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.