Thursday, November 17, 2011

Data Management: 101

Over the last two weeks, as part of a program evaluation, I've been doing  something that sounds relatively simple: data entry. Our individual client records are kept in hard copy form only, and so in order to meaningfully look at how our program has impacted HIV transmission in Malawi, the first step has been to put the data into an electronic version. The steps involved seemed simple enough: 1) collect almost client registers from 50 sites throughout the country, 2) randomly sample tens of clients from each site's register, 3) enter the data into the electronic database. The reality is that I now have a much deeper appreciation for this part of data management!

Counting then number of clients seen at each site

Step 1: collecting the documentation of the data. Because the client registers are used on a daily basis, it's impossible to remove them from individual sites for a prolonged period of time. We asked locally-based staff to make photocopies and send them to our headquarters, which proved more challenging than I anticipated. We then dealt with the additional complication of illegible copies, not knowing which pages correspond with one another, and the list goes on! We started our project two weeks ahead of schedule, and it seems we're now falling two weeks behind....

Step 2: random sampling. Well, this is a fairly complex process that computers have made super easy. Statistical calculations help to determine how many samples you need based on total clients and the level of "power" that you want. Software also helps to generate random numbers, which were necessary for the sampling. I won't bore you with details but this was the easiest part of the process!

Step 3: enter the data. Now the fun begins! It seems straightforward: identify all 100 or so clients required for each site's sample (using the random numbers) and plug their data into the database. But when you're entering 30 pieces of information for hundreds of clients, it starts to become tedious! Then there's the challenge of reading our data recorders' handwriting, understanding conflicting information that's documented, and - of course - making sense of the non-English comments that sometimes appear alongside a client. The other day, I spent more than an hour on the phone struggling to communicate with health workers at a few sites to get clarification on some of their data!

So after two weeks of data entry, my hands are hurting, I have a crick on one side of my neck, and I can say with full certainty that I won't be sad when when this part of the process is over. When I was working on Masters thesis, I thought that the quantitative data analysis component was so difficult, trying to piece together two years and seven quantitative classes worth of information as I analyzed Demographic and Health Services data. But today, after two weeks (and counting) of attempting to enter data to the highest quality in hopes of improving our impact, I have a much deeper appreciation for data entry. I have enjoyed mentoring our assistant data entry clerk and being able to take ownership of this project from the very early stages, but I'm confident that data entry isn't where I see myself in the future. The next time I read an article with the latest statistics on HIV or the hot health topic of the minute, and the next time I perform any type of statistical analysis, I will have a much greater appreciation for the work that went into just compiling meaningful data!

Monday, November 7, 2011

Clothes, my Old (and Now Renewed) Obsession, and the Malawian Textile Industry

In hard times, when "looking within" just isn't working, it's easy to look around you for little things that make you happy. While food (via cooking and self-taught nutrition lessons) has captivated my attention lately, I was recently reminded of one of my first loves: shopping!

Many of the Malawians I've spoken to buy clothing at a second-hand market, where they have every item (in every brand) that you can imagine. And so after weeks of trying to convince someone to take me, I decided to dive in head first, and explore the second-hand market. This past Saturday, my friend Eric and I walked through our favorite vegetable market across a tiny bridge to get the infamous "kawunjika" of Lilongwe. I watched groups of women sifting through piles of clothes, trying to grab the latest fashion before then next woman would. I tried on countless pairs of really skinny jeans and after negotiating down from an initial price of 1500 Malawian kwacha, I settled on a slightly looser pair at Mk500 (just over US$3). I left three hours later feeling very accomplished, and very tired...

As I reflected on my exhaustion, and how I wouldn't have the energy to regularly haggle at the kawunjika, I remembered a very different form of shopping I was recently introduced to.  

From time to time, a saleswoman comes by the office selling something: jewelry, homemade spicy mango something-or-other, office supplies...Two weeks ago, a woman came by selling just what I needed: brand new clothes.

