Having recently returned from one of the world's 10 poorest countries to one of the richest, I find it easy to let myself fall back into imagining that a simple transfer of wealth could alleviate the developing world's dual problems of poverty and disease.
The average Malawian makes less than $1 a day and has a life expectancy at birth of 37 years. As a white, middle-class, college-educated American, I could easily afford to double one person's income and probably extend his or her life by several years. But the 13 months I spent in this small sub-Saharan African country, where I worked as a nurse practitioner and a volunteer in missions for the Presbyterian Church (USA), have taught me that money can create almost as many problems as it can cure.
Like most Americans, I had never experienced true poverty until I flew into Malawi's tiny Lilongwe airport and traveled hours to Mulanje Mission Hospital, located among tea plantations in the shadow of Mount Mulanje. That first day, my housemate, an American doctor, told me, "We're not at the end of the world, but you can see it from here." I had read the statistics before I came -- that about 50 percent of the country's population is under the age of 15; that those between the ages of 15 and 49 are at greatest risk for HIV/AIDS, especially if they are women -- but that didn't prepare me for what I saw.
I watched rail-thin women walking for miles in the rain, shoeless, with their babies tied to their backs; weary men pushing enormous loads of firewood on their bicycles up mountain roads; starving children begging on the streets.
I walked those same roads, but I did so in comfortable shoes, and the chasm between my wealth and their relentless poverty immediately became a feature of my daily life. Money can be a useful tool if it is used discriminately. Otherwise, it encourages dependency and apathy, I discovered.
White SUVs owned by nongovernmental organizations, such as UNICEF, the World Food Programme and Save the Children were a common sight on Malawi's roads. The democratically elected government was known to be primarily supported by foreign aid. And because I am white, the people I met considered me a donor. In fact, as far as many Malawians were concerned, that was why I was there. So they asked me for help -- not for the medical help I had come to offer, but for money. I went from the nursing school to the public health clinic to the outpatient department, offering to teach, to write grants, to work on the antiretroviral program, to start a women's clinic. I found that everyone would say, "Yes, yes," but no follow-up would occur. Instead, the health-care providers would come to my door wanting help to buy refrigerators, to pay for school fees, to get new laptops. That is what our donations have trained them to expect.
Although Malawi has very few doctors and their poorly paid nurses are scrambling to leave the country for better pay overseas, my expertise was rarely viewed as an asset. There was little interest among the hospital administrators in my running a clinic that might benefit underserved women or teaching the health-care providers such skills. Knowledge, in itself, is not considered power -- money is. Even the smallest children had learned the English words, "Give me money." They knew I had it, and I knew it wouldn't really help them.
The few local health-care providers were eager to go to educational workshops sponsored by NGOs, not so much to supplement their education as to supplement their meager salaries. I remember one man rushing out to buy a toaster after getting his allowance. After attending a two-week UNICEF workshop on the prevention of mother-to-child transmission of HIV, nurses still refused to talk to pregnant women about being tested for HIV because of the stigma associated with the disease. I asked a group of nursing students what they intended to do upon graduation. They said they wanted to go to the United Kingdom, although there were some who wanted "to save Malawians."
But these nurses won't be able to save their fellow Malawians unless they can overcome the prevailing stigma themselves. AIDS disables whole communities because of the strain it places on the patients' minimal resources. The most productive members of society are the ones who are getting sick. Women are often abandoned by their husbands if they reveal that they are HIV positive. I was involved in supplying maize flour to 25 starving elderly people in a nearby village; 16 were women and 9 were men. All the women were caring for orphans, many of them their own grandchildren.
What's more, aid programs estimate that only 10 percent of those living in sub-Saharan Africa know their HIV status. To get a patient tested in Malawi, a health-care provider cannot simply send him or her to the lab. The patient must first meet with a special counselor who can see a maximum of eight people a day. At our hospital, there were four such counselors. This time-consuming process was mandated by the government because of the stigma associated with HIV. Malawians fear being ostracized by their community -- an outcome often considered worse than death, so many die without ever being tested for the disease. In a moment of cynicism, I thought about paying people to go be tested.
But perhaps the most telling moment came one morning, when an American ob-gyn I worked with began a discussion among health-care providers about what the developed world can do to help. She talked about health economist Jeffrey Sachs's U.N. Millennium Development Goals and his suggestion that the battle against malaria, Malawi's biggest killer, could be won if malaria nets were available to everyone in malaria-ridden countries.
No one at the meeting thought so. First of all, only a few of the providers themselves used nets and rarely advocated their use. Sure, people will take free nets if they are given out. But will they sleep under them? That's not as likely. Some Malawians believe they cause impotence; others say they feel hotter sleeping under nets; and some use them as fishing nets.
There are no easy answers to the questions I have after leaving Malawi. As Americans, we have good reasons -- moral, economic and political -- to be engaged with those living in poverty. They may think we are there only to give money. But money is not the answer; the real solutions are much harder than that.
Author's e-mail: email@example.com
Charlotte Gott, a nurse practitioner who has worked in family practice in South Carolina, returned to the United States from Malawi in March.