The perils of pill patronage... Clinic controversies...
Confronting a volcano... Progress and its discontents...
I brought with me to the village five bottles of aspirin and four packs of chloroquine (to treat malaria). I thought it better to bring gifts for the whole village rather than for individuals so as to skirt round questions of jealousy or favouritism. And I thought giving the pills to the clinic – which I well remember contained no medicines at all ten years ago – would be the most uncomplicated of presents. How wrong can you be?!
Those few pills were to take me on an instructive little journey through the minefield that is aid and development. There were certainly times when I wished I’d left the blessed things behind – but if I had I would have missed out on just the kind of lesson I came to the village to learn.
The saga begins early in my stay when I pull out the aspirin and chloroquine while in the company of Yacouba and Mariama and mention that I am about to give them to the clinic. Yacouba immediately suggests that it would be nice if I gave him and his family a share, the implication being that this is somehow his right as my official host in the village.
I hate this notion with every fibre of my being – the very idea that he merits a cut because of his position of authority as The Delegate violates every principle I hold dear. It seems symbolic of everything that is wrong with politics-as-usual in West Africa and its tendencies to graft and corruption. My reluctance is painfully obvious and the situation quickly becomes embarrassing. Yacouba tries to justify himself by saying that the clinic in central Sabtenga is far away from his area, Bidiga – if I gave the pills to him he could take them on behalf of the people of this district.
He is prepared to insist. I have to give way – I can’t afford to cause resentment at the start of my stay. But I still can’t bring myself to hand them to him. Instead I put all the pills on the floor and say that he should do what he thinks is right. A bit sheepishly Yacouba picks up one container of each, saying ‘For Bidiga’.
The subject comes up again in the evening in what’s becoming a regular gathering outside my hut. Each evening I eat my one meal of the day under the stars and set up a chair beside mine so that anyone who wants to can come up and chat – though only those educated enough to speak French or keen enough to speak through an interpreter can really do so. On this occasion the assembled company raise the question of my giving medicines to the clinic, which they have already heard about on the grapevine. They also think this is pretty dumb – it seems obvious to them that it would have been more sensible to give them to my neighbours.
They swear that the clinic will end up selling the pills. I tell them I’ve been assured by the Nurse, Harouna, that they will be distributed for free. ‘He would say that, wouldn’t he?’ snorts one man. ‘He’ll say that to your face but after you’ve gone...!’
I tell them, in case it will make them feel better, that Yacouba has taken one pack of each ‘for Bidiga’. This does not help the situation. ‘For Bidiga?! For himself!’ snorts the same outspoken man.
The fuss lasts for days. People in Bidiga are furious that The Delegate has taken the pills on their behalf – the idea that they could roll up at his concession and ask for them is manifest nonsense to them. But they are almost as incensed about my discourtesy in giving to the clinic instead of to locals.
I tell them I have held back one bottle of aspirin for my own use and that my neighbours can gladly have that when I leave – or before if someone needs it. But I also tell them that there is a question of democracy to be sorted out here. If The Delegate, elected by the people, takes something on their behalf, then they assuredly have the right to demand it from him. But it is also their democratic responsibility to take him to task if they feel he has abused his position of power. There is no sign that they have done this by the time I leave.
But the other key issue is why people feel so disconnected from the clinic, which is, after all, only two kilometres away and seems to me to be one of the most positive changes in the life of the village.
When I was here ten years ago the clinic had just been built but it was an empty shell which made you wonder whether building it had been worthwhile. Sankara had promised to make the UNICEF program for child health an absolute national priority but there was no sign yet in Sabtenga of this happening.
I vividly remember a pathetic episode in which I tried to administer oral rehydration therapy to Mariama’s baby boy Bubakar, who was ailing from diarrhoea. I knew that dehydration from diarrhoea is the world’s biggest child killer and I couldn’t bear the idea that this baby might be wasting away before my eyes for want of a simple solution of salt, sugar and water. The only problem was that I couldn’t for the life of me remember in what proportions I should mix them – in writing about the treatment in the abstract I’d never imagined I would one day have to administer it. My concoction was way too heavy on the salt; Bubakar spat it out in disgust and howled the place down. His mother looked at me scornfully as if I’d just tortured him and simultaneously destroyed her faith in Western medicine.
The contrast between then and now could not be greater. Mariama is today herself employed half-time as a medical assistant – doing everything from delivering babies (which she started doing seven years ago) through immunizing children (from four years ago) to administering that same oral rehydration therapy (though this time in small fail-safe packs supplied by UNICEF). The clinic has fewer staff than it would if it were fully resourced. But it is still a hive of activity and represents a major improvement in the village’s quality of life.
