Child marriage: Some context

Imagine being a girl growing up in a remote village in Zambia. You have attended primary school, and you have dreams. You want to be a teacher, perhaps, or a nurse, or an accountant or a pilot; to hold a station in life different from that of your family. You want to be a respected woman, like the well-dressed, articulate, and confident female teachers or visiting NGO workers that you’ve encountered. You want to stand on your own, even if your mothers and sisters did not have that chance. Marriage and motherhood are goals, too—important ones. But marriage is for age 25, maybe. When you finish school. When you can support children.
But when your family falls upon economic difficulties, money for school fees is the first thing to go—especially with many siblings. Perhaps you are forced or perhaps only subtly pressured; regardless, confronted with the inability to continue schooling, getting married seems not only to be the best option, but the only socially acceptable one for a girl out of school. It may help your parents economically. Besides, customary law holds that puberty is a marriageable age. Maybe some of your friends have already been initiated—officially introduced to the responsibilities of married life—and it seems logical that you should be too. Maybe the vast majority of the girls you went to school with have dropped out, focusing on their emerging families.
Or, perhaps, you’ll just find a partner who you think can help with school fees. When you fall pregnant by this partner, you and your family may see no other real way to make ends meet than to marry at 14 or 16, given the financial burden and social stigma of single parenthood.
And once you do enter into marriage at this early age, your life ahead looks difficult. You’ll likely start having babies early and often. In these frequent pregnancies, you’re more likely than those married later to face hemorrhage, obstetric fistula and complications and even death during childbirth; you have a greater risk of contracting HIV and STIs from your (often older) spouse; and you might face abuse not only from your husband but from your in-laws as well, who will be frustrated by your inexperience in keeping a household. If you’ve managed to stay in school up until this point, chances are you will no longer have the means with all of your new responsibilities as a young wife and mother. And with only primary education, your chances of earning a living to support your family are slim. Dreams collide with hard realities as you make the transition from schoolgirl to married woman almost overnight, carrying the weight of the transition squarely on your shoulders.
It’s not at all uncommon for girls in rural Zambia to be confronted with these and similar situations—in fact, all of these circumstances were discussed by girls themselves in the child marriage focus group field tests we conducted  in several villages around Chipata, in the country’s Eastern Province. The limited survey data available corroborates the struggle encountered by young girls, particularly rural girls, to resist early marriage. In Zambia, about 42% of girls are married prior to age 18, according to the most recent Demographic and Health Survey; the International Center for Research on Women ranks the country 16th globally in terms of the proportion of girls married before 18. These grim statistics are in spite of the fact that the legal age of marriage on the books in Zambia is 21 (due to the co-existence in Zambia of statutory and customary/traditional law, there has been difficulty in enforcement of the “legal” age), and in spite of widespread condemnation of child marriage over the past several years from policy makers. Eastern Province could be considered ground zero of child marriage practice in the country, with the highest overall percentage of girls married prior to age 18.
Plan’s 18+ Ending Child Marriages in Southern Africa program is a four-country initiative focusing on Zambia, Malawi, Mozambique and Zimbabwe. However, because the practice looks different in every country, individual offices are tailoring their own approaches to research and programming for their respective contexts.  Child marriage is not a new focus area for Plan in Zambia; it falls under the child protection program and the Because I am a Girl campaign, focusing on girls’ empowerment and education. However, 18+ represents a more targeted effort towards child marriage specifically, which is gaining traction and more international attention of late as a violation of girls’ human rights, and as a distinct form of violence against girls. The program will operate at all levels—starting with empowering individual girls and connecting them with mentors, through promoting dialogues to spark change, leveraging key influencers at the community level; and finally striving for change at the policy level.
It’s an ambitious effort in the sense that child marriage is not a standalone issue—it is the result of so many inter-related factors: among them: the availability child protection structures (law enforcement and procedures for reporting abuse), household economic stability, gender equality and deep-rooted gender roles and education. It is, at its heart, about power relations–not merely the power of the girls themselves (or lack thereof), but the power of the most important gatekeepers in their lives. And it is deeply cultural. This makes it a different kind of problem to address than, say, malnutrition or sanitation.
In the community of those who care about child protection, human rights and health and gender issues, the statistics are well known. The literature on the topic of child marriage details the health and social consequences of child marriage on a global scale, and the legal aspects of the practice have been examined. We know that there is a long list of inter-related drivers, and have some sense of which of these may be most relevant in Zambia. High level declarations have been made and the government has pushed the issue in high-profile campaigns, radio spots and live events in some of the most-affected areas.
What is missing is the community-level picture, a full sense of what’s happening on the ground. What are the  local drivers of child marriage? What are people thinking about this practice and how is this changing? And, perhaps most importantly, if we are creating this program for girls—who are these exceptionally vulnerable girls, and what do they need? And amidst the international and national attention to this issue, how can their voices be heard?
This is precisely why I have been working since coming to Zambia on qualitative tools and field guides for participatory formative research; this is how, in our pre-test of these tools, I ended up on a dirt road just outside of Chipata with six colleagues.We sat on wooden benches in rural schoolyards with groups of women and girls, men and boys, teachers and community group officers, listening as they shared their experiences, perspectives and stories with the facilitation of the awesome and highly dedicated staff. I’m grateful that not just the girls, but their parents and communities shared candidly with us. We are already learning much, even in the field-testing phase of this process.
Child marriage is a form of structural violence that continues to affect the girls who are poorest, most isolated, and those with the least voice. It looks different here than it does in India, Bangladesh, or Niger—all child marriage “hotspots”– but wherever it occurs in the world the effects are devastating. What I’m working on is  the very, very first step of the very first phase of the project–looking at what we already know and developing the questions we need to ask to design a program reflective of and responsive to the realities in Zambian communities.

