Thursday, July 22, 2010

Picture update


Goat perched on a pounder for no reason whatsoever. Seriously crazy animals.


Ntanding wanted to pose w/ the goat but it jumped down when she got close. Blurry but cute.


Classic Hawa


Infected bug bite before it burst


Brenden's parents made us an amazing chinese dinner at the Stodge


For Sarah's mom


Making heavenly blue cheese and tomato stuffed burgers. These are the faces Luke and Albien make when I tell them to smile...


Finished burgers

Education in The Gambia (written July 18)

Yesterday I had a very enlightening conversation with someone very familiar with the Gambian education system (let's call him Joe) and I wanted to share a few of the more interesting points. DISCLAIMER - I am merely paraphrasing what this person shared with me...I am NOT implying that all of it is true or that any of it can be generalized to represent all Gambians.

1) Teachers in The Gambia are paid very poorly and are not provided with accommodations, transportation, and generous hardship allowances the way other civil servants are. This is one of the main reasons for the extremely high number of teachers taking jobs in other fields after only a few years of teaching. If they stick it out for 15 years, they get retirement benefits, but that is only sufficient motivation to continue teaching that long for a small minority of teachers. This results in high turnover and wasted resources used on educating and training teachers who subsequently leave the field.

2) Sexual relationships between teachers and students (generally male teachers and female students, who often are in their late teens or early twenties even in middle school due to starting school late and/or failing grades) are a serious problem. The government recently cracked down on this issue and made a teacher impregnating a student a crime punishable with life in jail. While this seems like a positive step, the teachers feel unfairly targeted by the new law, since it only applies to teachers and not other civil servants who (according to Joe) are equally contributing to the problem. Joe also cited a couple examples of situations where female students very persistently "seduced" their male teachers.

3) In an effort to boost girls school enrollment, the government waives the school fees for every girl in the country Grade 1-9. School fees are often a barrier to attendance and girls' education is widely accepted to be a major element of development, so when I first heard about the policy, I wholeheartedly applauded it. However, according to Joe, many Gambians do not place value on things they do not have to pay for, so the well-meaning policy has actually exacerbated the problem of people not taking education, particularly girls' education, seriously. He explained that when a girl fails a grade, since her father does not have to pay for her to repeat it, it doesn't particularly bother many people. Joe also said that boys and girls perform relatively equally in school up to grade 5, but after that, the many girls get distracted by boys, start thinking about impending marriage, stop taking school seriously, and quickly fall behind the boys in school. Often they become pregnant and/or married and drop out before Grade 9. I asked what he thinks can be done to improve this situation and he had the following recommendations: a) increase teachers' salaries and benefits to the level of other civil servants to encourage them to stay in the field and do their jobs better; b) put more effort into educating parents about the importance of education, particularly stressing the role of parents in encouraging their children to do their homework; and c) only provide free education for girls through Grade 5, in an effort to get the older girls to take school more seriously. I would be concerned that c) could seriously backfire and result in girls who are serious about their education being pulled out for financial reasons, but it's an interesting thought.

NOTE - I recently had a follow-up conversation with a counterpart about this subject and I was happy to learn that the government is, in fact, aware of this issue and is responding with a change in policy that will make girls' free education contingent on their performance. Additionally, since the fee-waiver program for girls has achieved its targets for girls enrollment, now the waiver program will be extended to some boys as well.

4) Joe complained that development workers are always harping on teachers about these newfangled "students' rights" and trying to get them to stop using corporal punishment, the only form of discipline that the kids respond to. Teachers sometimes use other forms of discipline like timeouts, kneeling on the hard ground, etc and they are somewhat effective, but since beating is used so widely at home, often it is the only thing that works. I wish I didn't believe him...

Tuesday, July 6, 2010

Shades of grey (written June 28)

Last night I witnessed an interesting event while I was hanging out before bed that I thought was blog-worthy, so I wrote it up. Here's some background. There is a young (mid 20s) woman in our village (let's call her Sue) who has an ~18 month old child. She moved here a few years ago when she married her husband. When she came, she brought one of her younger sisters (let's call her Betty) along to help her run her new compound. Sue and Betty generally relatively equally share the burdens of running their portion of the compound (cooking, cleaning, laundry, etc) and caring for Sue's child. Most of the time, this set-up works fine, but occasionally Betty loses patience with having to do all this work and runs off to play with her friends like the elementary-school kid she is. Naturally, this is when problems arise.


