Two Steps Forward, One Step Back

During my first few months in my village, Mapha, the vaccinator and I would go out to neighboring villages three times a week -- he to vaccinate the babies and I to weigh them and give nutritional advice to their mothers.

The clinic in our village serves 25 other villages -- the closest of which is 3km away and the furthest over 15km. Under the Malian national health care system, villagers living less than 5km away from the clinic are required to walk to the clinic on fixed vaccination days -- Tuesdays at our clinic. On the other days of the week, the vaccinator should be going out to the more distant villages to give them their vaccinations.

And that is just what Mapha would do. He would start off early on his moto, a bag packed with his register and single-use needles, and a small cooler tied to the back of his moto filled with ice boxes and polio, measles, and yellow fever vaccines. When I went with him, he would ride a little slower on the sandy dirt roads so I could keep up with him on my bike.

During those early months, Mali was new to me and I was new to Mali. I could barely tell a mother her baby was at a healthy weight in Bambara and kept turning to Mapha, exasperated with my own limited Bambara and dependent on Mapha to help me give nutritional advice to the women.

We would arrive in a village and head for a central village meeting location, one with a bit of shade provided by stacked millet stalks or a big tree. Before we had managed to set up and hang the baby scale, the area would be full with fifty women and their screaming babies. At one small village, the town crier began his rounds of the village. In his loud voice, over and over, he announced that the white doctor had come, much to my horror and Mapha's amusement.

Mapha knew everyone and would alternate between screeching laughter -- his head thrown back -- reprimands and looks of disapproval that scared me with their severity when a mother had gotten behind in her child's vaccination schedule. The mothers all knew him too -- go easy today, Mapha, they would say. When the babies would start to cry after the shots, the mothers would point at Mapha. Mapha minen, they would say, Mapha's bad.

But then, perhaps 10 months ago, the vaccines disappeared. Mapha would go to San to get the vaccines to discover that there were none to be had, not only in San, but all of Segou, and maybe even, the rumor went, all of Mali. When the vaccines would come, it was never enough. They would be finished in one day, and the mothers would beg for us to just vaccinate one more child as Mapha tried to explain that the vaccines were simply gone -- boloci fura banna peuw.

After our Monday night radio shows Adama and I would have to announce that vaccinations would not be taking place the next day so that women wouldn't walk 10k to arrive at the clinic at 7am. I retired my radio show on the importance of vaccinations completely. Mapha no loner rode his moto out to the neighboring villages, staying behind to play cards outside the clinic. When we would receive vaccines, the crowd at the clinic would be so large we could not hear each other over the noise. There were fights and more than one black eye among the women over who had arrived first. The pushing and yelling got so bad that I began to dread the days when we did have vaccines.

No one can tell me exactly what the problem is or where the fault lies. At first we thought it was just a problem of getting the vaccines to Bamako and then the regional capitals and then to San and finally to us. But everyone I talk to says the vaccines are in hard to come by everywhere. Then there was the unconfirmed rumor that the Malian government had simply forgotten to order vaccines for 2010, thinking for some reason that the 2009 vaccines would last for two years. And finally there is the logistical problem that there are more people and more babies coming to the clinic for vaccines than the Malian government planned for based on birth certificates in our area.

Meanwhile, every couple of months, in Mali and much of West Africa, a huge door to door polio vaccination campaign takes place, funded by international donors. In every community in Mali, community health workers walk from compound to compound, administering an oral polio vaccine and marking the left-hand pinky finger of each child under five who receives the vaccine. There are t-shirts and paychecks for the community health workers go back and forth to each household, making complicated symbols with chalk on mud houses to signify whether all the children of the house have been vaccinated. There are unlimited boxes of the polio vaccine and white SUVs head into every village to monitor the progress of the campaign.

I am confident in saying that every child under five in my village has received the polio vaccine at least five times, but almost all babies are now behind in their vaccination schedule, if they have started it at all. Its a long walk to our village, and there are some villagers from the outer villages that Mapha has not seen for months. After working so hard and so long to convince villagers of the importance of vaccines, suddenly, Mali and the international community have dropped the ball. How can the polio campaign be so well organized and regular vaccines forgotten?

Those severe looks Mapha used to give? Now he just gives them to me, because we know the mothers are no longer at fault for being behind in their children's vaccinations.

The Daou Dynasty

The Daou family are the big-wigs in town. They are both the village founders and the holders of power today. Adama Daou is the Chief of the village. Moussa Daou is the mayor and Siaka Daous was the mayor before him. Mapha Daou is the vaccinator and Oumou Daou is one of the birthing women. Mama Daou is the wealthiest man in the village. Adama Daou is the President of the managing body of the clinic and Ko Daou is the President of the radio. And if there is any new committee formed, any political position open, be sure a Daou will be appointed or voted in.

Although the village is now a mixture of Theras, Konates, Cissés and Traoriés, the Daous have no desire to relinquish their power. And the others know it and respect their wish, fearful of treading on the toes of the Daou family.

Perhaps part of their success in holding onto power comes from their ability to manage their own family like a high functioning bureaucracy.

My host family is a branch of the Daou family, made up of the Chief of the village, Adama Daou, his two sons and their families, and the Chief's younger brother (même père, même mère), Lahmine, and his family. There are over thirty members in their branch alonge, and they are based out of a large compound in the center of the village, its entryway opening to the road that runs through town. Adama's sons and Lahmine, my official host, each have their won compounds for each of their wives, but like any bureaucrat, they and their wives and children spend each day at the office -- the big family compound.