I’m back!

Hello, world!

It’s been over a year since my COS from Peace Corps Burkina, and I stopped blogging for a long while as I focused in on my graduate program (Master’s in Public Health, at Tulane) and starting my post-Peace Corps life in New Orleans. I always meant to come back to the blog, but found myself absorbed in my academic and work life (and Mardi Gras, Jazz Fest, and all of the wonderful non-work perks that come along with living in New Orleans). In fact, there are still a few unfinished entries from my last few months in Burkina, which one day I may possibly get around to posting….insha’Allah….

However, this summer has found me taking on some new travels, and by request I’m re-instituting this blog—changing it to my “travel blog” rather than my “Peace Corps” blog. I enjoyed this medium of sharing my experiences while living in Mali and Burkina, and I’d like to continue sharing with anyone who might be interested in travels and issues related to public health, development, and gender.

To get everyone up to speed: I have finished my first year at Tulane, and I am completing my MPH professional practicum this summer with Plan International, an NGO working specifically on issues affecting children across several different sectors, from health to child protection/welfare to education to economic empowerment. Specifically, I have been working on the 18+ Project, a new (ish) initiative to end marriages of children in four countries in Southern Africa. The project is in the formative research stages and I am enjoying working on the research design and field testing as we determine which direction this program will go and how we will measure change.

Another entry will soon follow to talk more about the project!

On having (and not having) all the answers

My favorite song from Somalian rapper K’Naan begins with the line, “And any man who knows a thing knows he knows not a damn, damn thing at all…..”

Contemplating this lyric recently, I realized it is a strikingly appropriate expression of exactly how I feel my time in West Africa has humbled me. Simply put: it seems there is nothing like being assumed to have all the answers to make you realize that you actually have far fewer easy solutions than they think you do.

I am a 24-year old woman who left for my Peace Corps service in Mali at 22, literally within days of graduating from university. It’s sometimes astounding to me how much immediate decision-making latitude I am given, and how much people just automatically assume that I have the solutions for any and all problems they throw at me, mostly simply because I came all the way here from the USA. For some, it doesn’t seem to matter what I’m actually qualified to do: although I have made clear my role in health education, community mobilization, and maternal/child health, I have been asked to teach math (Ha! Ha!) and for advice on tree planting and farming (the only farming I have ever successfully done was under the close supervisory eye of my teen host brothers in Mali, and this success was owed to them, not me). You’re American, people seem to think, so you must know. And rather than throw up my hands and say, “actually, I don’t know!” I try my best to help people find solutions. That’s probably the most apt description of the role a PCV feels s/he ought to play in the community: “solution-bringer.”

I’ve been thinking about this idea of “bringing solutions to the people” a lot lately, since it is sort of what I have been trying to do in Burkina with the hearth model. The program utilizes community actors and builds on malnutrition activities that are already taking place in the community, but goes a bit further- requires a bit more purpose in its selection of participants, organization, and follow-up In short, it requires that a few key people make a bit more effort than they are currently making. It requires me, the cheerleader of this whole idea, to ask people like health workers and volunteer educators to have a little volonte, as they often say here—a little bit of a will to work, and not always with direct compensation. It’s a request that can be much trickier than it should be at times. But, one figures, it is not too unreasonable, especially if the benefits—want to recuperate some malnourished kids, anybody?–seem like a no-brainer.

