The David Gordon Memorial Hospital in Livingstonia, northern Malawi. There are only 177 specialists in the country and the doctor-to-patient ratio remains alarmingly high. Credit: Katie Lin/IPS

By Katie Lin
BLANTYRE, Malawi , Apr 23 2013 (IPS)

In Malawi, where the healthcare system frequently makes headlines for its shortages of drugs and medical workers, a fact that is often overlooked is that two out of four central hospitals do not have a specialist physician in attendance.

“A lot of conditions are not appropriately diagnosed because they are seen by clinicians who are not aware of the greater spectrum of diagnoses that are possible,” explains Dr. Theresa Allain, associate professor and head of Internal Medicine at the University of Malawi’s College of Medicine in Blantyre. “When things are not diagnosed appropriately, they’re not treated appropriately.”

“So there is a need for higher-level specialism, but we don’t have enough doctors yet to go into those posts,” she tells IPS.

And while much of the blame for the slow development of Malawi’s healthcare system has fallen on the external “brain drain”, whereby qualified medical workers leave Malawi in favour of better training opportunities and more attractive salaries abroad, Allain explains that the challenges go far beyond this single factor.

“We have to look at it in the context of the bigger picture because the College of Medicine is only 20 years old,” she says of the country’s fledgling medical training institute. “The first phase of the life of a medical school is just getting doctors qualified.”

In a 2010 report, the World Health Organization found Malawi had just 257 doctors serving a population of over 15 million.

There are currently 459 general medical practitioners registered with the Medical Council of Malawi.

Despite the increasing number, however, there are only 177 specialists in the country and the doctor-to-patient ratio remains alarmingly high at 1:33,300.

In Kenya, there are 1,654 registered specialists and the doctor-to-patient ratio is markedly lower at 1:5,190. And south of Malawi, South Africa has over 9,600 registered specialists and boasts a doctor-to-patient ratio of 1:1,320.

“It’s an evolving health service,” says Allain. “But each year, we graduate more doctors, and what’s interesting now is that the new graduates are beginning to demand better postgraduate opportunities.”

Andrew Mataya, 28, is a fifth year student of the Bachelor of Medicine programme at the College of Medicine and the possibility of specialising is one that he is now reflecting on.

“I definitely would like to specialise, but I’m not quite sure which area to pursue yet,” he tells IPS, explaining that when it comes to making this decision, he will take into consideration the working nature of that specialty, his relationships with his instructors and supervisors, and the service needs of Malawi.

“My career path, of course, depends on which specialty I ultimately do choose, and what opportunities are available when the time comes.”

In her State of the Nation address at the beginning of the year, President Joyce Banda expressed the government’s commitment to creating “a Malawi that has a healthy population, and a well-trained and skilled workforce.”

But as many of Malawi’s donor countries are confronted by a global recession, funding in multiple government sectors – not just healthcare – has decreased, indirectly affecting medical training programmes.

“The Ministry of Health did fund a number of specialist training posts a few years ago,” Allain explains. “But it is strapped for cash and our health service is struggling with very basic things, like drugs, so actually putting a budget aside for training specialists is not high on their priority list just at the moment.”

But that is not to say that advances have not been made.

The College of Medicine recently integrated two new programmes for higher medical specialisations: one in nephrology (renal medicine) and the other in emergency medicine.

Students would still be required to complete part of their training abroad in countries such as South Africa or Tanzania where the healthcare system is more developed. But as Allain says, the long-term goal is to create more postgraduate opportunities for those who are looking to stay and work in Malawi.

Dr. Francis Kamwendo, Deputy Head of the Obstetrics and Gynecology (OB/GYN) Department and a consultant OB/GYN at the Queen Elizabeth Central Hospital in Blantyre, has noticed a marked difference in his area of specialisation over the last decade.

“The developments are slow,” Kamwendo, who completed both his basic and specialist medical training in Sweden, tells IPS. “But we feel that we are growing, we are developing, and we are getting better at delivering special care.”

And Kamwendo envisions even more comprehensive OB/GYN services in the future.

“The department will develop in a way that will have sub-specialties,” he projects. “We will have gynecological oncology, maternal and fetal medicine, and we will also be able to take care of other diseases that a woman may have before she becomes pregnant, such as diabetes and hypertensive disease.”

