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Chapter Seven
The Medical and Relief and Development Departments

7.1 INTRODUCTION
These two departments are combined into one chapter because the nature of their work is so closely related; both deal with the physical needs of people. What follows is a general discussion of the history and the contribution of the medical department and subsequently more specific topics are addressed. We will see that the HIV/AIDS pandemic, while coming relatively late in the history of the Synod and of the country, has had such a devastating effect that it must be discussed, and not just in passing. The shortage of nurses, the mass emigration of existing ones, and lack of Malawian physicians will also be examined. The newly developed Nkhoma Synod Relief and Development Department, partnering with external agencies, will be seen to add a new and valuable dimension to the life and work of the Synod. We preface this chapter with the following evaluation from Rev. Ryk van Velden:
Looking at Nkhoma Synod from this perspective, it is remarkable to notice that while you find a very strong vertical, pietistic and personal ethics (moralistic) trend in the preaching, Nkhoma Synod in practice was always involved in a holistic ministry. Apart from the medical and educational projects, the Synod used to give attention to agriculture in the past. In later years the Synod broaden its holistic approach and understanding of its function by establishing the Department for Relief and Development; the Synodical Committee for orphan care and the Department for the Environment.   Although the Department is struggling, I am not aware of many churches which have a special Department/Synodical Commission only for the environment!

7.2 THE CONTRIBUTION OF THE MEDICAL DEPARTMENT TO MALAWIAN SOCIETY
In 1959 the Mission Council appointed a committee to advise the Council on the best way to integrate medical work into Church, society, and Government. Included were Mr. G. Nkhoma and Rev. K. Kalumo. In 1960 the Council decided to ask Synod to appoint the Malawian member of the medical committee; from that time, all expansion plans were to be considered by a Liaison or Joint committee of both Council and Synod. When the Mission was dissolved in 1962, the medical department was placed under Synod control, with a medical department under the authority of the Synod�s General Administrative Committee (Pauw 1980: 189-90).
The 1966 Medical Report listed:
Nkhoma Hospital, 171 beds; Mvera Hospital, 48 beds, Mlanda Hospital, 48 beds, and Malingunde Hospital, 50 beds. It stated that, �In the past year we saw an unusual number of children suffering from measles and whooping cough in most of our hospitals� . . . At Mphunzi many children died of measles mainly because of lack of penicillin at that time.
The Medical Report for 1967 revealed that the Nkhoma Hospital completed a new surgical unit. The first operation in this new unit was performed in June 1967. The President, Dr. Kamuzu Banda, visited in November and praised Nkhoma Hospital.
On Monday 27 Nov. 1967 the new surgical extension of Nkhoma Hospital was officially opened by the President of Malawi, Dr. Banda.
. . . In his speech he said: �I am also a Christian, and I received my first formal school training in the mission school at Kasungu�.
At the meeting of the GMSC in Cape Town 22-24 June 1969 it was stated that at Nkhoma Synod�s four hospitals and clinics there were 69,476 outpatients, 9,711 hospitalised patients, and 56 nurses in training. For the first time a qualified Malawian nurse was appointed, after five years of training in Scotland.
In his �Annual General Report for 1969,� Secretary General YA Chienda reported the medical department consisted of Nkhoma Hospital (185 beds), Mlanda Hospital (48 beds), Mvera Hospital (48 beds), and Malingunde Hospital (50 beds). �The attendance at the various dispensaries has been good except at Mphunzi.� His report also mentions �the poor state of most of the buildings�. The number of patients was increasing (in-patients increased from 9,711 in 1968 to 11,539 in 1969) but at Malingunde a ward was closed. The hospital facilities needed to be improved, but there was a lack of funds.
In 1973 Dr. Blignaut and Rev. C. Martin Pauw were ordered to leave Malawi by the Malawian government because Blignaut operated on an injured dog at Nkhoma Hospital. An offended Malawian reported this to Government authorities, resulting in the deportation.
The 1973 deportation of Dr. CJ Blignaut was a blow to the medical department. Added to this was the resignation of Dr. Swart. However, the DRC office in Cape Town persuaded him to rescind his resignation. He was appointed as Superintendent of the Hospital, after Dr. P. Pretorius had briefly served as acting superintendent.
A November 1974 meeting of the Moderamen happily reported that this removal of Blignaut had been reversed. They gave credit for this reversal to the President.
Committee is glad to hear that H.E. the Life President Ngwazi Kamuzu Banda has allowed Dr. Blignaut to return to work in Malawi. Committee also notes that Dr. Blignaut will come after he has written his examinations in March next year. Committee expresses extreme gratitude towards H.E. the President for his allowing Dr. Blignaut to return.
At the August 1977 meeting of the General Synod, Nkhoma Synod gave the following report concerning its medical department.
The medical work is continuing satisfactorily, but some time back there had been much difficulty in obtaining sufficient expatriate staff. An extensive renovation of Nkhoma Hospital with funds received through the CSC will start this year. Shortage of funds for the running expenses has become a major problem. The medical superintendent is Dr. CJ Blignaut, and the very able Hospital Secretary/ hospital Administrator is Mr. AK Kuleza.
