My friend Gani is nineteen or twenty, but looks like he’s fourteen. I can’t believe it when his family tells me his actual age, my eyes are betraying me. I ask why, why is his appearance so different from many of the others that I’ve encountered in Nangong-Ayeli, my hometown here in Karaga district, Ghana. They point to the hard work that he’s had to endure in his youth, and, I suspect, the lack of food and nutrition.
Could such a pronounced difference in growth really be the cause of a lack of nutritious food? In Karaga district, it seems it’s not so uncommon. In the Northern Region in general, 2003 stats say that about 50% of children are malnourished to some degree. In Karaga district, the number jumps to a startling 80% of children that are not getting enough of the right foods to eat, resulting in anemia, severe malnourishment, stunted growth, mental handicapping, and death.
This knowledge blows my mind, as I sit with Mr. Karim, a local social entrepreneur who is running a malnutrition treatment centre in Karaga town. Mr. Karim is a soft-spoken but articulate man, who never wastes a chance to talk about the centre that he started himself with some French grant money. He outreaches to families in the Karaga and Gushiegu districts, encouraging mothers to bring their severely malnourished to the treatment and feeding centre. Once they’re there, he brings the children through a graduated program to introduce more protein into their diets, using soya bean flour as the key additive to the meals that are predominantly based on maize. Soya bean is a good choice here, because animal protein is simply not spent on children, and most families grow at least a small plot of soya beans. By mixing small amounts of soya bean, and adding a multivitamin, he can proudly show before and after pictures of children absolutely transformed in just a few short weeks. While refeeding is progressing, he teaches the women a program that covers various topics of malnutrition and general health prevention. Once he discharges mother and child, he hopes they have learned, and will not come back. But sometimes they do.
For a variety of reasons, despite clear evidence that a changed feeding regimen can save their child’s life, the child does not receive enough of the right foods to maintain their rehabilitation. Sometimes it is that the mother does not maintain control of the food supply in the home, and the father either does not understand the importance, or does not want to invest that much in any particular child, to allow the soya beans to be used. Sometimes it is a lack of time that forces the mother to feel that she must de-prioritize making an extra type of meal for one of her children. Something that Mr. Karim does not mention, but which I suspect is an underlying issue in the use of soya beans, is that they are not actually considered food by most of the people that are living in these districts. Soya beans, especially in recent years, have had high selling prices and thus earned a reputation as a huge cash crop. This entices people to sell their soya beans, and coupled with a lack of history as food, serves as a huge barrier to families actually retaining the soy they produce so that they can feed it to their children. In order to leap this barrier, the whole family really needs to be convinced that by eating soya beans, the increase in health will far outweigh the time, effort, and money that it takes to do so.
This is a core piece of the strategy that my technology adoption team with EWB is testing: that fostering conviction in farmers is missing in a lot of the outreach work that happens in the Northern Region in Ghana. It’s that idea that we can have knowledge of an idea or technique that could improve our lives, but until we are convinced that it is worth the effort, we aren’t going to do it. Most extension for farming practices in particular focus on the dissemination of knowledge, without checking that farmers are firstly interested in the technique they are learning about, and secondly that they are actually being convinced to adopt the new technology. It’s like that time my Dad told me to get enough sleep in first year, but I thought that the work I was doing was more important, so I stayed up late consistently, and got a lot done, but realized later that I’d felt like crap the entire time. My experience convinced me to keep better sleeping hours, not the knowledge transferred from my well-meaning but unconvincing father (sorry Dad). It’s the same as knowing that sitting too long at the computer typing could give us carpal tunnel syndrome or something else nasty, but many people still do.
So how to go about fostering conviction that the added effort of adding soya beans to your diet could measurably improve your health and livelihood? Where the benefits outweigh the costs and the risks? Enter Dr. Saviour, the District Director of Agriculture for Karaga District, and my counterpart at the MoFA office. He has also identified that malnutrition is a severe problem in this district, and as part of his mandate to maintain food security in the district, has devised an intervention targeting the incorporation of soya beans into people’s everyday diets. A key reframing in his intervention looks at convincing the entire family to eat soya beans, because malnutrition and its effects are pervasive also in the adult population. This eliminates some of the roadblocks of Mr. Karim’s intervention, where only part of the family may be convinced of the merit of soy. It also means that preparation of soya beans is marketed not as a special intervention for just one child, but a regular ingredient in the same meal for the entire family, reducing the perception of extra work for the benefit of only one. The other major difference comes in the implementation of information dissemination. Instead of bringing people out of their normal context, the intervention occurs at a household level, where people are taught the merits of soya beans, the correct preparation, and are brought through the program as a household. Both the children and the adults will be eating soya beans, and will in all likelihood see a marked difference in their children, as well as themselves with reduced illness and increased energy and stamina.
This style of intervention is resource-intensive, and that’s the trick. With very small resources, many projects try to reach as many beneficiaries as possible, sacrificing the quality of ensuring conviction for the quantity of people reached. Dr. Saviour knows this, and so is piloting this intervention with only 10 households, in 2 communities. By focusing, he can ensure that all families can get adequate support to make a sustained change to using soya beans in their diets.
But what about that huge sacrifice I spoke of, the one of scale? Can the quality of this intervention really make up for the miniscule number of families directly affected? By ensuring the thoroughness required to make soya beans a sustained part of people’s behaviour, he’s betting that others will see the results of their neighbours and follow suit. Because there is nothing special about preparing your meals at home compared to moving to a nutrition centre for a few weeks, people can see that they too can fairly simply obtain benefits from the crops that they already grow. By word of mouth, Dr. Saviour believes that the conviction can go hand in hand with the knowledge of how to increase nutrition and health, and slowly spread through surrounding communities.
My role is to support him in his implementation, and we can move together to explore how to tweak and question the assumptions underlying his pilot. And because of my experiences here in Karaga, I cannot help but feel that this intervention could critically change the course of many lives in this district. Malnutrition is not a joke, even though it doesn’t keep you in bed like malaria or kill you with the certainty of HIV. It is an underlying factor that will make a person substantially more susceptible to all of those other health issues we hear about. While we’re out fighting fires, the slow spectre of malnutrition fans the flames.
Karaga is chronically malnourished. It shows in the photos on the wall of Mr. Karim’s nutrition centre. It shows in the statistics of Dr. Saviour’s research. It shows in my friend Gani.