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.