So Long, and Thanks for All the Injustice

So, apparently the world’s ending today. Maybe it’ll all end up looking like this? On the upside, it’ll make things a lot simpler for landscape photographers, because you won’t end up with people barging into your frame, or unwanted vehicles, or anthropometric clutter, or people telling you to stop standing in their field.

Also, the skiing will be killer without all those lift-lines. Especially for those of us smart enough to preposition ourselves with seal-skins and randonée bindings.

Okay, so maybe it isn’t. NASA‘s certainly pretty adamant that it will be a very ordinary Winter Solstice for most of us. In fact, Dr Karl Kruszelnicki presents my personal favourite quote on the whole conversation about theories the world will end today:

On the 21st of December, inconveniently only two shopping days before Christmas the Mayan calendar will click over. But to say the world will end is like saying today’s date is the 29th and therefore your cut lunch will turn into a shoe. That’s how rational and logical it is.

However, for some of us, it will be the end of the world. In a very personal sense, for some of us, our world will end: We will die today. In fact, around 70 million people die each year, which means 190-odd thousand people are going to die today. It is a part of the world we live in. Most of these deaths are natural, just a part of growing older and moving on. For friends and family members, this is often a time of grief, although can also be a time of celebration for a life well lived, under gracious circumstances.

For many people, though, their world will end too quickly. Far sooner than it ought. Their deaths are preventable, in as far as contemporary science and medicine are concerned, but due to a range of injustices- many of them economic, some of them social, others political- they will not have access to the services and technology that might have saved their lives. For example, today:

Roughly 13,000 of us around the world will die because we don’t have access to clean drinking water or sanitation facilities. We will get diseases, most involving diarrhoea and vomiting, dehydrate and die.

Around 1,800 of us will die of malaria, just a small portion of those who will die from a long list of preventable diseases. Around 3,800 children under five will die from vaccine-preventable diseases alone today, and 4,900 people will die of AIDS.

As many as 98,000 people in the world today- as much as half the daily total- will die from causes related to hunger and malnutrition- including that deadly interplay of malnutrition, unclean water and disease.

You get the picture. And that’s just today. Tomorrow, the same thing will happen, the same number, roughly, will die. And the day after that. And the day after that, too.

We have the resources to stop these deaths. And we’re doing it. In terms of disease control especially. With the right regime of drugs, nutrition support and care, HIV/AIDS is no longer the death sentence it used to be. Child mortality in Africa has recently been noted to have fallen significantly, as this widely-acknowledged piece in the Economist from May this year points out:

16 of the 20 African countries which have had detailed surveys of living conditions since 2005 reported falls in their child-mortality rates (this rate is the number of deaths of children under five per 1,000 live births). Twelve had falls of over 4.4% a year, which is the rate of decline that is needed to meet the millennium development goal (MDG) of cutting by two-thirds the child-mortality rate between 1990 and 2015 (see chart). Three countries—Senegal, Rwanda and Kenya—have seen falls of more than 8% a year, almost twice the MDG rate and enough to halve child mortality in about a decade.

Access to clean water is improving in many parts of the world (though in other parts of the world it is falling as water sources become increasingly polluted or used for agricultural production), and emergency interventions by the World Food Program, NGOs and Governments keep millions of people alive each year. We know that world has enough food resources to feed everybody- in fact, we’re producing 17% more food per person today than we were 30 years ago, and that’s despite a 70% population increase (or a good hefty 3 billion-or-so people)- a total of over 2,700 kcal per person per day, enough to sustain the world at the recommended level for adult males in the USA (2,700 kcal, versus females at 2,200 kcal), and well above the recognized average minimum requirement of 1,800 kcal.

We have the resources. The problem is distribution. Which in turn is an issue, as Amartya Sen, the Nobel-prize winning economist pointed out long ago now, of entitlements. In short, power, and will.

There have been many victories in the journey towards solving some of these problems. We still have a long way to go. The situation remains unacceptable. And we’re facing an uphill struggle in many areas. The increasing extremes and erratic nature of global climate patterns are having a direct and tangible impact on marginal communities around the world, and will exacerbate both hunger and water issues, especially in sub-Saharan Africa and large swathes of Asia. As industrialization and technology become increasingly available in poorer, populous parts of the world, demand for unsustainable lifestyles is increasing, resulting in dissatisfaction and the risk of extremism and violence. Industrialization and the intensification of agriculture is reducing the supply of clean water available to maintain healthy people even as water facilities are rolled out to higher and higher portions of the world’s population.

In short, this isn’t a problem with a fixed horizon. This is a constantly moving equation, one that requires continual recalibration.

We won’t fix it today. We won’t fix it tomorrow. But we need to try.

As you head into the Christmas period, I don’t expect us to save the world. But I do ask that we consider the question of what we can contribute to make the planet immediately around us a little better. Is what we’re purchasing really necessary? Has it come from a place of injustice, like the technology used in cell phones contributing to conflict in the DRC, or will its disposal simply add more non-biodegradable poison to the planet? Is there something I can do to help people far away who are not able to meet their basic needs, whose world could well end in the near future despite the human race having the potential to stop it? Or is there somebody closer to home who I could support? Only each of us as individuals can answer these questions. But I’d like to think that this season, this Silly Season of over the top purchases and wild conspiracies about the end of the world, is far better represented by asking these questions honestly of ourselves, and then acting.

Shalom, Salaam, Peace (for those of you without a Babel Fish). Merry Christmas, and see you on the other side of the Apocalypse.

Photo: Burning rubbish tip outside Bahir Dar, Amhara Region, Ethiopia

Handwashing, and other Epiphanies

The things of your daily existence inure you to the meaning behind them, becoming mundane and unremarkable, until they have little value beyond the objective. I think this is true for all of us, and why for many of us, we crave things like change, travel, newness- a job, a holiday, a relationship- to stay enthralled by life.