Last night, Sue decided she wanted to hang out with her friends instead of watching her child, so she assigned Betty to babysit. Betty was in the middle of playing a game with her friends when she received this unwelcome news, so she refused. This situation quickly escalated into Sue hitting Betty with a large stick and ranting about it not being fair that she had to watch her child by herself all the time. At this point, something cool happened. As I've mentioned previously, corporal punishment is very common here and generally witnesses stand by and let it happen without batting an eye. This time, however, something about the situation triggered the other women in the compound to run over to stop the beating. One of them even jumped on Sue's back and took the stick away from her. Once they had successfully stopped the beating, the women turned on Sue and gave her a serious tongue lashing, among other things, accusing her of being a bad mother for always trying to push her child-watching duties off on Betty.


This intervention in defense of a pre-teen girl (the generally accepted work-horses of any compound) really surprised me. My initial reaction was that the trigger must have been that Sue was so hugely and obviously in the wrong. But, after further thought, I started to wonder...how wrong was she? Well, of course, corporal punishment is not a strategy I support. And after all, she made a choice when she decided to have a child and now she has to live with that responsibility. But wait...I don't know for sure, but chances are very good that she had little or no choice in the matter when she was married off, sent to a new village, and subsequently, in part because of limited to no access to birth control, became pregnant (this is after she spent years watching all her younger brothers and sisters enjoy the privilege of attending school, while, as the oldest daughter, she had to stay at home and help her mother run their compound). Having a child is just as life-changing here as it is at home, and given the low use of family planning here and the minimal role women play in decision-making, chances are she had very little choice in when to have a child. After considering all this, while I still disapprove of Sue beating her sister, I have trouble blaming her for being bitter about the responsibility of her child. However, I have one more wrench to throw into this scenario. Most women here do want to have many children. At least once a week I have a conversation with some “Gambian women about how many children Jacob and I want to have (2 or 3), in which they are absolutely horrified and insist that having many children is “very good” and we should have at least 5 or 6. So, why do the women want so many children? My understanding is that it is to: 1) make their husbands happy by boosting their social status; 2) reduce their own daily workloads by adding extra pairs of hands to share the work; and 3) provide security that they will be cared for when they grow old.


Sorry the paragraph above is so stream-of-consciousness, but I haven't fully formed where I stand on all this yet. Lots of food for thought. So many shades of grey and so many layers of "root causes" and challenges. Living here truly makes me reassess my perceptions of "right" and "wrong" on a daily basis...

Monday, July 5, 2010

Health workshop for servicemen (written June 29)

Today I attended a workshop at the local health center targeting servicemen (military and police personnel). Interestingly, the reason the workshop targeted the servicemen is they are responsible for the vast majority of blood donations in the country, due to the long-standing relationship between the servicemen and the health system. While the workshop did touch on promoting blood donation, the facilitators (local health workers) used it as an opportunity to do a sensitization on a wide range of reproductive health issues, including HIV, sexually-transmitted infections (STIs), family planning, and encouraging men to take responsibility for their children's health.


I was really surprised and thrilled that the participants were attentive, engaged, and had a lot of great questions about some of the more taboo topics. Some examples of particularly good questions were:


1) What are the long-term health risks of using different forms of family planning (both to a woman's overall health and to her fertility)?

A: While all drugs have risks of potential side effects, family planning is proven to be quite safe, both to a women's overall health and her fertility. Which method is most appropriate for a particular women very personal and should be determined through consultation with a doctor.


2) Do you have to have another STI before you can get HIV?

A: Having another STI makes you more vulnerable to HIV, especially if the STI causes open sores in the genital area, but you can certainly get HIV without having another STI first.


3) If a woman is not ovulating while taking family planning, and thus not “using up” her eggs, does that extend her reproductive life?