South Africa was not the only benefactor for Nkhoma�s Medical Department. In 1977 the electrification of the Nkhoma hospital buildings was made possible by a large grant (�up to DM810.000�) by the Evangelische Zentralstelle fur Entwicklungshilfe (EZE) of West Germany. The grant stipulated specific controls over the spending of money, and it was anticipated to be a two-year project.
The General Secretary�s Annual General Report to Cape Town praised the medical work for 1980. The medical staff increased by six, thus there was no shortage of doctors in 1979. They got a hospital chaplain for the first time when Rev. M.U. Siwinda joined the staff in December 1979. The Christoffel Blinden Mission in West Germany continued to give a monthly grant of MK600, and Sonnevanck in Holland donated MK6400 for blankets and mattresses for the TB wards. This organization had the previous year given the money for an X-ray machine. Besides the Nkhoma hospital, there were the �out station� hospitals of Malingunde, Mvera, Malanda, and Malembo.
As in the past, the medical department was not confined to the Nkhoma Hospital.
Mphunzi Hospital: There is a small clinic on the old Mphunzi mission station. As part of the Land Development Programme of the government, which is financed by the World Bank, a new larger clinic will now be built at the foot of the spectacular Mphunzi Mountain.
In 1982, Nkhoma Synod submitted a report on its medical work to the CCAP General Synod:
The work at Nkhoma Synod is continuing satisfactorily. There are at present five doctors and many qualified nurses. These doctors visit clinics at various places in turns. Dr. CJ. Blignaut is the medical Superintendent. This is the only field which has the most expartriate (sic) missionary staff. Plans are underway to recruite (sic) some Malawian young men that they may be sent abroad to study medicine. The Synod has now allocated two ministers, namely Rev. L.J. Kamtambe and Rev. Siwinda to be hospital Chaplains in Lilongwe and Nkhoma respectively.
Concerning the medical mission work, a report by Dr. Chris Blignaut included the following:
The medical work started in 1915, the first medical doctor arrived in 1930, and nurse training began in 1958. At the time of this report � 1984 � the government subsidized 80% of the hospital�s expenditures. The balance was covered by donations, patient fees and an amount from the Synod for the Nurses� hostel, although this amount was actually also paid by the Women�s Guild of the DRC in South Africa. The hospital had 203 beds, 27,000 outpatients, and 6,000 in-patients per year. There were 5 mobile units and 8 clinics run by the hospital. The clinics reported treating 67,561 outpatients and 4,639 in-patients. There was much being done in eye work. In 1930 Dr. RL Retief started removing cataracts. In 1975 Dr. C. Blignaut returned to Malawi as a fully qualified ophthalmologist. In 1978 the Christoffel Blinden Mission in Germany began showing interest in the work, and in 1981 began rendering financial assistance. Because of this Dr. Blignaut was able to be involved in full-time eye work over the whole of Malawi. From funds from this organization, a ward with 18 beds, a theatre for eye surgery, and eye clinic and a microscope were all acquired. In 1983 they also donated a 4x4 vehicle (including funds for maintenance of this vehicle), as well as a workshop at Nkhoma where lenses were being fitted into frames. Rev. Siwinda, hospital chaplain, was involved in the spreading of Christian literature and in morning devotions in all wards and departments.
Operating under conditions of scarcity, an organisation may face difficult choices. An example is the choice the Synod faced in 1984: a medical technologist, or teachers?
The committee was informed that Synod should sacrifice three teachers� posts in return for a medical technologist who will be attached to Nkhoma Hospital. The committee does not agree, as Synod would need all 12 teaching posts when all three secondary schools are in operation.
However, just three weeks later, the same committee reversed itself.
Because the services of this man are greatly needed at the hospital, the committee agrees that he should come for a period of one year. This resolution replaces (M. 792).
The clinic at Malembo ran into an unexpected and awkward problem in 1985. A letter was received from the District Commissioner in Mangochi informing the Synod of a potential land dispute. The following account illustrates how important it is to maintain good relations with traditional authority.
The land on which the (new) hospital at Malembo is built appears not to belong to Synod. The committee instructs the Moderator to go there to meet with the local chief. He should go without delay before serious problems arise.
There never was a �hospital� at Malembo, but rather a clinic. Alternative property was provided, and the clinic is still operating there.
In 1990 the Nkhoma Synod gave the following report of its medical department to the CCAP General Synod:
The work at Nkhoma Hospital is continuing satisfactorily. There are at present five doctors and many qualified nurses. These doctors visit other small hospitals and Clinics at various places in turn. Dr. C.J. Blignaut is the Medical Superintendent. At Mvera, Mlanda and Malingunde there are small hospitals, and at Malembo and Chinthembwe small maternities. At Dzenza, Mphunzi and Chogodi there are out patient dispensaries. All these health Centres are administered from Nkhoma and are visited once a month by one of Doctors (sic). During 1988 a total of 127,000 new out patients were seen all these Units (sic), 8,500 we admitted and 2,900 deliveries were recorded.