From an outside perspective, we often perceive something to be more attractive than it might feel from within. I suspect there are probably people who feel that about my life as an aid worker (although possibly not if they follow this blog for long…). I get to travel, I get to see interesting things the world over. But even for me, the things I experience, after a time, grow commonplace. So commonplace that I often fail to really see what they’re about.

Sometimes, though, you reconnect with something you’ve interacted with many times before and it strikes you in a new way. This happened to me a couple of days ago on a field visit in southern Kenya.

I’m no stranger to field visits. I’ve been variously taking part in them or hosting them for the better part of a decade. There’s a general formula to them, and while they can be stimulating and a real improvement over sitting at my laptop screen, sometimes they can be downright tedious. Courtesy visits, social obligations and awkward conversations where you try to avoid coming across as patronizing, all the while wondering whether these community groups actually want you showing up at all, and whether you’re doing anything useful in the first place.

So too you see the same old stuff. Ask the same old questions. Field the same old queries.

School buildings. Farmers’ associations. Community empowerment groups. Water management committees. Boreholes.

Not to say that some of these aren’t worthwhile interventions, that they don’t produce really positive results for communities, or to forget that they’re employed time and again because, in the right circumstances, they actually work.

Not to say also that you don’t sometimes come across something innovative and inspiring that makes you think again about the cynicism that often plagues this career after some time.

But when I was told that as part of a field trip we were visiting a school to see where we’d installed a water tank, some latrines and a couple of handwashing stations, I have to say my heart didn’t tumble in somersaults of glee. We’re going to get to drive 45 minutes along dirt trails (actually I don’t mind the driving bit, there’s stuff to look at) just to see a couple of concrete structures and some kids washing their hands. Awesome.

I’ve seen this stuff before. Ten bucks says I’ll see it again before very long.

And sure enough, we get to the school. A primary school in the middle of the bush, five hundred kids and change, milling about between classes, staring at the weird white guy and his entourage dismounting from the four-by-four to go look at a big concrete water tank.

It’s a big concrete water tank. And it’s got our logo on it.

Yup, there goes the white guy and his entourage. Looking at the water tank. Now crossing the school ground. Now going to check out the toilets.

Yeah. I don’t feel at all creepy. Checking out kids’ latrine blocks. They’ve got our logo on them too.

And look, they’re pretty nice latrine blocks. Well constructed. Our logo again. Much nicer than the old latrines. And clean inside. Doesn’t mean they don’t stink. They do stink. Pit latrines tend to stink, any way you build ‘em. And five hundred kids using a dozen dry-drop latrines, well, just be glad I can only use words to share my experience.

Outside the toilet blocks, the little portable handwashing stations. A blue plastic tub on a metal frame with a tap at the bottom. Not too different to something you’d take camping. Only the handwashing station has no water in it. It fits sixty litres, but right now it’s empty. On the ground, a damp patch where the sand has soaked up the runoff. Butterflies are flitting above the mud, sipping at the moisture like shimmering strips of windblown tin foil.

Not much use, handwashing stations with no water in them.

Not to worry, the teacher said, that was normal. It was lunch time, middle of the day. They usually run out of water by lunch time. And sure enough, along came a couple of the older girls with a jerry can filled up from the water-tank, to fill the hand-washing station back up again.

And I guess that’s when it all started to click for me.

You see, I know all this stuff. I write it in proposals, I see it reflected in purchase requisition forms, I approve the tender bids or I read about it in reports. Of course, hand washing stops disease from spreading. Sure, schools are nicer to go to when there’re decent latrines to use.

But no, really, stop and think about it for a moment. Five hundred kids, in a semi-arid, water-scarce landscape, spending eight hours of their day crammed together on this one property. That’s a lot of toilet breaks. That’s a lot of poo. That’s a lot of germs.

Maybe it’s because I’ve got a seven-year-old at primary school now. I found myself imagining her in that location. How would I feel if these were her facilities? Okay, I guess. They’re not the nicest, but they serve the purpose. They’re safe, they’re kept clean (by the kids themselves, no less), they work. Not as comfortable as the sit-down flush commodes we’re used to in Australia, for sure. It’d take some getting used to. But okay.

But how would I feel if she didn’t have these facilities? How would I feel if I was sending her off to school for the day, knowing that she had to use a dirty, stinking drop latrine or, worse, had to scurry off into the bush to go to the toilet? How would I feel if she couldn’t wash her hands when she’d finished going to the toilet- especially in a part of the world where toilet paper may not be used? And knowing that she was in that environment with five hundred other kids, all doing the same thing, none of them able to wash their hands, heading off to eat their lunch, sharing all those germs?

I’m not a germ freak. I’m not the kind of guy who has to use antiseptic wipes every time I shake someone’s hand. In fact I’m a big believer in letting kids get exposed to germs from the get-go. Build a good immune system. Don’t polish every surface in the house with disinfectant just so your child doesn’t get a sniffle, or you’re going to be buying hypoallergenic pets for the next twenty years. I believe one of the reasons I have a pretty rock-solid constitution when I travel is because my parents didn’t freak out if I put dirt in my mouth.

But we’re talking real germs here. Cholera. Escherichia Coli. Acute Watery Diarrhoea. Typhoid.

Stuff that kills kids. By the hundreds of thousands. Stuff that, in a water scarce environment, is even harder to treat and to avoid.

How would I feel sending my child into that environment?

And I figured it out. I mean, not just connected the dots in an analytical fashion. I mean, the work we’re doing here actually hit me, emotionally, in a way that meant something.

This is important.

We’re making a difference.

Something so simple: a little blue watertight container with a tap at the bottom. A few simple messages. Wash your hands. And kids can come to school without the threat of becoming infected. Parents can know that their childrens’ practical, physical needs of the most basic kind, are being met.

Health. Dignity. Simple stuff like that.

If I had to, I could send my child here and not be frightened for them.

It’s funny how you forget this stuff. Take it for granted. I guess I’m so used to seeing it in project designs, walking around villages and seeing these activities in place, they’re almost invisible now. So normal.