Although Malawi is now looking to train more specialist physicians and its educational institutes are maturing to accommodate this development, Allain reiterates the need to first generate general specialists who are equipped with a high-level knowledge base that will enable them to treat the country’s most common medical conditions up to specialist level.

These conditions include pneumonia, tuberculosis, HIV, stroke, heart failure, and anemia.

“If you’ve only got 300 doctors, and perhaps you’re going to train 20 specialists, you don’t want to train very specialised doctors,” she says.

“If we train specialist cardiologists, they’d be able to look after one of those conditions, which is heart failure.”

In the meantime, Malawi has turned to “task shifting” in order to temporarily combat the lack of human resources available to its healthcare system, whereby less specialised health workers – known as clinical officers – are designated low-risk tasks, such as giving injections, performing HIV tests, and applying local anaesthetics.

And as for building up Malawi’s medical specialist sector, it is a process that will simply take time, says Kamwendo.

“Now that we are planning specialist education, it will help us produce specialists that will remain in the central hospitals, and they will overflow to the district hospitals with time.”

Pınar Selek, a Turkish sociologist who has on three occasions been tried and acquitted over a fatal explosion in Istanbul more than 14 years ago, is being taken to court again Jan. 24.

On Jul. 9, 1998, seven people were killed and more than 120 injured in an explosion at the historical Spice Bazaar in Istanbul. Selek was implicated as having organised the explosion.

Through the 1990s, Selek studied the armed conflict between the Turkish state and the separatist Kurdistan Workers Party (PKK). At the height of the conflict, she conducted interviews with numerous PKK members, including its leader Abdullah Öcalan.

“At that time, no one could speak out about the Kurdish problem,” says Erol Katırcıoğlu, professor of economics at Marmara University in Istanbul. “Not only did Pinar Selek speak publicly, she also did research.”

Selek was detained two days after the incident, and following a brief police investigation was indicted on the grounds that she was a PKK member. Additional charges were later brought against her as a primary suspect in the explosion.

Shortly after the case was filed, Abdülmecit Öztürk, a suspect in the case, ‘confessed’ to involvement in the incident, stating he had “placed the bomb in the Spice Bazaar together with Pınar Selek.”

At a hearing on Dec. 22, 1998, however, Öztürk retracted his statement, claiming it was obtained through torture. He said he did not know Pınar Selek and had nothing to do with the explosion.

Three trials and nearly 15 years later, the verdict on Selek’s involvement in the explosion continues to be tossed between lower and higher courts in Turkey. The Supreme Court of Appeals has refused to acquit her.

Conflicting reports, inconsistent testimonies and lack of evidence have resulted in a protracted and highly disputed case. Initial police reports dated Jul. 13 and 14, 1998, said there were no indications of a bombing. A police report released a week later supported these findings.

Selek remained in police custody until December 2000, after three court-appointed forensic experts concluded that the explosion had in fact been caused by a gas leak and not a bomb.

And while court investigations largely support the case that a bomb was not the cause of the explosion, lack of evidence continues to plague proceedings.

“The critical thing in this case was that the firemen who arrived at the place of the incident cleared all the evidence away,” says Turkish court correspondent Bülent Ceyhan. “They did it after putting out the fire.”

However, the Council of Forensic Medicine reported evidence of material found on victims and at the scene which it said could have been used to make a bomb. This is the report that the Supreme Court has referred to each time it has reversed Selek’s acquittal.

In 2006, the Istanbul High Criminal Court determined that “no certain and believable evidence that requires punishment could be found.” Selek was acquitted of the charges against her and released. But this and subsequent acquittals in 2008 and 2011 were overruled by the Supreme Court of Appeals.

According to Ceyhan, there are many variables that have affected the case, from poor forensic and police procedure to the absence of the Chief Judge at the last hearing.

“The main judge, Vedat Yılmazabdurrahmanoğlu, who previously acquitted Pınar Selek, was away from the court (in December) because of health issues,” he notes. “When he was not there, the court cancelled its last decision to set Pınar Selek free.”

Yılmazabdurrahmanoğlu has since recovered and will be in court on Jan. 24.

As the trial approaches, both domestic and international human rights groups continue to condemn the Turkish judicial system’s treatment of Selek’s case. Last month PEN International, an organisation that promotes freedom of expression, said “Selek is being subjected to a campaign of judicial harassment as a means of penalising her for her longstanding support for and work on minority groups in Turkey.”

Other supporters of Selek’s innocence, including fellow scholars, have also voiced their discontent.

