Tough Questions: Health Education at Yomandu

“Hey guys.” Jalloh and Bori pulled up the path on a motorbike. The saddlebags were full of drugs and files – today we were educating in the same place as the outreach clinic.
“Hey Jalloh. How you sleep?” We clasped hands in the enthusiastic Sierra Leonean way. Katie did the same.
“Fine. But you know, we are going to Yomandu.” Oh. We were in Kania.
“Did plans change?”
“Yes. Because Sahr Bindi, he told both people the same time. And Ahmidu had to go with the tractor,”
“Oh. Sahr Bindi told both camps the same time.” We had specifically told him to arrange for us to meet the Kania community at 9am, and the Yomandu community at 2pm. But as long as we did the health education for both groups of people, it was fine.
“Yes, he did.” Jalloh was wearing a baggy, nylon Chicago Bears jacket and artistically pressed jeans. I was wearing shorts and a running shirt. “How will you go to Yomandu? Will you walk?”
“Well, we don’t know where it is.” I tried to be diplomatic.
“Mmm, I have to go back for Sasseko, and then I will come. It is just there, by the road.” There were only two roads, none particularly close, but Jalloh’s nonspecific hand motion was unhelpful.
“A will show you.” A small boy skipped ahead of Katie and me with a big grin on his face. Katie shrugged, and we followed him.
“See you, Jalloh!” Katie called, I waved. Then we followed our guide. He wasn’t gangly, but his head was all a little too big for his torso.
“Wetin na you nem?” I asked, walking behind him.
“Aboi,” he said, softly. I leaned closer. “Aboi!”
“Aboi. Me nem na Christopher. Glad to meet you.”
The path wound between small, square houses. Each one had a porch, and each porch was wrapped with a waist-high wall. The wall was always cement, but there was also always a lattice of holes in the wall to let air through. There were people around on most of the porches, and I murmured hello to most of them. Some of them were quite happy to ignore us, and that was a welcome change.
There was thick, light green grass on either side of the path. It grows tall, almost as tall as me, and the blades are wide, maybe three quarters of an inch. They’re not sharp, but they are fibrous. The path itself was tamped down red earth, smooth and well-worn. We passed a grayish-brown water hole that made me think of parasites. We also passed a meeting of people out front of a patent medicine store. “Aboi – why dey de have meeting?”
“Dey talk about nourish.”
“Oh, about nutrition, and malnourished children?”
“Yeah.”
“Okay...”
At this point we were walking on red-dirt road. Apparently there are red-dirt roads throughout Africa, and I think they are often lined with green, bushy grass. It’s a nice scenery that’s growing on me. Aboi and I walked in silence, but Katie was chatting up a couple of little girls that had started trailing her. Their names were Matellani and Marie F. Jimusa, I later learned. We also picked up a lady who thought that Aboi didn’t know where he was going. He did, but that was okay. At one point when we were walking down a very nondescript path between bushy grass, Katie said to me, “We totally would have been able to find our way...”
After a while we were walking through a big market area. There were lots of small tin sheets propped up with sticks serving as stands and booths, and lots of different vegetables laid out on blankets and platters. I could see green bananas, peppers of many different colours, yams, cassava, roasting corn, peanuts, cloth, fuel – standard Sierra Leone market fare. The bustle was a bit more subdued, and we got a lot more attention than usual. I guess white people are much rarer twenty minutes outside Koidu.
On the other side of the market was where we were scheduled to do our education. The village was called “Yomandu.” We were in a small flat area in front of one of the amputee camp houses, and some people brought out benches and plastic lawn chairs. Katie and I waited around, smiling at the growing crowd of children. Eventually Jalloh and Sasseko pulled up on the clinic motorbike. We said our hellos, and Jalloh sat down. Sasseko drove off to Kaniya to join the outreach clinic.
“Sit down, yeah?” Jalloh told me to sit down. Only Katie and him were sitting down, but there was a large crowd gathered.
“They won’t sit down until I do?” I asked, but I already knew the answer.
“No,” Jalloh switched into a lecturing tone, as he often does, “you see, they have habits, of respecting their elders, and they don’t sit down until...” I zoned out.
“I’ve never been respected as an elder before,” I smiled.
