The Other Half

The highest lifetime risk of dying in childbirth in the world is in the West Africa Country, Niger, where a girl or woman stands a 1in 7 chance of dying in childbirth.....In contrast, in the United States, the lifetime risk is 1 in 4,800...in Ireland, a woman has only 1 chance in 47,600 of dying in childbirth.

Nicolas Kristof, Half the Sky: Turning Oppression into Opportunity for Women

The Community Health Aide Training Participants

Last week I was visiting a refresher training course supported by Samaritan's Purse for community health aides about screening for acute malnutrition, exclusive breastfeeding, complementary feeding,  diarrheal diseases, and water and sanitation.  It was encouraging to see the participants and their dedication, particularly the woman who walked over 10 km to attend the training.

The training venue

The training was at a health center and while we were there we met, "Rachel" whose one-year old son, "Omar" was severely malnourished and had to be taken to the District Hospital for treatment.  After we finished discussing with our field staff and the training participants, Rachel, her husband, and Omar joined us in the land cruiser for the 70 km trek back to Niamey.  While in the car I read the discharge papers and quickly learned that our land cruiser wasn't serving as an ambulance just for Omar, but for Rachel as well.  At the age of 25 years, she was pregnant for the fifth time and HIV positive.  Her first three children had died and now her son was severely sick.  As we drove through the desert sand in the intense heat, with Rachel vomiting and Omar crying in the back seat, I contemplated the differences in Rachel's life with the lives of some girls I met in Niamey earlier the same week.

  

These girls attend a vocational school that is supported by a mission organization from Canada.  The primary objective of the school is to prevent girls from marrying before age 18.  In order for the girls to receive a free education, the families have to promise that they will not marry off their daughters.  It is  a novel concept in a country where only 31% of girls regularly attend primary school.  When I first arrived the girls were chatty and active, but soon quieted down and listened to a topic that I'm pretty sure was brand new to them--self -esteem.

"Je suis belle, precious, intelligent, unique, courageuse"

 After the lesson, each girl took five different finger paints to represent different characteristics, beautiful, precious, intelligent, and unique, and placed them on tree branches.  

I probably will never find out if Rachel will be one of the 7 women in Niger who die in childbirth and if Omar will recover to not be 2 of the 5 children who are malnourished.  But my hope and prayer is that by continuing to build the capacity of community health aides to correctly screen for acute malnourished children and for organizations that invest in the lives of girls now, these girls and their children will not.     

It is impossible to realize our goals while discriminating against half the human race.  As study after study has taught us, there is no tool for development more effective then the empowerment of women.

Kofi Annan

Questions

It always amazes me how 8 or so hours after riding on a plane I arrive in a world full of contrasts and opposites.  As the flight flew closer to Washington D.C last week I felt my body release the pressure and concerns of the last few months. It has been a welcome respite to be in the States with beautiful weather, good food, crisp air, healthy children, clean sidewalks, American English, safe roads.  The first day I was here I enjoyed it so much I was concerned that I wouldn't want to go back to Niger.

Appalachian Mountains, NC

St. Peter and Paul's Cathedral, San Francisco

This concern was amplified with the news of kidnappings of 5 NGO workers in Niger last week.  Due to political and religious instability of Niger's neighbors to the North, South, and East, Niger continues to find itself in a "security sandwich" as border security is quite fluid and looks like it will be for some time.  All of this has made me ponder a quote from E.B White, "I arise in the morning torn between a desire to save the world or savor the world.  This makes it hard to plan the day."

Nigerien Military

When I've told people familiar with Niger, that I've been working there for the last few months, the typical response is, "Oh Niger, that is...an interesting place."  And indeed it is for multiple reasons--political, religious, developmental, nutritional.  Recently Niger has been in the spotlight as it continues to make strides in child malnutrition at a time when the international aid community has increased its awareness of the importance of reducing childhood stunting as shown in this video.  During the American Public Health Association I attended a session on maternal and neonatal mortality and one of the speakers happened to highlight the trends in the large population growth potential in Niger.  He remarked that if business continues there as usual, it has the potential to undue years of global health work simply because the environment cannot support the projected population numbers.  He encouraged public health practitioners to not just go to the "safari countries",  but to the places where mother's and children's lives are most at risk.