In 1994 Nkhoma Synod submitted a report to the CCAP General Synod meeting. With Dr. CJ Blignaut as the Medical Superintendent, there were five doctors and �many qualified Nurses�. There were several Health Centres: Mvera, Malingunde, and Mlanda (which were small hospitals), maternity clinics at Malembo and Chinthembwe, and dispensaries at Dzenza, Mphunzi and Chigodi. These all got visits from the doctors once a month. In 1993 there were 110,928 outpatients, 9,641 who were admitted, and 4,357 deliveries.
Dr. Johan Eloff took over the eye work from Dr. Christoff Blignaut early in 1997; Dr. Blignaut retired on pension in 1996.
Dr. Blignaut announced with sadness that he was leaving. He said that his real home was not South Africa, but Malawi. He came to Malawi in 1940, and got married at Nkhoma soon afterwards. He was involved in the eye work for many, many years. However, due to his growing age, and the advancement in new technology, he felt that it was fair to make place for the younger generation. He apologized for any wrong he might have done to other people, and then extended his good wishes to the Synod.
African Bible College opened a clinic in 1999. It has a full time American doctor, but on Wednesday�s doctors from Nkhoma Hospital (who formerly went to Lingadzi CCAP) see Nkhoma Hospital patients from the local Lilongwe area utilizing the ABC clinic facilities. Another Lilongwe facility is located at Chimwala CCAP.This was begun by a Korean lady. She has been running it all on her own, in the face of difficulties from the minister in charge.
Over the years, many children have been born; many lives have been saved through the work of Nkhoma Synod�s Medical Department. Additionally, the eye department has given a much-needed specialised service; many owe their sight to this work.
Today Nkhoma Synod maintains ten health centres throughout the Southern Region of Malawi. It has a Medical Board that investigates the possibility of establishing new locations.
The PCUSA gives the following description of the present state of the Nkhoma Hospital:
Nkhoma Hospital in Nkhoma, Malawi is a large and vital institution providing a wide variety of medical services to its community. Working with a staff of 135 people and an inpatient capacity of 220 beds, Nkhoma Hospital has five separate buildings for patient care: paediatrics, maternity, general medical surgery, ophthalmology and a 24-bed TB unit. In addition, Nkhoma serves as a referral centre for an extensive satellite system of smaller hospitals and clinics.
. . . Over 1,500 new patients are seen annually in the eye clinic. Nkhoma Hospital also manufactures its own glasses and eye drops. The eye service is extended to six other mission hospitals in Malawi by means of annual weeklong visits for examination and surgery.
The nutrition program at Nkhoma has three brick houses, similar to village mud huts, plus a kitchen and training room and a demonstration garden. They are proud of a new mud stove which allows three pots to cook over one fire. Children are usually referred from the hospital and stay two to three weeks with their mothers. The mothers go home with the knowledge of a balanced nutritional diet, new skills in food preparation and seeds for gardens. They can return every Monday for food supplements. Only traditional food is used.
Public health workers on bicycles and motorbikes follow up TB cases in the villages. They are often able to identify the early stages of other illnesses and assist in getting the patients to the hospital. They also work on water supply and sanitation. The prenatal clinic sees about 260 weekly. Family planning is being taught to village people and they then in turn give the information through to their fellow villagers. The hospital also has a static and four mobile Family Planning Clinics (PCUSA 2004).
CM Pauw in 2002 described how Frank Dimmock, a PCUSA missionary and Health Coordinator for the CCAP, wanted to �revisit� the administrative system at Nkhoma Hospital�, and perhaps write a new kind of constitution�. Pauw observed that Dimmock had done the same thing at Mulanje and Livingstonia CCAP hospitals and that it had produced good results.   Nkhoma Synod accepted Dimmock�s offer. He has been working closely with Dr. Reynier Ter Haar in producing the new constitution.   The implication here is that all three facilities had administrative problems, but were corrected.
The Medical Department of Nkhoma Synod has rendered invaluable service to the people of the Central Region of Malawi for decades. It has earned the respect of people outside of the Synod.

7.3 MALAWIAN NURSES, MALAWIAN DOCTORS
Medical personnel are essential to the operation of Nkhoma Synod�s Medical Department, particularly Malawian ones. Few would argue that expatriate medical personnel lack the depth of cultural understanding that Malawian staff would have.
In 1983, the Moderamen decided that it would be good to have a course to train registered nurses. However, it deferred to the hospital committee, which would have to determine the feasibility.   The Moderamen in 1987 gave its consent to nurses at the Nkhoma Hospital going to South Africa for advanced studies. It ordered the Hospital Committee to study the feasibility of this happening.
In 1996 Dr. Nico van Velden sent an urgent appeal to Rev. Koch, Secretary of the missions office in Cape Town. The reason for the urgency was that the nursing school at Nkhoma Hospital, along with the other nursing schools associated the Christian Hospital Association of Malawi (CHAM), was about to lose its funding from Concern International. Attempts at finding other donors had not yet succeeded. In writing to Koch, van Velden said that he knew that the Missions Office had no funds to give, but that perhaps they could put Nkhoma Hospital in touch with those that did. He then submitted a budget that a shortfall of MK 667,660.