However, the process is a bit like trying to sell a new product to people who have never heard of it and may have only marginal interest in it. I feel sometimes like a kid selling wrapping paper (or Girl Scout cookies, or those coupon books….) for an elementary school fundraiser; I know that my potential buyers probably have 35 shiny rolls of last years’ paper still stuffed in their closets, that they think they’ve heard the sales pitch countless times before, but somehow I have to make buying wrapping paper from me seem like the best idea ever. That’s kind of what introducing the hearth is like. Many potential solutions have been brought to the table when it comes to malnutrition. Women are used to occasional culinary demonstrations and to going to the health center to get some free porridge powder if their kids are moderately underweight. So this idea of organizing a program which requires them to come every single day and asks women to actively participate in the recuperation of their own children can be a bit of a hard sell, both for the women themselves and for the health workers who strongly doubt the motivation of women to participate.

That is why, when it comes down to it, my job seems to be as much about community organizing and mobilization as it is about public health. Sure, I am focused on nutritional education, but half of what I do seems to be trying to motivate people to come together, to open parent’s eyes to a new way of looking at the health of their children—to see that it is, in fact, in their hands. This has turned out to be somewhat of a messy process at times. I have had hearth groups where everyone got along, the dynamic was great, and we spent two fulfilling weeks together and I still keep in touch with the mothers. On the other hand, I’ve also had groups that I have had to end after 4 or 5 days because the women simply stopped coming, and there seemed to be no ‘group dynamic’ to speak of. The successes keep me going, of course, but the failures have at times made me question my efforts at being Mother Teresa. I consider myself a very patient person, and I pride myself on getting to know the women on an individual basis, but to put in all the effort and find participation lagging after just a few days can be discouraging to even the most idealistic person.

I wrote in a previous post about the challenges and rewards of investing in people rather than handing out Band-aid solutions, and in the end I still believe highly in the value of engaging the community in creating its own solutions. Those challenges are still there. I still feel like the cheerleader trying to drum up support for something new, not always knowing if people will go along with it or will just think that she’s crazy. At the same time, there are some great moments. My former-participant-turned-friend, Awa Zorome,has returned to help me with the hearth sessions, and few things make me happier than seeing her deliver the message that she’s learned to other mothers. She has even brought a few of her neighbor friends over to my house so that we could cook together. And that, more than anything else, makes me take heart that somehow, someway, the message resonates, one person passes it on, and change does percolate in the community in this (slow, imperfect) way.

Mali and Burkina have indeed shown me how little I know, how few clear answers I have. But I’ve also learned that this is not necessarily bad; sometimes it IS better to come to the table empty handed, to turn things around and to say to people used to being the receivers of help, ‘What do YOU have to teach me?” The value is not in my coming here to simply tell women what they should or should not be feeding their kids; nor is it in my handing out bowls of enriched porridge that I myself have prepared. Rather, the value of my time is found in the exchange, in the preparation and sharing (both literal and proverbial) of a communal meal, of helping one woman at a time see that the tools they need to assure that their children grow up healthy and strong are well within their reach.

The most beautiful moment as a volunteer implementing the hearth is the moment you realize that the program is no longer about you at all—that you have become secondary to the women from the community, who have risen up naturally to lead the process of change. I’m not sure I’ve had one extraordinary moment like this, but I am beginning to see, in small ways, the ripple effect occurring, to see a few women taking the reins, sharing information more and more, establishing a dialogue about nutrition and coming up with some of their own answers. And it’s a beautiful thing.

I may not hold the be-all, end-all answer to any problem. I don’t need to, I’ve learned; I may not know, and you may not know, but when we come together we realize that we know more than we thought we did and can do more than we thought we could. And that realization is the beginning of something very good.

Six months in: Thoughts on work

First things first: my apologies to everyone for having abandoned this blog for awhile. I don’t really have much excuse, considering I can can charge my computer and have regular Internet access. I always say that I really want to capture my experiences in a systematic and regular way. Turns out I’m not so good at the regularity part. But, the good news is that I have managed to keep myself reasonably in Solenzo in the months since my last post, and despite setbacks am still truckin’. And as I’m almost at the halfway mark (!!!) I thought now would be a fitting time to reassure everyone that I’m still alive and kicking, six months in.

 

So today, I wanted to talk a little bit more about what it is, exactly, that I’m working on here in Burkina. My title is officially “Child Malnutrition Specialist,” but like most Peace Corps assignments it’s been largely up to me to define what that actually means. The assignment was developed in response to a major health problem in Burkina: estimated prevalence of acute malnutrition in child under 5 in my region, the Boucle de Mouhoun, was about 13% in 2011. The local Centres d’Education et de Rehabilitation Nutritionelles (CRENs) were developed as a direct response to this persistent health issue. They have done a great deal to ensure that children with severe acute malnutrition receive the special dietary regime and specific care that they need to recover. However, the CREN staff is largely focused on dealing with the relatively small numbers of children with advanced states of malnutrition; many more children in the earlier or moderate stages of malnutrition remain at home in their communities receiving no care or follow-up whatsoever; sometimes their families don’t even recognize their state of malnutrition, especially since many do not take their children regularly to be weighed (once a month for the first year is recommended for all children, but few mothers actually stick to this schedule).

