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 of 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:
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.
Also posted at: http://scoutbanana.org/health-in-africa/from-the-field-a-lesson-on-nutrition-in-malawi/
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:
- 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.
- 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.
- 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.
- 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.
Also posted at: http://scoutbanana.org/health-in-africa/from-the-field-a-lesson-on-nutrition-in-malawi/
Interesting! I think you are on to something :)
ReplyDeleteThanks for your comment; have you noticed any issues of nutrition from your travels!
ReplyDeleteI would also love to hear what you (and others) think the way forward is. Is culture important? And if so, how do we effectively understand and utilize it in solutions?