There is such a shortage of nurses in Malawi today that health care has drastically suffered. A 2004 New York Times article illustrates the problem.
At Lilongwe Central, an 830-bed hospital, there are supposed to be 532 nurses. Only 183 are left. That is about half as many as there were just six years ago. And only 30 of those are registered nurses, the highly skilled cadre that is most sought abroad (Dugger 2004).
At Lilongwe Central Hospital, often a nurse is responsible for fifty patients. The article goes on to say that two thirds of Malawi�s nursing positions are vacant, and that since 2000 more registered nurses have left Malawi than the 336 that are left now. The problem is emigration. A registered nurse in Malawi earns US $1,900 a year; starting salary in Britain�s National Health Service is US $31,000 a year � and working conditions are far better. Besides Britain, Malawian nurses are immigrating to Canada, the US, Australia and New Zealand. Malawi and other African nations are starting to complain that poor nations are subsidising the rich ones who receive these nurses.
At Nkhoma Hospital, there is also a felt shortage of nurses. However, the training of nurses continues at Nkhoma.   The PCUSA, a partner of Nkhoma Synod, gives a fuller description of this nurse training.
Nkhoma hospital also serves as training institution. A nurses school at the hospital trains general nurses and midwives. Over 60 students are currently in training. We hope to expand to post graduate training in the near future (PCUSA 2004).
Malawian doctors, while rare, have existed. There is the story of Jeremiah Mgawi. He was fortunate to find a sponsor for his medical studies in 1984.
We have received a letter from the secretary of PHAM that the organization called MEMISA in Holland has agreed to help Jeremiah Mgawi with an amount of 5000 Dutch Florins (K2100). The money will be sent to the Synod Office at Nkhoma as soon as it is received by PHAM.
More than a decade later, he had completed his medical studies. Along with a colleague, he offered his services to the hospital at Nkhoma Synod.
Two doctors applied for work at Nkhoma Hospital, namely Dr. Mgawi and Dr.Chaziya. The committee affirmed that both were actually needed at the Hospital, but due to a lack of accommodation, it was suggested that Dr. Mgawi be given priority. As soon as other accommodation would become available, however, Dr. Chaziya should also be taken.
The Synod insisted that �accommodation be found for both of them.�
Dr. Mgawi, according to one Nkhoma Synod minister, fell into alcoholism and drug addiction. He also beat his wife. He was restored to service, only to lapse into his former behaviour. This caused a final dismissal.
Rev. CL Chimkoka adds to the story by saying that Mgawi was actually known to operate while inebriated. When he left Nkhoma, he set up a private practice in Malawi for a brief time, then returned to South Africa. It was there that he died in his sleep from a drug overdose. The other Malawian doctor, Chaziya, left Nkhoma after two years. He was unhappy because he did not receive the same housing and car allowance as white doctors. Malawi trains nurses, but no medical doctors.
In 1996 a joint meeting between the Moderamen and the DRC personnel formulated the following plan regarding Malawian medical personnel, to be reached by 2000:
Dedicated Christian Malawian doctor(s) with integrity will work at Nkhoma Hospital with the possibility that one may become the superintendent in due course. (Remark: In order to find doctors the Synod must develop an attractive salary packet for Malawian doctors).
The majority of doctors, sisters, and other medical staff will be Malawians. The remaining DRC health personnel will render professional service to Nkhoma hospital for example in areas of specialty.
Meaningful and continuous equipment (professional and spiritual) of health personnel (DRC and Malawian) for their ministry as Christians in the health services will take place through seminars, visitation, counselling, and practical work with the help of DRC health personnel. (The possibilities to allow able, Spirit filled health personnel (DRC and Malawian) to do spiritual work/counselling even during working hours will be investigated.
As of mid � 2004, these goals have yet to be realised.
In 2001 the possibility of a Malawian doctor again presented itself. A Dr. Henry Phiri expressed interest in working for Nkhoma Synod�s Medical Department. In June of that year, Nkhoma Hospital�s Dr. Reynier Ter Haar informed CM Pauw, Secretary for Foreign Partnerships and Missions, Commission for Witness in the Western Cape, �due to the urgent need for Malawian Doctors, we can accept this application�.   It did not produce a long-term result. Like Chaziya, Phiri�s stay at Nkhoma was short.

7.4 THE CHALLENGE OF HIV/AIDS
In the midst of the continuing difficulties of experienced by the challenges of financial hardship, lack of trained leaders, etc, the mid 1980�s revealed a new and even more sinister problem of HIV/AIDS .
The PCUSA report on the work of Nkhoma Hospital affirms that AIDS has become a problem in Malawi. Inevitably, this affects the life of Nkhoma Synod.
Like other hospitals in Malawi, Nkhoma is seeing an increasing number of AIDS patients. The AIDS epidemic is affecting the work force and productive part of the population. It results in loss of skilled labour and many orphans that need to be looked after by the extended families (PCUSA 2004).