We take for granted the ability to turn on a tap and get clean water out of it. That doesn’t make it any less a blessing. So too I take for granted that we do things like put water tanks and latrine blocks in schools. Shrug it off.

Yawn. It’s just what we do.

Walking back down to the Land Cruisers, I was still the weird white guy with an entourage, checking out the kids as they queued up at the little blue wash stations to rinse their hands before lunch. But it made sense in a different kind of way. I was actually glad I came. Glad I came to see a concrete water tank with our logo on it, and a little blue bucket on a stand, and a bunch of kids staring at me wondering what I was doing in their school. I’ve seen it dozens of times before. But this time it actually meant something. Refreshing. Like a nice cool glass of water.

I wonder what else we’re doing every day that we’re not seeing, that’s hiding something precious.

Photo Essay: Nutrition Program Walk-Through

 

I’m managing our emergency response program addressing malnutrition in Niger for a few weeks. For those who work in the aid sector, you probably have a fair idea of what that actually means. For the rest (those of you who are interested), here’s what we’re doing.

First, some background, so we’re all speaking the same language.

Malnutrition, simply put, is the state that results when a person’s body doesn’t take in enough nutrients- the chemicals that allow our body to function correctly, which we do generally by consuming a balanced and sufficient diet. Malnutrition can be due to the overall food/calorific intake being too low, a poor diversity of food-groups, or an illness that inhibits the body’s correct processing of those chemicals. Malnutrition has a large number of indirect causes, and a large number of direct results. Key among the latter are nutrient deficiencies, poor physical development (‘stunting’), rapid weight-loss (‘wasting’), susceptibility to disease and, in extreme circumstances, death (although direct death through malnutrition is relatively rare- it is more likely to be caused by disease which is more virulent in a body weakened by malnutrition).

We deal with two main types of malnutrtion: Long-term, or ‘chronic’ malnutrition, and short-term, or ‘acute’ malnutrition. Chronic malnutrition exists where populations consistently lack access to sufficient or balanced diets, or are exposed to regular and frequent cycles of acute malnutrition. Acute malnutrition exists where there are substantial short-term shortages in food availability.

Niger experiences both chronic and acute malnutrition. It is a landlocked country which is two-thirds desert, so growing food is a challenge. Rainfall is erratic and unreliable, and the desert encroaches into arable land. Roughly 90% of its agricultural harvest is a single crop (millet) which grows well under the circumstances, but means that diets are unbalanced. Traditional childcare norms (non-exclusive breastfeeding, early weaning and poor hygeine and sanitation practices) mean that children are health-disadvantaged from an early age. So the background chronic malnutrition is high, primarily among children. It means childrens’ bodies do not develop as well as they should. They are stunted (small for their age), and their brains may also not develop as well as they would have with a good diet. It has huge implications for Niger’s development as a country.

The harvest is brought in once a year. Depending on how good the harvest is, villages will have enough to eat. However stocks will dwindle through the year, so as the months go by, people will drop back to having two meals a day, one meal a day, and sometimes not even eat every day. This is known as the hardship or hunger season (saison de soudure). The onset of the dry season (February through May) reduces the availability of wild foods, and also puts herds of cattle under pressure. The worse the prior year’s harvest, the earlier this hardship season begins, the more pressure this puts on communities’ abilities to cope, and the deeper the crisis.

The rains traditionally arrive in late June (although as the world’s climate changes, they are becoming increasingly erratic and unreliable) and last until September. This enables the next year’s harvest to grow and flourish- depending on how good the rains are. It also brings with it malaria. The relationship between disease- especially malaria and diarrhoeal disease- and malnutrition is such that children who are malnourished are more likely to get sick because their bodies are not as well equipped to defend themselves; and children who are sick are less able to maintain their nutritional status. It is a vicious cycle.

These factors then give rise to acute malnutrition. In Niger, acute malnutrition traditionally starts to rise from May and June and continue until after the harvest in October, but on a bad year may begin to spike in February, and can last throughout most of the year, with substantial caseloads still recorded in November and December. It affects mostly children, and mostly those children under the age of five. Child deaths also spike during this time. It is inevitable, and the less work that is done to manage acute malnutrition, the more children will die. We focus on children because physically they have the fewest bodily reserves to handle shortages of food and therefore they become malnourished quickest, and also die quickest. It’s worth noting that children who are chronically malnourished already will be the first to drop into acute malnutrition once food runs out.

There are different ways to manage malnutrition. In refugee camps, malnutrition is typically done on-site in feeding centres, where women bring their children to receive a cooked ration directly from the supporting organization. ‘Wet ration’ feeding centres are expensive to run, as they require staff to prepare and distribute the food, often for hundreds of children at a time, but they work well in relief-camp settings where tens or hundreds of thousands of people may be in one physical location which can be easily accessed- so they are efficient. The biggest advantage is that staff can actually watch the malnourished children receiving the ration, so they know it has been received.

In a peace-time context like Niger’s, where rural populations are low and spread over large areas, wet feeding centres are too expensive to put into every village, and distances too great to expect women and children to travel to twice a day. The solution is a model called Community Management of Acute Malnutrition (CMAM), which brings women to distribution points once a week or once a fortnight to receive a ration for their child, which they take home and give their children as instructed. This has the advantage of being far more affordable to reach a population spread over a large area, but requires trust that the women will in fact give their children the ration- not always the case, when they might have two or three other children at home also not eating properly.

The first stage of the program is ‘screening’. Community volunteers are trained to identify children in their village who they suspect could be malnourished. They encourage those children’s mothers to take them to the nearest government health-centre.

There, program staff working alongside government health workers assess the children for malnutrition. This is done using something called a MUAC (mid upper-arm circumference) tape, which goes around the child’s bicep to assess how badly wasted it is (apparently that circumference does not change greatly in young children above the age of six months). It is marked in millimetres to measure the actual circumference, and colour-coded. A green reading indicates the child is healthy, a yellow reading indicates moderate acute malnutrition (MAM) and a red reading indicates severe acute malnutrition (SAM).