The roles of family members are well defined. The men handle farming, financial matters, the building and upkeep of family houses, and the raising of animals -- the cows, goats and chickens that fill the family compound and wander the village in search of food. The women do the cooking and raise the children . There is no such thing as 'gender bending', in this family, men and women stay where they belong. The rules stretch right down to who is in charge of fetching a glass of water (women) and who names the children (men).

There are ten women in my branch of the Daou family -- all various wives of the four men. The women take turns cooking for everyone, switching every two days. Millet porridge for breakfast, millet to for lunch and millet rice for dinner, a regimen that also rarely varies. While only one woman is on cooking duty at a time, stirring huge pots over a wood fire, all the women gather each morning to pound the millet together, laughing and gossiping as the tall, thick pestle flies up and down in their hands. While it is the women who cook, the men maintain control over the graineries, doling out millet little by little as the year goes along.

There are special dispensations too, rules set in place in case of death or births. Maternity leave for one -- after woman gives birth, she has forty days vacation from cooking duties, pounding millet, and any other work at the family compound. My host mother, Soté, recently gave birth to her sixth daughter, Tata, and is currently enjoying her last days on maternity leave. She takes her time getting dressed in the morning and heads over to the family compound not to pound millet but to show off her baby.

When Gaousou, one of Adama's brother's, died in February, there were bylaws already in place. After the funeral, Gaousou's wife Rokia moved into the family compound permanently along with her three children. She is still there today and will stay there until five months have passed since Gaossou's death. She is in mourning and although she helps out, she does not take on cooking duty or even step foot outside the compound. Once five months have passed, late this coming July, Rokia will be allowed to leave the compound. She will also be remarried to one of the men in the family, a way of ensuring her security and the future of her children. Its the Daou family form of life insurance, in a different form.

LIke any bureaucracy, there are always people milling about the compound and others coming in and out. Even today, two years in, I'm still trying to figure out who everyone is and how they fit into the Daou dynasty.

I am a Daou, too, and although I don't share cooking duties or help in the fields during farming season, I am certainly an element of soft power in the village for the Daous, a celebrity endorsing their brand. The Theras are the next most populous family in the village, and I know they would give a lot not only to become the mayor (they recently achieved great success by seeing a Thera appointed Imam of the main mosque), but also to see me -- or my Peace Corps successor -- named Thera. But as every Daou knows, the Theras are bean eaters, and I would never touch beans to save my life.

The Impact of AID

It is hard to escape the impact of aid and development organizations in my village. UNICEF, USAID, World Vision, the European Union -- development organizations and NGOs are certainly trying to make a mark. Whether they have been successful is a debate to get into at another time. However, it provides an interesting perspective to detail exactly what exists in my village because of a development project. Whether its a person whose salary is paid by an NGO or consortium of aid programs and local community groups, vaccinations that are subsidized by foreign governments, or a new building, aid is everywhere.

Without aid, none of this would be in my village:

• The clinic
• Mosquito Nets
• Vitamin A
• Birth Control
• Malaria prophylaxis for pregnant women
• Vaccinations and sterile, onetime-use needles
• HIV/AIDS testing and retrovirals
• Nutritional supplements for malnourished children
• The new hospitalization room at the clinic currently under construction
• Enriched porridge powder and the profit it brings in for Mama Traoré
• The bikes given to the community health workers
• The ambulance that comes to our village from San
• The solar panels and batteries that light the clinic at night
• The mayor's office and the salaries paid to the mayor and his staff
• The doctor
• 2 nurses
• The public elementary and middle school
• Student sponsorship/scholarships
• The preschool
• The radio
• The library and the books that fill it
• The local cereal bank
• The generator that provides electricity along the main road at night
• The covered market area
• The businesses that support the NGO and aid workers traveling along the main road; the income generated by the purchases of community members such as the doctor and myself who receive their salaries from an aid organization
• 3 pumps
• The local church
• All technical and educational trainings, including trainings on health topics, business management, knitting and sewing, animal raising, and improved farming received by villagers
• The Youth Center
• A trench to collect rain water for farming
• Money in villager's pockets from trainings, projects, and short-term jobs with development agencies
• Me.

The list could go on and on. Take just one of these items and extrapolate from there. Vaccinations = a job for Mapha, the vaccinator = good food for Mapha's family and a concrete house with a tin roof = health and opportunity for Mapha's children = health for the thousands of children Mapha vaccinates = more hands in the fields and more mouths to fill = a larger population...and on it goes.

Most Malians I know are appreciative of the aid that is given to their community. Like many Americans who feel that it is their duty as those who have to help those who have not, many of the Malians I have come in contact with, express an expectation that toubabs should help out where they can.

The help is coming in. The community plays a large role in receiving much of the aid -- they provide the physical labor or a percentage of the money required to complete a project. USAID in collaboration with Peace Corps built the radio, for example, with a large monetary contribution from the village, manpower to build it, and it is now staffed by Malians who receive no salary.

Aid is interwoven into so many aspects of the village that it is hard to imagine what the village would be like without aid, or what effects aid will have on the village in the long run.

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.