The church as a whole was slow to address the problem, because of its association with sinful activity. Its initial response was to view the pandemic of HIV/AIDS as an issue outside of the role of the church, often taking a position of condemnation towards those suffering from this plight. As it became more and more apparent that AIDS was affecting the entire population, including the congregations of the CCAP, church leaders began looking for ways to attend to it. Recognizing their failure to address the issue adequately, the Nkhoma Synod developed the Chongoni Document as a charge to themselves and a declaration of their recognition of the position of the church regarding the issue of HIV/AIDS:
Chongoni Declaration Of Nkhoma Synod
We,
Ministers of Nkhoma Synod CCAP,
Gathered Here at Namoni Katengeza Church Lay Training
Centre from 10 to 11 May 2000;
Noting with great concern the devastating effect
Of HIV infection and AIDS in Malawi,
Do hereby DECLARE that we as a Church
Confess and repent before
The Almighty God
That we have not obeyed His Word,
And that we have not been fully involved
In addressing the HIV/AIDS crisis,
And that we ask for God�s forgiveness,
And that from now onwards,
We will take
A preventative, care and support stand.
Taking this significant stand on the issue of HIV/AIDS in 2000, indicates the sensitivity of the Nkhoma Synod to role and opportunity of the church to act in a proactive way towards those in their midst suffering from this disease. Missionalia Magazine identified the opportunity facing the church that had been recognized by the Nkhoma Synod a full four years earlier,
This creates both a challenge and an opportunity for churches to make a unique contribution. Churches, more than any other institution in the country, are in a position to influence community attitudes, provide education about AIDS, diminish prejudice, provide care and nursing (Nicholson 1994: 228).
The Nkhoma Synod developed the AIDS desk as a multidisciplinary team devoted to addressing the multifaceted issue of HIV/AIDS. In a similar way to the that described by MAP International, and discussed in their booklet aptly titled, �Choosing Hope�:
Traditionally, the Church has avoided talking about these issues. The AIDS epidemic has come upon the world primarily because we have left God�s plan for sexuality. The Church � must teach people about God�s view of sexuality, which includes: the roles of husband and wife, man and woman; attitudes and relationships that we should have towards one another; the relationship of men to women and women to men; sexuality as a reflection of Christ and the Church.
Similarly, the Church must discuss sexual issues with youth and parents. This includes talking to youth about body changes, sexual temptation, and healthy sexual experiences within marriage (MAP 1996:5 counselling).
The Nkhoma Synod recognized the church�s responsibility to teach their people, from the early youth to the adults what God�s principles are concerning its responsibility regarding these issues. Synod decreed in 1991 that a hospital be opened at Namoni Katengeza. Although not completely stagnant, this scheme has not yet been realized, due to the all-too-common �lack of funds� � and personnel.   It also mandated that one of the committees of Synod would be the Hospital/AIDS Committee.   The AIDS commission, headed by Rev. Zulu oversees the HIV/AIDS education for the Nkhoma Synod in a comprehensive way, addressing not only the role of clergy and pastoral duties, but also issues surrounding gender relations, orphans, youth along with the medical and social implications caused by the disease. Synod affirmed the freedom of an individual to take a test for HIV/AIDS before marriage stating that if one had doubts about one�s partner, then the marriage should not take place; testing should be by mutual consent.
Both NIFCOTT and Zomba Theological College participate in NetACT, or Network for African Congregational Theology (see 13.2 for a more detailed description of NetACT). Although not its central aim, this organization seeks to equip its member institutions with the training and skills necessary to heighten churches� sensitivity and receptivity to the multifaceted ramifications surrounding the HIV/AIDS pandemic. Both of these institutions have been given the specialized �HIV/AIDS Awareness: Breaking the Silence� training developed by Rev. Christo Greyling, which has in turn then been integrated into the curriculum at their colleges. In addition, Lewis Mwanamqekha from Zomba Theological College has received additional facilitators training for application to those outside of the colleges academic circles, including churches and other bodies within or associated with the Nkhoma Synod.
In addition to recognizing the need for the pastoral and spiritual involvement with HIV/AIDS, Nkhoma Hospital has been proactive in assisting with the concrete physical needs of those suffering from the disease. The hospital at Nkhoma today is a 220-bed facility that stays about 80% full all of the time using donated equipment that is admittedly �a bit out-dated�. The out- patient department (OPD) sees about 80 patients per day. It has four doctors: only one of which is South African, another is American, and then there is a Dutch husband-wife medical team. It is self-supporting apart from projects; among expatriate donors are DFID (British) and Friends of Nkhoma (Dutch) with the Malawian Government subsidizes an immunisation programme. It is estimated that about half of the patients are HIV/AIDS � infected.
CCAP General Secretary YA Chienda says that the HIV/AIDS phenomenon has affected the work of the CCAP �very much�. He was the Nkhoma Synod General Secretary when AIDS was first identified. He asked a doctor at the Nkhoma hospital if any AIDS patients were Nkhoma Synod members. He describes feeling shocked when he learned from the doctor that three-quarters of them were. The shock continued as he saw that Nkhoma Synod leaders and ministers were among the patients. �This was terrible to me,� he says. He reached a point where he was conducting a funeral nearly every day. He says of that experience, �I never before buried the dead while a minister like that�.
