Picture update (with a cute video!)

Small boy army/soccer game Fatou enlisted to help us carry firewood across the village for our neem cream demo (local insect repellent). The "small boying" phenomenon here was a bit disturbing to me at first, but have to admit it has its benefits. In a nutshell, it means any adult can ask any child to run errands for them around the village and the child has to comply.


Making neem cream


Jacob with Jonyi, our favorite host sister. Mom, Jonyi's shirt here should look familiar!


Lisa's adorable host brother, Bru Bru. In case there was any doubt that children are universally messy eaters (that's rice all over him)...


Bruschetta and alfredo pasta with mushrooms and eggplant. We got two thumbs up from Lisa's Gambian co-workers for this one!


Making ebey on our gas stove for the first time. I caught Fatou unprepared, so I managed to capture her infectious smile that she usually refuses to show the camera.


Pounding the cassava


Not-so-convincing attempt at a candid shot of me helping Fatou make tiyokatos (like peanut brittle)


Little Ntanding rocking out. She's maybe 6. Love this!

Community-Led Total Sanitation (CLTS) Workshop

Last week I attended most of a 5-day UNICEF-funded workshop on a new technique for mobilizing communities to improve their sanitation practices (which is a nice way of saying “convincing people to stop open defecation”). The technique, which is called Community-Led Total Sanitation (CLTS), was developed a few years ago in Asia and has successfully been implemented in two other regions of The Gambia, but never in our region (LRR).

CLTS is different from traditional sanitation development projects in the country (which largely have failed) because it is focused on changing people's understanding of sanitation, and thus motivating a change in their behavior, rather than building latrines or providing building materials for latrines. The concept of using behavior change communication to empower communities to create local solutions to their problems is very much in line with Peace Corps' (and also CARE's) approach to development, so I went into the workshop very interested to learn more about it.

The part I was skeptical about, however, is that way that CLTS motivates people to change their attitudes and thus their behavior is by using different tools and demonstrations, as well as using crude local words (equivalent of the word “shit” in English) to trigger a shame or disgust reaction. It is important to note that public health facilitators DO NOT tell the village what to think or do – they just present the community with information and let them draw their own conclusions. So the idea is to call a community meeting, then employ the following tools, proceeding through them until reaching a “trigger” point, where the village (ON THEIR OWN) comes to the conclusion that they cannot continue open defecation and decide they want to find a solution to the problem (ON THEIR OWN):

1) Defecation area mapping – Create a map of the village on the ground. In addition to key landmarks, identify the locations of compounds, latrines, and ask the people without latrines to show where they go to defecate (see pictures below).

2) Defecation area transit walk – Ask community members to take you to visit a commonly used open defecation site (people will be embarrassed and not really want to do this).

3) Fecal-oral contamination – Collect a sample of fresh feces while on the transit walk, return to the meeting site, and place the feces in the center of the circle. Take a piece of fresh bread, eat a bite, offer it to community members, then place the bread next to the feces in the center of the circle (flies will quickly start to gather on the feces and move back and forth between the bread and the feces). Take a cup of fresh water, take a sip, offer it to community members, then take a thread, drag it through the feces, dip it in the water, then offer the water to community members (they will refuse it). Offer the bread to community members (they will refuse it). Ask the community why they no longer want the bread and water when their food and water is contaminated by feces all the time because of their open defecation near their village.

4) Shit calculation – Calculate the amount of faeces a single compound produces in a week, a month, and a year.

5) Medical expense calculation – Calculate the cost of a single visit to the hospital for diarrheal disease (including cost of travel, the hospital visit, buying medicine at the pharmacy, the value of a day of work lost, etc).

I observed two triggering activities, both in small villages off the road in our area. The first village had 20 compounds and I think 4 or 5 latrines. Our team went through Tools 1, 2, and 3 before deciding the village was sufficiently “triggered.” The second village had 23 compounds and 8 latrines. That village “triggered” after only Tool 1. I expected the communities to be angry or offended when we used the crude language and brought them to realize that they are quite literally “eating their own shit.” In reality, they were engaged and appreciative and motivated to change.

The next step is the communities are having follow-up meetings to create a plan for construction of latrines (using locally available materials like wood from the bush and local cement made from cow dung and termite mounds). Each community will send two representatives (one man and one woman) to a day-long workshop in a nearby town to flesh out their plans with deadlines and responsibilities. Local health staff will be responsible for following up and monitoring progress. When the local health staff deem the village “open defecation-free,” the village will throw a party to celebrate their accomplishment.

Originally I was concerned about encouraging people to make local latrines rather than strong cement ones that will last longer. However, after discussion with local health staff, I realized that latrine-building and -subsidizing programs generally only can afford a few latrines per village, far fewer than are needed (and they generally end up in the village elders compounds), and when attitude and behavior change strategies are not used, there is no guarantee that people will actually use them. Individual compounds or the village as a whole can always save up for improved latrines later, but the attitude and behavior change elements have to come first. Additionally, building local latrines is free, so it allows even the poorest compounds to contribute fully to the village's achievement of “open defecation-free” status without financial strain.

I mentioned earlier that at first I was uncomfortable with the idea of disgusting and shaming people into doing what we think they should (regardless of whether it would be beneficial to their health). However, when I thought about it, I learned in my biological anthropology courses that human disgust reactions evolved as a powerful and innate defense mechanism. It makes sense to tap into that biological mechanism. Also, remembered that I read somewhere that Americans are significantly more likely to wash their hands after going to the bathroom if they are in a public restroom with other people around. Same idea. No matter what the situation, peer pressure and shame are always powerful motivators for behavior change. Very interesting stuff.