Some more community members arrived, including some we remembered from our previous visit to Yomandu. By the time Sahr Bindi arrived and told us we could start, there was a crowd of about fifty gathered around. And by around, I mean that we were in the center of the group. We’d tried to direct it so that we would be at one end of the crowd, but then more people gathered behind us. It wasn’t a big problem. Also, the benches had initially been placed in front of a small flowerbed, but the edge of the flowerbed could be a seat. So we moved the benches. It’s important to make sure there are both desirable and undesirable seats around, because the children will take the undesirable seats. If there are only good seats, the adults tell the children to leave. But the children have the best understanding of English, and the children are the ones with the most potential to put our education into action.
Jalloh began by introducing us and himself. “Okay. Na morning,” the crowd murmured good morning, “Me na student, me comot na Fourah Bay College na Freetown for de do internship na Dorma Amputee Clinic.” A tip for reading Krio: to conjugate a verb, you just put “de” in front of it. If you can’t tell what something means, say it aloud, and listen closely. For example, “comot” is “come out,” so it means “come from.” Jalloh looked at Katie expectantly.
“Me nem de Katie,” Katie always says “nem de” but I’m not sure why, “me na student, a comot na America.”
Sahr Bindi piped up, “Kumba Katie!” Every second daughter in Kono district is named Kumba. Everyone laughed; our Kono names are very popular.
“Me nem na Christopher, an me na student, a de study na America, but a comot na Canada. We comot na Amputee Clinic for de teach una (you) about health education.” Jalloh nodded, and then explained why we’d come in Krio. Then Katie gave the malaria module.
“Okay. So una de get malaria wey de mosquita, dey bet. So if me na mosquita...”
I looked around the crowd, caught the eye of as many people as I could, and returned their smiles. After giving these health education modules a few times, it seems like the best way to retain interest is to let the audience members know that you are paying attention and interested in them, and so I decided to try eye contact for this, even while Katie was speaking and not me. Aboi and Marie (his sister) were sitting across from us on the edge of the flower bed, along with fourteen or fifteen other children.
The health education went off without event until the family planning section. In the family planning section we talk about how smaller families (having fewer children) is better because it allows the family to focus more resources in terms of money for nutrition and school and time for attention on each child.
“I wan for ask, if dem small small girls, dem pikin, can use injection.”
The woman asking the question was middle aged and dressed in bright blue African garb. She held herself with confidence, and asked her question with a gregarious smile to the crowd. Jalloh translated, but I had understood the Krio. Katie and I conferred briefly, and the woman added some detail. Jalloh translated the detail, “She says, many women think that it is not safe to have the injection until they have two-three children. That if they have it before having two-three children, they will be infertile.”
“The injection, the condom, these methods are safe. It’s not true that you need to have two or three children before it will work. If it doesn’t work before two or three children, it won’t work after. You should consult your doctor, because every woman is different.” Katie gave her answer with a very concerned look on her face. Jalloh translated it. The woman nodded. I added something.
“It’s better to use condoms for the young girl because there are no chemicals. But using the injection is much better than getting belle (getting pregnant). Wey you done get belle, you could die.” The woman nodded again.
Katie kept forging ahead until the end of the family planning module.
“So, una de got any question?” Katie asked if anyone had questions. Jalloh repeated her, and added some Krio to explain.
“Me de got question.” A young man behind our right shoulder spoke. We turned. He told a long story about a girl and a guy, involving various attempts by the guy to get the girl to use contraception. First he tried condoms, and she refused, and then she agreed to use injections, but then when the boy took her for injections she again refused, and told him she had too negative a perception of these contraceptives to use them. Jalloh said,
“Okay, so he is asking about what to do when the girl won’t listen, won’t use contraception.”
“Jalloh, he told an entire story, and I didn’t understand all of it. What did he say?” I had understood enough to recognize that it wasn’t so simple.
“No, it’s just that, he wants to know how to convince her.”
“Jalloh, I want to know the entire story. He talked about trying different methods, and negative perceptions... Can you just translate what he said?” Katie nodded. We both understand Krio to a certain extent, but I’m much more willing to guess at what was intended.
“Okay, he just said, that the boy tried to get the girl to use condoms, and she refuse, and then he try to get her to use injections, and still she refuse, and what does he do?”
Katie responded. “So it’s very important that he talk to her, and that she understands that he is worried not just for her health but also for his, and it’s really best to use condoms. He needs to be very clear with her why it’s so important to prevent pregnancy, and really make it clear that he is concerned, and that it’s very important.”
