Heeding nature's call (written October 10)

A couple random frustrating thoughts about heeding nature's call while living as a Peace Corps Volunteer:

1 - The sun is hot - so hot that if I go outside to use our latrine during the day without shoes on, I need to run back inside put something on my feet, and then return to do my business.

2 - I have to go outside in the first place (but thank you thank you Peace Corps for giving us our own so we don't need to go running out into the compound in the middle of the night)!

3 - Outdoor bathroom. Rainy season. Bad timing. Enough said...

4 - In the rainy season, both your toilet paper and soap need to stay inside your house. Don't forget to take them with you when you go out!

5 - If I go to the bathroom either at dawn or dusk I am liable to end up with mosquito bites in unfortunate places.

6 - Insects live down there. Some of the time they like to come out.

7 - Squatting technique and aiming ability are important skills.

8 - Occasionally people drop important things down there - such as cell phones, sandles, and concrete latrine covers (don't ask I don't know how that volunteer accomplished the task).

9 - There are occasionally small child level eye sized holes in your fence, which take an inordinately long time to repair.

10 - If you are away from home and need to go, you need to distinguish between #1 and #2. If you ask for #1 you will most likely get taken to a concrete slab in someone's backyard. Sort of poses a problem if you all of a sudden decide #2 is going to happen too.

The Violet Shyness of their Eyes

While we were in Kombo last week, I picked up a book at the Peace Corps office entitled "The Violet Shyness of their Eyes: Notes from Nepal" (by Barbara J. Scot, published in 1993). I have read quite a few Peace Corps memoirs, but all of them have been written by people who served in Africa, so I figured it would be interesting to read a volunteer memoir (Scot was taught English for a year in Nepal when she was in her late 40s...she never actually says she was a Peace Corps Volunteer, but it certainly sounds like she was) about a completely different region and culture.

Once I got into the book, however, I was surprised to find that many of the challenges Scot describes sound very familiar. Some of these challenges I knew were common to almost any Peace Corps-type experience (culture shock, wild fluxuations between euphoria one moment and feeling completely helpless and incompetent the next, isolation, constant scrutany, self-reflection, questioning what you are doing there, frustration with gender roles and the treatment of women, etc), but there are others which I naively thought were specific to Africa, or even West Africa. A few examples include, in no particular order: students "learning" by rote memorization in a language they barely understand; the pervasive belief that anything Western is better than anything non-Western; the intense desire of young adults, especially educated ones, to go to the West to "make their fortunes;" a lack of value placed on personal privacy and personal possessions ("in Nepal it is considered selfish not to share"); and the frequent wearing of white clothes in a dusty, dirty environment (and people's mysterious ability to somehow keep their white clothes clean). Very interesting.

Scot also spends quite a bit of time discussing her evolving opinions on the ethics of development, which is something most Peace Corps-type volunteers grapple with at one point or another. I don't agree with everything she says by a long shot (and to be perfectly honest, I actually wouldn't recommend the book at all) but she does raise some important and difficult questions. Here are a few good quotes:

"What do you do as a culturally sensitive development worker when elements of the system you are trying to be sensitive to are basically abhorrent to your own values?...The women in this group make no bones whatsoever about their intentions to enlighten Nepali women to the possibilities of change from their present subordinate status. It seems easy. We're right and they're wrong. But what what if the Nepalis came over to the US and started telling Iowa beef farmers that it was wrong to kill cows. Or what if the Saudi Arabians came and told women in New York that it was wrong for them to drive cars? Is that what is meant by cultural imperialism? A 'culturally sensitive' development worker is beginning to seem like a contradiction in terms."

"Saturday is a bidhaa, a holiday, in Nepal, and little clusters of men gathered lazily under the chautaara, the resting tree, with its gnarly roots. Little boys tossed a ball made from old socks back and forth to each other. The women at the water tap, in their wonderful wildflower shades of clothes, stood talking with their golden water urns glowing in the sun. Four little girls played a complicated jump rope game. Could I honestly say these people's lives would have been improved if they had spent their bidhaa at the mall?"

"So much development aid has been pouring into Nepal - an inundation of mostly good intentions - and much of it has run off like the early spring thundershowers, noisy and colorful, but with little substance. The positive aspects of modernization that will really grow and flourish here will have to come from [Nepalis]. And their society will be so much richer for finding ways to modernize that are compatible with their indigenous traditions."