The impact of HIV/AIDS has affected nearly every aspect of the Nkhoma Synod, with no promise of relief in the anticipated days to come. Funds that could be used to support a diversity of ministries are instead being funnelled into caring for the sick and dying. While the Nkhoma Synod has moved forward with a proactive response to this plight, it is certain that this will be a continuing challenge for the Synod in the foreseeable future.

7.5 FISCAL CONSTRAINTS AND OUTSIDE DONORS
This section will illustrate how the Medical Department of Nkhoma Synod became the recipient of an international humanitarian effort. Working against the background of the scarce resources of the people was the willingness of medical personnel to come and work, and donor organisations to contribute.
In April of 1964 it was noted that the medical Department would be an increasing burden to the GAC in 1964. The reasons stated was that the shortage of expatriate staff would generate fewer grants from the government, and the necessity of hiring Malawian personnel who would only work if paid according to government salary scales.
The GAC in 1968 expressed concern over the shortage of doctors. The Committee made it clear that they looked to the DRC to rectify the situation.
Seeing the great numbers of people who stream to our hospitals for help, especially so at Nkhoma, we all realise that more doctors are realy needed, and urgently. The General Secretary must write to the D.R.C. about our great need.
In 1971 the GAC expressed a similar concern. This time it was about an acute shortage of nurses (see section 7.3, �Malawian Nurses, Malawian Doctors.�)
The chief concern is for the shortage of sisters and nurses. We must therefore entreat the Lord to call workers to this work, because there is a very real danger that if such staff are not found, the training of nurses will be stopped which is a terrible thing.
In 1977 there was a proposal for a doctor for Mvera hospital. Dr. Blignaut vetoed the idea, citing financial constraints. After all, he explained, there were Government hospitals at Dowa and Salima with doctors � 16 and 28 miles (�quite near�) from Mvera respectively, on good roads, with bus service. In addition, the Dowa doctor visited Mvera weekly or perhaps twice a month.
In addition, in 1977 Dr. Blignaut reminded the Synod that they had pledged the revenues from Synod Week to the work of the hospital. They responded that when it came in from the congregations, the hospital would get it. Moderamen instructed the hospital to raise its fees �because of lack of funds�. At the same time,
Committee is very grateful to hear that the Mother Church has helped us to get grants from Holland for the Eye Clinic. Committee instructs the General Secretary to write a letter of thanks, and asking them to continue finding similar grants elsewhere.
The international nature of the medical assistance that Nkhoma Synod received can be seen in the aid that came in during the seventies and the eighties. In a letter dated 15 November 1977, Treasurer G.C. Reyneke informed Synod about progress in the modernization of Nkhoma Hospital. He said that West Germany�s Evangelische Zentralstelle F�r Entwicklungshilfe had donated DM 810,000 or about MK 300,000, subject to certain controls. The money could be used only for purposes set forth by the Christian Service Committee. Other controls detailed how the books would be audited.
In 1983 The Christoffel Blinden Mission asked permission to send a specialist who would make and repair eyeglasses at Nkhoma Hospital. This was accepted.
The Moderamen noted in 1985 that there was an opportunity for members of Nkhoma Synod to go to the Medical University of South Africa (MEDUNSA) for medical studies. They instructed the Education Secretary to take the necessary steps to see that this happened. Applicants already existed.
The Committee decided that those who applied to be trained at the Medical School at MEDUNSA, should go. The Senior Clerk of Synod should find out about the possibility of this. But the candidates who will be considered will be those who have applied already like messrs Samuel Kainja and Robert Chirwa.

These two particular individuals never left for South Africa.   A decade later however, two South African-trained Malawian doctors did arrive at Nkhoma Hospital, although they did not give extended service (see section 7.3, �Malawian Nurses, Malawian Doctors�).
The same meeting gratefully acknowledged the donation of MK 10,013.17 from donors in Holland for the Chilanga School for the Blind.
Sometimes the international aid that was received was not quite enough. In June 1990 at an emergency meeting of the Synod, prompted by a financial crisis, it was decided to suspend the position of chaplain to the hospitals of Lilongwe. Later in the year, Lilongwe CCAP offered to support Rev. Katundu so that he could continue the work of hospital visitation. The Moderamen gratefully accepted this offer.
In 1991 Nkhoma hospital found itself in financial difficulties because the Malawian government decreased its subsidies to private hospitals. That year it found itself with a deficit of about R 60,000. The Private Hospitals Association in Malawi (PHAM) sent a representation to the government. The Malawian Government has enough problems. To alleviate the crisis, donations amounting to R 35,000 were sent from South Africa.