 

While nutritional supplements and weekly follow-up do exist for moderate cases at the local community health centers, adherence to these regimes is often shaky, and the response is weak in terms of actual behavior-change; mothers show up weekly for weighing and to receive rations of porridge powder and/or “chocolat” (the local name for the special enriched peanut butter, Plumpy Nut, that helps kids gain weight); but there is not, as far as I have seen, a great attempt to help them understand the principles of better nutrition and how to sustain the gains their children have made once they have stabilized and are no longer eligible for rations. I sometimes wonder, as I see mothers arguing with health workers about whether their kids need more ‘chocolat.’ whether the whole system sometimes actually discourages mothers from adopting positive nutrition practices. These supplements save many lives, to be sure, but they were never intended as a permanent solution, and yet there are mothers coming back week after week hoping, sometimes expecting, more, even when their children have moved back into the green. Not to mention all the well-nourished siblings getting part of the rations intended for their sick brothers and sisters.

 

Suffice it to say, this approach helps deal with the immediate problem of malnutrition but doesn’t really work as a long-term solution, especially when the community as a whole is not really being engaged. The women of the community once again become passive receptors of help rather than potential agents of change; it is connected to the broader mentality that sometimes develops when international aid dominates a particular sector. That is, how can the outsiders help us? Rather than, what is within our power to do to make positive changes?

 

End rant; at th heart of the matter, the question for me is: what is a Peace Corps volunteer to do about all this? how does one build a community response around an issue that has been dominated by outsider-imposed solutions? Well, the thinking goes, one could start by finding the positive practices, capitalizing on them, and training ordinary women to use these practices themselves and then disseminate them, thus becoming positive models. Voila! Change happens, and a ripple effect begins. That’s the premise behind the whole Hearth (in French, Foyer d’Apprentissage et de Rehabilitation Nutritionelle, or FARN) model. I think of it, in American terms, as a sort of Nutrition Boot Camp. Get a group of women with malnourished kids together. Have them meet every day for 12 days to prepare a healthy, enriched, and accessible recipe utilizing local ingredients. Monitor the kids throughout the process and highlight positive changes in weight, health, or energy. Follow-up with the group within one month by individually visiting each mother, to reinforce the messages they learned and troubleshoot problems. And then, hopefully, use these mothers as educators for future groups of women. That’s the essence of FARN, and it’s a process I’ve now been through twice, stumbling and making changes along the way.

 

While the idea is relatively simple, implementation is complex in ways I didn’t anticipate, and that has required some adaptation on my part. For example, the original Hearth model calls for a “Maman Lumiere” or designated mother who is a positive example for the others. While having a local woman lead the process makes perfect sense from a capacity building standpoint, I’ve found here resistance to the idea that one woman should be held up as a golden example for her peers; she is likely to shy away from such a designation, given the culture. Thus, I’ve found it more appropriate to highlight positive behaviors that I’ve observed mothers engaging in, rather than focusing on the mothers themselves. I don’t have designated Maman Lumieres, but have been using health workers to help me with my messages, and hope to incorporate some of the mothers who have now been through the FARN to become teachers for the others—without calling what would certainly be construed as unwelcome attention to them.

 

Second implementation challenge? Attendance and buy-in of the program by the women, especially since it is intended to be done over the course of two weeks, and women are required to contribute ingredients for the daily meal. In a perfect world (and in the official FARN manual), the process calls for initially visiting each potential mother, explaining the program getting the agreement of both her and her husband, and setting things up with everyone on the same page. In reality, as it is often only me doing the recruiting and as I don’t have a great deal of support in implementation from health center personnel (I’m hoping this is starting to change as more FARNs get under way), such detailed coordination of everything beforehand is not feasible. The best I can do is identify the women we want to target, explain the model with those that show up, and hope that of these, a significant number will see things through to the end. A number of practicalities get in the way from a perfectly-unfolding FARN. Some women bike significant distances, and lose interest after a few days for this reason. Some women’s children inevitably fall sick and miss a handful of days. Others are resistant to the request for ingredients and others only bring corn or millet but no protein ingredients. Still others just seem to show up when they want to, frustrating the others who have managed to make it to all or most of the sessions. And some of the women who are the best participants have children who are not malnourished at all- which brings up the question whether rehabilitation or education is the primary goal of the model. I hesitate to discourage any eager, committed mother, from participating, regardless of the nutritional status of her child. In practice, in a program that requires buy in and relies on the willingness of mothers to be active learners, I am hard pressed to refuse anyone who seems even somewhat motivated.

