Jay Ruderman:

Welcome to All About Change. Now is a great time to check out my new book about activism. Find Your Fight. You can find Find Your Fight wherever you buy books and you can learn more about it at JayRuderman.com. Today, my guest is Mercy Kafotokoza. Mercy is a Malawian nurse, midwife, and public health professional with a master’s in public health. She’s also a mother of three and a passionate advocate for equity, compassion, and the power of proximity. As a young girl, Mercy experienced the heartbreak of losing her uncle to a preventable condition, a simple tooth infection that spread to his brain due to a lack of access to timely medical care. Then, as a young nurse, she again saw patients lose their lives because they didn’t have access to proper care. Mercy is now the founder of Wandikweza, a community-led organization delivering health with dignity directly to people’s doorsteps. At Wandikweza, no community is too remote to get help, and her strength touches me from across the world. Mercy Kafotokoza, welcome to All About Change. It’s my honor to have you as my guest today.

Mercy Kafotokoza:

My pleasure. Thank you for having me.

Jay Ruderman:

Mercy. I want to start off by talking about your career as a nurse, and you had a personal loss that really deeply affected your family and affected you, and, in fact, was the cause for you to become a nurse and to go into healthcare. You also worked inside of hospitals in Malawi and you saw the inadequacies of the system. Can you talk about both your personal life and the beginning of your professional life and what caused you to believe that healthcare needed to be brought to the people?

Mercy Kafotokoza:

Thank you so much, Jay. So I grew up with my grandmother. My maternal grandmother. She single-handedly raised me as a single woman. So my uncle had a toothache and that toothache was extracted at a traditional healer in the village. But after five days it got infected. But my grandmother didn’t know that these were signs of infection. So when she tried her best to find money to take my uncle to the next clinic, that I realized when I grew up that it was 54 kilometers away from our village. So she sold her two chickens, hired an ox cart, and took me and my uncle to the clinic. So when we got there, the nurse said, you had come late, you delayed. My uncle died after two days. So I made a promise to my grandmother that when I grow up, I shall be a nurse so that no one in our community or in our family should die because of something preventable.

So when I became a nurse, it didn’t take long for me to realize that there’s need to change because I entered nursing with the memory of the death of my uncle, I carried with me. So working in the public health facilities was a harsh awakening. I saw again and again what my grandmother feared, the death that could have been prevented. So every time I could see preventable deaths, I still remember one day a pregnant woman arrived too late at the hospital and after a cesarean section was conducted, we lost her and her twin babies. But this was not because there was nothing that we could have done, but because she came late to the facility. So then I said, I think I’m not doing something good here. I have to change how things are being done from reactive to being proactive to transform how healthcare is provided at community level.

Jay Ruderman:

So first of all, I want to commend you and I think there’s a couple of things that we should do. One, I think that we should unpack what Malawi as a country looks like and where people live and the network, the transportation network that’s set up right now. Because I think a lot of people listening to this podcast do not have a lot of knowledge about Malawi, but also the idea of coming to people’s homes and serving them is an idea that I’ve seen. So talk a little bit about your country and how it’s set up, where people live, how the transportation looks like, how the roads look like.

Mercy Kafotokoza:

Thank you, Jay. So Malawi is in the central part of Africa. The population is about 20 million. And [inaudible 00:04:55] percent of these live in the rural areas. So only half of the population live within five kilometers of a health facility. And most of these places there’s no public transport. And the only easiest way of public transport, it’s an ox cart. It means people traveling over 20 kilometers, 30 kilometers on an ox cart when they’re sick or when women are in labor. So the cost, the distance and lack of awareness hinders people from traveling from there where they are to the nearest facility and the public health services are free of charge.

But there are some that are private and these are very expensive that people living in the rural areas cannot afford access to healthcare. And most of these people have no source of income. So they live below the $1 per day. And mainly they depend on agriculture too as a source of income. So the cost, the distance and local of awareness prevent people from traveling to the next facility. And it’s also the terrain as well. It’s mostly, it’s mountainous and some places even when it’s flat, but maybe the rivers, the roads, there are no paved roads for people to travel. Most of the time is to be just footpaths.

Jay Ruderman:

When you started your career working in a hospital and I had a chance to visit one of the main hospitals in the Lilongwe, which is the capital of Malawi, the hospitals are overcrowded. They’re dealing with a lot of people, not all who can enter the hospital, a lot of whom are waiting outside. How did this idea come to you? At what point did you say, you know something, this isn’t working, people can’t get here. If they get here, the treatment is not adequate. They’re not all being able to be treated. People are dying before they can be treated. How did you come up with the idea that Malawi needed a better system of healthcare?

