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Grassroots Revolution

Grassroots Revolution

Grassroots Revolution

Trusting the people to solve their health problems

By Brian W. Simpson

"My neighbor was pregnant, and last month she was going to the well to draw water and fell down.

"There was not a road to the hospital. We put her in a wheelbarrow. It was raining very hard. We had to wait three to four hours for the rain to pass. It was midnight, and we were very far away.

"Before we got to the hospital, she died."

Alice Daniel sits in a teal blue room of the small clinic in Mpape, Nigeria, an impoverished community of tin shacks just outside the capital city of Abuja. Indignation simmers beneath the words of her story. Daniel knows that for many Nigerian women, pregnancy is a roll of the dice. Joy or death. In Nigeria, a woman's lifetime risk of death during pregnancy or childbirth is 1 in 18. For women in industrialized countries, the risk is 1 in 8,000.

Her neighbor's death encouraged Daniel to help pregnant women in her community get antenatal care at the clinic as well as reliable emergency transportation. "I want to save my women," Daniel says.

Sitting near Daniel on a wooden bench, businessman Abdullah Abubakar joins the conversation. When his wife went into labor in 2002, Abubakar rushed her to the hospital on a motorcycle. "Before we could get to the hospital, the baby died. It nearly claimed my wife, too," he says. "Since then, I feel pain when I see women in labor without help. I must support them."

The barriers to safe births for mothers and babies in Nigeria—Africa's most populous country—are considerable: The nearest clinic is likely far away and has paltry stocks of medications. Health providers are not always well trained or particularly trusted by the community. In some parts of the country, a woman must have her husband's permission to leave the house (which creates a serious risk if she goes into labor while her husband is away). Many women are not educated about pregnancy's danger signs such as headaches, swelling feet, bleeding and so on. Transport to a clinic or hospital is often prohibitively expensive or nonexistent. Such obstacles often prove insurmountable for Nigeria's poor, so they resort to what they have always done: giving birth at home and praying.

Today, even the most basic tools of medicine and public health—immunizations, antibiotics, safe drinking water, antenatal care and so on—still elude many of Nigeria's 140 million citizens. And it is not just mothers who are dying but babies, children, adolescent girls and boys, and men. Traditional indicators of population health are a compendium of misery: More than 1 million Nigerian children younger than 5 years of age die every year, according to UNICEF. Seventy percent of these deaths are due to preventable or treatable infectious diseases such as malaria, measles, HIV/AIDS and pneumonia. Life expectancy for a child born today is just 47 years.

Indignation simmers beneath her words as Alice Daniel recounts the death of a pregnant neighbor. "I just want to save my women," Daniel says today.

The country is rich in petroleum reserves, but it has failed to secure good health for its people. The health system lacks clearly defined roles for the federal, state and local governments, hobbling efforts to improve health, says Susan Krenn, program director for the Bloomberg School's Center for Communication Programs (CCP). Politicians prefer to construct hospitals and other buildings than to invest in less flashy public health prevention programs. "To me, Nigeria has always been a country of contradictions," says Krenn, who has worked in Nigeria for more than 20 years and lived there in the early 1990s. "You've got some of the brightest, most hardworking, compassionate people in the world, and you've got lots of resources, but somehow it doesn't all connect in a way that works."


EXPERTS IN NIGERIA and other countries increasingly are turning to the communities themselves and to people like Alice Daniel and Abdullah Abubakar. Rather than parachuting in high-cost, ready-made solutions to be imposed on locals, experts are designing efforts to help people in communities solve their own problems. USAID's Community Participation for Action in the Social Sector (COMPASS) is one example. The five-year program began in 2004 and works to improve health care and education for 23 million Nigerians. Another major USAID program called ACCESS aims to save the lives of mothers and their newborns. As a partner organization to these and other efforts, CCP is helping communities to find ways to reduce maternal mortality, improve primary care facilities and increase childhood vaccinations.

It's no small challenge. Solutions directly imported from the West have often met resistance in Nigeria, especially in the country's Muslim north, says Nasiru Ilallah, child survival program coordinator for COMPASS.

"Even when Western education came, people resented it. They thought, the white man is trying to make them Christians, take away from them their religion," he says. "The refusal of mothers to give the polio vaccine to their children is this issue."

Five years ago, Muslim clerics in Kano state (which has a population of 9 million) began railing against the polio vaccine, claiming it was part of an American plot to make Nigerian girls infertile. The Kano government halted the campaign, and the poliovirus resurged, spilling over into Chad, Sudan and 10 other African countries and setting back the global eradication effort.

Ma Umba Mabiala saw firsthand how a campaign's top-down approach can fail. The senior program officer with CCP's Africa division remembers telling other people involved with the campaign, "I don't feel quite comfortable with the methodology used to address the polio issue. We need to make sure people feel polio is their own issue." One person replied, "We don't have time to involve the people."

That mentality doesn't lead to success, argues Mabiala who believes it is crucial to first get to know the people and let them get to know you. "You need three to four weeks to build a community coalition," he says. "Some people say you're wasting time, but it's part of the process of building trust. If people don't understand you and don't know you, then they don't feel what you want is in line with their own goals.

Even the most basic tools of medicine and public health—immunizations, antibiotics, safe drinking water, antenatal care and so on—still elude many of Nigeria's 140 million citizens. Mothers, babies, children, adolescent girls and boys, and men are dying.

"We as program officers need to admit we don't have all the solutions, especially in a very complex environment like northern Nigeria," Mabiala continues. "Culturally speaking we may not know how to deal with some behavioral issues. We need to listen to people. How they speak to each other is important. How they share information is important. When we listen to them, we learn things. Those things help us to start to move forward."


A PROCESSION OF women and men wind their way along a path curving through a barren field. It is early May, the end of the dry season in northern Nigeria. The land is chessboard flat, and the dirt is baked to a powder. They walk to a freshly painted, cream-yellow building in their small community of Dawanau, on the outskirts of the city of Kano.

They are here to show off the building being renovated. New bars are on the windows, new glass is in. Outside, a painter is touching up green paint on a window's bars. The men and women shuffle inside. The rooms are clean, but empty. Voices bounce off the bare walls and concrete floors. The people are beaming.

They did this themselves.

The house, previously unused and water-damaged, has been transformed as a temporary home for midwives. The renovation was one of their solutions for Dawanau's health problems. The people knew how important skilled birth attendants are for reducing the high rate of maternal mortality, but they also knew that trained midwives were reluctant to come to Dawanau because there was nowhere for them to stay before or after delivery. So the community decided to make an apartment for them.

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