MILK IT

A few weeks ago, the “got milk?” campaigns of my childhood came back to me as my counterpart and I discussed one of our malnutrition patients who had recently shown rapid improvement. For almost six weeks the patient in question gained no weight, and some weeks even lost weight despite a generous ration of Plumpy’nut. Then, within three weeks he was completely healthy, even plump! I asked my counterpart to what the drastic improvement was due, and she replied with a smile: “His family got a cow! Now he drinks milk every day.” I felt like I had discovered the golden elixir. Milk! We need to give all the children milk!

So, when I later read about the Government’s pledge to eliminate malnutrition and the various programs in place to do so, I seized the opportunity. In his press conference, the Prime Minister mentioned various milking drinking programs for children, including district milk drinking days.

It has been my experience that with many social development programs in sub-Saharan Africa (particularly those designed at the international and national level); resources are often given to people with long job titles but seldom used to benefit the average-child-living-on-less-than-$2-whose-picture-you-saw-on-a-UNICEF-board-and-who-you-hoped-your-donation-would-help. Could the milk initiatives fall into this trap?

The next day, I went to the local sector government office to visit a good friend with mandate over my Health Center. I asked this personal casually if my Health Center had any cows. Had I asked this question deliberately, knowing the answer, and knowing where the milk was going? Was this the first step in a plan others (concerned about corruption and malnutrition) had engineered, and I had eagerly agreed to help? How absurd! I am a silly white girl who understands next to nothing…

My friend responded energetically. Of course the health center had cows, had I not seen them? Was I not giving milk to children in the malnutrition program? Well no, this was the first I heard about cows, but I would very much like to give milk to children. I TOLD HIM! I TOLD HIM TWO MONTHS AGO TO STOP TAKING THE MILK! HE’S STEALING THE MILK! The outrage in the government official’s response was incredible.

The following day, I was called into the sector office by said government official. While I waited, I heard screaming in the adjacent room. WHAT ARE YOU THINKING? I TOLD YOU! THAT MILK IS FOR POOR PEOPLE! CHILDREN! GIVE THE MILK TO THE CHILDREN!

My heart was pounding. A few minutes later, the government official stormed back into his office and looked straight at the nutritionist, who had also been called in. YOU WILL MAKE SURE THE CHILDREN RECEIVE MILK! I WANT WEEKLY REPORTS!

To be continued…

Eliminating Malnutrition in Rwanda

While on an official visit to my district in January, Rwanda’s Prime Minister Pierre Damien Habumuremy vowed to eliminate malnutrition across Rwanda in just six months. 

I applaud the Rwandan government for vocalizing their commitment to eliminate malnutrition and taking such an active approach. In theory, this is an attainable goal. Rwanda is an incredibly fertile country, so drought and poor crop yields are not huge issues as in other parts of theworld, like the Sahel. (However, as I write, huge mudslides due to large rainfalls are devastating crops acrossRwanda this week). Furthermore, Rwanda’s community health system is extremely well organized, so community health workers should have no problem teaching the population about food security. 

The reality, of course, is much more complex than rainfalls and soil nutrients. To eliminate malnutrition it is essential to also address endemic issues like class inequality, corruption, alcohol abuse, polygamy, unemployment, and attitudes toward family planning, among many other things. Malnutrition is a problem deeply rooted in poverty. In my limited experience, I have noticed these issues take more than six months to solve.

It’s been a while since I actually blogged about my “work”, so let me describe the nutrition services at my health center as of late:

We have thirteen severely acute malnourished children and twenty two moderately acute malnourished children under the age of five. My health center covers over twenty thousand people, and I would guess the real figure is probably twice that for children under five, to say nothing of infants with chronic malnutrition, malnourished children over the age of five, or malnourished pregnant women.

Severely malnourished children under five years of age who have been identified by community health worker come in (with a caretaker) once a week for growth monitoring, physical checkups, education sessions, and a weekly ration of Ready to Eat Therapeutic Food (RUTF), commonly known by its brand name Plumpy’nut.

