Malnutrition and hunger in Malawi is more than not having a plate of food to eat. It's a volatile mix of social, health and economic factors - and HIV/AIDS has added a dangerous dimension to the country's food crisis.
This is borne out in a recent Food and Agriculture Organisation (FAO) report which said that HIV/AIDS is hitting the Southern African farm sector hard, with stricken families struggling to produce enough food to survive.
"The disease is no longer a health problem alone, but is having a measurable impact on food production, household food security and rural people's ability to make a living," the report said.
Jennie Mueller is leader of the Hope project funded by Development Aid from People to People (DAPP), which helps communities implement programmes to cope with the disease. She explained: "Communities rely on agriculture and [the income of] agricultural labour. If one person goes down then they all go down. If they have one sick person it’s one less person being productive.
Skilled workers are dying. Eight teachers died at one school last year and they can't be replaced. Recently the police recruited 200 people. They have lost 186 people to HIV/AIDS recently and 86 of those people were in the group of new recruits. Thirty-eight percent of Malawians who have HIV/AIDS are in the productive age group," Mueller said.
"The problem is so big and so many people don’t know if they’re infected because there is a maximum of six testing centres for 10 million people," she said.
"Female-headed households are the most vulnerable. Women who have their own children would have the added burden of looking after the children of dead relatives and friends. On a low income or with very little resources, she would be responsible for upwards of five children. Most people never have more than six months’ of food saved up and after six months the whole household would have a food deficit," added Mueller.
"Child-headed families and orphans have no access to land and some don't even have houses. They have no shelter and so have to beg for food and they end up in a bad nutritional state. You start seeing the signs after two months - many of Blantyre's street children are in that position," she said.
Mueller said there were between 600,000 and 700,000 children orphaned by the disease in Malawi and there were "simply not enough resources" to help them.
"Women are either affected directly or they are infected themselves. If they get sick they lose the little income they have. When they're sick they stop eating normal food and start fasting because they can't swallow [because of] oral thrush. They lose weight and get infections because of their poor nutrition," said Mueller.
She noted that though Malawi had one of the highest infection rates in Southern Africa, its HIV/AIDS initiatives were ahead of many other countries.
One was the promotion of a minimum of six months' exclusive breast feeding for mothers who don't know their status. Mothers usually "mix feed" by alternating with other foods but this increases the chance of a slight tear in the baby’s intestine and the risk of the virus entering the baby's blood. Until the baby is completely weaned, mothers are encouraged to only give the baby very soft foods.
Another was the country's home-based care system in which village committees organise volunteers to help families care for people laid low with the disease.
"Hospitals can't deal with the overwhelming number of sick people and home based care minimises the number of times a person would have to go to hospital," she said. "It helps families understand the illness and people can die with dignity at home. It provides hope and a way to cope and it helps the grieving process because the community would already be reaching out to that family over the period of illness."
Mueller explained that once established, each village committee - known as a Village Aids Coordinating Committee (VACC) - would have four technical sub-committees focusing on youth, home based care, orphan support and high risk behaviour. One member from each VACC sits on a regional community committee.
Mueller's organisation steps in to help with capacity building, training and information dissemination. They also help with income generating projects which help families replace lost income.
One such project is the introduction of mushroom farms which are now supplying the local hotels and a large supermarket group. People also sell the mushrooms in their communities and make soothing mushroom soup for people too sick to eat. They're trying to diversify into other vegetables that ill people can eat and which will help build their strength.
They help train the home based carers and the trained carers help reduce the risk of the family contracting the virus. One of the difficulties they face is a shortage of male volunteers which presents cultural problems as some men consider it inappropriate for any woman other than their wife or a sister to care for them.
"Home based care makes [treatment of HIV/AIDS] a little easier, she said, "but the illness causes economic problems which become nutritional problems."
"There is such a decreased productivity level that communities can't cope. In child-headed families the eldest child drops out of school to find food for brothers and sisters. That's where food distribution programmes come in handy - it gets the children through school and without it they would need [help] for life."
Mueller said sometimes spouses or children of people who die are kicked out of their homes. "Perhaps the wife was not close to the relatives or the relatives are simply not interested in looking after the children. Some street kids just get kicked out," she said.
She advocates a "living will" which would prevent this from happening. This could be done by a family member who can write and it can be notarised by a district commissioner. However, "it's a little bit new and not widely implemented but that way the resources remain in the home."
Mueller said the World Food Programme's (WFP) HIV/AIDS nutrition support programme recognised the link between the disease and malnutrition. It was now not only giving assistance to people living with HIV/AIDS, but to the whole household. The previous "care package" would have been shared by the household but wasn't enough.
Nutritionist Charlotte Walford, who heads a European Community nutrition rehabilitation unit which assists health centres in southern Malawi said: "Over the last few years we have seen an increase in moderately malnourished children due to HIV/AIDS. They are admitted to hospital because they are too sick to eat because of an infection like oral thrush."
She said that with diseases like HIV/AIDS and malaria, which affects more children than adults, people need special food when they are convalescing but they don't get it because they're poor.
"They lose weight and don't recover properly and when they get sick again they continue to lose weight. When they're getting better they need to boost their red blood cells, but if they get diarrhea they fall into a downward spiral and HIV/AIDS exacerbates that downward spiral.
"So it's not always food insecurity - malnutrition and infection is a vicious circle."
But as word of the country's needs filter out, more people are travelling to Malawi not just to sunbathe next to the country's famous lake, but to volunteer at under-resourced facilities like orphanages.
One of those is Blantyre's Open Arms orphanage which is currently looking after 37 babies and toddlers. Run by a retired British couple Neville and Rosemary Bevis, and a staff of about five Malawian "nanny mums", the centre has a policy never to turn away people who arrive at the centre. "We sometimes have to do it if we're phoned but if people come in person we won't turn them away," said Neville Bevis.
Most of the children either have HIV/AIDS and their families could no longer care for them. Or their parents have died and a sibling or relative has travelled to Blantyre and asked for the orphanage to take the child in, who is often malnourished and ill.
As Open Arms is only a transition centre, when the children reach two-years-old and are healthy enough, they are reunited with their families and monitored. If this is not possible - or if they feel the child will be at risk of malnutrition - in consultation with Malawi's social services, they are either sent to a nearby orphanage called Yamikani House or placed in foster care.
Neville Bevis said they have no Malawi government funding and rely on donations to cover their running costs, and the costs of hospital care, when the babies become ill.
The "nanny mums" are helped by a core of volunteers from around the world who feed and play with the children.
The orphanage also grows vegetables which it sells to nearby hotels and this season was paid by the government to grow an experimental crop of paprika.
European Commission Southern Malawi Nutrition Outreach Project: email: [email protected]