Authors:   April Hill, Miku Kono, Jade Westlake  (Global Health Program students)

This project was a culmination of three years of collaboration between NTU and Malawi. Nutrition and WASH (water, sanitation, and hygiene) education, school gardening, and COVID-19 surveillance are the three major subprojects of the Sustainable Healthy Actions by National Taiwan University (SHANTU) project initiated in Taiwan and Malawi. This project is led by the project Principal Investigator (PI) Prof. Chang-Chuan Chan and co-PI Dr. Chi-Hsin Sally Chen. These subprojects were occurring simultaneously, and we assisted on these subprojects during the school year in Taiwan. To continue the work on these subprojects in Malawi and foster the link between Taiwan and Malawi, we traveled to Mzuzu, Malawi for six weeks, from July 6th to August 20th, 2022, to assist with the SHANTU project in person. We worked with Luke International (LIN), a non-governmental organization based in Norway, Chiputula Primary School, a public school in Mzuzu, and the Mzimba North District Health Office (DHO). With these organizations, we completed a variety of tasks and gained a holistic appreciation for public health work abroad.

The DHO invited us to assist in supervising the third round of their polio vaccination campaign. Because a case of polio was detected in a 3-year-old child in Malawi’s capital city, Lilongwe, the World Health Organization (WHO) recommended mass vaccination of children under age five in Malawi and its surrounding countries. This was the first mass vaccination campaign the country had conducted since 1992. Before the campaign, the DHO dispatched social mobilizers and local volunteers to each household in a designated area to inform parents of eligible children about the upcoming campaign. In the first two rounds of the campaign, the vaccination teams from all the health centers in Mzimba North visited each eligible household, but some children were missed. Our job was to assist supervisors who would fill out reports about the vaccination teams and social mobilizers' job performance. The reports included details such as if the vaccination teams properly marked the houses and the children’s fingers, if the vaccination teams were adequately equipped and handling the vaccines properly, and if the families knew details about when the campaign was occurring and for what disease. If the houses were marked incorrectly or families reported not knowing about the campaign, the reports would inform the DHO officials that the social mobilizers and vaccination teams may need additional training. We divided into different teams and visited various villages, where we were paired with local supervisors to gather information. Working with the DHO was an amazing learning experience. For an important campaign such as this, understanding how to do outreach and working with various people from the community was crucial. From the local volunteers, health clinic employees, DHO officials, and parents, it took a collaborative effort to ensure the campaign ran smoothly.

We also assisted the DHO in checking the Integrated Disease Surveillance Response (IDSR) reports and the COVID-19 campaign. The IDSR records are kept at every health center and track the occurrences of every infectious disease. We visited various health centers with the DHO officers to check the records. The IDSR records are sent to the head office via email or WhatsApp, but officers are required to physically check a certain number of centers each month. To check the IDSR records, we counted the number of cases per month and checked that the final report that is sent to the head office matched the number recorded. At some health centers, there were discrepancies between the recorded number and the number sent to the head office so the officers discussed with the health center employees how to improve their record-keeping. For the COVID-19 campaign, we attended meetings about surveillance and assisted in checking records at the health centers, similar to the record checking we did for the IDSR. While the meetings and record-checking were partially conducted in the local dialect, Tumbuka, we observed how the DHO officers work with the health centers to maintain accurate records and increase the vaccination rate in their area.

For our other subprojects, we worked closely with a community around Chiputula Primary School. Nutrition is an important subject that is only taught at this school through their science and technology book. The Head Teacher, Mr. Ollens Msonda, wanted more in-depth lessons on different nutrition topics the children could also share with their families. We created an assessment to test their existing knowledge and topics from the book we wished to expand on. After analyzing the results, we created a short curriculum for the classes we were going to teach. We taught Standard 5, 6, and 7 classes, with a total of over 1,000 students. Through games and food activities, we talked about various topics such as food pairing, whole grains, salt and sugar, and malnutrition. The students seemed to enjoy the activities and were always excited to see us. Through the nutrition classes we taught, we learned about creating culturally appropriate questionnaires and curriculums and working together with the teachers to create fun and educational activities.

