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.

Checheka!

Checheka is the command form of guchecheka, which in Kinyarwanda means to be quiet. Checheka is what mothers say to their children when they cry. Checheka is what the battered woman told her beat up twelve year old daughter when they came into the health center at 3AM after a domestic dispute. Checheka is what my local leaders told an old man during Genocide Memorial Week when he began to name names during a community meeting. Checheka is what a coworker and friend told me after I finally lost it following a staff meeting during which, once again, personal interests and gripes of a few were put before poor, sick patients, most of them children.

As a Peace Corps Volunteer, it is very much not my job to be a whistle blower. In fact, when I have brought up corruption issues to my supervisors at Peace Corps they have specifically told me to stay away and essentially, checheka. This is of course, for my own safety and the safety of others in my community.

Lake Kivu

Those of you who know me (at all) know that it is not at all in my nature to checheka. My senior year of high school, I walked into the superintendent’s office to demand administrators give fewer, shorter speeches during graduation to allow for more student speakers. The request was denied, but brought up during said administrator’s long speech. After a Trustee dinner at Cornell, I walked up to University President and asked him why his table included only male students. The observation was noted, although I was not invited to the next dinner so I can’t tell you if it made any difference. I regret neither bold, unfruitful move. I am not shy about voicing my opinion. I have a blog after all, don’t I?

Rwandans, on the other hand, are extremely private and reserved. Keeping quiet about everything is very much part of the culture. “Rwandans, if they have something against you, they will take it to their grave!” a Burundi-raised Rwandan told a friend of mine. Besides being potentially dangerous, the probability of my foreign opinions making a difference on most larger issues here is very slim.

Still, I find myself extremely conflicted. Not only because checheka-ing goes completely against my very opinionated and vocal nature, but precisely because the culture of checheka-ing has caused literal devastation in Rwanda already.

Throughout April I am reminded how my countrymen sat by eighteen years ago and checheka-ed as almost one million people were slaughtered here.  There is no denying the horrendous role the United States and other European countries played (or didn’t play) during the 1994 Genocide. Yet, I also –quietly-- wonder how productive it is to be so critical about the silence of foreigners millions of miles away eighteen years ago, when right here in Rwanda, today, the culture remains one of silence and, at least outward, complacence.

April

April is Rwanda’s rainiest month. Eighteen years ago in April, the plane of Rwanda’s then Hutu President Juvenal Habyarimana was shot down as it landed in Kigali. In the one hundred days that followed, almost one million people were killed in Rwanda for being of the Tutsi ethnicity, or for sympathizing with Tutsi.

Every April, Rwanda commemorates the genocide that took place here in 1994. Between April 7 and April 14, business is put on hold each afternoon and communities gather to remember the events that destroyed the country. The following one hundred days are national days of mourning. No weddings or other public celebrations of any sort are held, it’s against the law. On national television, vivid images of the massacres are shown. The radio blasts what I can only describe as the exact opposite of Christmas songs: ballads dedicated to those who were lost, pleas of unity and peace. 

Yearound, discussing ethnicity in Rwanda can land you in prison for “inciting genocidal ideology”. No one has ever told me directly whether or not they are Hutu or Tutsi. Genocide survivors live alongside perpetrators. Everyone is Rwandan now. During April only, people mourn genocide victims publicly.

“Those people that killed my parents, they are free!” a friend told me. “Are you sure?” I asked. “Yes! I saw them kill my parents, my brothers, and my sisters when I was so small” he replied. “They are not in jail?” I replied, incredulous. “They served some small time, and now, they are my neighbors again” he said, shaking his head, laughing. “You are not scared? Angry?” I asked, trying to imagine the situation. “In Rwanda, we must move forward. Everyone! It is also the government program. It is not easy, but we must.” I cannot fathom being capable of forgiveness like this.

Meanwhile, the rains continue. The ominous dark clouds cast a permanent grey shadow that perfectly reflects the national mood. Water falls from above and lands like violent tear drops on the tin roofs, as if the skies were also mourning the dead, angrily. And then, when the rains fade, you notice a change: clarity in the air, like a window after it’s been washed with Windex. You realize the bean vines have become suddenly tall. Parents finally have food to feed their malnourished children. There is an abundance of water which brings relief to everyone. Maybe there is hope after all. 

Visiting a Memorial Site, connected to a secondary school, in the Western Province

On the Road

If you want to “experience culture” in Africa, take public transportation. If it’s your first time, maybe take a Zanex with you. Some of my best and worst experiences over the last eighteen months have involved public transportation.

Moto-taxi drivers in Rwanda wear helmets and carry them for passangers

After the fantastic safari with family, I headed south and reunited with a friend who had been in PC Niger and is currently a Tanzania PCV. Our original plan was to climb Mt Hanang, Tanzania’s fourth highest mountain, but rain kept us at lower altitudes. The following day, we set off further south en route to her site.  