"Nepal is not 'behind' the West. It's just a different place. And it has much that the West is crying for: stable families that guide children into solid identification with their society as a whole; a spirituality that pervades their daily life; and a blend between work (that's still mostly honest physical labor) and play that validates the importance of enjoying life. We should be studying them to see how we can compensate for what we've lost before they've modernized so much that they have little left to teach."

"I, for one, am not about to give them much advice on women's equality until we have worked things out a little better at home. For just a generation ago, I was taught as surely as any village Nepali girl-child that I was a second-class citizen at best, and that I was not worth very much without a man. I, like them, knew it was my duty to get married and have sons, even though my grandmother talked about preserving family names instead of religious duties to release the father's soul to the next reincarnation."

The issues Scot is getting at in the quotes above are just a few of the many issues we are struggling to come to terms with here. Given that I intend to pursue a career in international public health and development, this ongoing struggle that is absolutely critical both in terms of my personal and professional development. As they say here...it's not easy de!

HIV Workshop (written Oct 5 - yes, I was busy Oct 5!)

Last weekend I attended a truly excellent workshop put on by one of Peace Corps/The Gambia's volunteer committees, the HIV Task Force. It was a three-day workshop and the format was: Day 1 - Technical HIV information, including the science of HIV, transmission and risk, and the state of HIV in The Gambia; Day 2 - Presentations by Gambian health educators, on topics including culturally appropriate ways to talk about sexual and reproductive health (and HIV specifically) and HIV support groups in The Gambia; Day 3 - Teaching about HIV in school, including the use of drama and a run-through of the draft curriculum for the HIV Bike Tour we will be doing in November (more to come on that in a later post).

Like I said, the workshop was incredibly well done and there are many things I could share, but I thought the information about the state of HIV in The Gambia would be particularly interesting for all of your at home. Here are some key facts, in no particular order:

1) The best estimate of the HIV prevalence in the Gambia is around 1%. (For comparison, the prevalence in the US is about half a percent, while South Africa is 18%. See this link for data on other countries if you're curious: http://en.wikipedia.org/wiki/List_of_countries_by_HIV/AIDS_adult_prevalence_rate.) My understanding, however is that that value, is calculated almost solely based on pregnant women reporting for antenatal care and agreeing to testing. Gambian statisticians assume one infected man for every infected woman, and go from there. This strategy for estimating the prevalence, while the simplest and most straightforward, has a some potential flaws, the most concerning being overlooking more difficult groups to capture such as sex workers, anyone who is not sexually active, children, young unwed mothers who are often unlikely to seek antenatal care, women who can't or aren't getting pregnant, either by choice or due to infertility or old age. All of this may result in an underestimation of the official rate, while ignoring polygamy may result in an overestimation of the official rate (since they are assuming one man for each infected woman and one man can actually infect up to four wives without even looking at fidelity issue). All these factors may cancel each other out, but it is really hard to know.

2) Contrary to popular belief, 80% of HIV transmission in The Gambia is estimated to occur through heterosexual sex (we don't have stats on what percentage of that is intra-marital, but anecdotal evidence suggests it is quite high). This is a common theme throughout Africa.

3) While the HIV prevalence in The Gambia is (supposedly) quite low compared to many other countries, particularly in Southern Africa, The Gambia has a LOT of risk factors that are serious reasons for concern, including: polygamy (concurrent relationships); the practice of wife inheritance (brothers marrying their deceased brother's widows); pressure to have a lot of children soon after marriage; early marriage of girls (young girls generally have not finished their education and have very minimal decision making power, while their older husbands have had more time to contract HIV); the practice of female circumcision (razors are often shared during ceremonies and circumcised women are at an increased risk of traumatic sex and childbirth, which carry huge risks of HIV transmission); resistance to condom use (sex outside of marriage is condemned by Islam and inside of marriage everyone wants to have a lot of children, so the only logical conclusion is people using condoms must be participating in un-Islamic activities); and The Gambia's small size, highly mobile and transient population, and location at the intersection of several major African highways.

A few important protective factors against all these risks include: free and widespread voluntary testing and counseling and support groups; free and readily available anti-retroviral drug therapy; a high level of social and cultural cohesion, and widespread male circumcision, which most health authorities believe reduces HIV transmission rates (dearest reader Mark - kindly keep your comments on this to yourself - you've already said your piece on a previous post - point taken).