If the child is malnourished, it is then weighed on a hanging scale, then placed on a measuring board to take its height (which generally encourages loud wailing from the hapless child). The child’s weight for its height is then assessed against the average weight for a child of that size; obviously, the lighter a child of a particular weight, the thinner it is. These measurements are taken at intervals while the child is in the program to track changes in its weight. Additionally, they are assessed against a chart of ‘z-scores’ which plots the average weight for a child of a particular height. If the child is more than two standard deviations below the average weight for its height, the child is moderately acutely malnourished, and if it is more than three standard deviations, the child is severely acutely malnourished.

It may sound a bit technical, but in fact it takes no more than half a minute per child using MUAC, or ninety seconds to weigh, measure and score children using weight-for-height. The child’s information (name, village, score) is then recorded on a health card which is given to the mother- blue for moderates, and pink for severes. Program staff also assess children for possible medical complications (e.g. malaria, oedema), and if these are present, children are refered to an intensive care facility, managed by another organization.

So to sum up, we have four categories. Healthy, Moderately Acutely Malnourished, Severely Acutely Malnourished, and Severely Acutely Malnourished with Medical Complications. Our program looks after the moderates and the severes. And because the physical needs of moderates and severes differ, we treat them differently.

Moderates receive a bi-weekly ration of a reinforced meal-mix (‘reinforced’ meaning the staple has had things added to it to increase its nutritional value). This is usually a cereal flour (in our case Corn-Soya Blend, or CSB), sugar and oil, mixed together. Mothers take this home and feed their children the ration over two weeks, then return to have the child re-measured for progress and receive another ration (if required).

Severes receive a weekly ration of therapeutic food. We use a product produced locally in Niger called Plump’ynut. Each ration is self-contained in a small foil packet and tastes like sweetened peanut butter. It is specifically designed to address severe acute malnutrition, and generally speaking, the kids (and, sadly, sometimes the adults too) love it.

There are tweaks to the program beyond this, but this is the core. Our biggest challenges include ensuring the malnourished children receive the ration they are supposed to, and that it isn’t shared with other children (or worse, adults). In fact it’s not unusual for mothers to deliberately underfeed their children so that they remain on the program, so that they can continue to access the food ration which can contribute to their whole family’s wellbeing. Sometimes, an additional ration is given to the families of malnourished children to try and prevent this from happening.

The harvest is slowly coming in. Between now and mid-October it will be gathered, and during this time the food situation in the villages here will gradually improve. Malnutrition levels will lag- October is the peak malnutrition month historically. Millet is fine for adults, but kids under two will not get its full nutritional benefits (we push as hard as we can for mothers to keep breastfeeding). During the 2005/6 crisis we were still seeing kids in the program as late as April and May the following year, and I’d certainly expect to see some of the same patterns this time round.

The nice thing about working on a nutrtion program- as opposed to many other programs aid and development workers can often get involved with- is the short-term horizon. It’s normal for us to phase out of a place and never actually see the work that we do bear much fruit, beyond, perhaps, the provision of some basic goods and services. Here, however, it’s pretty easy to tell when a really sick kid shows up at the nutrition centre. Most of the kids in our severe program are ill enough that if they were to get malaria or cholera, they could die in a matter of forty-eight hours. Getting them out of that state and to better health is the aim of the program, and if the mother is feeding the child the ration, stays in the program, and the child doesn’t get ill during this time, then we can turn them around in a matter of four to six weeks. The really sick ones- the ones we refer straight on to the intensive care clinics- may only have lived a day or two past when they come to us.

It really is the business of saving lives out there. The teams on the ground (across several organizations) do amazing work, and there are many children who will live who would otherwise have died without their assistance. It’s a privilege to be able to drop in and be a part of the work they are doing for a few weeks.

Back in the Headlines: Niger

I spent a year living in Niger from mid-2005, courtesy of a media-labelled ‘famine’ that put about a third of the county’s population at risk of acute food shortages, and during which time tens, possibly hundreds of thousands of children died. From time to time I run into former Nigerien colleagues, and they always tell me, ‘you must come and visit us again’. Of course, they don’t really mean it. Given my role in emergency response, the only time I visit a country is when it’s in a really, really bad way. Nobody wants that.

The title of this post is, unfortunately, a total misnomer. Niger isn’t in the headlines. It’s barely ever been in the headlines. It got a couple of weeks of coverage in mid-2005, courtesy of a BBC camera crew who visited an MSF feeding centre in the east of the country and snapped some shots of a few skeletal children, thus propelling the story of a famine into the headlines. It also made a blip a couple of months ago when a low-level military coup deplaced Mahmoud Tanja as President of the country, all in the name of a more streamlined democratic process. Maybe 2 days’ worth.

Most people outside France confuse the country with Nigeria, can’t prononce its name, and wouldn’t know the proper noun for its inhabitants (Nigerien, versus Nigerian). I remember doing media interviews with Australian press when I was in the field. Standing on some street corner with a Thuriya Satellite telephone against one ear, the conversations always started the same way: “We’re joined now by an aid worker in Niger. Tell us, where exactly is Niger?”

Niger is facing another food crisis. At this point in time, failed rains have precipitated a state whereby 7.8 million people, more than half the population of the country, are facing food shortages. The government and aid agencies in Niger have all sounded the alert, far earlier than in 2005 (when it wasn’t until mid-year, as the country approached the height of the traditional ‘hardship season’ that the media, and by inference the world, finally started to pay the emergency any attention), and the implications are that 2010 will be a worse year for Niger than 2005 was.

Of course, nobody outside NGO circles is talking about Niger at all.

It Just Ain’t Sexy

There are all sorts of reasons why countries like Niger don’t get press coverage, fitting neatly into the category we in the industry refer to as ‘forgotten emergencies’. That Niger is a geographically obscure former French colony doesn’t help. But beyond that, there’s the dynamic of the emergency itself. Complex.