Women at Guineobangou Health Center

This encouragement coupled with prayer and realization that I still have many unanswered questions about life in the desert.  Many questions that perhaps will never fully be answered, but at least have the potential of resolving by returning.

Answers to desert questions often depend upon what one brings in coming, how one my be accustomed to moving through anything.  Embracing desert and mountain spirituality requires assuming the hazards of a rugged land, remaining open to the threat it poses.  There may be no substitute for the instructive power of place. 

Belden Lane  

Oasis

There has been some encouraging news about Niger this past week.  On Wednesday the Medical Journal, The Lancet published a case study about Niger reporting that there have been significant reductions in the mortality rate of children under the age of 5 between 1993-2009 based on analyzing household surveys.  The authors of the study attributed it to increases in child survival interventions such as the use of insecticide treated bed nets, improvements in nutritional status, vitamin A supplementation, usage of oral rehydration salts and zinc, care-seeking for fever, malaria, and childhood pneumonia, and vaccinations.  The increases in the child survival interventions have been possible because of collaborations between the government and international NGOs to increase universal access of health care for pregnant women and children by building rural health centers throughout the country, reducing the cost for maternal and child primary health care, and increasing or building the capacity of the health care work force.  In relationship to it's neighbors, Benin, Burkina Faso, Chad, Mali, and Nigeria, Niger is the only country on track to achieve the Millennium Development Goal #4 (reduce by two-third the under-five child mortality rate).  This is no small feat for a land-locked, resource-poor desert country that is often at the mercy of extreme crises such as famine and floods.  Which is why this report from Reuters on the same day was also encouraging.  The Ministry of Agriculture reported on state-owned radio that this year's harvest for millet, sorghum, and maize should be better this year, reducing the rates of food insecurity that plagued the country last year and increasing the rates of malnutrition.

When I was in the desert a month and half ago I experienced my first oasis.  We would be driving along through the sand, struggling to find our way and then out of nowhere, grass would appear with a little water and a camel or two grazing.  In a similar way I find this news about the positive changes in Niger to be an oasis.  For months I have heard, and lately seen, the ravages of the 2011 drought  resulting in emergency-levels of malnutrition, the arrival of the Malian refugees straining the resources of Nigerien rural health centers and staff, and the spillover of Muslim-Christian tension resulting in the burning of churches in the Zinder region of Niger.  This news is an oasis in the midst of a food, political, and religious desert.

As I've been thinking about oasis this past week, I've been thinking about other sources of oasis.  This past week it has often rained in the early part of the morning.  Perhaps nothing is more refreshing in the desert than seeing the sun rise after a nightly rainfall, as I did during my morning run this past Tuesday.  And, I've been attending a small church each week.  Christians are by far the minority in this Muslim country and last week, despite increased threats of security, our small group gathered and found oasis in Romans 8, particularly 31, "If God is for us, who can be against us?"  All of this is a reminder that God has not forgotten to provide oasis for the people of Niger.  He has not forgotten the small child at the mother's breast, He has not forgotten the mother searching for food for her child, He has not forgotten the farmer struggling to harvest his millet, and He has not forgotten me and my continual search for desert oasis.

Indifference

In my ongoing contemplation of how the geography of desert shapes people's lives physically and spiritually, I had a new realization this past week.  It brings about indifference. Since I arrived in Niamey I've been searching for a word to describe the interactions I've had so far with the Nigeriens I meet in the street and in the market.  I think indifferent is probably the best.  Part of this is because I live in the capital city and I am just one of many expatriates that descend and ascend on the city on a regular basis.  Some stay for years, some for just a few months.  We come and go and interact with other expatriates in our own contrasting universe of  air-conditioned homes, SUVs, supermarkets, and guarded offices.  We have little "need" and time to form relationships with the people we are serving.  Part of this is also due to the Muslim/Christian divide.  I have never lived in a Muslim country before and still learning how to greet properly.  And some of this is due to the nature of the land that is Niger.

This past week I went to visit five Health Centers that Samaritan's Purse supports.  We left early in the morning and within minutes of leaving the city limits it is easy to see the barrennes that makes up the majority of the country.  

