Shantaram

Greetings from Burkina Faso!

I’ve been reading a lot lately, enjoying the lack of academic studies post-graduation and realizing that without electricity there are a limited number of things to do after the sun goes down (around 6pm). I just finished a book that was recommended to me by my good friend, Steven Somers, and I have to admit it was one of the best I have ever read.   The book is Shantaram by Gregory David Roberts.  I’m going to avoid discussing the details of the plot, but the protagonist, Lin, is an Australian who moves to the city of Bombay, India.  The story is told in the first person from Lin’s perspective.  Although Africa is only briefly mentioned in the novel, there are a number of themes in the book that apply very well to my experience in Africa and my work for the next two years.

During one section of the book, Lin is taken to a hidden market in Bombay where children are bought and sold into slavery.  He remarks:

“I was a stranger in a strange land: it wasn’t my country and it wasn’t my culture.  I had to know more.  I had to know the language that was spoken, at the very least, before I could presume to interfere.”

Lin is observing human trafficking, an economic practice that is morally wrong from a modern Western perspective to say the least.  While his gut reaction is moral disgust, his guide, Prabakar, informs him that the children being sold at the market have been displaced by horrific regional conflicts and are much better off serving in the households of wealthy families.  In the midst of this dilemma, Lin is acutely aware that he is an outsider and lacks the knowledge, cultural experience, and resources that are necessary to stop what he is seeing from happening.  At the very least, he deems it necessary to know the local language before he could “presume to interfere.”  He astutely observes that even if he could single handedly shut down this hidden market, another would immediately spring up somewhere else in the city because the demand for child slaves would still exist.

Many parallels can be drawn between Lin’s experience and the obstacles to public health work in Africa.  It’s easy to observe that there are serious public health problems here, but the process of understanding the fundamental reasons why these health problems persist is often long and tedious.  It requires an understanding of local cultural that is difficult, if not impossible, to achieve without living in the communities where these health problems exist.  There are well over 20 unique ethnic groups in Burkina Faso, each with a unique culture and language. These groups are connected through channels of commerce and share a common history of French colonization, but each of these groups also has a unique set of health needs.  On a positive note, the resources to solve most public health issues already exist in Burkina Faso, but the knowledge, motivation, and organization required to successfully utilize these resources is often lacking.

While the availability of medication and access to medical services are key concerns in Burkina Faso, to simply address these issues would only scratch the surface of the public health problems in the country.  This is not to say that the two are not extremely important to any functioning healthcare system, but the presence of health resources is far from a guarantee that people will use them.  Preventative medicine is difficult to preach and rarely practiced in Burkina Faso for a variety of reasons, but high on list is the fundamental difficulty of producing behavior change among the population.

 Although all of the nurses who work at community health clinics in Burkina Faso are Burkinabe, most are not from the village or even the region that they work in.  Their entire formal education has been in French, but many do not speak the local language of the communities they serve, which can be problematic because only a limited number of villagers can communicate in French.  Government employees are considered “fonctionnaires,” a French term which, in Burkina, has mixed connotations but essentially implies that government employees are a privileged class.  They have graduated from universities in the major cities of Burkina and more money than the average Burkinabe farmer.  In many cases, the Infirmiere Chef du Poste (head nurse) of the CSPS (community health clinic) would rather live in a regional capital and commute to work by motorcycle than live without running water and electricity in the communities they serve.  Physical and cultural separation from the communities that CSPS staff serve is problematic from a public health perspective for a variety of reasons, as it tends to promote a reactive model of healthcare rather than a preventative model.

Sign leaning against the side of the CSPS in Sanga
"AIDS Exists.  Protect yourself with a condom."

The most basic advantage of a Peace Corps volunteer in terms of development work is cultural integration: becoming a member of the community. In the grand scheme of things, the two year commitment of a Peace Corps Volunteer is barely enough to integrate into a community, understand their health concerns, and help to build the capacity of the communities to take initiative and address their own health needs.