The media labelled the 2005 crisis as a ‘famine’. The word ‘famine’ makes for a great headline. It has an emotional hit with it. We get images in our head like Ken Carter’s infamous pullitzer-prize winning image of a vulture stalking an emaciated toddler in Sudan. We think of Ethiopia in 1984 and Band Aid; of the Biafra famine and airlift of the late sixties; of the great famines of the Victorian period in India which cost millions and millions of lives.

What happened in Niger, of course, was not a famine. Which was a double-edged sword. On the one hand, no country wants a genuine famine. On the other, it meant that as soon as people started to delve into the root causes of what was happening in Niger, they lost interest. It was too complex to stay on the front pages. Not sexy enough.

It’s the old challenge we’ve faced for years in the aid industry. Natural disasters are fast, shocking and simple to explain. From a media perspective, they are attractive. People eat them up. Disasters like the Haiti earthquake, or the 2004 Boxing Day Tsunami, jolt themselves into the public conciousness and hold headlines- and attention- for weeks. Sympathy- and cash- flows.

By contrast, complex emergencies such as famines, wars, refugee crises and political emergencies are slow-moving, complex, and distinctly lacking in hope. They take far too long to explain to an audience used to the sort of oversaturated ADD-pandering stimulation provided by MTV, Jerry Bruckheimer and Fox News (complete with soundtrack). People lose interest. If they bother to learn even the slightest bit about the crisis, they feel their money will be wasted there. If it’s a war, then anything they give will just get blown up. If it’s a political crisis, then it’ll get eaten by a corrupt system. If a famine, then the children whose lives they save this year will just die in the next hunger season.

There’s more than a grain of truth in this prejudice.

A Beginner’s Guide to Famine

Famine is already a complex proposition. Hunger and starvation are pretty straight forward, but in fact famine is invariably a symphony of contributing elements. It’s food shortages, distribution systems, politics, purchasing power, economics, growing practices, feeding practices, health systems, soil mechanics, climate patterns, and many other things all wrapped up together. Famine deaths are rarely (though occasionally, in acute circumstances) due to actual lack of food, but usually a vicious interplay between nutrient deficiency and disease.

This downward spiral is in itself multipronged and complex- if quite easily explainable if you’re willing to take the time.

We eat food because our body needs certain inputs to maintain healthy life. Energy in the form of sugars, carbohydrates and fats. Building-blocks in the form of proteins. Specific functions supported through the intake of vitamins and minerals- micronutrients. Reduce the intake of any of these things, and the body doesn’t work so well. Reduce them enough over the long-term (chronic malnutrition), and the body doesn’t develop properly- it becomes smaller (stunting) and brain function is reduced. Reduce them enough over the short-term (acute malnutrition), and the body starts to consume itself (wasting), ultimately leading to death if not checked.

In both instances (but particularly situations of acute malnutrition), the lack of essential supplies means that the body is more succeptible to disease. The inbuilt defence mechanisms to fight bacteria and viruses are weaker. At the same time, many diseases also inhibit the correct absorbtion of different nutrients- resulting in a downward spiral, where poor nutrient intake results in disease, which in turn slows nutrient intake. The alternative cycle is equally true where certain diseases (such as malaria, or diarrhoeal diseases) are endemic in a population- disease inhibiting nutrient intake, leading to higher succeptibility to disease.

In both cases, high mortality results. Usually among the most vulnerable members of a population- young children.

There are additional complicating factors. The biggest is hygeine, which contributes to the prevelance and spread of diarrhoeal disease. This in turn is driven both by mechanical factors (is there a sufficient supply of clean water for drinking, washing and cooking?) and behavioural factors (do people wash their hands after going to the toilet and before handling food? Do they boil water?).

A nation’s public health system is the next tier. Is there a network of hospitals, clinics, doctors and nurses to support a population and treat illness? Are there campaigns to reduce endemic and epidemic diseases (such as vaccinations, or mosquito net distributions)? Are there public health messages reaching remote communities to reduce risky behaviour?

Yet another driver that contributes to mortality cycles is population displacement- and particularly, relief camps. Cramming large numbers of people together puts huge stress on food and water production and distribution systems, and existing health care systems. People quickly become under-nourished. Hygeine systems and fecal waste management become difficult. The physical proximity of people to one another vastly accelerate disease transmission rates. The chances of an outbreak of diarrhoeal or viral disease increases by orders of magnitude, and the rapidity with which it can take hold can have catastrophic impacts on existing support networks, and ultimately on mortality.  In the aftermath of the 1994 Rwanda genocide, tens of thousands of ethnic Hutus died in a matter of weeks after diarrhoeal disease ravished displacement camps on the Congolese border.

In short, camps kill.

Malnutrition

The term famine, in the international public health context, relates to a state of excess mortality driven by food shortages- both acute and chronic- across an entire population. In other words, if we call it a famine, we should be expecting to see a rise in the number of people dying in multiple age cohorts, attributable directly to these physiological effects of limited food intake.

In Niger, this was not the case. In fact, during the 2005 hunger season, there wasn’t a single case of a recorded adult death directly attributed to food shortage. The mortality and morbidity was almost exclusively confined to the cohort of children and infants under the age of 5. A nutrition crisis, certainly, but not a famine.

Is this just semantics? Famine, nutrition crisis, surely it’s all pretty much the same thing. People need food, right?

Well, no, actually not right.

Famine, as we’ve already discussed, is a highly emotive word with which we immediately attach baggage. Drought, crop failure, rake-thin Africans and starving babies. People need food, and need it fast. We think famine, we think problem. We think solution, and we think food distribution. Trucks and airplanes loaded with sacks of grain, long queues of colourfully-clad black women with plastic bowls beneath a World Food Program logo. Donors expect it. And, sadly, aid agencies often jump to it as well.

