn region of northern Uganda. In the village of Bobi, 31,000 people now have access to clean water. Here is the story from Charity:Water founder, Scott Harrison.
“20 years of war displaced nearly two million people in Northern Uganda. Seeking solace from Joseph Kony’s rebel soldiers, they gathered in camps for safety. Bobi is the largest IDP (Internally Displaced Persons) camp in the Gulu Province. When I visited in August, I found 31,638 people living there. They drank from only one working well. On October 24th our partners on the ground in Northern Uganda used those contributions to begin work in Bobi. The rehabilitation of 3 broken hand pumps and 3 newly constructed wells were completed in November. Water committees were formed and trained to maintain the new water sources. The wells have transformed the lives of the 31,638 men, women and children living there. Bobi, one of the most hopeless and depressing places I’ve ever visited in Africa, now looks to the future with hope and health.”

Uganda Facts
(CIA, The World Factbook)
• Slightly smaller than Oregon with a population of over 30,250,000.
• Life expectancy at birth is approximately 52 years.
• The high rates of HIV/AIDS have significantly increased mortality, impacting life expectancy and population.
• There is a very high risk for contracting waterborne diseases including: bacterial infections, hepatitis A, and typhoid fever.
• 35% of the population lives below the poverty line with average income at $1,500.
• The country hosts over 250,000 refugees from Sudan, the DRC, and Rwanda, along with 1 million internally displaced peoples (IDPs).
• Agriculture employs 80% of the workforce. The major export of the country is coffee.

To Fetch A Pail of Water
Of all the water on earth, 97.5% is salt water. The remaining 2.5% is fresh water, 70% is frozen in the polar ice caps and the other 30% is soil moisture or lies in underground aquifers. In all, less than 1% of the world’s fresh water is readily accessible for direct use. Moreover, there is a natural inequity in resource distribution that allows some countries to be rich in water, while others struggle.