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MAL 3 Written Evidence Submitted by Michael King O.B.E. F.R.C.S – Chief Government Surgeon in Malawi 1976-94, Volunteer Surgeo

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MAL 3 Written Evidence Submitted by Michael King O.B.E. F.R.C.S – Chief Government Surgeon in Malawi 1976-94, Volunteer Surgeo MAL 3 Written evidence submitted by Michael King O.B.E. F.R.C.S – Chief Government Surgeon in Malawi 1976-94, Volunteer Surgeon in North Malawi 1994 – 2009, and Mrs.Elspeth King Ph.D (London) - University of Malawi lecturer 1980-94 1) CONDITIONS under which the UK could provide development assistance to MALAWI British Aid to any country should be conditional on Budget Transparency and on the protection of Civil Liberties by Government. Malawi is no exception. DFID should now prioritize (1) Universal Family Planning, the provision of Basic Health Services for all the Rural Poor, and providing drugs for curable diseases (2) Private Sector development. British Aid should terminate (1) Budget Support, (2) Support for fertilizer subsidy (3) Funding for HIV/AIDS. Britain should require Malawian health staff in UK to return to work in Malawi and provide incentives for them to do so. THE DEVELOPMENT SITUATION in MALAWI Donor Aid has been based on optimistic and politically correct ideas from wealthy countries. But this foreign funding has saved Malawian leaders from addressing the causes of the deteriorating plight of their people. Britain cannot solve those problems; that responsibility must now be passed to the numerous educated and professional Malawians – the doctors, nurses, engineers, teachers, accountants, businessmen, lawyers, civil servants, clergy, civic leaders and farmers etc . The President must co-operate with them, and with elected MPs. If he and they cannot manage to perceive all these facts, then disaster will soon come. The problems are huge – but united they must tackle them. 1) MDGs concerning Poverty, Maternal Mortality, Child Mortality, Gender and the Environment A) Population and Land - 85% of Malawians live in villages as subsistence farmers. The human population has increased from 4 million to 15 million in 30 years. With a birthrate of 6 children per woman, sub-divided family gardens have become too small for survival –“from 0.3 hectares of land you cannot grow enough food to feed the family in Malawi”(Oxfam). Donors have not grasped this nettle of over- population, nor have Malawians. Is it immoral for Britain to fund policies which keep people in worsening poverty and malnutrition? Should UK Parliament progress to a demographic conditionality? “Donor policies enable governments to tell everyone their problems are being solved, when they are worsening. The biggest problem here is malnutrition. Food is being distributed now by WFP, but as these big families survive and the local population increases, long term food shortages are becoming worse. NO POLITICIANS in Malawi or in Donor countries will face this……so Malawians are becoming steadily more dependent on foreign aid.” (Scots doctor) Malawian University student: “In Chikwawa district, men with cattle can buy many wives. One man in my Paiwa village has 3 wives and 17 children By begetting large families, my Sena people in the Lower Shire Valley are digging their own graves…. our land is desertifying. Malawi should at least strive to achieve a low birthrate.” “Soil fertility declined in 1990s, most farmers produce only enough food to last 4 months” Action Aid Report 2002 Projects to prevent measles and diarrhoea may save some lives but, with a high fertility rate, they may also increase the widespread malnutrition. This is the predictable result of infant survival campaigns without birth control. And, since health cannot be imposed on malnutrition, diseases like TB, pneumonia, malaria and meningitis are now flourishing. Despite major UNICEF programmes, Mzimba district birthrate is still 6.7 children per woman, with population increase of 3.7% a year - with worsening malnutrition, deforestation, soil erosion, and drying rivers. Good rains no longer make up for past droughts here. The water table is now sinking in Mzimba district, causing many wells, village boreholes, and gravity piped systems to dry up. There is no easy solution to Mzimba’s water plight- UNICEF 1997. 1995 UN nutrition project at Usisya, a lakeshore village, with about 30 babies born per week at a small health centre. By 2008, the land is crowded, with degrading sandy soil, and continual famines. Fishermen complain that fish stocks in Lake Malawi are declining. A lady said –“With no birth control in Usisya, we have to go on until we have 12 children!” Should both Donors and Malawians meekly await – and ensure - the next famine? – like East Africa? B) Family Planning Donors assume people want birth control if they are healthy and educated. Probably the converse is true – if men and women can make responsible decisions about sex, marriage and parenthood, benefits to their families will follow. In Malaysia (1967-70) we saw a rapid improvement in living standards of Singapore once Mr. Lee Kwan Yew’s government insisted all citizens must replace old Chinese concubinage with a one wife and only two children policy. This was achieved with tax incentives and very good family planning services. In Chinese culture, the good of society takes precedence over the rights of the individual. African culture is different but the message is the same. “Ana ndi chuma cha mtosogola” – Beget children to increase the crowds at funerals – Malawian Chichewa Song Make Family Planning Services easily available to every Malawian Man and Woman and thus enable them to take charge of their own lives and families – this is real human liberation. A low birthrate is now the only way out of poverty for Malawi. Political support for one-wife marriage and small families is urgently needed to save the soil, trees and rivers which sustain life in Malawi. 