We assisted with the creation and management of a school vegetable garden at Chiputula Primary School during our whole six weeks of stay in Malawi. The fields were cleared and cleaned for gardening, and the seeds for rape, Chinese cabbage, and mustard were already planted in the nursery when we first visited the school. We worked with the students and teachers at Chiputula Primary School, watering the nursery and seeing the sprouts, building raised beds, picking up trash, and transplanting the nursery plants into the raised beds. The students were enthusiastic and were taking care of the garden before and after classes. The students, teachers, LIN, and SHANTU all worked together on the gardening project, and we learned that sharing knowledge and resources among the team is one key to succeeding in the implementation of the project. 

Through the head teacher at Chiputula Primary School, we became connected with Anno’s Africa, an organization that aims to provide traditional and contemporary dance, music acrobatics, art, and drama classes to students who otherwise may not be exposed to visual or performing arts education. We got to run some outdoor activities and line dances, and the kids picked up the activities quickly. We also observed classes by Anno’s Africa, including art, music, dance, acrobatics, and guitar. It was an amazing experience being a part of enriching students’ talents in creative arts, spending time with our students outside of the classes, and learning about Malawian traditions.

We also met Dr. Griphin Baxter Chirambo, the Head of the Department for Nursing and Midwifery at Mzuzu University, and Dr. John O'Donoghue, the Founder and Director of the Malawi eHealth Research Center and professor at the University College Cork in Ireland. We had dinner together a couple of times, including traditional homemade Malawian food made by Baxter’s wife Lea, attended Baxter’s birthday party, and received a tour around the Mzuzu University campus from Baxter and John. In addition, we brainstormed study ideas and an upcoming schedule while we were all in Malawi, and we look forward to collaborating on a population-wide nutrition study in Malawi. We are excited to work on the project and attain valuable research experience and skills with the global team members.

Through this internship, we had the opportunity to gain experience with practical applications of global health work in Malawi, a country that offers significantly different experiences from those available in Taiwan. One of the key elements of our internship was learning when to lead and when to follow. Most of the time, we focused on supporting the activities that DHO was already working on or following the directions of the teachers and students tasked with overseeing the community garden. In the end, for successful and sustainable global health work, the work must benefit the host organization and fieldwork sites in the ways they need. However, sometimes the organization’s needs, plans, or situations change suddenly. Because of this, we developed a lot of flexibility, adaptability, and innovation that enabled us to complete our objectives.

We learned that global health requires patience. Enacting global health programs and seeing results from global health capacity building can take a long time, and milestones are often measured in years instead of months. As we spoke with community members and leaders in public health, we realized how much the public health landscape in Malawi has changed over the past decade. Many of the activities that we did and surveillance programs that we learned about did not exist only 20 years ago. While we had an incredible experience and saw success in the projects that we implemented, we also acknowledge that our internship was the culmination of three years of collaboration between SHANTU and LIN in Malawi. In this way, our visit to Malawi was a unique opportunity to see the results of this virtual relationship come to fruition.

We also learned about Malawian culture, particularly the importance of community leaders and respected individuals in decision-making for the community. Approval by the community leaders is very important for outsiders, and without their approval, we would have had fewer opportunities to participate in events, learn, or implement our projects. These community members attended meetings at Chiputula, saw the transplanting of the vegetable garden, and invited us to community events, all of which gave legitimacy to our actions within the communities we served. We experienced important aspects of Malawian culture, including dietary patterns, music, dance, and hospitality. Although these do not always relate directly to global health work, culture and traditions largely influence the way that people experience health.

Working on public health campaigns, promoting nutrition education and community gardens, and connecting with others who are passionate about global health were unique experiences that will shape our actions and beliefs as future leaders in global health. Many of us laid the groundwork for collaboration and continued work in Malawi, and we cannot wait to see what opportunities arise. We learned so much about health and the world thanks to the collective efforts of so many. We are grateful to all the people who provided us with this opportunity, and those who opened their hearts and their lives to teach us and pass on their knowledge and experiences. Tawonga chomene.