But we’ve already talked about what famine is. It’s so much more complex than this. If we use simple, loaded language to describe the problem, we run the risk of failing to pause and fully understand it. We’ll be easily pressured into jumping into a knee-jerk response. We won’t tackle the problem where it needs to be tackled. And people- children- will die.

Complexities of the Context

Over the last couple of decades, Niger has been consistently ranked at the very bottom of the UNDP’s Human Development Index- somewhere among the poorest three countries in the world, as a rule. This is more than simple economics. It relates, yes, to the fact that the nation produces virtually nothing for the export market except a few crumbly chunks of Yellow-Cake Uranium, but also to the low adult literacy rate, the extremely high birth rate, or the catastrophic infant mortality rate.

Niger exists on the border between Sahel and Sahara- the former being that vast semi-arid band of mixed grass and woodland that stretches from east to west across the African continent and marking the gradual transition from the true-desert of the enormous Sahara to the moist tropical jungles that seethe around the Congo River. The Sahel is characterized by short, intermittent and unpredictable rains, high temperatures, and a current trend towards increasing aridity and desertification. A third of Niger- the southern region- is Sahel. The other two thirds are desert. The vast majority of the country’s population of 15 million live in this southern band, and it is here that the nation attempts to provide enough food to feed itself. 82% of the population are involved in agricultural or livestock production, much of it subsistence. Just 15% of the land area is actually arable.

Niger’s staple is millet, supplemented by sorghum, and small quantities of market vegetables. Millet is a hardy crop which grows well in drought conditions, but which is low in nutrients and hard to digest, particularly by children, and by people who are unwell. It is generally ground into powder and turned into a paste or porridge- something which takes a lot of physical work and energy. Children are typically fed millet from an early age- the traditional weaning age is two, disregarding the health status of the child or the potential benefits of remaining on breast-milk.

Adult males in the family are likely to be fed before children, as they are economically productive and need to be kept healthy to continue bringing resources into the family. Superstitious beliefs in many parts mean that children are not fed eggs (there is a fear that they will grow up to be thieves)- the best and most easily accessible form of protein in most villages. Strong conservative and male-centric values mean that men take the largest and tastiest portions of food, and children and women are fed only after men are satisfied. (There were many reports during our feeding programs of men taking the nutrient paste we had provided to infants and eating it themselves because they liked the sweet taste).

A large portion of the country’s agriculture is subsistence, with any surplus production usually sold on local markets for cash income. Families are large- Niger has a fertility rate of 7.1 children per woman, and it’s common for men to have more than one wife. Water in this arid country is in short supply- 3- 600mm per year, or around a quarter of that of continental Europe. Resource production is spread thin.

In rural areas, all kinds of traditions prevail in child-care. Generations of high infant mortality has resulted in a certain detachment by mothers towards newborn children. In places, mothers will not care for children until they are weaned (when it’s clear that they are not going to die as babies) and the task falls to other women. Colostrum- the thick, nutrient-rich substance that womens’ breasts produce during the first few days following childbirth and which provide newborns with a huge kick-start for life- is considered unclean, and infants are fed water until the mother’s milk becomes ‘normal’. This is a double-whammy, as it means that not only are children denied that boost they need to start life off, but they are often given unclean water, which makes them sick straight off the bat. Assuming they survive (almost 80 in every 1,000 children born in Niger die before they reach the age of 1), they start life off sick, and poorly able to absorb what nutrients come their way, paving the way for high vulnerability to malnutrition.

Roll all of this together, and nearly 170 out of every 1,000 children born in Niger die before they reach the age of five. That’s almost 17%, or more than 1 in 6. Given that the average woman gives birth to 7 children, that means that on average, every woman in Niger will lose at least one child.

In perspective, the infant mortality rate in Australia is 5 per 1,000 live births. The under-5 mortality rate is 6 (in other words, just one out of every 1,000 children born in Australia will die between the ages of one and five, compared to 90 in Niger).

I hope you’re getting the picture.

All this context mumbo-jumbo (that most readers have probably stopped perousing by now) really means that Niger’s population- and specifically, it’s children, are in any given year extremely vulnerable to anything that might reduce their food intake. If, in a normal year, these are the background statistics, and this is the difficulty people have in simply not dying, it means that when the resources available go down, large numbers of people are very rapidly pushed into a place where they will be at risk of death. Which is how, this year, 7.8 million Nigeriens now find themselves at risk of ‘starvation’.

The crisis, as we can see, is not so much an immediate, short-term issue, but rather it’s couched in this long-term situation.

Anatomy of a Crisis

Short-term factors still play a part however, layered into all this complexity. In 2005, the causes were manifold. First off, there were the combination of failed rains across the southern part of the country in the 2004/5 growing season, and a locust invasion which finished off the rest of the crops. So, acute food production shortages.

Merchants with significant purchasing power- many from Nigeria- foresaw that there would be a food shortage, and as soon as the harvests came in, they bought as much as they could from farmers. Many farmers even mortgaged off their coming season’s harvest before it was in- pushing themselves into debt and annihilating their own production and purchasing power to cover short-term needs. Many men left the land and moved to urban areas or out of the country to find waged labour.

As the year progressed and demand for food on the market spiked, it was trickled back onto the market by merchants who were hoarding it- but at hugely increased prices- a simple supply/demand effect. The merchants made a killing. Literally.

This layering of natural and man-made factors pushed a chronically food-insecure context into a critical emergency. Food shortages across the country meant that households simply didn’t have enough to eat. Children- already chronically underfed with low physical tolerance or resistance to nutrient deficiency and disease, bore the brunt of this. They started to waste away by the hundreds of thousands. Many died.

The politics of a male-dominated conservative society compounded things. It was commonplace for men to leave food and seeds locked away in their storehouses. They would take the key with them and forbid the women from touching the food supplies. They would be gone for months at a time without being in contact. We heard of many instances where women refused to take their dying child to a nutrition centre or hospital, because to leave the village they needed their husband’s permission, and he was travelling looking for work.