Every once in awhile we would drive pass a village composed of a few mud huts, a mosque, and perhaps a health center.  Each village rose out of the sand, like a mirage, indifferent to non-arable land desert heat and sun, and proclaiming an insistance to survive.  

I needed to go on this trip for multiple reasons.  Right now I'm in the process of deciding the direction for our health and nutrition program--what projects should be continued and what new ones could feasibly be added.  For practical purposes, I needed to go and see the distance between the health centers, see their infrastructure, review their registration books.  But really, I needed to go and meet the people.  I needed to find connection.

I needed to meet the community health workers we support.

I needed to see mothers with their children and learn how we can better help them keep their children alive and healthy.

And I did.  One of the last stops was at a health center where the community aids were weighing children and giving out supplementary food (unfortunately not plumpy'sup because we don't have any new supplies since the last order was declared contaminated by the World Food Program).  As soon as I arrived as I was swarmed by many women with their young children eager to greet me, displaying gratefulness, not indifference.

And in my heart, I think my indifference to this place is beginning to ebb away. I've had difficult days wondering why God has brought me here when I often feel so useless and disconnected to the world around me.  But I'm learning that God's silence is not the same as indifference. Slowly I'm beginning to see how I can apply here what I learned in school and elsewhere.   And although I would prefer to be living in the community, with opportunities to form deep relationships with the people, by being in the capital city I have the prospects of helping a wider away of people. I guess in this case its quantity, not so much quality.  Thank you for your continued prayers as I continue to discern how to connect and help well.

We long for silence, realizing that our only way out of the desert is to go deeper into it, beyond the breakdown of language to the "still point" where God meets us in emptiness.

The Solace of Fierce Landscapes: Exploring Desert and Mountain Spirituality

Belden Lane

Security

In the last three weeks I've been in Niger one of the words that I've heard the most often is security.  We talk often about personal security, political security, and food security.  Although Niger itself is stable as a country, some of our neighbors, Mali and Nigeria, are not.  And as Niger experiences the brunt of the Sahel famine, it is quite food insecure.  I've been calling Niger "ground zero" for malnutrition as it also has one of the worst rates of malnutrition in the world right now.  In the last two weeks I've seen more children who are malnourished then in the four years I was in Cameroon.  This past Thursday I went to village where Samaritan's Purse was distributing millet, rice, and oil to the most food insecure households.

Distribution of millet

    
After I saw the food distribution, I went with the president of the local women's group to visit her farm, where she planted moringa trees with seeds given by Samaritan's Purse.  She was using the leaves to supplement her family's diet and this was very encouraging as the leaves are very rich in vitamin A, C, iron, and calcium.

Daughter of the women's group president holding a moringa leaf

Because Niger is one of the "hot spots" for international aid right now, its been quite interesting to see and learn about which international NGOs are here and what they are doing.  We stopped at a health center for me to see it and learn about their needs.  At the same time Doctors Without Borders (MSF) was at the health center doing a immunization clinic and measuring mid-upper arm circumference (MUAC) to because there had been a measles outbreak in the area.

A MSF worker measuring MUAC to determine nutritional status

Next we visited a women's group and asked them questions about the health of their children, the common foods, their breastfeeding practices.  Shortly after I asked about breastfeeding a grandmother told me about her grandson who was born 4 weeks ago, yet only weighs 2 kilograms.  She brought me this boy to examine.

Our next stop was the refugee camp for the people who escaped from Mali.  MSF was also there providing medical care for all of the people there.  During the tour I saw a mother who had just given birth to a boy a few hours earlier.  I wondered what was going through her mind--if she hoped to be able to return home and raise her son in her own land.

The MSF clinic

One of the tents for the Malian people

As I learn and see more about the harsh realities Nigeriens face living in an insecure place I find it quite overwhelming at times.  A week ago I was talking with the country director about malnutrition here and why it is the way it is.  He told me that instead of asking why, the question is what.  What do I do?  What can I do?  Watching a mother watch her child struggle for breath because he is so malnourished breaks my heart.  No mother should EVER have to bury her child for something that is completely preventable.   How to best treat AND prevent is the ongoing question in this insecure place.