Jalloh translated this. Then I added something. Usually Katie answers first, because she is very good at emphasizing communication and its role in resolving many of the questions that arise. My answers tend to be more direct and practical, and I try and say them in simple Krio/English mix that doesn’t require translation to be understood. Jalloh translates them anyway, but sometimes he adds a lot of words that disguises the crux of the message.
“If de woman, she no de listen to you, den you faut go talk na someone she does listen to, some elder. Or, you de go talk wit’ her friends, and tell dem why you worried, and ask dem to talk to her. You need to recruit allies, make sure she is hearing about why contraception is important from many different sources.”
When Jalloh translated, he added a line about taking the girl to the clinic or the doctor. The young man nodded and listened carefully with a concerned look on his face. Some of the best and most difficult questions at these health educations are asked by young men. They seem genuinely and passionately invested in helping their friends and family, and they give me hope for the future of Sierra Leone.
“A de got question.” While Katie was speaking, I had been watching all the people around me, counting heads and taking note of who was listening. A tall woman in an iridiscent solid blue dress had been standing directly behind us, but she had orbited around the group to the front, and was now asking a question. “You de work for send you pikin na school...” [Krio I didn’t understand] “but you no can walk wit you pikin na school, and dey go get belle, and den...” [Krio I didn’t understand] “but de man, e’ say why you no tell ‘im, why you hide de pikin belle?”
“Okay. So the woman,” Jalloh paused, “she says, what do you do when your husband accuses you, of hiding the girl’s pregnancy, but you didn’t know? He says, that you, the wife, you should know what your daughter is doing, and he gets angry, because you don’t know.”
My mind flashed, and I got distracted by what “gets angry” meant in this small village outside Koidu. Until two years ago, beating your wife was legal in Sierra Leone.
Then, my mind switched to a question we had fielded yesterday, from a local chief. He was tall, and dressed in a grey pea coat (let me remind you that this is Africa). He owned a motorcycle, and demanded that the meeting proceedings follow a certain protocol. And, he had set up the seating so that the women were out in the rain and the men were under the porch. This was his question:
“What do you do, when you know the daughter is pregnant, and you want to find the father, but that woman, the mother, she knows too, and they conspire against you! What do you do when she no de tell you who de papa? Wey you wife no de help you? Wetin you faut do?” He said the question with force, vehemence. It was backed up by the stern nodding of other men. Indeed, what do you do when women are constantly conspiring against you? I had let Katie answer that question. I didn’t know where to begin.
Now, we were facing the opposite question, the other perspective.
“It’s not only important to have a trusting relationship with your children,” in my mind’s eye, I blinked in disbelief at where it looked like Katie was heading with this. It’s difficult to tell a woman in a society with endemic domestic abuse that she needs to have a more understanding relationship with her husband. But at the same time, what else can we say or do? “It’s also important to have a trusting relationship with your husband. He needs to know that you care about the daughter, just like him, and you need to say ‘Why would I hide it? I am concerned above all for her health, it is most important, and we need to help her stay healthy and well.’ He has to know that driving the daughter and the mother from the house is not going to help the health of anyone.” Jalloh translated. Sometimes I worry that the feminist nuance in our answers is lost through his translations. On the other hand, sometimes he does a good job of making our answer culturally relevant. There’s no perfect system.
The woman nodded. Her eyes were deeply set, and her cheeks were drawn down such that her mouth’s neutral position was a frown. But when she had spoken, her features had animated significantly, and she had looked like a different woman. I wondered how she interpreted the answer, and whether it was useful to her.
There was a moment of general talking, and Katie and I glanced at each other to check if we should proceed. But Jalloh said, “She has another question.” The woman in iridiscent blue spoke again. I didn’t understand her question, but she was gesturing wildly. At one point she reached out and grabbed an eight year old boy on the head, and he looked sheepish. Everyone laughed. I think she said, “and dis de papa...” Jalloh translated the question, smiling.
“Okay, so she asks, she says that herself, she is a widow. Her husband is dead. And she has many children to take care of, but she can’t stay home and watch them. So when her daughter goes and gets pregnant, and the father is a little boy like him,” Jalloh pointed to the sheepish eight-year old. I laughed, but was not totally willing to think there was no kernel of truth to the question. “Then, what can she do? She has no money for the child.” I raised my eyebrows. Again, I had no idea. What do you do? It’s a tough question for a North American family, for a North American single mother. It’s perhaps a tougher question for a widow in a relentlessly patriarchal and poverty-stricken society.