Mercy Kafotokoza:

I think nine years into my career I said, no, I think I’m not doing something right. We are just sitting at the facility or at the hospital waiting for complications to come, and then we react when complications happen. Especially when I saw the death of that young pregnant woman who died and her twin babies also died. I said, something really needs to change. We need to focus on prevention. So when the quesadilla focuses on prevention going into the communities where our problems are, focusing on prevention and not just waiting for complications to happen, also you saw how crowded those public facilities are. Our model reduces congestion in the public facilities because we deal with those issues at community level. So we deal with, instead of these people or patients going to the clinic, we bring the care at the household level. And this also leaves the burden on the nurses and the clinicians and the doctors at the facility level because maybe if there were about 50 people that they have see that day, they might see only 20 because we have [inaudible 00:08:08] at the household level.

Jay Ruderman:

So are you able to get mothers to come and deliver at the clinics or maybe a hospital, or are women delivering at home?

Mercy Kafotokoza:

We have seen improvement with women delivering at home, especially in indoor, because we have been indoor since 2016, and we also constructed a maternal shelter like women who come in their last trimester or a few weeks before they can deliver, being in that shelter. So when labor starts, they can easily walk into the labor ward. Also in the government facilities, some facilities have got shelters, so women who do come, but we still see women still delivering at home because of long distances, because of lack of knowledge. Sometimes because of cultural background, some women would just think of not disclosing that they’re pregnant, so they’ll hide their pregnancy up to the end and then when labor starts, the facility is far away and then they’ll opt to deliver at home. So we still have home deliveries, but the people, women delivering at the facility, we are seeing improvements.

Jay Ruderman:

How did you think about this idea of getting people the healthcare that they needed in particular, women that were so far remote and did not have the ability to get to a clinic?

Mercy Kafotokoza:

It came out of providing access to healthcare, to women in the rural areas. So we started with community health workers. We are training community health workers. These are just local women in the community that were trained how to identify complications and make referrals. And then we added mobile clinics. So our mobile clinics are done in a van that we go into very hard to reach areas. A team of health professionals go into the hard to reach areas and provide these services. So the noncommunicable diseases, maternal and child healthcare services is provided using mobile clinics. But we saw that when the mobile clinics are not there, there was need for continuity of care, continuum of care, even if the community health workers are there. But there was need for someone with higher education compared to the community health workers. That’s when the nurses on Bikes idea came in and why we use motor bikes, because it’s the easiest way of going into the communities.

They can do rough terrain, they can go through the footpaths and also it’s cost-effective. It doesn’t use a lot of fuel. [inaudible 00:10:35] fuel consumption as well. But also because our aim was to reach people with speed, to provide care with speed. So even with the motor bikes, the nurses can easily maneuver around the terrain and they can beat the traffic if there’s anything and go to the communities on time. So the reason we are using motor bikes is because it’s of the speed, it’s cost-effective. And also I think I can say climate change resilient because even when there are floods, when roads are broken, someone, a nurse can easily go to the communities using a motor bike.

Jay Ruderman:

When you and I visited one of the villages and there were two women who had just delivered babies and the nurse on the motor bike was there, I was impressed by a couple of things. One, the professionalism of the nurse, that he had in his motor bike, all of the necessary tools that he needed to diagnose and to check on the postpartum care of these women. Also, it was interesting to me that as he sat with them outside to look at their babies and to examine the women that the entire village gathered around and that during this other people would come up to him and say, well, there’s something that I want to talk to you about.

Mercy Kafotokoza:

I am a nurse and a midwife. One day I was working in the labor ward. A woman was brought to the labor ward in an unconscious manner, seven months pregnant. She was rushed to the theater and two twin boys were extracted. Unfortunately, the woman died. Two days later, the twin boys also died. The guardian said the woman had been complaining of severe headache and swollen legs, and she had been taking painkillers at home. If the woman had come to the hospital on time, she could have lived. Everyone has the right to healthcare, but this is not the case in remote areas. Malawians, we live as a community, so there’s always community support.

So what you saw with those two women and everyone coming in is community support. And that’s why the nurses on bikes is also effective because when the nurse is there, he doesn’t just focus on the women, but he can also take care of the other people that are there. They can take advantage of health education. They go around and see what is happening in the community, what is missing, where can we close the gap? And also the moral support you saw there were a lot of women that were there, men and women. Men and women as well. So it also provides moral support to the women. It’s like, in a Malawian context, it’s not just you with your baby or you just the household, but it belongs to the whole community.

Jay Ruderman:

And how do you go about choosing these nurses and how do you go about training them?