Peter Sluglett, president of the Middle East Studies Association of North America and professor at the National University of Singapore, appealed to Turkey’s Prime Minister Recep Tayyip Erdoğan to drop the charges against Selek in a letter issued by the Committee on Academic Freedom on Dec. 12, 2012.

“The ongoing prosecution of Selek sends a chilling message to the academic community and signifies an ongoing policy of violating the freedom of academic research in Turkey,” Sluglett said.

He also urged Erdoğan to “take note of mounting international condemnation of the erosion of democratic rights and freedoms in Turkey.”

As Turkey continues to pursue European Union membership, Katırcıoğlu says that the verdict may affect its chances of integration.

“If the verdict turns to be ‘guilty’, especially for people who want to see Turkey as a democratic country, they will not be satisfied,” he said. “Pinar Selek’s case is not only a case about a woman searching for justice, it is also a case which indicates a search for justice in a society.”

Supporters hold a candlelight vigil in Dharamsala, India, for Dolkar Tso who self-immolated on August 7, 2012. Credit: Katie Lin/IPS.

By Katie Lin
DHARAMSALA, India, Sep 6 2012 (IPS)

Two Tibetan teenagers set themselves on fire and took to the streets of Aba in southwestern China last week, managing to walk only a short distance before collapsing. They both died the following day.

Since 2009, there have been 51 self-immolations inside of China, as Tibetans protest against increasingly repressive Chinese policies and call for the return of the Dalai Lama, who fled Lhasa, the former capital of Tibet, for India in 1959.

In an address to the Foreign Correspondents’ Club of South Asia in New Delhi last month, Tibet’s prime minister-in-exile, Lobsang Sangay, expressed his disappointment at the lack of attention Tibet has received from the international community as the number of self-immolations continues to climb.

“The tragedy in Tibet has been unfolding for the past 50 years but the reaction does not seem to be as much as for the Arab Spring,” he said.

Indeed, the world watched as the self-immolation of Mohamed Bouazizi in Tunisia sparked a revolution in orthern Africa in 2011, bringing down a number of dictatorial regimes across the Arab world as it spread.

Yet despite the string of self-immolations in Tibet and numerous appeals made by both the Tibetan government-in-exile and various rights groups, the desperate actions of these self-immolators seem to have elicited little response from the international community.

Tenzin Norsang, joint secretary of the Tibetan Youth Congress (TYC), an international non-governmental organisation with more than 80 regional chapters worldwide, cites a general lack of interest as the cause for this apparent low response.

“The first thing, is interest,” he says, “If you’re not concerned, if it’s not your struggle, you won’t make an effort to understand it.

“And this is not only the case with Tibet. After the Second World War, more than 100 countries gained independence and nobody took interest.”

Rigzin Namgyal, a 26-year-old yoga teacher, also from Aba in southwestern China, where most of the self-immolations have taken place, echoes Norsang’s view about the level of international attention reflecting a lack of interest, but sees the struggle’s age as being the main issue.

“People like variety and spontaneity, but they’ve been hearing about the Tibet issue for 50 years, since we lost our country,” he says.

Shortly after the establishment of the Chinese Communist Party in 1949, 40,000 People’s Liberation Army troops invaded Tibet. Following three years of armed resistance, the number of Tibetan rebels was growing and fears arose that the Dalai Lama’s safety was under threat. Finally, in 1959, Tibet’s spiritual leader escaped to India, inspiring a mass exile of more than 80,000 Tibetans.

“Tibet has been in the news for the last 50 years, that’s why they’re not giving specific attention to it – it’s an old issue,” Namgyal continues.

However, according to Dr Robert Barnett, director of Modern Tibetan Studies at Columbia University, the effectiveness of a protest to effect political or social change is not entirely dependent on its presence on the front page.

“Protest impact depends on the type of government you’re dealing with more than the type of protest or media coverage you get,” he says.

“You could argue that Tibetans and their supporters are thinking in terms of strategies that have worked with weak governments, not with an extremely robust one, like China,” Barnett says.

“Tibetan protestors, especially those abroad, tend to use protests and foreign media to communicate their anguish and suffering, but in China that’s widely seen as courting sympathy or even as trying to get more funding and benefits.”

The Tibet issue has made headlines in the past, namely during periods of civil unrest, such as during the 1987 protests and the 2008 uprisings, both of which increased tensions between Tibetans and Chinese authorities and saw a rise in the arrest and arbitrary detention of Tibetans.