“I don’t know, that’s a really tough question.” Katie nodded at me, concerned. She had a better answer than ‘I don’t know.’
“She needs to make her daughter understand that the family can’t afford to have that happen. She can’t say ‘don’t get pregnant,’ she needs to be honest with her daughter and say ‘we can’t afford it if you get pregnant, so you need to use proper contraception,’ and she needs to make that contraception available.”
Jalloh translated. Again, I think some of the nuance was lost. Sierra Leoneans often ask about how they are to discipline and control their children, and Katie’s answers all focus on imparting an understanding of the bigger picture to the children. They are idealistic responses, but from the perspective of changing behavior here in Sierra Leone, I think they are very appropriate. It’s true that not all children are able to understand what is important for their family, and sometimes even when they do, they don’t do it. But teaching children how to consider the bigger picture of what a family needs as opposed to what an individual wants is one way of helping the much-needed societal shift from considering very narrow, small short-term views to considering how one’s actions fit into the society as a whole.
Then, Katie proceeded with the teenage pregnancy section of the health education. By now there were around eighty men, women and children in the crowd. I was especially happy that Aboi and other children around his age (twelve) were in the audience, because teenage pregnancy was lurking dangerously near in their future, but they were still young enough to be both impressionable and ignorant. At the end of this section, there were a few more questions, although many of them had already been asked. It’s both troubling and reassuring that questions related to teenage pregnancy arise so spontaneously out of discussions of family planning.
“A de got question. Now, we de got dis human rights, wey you discipline you pikin, dey turn an go na police. Eh, eh?” It was the first woman again, the gregarious one. She asked the crowd for confirmation and got it.
In fact, this was almost identical to a question the motorcycle-riding, peacoat-sporting chief had asked yesterday. Apparently in Sierra Leone, many parents are worried that the increasing prevalence of human rights is being taken advantage of by their children, and that if they try to control their children in any way the children will go to the police. I have no idea whether this actually happens. Katie thinks that the kids probably just threaten, she doesn’t think they actually do. The police are not exactly a powerful or respected institution in Sierra Leone.
“Jalloh, tell them that we struggle with problems of how to control children like this, even in North America. Tell them we understand that it’s very hard, but that change needs to happen gradually. In the past, corporal punishment was acceptable, and was used, but now times are changing, and it is not always easy.” I tried for a bit of crowd appeasement. It seems to work well – if you throw in a “Jalloh, thank her for asking such a smart question,” or something similar, the audience laps it up. After Jalloh translated that, the woman nodded emphatically, and everyone else seemed to agree. Then Katie added something more substantive.
“It’s very important to have an understanding relationship with your children. Jalloh, can you tell them the story about the water, from yesterday?”
“Yes, yes, I know it.” The story about the water was how Katie answered the chief’s question yesterday. She created a hypothetical situation where a child refuses to get water, and the parent needs the child to do so. She said that instead of hitting the child, yelling at the child, or forcing the child, the parent should explain and educate the child from a young age that fetching water is important for the family.
Katie also said something very interesting to the chief that she didn’t say to the crowd at Yomandu. “I am from America, but my parents are Chinese. In China, corporal punishment was common. But in America, it is not allowed. So in America, if they see a Chinese child with bruises, then they think they are beating the child. So I have some Chinese friends where the parents beat their children, and some Chinese friends where their parents did not beat them. And from my experience it was much more efficient and better for the child as they grow up to not beat them.”
After this woman’s question, another woman, and then a man, confirmed the community’s desire for us to speak directly with the children. They seemed at a loss for how to stop teenage pregnancy amongst their children, and for how to get their children to listen to them. Katie and I mentioned that we are designing a peer education program to be implemented after we leave, but more importantly, we emphasized that change requires that teens hear the message of communication, contraception, and responsibility from many different sources. From parents, from teachers, from friends, from people like Katie and me. They seemed to understand.
Throughout the presentation, I kept turning around. During the health modules, Aboi and the other children had migrated behind me. There were about twenty of them. Every time I looked back, they would stare at me, faces expressionless. But if I gave them even a millimeter of smile, their eyes would open wide and their faces would dance with big grins. All these questions and all this education was for them.