Dear Penny:

I have walked a mile in your shoes and continued for more than a marathon in your 
shoes having worked in development from 1980 to 1999.  

I started with 2 years in Zaire.  I held hands with some of my friends when they buried 
their children when I was a Peace Corps volunteer teaching high school biology and 
chemistry.  I saw goiters so large that they were down to a woman's knees and cretins 
who ran around the market place unclothed and were given scraps of food like dogs.  
That's how they were treated.  There was little iodine in the diet because it was a flood 
plain and the iodine was washed away.  Furthermore they ate a bitter form of cassava 
that took 3 days of soaking or fermenting before it was no longer poisonous.  The 
thiocyanate in this form of cassave would .  It took until the mid-1990s for this cause to 
be recognized internationally.  I had wanted to work in iodine deficiency - but I never got 
the funding I needed.  UNICEF managed to work on iodization of salt --- and I had nothing 
to do with it.

When I lived in Peru I was doing surveys on the primary health care system in 1984.  
Good on immunizations, mediocre on rehydration from diarrhea.  Hopeless on growth 
monitoring.  I found a child that was starving, not just a little bit, this baby was on deaths 
door.  He was clearly abused as well.  I little heap of rags on the floor.  He was over one 
year old, but probably weighed all of 8 pounds.  A skeleton.  I'm fairly certain he died 
within a day of my brining him into the health center.  I visited the nutritional rehab 
center in Lima and that confirmed for me that I should do my doctorate in International 
Nutrition.

In 1985, I went to Niger for the first time.  Post famine.  I have never seen more vitamin 
A deficiency in any country I have visited (I lost track after 33 countries).  In every clinic 
I visited I saw the children with the melting eyeballs.  I'm not kidding.  It is shocking.  It 
is horrifying. When they get to that point it is almost always lethal.  I ran around to all 
the agencies to try to get them interested in vitamin A deficiency.  The food that was 
being dispensed actually was increasing the metabolism of these children and throwing 
them into a worse biochemical state in regards to their serum retinol so that they were 
actually dying faster.  No one wanted to hear about it. 

So, here's the argument for patience and perseverance.  I took me a while to get it and 
Niger really demonstrated it for me.  I kept going back to Niger to train Peace Corps 
workers.  Initially I worked with a guy that worked for Helen Keller International and we 
worked together a bit.  I was eventually hired as a Nutrition Manager and eventually 
became the Nutrition Director at Helen Keller International.  When I first started, the 
Minister of Health wouldn't even speak to us because he'd had a bad experience with the 
first guy.  By 1999, through various Ministers of Health, various international health fads, 
and three different in-country directors, the slow patient work had paid off.  The clinical 
xerophthalmia had been completely eliminated, the subclinical vitamin A that increases 
death rates by 30% had been dramatically reduced and more importantly, sustainable 
gardening programs were starting to take hold.  That took 14 years.  I cannot take credit 
for much of any of this.  It was the in-country directors, the ministers of health, the 
health care workers and a marvelous project that really empowered the health care 
workers and transformed them from disgruntled employees to the capable creative 
people they were.  

It would have been easy to ask for donations for vitamin A capsules and treat a few kids 
in those clinics.  I would have saved a few of the worst cases. Maybe.  Some of those 
would have probably died later because they were so weakened already.  It would have 
done nothing at all for the larger volume of children who had mild vitamin A deficiency.  
These children don't stick in my head because you don't see that they have vitamin A 
deficiency.  Yet, as with many health conditions, these are the ones that are more likely 
to be saved and prevented from becoming the "poster child" image that sticks in your 
head.  You should work on preventing the poster child.

Rather than having women send milk to Africa, you should be propagating a proper milk 
bank in Africa with appropriate screening.  The true costs of sending the milk to Africa for 
the long haul would be astronomical and unsustainable.  You would have to ship the 25-35 
ounces of milk for a six month period followed by almost as much for the next year a half 
for each and every baby.  I once had to calculate what it would cost to ship iron folate 
tablets (much smaller size, fewer tablets for a period fo six months for pregnant 
mothers.  The amount far exceeded the cost of the iron-folate tablets.  Setting up local 
pharmacies or regional pharmacies was far preferable.  I remember the bill for one clinic 
for moms for three months was well over $6000.  It was a no brainer that I concluded 
that using the money differently would have a better impact.

South Africa is a sophisticated country.  They definitely have the wherewithall and 
expertise to set up something sustainable.  Ask them what they need.  Work with them.  
It is easy to fall into the trap of being the crusader.  It is more immediately gratifying 
emotionally.  Keep those faces and images in your mind and go for the long haul 
approach instead of the quick fix.  There are MANY MANY levels on which you can work 
on the issue of HIV.

Good luck.  I know that if you really take a step back and look at the big picture you can 
see the same successes as I did over time.  Remember though --- while it took 14 years 
in Niger, the result was one that was completely incorporated into their own health care 
system and their own practitioners owned the process.  

Susan Burger, MHS, PhD, IBCLC

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