Into this mix came a government fearful of the implications of an emergency on its population. The last time there had been a major food emergency in the country the government had collapsed as an indirect result. Frightened the same might happen, they became aggressively defensive. Journalists who threw about the word ‘famine’ were kicked out of the country, accused of embarrassing the government which supposedly had everything under control. NGOs had to tiptoe around government sensitivities. Authorities were slow to admit anything was wrong, reluctant to ask for international assistance.

NGOs sent in their emergency teams, loaded with the ‘F’ word and all the professional expectations that carries. Fundraising campaigns were run, small amounts of money raised. We ran food distributions and set up feeding centres. Tens of thousands of metric tons of food aid flowed into the country. Tens of thousands of families received food. Tens of thousands of children were admitted to nutrition programs.

We undoubtedly saved lives.

We undoubtedly failed to prevent some deaths.

Lessons Learned?

Aid reached Niger too little, too late. NGOs rushed in expecting to find an acute famine based on food shortages (failed rains and locusts) but failed to understand the broader context for several months- everything from cultural practices to the ecnomics of supply and demand to a fragile and defensive state structure. While bits and pieces of the long-term situation in Niger certainly began filtering through in the early days, the complexity of setting up a time-critical emergency response and all the operational demands that such a program demands meant that precious little time was dedicated to reflection and understanding. Spurned on by the emotional sense of urgency, key clues were missed.

It took months to re-orient the response to focus on the structural issues. Food distributions- particularly the network of nutrition centres for young children- certainly kept many alive while the process was reshaped. Had the government been more proactive and had the international community (including donors and the international media) pulled their act together in a more timely fashion, that band-aid measure could have prevented far more deaths, and allowed that re-orientation to take place earlier in the journey. As it happened, by the time the context had been analysed and fully understood, donor and media interest had moved on, and there was little additional funding to run essential programs.

But dealing with these big-picture changes is not easy. How does an NGO change the child-care or hygeine practices of a nation? How do they influence government expenditure on health-care networks or vaccination programs? How do they transform the agrarian sector of an entire economy?

The fact is, they can’t. They can tackle the practical issues on a local (village) level. They can advocate to regional and national government officials. But the potential for this big-picture, long-term impact is limited. And sadly, small, short-term changes in a locale which is couched in a much bigger and more complex context tend to be easily undermined.

The Now and the Not Yet

Niger is again on the brink of a food emergency. It remains a severely impoverished country with political upheaval, and a long-standing set of cultural practices, beliefs and dynamics that are unlikely to have changed much over the past 5 years. Programs have been running to tackle chronic malnutrition and food insecurity, but I can’t comment on their efficacy. To the best of my knowledge, millions of children have once again been placed at risk of acute malnutrition, and by all accounts, the lead-in to the current crisis is worse than the lead-in we saw in 2004/5.

Once again, there is no media interest. Once again the year ticks on, and NGOs and the UN have all put out their early-warning reports, and nobody seems to care. Once again, other emergencies overshadow the crisis in Niger- such as the earthquakes in Haiti, Chile and China.

Niger’s hunger season traditionally runs from May to September. That is, the period after the seeds have been planted in the ground and last year’s harvest has been mostly consumed, but before the next harvest is brought in. Every year, rural Nigeriens have to struggle to find a way to keep food on the table- either ration their own dwindling supplies, cut back on the number of meals a day, scrounge for bush fodder, or look for waged labour in urban areas. The longer the hunger period, the harder it is to make these coping mechanisms meet the needs of families. It’s April, and we’ve been seeing signs of food stress for months. The hunger season has already been underway for some time.

If the world intervenes now, lives will be spared. If the media can raise public awareness, and governments and individuals give money and resources to respond to those needs, and NGOs can mobilize response programs early enough, fewer children need to die there this year.

If, as generally happens, we wait to see photographs of emaciated children in feeding centres on BBC and CNN, then lives will have already been lost. The time it takes to ramp up response programs will cost even more lives. This is the practical reality of the aid sector.

The government, at least, appears to be picking up on the mistakes of the past, and is already sounding alarm-bells at its level, accepting that there is a problem. NGOs too have been engaged since early 2006 with the structural issues in-country and are far more aware of the context than they were in 2005. Programs would be run differently. Best practice in the management of child malnutrition has come a long way even over the last 5 years. The UN and interagency partnerships are far better established than they were before, and long-term nutritional programs aimed at structural issues have been running. You can read more about how 2010 differs from 2005 in this analysis by IRIN here. But resource needs remain, without which programs can’t be run.

Sitting as I do in an aid and development charity, knowing full well that we can’t create resources out of thin air, I’m frustrated to know what to do. I have no power over what stories the media runs. I can’t swing government policy. I don’t have the ability to tell the Australian public where to give their [generously donated] funding. All I have is the memory of the faces I saw when I was there five years ago. The barren landscape and the fields dotted with sorry-looking stalks of millet. Skinny children with piano-key ribcages and oversized round skulls. Fierce heat. Looking at the statistics sheets on our feeding centres: The number of new children admitted; the number of those recovered; the number of defaulters; the number of dead.

I’m unlikely to be the guy on the ground this time round. My role doesn’t have me travelling quite so much at the moment, and that’s not likely to change into the near future. I have mixed feelings about this. I don’t particularly want to get embroiled in what is a complex, slow-moving and at times seemingly hopeless context like Niger’s. On the other hand, you don’t get involved with a country in a situation like that without leaving a bit of your soul there, and taking a little of its soul with you.

I sincerely and with all my heart hope that people can get their act together and choose to do something to prevent people dying needlessly in Niger this year.

Photos:

1. Niger River at Sunset: The sun sets over the Niger River as viewed from the Grand Hotel in central Niamey.

2. Feeding Centre Mother and Child: A woman and her malnourished child await registration at an NGO-run feeding centre in central Niger.

