Hard Choices: Malnutrition, Shame, and Courage

POST BY DANIELLE ALLYN // PUBLISHED MAY 2016

It’s about poverty. It’s about food insecurity. It’s about ignorance. It’s about neglect. It’s about shame. The solution is goat’s milk. The solution is maize porridge. The solution is breastfeeding.

Caregivers, farmers and families in Rwanda obtain nutrition and health knowledge from a variety of sources, from umudugudu (village) elders, to relatives, to individual observation and personal experience. Before joining GHI, caregivers possess a unique understanding of the problem of malnutrition, its causes, and corresponding treatment. These understandings often contain both fact and misinformation. In prioritizing nutrition education, GHI restores a critical missing link between agricultural productivity and household nutrition.

In the words of Theonile Uwamariya of Kayanga, Gasabo, “[malnutrition] is not a problem of poverty, it is a problem of lack of knowledge,” because, “you may have something to cook, but if you do not know how to cook a balanced diet, your child may still experience malnutrition.”

Aline Mukamana of Gasiza corroborates Theonile’s assessment and likewise challenges convention:

“It is possible for a child to be malnourished even if the family is not poor; if a family is unaware of what the right foods are. For wealthy people, they never believe that their children are malnourished. It is dangerous for their children. They may have money, but they do not know how to cook the right foods, and in the long run their children are the ones who end up suffering.”

Though Rwanda continues to make progress in eradicating malnutrition, over one-third of young Rwandan boys and girls do not consume a nutrient-diverse diet, undermining the body’s critical window for growth. Gardens for Health International works in the Musanze and Gasabo Districts of Rwanda. Our program reaches across eighteen sector-level government health centers. Approximately 40 families enroll in our nutrition and agriculture education program each triennial growing season, totalling 120 families per health center annually, or roughly 2,160 program-wide. According to the Rwanda Housing and Census Project, 10.5 million people call Rwanda home. Of this 10.5 million, 1.6 million are under the age of 5. Using the national chronic malnutrition rate of 38%, this means that 608,000 young Rwandan boys and girls currently lack the nutrient diversity necessary to promote growth.

For GHI’s 2016A season, 2,127 caregivers across our four partner communities in Gasabo District sought enrollment in the program. In Gasabo, we invited 160 of these families to enroll -- 7% of the total target population. The need for comprehensive nutrition intervention at the household level is clear and, while GHI, the Government of Rwanda, and others continue to make progress, much of this need remains unmet. Yet GHI Field Staff extend program invitations discreetly, compassionately, and with an intimate understanding of the localized cultural barriers to enrollment (some families are reluctant to join the program). Why?

“If you have a malnourished child, the community thinks that you are poor. Before joining GHI, I would think that a mother with a malnourished child must be poor. Anytime I saw a child who was malnourished, I found that most of these families were poor. I would not think that a person that had food to eat and to cook could experience malnutrition. At first I felt shame at bringing my child to the program.” (Theonile Uwamariya, GHI Partner, Kayanga, Gasabo)

“Almost all of my neighbors came to know that Patience [my daughter] was experiencing malnutrition. I viewed this as a problem, because they were talking about me. I am poor, so it was a heavy burden on me to know that people were talking about me.” (Joseline Nyizayimana, GHI Partner, Gasiza, Musanze)

Poverty indicators are culturally specific and varied; in Rwandan communities such as Theonile’s and Joseline’s, many people draw connections between undernutrition and poverty. In the United States and other industrialized nations, however, research continues to corroborate the correlation between a lack of economic resources and obesity. Universally, poverty’s physical hardship is exacerbated by social stigma. For many GHI partners, shame may be especially pronounced due to a family’s role in food production: 

"When I first learned [that we had been invited to enroll], I was unhappy because they said that my child was malnourished. This was a shame for a father like me, because I have food in my garden, I have a cow and can give him milk.” (Leonard Baziruhoze, GHI Partner, Kinigi, Musanze)

Among farm families, male caregivers in particular often exhibit reluctance to confront children’s nutrition status. Partner mother Aline Mukamana of Gasiza notes that conversations with GHI Field Staff helped assuage her husband’s enrollment-related anxiety. 

“I was unhappy,” said GHI Partner David Sebazungu of Kabere, Musanze. “I was angry. I asked, ‘How is my child malnourished when we have food at home?’”

After participation in the GHI program, however, both men and women report an evolution in attitudes toward malnutrition, its causes, and its treatment. In all cases involving multiple caregivers, enrollment decisions reflect negotiated family discussions. In some cases, male caregivers advocate proactively for child health, encouraging their spouses to enroll in the GHI program. 

“By the time that Theonile [my wife] told me about Joshua’s [our son’s] condition, I said, ‘No, go ahead [and enroll]. These trainings are something good for our family. They will be helpful for our children and helpful for us. No matter what, we have to find a solution.’”

Families experience varying levels of shame and paralysis upon their child’s diagnosis. Some caregivers report negligible levels of shame, while others speak openly about the difficult social environment in which a child’s diagnosis occurs. Still others acknowledge shame and accompanying hesitation, and yet choose to confront these feelings directly in the hopes of improving the health of not only their own children but of others in their communities.