4) One additional reason for concern relates to the two strains of HIV. For those you who many not be aware, there are two strains of HIV - HIV1 and HIV2. There are several differences between the two strains, but the most important one is that HIV1 is significantly more virulent (i.e., aggressive). For more information on the differences between HIV1 and HIV2, visit: http://en.wikipedia.org/wiki/HIV. HIV2 is thought to have originated in West Africa and until recently, it accounted for most of the cases in The Gambia. Since HIV2 is comparably "better" (50% of people with HIV2 never progress to AIDS at all), that was a good thing. However, in recent years, for reasons not completely understood, the cases of HIV2 have been declining here, while the cases of HIV1 have been rising. Bad news.

5) In The Gambia, in addition to biological risk factors such as women being twice as likely as men to contract HIV through heterosexual sex, women are at a particularly increased risk from HIV because of a lack of decision-making power, economic dependence on men, early marriage, and the prevalence of transactional relationships such as sex for grades or school fees between students and teachers and "sugar daddy" relationships. On the topic of early marriage, which sometimes happens as early as 13 for girls, we learned that in some tribes, a girls marriage can be triggered by one of two things: ability to carry a pounding mortar (signifying she is strong enough to carry a man) or debut of sexual activity (which means she is at risk of shaming her family by becoming pregnant). The same triggers do not apply for boys, who are rarely married before 17, and often much later.

6) This isn't Gambia-specific, but it is something I didn't know and found interesting (and important to know): An infected person is more likely to pass on the virus during their initial spike in viral load, which occurs during the first three months after contracting the virus. The scary thing about that is that many HIV positive people do not test positive until they have had the virus for 3-6 months...so that means that people are most likely to infect others during the time period when they often do not have any symptoms and, even if they were tested, they probably would test negative. Yikes. That is one of the many things that makes the spread of HIV so difficult to combat.

Ok, that's enough for now. Keep the feedback coming guys - let me know if I'm getting too techy or you'd rather read posts on other topics...

Resisting the urge (written Oct 5)

When asked how her Peace Corps experience has changed her, one of our second year Environment/Natural Resources volunteers responded with the following: "I've realized how patient we really are and the importance of patience in our work. Because for a lot of what we do, it's so much easier to just go and do it...go plant that live fence, write that grant, or just do things yourself. But that's not what we're here for. And even if it's going to take another week to get other people involved, it's worth it in the end, so communities have ownership over the projects." So true! What she was getting a there is one of the most challenging and frustrating, but at the same time, the most important aspects of a volunteer's service. It's a little hard to explain, but let me give you a brief example:

This morning I spent close to two hours helping a counterpart type up a two-page handwritten latter that would probably have taken me 10-15 minutes to type up and edit myself. Was it frustrating? Naturally. Did I have to actively fight the urge to take over and do it for him every minute of it? Absolutely. So why didn't I give in to that urge? Because over the course of those two hours, my counterpart learned how to do countless simple new things on the computer (formatting, using the SHIFT key instead of CAPS LOCK, how to use Word's dictionary, etc), got a valuable English grammar lesson, realized he was consistently spelling certain words wrong and learned how to spell them correctly, and improved his typing skills, just to name a few.

If I had typed up the letter for him, he would not have learned any of that. Down the road, those lessons learned and skills gained will be infinitely more valuable to him than an extra hour and a half on a Tuesday morning in October.

Why it's hard to be optimistic (written Oct 5)

DISCLAIMER - Usually I try to keep my posts pretty upbeat, but I also want to accurately represent my experience here (which is not, contrary to popular belief, all saving babies and cooking food that no one would believe we were able to whip up in a hut in Africa), so occasionally I have to mix in a more negative post or two. Here goes...

Over the past few days, I've had a few experiences that are making it hard to be optimistic about health work here:

1) First, a little background on this one. As I've mentioned, Reproductive and Child Health Clinics are widely and regularly available (and attended!) here. At the clinics, children are weighed and given vaccinations. Every child has a clinic card with their weight chart and immunization record. Most mothers cannot read and/or understand the cards. In theory, the nurses weighing the babies are supposed to be flagging underweight children for nutritional counseling, follow-up, and therapy at a rehabilitation center if necessary. Sounds good, right? Unfortunately, time and time again, I have seen nurses weigh an underweight child, mark their weight on their chart (well below the recommended weight for age), and hand the card back to the illiterate mother without a word. Occasionally they keep a tally of the underweight kids for regional or national statistics.

