Thursday, April 8, 2010

Mixed Signals in Development

When Alimata would arrive on Saturdays to be weighed, I could barely stand to look at her. She was, literally, skin and bones. Her skin was taught across her cheekbones, pulling her mouth tight and her eyes were listless. It made me cringe to pick her up to weigh her and measure her arm, to feel the unnatural lightness of the two year old and the closeness of her bones to my hands.

Alimata was one of many cases of severe malnutrition I and my Malian colleagues at the local health clinic had started to treat weekly as part of the malnutrition program we established. But Alimata's case was by far the worse, and at her weekly weighings I watched with despair as her weight dropped ever lower. After several weeks treating Alimata with Plumpy Nut, a peanut butter based and vitamin enhanced food that is supplied free to malnourished patients by UNICEF, we had seen no positive change in Alimata. The head of the clinic, Doumbia, decided it was time to refer Alimata to the nearest hospital about 50K away.

I had thought that the referral would be the obvious solution -- at the hospital, Alimata would receive better treatment and would soon get healthy. But her mother's reaction proved me wrong. Kadia already walked 7K to the clinic every Saturday with Alimata strapped to her back, and she balked at the idea of going all the way to the hospital, where she would not only have to pay for transport but would also have to pay for food and lodging for herself. The real difficulty, however, lay in her husband's approval. He refused to let her go -- who would cook, clean and pull water for his bath without Kadia around? Kadia simply could not take her daughter to the hospital -- it wasn't an option.

"Fine," said Doumbia, "We have done all we can for you. If you refuse our referral, we will be forced to drop you from the program."

For me, it was a terrifying moment. Doumbia clearly felt like he had done all he could and the case was now out of his hands. But Kadia stood before me close to tears, helpless, with a two year old in her arms who would surely die if she walked out the door. There had to be a better solution.

And there was. Doumbia and I came to an agreement, and the next day Alimata walked all the way back to the clinic, this time with Kadia on her back and bowls of millet, peanuts and beans on her head. That morning, we taught Kadia how to make ameliorated (enriched) porridge with local ingredients, and everyone laughed with relief and giddy excitement when Alimata began to drink the porridge as if she would never stop. Kadia continued to make the porridge throughout the week, and on Saturday, for the first time, Alimata's weight had gone up instead of down.

Our success with Alimata and the ameliorated porridge put an idea in our heads. We enlisted our community health workers to begin ameliorated porridge demonstrations, at which mothers would learn how to provide better nutrition for their children and the porridge would be sold and provide a small profit for the community health workers.

The demonstrations took off and the porridge was a hit. Due to the large size of Malian households and the hierarchy over who controls the money, it was simply easier and more practical for women to buy ready-made porridge for their children then to make it themselves. Women wondered why we were not selling the porridge daily. Others, from far off villages, asked if the porridge was available in powder form so that they could take it home, boil water, and have an easy way of providing nutritious food for their children all week long.

With the help of Mama Traoré, one of the community health workers, we dried peanuts and millet and beans, ground them, and packaged them into ameliorated porridge powder to be sold at the clinic. Each bag sells for 100 Franc CFA, or about 20 cents, and makes more than enough porridge to keep an infant full all day long. On her way to the clinic, a huge bowl atop her head filled with bags of porridge powder, women and men call out to Mama, asking for one, two, three bags of powder. On vaccination days, mothers carefully pull out 100 Franc CFA pieces from knots in their clothes to buy porridge. and on Saturdays, Kadia walks all the way to our village, Alimata strapped to her back, in search of porridge powder. These days, I don't cringe when I see Alimata, although she cringes when she sees me. No doubt she remembers those days with little pleasure.

The porridge powder had been selling for several months when a shipment arrived from UNICEF two weeks ago: 15 huge sacks of corn-based porridge powder that will expire by the end of July. That gives us four short months to use porridge powder for which we have no need. Not only do we have no need for it, but it provided the perfect example of aid misplacing the local economy.

The powder we sell is affordable, and Mama makes a good profit from it. The powder from UNICEF is made mostly of corn, with a small amount of soy beans and sugar added. It is likely that the corn is produced in Western countries, and the purchase of the corn in addition to the transportation costs to send it across the ocean to Dakar and across land to Bamaka and finally up to our village must be phenomenal.

To make matters worse, the powder had clearly been sitting for a long time, and when Aissa and I took some home to test it out, she handed me the sifter to sift the porridge before we added it to water. I recoiled when I saw what was inside: bugs and worms, worms, worms galore. We sifted out what we could, but the little worms were white and tricky and small: hard to get out. They'll cook, Aissa said. I squirmed and refused to try the porridge.

The inefficiency and waste bothers me, but what really gets to me is that we didn't need the powder from UNICEF. Malnutrition here is based not on a lack of food but a lack of the right kinds of food and the knowledge of what makes up a nutritious diet. The village had found its own solution to malnutrition, and that solution was putting money in Mama Traoré's pocket and the line of producers who farmed the millet, peanuts and beans. Plus, mothers were now getting a better idea of how to provide healthy nutrition for their children, whereas the UNICEF porridge was too foreign to be easily understood as anything other than toubab porridge.

We are doling out the UNICEF powder anyway, advising malnourished recipients to sift, sift, and sift again, and Mama's powder is still selling. We hope we will be able to finish the 15 sacks of powder before the end of July -- otherwise they will be sent to the goats -- just like the shipment we received from UNICEF last year.

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