While the genius behind Plumpy’nut is that it can be produced almost anywhere in the world with local ingredients, Rwanda’s Ministry of Health and other international donors continue to buy tons of the brand name paste produced in France and import it to community health centers across Africa. When used correctly, treatment should not be needed for more than two consecutive months, but there are cases at my health center that have gone on for six; and a number of children relapse within two years. Although we always explain what RUTF is and why we provide it, many mothers are skeptical, sometimes give it away, and almost always insist their children prefer sosoma: fortified flour. (For further interesting discussion on Plumpy’nut, I’ll direct you here).

Moderately malnourished children under five come in twice a month for growth monitoring, education session, and a two week ration of sosoma. While sosoma is a more culturally appropriate food to give mothers, it often ends up being fed to the whole family, instead of just the malnourished child who desperately needs it. I have personally witnessed many cases where after receiving the fortified flour, a caretaker will go straight to the market and sell it. My coworkers tell me they use the money to buy sorghum beer. 

Despite some challenges, I’m really proud of how much counterpart and I have improved the nutritional services since I first arrived fifteen months ago. Physical examinations actually occur; weekly adherence by patients is higher; more house visits and education sessions are conducted; the health center kitchen gardens are functional; community health workers are leading neighborhood monthly growth monitoring at much higher rates; and all mothers who accept services from the health center adhere to modern birth control methods. Most importantly, I see how much pride my counterpart takes in the new reforms, and I know this will continue long after I leave and/or the government shifts health priorities again.

The government’s pledge to eliminate malnutrition has caused some stir in my neck of the woods. For one, the nursing staff seems slightly more interested in providing necessary antibiotics for sick, malnourished children despite their lack of health insurance. Malnourished children are rarely only malnourished. Nearly all the children come in with parasites and often pulmonary infections. When the children are given antibiotics, the subsequent weight gain can be astounding. Unfortunately, antibiotics are not given out very often.

The local government sector office is also feeling pressure, and more frequently asks for reports from the health center on malnutrition. I could go into how much more unnecessary, redundant paperwork this requires, and how much time away from real patients this takes, but I’ve done enough critiquing for one blog post.

Another exciting result of the Ministry’s pledge: the district hospital finally hired a professional nutritionist to supervise health center programs and take on the most severe malnourished cases that get referred! Although this nutritionist is often tied up in meetings, trainings, and office work, I have been extremely impressed with his rapport and enthusiasm, which seems to have also motivated (and in some cases, intimidated) other staff into being more vigilant.

At my health center, the director sat down with the community health workers and demanded they bring in all malnourished children. The CHWs complied and the numbers in both our severe and moderate malnutrition programs doubled. I was excited to have the influx of cases to treat at the health center (although slightly bitter the CHWs hadn’t listened to me over the last year when I begged them to bring in more cases I knew existed).

My counterpart, the health center nutritionist, however, looked at the new malnutrition cases with agony. “Maybe we shouldn’t record all of them. The Ministry of Health will not be happy with the higher numbers in our monthly reports.”

For Integration Purposes

If you want to compliment a Peace Corps Volunteer (not that our egos need any more boosting), compliment her integration. “Oh, I knew so-and-so, she was so well integrated!” What qualifies as praise-worthy integration will depend on who you ask, but it can range from a volunteer’s language or bargaining skills, to her ability to (and frequency with which) withstand long cultural events and/or terrible road conditions.

Being the competitive beings that PCVs are, integration is always a topic of discussion when we gather. The subtle ways volunteers try to one-up each other are exhausting. “Last week, I sat through a FOUR HOUR church service” one volunteer will complain. Another will respond “Four hours?! My service is six hours and I go every week”. While visiting a more ‘urban’ PCV, a particularly obnoxious colleague will remark on each and every amenity. “You’re so lucky you have electricity. I have to walk an hour just to charge my phone!” or, “Wow, the stores here sell mayonnaise; I only have one store in my village and it doesn’t even have toilet paper!” the most obscene, “OH MY GOD—you have a ROAD!” This is to say nothing of the general attitude PCVs have towards expats and other westerner’s living in developing countries. To put it modestly, our egos get carried away.

I believe a competitive spirit is essential to good work. As a PCV, I am party to many of these obnoxious chest beatings. Sometimes it feels necessary to validate your struggles out loud. It’s important to recognize, however, when this need to feel integrated, and the actions that accompany it, go too far.

In January, I received a text message from a person at my site who I considered a very good friend. This person was asking me for the equivalent of $200 because of a “family emergency”. Instead of immediately seeing red flags ($200 is almost my entire month’s living allowance) and politely telling this person that I could not lend such a large amount, a voice popped into my head. 