A: Very good question, but no, a woman's reproductive life does not end simply because she "runs out of eggs." A woman is born with far more eggs than she could ever use, but all the eggs slowly break down over time. That combined with many other factors, determines when she stops being fertile.


4) The Koran does not approve of family planning, therefore I do not approve of it.

A: This led to a lengthy discussion in Mandinka that I couldn't completely follow, but the gist was that the Koran, like any religious text, can be interpreted in many ways and needs to be interpreted in the modern context and weighing pros and cons. For example, a man is supposed to ejaculate into one of his wives every time he ejaculates. If he uses a condom when having sex with one of his wives, technically, he is still doing that, and at the same time protecting himself and his wife from the very serious risks of HIV, STIs, unwanted pregnancy, etc. Clearly pros outweigh the cons. Another one solid pro-family planning argument was that the Koran says that a man is responsible for providing for all his wives and children, and if he has more wives and/or children than he can provide for, that is very much frowned upon.


5) What steps does the health system take to make HIV/STI testing and family planning available to commercial sex workers?

A: By law, the health system is required to provide HIV/STI testing and family planning to anyone who requests it.


6) What is the difference between HIV1 and HIV2?

A: HIV1 and HIV2 are two different viruses, both of which lead to AIDS. HIV1 is more aggressive, easier to pass on, and harder to treat. HIV1 is more prevalent than HIV2 (both in The Gambia and throughout the world). About half of the people HIV2 can control the virus without medication, while almost all people with HIV1 need medication to control it.


7) How is it that researchers have not been able to come up with a cure for HIV yet?

A: Diseases that are caused by viruses, which can be very difficult treat and cure because the viruses can mutate very quickly. As soon as we come up with a treatment, the virus mutates so the treatment doesn't work anymore.


8) Since there is no cure for HIV, this is a very scary disease...what can we do to control it?

A: Education is the most important thing. People need to understand the risks and know their statuses so they can make smarter decisions about their sexual health. We also need to work on destigmatizing the disease so people are not afraid or ashamed to get tested and treated.


9) I heard HIV came from animals. Is that true? How can that be?

A: Like we said, viruses can mutate very quickly, and sometimes those mutations allow a disease to jump from animals to humans. This is what happened with swine flu, for example, and that is what doctors think happened with HIV. However, at this point, it really does not matter where HIV came from. It is here and can be spread among humans, so we need to focus our efforts on controlling it.


10) Should there be agreement between husband and wife before starting family planning? It seems the hospital just gives it out without the husband's consent, when the woman just wants to go "play outside."

A: Like we said, by law, the health system cannot deny family planning to anyone who requests it. Ideally, yes, a woman should have discussed her desire to use family planning with her husband before visiting the health center, but we cannot force her. (The men were quite displeased to hear this.)


11) Which method of family planning is least disturbing to the womb (i.e., least likely to have a negative effect on long-term fertility)?

A: All methods of family planning are safe, but, as we said before, which method is most appropriate for a particular women very personal and should be determined through consultation with a doctor.


12) Why is it that women don't donate blood here?

A: Women should not give blood if they are under 17, pregnant, breastfeeding, or anaemic, which, given the high fertility rate here, includes most Gambian women.


13) Why can't we immunize babies by giving the immunizations to the mother before they are born?

A: Good question, but unfortunately it does not work that way. Some antibodies can be shared with the baby through the umbilical cord and some through drinking colostrum immediately after birth. Colostrum is a very nutritious type of milk produced by the mother in late pregnancy. Unfortunately, however, the colostrum only protects against some diseases, so we still need to immunize babies against a lot of diseases after they are born.


I also was very impressed by the creative techniques the facilitators used to tailor their messages to their overwhelmingly male servicemen audience. Here are a few examples:


1) The facilitators stressed that family planning is NOT used to encourage prostitution and is NOT just western medicine used by white people to ensure that they only have one or two children (which is exactly the opposite of what most Gambian men want). They encouraged the men to think about it literally as a technique for ensuring that their families shape up the way they want them to (birth spacing-wise), whether that means having two children or twelve. They also cited several local practices women use to try to encourage or discourage pregnancy (wearing or placing jujus under their pillows, drinking holy water, eating certain herbs, etc) and said, look, Gambians already have their own methods of family planning...this is just another (more effective) way to go about it.


