13 December 2014

On the Road

Early morning, and I’m sitting on the patio at Dedza Pottery Lodge, staring at a cluster of thick gray-white clouds hovering motionlessly over the mountain just south of us. In the chill of morning, it looks almost like an alpine scene, wintry, even though it’s January in Malawi.

I’m here with my colleague Katharine, a spunky 29-year-old blond from London, to assess a health program funded by the governments of Germany and Norway. Malawi is one of the poorest countries in the world; nearly three-quarters of Malawians live on less than $1.25 a day, in one of those statistics that is impossible to absorb. We’ve been driving through the countryside for a couple of days now, interviewing staff at hospitals and health centers during the day, and typing up and analyzing our notes late into the night.

The mornings are quiet. Below the veranda is a well-tended garden full of flowers—bright reds and yellows, pale pink roses. A gardener in blue coveralls is pushing a wheelbarrow across the lawn, and at the next table, a father and son on holiday are discussing their plans for the day, while Katharine reads Bridget Jones on her kindle and sips some tea.

I woke up this morning out of a strange dream. Blurry images of my childhood; family in a dark, slanted landscape. Couldn’t remember what the dream was about exactly, but I could feel the images inside me when I woke, crawling around like spiders.

Summoned by Johanne, our driver, we pack up our computers, water bottles and cans of Pringles, and load into our Toyota Hilux. Twambilire, our colleague from the Ministry of Health, is already in the back seat, checking messages on her phone. We pick up Mabvuto, another colleague, and we’re off, heading southwest to Katsekera.


The road to Katsekera is steep and muddy because of the rains. It serves as an international border—on one side of the road is Mozambique and on the other, Malawi, and people cross lazily back and forth, over the invisible line in the grass.

On either side, the land is lush and green, stretching out like a massive yawn punctuated by granite mountains that rise up out of no where, like waves cresting.

Pass by people on the road, some strolling, others striding hastily with purpose. There are women with babies on their backs, men in suits, young guys in jeans and shades, others carrying hoes over their shoulders and umbrellas.

Each of us has an allotted place in the car. Katharine sits in the back between Twambilire and I. She’s is as full of energy and humor as a parade, firing off questions, singing along to the music. Twambilire, a 50-something mother of four girls and veteran nurse-midwife, is as cool as jazz; she wears pretty red suits as if they were a second skin, putting me, in my hippie skirts, to shame.

Mabvuto, the chief, as we call him, a big bear of a man in his thirties, sits in the front with Johanne. Mabvuto is the comedian of the team; each morning, he tells jokes. Today, the joke is on Johanne, a self-described evangelist with serious eyes who is in the middle of a month-long fast, which Mabvuto and Twambi find ridiculous. They goad him, say they would never give up food for God. And why would God want that anyway?
Johanne is unmoved, his eyes fixed on the road.

—To cast out demons, Jesus said we should fast and pray, he says evenly.

Mabvuto smiles and looks out the window, Twambilire returns to her phone. After a while, the car gets stuffy and humid, so Johanne cracks the windows, letting in a rush of cool, wet air that smells of wood smoke and the sweetness of the grass outside.


There was debate for several weeks among the team—four based in Lilongwe, an expert in Berlin, two in London, and me in Washington, DC—about what to call our exercise: an assessment, evaluation, a study? Some members of the team wanted to emphasize the non-scientific-ness of the assessment/evaluation/study, and were thus keen to avoid words like “evaluation” because of their (superior?) connotations of precision and generalizability. In the end, we agreed on: “Rapid Qualitative Assessment”.

We developed a conceptual framework and an interview guide, which were reviewed and revised a half a dozen times. Informants and facilities were carefully selected (convenience sample) for Focus Group Discussions. There were meetings and phone calls.

The words we use to describe what we are doing suggest science and precision.

Real life is another matter.


Pull up to the health center 20 minutes late. Get out of the car slowly, groggy from the sedation of the road. There are dozens of women waiting on cement benches outside, many with babies in their laps. The babies’ cries and coos bounce off the cement walls with the buzz of flies and occasional chirp of the bats hanging in the eaves above. Inside it smells of chlorine mixed with the sharp, sour smell of bodies. 