In particular, the way of the desert teaches us how to pray: how to stand before God, how to speak to God, and above all how to keep silent before God.  It reminds us that God is born in barrenness, where there is an absence of pride, of masks, of illusions and of false images.  Paradoxically, God fulfills in emptiness.  God appears when we are not filled with other attachments and distractions, when we are not full of ourselves.

John Chryssanvgis, In the Heart of the Desert

Desert Nomad

This past week some colleagues and I went to the Northern part of Niger, close to Algeria, to assess the possibility of expanding our work in that part of the country.  Because there are no domestic flights to that part of the country and it would've taken days to drive there, we flew on a humanitarian aid plan operated by the U.S Air Force.

Our plane to Arlit

Inside the plane

That part of Niger is predominately desert and most of the people that live there are Tuaregs, who have for centuries lived as nomads wandering from oasis to oasis, constantly in search of water for themselves and their livestock.

Tuaregs at an oasis

 In the mid-1960s a French multinational mining company discovered that underneath all of that sand was huge supply of uranium.  The company came and created a town, Arlit, for the sole purpose of catering to the needs of the Nigeriens working at the mining company.  The mining company designed the town and built the houses, the hospital, the grocery stores, and the restaurant.

Mining for Uranium

In 2006 the little mining town in the desert became well known after a few expatriates were kidnapped and held for ransom.  Because of that and the political situation in Niger and neighboring Libya, almost all of the NGOs left the area.  Recently the area has become more stabilized, however we had to be accompanied by both Nigerien and American armed forces everywhere we went.

Our Nigerien escorts

 
The first day we were there we wanted to do an assessment of a local village.  We, and a Civilian Affairs team from the US military, first stopped at the Prefet's (regional authority) office to announce our presence and explain our plans.  While we were meeting with the Prefet and his officials, another well-dressed man came in and announced that he would lead us to where we wanted to go.  So he, and his two car entourage, and us in our four car entourage went tromping through the desert in search of women and men we could talk to about their life and do a water assessment.

After about two hours of wandering through the desert we finally found some people huddled under the shade of one of the few trees around.  Myself and a colleague asked the women questions about their access to education, health services, food, and their livelihoods.

One of the women and her son we interviewed

They explained to us their life as nomads, staying in one place as long as there was water, but never long enough to send their children to school for any length of time.  Their diet consists of millet and rice with the occasional camel and goat milk.  When we asked about if the women breastfeed their children and for how long, they explained that they first give their children sugar water and typically breastfeed their sons for two year and their daughters for one year.  They explained to us that they breastfeed their son longer so that he will be more intelligent.  After they were finished telling us about their life, I saw one women give a baby a bowl of brown water to drink.  The nomadic life is a isolating, difficult one demanding fortitude and perseverance in both mind and body.  The women explained to us their many needs and discerning if and how to help well is challenging.  How do you provide health and nutrition education for a group of people when you do not know where they will be in the next month?  Follow them on a camel through the desert?

And if the best way to start working with a community is to learn from them, what does it mean to live a life of moving from spring to spring in the desert?  

To survive at all, the desert dweller--Tuareg or Aboriginal--must forever be naming, sifting, comparing, a thousand different "signs"--the tracks of a dung beetle, or the ripple of a dune--to tell him where he is; where the others are; where rain has fallen; where the next meal is coming from. 

Chatwin, The Songlines

Desert Pilgrimage

Ever since April, when I accepted to be the Health and Nutrition Manager for Samaritan's Purse in Niger, I have been wondering what it means spiritually, physically, and professionally to live in the desert.   I feel like in the last week this pilgrimage has begun as I've learned more about my work and developed a daily routine.  

Morning lights from a Mosque

In the early morning hours I meander through the darkened streets of Niamey.  The call to prayer echoes in the shadows as I run pass women rifling through putrid garbage piles, men sleeping outside to escape the heat, people walking home from the mosque, night watchmen, and the grandiose Chinese, American, French, and Malian Embassies.  It is a juxtaposition of sights and smells in the fierceness, solace, and disparities of this place.

Children playing video games in a hut

 On purpose I run pass the Niger River and pause as soon as I see it, to remind me that there can be life and growth, even in the desert.