One of the goals which was formulated in April 1996 at a meeting in Malawi when the Moderamen, the Personnel Committee and Rev. JH Koch met together, was the employment of two dedicated Christian Malawian doctors who would take the place of two vacancies for personnel of the DRC. It was recognized that in order to find such personnel, the Nkhoma Synod would have to offer attractive salaries like other mission hospitals of Malawi were doing. Narollah Trust in South Africa considered donating MK 80,000 annually to meet this need. It was agreed with Nkhoma Synod that these funds would be used for medical work at the hospital. It was agreed that the hospital should upgrade the salaries of the two doctors from the funds which being generated by treating private patients.
The Executive Commission For Witness and Mission held a joint meeting with the Moderamen of Nkhoma Synod in early 1997 where several decisions, largely related to the �Goals for Partnership� were reached. It was decided that recruiting of Malawian doctors should be a priority and funds would have to be found for accomplishing this. This matter was referred to the responsible commission of the Synod, who had to determine a realistic salary package. The services of a Christian worker were required for the hospital with the aim of training the hospital personnel to be equipped to do spiritual work amongst the patients. The ideal person should preferably be a woman with a medical background.
The donations from various sources continue to arrive. A May 2003 Moderamen meeting noted the arrival of two new ambulances for the hospital. In light of this, the Moderamen directed that the Synod office and the hospital should exchange one vehicle, so that the Synod would have a car to use.   Vehicles for Nkhoma Synod, or the lack thereof, are only part of the problem as the road to Nkhoma continued to be unpaved and often in disrepair.
Nkhoma Synod appoints a member to the Board of Directors of CHAM (Christian Hospital Association of Malawi). At the time of this writing, that person is the General Secretary, Rev. Dr. Winston Kawale. This organization coordinates health services and solicits funds from the government and from donors.
The CCAP General Synod Standing Committee included in its �Ten-Year Strategic Plan 2000-2010� a section regarding health care, noting that almost all synods operated hospitals and clinics, and the funding came from the government, from overseas donors, and from patient fees, rather than from synodical resources. It went on to acknowledge that a crisis in health care was caused by the HIV/AIDS pandemic, as 75% of patients were HIV-infected. This created the need for the training of more nurses and other health care workers and volunteers. The report spoke of the role of pastors.
Ministers and other church leaders should be given opportunities to train in the pastoral care of AIDS patients both in the home and in hospital. It is important that the Church takes on a strong and focused pastoral role in the care of AIDS patients and their families. Counselling and spiritual support for both patients and families is a valuable complement to the work of the health professionals in the Church.
The Strategic Plan report admitted that overseas donors would be needed for expansion of health care and training facilities. The section on health ended by saying all pastors should regard themselves as chaplains of the hospitals within their jurisdiction.
It has been shown in this section that an international effort was needed to keep the Nkhoma Synod Medical Department operational. This international effort took the form of both financial support and personnel. However, Nkhoma Synod makes a real contribution in that it can provide nurses and chaplains that understand the patients� needs better than can expatriates. The training and retention of Malawian medical personnel remains an elusive goal.

7.6 THE RELIEF AND DEVELOPMENT DEPARTMENT
At the CCAP General Synod meeting of 1990, Nkhoma Synod announced the inauguration of a major new work. It concerned the area of development.
Another decision that was taken at 1989 Synod meeting was the formation of (the) Relief and Development Committee starting from congregation, Presbytery up to Synod level. These committees will be responsible for seeing areas that need development in their respective constituencies. This will range from individual church members non church members (sic), families and villages as to how they can be helped to introduce and initiate development in undeveloped areas within their own lives so that a change for good can be experienced in their economic and spiritual lives.
Beginning in September 1990 there was forged a partnership between the Nkhoma Synod Relief and Development Department (NR&D) and the Christian Reformed World Relief Committee (CRWRC). A component of this partnership has been the Women In Development programme that involved health, income generation, and agriculture. This programme used 23 community development facilitators working with 100 community groups in five districts, and with almost 6,000 individuals or households. The WID programme expanded from impacting 2545 families in 1998 to 5733 families in 1999/2000. This expansion was the result of the decision to work in the lakeshore area, which was afflicted by drought. The results of this work were so positive that communities requested further development through WIDs; this tended to have the result of reducing food insecurity. NR&D also initiated an Adult Literacy programme (see section 5.3) and a Diaconal Development programme that trained �diaconal committees� working in local congregations. NR&D collaborated with Malawi government local officials in such areas as literacy, forestry, agriculture, and health. Under yet another programme was known as Partners for Christian Development (PCD). This involved an exchange with North American farmers and business people (CRWRC Web Page: accessed 4 August 2004).
The 1994 CCAP General Synod received a report from Nkhoma Synod concerning its new Relief and Development Department, directed by Rev. WDM Gande. This department was divided into several different areas. One was Women In Development, which had trained 8 women to be Community Development Facilitators. Their aim was to assist communities to achieve self-reliance by providing seeds, chickens, and training in needlecraft work. There was also an agriculture section that was to deal with village, teaching them �Forestry, Nurseries, intercropping of maize and soya beans; dry planting of vegetables and cross breeding of goats for nutritional milk to small holder farmers.� Another section, labelled �Income Generating Activity�, operated at Mchenkhula, Thyolakhosi, Mchenga and Chilobwe. Among its activities was assisting people in starting small businesses.