Below are some pictures from the two triggering activities:

Village 1, shot of the village. This is what a typical small Fula community off the main road looks like. Notice all the green that has replaced the red-brown dust everywhere. Woo rain!


Village 1, making the community map


Village 1, completed map. Sorry for the weird angle - I was trying to fit as much of the map in the picture as possible. The branch is the tree under which we were holding our meeting, the upside-down bowl is the mosque, the bidong is the seed store, the circles with white cards in the middle are wells, the blue cards are compounds, the green cards are latrines, and the sawdust represents the routes people without latrines take when they go to their preferred open defecation spots.


Village 2, Musa facilitating the triggering activity


Village 2, village elder and "natural leader" driving home a point to his community


Village 2, attentive community. We had an excellent turnout in this village.


Village 2, completed map. Slightly less creative than the previous day, but the idea is the same.

Assorted reflections from late July and early August

1) I recently participated in an H1N1 immunization campaign which included people suffering from chronic diseases as a major target group, and it was quite eye opening to see how many people in this area have high blood pressure, hypertension, asthma, diabetes, etc. Like many Americans, I tend view chronic diseases as the consequence of decadent lifestyles, and thus, mainly an affliction of the wealthy. Not only is this a huge misconception within the US itself, but it is rapidly losing any element of truth for many countries in the developing world as well. My impression was that there was some incidence of chronic disease among Gambians living in Kombo (the capital area), but that it wasn't a major concern up-country. After spending several days looking at dozens people's of hospital slips confirming their conditions, I can confidently say that my initial impression was incorrect. While not surprising given the level of salt and sugar Gambians regularly consume, it is frustrating and seems a bit unfair that Gambians are increasingly having to deal with chronic disease on top of the ever-present infectious diseases of the developing world (malaria, diarrheal diseases, etc).

2) It is extremely common for both male and female Gambian civil servants (health workers, teachers, policemen, soldiers, etc) to live in a completely different part of the country from their spouses, rotating postings periodically and only coming home for visits every once in a while. I'm sure there are exceptions, but I know quite a few Gambian civil servants, many of whom are married, and I can't think of one that lives full-time with his/her spouse. This is a small country, so theoretically living in a different part of the country from your spouse shouldn't be more than a half day's drive (obviously not ideal but not unheard of in the US), but a lack of basic transportation infrastructure makes travel significantly more time-consuming than it should be. I cannot believe that this system does not have some far-reaching effects on some of the country's most educated and service-oriented individuals and their spouses and families...

3) I recently had a very surprising and enlightening conversation with a highly educated female civil servant who I consider to be one of the most empowered Gambian women I know. I'll call her Binta. She noticed I was reading a book with veiled girls on the cover and asked to look at it. In the introduction of the book there was a blurb about the author that mentioned her expulsion from the University of Tehran for refusing to wear the veil. Upon reading that, Binta exclaimed “that's the way it should be!” Shocked, I tried my hardest to maintain my composure and asked her to explain. She cited the Koran and explained that when women don't cover themselves properly and/or wear tight trousers, men start thinking inappropriate thoughts about them. At this point, Binta could tell I was biting my tongue and asked me what I thought. As diplomatically as possible, I said that I'm not a Muslim, so I don't understand these issues from an Islamic perspective, but it seems unfair to me that women should have to dress in a certain way because men cannot control themselves. “Why don't men have to cover up to avoid tempting women?,” I asked. She laughed and just said that men are different from women.

Binta also mentioned that the Koran says that men are responsible for providing for their families and a woman's place is in the home raising children, where she won't come into contact with any men who are not immediate family members. She lives in a different town from her husband, leaves her compound for work every day, and works with mostly men, so I couldn't keep myself from asking exactly how she reconciles the reality of her life with that belief. She blamed poverty and essentially said that you do what you have to do to feed your family.

I was curious what Binta, an educated women with a professional career, thought about girls education, so I mentioned that in some countries, such as Afghanistan, Islamic extremists oppose girls education, and that is something I personally take issue with. Her response was that she can understand opposing girls education because it brings girls in contact with boys and men that are not their immediate family members, either during their schooling or in the workplace when their education allows them to find jobs. She only has one son who is not yet school-aged, so I couldn't ask her whether she was sending her daughters to school. I wish I had thought to ask her what she would do if she did have school-aged daughters.

This was quite a challenging conversation for me, and it made my ignorance of these complex issues quite apparent (to me at least). I clearly have a lot to learn about the many faces of Islam, and I am realizing that I need to be much more careful about assuming that if a person is educated and seems “western” or “progressive” in certain ways, then they must have western social values similar to my own.

4) The other night Jacob and I were making dessert with a few Gambian friends when Jacob kiddingly tried to grab a chuppet (like a cross between funnel cake and a donut hole) out of my hand just as I was about to take a bite. Indignant, I jokingly turned to him and said “You are rude!” in Mandinka. At this point, our (educated and “western”) Gambian friend turned to me, legitimately scandalized, and scolded me for saying that to Jacob. Very seriously, she explained that in Gambian culture, a husband can say that to his wife, but a wife can NEVER say that to her husband. My bad.