It was with some urgency that we set out towards Malawi. The ‘Administrative, Budget and Planning Board’ that had been threatening for some months now to meet had finally congregated in the Tanzanian equivalent of a greasy spoon, yielding some worrying conclusions. We were seven months through a nine month trip. We still had 5,000 miles and five huge countries to see. We had spent 60% of our entire budget in the initial two European months. Dan had no trousers left…

We set off for Malawi post haste, determined to make the most of our time left on this continent. Our first decent tarmac road for days meant we could creep up to our top speed of 55 mph. This turned out to be a bit of a terrifying experience. Something had changed, worked its way loose, or worn out, something we had missed despite our daily checks on the car. It wandered across the road like a distracted cow, correcting direction as violently as if it had been spooked. Safe as to say that handling isn’t Tess’ strong point at the best of times. In a car that takes a half turn of the steering wheel to produce any effect and only has three brakes, one of which intermittently seizes on, our movement was something akin to a drunkard with his legs tied together. This 500 mile leg also proved too much for our drive shaft, which had been protesting thanks to a disintegrating universal joint. The team took a relaxed and very protracted lunch as we dropped the drive shaft off, managing to replace old joint with new thanks to a forward thinking quartermaster and the best of Land Rover tools: a lump hammer.

The long and winding road (Photo: RWH)

All of this didn’t make for a relaxing drive. We approached the Tanzanian-Malawian border late at night, predictably finding a huge steel gate proclaiming it closed. We found hawkers, tinkers, fixers and beggars, spectral shapes melting out of the grimy darkness, their outlines sharpening against the greasy light of burning paraffin wicks on the market stalls as they approached to grasp and knock at our windows. We were exhausted from being on the road for days, from a string of washed out camps in soggy sleeping bags. We retreated into a nameless hotel and paid over the odds for a slice of foam and an icy bucket of water.

Dry slumber, sweet coffee and the emerging morning sun revealed a town reborn. The spectres were friendly today, distinguishable as individuals, helpful Christians. After so long on the road, it still surprises us how the body’s basic needs influences perception so much. We were ushered into Malawi with smiles and without the need to pay for a visa. At the many police road blocks, we were greeted with friendly but stringent adherence to the law, and a peculiar eagerness to exhibit Malawi’s beauty to tourists. One officer in particular stands out. He bounded eagerly to our window and enveloped our hands in his that were clad in white cotton. Eyebrows arched, eyes sparkling, he leaned in and, as though he had only just clapped eyes on it himself, asked us “Have you seen our LAKE!?”

Lake Malawi (Photo: RWH)

The very north was lush, the road a raised cob through endless flooded rice paddies, a hangover from Tanzania. People padded along the road, dried mud extending up their ankles like socks covering their bare feet. Sit-up-and-beg bicycles meandered along, sugar cane, firewood, or children clinging to the back. Before long the road began to rise, and we found ourselves in a completely new landscape, where huge rounded tors pushed up from great expanses of planes. Woodland appeared, hardwoods of size and density that we hadn’t seen since Europe. Although it had lost none of its strength, the sun had begun to cast shadows at midday again, and no longer dropped like a stone at its setting. We were southward bound, and Capricorn was closer now than the Equator.

Our goal was Zomba, a small city which had been the British colonial capital back when Malawi was Nyasaland. It is a green and leafy settlement, full of parks, croquet lawns, tea houses, botanical gardens, a golf course, and even a gymkhana club. Modern Africa has had its way here too, however, and the streets writhed with the movement of minibus stands, maize sellers and wooden stalls, all bustling to the cracked music of the local bars. We were here to run a feasibility study for an international research study, and would be staying in a district hospital a few miles outside of Zomba.