Mercy Kafotokoza:

So we recruit nurses that have basic nursing training. So the ones that have graduated with a nursing degree or a nursing diploma. And then when we recruit them, they learn how to ride a motorbike. So they get their license. So the motorbike training, they get their license, but we also add another training on how they can conduct community health, how they can provide healthcare at the doorstep because they’ll be trained to provide care in the hospital. But now here they’re providing care at the doorstep, how they can be part of the community, how they can develop relationships in the community, how they can learn the language in the community. Because sometimes these nurses will be coming from other districts that speak different languages from the communities where they are. So they take time to learn more about the community, understand the community, develop relationships. And most of the times it really takes time, six to nine months for these nurses to really understand the communities and be part of the community because they operate as one of the communities and not as an outsider when they go into the community.

Jay Ruderman:

So Mercy, you talked about a healer in the community or sometimes has been referred to as a witch doctor. What role do they play in the communities? Because I understand that they play a dual role. There’s some negative aspects of what they’re doing, and there’s some very positive aspects of what they’re doing. Can you describe a healer and how you work with them? Because they are a fact of life in most of rural Malawi.

Mercy Kafotokoza:

So there are two. There are some that are traditional birth attendance that will mainly focus on maternal and child health, like women delivering at home. So these are traditional birth attendants. The government phased them out, so they’re no longer there. The traditional birth attendants. People still trust them, the knowledge, the indigenous knowledge is still there. And we utilize them as champions that people can go, the pregnant women can go, to disclose about their pregnancy. But we also train these previous trained traditional birth attendance to be able to identify complications and whether refer them to community health workers. And even some have been trained to be community health workers. The traditional healers, these are kind of doctors. So they run their thing as a clinic, someone who is sick, they can go, someone maybe, who is coughing can go. So they act as a clinic unlike the traditional birth attendants.

So the way we work with these traditional healers is to make them understand complications and make referrals. For example, if someone is coughing, we work with them to say, okay, if you want to give the help to some to someone who is coughing, but make sure if they cough, it’s more than a week, make a referral. It could be TB. So we work with them, hand in hand, to know their limit and make referrals because we cannot deny it. People go there and this is an environment maybe where it’s 45, 50 or 60 kilometers away from the nearest clinic. And these traditional healers, they are closer to, almost in each and every village almost have these traditional healers.

Jay Ruderman:

Historically, Malawi has had one of the highest infant mortality rates and death of the mother. Can you talk about some of the main causes of why that may be happening and what’s some of the progress that you’ve been able to make?

Mercy Kafotokoza:

Yes. So about 381 mothers will die out of a hundred thousand life births. And mainly this is because of delay. They access care delay, it’s either there will be bleeding complications of maybe abortions and also infection when they give birth. So it’s either infection, bleeding, complications of maybe abortion that causes all these deaths, but cost, distance and lack of awareness. Sometimes they don’t even know that these are signs of infection. Fever, for example, they might think of going to a traditional healer, taking more time at a traditional healer instead of going to a clinic. So the way we are doing it is to make sure our care is closer to the people through the nurses on bikes. So the nurses on bikes, they can treat complications at home before they make referrals. If it’s something that they can stabilize, they can stabilize it before it becomes worse.

And these nurses on bikes, they have scheduled visits so they know who is pregnant in my community up until the child is at least five years old. So they have scheduled visits from six weeks, one month up until the child is five years old. So they routinely guard these households to avoid complications, working hand in hand with community health workers. So community health workers also proactively do the home visits. If these women don’t come to the facility, definitely the nurse on a bike will go to them or the mobile clinic will go to them. If they miss all these [inaudible 00:18:58] community health worker will [inaudible 00:19:00]. So we have a system that is intertwined or interrelated or integrated to make sure we don’t miss anyone.

Jay Ruderman:

And Mercy, can you talk about some of the successes that you’ve had since you have founded Wandikweza, and started the remote clinics and the nurses on bikes and ambulance service that will bring people quickly to a facility. How have you been able to save lives?

Mercy Kafotokoza:

Right now 85% of women start antenatal care in the first trimester. The reason we need women to start antenatal care in the first trimester is to identify complications on time, if there are any. And also that way is from 40% when we started in 2016, right now we are at 85% and 97% of women give birth at our facility. So in the communities that we serve, 97% of women give birth at the facility and we are able to respond to children when they get sick or when they show symptoms of illness within 24 hours. So whether a child has pneumonia, whether a child is [inaudible 00:20:07], we’re able to test and treat within 24 hours because this is a crucial time for children to get access to care on time.

Jay Ruderman:

I want to talk about female empowerment because I think that you are a fairly unique case in Malawi, you saw a problem, you took it upon yourself, you’ve had a lot of success. Tell me about the challenges that you faced as a woman in Malawi moving forward. In terms of the culture of the country.

Mercy Kafotokoza:

It was not easy. And it’s not easy, especially in our cultural contracts. Women are not supposed to make decisions, let alone concerning health. That’s why most of the women, when they’re sick or when they want to seek care, they wait for their husband to make a decision or their uncle or their father. So a male figurehead to make decisions on behalf of women if they want to access care. So me as a woman, I faced a lot of challenges at the community level, cultural barriers like there’s nothing that a woman can do. But when they men… It took me time. I think it took me two years to get the trust at the community level that things can be changed even when the woman it’s a leader.