It was the voice of a PCV who I do not think is well integrated, telling me: “I would never lend any Rwandan money.  They’d never give it back. You can’t trust anyone here.” 

 Well, I would show her! I consider myself to be a very well integrated volunteer, with lots of friends in my community that I can trust. Obviously I can lend this friend the $100 I’ve been saving for months for my next vacation; this is a friend, with a good job, who will pay me back next week because this friend told me so, and because I am integrated and I know. IDIOT.

By April, I was mad. Polite comments throughout January and February, and repeated calls and pleas during the entire month of March had been ignored. I felt betrayed and disrespected. The usual “You’re white! You’re rich! Give me money! Give me food!” on the street stung even more than usual. Finally, I confessed to another friend. Immediately, this friend’s head dropped. “Alma, do you know how many times people have told me similar stories? This person is not to be trusted; this person has done such things before.” So much for integration, for knowing my community, for being able to trust. Was the PCV I looked down on right after all?

The friend I had confided in told me not to worry. “I will take care of it.” The next day I received another text message from my lender (we’ll call the person Sin Verguenza, Spanish for a person “without shame”, because that is what this person is). Sin Verguenza tells me “I’m sorry I have not been able to get back to you recently. My son is in the hospital about to undergo surgery and I have neglected some of my duties. Please forgive me. From the bottom of my heart, I am so sorry. I will pay you back as soon as I can”. I didn’t know if the story about the surgery was true, but I didn’t care. I was sick of excuses and called Sin Verguenza to demand the exact date I would be paid back. A date was given, and then ignored, twice more.

I have mentioned before that in Rwandan culture it is inappropriate to show or express any emotions. Conflict between two individuals seldom plays out directly. I have also mentioned before that I am a very direct and vocal person. So, when I saw this person next, I acted the only way yours truly knows how to act when angry: directly and passionately. “You should be ASHAMED of yourself! What you have done is despicable! Absolutely abominable! I helped you because I thought you were my friend: YOU ARE NOT. You make more than THREE times my salary, I am a VOLUNTEER, I came here to HELP your country, and here you are taking advantage of me! YOU SHOULD BE ASHAMED OF YOURSELF!” I would be lying if I said I didn’t take out a lot of pent up anger and frustrations on Sin Verguenza. I don’t care, because this person is a sin verguenza, and I think this person deserved it.

Sin Verguenza tried to give me more excuses, which I quickly told Sin Verguenza to shove somewhere else. I was done hearing them. Pay me back, period. Sin Verguenza agreed, and again did not follow through. At the end of the week, the friend who I had confided in called me in. I should mention, this friend works in the same organization as Sin Verguenza, and has a position of authority over Sin Verguenza. My friend, along with another very, very dear friend, sat me down and apologized. They told me they wished I had asked them for advice sooner, and wrote me out a check (from the other dear friend’s personal bank account). I had worried enough, they told me. They would deal with Sin Verguenza from here. After making sure my friends had thought this through and I was not placing financial burden on anyone else, I thanked them from the bottom of my heart. Honestly, I don’t have words for how much the gesture has meant.

If you’re wondering what happened to Sin Verguenza, I don’t know. I refuse to answer phone calls; I have not seen Sin Verguenza around, nor do I want to. This person is shameless.

At the same time, I should also be (and am) ashamed. What I did was stupid. I did it because of my ego, so I could one up the other PCV. Instead, I caused a scene and gave my real friends extra problems. The truth: I do feel integrated in my community, the other PCV was wrong—while trust in a post-conflict country like Rwanda is difficult to come by, I have friends I can trust. Regardless, my “Peace Corps experience” is no more or less legitimate. A volunteer with electricity can experience just as many or more challenges as one without, and an expat worker who lives in Kigali and drives around in a Land Cruiser is often helping just as much or more than a PCV in the hills (well, maybe…).

So this all ends well, as do most of the stupid things PCVs do ‘in the name of integration’. But I would also suggest reading another blog, by an RPCV in Zambia, where “loneliness, stress, and some of the other hardships of being a PCV (...) end up with a strong desire/need to seek out some kind of companionship, comfort, or support” -- in essence, a desire to integrate-- led to a very different outcome.