The “seats” on our 6AM bus were the first two behind the driver, although there were plenty of people in between. The narrow space and surface area between the driver’s seat and the first row of passenger seats was occupied by five other Tanzanians. My friend sat next to the window, knees against the driver’s seat, a backpack between her legs and another on her lap. I sat next to her, another backpack on my lap, facing a fellow passenger sitting on a makeshift seat, our knees pressed against each other.

A few seconds after we got seated, someone ran off the bus. When others followed, I figured there must be another bus leaving at the same time. Suddenly my friend urged me “Get off the bus! It’s smoking!” I looked up and realized: less than two feet in front of me the mechanical mess next to the steering wheel was, in fact, full of smoke. 

Once out of the bus, we watched the driver and a couple ticket sellers fiddle with engine and then motion to the passengers it was safe to get back on. My friend and I looked at each other and shrugged: trying to switch itineraries at this point was too complicated. A little smoke never hurt anybody.

About two hours into our bumpy journey, a big pothole caused us to fly a few inches out of our seat, for the hundredth time. Then the bus jerked sharply to the right. My backpack went flying into the isle, and my body followed. I felt my friend’s arm trying to yank me back into the seat at the same time I felt other passengers falling on and around me. The sound of people screaming was mixed with the sound of large tree branches hitting the bus. We shook right and left, up and down, and then finally (after what was in reality probably less than ten seconds) the bus hit a tree, and stopped.

I got up, and along with everyone else, got out. A woman lay on the ground in front of the bus with her eyes closed and I feared the worst, but soon realized she was just napping—all the commotion must have worn her out.

We parked ourselves about twenty feet away from the bus. “How long do you think we should wait before we try to walk or take a motorcycle?” my friend asked. The road we had been traveling on was just a sandy dirt path and our surroundings were all farmland. Neither of us knew exactly how far we were from our destination, and none of the other stranded passengers seemed sure either. After a half hour or so, some women who had been waiting near us started to walk, and we followed. One of the women offered (and then insisted) on carrying one of my backpacks.

After walking about an hour, we ran into a small village. There, one of the women asked if we might get tea. A young man escorted us to what looked like someone’s living room and we were promptly offered water to wash our hands, delicious milk tea, and of course, fried dough. My friend and I shared our bananas and mangos as well. We sat, ate, and giggled with the women for what might have been my favorite hour in Tanzania. Just as we finished our tea, someone came running into the house to announce that the bus was fixed and ready to continue. A couple more close calls and a few hours later we arrived at our destination and praised Allah for the safe arrival.

Buses leaving Nyabigogo Bus Station in Kigali

This trip was a more extreme version of many, many journeys I’ve taken since my original flight to Niger. My transportation adventures, more than anything else, have made me realize that with a little patience and a sense of humor, in the end, things usually turn out alright.

Adventures of my Electronic Equipment, Part 874

So, I’ve told you about my iTouch and cell phone adventures (parts I and II). Now let me tell you about the adventures of my digital camera.

Leaning out of the vehicle to photograph a sleepy lioness

On Safari, I took lots of pictures (more on facebook, previous posts and the pictures page of this blog). Most of these, I took from a Land Cruiser that had pop up roof. While driving around the Serengeti, I stood on my seat with my head and arms outside the vehicle. When the vehicle stopped so we could observe animals or take in a pretty view, I lifted myself out of the car and sat on the roof. At some point during one of our morning drives, I sat on the roof, and my camera fell out of my pocket, onto the ground.

When our vehicle stopped for breakfast, I searched the car to make sure the camera hadn’t fallen into a seat crack. Our drivers also searched the car, to no avail. The reality sunk in deep: my careless ways had finally gotten the best of me. My camera was gone, lost forever on the plains of the Serengeti, a toy for the hyenas.

I was pretty sulky the rest of our morning drive-- thinking about all the beautiful scenes I was unable to capture on my camera: the lovely waterproof, dustproof, and shockproof Pentax that I call my “Africa-proof” camera. It had been so good to me since I first arrived in Niger last October.

With one of our drivers, who helped find my camera

After lunch at camp, our guide told me he was going to look for the camera before our afternoon drive. Embarrassed, I thanked him for the effort, although I realized the likelihood of finding the camera was small. Still, I couldn’t help but hope. By the time four o’clock rolled around I figured the search party must have had no luck. As I walked towards the group I saw our guide and shrugged, “No luck?”

“Here it is!” he said triumphantly handing over my camera. After three hours of searching the plains, they found it!

I’d like to say I have learned my lesson. But, I also thought I had learned my lesson after the iTouch incident, and the telephone incidents. The problem is, with the sort of luck I’m having, I think I’m becoming more careless.