Niger River

More difficult then running past the river and reflecting on life and growth in the desert is figuring out ways how to actually it in the desert.  Last Tuesday I attended a Nutrition cluster meeting for all of UNICEF's partners who are working to address the high levels of malnutrition throughout Niger, mostly by distributing plumpy'nut and fortified foods.  We were briefed on the current situation--over 157,000 children considered to be malnourished, which is on track with levels in 2010 when the last famine swept through Niger and not much better then in 2005, when many of the large international non-governmental organizations (NGO)s started working here permanently.  To me, what this signifies is that we are not getting at the root of the problem.  While I strongly believe in giving plumpy'nut to children who are malnourished, I don't believe in giving it to them for their whole childhood.  And for the Nigerien children who are susceptible to almost annual famines, they could indeed receive it that long.  The reason why plumpy'nut is successful is because it can be give to children before they become so severely malnourished that no other treatment works, not as a staple food.  The problems of food security in the desert are complex and complex solutions are elusive.  The pilgrimage of finding and cultivating life in the desert has begun.

Camel carrying goods

    Food for pilgrim people, manna from on high. Jesus, bread of heaven, feed us before we die.  Feed us with your love, feed us with your life, come into our longing hearts.  

Stream of living water, flowing from above.  Fountain who revives us, spring of saving love.  Feed us with your love, feed us with your life, flowing to our thirsty souls.  

Food for Pilgrim People, World Communion Song from Korea

The New Country

Street in front of our house

I arrived in Niger from Cameroon on Tuesday evening. I've never been to Niger before and to aid in the transition, I was secretly wishing that Niger wouldn't be that different from Cameroon.  But from the moment I first saw Niger from the plane I knew that was a false hope.  Everything is just different.  I now live in the capital of Niger, Niamey, and share a house with three other girls, who also work at Samaritan's Purse.

One of the first things that I noticed about Niamey is how quiet it is.  In Cameroon, music is constantly playing, especially in any city of a significant size.  But here it is eerily quiet.  Except for the Muslim call to prayer in the mornings and evenings.  It is Ramadan and that may possibly explain why it is quiet during the day in a city that is over 95% Muslim.

View of our house

There are also language differences as the official language is French, no more Pidgin, which at this point removes a lot of humor from my life. I keep wanting to say ashia to people until I remember they don't know what it means.  I've been told that there is a similar word in one of the local languages, I just need to learn it!


 I now have an office job as the Nutrition and Program Manager and directly oversee two Nigeriens, who supervise 20 other Nigeriens. The 20 Nigeriens they oversee provide health education and food distribution in outlying villages.  It is the kind of work that I used to do and enjoyed as a Peace Corps Volunteer in Cameroon.  Now I'm two times removed from that work.  With a terrible famine sweeping across the Sahel region and Niger being one of the countries most affected, currently it is kind of like "ground zero" for any organization working to treat malnutrition.   For more information on the severity of the situation click here: malnutrition in the Sahel.

Boxes of "plumpy'sup" in storage

One of my job responsibilities is to oversee the distribution of plumpy'sup and fortified cereals.  Plumpy'sup  is like plumpy'nut, but is for children who aren't as severely malnourished and can supplement their daily diet.  The first day I was at the office I was amazed at just how much of these fortified foods are in storage. Tons.  Literally.  The World Food Programme (WFP) buys the food and Samaritan's Purse (SP) distributes it.

However, on Thursday I learned that over 1,000 children didn't get their months ration because of a possible bacteria contamination leading to a recall of plumpy'sup.  I'm realizing how detrimental this is for families as they currently are depending on these food rations for their livelihood.  

Boxes of "super cereal"

Besides the religious, language, work, and climate differences, I also live quite differently then in Cameroon.  One of the advantages of living in the capital city is access to large grocery stores.  Grocery stores that sell cereal and cold milk and more flavors of tea then I've ever seen in the States!   Since Niger is land-locked everything is imported and I pay easily 2-3 times what I paid in Cameroon for fruits and vegetables.  In addition, I now live behind a walled house with guards so its much more difficult to get to know the Nigeriens and the wildlife.  But I'm trying.  

My neighbors

Nigerien wildlife

You are being asked to trust that you will find what you need in the new country.  That  requires the death of what has become so precious to you: influence, success, affirmation, and praise.  Trust is so hard since you have nothing to fall back on, still trust is what is essential.  

Henri Nouwen