 

So yes, challenges abound. Probably the one I struggle with most now: health personnel understanding, buy-in, and willingness to make good use of the model. The general mentality of the public health system here is quantity over quality—personnel tend to want to draw large groups to share and disseminate health information, an approach that gives them impressive numbers for monthly reports, but requires very little meaningful personal contact, evaluation of impact or follow-up to see if anyone has absorbed or utilized the message. While there is certainly a role to be played for mass or large-group communication in health, the Hearth/FARN is all about focusing intensely on a small, very manageable group of no more than 10-12, and giving these women the individualized attention they are probably not used to receiving from the health care system. Women are always so surprised when I show up at their compounds for follow-up visits, and sit with them for an hour or more; the quality over quantity approach goes against common practice here. While this is a positive thing, the model is harder to introduce to health personnel for that reason. I often get a reaction from health workers that runs along the lines of, “wow, sounds great. As long as you’re here to do it, because we don’t have time/money/moto gas to do it.” The key phrase being, “as long as you’re here to do it.” This is the one sentence I hope I won’t hear at all by the end of my time in Burkina, but the truth is, I see it as a continual struggle; personnel motivation, and not the motivation of the women participants, has been my single biggest obstacle in implementing the FARN. As word build about the previous FARNs and word of mouth gets out about “my program,” I hope it will shift to becoming not my program at all, but a great potential tool to be used by various health structures in the district. I have no illusions, however, that this shift will happen easily. I’m almost at 6 months, and I’m just now starting to feel like I’m turning that corner where I find my flow work-wise. I’m still doing a lot of cheerleading to move things along little by little, a great deal of effort for results that are not quick to become apparent.

 

This blog was not meant as a litany of complaints about all the obstacles and frustrations I’ve faced in work; I really believe in the FARN as a potential force for positive change as far as nutrition is concerned. In fact, it is my interactions with the women, hearing them tell me themselves what they have learned and what they will change, that energizes me, that reassures me that somehow, all this effort I’m making, all the figurative arm-waving I’m doing and enthusiasm I’m trying to build, will end up being positive in some way. Still, I’ve committed myself to being honest with myself and with others about my experiences—successes and failures. And I have a long way to go before I feel like I’ve achieved any veritable success in Solenzo—I’m not sure, at the end, what I will even define as having been “successful.” If I do 20 FARN groups and engage 200 women in nutritional rehabilitation, is that success, even if no one will continue it upon my departure? Or is it more important that I focus on getting staff trained in how to implement the model, whether they will actually use it or not? These are issues I struggle with.

 

I bring up these questions only to highlight that no change, no matter how small, is achieved without some setbacks in this context. Doing this work, more than technical or language skill or cross-cultural competency, requires epic patience and a high tolerance for the million and one frustrations that you are bound to face daily. But if you can ride it all out, the rewards seem to come when you least expect, and most need, them. One of the women in my first FARN, Sandrine, told me on her 1-month home visit, pride in her voice, that she had been making enriched porridge regularly and she thought her daughter was eating more and had more energy, despite the fact that she had been one of the slower children in the group to gain weight. Hearing these things, and seeing how proud she was of the change, I could only think, yes. This is why I’m here. This is what I came to do. I live for moments like these.

 

And I hope the next six months will bring me more.

Chipping away

On several occasions in Mali, I wrote about encounters I had with deaths that should never have happened—women and children perished from malnutrition, anemia, childbirth complications–diseases that, had they grown up elsewhere than in one of the poorest countries in the entire world, they would never worry about encountering, or at least would never die from. Burkina is really no different from Mali, in that sense. The child mortality rate is just as staggering, if not more so, than Mali’s; an absurd number of women still perish from childbirth.

Needless to say, one develops something of a thicker skin after being constantly exposed to such circumstances. It’s not that each loss that you encounter matters any less, but you realize that breaking down every time not only takes a lot more emotional energy than you have saved up, it also goes completely against the coping style in this culture, which is to keep a stiff upper lip and more or less deal with your sorrows outside of the the public eye. And so I have tried, to the extent that I can, to avoid internalizing the deaths around me. But events often make this difficult.

Mariam was older than most of the children coming through the malnutrition unit, at 5 years old. She had been at the district hospital for nearly a month; her progress had been one-step-forward, -two-steps-back from the start, gaining weight for a few days in a row before falling backwards. She suffered from severe kwashiorkor, a form of malnutrition defined specifically by protein deficiency. Kwash is more complicated than other forms of malnutrition to treat, and there are often complications and diminished function of various body systems as the child’s condition deteriorates. The very fact that Mariam had been at the CREN for so long was a testament to how challenging this condition can be.