In addition, in 1994, a delegation from the Relief and Development Department flew to Kenya for a conference.
On March 21-25 (1994) the staff of the Relief and Development Department attended a training conference in Kenya. The theme of the conference was �Building and Strengthening Capacity.� This theme was developed at the individual, community, and organizational levels. The focus was on increasing capacity in agriculture, micro-enterprise, and literacy. A technical manual on these topics is being prepared. Drafts of the manual were discussed in Kenya.

An organization known as Food Resource Bank issued a report on its work in Malawi early in 2004. It described a programme known as Nkhoma Lakeshore Expansion Area Project (LEAP). It identified the Nkhoma Synod Relief and Development Department (NR&D) as its �local partner�. Among the �Implementing Partners� were the Christian Reformed World Relief Committee (CRWRC), the Presbyterian Church USA (PCUSA), the Reformed Church of America (RCA), the United Church of Christ-Wider Church Ministries (UCC), and the United Methodist Committee on Relief (UMCOR). There were three districts in which FRB funding got involved � Nkhotakota, Salima, and Mangochi. It involved 15 Community Development Facilitators, 75 groups, and 3,927 active participants. It reported that NR&D worked with the National Library Service to improve the Rural Lending Library Centres. An income generation programme sought to train people to save money. It included �household and small business management, start-up loans for small businesses, and tracking income and savings from the small businesses� (McAuley 2004).

7.7   CHAPTER SUMMARY AND CONCLUSIONS
Few people in Malawi have access to real medical care. The resources of the Malawian Government are very thin. Nkhoma Synod has demonstrated an ongoing commitment to the meeting of the medical needs of the people. In order for this to happen, there continues to be a need for close cooperation between Nkhoma Synod and expatriate organisations.
In 1964 and in 1991, the decline in government subsidies caused financial distress for the hospital department. The drop in expatriate personnel caused the 1964 crisis. The one in 1991 was alleviated by South African donations.
In 1969 the first qualified Malawian nurses entered service. In 1985, the Synod saw an opportunity to send medical students to MEDUNSA in South Africa. The report of the flight of nurses from service in Malawi makes one aware of a serious, if unseen, crisis. Only if one has been a patient in a Malawian hospital, or if one is involved in the health profession, is one aware of this situation. The reception of two Malawian doctors, and their quick loss, was a tragedy for Nkhoma Synod�s medical department. Lives are lost because of the shortage of medical personnel. The shortage, in turn, is aggravated by inability to pay them better. In 1996, the Narollah Trust offered funding to make more Malawian doctors for Nkhoma Hospital possible. It has yet to happen.
One pervasive fact of life in Malawi is that few people have access to meaningful health care. In chapter fourteen, which deals with the spirituality of the people of the Synod, it will be shown that there is an ongoing struggle against what has been described as �witchcraft�. People in Malawi often resort to �African doctors� with some churches in Malawi doing nothing to discourage this practice. This present researcher has personally seen the charms that Christian mothers will place around the necks and wrists of their children. For many people even today, death is never caused by natural causes, but is always the result of magic. It does little good to tell people to stop going to �traditional� doctors if an acceptable alternative cannot be offered. Nkhoma Synod, in the tradition of Presbyterians elsewhere, has tried to minister with the provision of modern medicine. This chapter suggests, however, that available resources are never equal to the need.
In 2000 the Synod issued the Chongoni Declaration, declaring a commitment to an appropriate, Christian response to AIDS. The AIDS situation affects every dimension of life in Malawi, including the life of the Synod. Ministers, who are already stretched far too thin, must spend their limited time and resources visiting the sick, the orphans, and conducting the funerals for AIDS victims. A concurrent tragedy must be realized by the fact that many of those in whom precious resources have been invested in them for their training; are the very ones dying of the disease.
The scourge of AIDS has become the focus of health-care providers in Africa in the last twenty years. Estimates of those infected with HIV/AIDS range as high as one-third of the population. New drugs (ARVs, or Anti Retro Virals) are becoming available. However, these are proving to be of unlimited use, because of their expense, and because people often fail to take them in the prescribed dosages .
Nkhoma Synod participates with organizations such as NetACT to advance the opportunities for training and awareness of pastors and church leaders in the fight against AIDS. These leaders in turn are trained to train others and help break the cycle of denial and alienation suffered by those infected or affected by the disease.
The establishment of the Nkhoma Synod Relief and Development Department was an important event in the life of the Synod. While many needs arise in many areas, the Synod working through a host of partners, or NGOs, can show that it can still meet the material as well as spiritual needs of its people. This too, is essential to how Nkhoma Synod developed its self-understanding of being a church. It sees itself living in community, giving attention to all areas of need, not just a hierarchy of religion professionals leading in worship on Sundays.
Having looked at the Synod�s two departments which seek to meet the physical needs of its people, the next two chapters will look more deeply into describing the thrust at their spiritual needs; with the focus of chapter eight evangelism, and chapter nine dealing with missions, principally to Mozambique.

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