November 1985. I was 25 years old when I first visited the African continent and began a 25-year apprenticeship: unlearning certain things and gaining new insights into many things I could not have learned otherwise.
We landed in Nouakchott, Mauritania (the Islamic Republic of Mauritania, to be exact). Almost immediately, I joined a group comprised of two expatriate nurses, two drivers, one expatriate project director, and two local community health workers. We headed to the desert north (not the profound north but far enough) to assess the nutritional needs of children in rural communities.
That year was towards the end of a multi-decade drought that had affected the Sahel region of northwest Africa. Villages were disappearing in the sand; formerly nomadic groups were settling in the capital or regional cities; everyone was hungry. When I say “hungry,” I don’t just mean food insecure. People were starving in out of the way places, and we went to find out just how bad it was.
We were going to weigh children, the most vulnerable group in the population, to determine the need for a food relief program the U.S. government was considering.
(I think back on that trip with shame. The children we saw and weighed were in such bad shape that in at least one village a child died before we could even register its weight to compare it to their age. The idea that we had to “prove” the need of these villagers struck me then as bizarre and now strikes me as wrong…)
About 100 km in, we came to the end of the paved road, and then it was a desert track through imposing dunes that were overtaking palm groves and any other living thing in their path.
The hamlets huddled up against the disappearing groves where water was near the surface, and soon enough inhabitants would have to leave to find the basics of life somewhere else. The final remnants of their meager goat herds stood passively by the remaining bushes, and everything was gray.
The two dozen or so hamlets we visited during those five days quickly merged into one another–a few walled compounds with drifts through the doors, roofs collapsing due to disrepair, a few tents inside the mud-brick compounds where people lived. And each community had a tree. It was on that tree that we hung our scale to weigh the twenty or so village children six months to 3 years old.
It would have been better to measure wasting–the weight of children compared to their height to assess the acuteness of the malnutrition, but we had no height board nor anyone trained to use one. We took the weights by sliding the children into a harness and hanging them on the scale, which hung from the tree. We used whatever data on age we could figure out. Most moms had vaccination cards for their children, and for those who did not, we asked when their child was born in relation to the others who had cards.
The results were terrible in almost every case. A point in time measure of weight-for-age is not ideal; you want a couple of points in time to judge a child’s growth trajectory to look for faltering. We could not do that, but the point estimates showed that these children were in a clear danger zone. They were wasting away to nothing.
(I recall picking up a child of just over two who was so light I remember thinking that their bones must be disappearing within them.)
Only three villages of all those we visited remain in my memory. Only two matter for this story. We arrived in the first, pulling in in our aging LandRovers (the only motor vehicles for possibly hundreds of miles around), and a man approached us, announcing himself as chief.
He greeted us with a laugh and welcomed us. He immediately asked what we had for him. He explained that things were terrible and that a little help from us could make things better. He could maybe build a school or hire a nurse (there was zero chance for either of things to happen, and he knew it).
We explained our mission, and he directed us to a tree and began screaming at women to bring out their kids. He had a kind of scourge made of sticks, and he threatened them to fall in line or else. They complied passively, eyes cast down. They, too, were gray. The men hung around, watching, and looking tired. We explained what we were there for and began.
The chief kept up his banter and his endless streams of requests, paying no attention to the women, the weighing, or anything else. He cracked jokes with the drivers and talked about the village’s needs that he needed money to fix and, couldn’t we help out.
Most moms had no vaccination cards, and it took us a while to discern the ages of the children. And when we started weighing, we realized that all these kids were in bad shape–every single one. The nurses whispered to me that most of these kids were going to die, and there was nothing they could do. Diarrhea was everywhere. When we finished, the nurses talked to everyone about rehydration and breastfeeding, and the chief berated the mothers for not doing their jobs. We left stunned. I felt ill, and probably the only reason I did not feel a lot worse is that I did not have any children yet (my wife back in the capital was pregnant with our firstborn).
About 10 to 12 kilometers away, we entered another village. As before, a man approached our vehicles as we entered announcing himself as the chief. He told us immediately that the children there were in a bad way. Had we come to help them, he wanted to know. Could we please check them out? What were his options for helping them? The questions poured from him, and he was desperate to find relief.
We explained our mission, and he went house to house, encouraging people to come. He offered us tea and bid us rest while the mothers arrived. He queried us about how soon the food might come pointing out over and over that the children needed help now. He organized the crowd by asking whose children were sick and needed help the most to line up first. Everyone knew the answers and quickly sorted themselves into groups.
As we began to weigh the children, he asked if we might stay long enough to give the community members advice on how to best care for their children. He begged us to stay on overnight so we could, perhaps, treat some of the sickest.
Every mother had a vaccination card, kept carefully in plastic bags, and the chief proudly told us how he had arranged for a vaccination team to come to the region from the district health office.
And, while the children were not healthy, they were doing okay. The nurses noted this immediately and wondered what resources this village had that others did not. They asked a lot of questions about goat milk, consumption of vegetables (there were none), but in the end, they could not figure out what unique characteristics helped these children be in such relatively good shape.
The nurses provided information on rehydration to everyone and talked about breastfeeding. The chief asked them to identify the children most in need of help and sat with them and the mothers while they counseled them in a smaller group. He encouraged them to follow the advice.
We talked about that village for the rest of our trip. Years later, I would learn of a concept that could describe such cases. We call them “positive deviants:” those places or families where children seem to thrive while others in the same area do poorly. It is always essential to identify the key characteristics of positive deviance, and in that case, we debated it as we drove on through the dunes.
Sometimes, I wonder how many children in those villages lived.
Lesson: Leadership makes a difference. Leaders who are focused on their community, the people in their organizations, and institutions can help create health and well being. Understanding one’s community, and those most in need within it, can and does make a difference to outcomes.
It was the first time in my life that I thought about the difference that a “good leader” could make. And over the many years I spent in Africa, and when I returned home, I found many examples to bolster my conviction that a leader’s focus on the needs of the least in any community is the key to a healthy community.
I still believe that.
I learned that in Mauritania. I relearn it every day now in my country.