We were all worried about her—she had been bouncing back and forth between pediatrics and the CREN, with a bout of severe malaria and another of diarrhea. Still, there was reason for hope. The edema (swelling) of her feet and legs, caused by kwash, had started to go down, and she seemed marginally more active and cried slightly less than she had at first. Often in malnutrition cases, significant amounts of progress can be made after a period of decline, so no one really saw it coming when we arrived one morning to discover that we’d lost Mariam overnight.

Mariam’s mother’s emotion didn’t seem to register on her face as she told me this; she was more or less expressionless., which is why at first I thought perhaps I had misunderstood her when she said softly, Awa, a banna. She died. But then I saw Mariam’s father and some other men from her village who had come to collect her things, and it was clear that, tragically, I hadn’t misunderstood. She was gone. At five years old. Of a slowly progressing, often reversible disease that was just too advanced this time. The two nurses helped Mariam’s family gather their belongings, and as they left the hospital we all sat on the front lawn of the CREN in total silence. Each of us, perhaps, processing things. I can’t speak for them, but I know for myself I could only think: what a shame, what a waste. And then: how can things change? Is it a question simply of knowledge? Or of an underlying attitude? Did Mariam’s parents realize the severity of her illness? And if they did, what delayed their seeking treatment? It felt like the day in Mali when I lost Hamale, all over again.

Coming as I do from a place where the death of any child under any circumstances would be considered a very unusual tragedy, it can be hard sometimes to fathom what seems to be complacency, or at least apathy, surrounding preventable disease and death in places like West Africa. And for health workers, tasked with trying to convince people to adopt healthier behaviors, it’s a particular dilemma because such an environment can breed fatalism, the attitude that there is nothing that one can do except to accept the fate the universe has bestowed upon him. People are not actors in this mindset; they don’ t shape their own futures; God or some other greater universal power does. And while the belief that God ultimately controls things and leads those who die to a happier place sustains and comforts millions in the western world just as it does here, we also have a much stronger safety net in terms of health services, and it is a blessedly rare occasion when we are forced to invoke God’s will as an explanation for an untimely death. In Burkina, it’s a saying most people are all too familiar with. “Allah m’a son,” It wasn’t God’s will. While the need for some comforting or pacifying adage at a death seems to be a universal human need, that little phrase often makes me wonder how often people really internalize the idea that there is nothing they could do to avoid such tragic circumstances. If there is a great and wise higher power who keeps order in the universe, and I personally do believe that there is, that doesn’t absolve the responsibility of humans to make decisions to the best of our knowledge ad ability that will keep us healthy and living.

No problem is ever a matter of one simple factor, though. Changing people’s attitudes and orienting them towards prevention can be powerful, but it won’t do much for a family whose money has run out and whose remaining harvest has to be stretched out over several months so that they won’t starve. For the entire village stricken with drought and barely surviving off of international assistance in the form of food aid. For the woman in a powerless marriage whose husband doesn’t accept her using birth control to avoid a fifth or tenth or fifteenth pregnancy.

Basically, Stuff happens. And here, potentially devastating “Stuff,” from famine to war and civil strife to a host of dangerous tropical diseases, is just plain more frequent. These are realities. To deny them, to assert that a better standard of living and better health would be immediately available if people would just change their mentality, would only serve to demonstrate the privileged and elevated position from which such an observation must come. It reminds me of the debate over welfare reform in the 90s, when some were yelling that if women on welfare would just go and get jobs and stop getting in trouble all of their problems would be over and they wouldn’t be in poverty (completely ignoring the issues of inadequate minimum wages, the economic and social isolation of poor communities, biases in the criminal justice system…). Such a stance is irresponsible and serves to undermine the complexity of such issues as poverty and the societal distribution of wealth.

I’m meandering a bit, but my point is that during my time here I have often struggled to reconcile what appears on the surface to be apathetic or fatalistic behavior that leads to unnecessary illness and death, with conditions that have much more to do with global economies, power dynamics and other factors well outside the realm of influence of your average rural Burkinabe and his family. And as a health educator, of course the irony doesn’t escape me when I’m talking to families about supplying a rich and varied diet during the rainy season, when people are lucky to scrape by eating millet three times a day until the next harvest rolls in.

Yet I know that there are some factors people can and do control—which is why there are also children in the same town who are healthy, well-fed, and without problems. The best I can hope for it to maybe enlighten people, one by one, on the things they can change. The whole question of system overhaul is much, much bigger than me. So I’ll deal with this gigantic problem in the only way I really know how: chipping away at it, piece by piece, person by person. As I said in another entry last year, if I can change one person’s mind…it’s something.