But the world’s general knowledge and positive reception of the issue can largely be attributed to the high profile of the Dalai Lama, the widespread image of Buddhists as being non-violent and compassionate, and, as Barnett puts it, “the tone-deaf propaganda statements and policies of Chinese officials, who often bring embarrassment to themselves.”

But this movement will inevitably face several challenges in gaining attention in the future, as China works to improve its propaganda style and as the Dalai Lama, now 77, ages.

In addition to these factors, Barnett believes that, due to all of the media attention garnered and international sympathisers gained during the protests in the late 1980s, there exists a “success deficit” when it comes to communicating the issue of Tibet.

“Many (Tibetans) still tend to rely on publicity for everything,” he says.

“Put crudely, we all need to learn to ‘think politically’ in a deeper, long-term sense – not to conflate politics only with media inches and TV coverage.”

As Barnett sees it, the Tibetan movement has actually received a relatively high response from the international community, especially as compared to other serious cases of human rights abuse, such as mass rape in the Congo.

Support groups and organisations, including the TYC and Students for a Free Tibet continuously run awareness campaigns, and a number of influential administrations have pledged their support to the Tibetan cause, including those of Australia, France, Canada, and Japan.

But Norsang says that these campaigns and statements of concern are simply not enough.

“We have received a huge amount of international support, with many people expressing their solidarity,” he says. “But now, apart from their concern, we need a practical solution.”

On Sep. 18, the United Nations General Assembly will hold its 67^th session in New York City – and it is on this day that TYC plans to stage a protest in New Delhi in an effort to communicate the need for fact-finding delegations to be allowed into Tibet.

In the meantime, the Central Tibetan Administration has made an appeal to supporting administrations to collectively engage the Chinese government in dialogue during the meeting, encouraging it to open its borders to both fact-finding delegations and international media.

As TYC members and supporters migrate to New Delhi to take part in an organised indefinite hunger strike, which began on Sep. 3, Norsang tries to maintain some perspective.

“I feel proud of what we have achieved so far,” he says. “Compared to the struggle of other countries, like India, which was under British rule for 200 years, our struggle has achieved a lot in 53 years.”

As Malawians celebrate Joyce Banda’s appointment as president on sites, like Facebook and Twitter, the increased use of social media in Malawi comes full circle as her new government takes office.

On Jul. 20, 2011, the peaceful country of Malawi broke out into nationwide anti-government protests. Credit: Katie Lin/IPS

For it was during the country’s civil society mobilisation against the former government that social media first gained popularity as a platform for airing grievances here.

Now, as Banda begins to purge the Malawian government of corrupt officials and woos international donors back in an attempt to ease the country’s economic woes, users on social media have increased.

The news of President Bingu wa Mutharika’s death began circulating as rumours on Facebook newsfeeds in Malawi two days before it was officially confirmed by government officials on Apr. 7.

The subsequent appointment of former Vice President Banda as the new head of state, and the first female president in southern Africa, only amplified the level of online activity as messages of support and optimism sprouted up all over Twitter and Facebook.

July protests stir up online community

But the country’s online community was first stirred to action during last year’s protests. On Jul. 20, 2011, the apparently peaceful country of Malawi broke out into nationwide anti-government protests in response to a deteriorating economy and political mismanagement. Persistent fuel and foreign exchange shortages added to the frustrations.

The protests lasted two days and resulted in 20 deaths.

So when the Malawi Communications Regulatory Authority (MACRA) temporarily shut down private broadcasters and popular news websites were blocked, Malawians turned to social media platforms such as Facebook and Twitter for the latest information.

“There’s a tendency among officials — especially government politicians — to control the flow of information,” explains Arnold Munthali, new media editor for Blantyre Newspapers Limited (BNL).

“However, social media has created a socially free and more politically aware population, which the government is helpless to control.”

According to the social media statistics portal, Socialbakers.com, there are currently 132,580 Facebook users in Malawi. While this represents less than one percent of the nation’s 15 million people, the number of Facebook users grew more than 50 percent between March 2011 and March 2012.

Such a remarkable surge in usage over a period of civil unrest indicates that social media has a place in Malawi, despite the country’s low internet penetration. In 2010, the International Telecommunications Union estimated that just 4.5 percent of Malawi’s population was using the internet, with access limited primarily by poor communications infrastructure.