To my surprise, I learned that Malawi has a textile industry. Companies particularly in South Africa and Canada contract with a factory in Blantyre and have their clothing mass produced. I was surprised to learn this, given the hundreds of clothes "Made in Mexico" or "Made in Tawain" or "Made in [insert non-African country]" I've purchased over the years. Malawi's textile industry, I discovered upon inquiry, exists, but is not on the mass scale that other countries have been able to capitalize on.

Could it be, as Sema-Banda wrote a few years ago, that the dwindling cotton industry is the root of low textile export? Or is the "Made in Malawi" brand so little known because exports have been stunted due to competition from the second-hand market? I bought a brand new "Made in Malawi" blouse at Mk1000 (US$6), though I'm told I could negotiate down to Mk300 or less (<US$3) for the same shirt in the market.

Or maybe, as Pereira eloquently blogged about, it's much more complicated than that. There's a history of the textile industry here that must be considered from the 1994 structural adjustment policies (SAPs) that introduced a liberal trade policy, to Malawi's importing of fabric (despite being a cotton producer), to two key elements "private investment and the political will to entice that investment."

My recent shopping adventures have stimulated my curiosity on Malawi's textile industry while reminding me of Dr. Edozie's undergraduate course where we read and discussed "T-Shirt Travels," a story on how the clothes we give away "to charity" in the U.S. actually have significant impacts on developing country's economies. I won't bore you with jargon, but needless to say, I've discovered two exciting forms of shopping that I just wouldn't be able to do in the U.S. My pocketbook needs to take a break but I'm sure I'll have plenty of updates (and several new clothing items) over the coming weeks.

A small-scale version of market shopping: piles of clothes are
left for the buyer to sort through and select. 

The shirt I bought.

Good Times, Good Peoples at Lake Malawi: Salima Style

This past weekend was my third trip to Lake Malawi. Rather than heading south to Mangochi or Cape Maclear again, I and 13 of my friends traveled to Salima. Just an hour and a half away from Lilongwe, Salima is a beautiful, Michigan-esque lakeside town; there were so many trees and such beautiful vegetation that I envisioned the natural beauty of my home state, with a twist of course.

We stayed at a lodge called Safari Beach, which I settled on after contacting at least 15 different venues. The place was beautiful and quaint, as we stayed in two-story family-style bungalows, complete with two balconies overlooking the lake. The food was delicious (which, of course, was essential), and they even had a Saturday night lakeside barbecue with an awesome DJ, just what we needed for a late-night dance party.

What was my favorite part of the weekend? Well, besides the amazing company, the time at the beach, and a late night swimming fest, I really enjoyed the "safari" element of the lodge. There were colorful lizards, no-tailed squirrels, and these cute little rabbit-looking rodents, but the highlights of all the animals were the baboons. They hopped on our decks and thatched roofs, walked in the pathways, drank from the pools, and a big papa even tried to steal my french fries! (Definitely much cuter from a distance).

All-in-all, another fabulous weekend by the lake! I think for the next adventure I'll have to travel north...

Our cute bungalows

The view from my deck

Adorable...when they're little...and at a distance...

Breakfast time!

Lakeside; seems there's a fish market over there

Conference center at the lodge (the baboons loved jumping
on the roof)

The view!

Fun on the beach

Friends hanging out

Went kayaking (and didn't fall in!)

Beautiful landscaping at Safari Beach Lodge

Welcome back dinner (there was no power...)

Tuesday, November 1, 2011

Food Deserts in Malawi?

A buzzword that captured a lot of media attention a few years ago was the idea of a "food desert." Defined by the CDC as "areas that lack access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods that make up the full range of a healthy diet," food deserts are traditionally discussed in the context of developed countries like the U.K. or U.S. whereby communities (often distinguished by geographic location, racial/ethnic background, and/or socioeconomic status) are unable to reasonably access healthy foods [1,2].

Food deserts aren’t something we talk about in the developing world context, but as I think of my situation in Malawi, we're facing a similar issue; it is systematically impossible for certain communities to access a variety of “healthy” foods, which combined with other factors like culture, education, and food security, can significantly impact one’s diet. In particular, foods like low-fat milk, yogurt, or whole grain anything, are expensive and often physically difficult to obtain here. A single-serving of yogurt can cost as much as 220 Malawian kwacha, which is almost enough to purchase a large  meal of nsima, meat, stew, and vegetables that would fill you for several hours. Healthy foods are here but for the masses, they are inaccessible, like a mirage in the middle of a desert.