Mr. Kathyoka, the facility in-charge, shakes our hands and leads us to his office. I try my best with a Chichewa greeting, which he pretends is endearing. Mr. Kathyoka is middle aged and wears worn trousers and a button down shirt with the sleeves rolled up. His office is spare—a small metal desk; a couple of wooden chairs; some files piled on a bookshelf. A single window. Lights are off because, like most health centers, there is no electricity.

It takes a couple of minutes for his head nurse and a midwife to arrive. Guilt, because we know that, just like the dozens of other visitors they receive each month from other programs and projects, we are taking them away from patients who have come from God knows how far.

We sit in a circle. Mr. Kathyoka's health center has done well in our program—I have the data in a folder—and we want to understand why. We have notepads on our laps and pens in our hands. The interview guide is there.

We look at each other expectantly. Like at church just before the preacher utters her first word—everyone is locked in, waiting.

—Thank you so much for having us, I start. Tell me about the program.

A pause. It is a good program, Mr. Kathyoka says. It improves services and lives. It helps us see our mistakes.


—And the nurses and midwives, what do your colleagues think?


—They think it is good.

How quickly our questions seem in the wrong order, too direct and impersonal. Outside I hear some boys kicking a ball around; someone sweeping a broom against the cement floor; a radio playing music.

Eventually we coax them into telling us about some of their worries and frustrations about the program. They tell us about missing the deadline to deliver the required reporting information to the district office because of the rains; of district managers who say they will come to visit but rarely do; of quibbles among staff about money; about rumors of witchcraft among villagers suspicious of the program; of broken equipment and delays in getting needed supplies and medicines; of a woman who died in labor on the side of the road.

When we get up to leave two hours later, it is unclear what has been revealed and what has perhaps been concealed. A donor program worth millions of dollars, that brings money and equipment and recognition. Strangers from abroad, passing through for a few hours, people they will never see again, who know and see so little.
The art of interviews is more difficult than is generally assumed.

Towards the end of our interview, when everyone was weary and ready for lunch, I asked if they had any questions for us. There was a pause, then a nurse spoke up.

In a deep, intransigent voice she said: Many other international programs come and go. Will this one stay?

Another pause.


Sometimes, when you’re on the road, looking out the window, you catch someone’s eye by mistake. I don’t like to make eye contact, unless the person is already smiling and waving, because then I feel like a voyeur: watching someone from behind a glass plate, zooming by at 50 miles an hour, a swoosh of air and we’re gone. 

But sometimes you catch someone’s eye, maybe a child who looks scared, about to cry. Sometimes it’s a woman at a vegetable stand with a meek smile, tomatoes piled up in pyramids. Sometimes, it’s a teenager who makes a hip hop dance move, beckoning you to watch, then looks at you with defiance when you turn your head. Sometimes, the face is just blank, or at least it seems blank, impossible to read. A little hard maybe, unamused. 

Sometimes, when I look at peoples’ faces, what I’m really thinking about is my own face—sweaty, didn’t put makeup on today, bad night’s sleep, stomach a bit off, those strange dreams.

My colleagues are talking in Chichewa in the car, laughing. I wish I knew what they were saying. Invisible walls all around. 


We're going to Phimbi health center today. It's a two-hour drive north in the hills, up from Balaka Central Hospital. 

It’s rainy and warm and we have to crawl slowly over roads marked by deep muddy canyons. I'm in the middle seat today, and each time Johanne inches ahead my shoulders and legs knock against Twambi and Katharine.

We arrive late and begin the familiar recital: walk up slowly, over a gravel driveway that crunches beneath our feet. Stares of mothers waiting. The in-charge standing by, anticipating our arrival. Shake hands. Sit down. 

We're ready to begin, pens in hand, expectant faces. One more look at the interview guide, which is dirty and wrinkled, and I start in with some words of thanks for their taking the time to meet with us. 

Then it starts to rain. Not a light, gentle shower, but heavy, relentless columns that pound down against the corrugated iron rooftop like bullets.

The noise is so loud that we can’t hear anything else, not even each other. So we, all of us -- the health workers, the facility in-charge, our little team from Lilongwe -- just stare out at the rain, hands folded in our laps, not saying a word.