As the days of protest unfolded, however, Malawians across the country took to cyberspace, posting photographs of wounded demonstrators and damaged property on Facebook; alerting protestors of volatile areas and describing the police presence at each location, through Twitter channels; and posting on Youtube cell phone videos documenting the chaos.

Some subscribed to pro-democracy Facebook groups. Others, like 28-year-old Rogers Siula, a media planner who participated in the July protests in Blantyre, took to the blogging sphere.

“We are in an environment where young people, who have incredible potential to flourish and steer Malawi into a dynamic, fresh and energetic country, are being oppressed left, right and centre,” says Siula.

“In this tense political atmosphere, platforms like Facebook, blogs, and Twitter are safe.”

It is this aspect of anonymity that social media offers which appeals to Malawians – but it is also that which affords government officials the ability to disguise their identity online and therefore more easily identify and monitor particularly outspoken individuals.

Online activism gains momentum amidst attacks and arrests

Malawi may have moved into a new year, but old tensions followed, giving rise to new controversies.

On Jan. 17, 2012, a group of market vendors in the country’s capital of Lilongwe stripped women wearing trousers and short skirts after the late Mutharika reportedly voiced concerns about how women were dressing.

Concerned citizens gathered online to condemn the vendors’ actions, including a group of women who launched the campaign, “Stop Violence Against Women in Malawi.”

They advertised in newspapers and on the radio, and also reached out to more than 5,000 people through Facebook – 1,413 of whom accepted an invitation to a peaceful sit-in, according to the group’s page.

More recently, the arbitrary arrest of prominent human rights lawyer, Ralph Kasambara, in February gained international attention through the emergence of support groups on Facebook, such as the “Free Ralph Kasambara” group, where supporters publicly deplored the persecution he faced.

Eight days after his arrest, Kasambara was released on bail. He credits social media with playing a pivotal role in his release.

“It brought the local problem into a global context, and as a result of that, our friends from the International Court of Justice were able to … get information as it was happening around here,” says Kasambara.

Social networking a source of support in the perpetual ‘hunt for fuel’

But social media is not just being used to fuel nationwide political action. On a smaller scale, it is also helping Malawi’s urban population tackle day-to-day battles, such as the ongoing struggle to locate fuel.

Frederick Bvalani is one of the co-founders of Malawi Fuel Watch (MFW), a Facebook group with over 7,400 members that shares information about the location and price of fuel in the country’s cities.

“The relatively low cost of communicating on the internet and the available audience on a forum like Facebook make it ideal for promoting change and connecting people that want to see a different and better Malawi,” says Bvalani.

For Billy Ngoma, 27, the benefits of MFW are obvious.

“You can spend six to eight hours in a long queue to get 25 litres of fuel,” he says. “The fuel watch group has helped those of us who use social networking so we know which gas station will have fuel.”

The future of social media in Malawi

From the online orchestration of the July protests to the buzz surrounding Mutharika’s death, it seems that social media is quickly gaining its bearings in Malawi.

However, the increased use of such speedy information-sharing platforms over the past year has also exposed some misuse of them.

Just as quickly as news of July protests and Mutharika’s death spread, so too did rumours and misinformation.

And on the part of the media, Munthali explains that BNL was simply unprepared to respond to the online community by the time the need to do so arose during the July protests.

“Our initiative was poorly marketed – apart from the feed from our reporters via text messages, we had few else to rely on as our Facebook and Twitter followers were not impressive.”

But such shortcomings are not enough to make the media shy away from embracing these widely used social platforms.

Nor is the threat of censorship.

“With the traditional media constantly hounded by unpopular laws enacted and enforced by the Malawi government, we intend to enhance our online presence by becoming more interactive with our audience,” he says.

And the means by which Malawians might engage with social media are improving. Since 2009, the MACRA has been rolling out Information and Communications Technology centres across the country. This initiative, alongside the installation of fibre optic cables in urban centres by Malawi Telecommunications Limited and the increased use of cell phones, will undoubtedly affect internet usage, and therefore, information access, in both rural and urban areas.

As President Banda transitions into her new role and the challenges that the country faces persist, it is still too early to know what effects this change will have – but Malawians will, no doubt, be talking about it online.

“There is something about the internet that gives people boldness to speak their mind – people are connecting, sharing stories and ideas,” Bvalani says. “Others who have suffered in silence speak out.”

“Social media has given Malawians a platform to have a voice.”