Food deserts are also characterized by lack of access to fresh fruits and vegetables, such as was all too common in cities adjacent to my undergraduate institution of Michigan State University. In certain communities, the only accessible places were often convenience stores, which carried non-perishable, non-nutritive foods. Here in Malawi, this is not a primary issue. Fruits and vegetables are available in large quantities and relatively inexpensive prices, even by living standards here. But these healthy foods present other unique challenges, creating an obstacle to a nutritious and fulfilling diet. First, to eat them in their most nutritive states (raw), you need to clean them. This assumes the availability of clean water, which is not always a reality. Second, once you’ve purchased fruits and vegetables, you need to store them. And this is something that I’ve found to be a challenge. Electricity is not consistent, thus refrigerator storage is not a long-term option. Those who can afford a freezer often store things there, but of course this isn’t an ideal way to store fresh fruits and vegetables. And leaving many of these items on a shelf or in a storeroom drastically decreases their shelf-lives.

When I informally asked friends and colleagues here – “how are you able to keep food?” – the responses I got were interesting. In addition to storing food in deep freezers, many keep large quantities of maize meal, Irish potatoes, and eggs but buy fresh foods like fruits, vegetables, and bread on an almost daily basis. Even if we’re on the main road coming back from a field visit, a co-worker may pull over and within three minutes, purchase enough fresh veggies for that evening’s dinner. And while this makes a lot of sense, it presents additional challenges.
  1. You must be able to get to a place that sells these fresh foods at an affordable price. I walk 30 minutes to get to the open-air market (as opposed to buying things at almost quadruple the price in a grocery store near work), which is ill-advised to do after work hours when the sun is already setting. Even driving or taking a taxi is challenging with the fuel crisis that has peaked at my three-month mark.
  2. Fruits and veggies aren’t sold individually; they’re sold in bundles. Thus, what I call inexpensive – one bundle of tomatoes for a one-person household once a week – becomes more expensive for a woman who has, on average, 5 – 6 children and a husband to feed.
  3. If you buy fruits and vegetables, and they start to spoil, you have to cook them, and cook the nutrition out of them to make sure that you’ve killed all the bacteria. For example, if I have tomatoes that I’ve tried to save for three days, I usually end up making a stew or pasta sauce, and I usually add spices and salt. And while I do these things modestly, ask any Malawian, the meal accompanies the pile of salt used for seasoning, not the other way around.

So, here in Lilongwe, when you look at the facts – the high costs, the far geographic proximity, the unavailable safe food storage – I am, by definition, in a situation where I cannot access healthy foods. And while I know many expats here whose situations are different – fuel reserves provided by their governments, generators in the homes to ensure 24/7 power, higher incomes to warrant paying 800 kwacha for 5 apples (the same price of buying a Malawian meal for three or four) – it becomes almost impossible to expect the local community to have access to these nutritious foods. By definition, I’d say that here in Malawi (and throughout the African continent), we are most certainly in a food desert.

And once we understand that, we see that the solution to improving diet is not just based on changing individual preferences but reshaping a greater system and set of policies [3].
What do you think?

[1] Cummins, S., and Macintyre, S.(24 Aug. 2002). Food deserts” - evidence and assumption in health policy making. BMJ, 325, 7361, 436-438. Retrieved 27 Oct 2011 from <>
[2] Pearson, T., Russell, J., Campbell, M. J., and Barker, M. E. (2005). Do ‘food deserts’ influence fruit and vegetable consumption?—a cross-sectional study. Appetite, 45, 195-197. Retrieved 27 Oct 2011 from <>
[3] Caraher, M., and Coveney, J. (2003). Public health nutrition and food policy. Public Health Nutrition, 7, 5, 591-598. Retrieved 27 Oct 2011 from <>