The care taken over pregnancy, childbirth and the follow-up care seems particularly impressive. Over the weeks I watch a multitude of babies being immunized and their growth monitored, and meet scores of mothers prepared to pay to have their birth and baby supervised by the clinic rather than trusting them to a yaaba like Coca Maloni.
Health education is an important part of this pregnancy package. I sit in with Rabietu, Mariama and 14 other women on one of the discussions that precede their monthly examination. These can be on nutrition, hygiene or on different methods of contraception. But the session I attend is on colostrum, the clear fluid which the breast contains immediately after the birth and which is an important source of nutrients and immunities. Bissa tradition holds that colostrum is bad for the baby and only one of the 14 women plans to feed it to her baby – the rest are planning to expel it while waiting for the milk to come in. By the end of the discussion all but one seem to accept the new wisdom. The odd one out claims at the end that she has just been playing devil’s advocate because she enjoys a good argument. But she has a wider point – that the cost of having a baby through the clinic ($11 – or $16 if the mother’s vagina tears and needs stitching) is simply too great a burden for a subsistence family to bear.
Money is the main problem with the clinic. All medicines have to be paid for, which in practice produces the perception that you can’t walk into the place without handing over 100 francs (20 cents). This is national policy rather than the fault of this clinic – the Government clearly doesn’t have the funds to pay for free or even subsidized medicines.
But many villagers don’t see it this way. Hence the problem with my wretched aspirins. When word gets back to Harouna, the Nurse, that people suspect he will charge patients for them he storms in to see me and demands to know the names of his accusers. I stall him, not at all sure that I want to betray people’s names to such a raging bull, but he then rants and raves at the individuals he suspects anyway. The whole issue is by now the talk of the town. Nice to know you can have such a positive impact on a community.
Luckily Harouna calms down by the time I formally interview him a week or so later. He explains how the hornet’s nest I’ve stumbled into was first stirred up. A few years ago a French charity stocked up the clinic on a one-time basis with medicines for free distribution. Doubtless some of those medicines saved lives that would otherwise have been lost. But ever since then many people in Sabtenga have expected free medicines and have supposed that any charge is a scam by the clinic staff.
It’s a lesson in the distorting effect that seemingly magnanimous aid can have on local conditions. It is not dissimilar to food aid and its damaging impact on the prices farmers can get for their crops. Aid can only be injected into a society in the most careful and sensitive way. Harouna says he would much rather I had not come bearing gifts because by doing so I have further muddied the already cloudy issue of payment.
But I’m afraid money is not the only thing standing between the clinic and the confidence of the community it serves – the other thing is Harouna himself. He really is a most irascible man – the raging-bull incident over the guilty names was actually not at all untypical. The very first moment I met him he launched off into a tirade of abuse against Mariama, who of course works for him. He was full of smiles afterwards, claiming a misunderstanding, but I had the distinct impression that he was putting on a display of his own power for my benefit. His success in intimidating me makes it easy to understand why many villagers feel he doesn’t quite have the bedside manner they would wish for.
I feel duty bound to confront Harouna about his abrasiveness and I fully anticipate a Krakatoan response. To my surprise he takes it quite calmly, though I’m not sure what he says does him much credit.
‘I don’t understand this village,’ he says. ‘Everywhere else I’ve worked [and he’s had seven other postings since 1969] I’ve had no problems and been well liked. Here I’ve had trouble right from the start. I told people then that if they had a problem with me they should tell me to my face; instead they just beef about me behind my back. They’re damned right I get angry. The language is one problem: I don’t speak Bissa and not everyone in the village speaks Moré or French. But in my other postings – two of which were in Bissa communities – that never caused any trouble.
‘Given all this I’m not motivated to mend fences with the village and I’ll be seeking a transfer when my two years are up in December. I’m demotivated. I wasn’t welcomed. Now I just do the minimum.’
The negative feeling seems mutual: Yacouba, who inevitably chairs the village health committee, tells me he has already complained to Harouna about his behaviour and will be asking the authorities to move him on. They can’t seem to get rid of each other fast enough.
This is a shame because I am genuinely impressed with the way the clinic works, which far exceeds my expectations when I arrived. Notwithstanding all the problems, the health of the village is infinitely improved and things which seemed so difficult and distant ten years ago – from family planning to treatment for diarrhoea – are now on everyone’s doorstep. But it’s fascinating too to witness all the burning issues concealed beneath the surface. Statistics, even optimistic ones, never tell the full human story.
©Copyright: New Internationalist 1995