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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