3. New Admission: A malnourished infant awaits registration at an NGO-run feeding centre in central Niger.

4. Maria: 2-year old Maria exhibits signs of acute malnutrition. NGO staff talking with her mother try and convince her to take her daughter to hospital.

5. Food Queue: Women queue at an NGO-run food distribution in rural Niger.

6. Warehouse: An NGO warehouse stacked with WFP food aid in rural Niger.

7. Millet Stalks: Staple crop of Niger.

8. La Nutrition: An NGO staff member registers an acutely malnourished child into a feeding program.

9. Recovery: A child who has been in an NGO-run feeding program for some time exhibits signs of improvement.

10: Split Peas and Mais: At an NGO-run food distribution, a man demonstrates the food being distributed.

11: Traditional Coping Mechanisms: An elderly woman sells a plate of baked leaves which she has foraged from the bush as a food source.

12: Hilltop Sunset: The sun goes down over the hills beyond the Niger River near Niamey.

Today

Today a man died and the world watched. He captivated the world’s imagination first through his talent, and later through his increasingly bizarre persona, and the chronic secrecy with which he veiled himself. By the end of the day there will barely be anybody in the Western world who won’t have heard this news, and probably not a great number of people in other parts of the world either. People will say many things about him in public. Most will be nice, and will overlook the sordid. Some will be sarcastic and unkind. I may even sitfle a snicker at some of these. There will be mountains of flowers, cards and weeping fans. There will be memorial services, and his music will be played ad nauseum for the next couple of weeks. People may remember but will not talk much about the fact that he was accused of inappropriate relationships with children, that he was an emotionally and socially damaged individual, and that he has forced his own three children to live largely as reclusive prisoners throughout their childhood. People may reflect on the fact that he too had his childhood taken from him at an early age, in an industry where a talented and precocious child will be swallowed whole and destroyed without the slightest twinge of concience.

Today, about thirty thousand men, women and children will succomb to complications of the AIDS virus, a disease which effectively disables a person’s immune system, leaving them vulnerable to any disease, however mundane, to invade their bodies and slowly break them down until their shell can no longer support life. Most of these people will die in underdeveloped portions of underdeveloped countries. Some of these people will die alone, in anonymity, or under a blanket of stigma associated with the disease. Some will receive a small memorial service and some flowers. The families of many will not be able to afford such things. Nobody beyond their immediate families and friends will know of their names, know where they are buried, or remember them. Their stories will never be told. The mark they left during their passage on earth will not be known.

Today, hundreds of people will be violently killed in tribal violence in Darfur, Southern Sudan, northern Uganda and the Democratic Republic of Congo. They will die alone with the malice directed at them and their names and fates may never be discovered. Today dozens of people will die in shootings, bombings and air-raids in Somalia, Iraq, Afghanistan and Pakistan. We may hear of their fate as a footnote on our evening news report. Today, thousands of children under the age of five will die in Niger, Mali, Burkina Faso, and a dozen other sub-Saharan African nations because they don’t have access to a sufficiently nutritious diet, clean water, and public health care. The youngest may not even have names, and they may be remembered even by their parents as nothing more than a number. “I have six children, and three who died”.

Death is an inescapable part of the world we live in. It is a passage to something new. Some believe it marks the start of a journey to a second life, or to a rebirth here on this earth, and may find cause for hope. Others believe it is the end of the seething brew of cerebral chemical reactions that define who we are as people, and that our molecules simply return to the physical universe from which they were once bonded. The process of death itself may be painful, it may be frightening, sometimes it can even be beautiful. Mostly, when we mourn it, we mourn for ourselves who are left behind by it, and the loss we must move on with in our own lives.

Death brings cause for reflection. It is why we celebrate it with services and wakes, why people in offices across Australia and the rest of the world will make small-talk over coffee-machines and water-coolers about the passing of Mr. Jackson for the rest of Friday, and why, two weeks from now, we will be begging our news providers to please, for the love of all that is precious, stop talking about Michael Jackson.

And so my question for you today is this. What is it that makes the death of a single musician cause for global reflection? Why will one man be the subject of thousands of hours worth of broadcasting time, while the deaths of today’s 30,000 AIDS victims, or the hundreds of people who will die in violent warfare, or the thousands of children who will slowly succomb to disease, will probably not be mentioned? What does it say about our society, about our media, about the authority in our lives, and about our priorities, when we will remain comfortably oblivious to the death of innocents, but publically mourn the loss of a single man as though he represents something about us. A man who suffered terrible social and emotional problems. A man whose last two decades of life appeared, from the outside at least, to merit great sadness and pity in as much as they clearly drew scorn and harsh mockery. A man who probably placed the wellbeing of several children, including his own, in jeopardy. A man who, materially-speaking, had everything a human being could possibly have imagined or aspired to in wealth and fame, and yet lived in tragic isolation and died young. Is this man our spokesperson? Our role-model? Does he represent what is important in our culture? And is our inability to reflect on the suffering of thousands a symptom of ignorance? Of callousness? An unwillingness to be challenged to change? Or will we simply, as we do so often, shrug off the question and say, “yes, well, that’s just how big media is and we can’t expect them to change”?

I don’t write to criticise. I don’t mourn the death of Michael Jackson personally as, to me, he meant nothing. I felt sympathy for him while he lived, and I feel sympathy that by the time his life ended prematurely, there is little about him to suggest he had found peace. There is nothing here to gloat over or to celebrate. But I take it as an opportunity to reflect, as death has wont. Likewise, I don’t criticize people unaware of or unable to grapple with issues of international poverty and humanitarianism. This is my paradigm and I don’t inflict it on others. But I do encourage people to think, to challenge themselves, and to risk asking big questions and so expand their own horizons and ways of thinking.

Thank you.

Note: Many people who read this blog left comments on my Facebook profile a few weeks ago when I raised a similar, less wordy question about the crash of AF447. They were thoughtful, intelligent and measured, and for those responses I thank you.