It's hard to put into words how irresponsible, negligent, and downright unethical this seems to me. It makes me more than just frustrated...it makes me angry. These women sometimes travel long distances every month to attend these clinics. They are doing the right thing; they are coming to the clinics for help so they can keep their children healthy, and the health workers are noticing a condition that can generally be taken care of easily and cheaply using locally available foods, if it is caught early...and they are doing NOTHING! Is it not their job to help these children?? I have raised this issue with health workers countless times, and everyone always agrees that it's an important issue that can and should be addressed, but nothing changes (unless I actively sit next to the weighing station and prompt the nurses to take appropriate measures).

2) Yesterday I was leaving work at the health center when a pre-teen boy stopped me to ask me to help his younger sister, who had a severe puncture wound on her foot from a rusty nail. They had arrived at the health center riding double on a bike. Since it was "after hours" (around 3pm...that's a whole other issue), there was only one nurse manning the out-patient department and he tried to make them come back the following morning, claiming he didn't have the supplies to dress the wound. The nurse knew perfectly well that once sent away, people often don't come back. In this case, the brother had brought his sister after school, so in order to bring her in the morning, he would have had to miss school. I spent the next hour pushing the girl thorough the after hours out-patient system, ensuring that she got the drugs she needed (the nurse tried to send her away without even giving her tylenol, much less antibiotics or a tetanus shot) and explaining to the brother what to do when the loose bandage fell off in a day or two.

From one perspective, it's nice to know that I was able to make a difference in the life of this little girl (and show her brother that not all health workers are unhelpful), but that does not even begin to make up for the colossal failure of the health system that this incident represents. Just like the women who bring their babies to clinic, this girl and her brother did the right thing by coming to the health center, but the health workers there were not doing their jobs and would have completely failed her if I had not intervened. Can I really blame this girl annd her brother if next time she is injured or sick, she doesn't bother to come to the health center?

3) The other day I had a discouraging conversation with a Gambian-American gentleman who had come back to the Gambia to visit. He has been living in the US for quite some time and has a wife (also Gambian) and two kids. Upon mentioning that he has two kids, he added that he and his wife do not intend to have any more, a decision which his friends and family in the Gambia thoroughly disapprove of. He said that when he suggests they should consider doing they same, they laugh at him. If a Gambian-American who fully supports and practices family planning cannot successful encourage it here, how am I supposed to be able to??

This conversation reinforced a concept I have been thinking a lot about lately regarding the factors influences family size. I think I've mentioned this before, but some theorists argue that how many children people have is primarily motivated by economic reasons, rather than social/cultural/religious ones (or access to family planning services). In a nutshell, the concept is that as long as it is economically advantageous to have a lot of children, which is the case in any population that is dependent on cheap unskilled labor, people will (and society will encourage it). If/when it stops being economically advantageous to have all those children, such as when a country's economy shifts to depend more on more expensive skilled labor, people will stop (and, again, society will encourage it). An example of a shift of this kind was the US around our grandparents' and great-grandparents' generations. Many of our grandparents and great-grandparents come from large families, but as it became more expensive to raise and educate children for the increasingly skilled workforce, this trend fell off. Accordingly, most of our parents come from smaller families. Of course, it is more complicated than that, and there are a lot of factors at work here, but I think it's a very interesting way to frame the issue.

Getting back to The Gambia, the Gambian-American gentleman's actions seem very much in line with this theory. He grew up here, in a culture that overwhelming supports having a lot of children (the average number of children is six), and when he moved to a country where that was not economically advantageous, he and his wife did a 180 and made the decision that made the most sense economically. They never looked back and have never regretted a decision which seems crazy to Gambians who have not lived in "toubabadou." While I'm sure there were other factors motivating their decision, it does not seem like much of a stretch to suggest that the main motivation for their decision was a dramatic change in their economic environment. If that is the case, then how should we go about convincing Gambians who most likely will never leave the Gambia to have fewer children. And, more importantly, should we even be trying? What do you all think? I'd love to hear your thoughts.