I don’t know and can never say whether changing the minds of Mariam’s parents would have changed her fate. Whether knowing she was ill earlier would have made them act sooner, or whether being able to identify high protein foods would have meant they gave her more high protein foods and thus avoided her illness entirely. The gap between knowledge and behavior is often a quagmire in public health, as the struggle to promote condom usage despite widespread knowledge of HIV transmission (or, in the States, the continued prevalence of high-fat diets despite awareness of obesity as a huge problem) shows.

No one has come up with the perfect answer, and it would be foolish and extremely naive of me to expect that in a 12 month assignment I, the lone foreigner with my generalist degree and all my great intentions, would be able overhaul something as complex as the behaviors and attitudes surrounding nutrition. But, I do believe that once we are able to get some hearth projects going, to work with women on feeding their children with foods that are nutritious and, even more importantly, available to them– we can make a difference with small groups of women, and maybe those women will share with others—and ripples of modest but real change can then start within a community.

As long as there are still Mariams (and there are still far, far too many), there is still work that needs to be done. And for all the frustrations, I’m still glad to be here, in this country of open, generous and hard-working people, chipping away.

Starting over

June 4, 2012

Looking down the incredibly congested, terribly dusty road through Ouagadougou’s Zone du Bois neighborhood feels an awful lot like standing in the middle of downtown Bamako. The chaos. The fine Ouagalais ladies dressed in florescent bazan and full head wraps, sweat already pouring down in the 95-degree early morning. The rude moto drivers who pass within an inch of you without so much as a cry of warning. Vendor ladies selling gateaux and even children yelling, ‘tubabu, tubabu.’ Except this time, I know enough to chase them down and scare them until they run laughing down the street; I know to greet brightly as I pass, though not everyone speaks Dioula/Bambara and so I have to fall back on French.

So it’s not starting over…not completely. Burkina feels, in all the fundamental, important ways, much like Mali. A kindness and openness, vibrant culture, a certain bond over having little and sharing much. And yet, as this first two weeks has shown me, I am embarking on a different kind of adventure—and with the benefit of hindsight, perspective and having “been there, done that,” I am seeing even things that seem familiar to me with fresh eyes.

I arrived last Sunday evening and began my fully packed training the Tuesday after Memorial Day. A lot of administrative procedures and background information were involved as in my first Pre-Service training, although this is much more streamlined—just under two weeks start to finish. Much of my training time has been focused on brushing up on language (getting my French up to speed to work in a professional environment, while also reviewing Dioula, which is essentially the same as the Bambara I spoke in Mali, with a few slight differences) and technical training related to my assignment. I visited several CRENs (Centre de Recuperation et Education Nutritionelle) here in Ouaga to see the type of work they do. We visited two sparkling, bustling CRENs, one run by nuns and the other with large funding from the Protestant church (neither of which, I realized, is much like what I saw at my own CREN, at the state-run district hospital…but I’ll get to that); we observed everything from the mixing of the special UNICEF fortified milk they feed inpatient, severely malnourished babies, to the the education sessions they held for the mothers as they fed their babies spoonful by spoonful, to the pediatric unit which provides backup and treatment for ailments that often accompany malnutrition. I wrapped up the week with some more theory on the Positive Deviance Model for treating moderately (not severely) malnourished children at the community level. This model will be an important part of my assignment, as I’ll be tasked with training community leaders in how to implement a Positive Deviance program in villages.

The brief, two week introduction to everything was actually a relief to me—as any PCVs know, Pre-Service training is not an experience one necessarily wants to repeat, as important as it is. I got enough of an orientation to get to know the need-to-know people at the Peace Corps office, understand the most important aspects of Burkinabe culture, and get a better sense of what I’m here to do. I also had the chance to visit my site, which is at least a 6-7 hour ride from Ouaga under the best of circumstances (ie, Peace Corps vehicles) and much longer on public transport. As a site it’s quite different from Marena, and I’m honestly glad for the change. In a way I felt it would be difficult to be assigned to another small village with a similar dynamic when my heart still aches for the one I left behind.

Solenzo is in fact not really a village at all, but a moderately-sized town, complete with a daily market, several schools, mosques, churches and radio stations, and of course the district reference hospital out of which I’ll be working. The hospital takes care of referrals from some 32 community health centers in the district, does surgeries, and handles high-risk deliveries (Multiples, Ceasareans) at the reference maternity. It is also home to the department in which I will be working, the CREN.