80% of Malawians are Christian. As contraception allows a couple to avoid polygamy and live in a faithful Christian Marriage, Catholic Mission Hospitals should be informed that DFID can only support Mission Hospitals with family planning clinics. (But we would not expect Catholic hospitals to perform abortions). All parents want a better future for their children and this is the political justification for universal family planning. Abortion Support is needed for all levels of Family Planning, including the Morning-After Pill and Abortion facilities to reduce the maternal mortality caused by unsafe abortions – there were 70,000 unsafe abortions in 2009 alone causing 17% of maternal deaths. Abortion is still officially illegal in Malawi and now is being re-considered by government. In 1994, a Meeting of SubSaharan African Medical Associations in Malawi recommended that safe abortion should be legal in all African countries. They also advised that HIV-positive pregnant women should be offered termination - because the lower immunity caused by pregnancy hastens rapid progress to full blown AIDS and death. We hope our British Government asks the Malawi Government to give precedence to the advice of the Malawi Medical Profession and the Malawi Nursing Profession about regulations for safe abortion. Religious objections to safe abortion are akin to stoning women to death in Arabia. Family Planning is very well received now – but the service is not adequate for the needs of 10 million Malawian adults - including teenagers. DFID has supported Marie Stopes International and Banja la Mtosogola with its two dozen clinics, based in towns, with staff going on outreach trips to do surgical mini-lap tubal ligations in villages – plus vasectomies. Banja does well, but it charges clients. Extra funds for more Banja clinics would be DFID money well spent. British Aid should now prioritize supporting birth control services in all the overcrowded and understaffed government District Hospitals and Health Centres. As Malawian patients come in huge numbers to these free hospitals, DFID should provide extra Family Planning staff to visit the wards and clinics - to advise and serve all parents of sick and starving children, all ante- and post-natal mothers and maternity patients, and all adult in-patients and outpatients (usually with malnutrition, TB, HIV, malaria, pneumonia, and surgical conditions) – these people may not be in a good situation to bring another child into the world. Rural Health Centres until 1997 were staffed with one Medical Assistant and two Nurses. By 2005 half were closed, and others only opened occasionally – due to so many staff dying of HIV or migrating to UK. Thousands of Malawians lost their local health and birth control services. DfID should fund training programmes to provide enough Medical Assistants, Clinical Officers, Nurses and Assistant Nurses to allow all Health Centres to re-open – with family planning services. DFID should also start a Maintenance Project for Rural Health Centres and staff houses. C) Health Staff Training Doctors are trained at College of Medicine (founded 1991) - intake 60 per year now. A few went to the District Hospitals with 150 beds (and very many floor patients). Now at District Hospitals, they are busy with administration. However Malawian doctors can, and do go abroad, so their skills are lost to Malawi. If they come to UK for further training, most remain here- especially if they have learned technical skills that cannot be practiced in Malawi. Their salaries are higher in UK. Britain should require Malawian doctors to return to Malawi - with extra support. Most of the “doctoring” in rural Malawi is done by Clinical Officers, some managing hospitals with no doctors. The Clinical Officer cadre is an affordable grade and often very competent. Most of the surgical operations, including trauma and orthopaedics, and Caesarian Sections and tubal ligations, are performed by Clinical Officers (not doctors).Clinical Officers have been trained at Lilongwe College of Health Sciences - there is also a lower grade of Medical Assistant with two-year training. Both these grades do not have internationally recognized qualifications so they stay in Malawi. British Aid could raise standards of health care delivery across Malawi by financing these paramedical training courses. a) Improve the training and increase the numbers of Clinical Officers .
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