As a traveller or backpacker you could be forgiven for thinking Malawi is a progressive, developed African country with a flourishing economy and good infrastructure. It would be easy to navigate from hippy hostel to plush lakeside campsite, experiencing the beauty of the country and the company of those Malawians lucky enough to work in the tourist industry. In reality, Malawi has one of the least developed economies in the world, highly dependent on aid and IMF/World Bank input throughout the ‘00s. 70% of their export revenue is raised from tobacco sales, the price of which is dwindling. Despite having a multi party democratic political system, the international community has expressed repeated concerns over senior level corruption and human rights breeches including illegalizing homosexuality, freedom of speech, and censoring of the press; there is only one television station, and it is government owned.

Attending clinic (Photo: RWH) Written informed consent obtained for publication online from all relevant parties in accordance with current UK General Medical Council guidance.

From a medical point of view, Malawians born today can expect to live to 50 years, if they make it beyond 5 years old; 8.3% won’t. The HIV/AIDs prevalence is 10%. The maternal mortality rate is one of the highest in the world. CRADLE, the study with which we are working, aims to help tackle the last of these problems by determining if a nationwide blood pressure monitoring service for pregnant mothers would reduce mortality. It would aim to identify and treat those mothers at risk of pre-eclampsia, a condition which can be identified by high blood pressure in pregnancy, and can progress to eclampsia, which can be fatal for both mother and foetus. Our job was to work out if running such a service in Malawi was a possibility.

As it turned out, this feasibility study led to our best experiences in this country. Guided by Grace, a hugely hospitable battleaxe of both Malawian and British citizenship, we bounced around the country side, visiting rural clinics and health centres. Tess was integral to our work, as most of the tracks were used by a four wheeled vehicle only once a month, bound for the very clinics we were visiting. Elephant grass encroached on both sides, and we crawled through villages and past markets seldom seen by outsiders. Cyclists would swerve into the long grass at the site of us, staring nonplussed as we passed, apologizing furiously.

Health education at the beginning of clinic (Photo: RWH) Written informed consent obtained for publication online from all relevant parties in accordance with current UK General Medical Council guidance.

The clinics themselves are often run in the village church, Malawi being 80% Christian. Invariably, tens of women and children gather under a tree outside, waiting for the health workers to arrive and deliver an educational talk to begin. Then they all line up to be seen by respective professionals; all nurses and clinical officers, no physicians. Family planning, infant vaccinations, maternal advice and monitoring; all bases were covered in these multipurpose clinics.

We were surprised by the clarity of organisation of healthcare here; the system for information gathering and auditing is really impressive. The facilities themselves of course suffer from under investment and under staffing, but the whole sector seemed to have a positive ethos for development. We wondered if this was a legacy of Dr Hastings Banda, the British trained GP who led Nyasaland to independence and ruled Malawi under a one party system for 33 years. We are hoping to feed back or assessment to CRADLE in the near future.

Towards the end of our stay, we received an invitation from the District Health Officer to visit him in his office. We were assured this was a great honour, and indeed the security and establishment suggested as much. Ushered into his office we were greeted by a portly man of short stature, who rose from his excessive leather wing-backed chair to extend a well manicured hand from within his rather ill fitting suit. I was reminded greatly of the Fat Controller, if any of you can remember Thomas the Tank Engine. This was a ceremonial handover of the blood pressure monitors that we had smuggled across Africa in the back of our car, originally intended for the CRADLE project in Ethiopia before they had pulled out of that country. There were many smiles, many handshakes, a few photos, and we were ushered out again.

The District Health Officer (Photo: RWH)

The time had come to leave Zomba and the excellent company of Grace. The Administrative, Budget and Planning Board had been unable to agree on whether we should go to Mozambique or Namibia, and so we had compromised by committing to visiting both. Although geographically inconvenient, especially given our time and budget deficits, this solution would also afford us the excuse of driving through Zimbabwe and Botswana. As it turned out, visas for Mozambique require letters of invitation and confirmation of accommodation booking, both of which had to be ‘drafted’ in an internet café before application. Having successfully duped the embassy, we set off towards Mozambique, skirting south along the crystalline shores of Lake Malawi. Tess still wandered across the road, but given the state of the roads in Mozambique, we didn’t expect to get above 40mph the whole way.