2) The facilitators encouraged the use of family planning as a preferable alternative to simply cutting off sexual contact for an extended period of time after a baby is born, which is what many women do as a birth-spacing strategy. The reminded the men that not only is that strategy frustrating for them, but it also can lead to problems like infidelity, unwanted pregnancies, STIs, etc.


3) The facilitators stressed that letting STIs go untreated is risking future infertility (which most Gambian men definitely want to avoid).


4) The facilitators encouraged condom use as a helpful tool for men who suffer from premature ejaculation, and thus have trouble satisfying their wives, leading them to "stray" (very interesting comment on several levels).

5) The facilitators pointed out that the common practice of wife inheritance (a brother marrying is brother's wives and caring for them and their children if his brother passes away) is a huge concern for the spread of HIV. Since people don't actually die of HIV, but instead die of pneumonia or tuberculosis or some other disease once HIV has weakened their immune system, a brother can inherit his brother's HIV-positive wives without knowing they are HIV-positive.


6) The facilitators used the analogy of HIV as invaders attacking a country's soldiers, making the population vulnerable. In someone with HIV, the soldiers and invaders are constantly fighting. CD4 count is how many soldiers are in the country and viral load is how many invaders are in the country. Logically, then CD4 goes up, viral load goes down, and vice versa.


Those are just a few tidbits from what was a fascinating and very successful workshop. Funding for the workshop was provided by the World Health Organization. I am encouraging the public health team to request more funding to do another one very soon!

American Doctors in The Gambia

On July 1 a group of doctors, nurses, and dentists on a mission trip to The Gambia came to our village to provide free medical care to anyone who came. There were a few young kids in our compound who needed some medical care so I made sure they went. I ended up spending most of the day making sure the few friends I had there made it through the system, received, and understood the care the needed. I think the program worked out pretty well.

At the conclusion of the program the people on the mission trip wanted to go on a "Prayer Walk." Basically they wanted to walk through the village and see what is important in the village so they could pray for happiness and success of the village. I walked with them pointing out important areas in the village. At the conclusion of this walk one person asked if it would be ok if they prayed for me and for our village. Not knowing quite what to expect I said yes. Looking back it was actually a pretty interesting and pleasant experience. I guess it was cool to see people who were very passionate and faithful but were not remotely over the top or fundamentalist. Unfortunately it is not a sight we see in the world all that often...

Culture and Movies

Maybe a month or so ago a Gambian friend of ours got a TV and DVD player in her house. My first(well maybe second or third) thought was that this is a great opportunity to share a bit of American culture with some of our Gambian friends. The next step was figuring out what movies our friends might like. Unfortunately this has proven harder than expected. What I realized the other day was how much culture and simply what is familiar influences the types of movies you like. The movies our friends own are Nigerian movies featuring African actors wearing West-African style clothing in familiar village settings. In short it is full of familiar imagery and story lines. However, all of our movies are nothing like that. Most of the actors are white, none of the scenes are set in Africa, and often time the clothes don't even look remotely familiar (for example the period clothes in Pirates of the Carribean). This lack of familiarity I think makes it harder for our friends to relate to the movie and thus are less likely to enjoy it. So far we have tried Monsters Inc (Pixar), Pirates of the Carribean, and Casino Royale (James Bond). Monsters Inc is the only one that I think they really liked...

Picture update (I really need to think of a more creative name for picture posts)


Jonyi and Aja playing in the rain


We stayed warm and dry inside and ate chocolate with Fatou :-)


Loving the rain!


Taking a break and seeking cover (and making faces at us across the compound-turned-lake)


New braids - twists this time!


Twists close up


Front shot


Fourth of July potluck in Basse


Some of the group


More of the group


I really wasn't going to take a picture of the food for once, but then I got teased for my highly organized plate and everyone said I had to take a picture of it...


Basse house/office. While it looks like we're just lounging around, we were in fact working hard on creating a qualitative data analysis codebook for a research project on stigma and discrimination of people living with HIV/AIDS. It was very hot and Lisa was sick, but we pushed through.


See...working hard!