Two years of developing things, understanding things, working with men, working with village leaders as well. Most of the village chiefs, they are men. So being in those circles, being in those tables with maybe they’re only men, to understand what we are doing, to understand how things can be changed, it really took time. And also even at the leadership level, when we go to present what Wandikweza does, there’s bias when an organization, it’s led by a man and when it’s a organization, it’s led by a woman. So even in those spaces, there’s that bias towards men-led organizations compared to women. So both at community level as well as at the leadership level.

Jay Ruderman:

And what inspired you?

Mercy Kafotokoza:

It’s those women. When we see those women, those children getting their care, those smiles, the hopes that we give to the people, everything is okay. So that fuels what we do every day. When you see someone that was neglected, someone that was isolated, now they are part of the community. Now they have the hope. Now they’re thriving. That keeps us going, especially me, it keeps me going. I always carry my uncle and my grandmother. By the way, my grandmother lived 97 years. So she saw Wandikweza and she was there. She was my cheerleader. Sometimes I feel like giving up, it’s so heavy on me, and then I could feel like giving up. And then my grandmother would always say, you can’t, this is not the time to give up.

You don’t give up on people. You don’t give up. You keep on going. So the promise that I made to my grandmother, the promise that I made to my uncle, even if he was dying, I said, I will make sure I change things. And that’s how Wandikweza was born. To take care to the people and not people going to where the care is because of the circumstances that we go through.

Jay Ruderman:

Those of us who are involved in activism always have setbacks, and there are times that we feel like we want to give up. And I commend you for pushing forward because persistence will always win out the day. And you’re lucky that you have role models in your life that inspire you and keep you going, and memories of people who’ve always supported you. But Mercy, I’ll tell you, one of the things that I was very moved by is not only are you as a woman really making a difference in your country in a significant way, but when I’ve gone to your clinics, they’re all women who are working there, who are running the clinics that you have then passed on this leadership to and made them. And I could see that from the smiles on their faces, how proud they are of the work they’re doing.

Mercy Kafotokoza:

They also act as role models, even in the village to a girl child. Because of the girl child seeing a nurse on a bike who is a woman, riding on a motorbike, it’s like they see role models and these women, they are now empowered, making decisions, sending their children to school, having their voice. And it’s also reducing. It’s contributing to reduction in domestic violence because when these women have their own income, they can at least have a voice even at the household level, these nurses, these, even the community health workers, 80% of our community health workers, female.

So if it’s even changing the narrative, even at the community level, so the community level to the facility level as well as to the nurses as well. We also do have the nurses on bikes that are male, but they work hand in hand. There’s no undermining the female nurses that they cannot do this. And also it gives the self-esteem even for the nurses, because when they ride and then do the rough terrain, provide the care at the doorstep, they feel like, I can do it. I can save life. So it also promotes the self-esteem even to them. I’ve seen girls saying, when I grow up in the village, when they see these nurses, I want to be a nurse and ride a motorbike like her. We are here to see what happens to those girls.

Jay Ruderman:

That’s beautiful. That’s beautiful. Mercy, listen, I’ve really enjoyed our conversation. Obviously we’ve met each other, we’re working together. I hope that things in Malawi will continue to improve. I wish that you will go from strength to strength and that your organization, Wandikweza will continue to grow and that you’ll continue to grow. And I’m glad too to know you, and I’m sure we’re going to meet again very soon. I know that next time I meet you, I’m going to hear about more success that you’re having. So thank you so much, Mercy, for being my guest on All About Change today.

Mercy Kafotokoza:

Thank you so much for having me, Jay.

Jay Ruderman:

Thank you for being part of the All About Change community. We aim to spark ideas for personal activism, helping you find your pathway to action beyond awareness. So thank you for investing your time with us, learning and thinking about how just one person can make the choice to build a community and improve our world. I believe in the [inaudible 00:26:40] people like you to drive real change. And I know that what we explored today will be a tool for you in that effort. All right, I’ll see you in two weeks for our next conversation, but just one small ask, please hit subscribe and leave us a comment below. It lets us know that you value this content and it supports our mission to widely share these perspectives. If you’re looking for more inspiration, check out this next video. I chose it for you and I know you’re going to enjoy it. I’m Jay Ruderman. Let’s continue working towards meaningful change together.

Today’s episode was produced by Tani Levitt and Mijon Zulu. To check out more episodes or to learn more about the show, you can visit our website Allaboutchangepodcast.com. If you like our show, spread the word, tell a friend or family member, or leave us a review on your favorite podcasting app. We really appreciate it. All About Change is produced by the Ruderman Family Foundation.