The CREN is where mothers with severely malnourished babies are taken in, after paying a flat fee of around $14, to stay for as long as it takes the kids to recover. This could be weeks, or it could be months, but they are not discharged until they have reached at least the 85th percentile of weight-to-height ratio. The babies and mothers are provided with beds to sleep in and all of their meals, which are specially planned to be very rich in nutrients and adapted to the child’s current state of malnutrition, so as to slowly bring them back to health and avoid overloading their systems, which can kill a seriously malnourished child. The children undergo daily weighings and medical evaluations; they receive systematic treatment for vitamin deficiencies, bacterial and fungal infections, and malaria. The mothers are required to help prepare meals and are engaged in regular education sessions with the hope that their children will sustain the intensive progress they’ve made in weight gain when they are discharged.

Those are the basic services of all CRENs, but the nuts and bolts obviously vary from place to place and depending on funding and resources. My CREN consists of two small buildings, one the dormitory for the mothers and children, the other for food storage and an office/exam room; and a hangar where the mothers prepare the meals. The entire place is, generally, the worse for wear; furnishings are sparse and, compared to the open, clean, bright facilities we visited in Ouaga, the differences in resources available in the capital versus the far-flung provinces become very apparent. (But that is a whole different blog entry….). In any case, however, its clear that the CREN serves an important need for a small number of kids who are barely hanging onto life. It is also, en principe at least, supposed to be at the center of efforts to address moderate malnutrition by educating communities, and that is where most of my role will come in.

This is what I know about what I’ll be doing as of right now, and it seems like I will be able to build nicely on my experience working at the primary, community level in Mali. I’ll at least theoretically be working more from an organizational standpoint, thinking about strategy and work plans at a slightly more macro level, but I’ll still be able to be in the field most, which I find the most satisfying. And like Mali, although the roads to anywhere are never straight or smooth, I have a feeling this journey through the “land of upright people” is going to be interesting in its own right.

Moving forward

 “The most difficult challenge is leaving.” –Peace Corps advertisement

As most of you probably know, I’ve spent the past several weeks in America, since we were abruptly pulled from Mali following the coup d’etat there. And these weeks have been an emotional tug of war for me, showing me how much I’ve changed and how some things never do. America definitely was a shock to the system, especially since I never actually left Mali during my nearly two years there. The food is fabulous, my feet and body are amazingly clean and free of dirt, and the hot showers twice a day are fantastic. Family, friends and former colleagues have been warm and embracing, ever generous with their time and couches, and curious about my experiences. It struck me how you can be gone for a large amount of time, come back and life will be exactly as it was when you left it—in some ways that is comforting. There is always something to come home to.

The sadness about Mali still lingers, though. At the transition conference, during our somewhat weepy group counseling session, one of the PC people compared being pulled from Mali to losing your first love—the separation may be necessary, but it hurts like hell, and you will forever compare subsequent experiences to it. That is, as it turns out, an extremely apt description of the emotional tangle that is re-entry under such unforeseen circumstances. I went downtown to go shopping, and aside from being blown away by how excessive our choices in America seem, it hit me that no one greeted me, nobody said good morning, how is your health; there was hardly a glance in my direction on public transport, nor were any random conversations struck up with strangers. I find myself thinking about Mali throughout the day, wondering how my villagers are doing, looking up the latest Mali news. I’ve been in sporadic contact with various friends still in Mali, including my host family, who have assured me that while the situation may be deteriorating on a macro level, things in village are still totally quiet and safe, and life has plodded along as normal. Being plucked out of the life you’d finally gotten used to is jarring, and having to watch from the sidelines with what the country is going through is agonizing.

But, as they say, you’ve gotta keep pushin’ on. And I soon will be. While in Ghana for the transition I interviewed with Peace Corps Response, a program that sends returned PCVs out on shorter term assignments responding to very specific needs. I’m starting a new assignment May 26 in Burkina Faso. Most people don’t have a clue where that is—it’s east of Mali and north of Ghana in West Africa, a small, landlocked country culturally and climactically quite similar in many ways to Mali. The assignment is for 12 months and I will still be working in health, but with a more specialized focus on child malnutrition and training community health workers on malnutrition issues. While I still feel I have “lost my first love,” I am looking forward to this new adventure, to getting more specialized experience, to improving my French, and to getting to know a new country and new people. I won’t get to do the third year in Mali that I very much wanted, but if things calm down enough, I may even be able to visit, and I am grateful for the opportunity to continue my service, albeit in a different place. I’m doing something of a crash course in Burkina, so as I learn more about this country I’ll post!

To everyone who reads this blog regularly, thanks for all your continued interest in my experiences in Mali, and more importantly, ce n’est pas le fin! Stay with me as I explore this new place!  My contact info is the same and I hope to be in touch with many of you in the coming months.