“I did not try to hide Joshua’s condition. I thought that maybe there were others out there with the same problem, so I told them to get their children tested for malnutrition. Many who went, who thought that their children would never experience malnutrition, found that their children were also sick. I told one mother to take her child to get tested, and she said, ‘This is a waste of time. This is only for people who have nothing else to do.’ I told her that if she was unwilling to go, that she should give me her child and I would take her to the HC. When I did I found that the child had malnutrition. I returned and told the mother, ‘You see, this is important. The child was sick and you did not know.’”

Women like Theonile Uwamariya refuse to assume passive roles in nourishing their children. They reject default positions as bystanders to the wellbeing of their communities. When Theonile chose to reveal the reality of her family’s experience, she did not make this decision because it was easy. She made the decision because it was important, and she was courageous.

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Amahitamo agoye: imirire mibi, ipfunwe, no gushirika amanga

Ni ubukene. Ni ukutihaza mu biribwa. Ni ukutamenya. Ni ukutagira icyo witaho. Ni ipfunwe. Igisubizo ni amahenehene. Igisubizo ni igikoma cy’ibigori. Igisubizo ni ukonsa.

Abantu barera abana, abahinzi n’imiryango yo mu Rwanda bahabwa ubumenyi ku mirire myiza n’ubuzima, uhereye ku rwego rw’umudugudu, abayobozi, abo bafitanye isano, ibyo babwirwa n’abantu ku giti cyabo, cyangwa se ibyababayeho ubwabo. Mbere y’uko babarurwa muri GHI, abarera abana baba bafite ukuntu kwihariye baba bumva ikibazo cy’imirire mibi, ibiyitera, ndetse n’uburyo bwo kuyivura. Ibyo baba bizi akenshi biba birimo ukuri n’amakuru atari ukuri. Mu rwego rwo kongera ubumenyi mu mirire myiza, GHI igaruka ku ihuriro risa n’iribura hagati y’umusaruro w’ibiribwa n’imirire myiza y’urugo.

Mu magambo ya  Theonile Uwamariya w’ i Kayanga muri Gasabo,

“[imirire mibi] si ikibazo cy’ubukene, ni ikibazo cy’ubumenyi buke,” kubera ko, “ushobora kuba ufite ibyo guteka, ariko iyo utazi gutegura indyo yuzuye, umwana wawe n’ubundi aranga akagira imirire mibi.”

Aline Mukamana wo mu Gasiza yunga mu rya Theonile, bose bemeza ko imbogamizi ari zimwe: “Birashoboka ko umwana agira ibibazo by’imirire mibi n’aho yaba aturuka mu muryango udakennye; mu gihe umuryango we udasobanukiwe ibiribwa bya ngombwa wamugaburira. Ku bakire, ntago bajya bemera ko abana babo bafite ibibazo by’imirire mibi. Ni ikibazo gikomeye ku bana babo. Bashobora kugira amafaranga, ariko batazi gutegura indyo iboneye, kandi iyo bibaye hagashira igihe kirekire birangira abana ari bo babihuriyemo n’akaga.”

N’ubwo u Rwanda rukomeje gutera intambwe mu kurandura imirire mibi, hejuru ya kimwe cya gatatu cy’abana b’abanyarwanda b’abakobwa n’abahungu bato ntago barya indyo inyuranye kandi yuje intungamubiri, bikababuza gukura ku mubiri.  Gardens for Health International ikorera mu turere twa Gasabo na Musanze two mu Rwanda.Gahunda yacu ikorana n’ibigo nderabuzima cumi n’umunani bya leta.Imiryango igera kuri 40 ibarurwa muri gahunda yacu y’amahugurwa y’imirire myiza n’ubuhinzi buri gihembwe cy’ihinga; ubwo ni imiryango 120 yose hamwe ku kigo nderabuzima buri mwaka cyangwa se ugereranyije igera ku 2.160 muri gahunda yose. Abagera kuri 10.500.000 batuye u Rwanda, muri 1.600.00 bari munsi y’imyaka 5. Ukoresheje ikigereranyo cy’imirire mibi y’akarande ku rwego rw’igihugu cya 38%, ibi bisobanuye ko abana bato b’abanyarwanda b’abahungu n’abakobwa bagera ku 608.000 batabona indyo yuzuye inyuranye ituma bakura neza.

Mu gihembwe 2016A cya GHI, ababyeyi 2.127 batuye mu muryango mugari dukoreramo mu karere ka Gasabo bifuje kubarurwa muri gahunda yacu. Muri Gasabo, twabaruye imiryango 160 Gasabo— ingana na 7% by’abo twateganyaga. Kwifuza gusobanukirwa imirire ku rwego rw’ingo ni ikintu kigaragara ko gikenewe; mu gihe GHI, leta y’u Rwanda n’abandi bakomeje kubikurikirana ariko ibi byifuzo ntibirabasha gusubizwa ngo bikemuke.  Ibi ntibibuza abakozi ba GHI bakorera mu muryango mugari kurenga ubutumire butangwa na gahunda bakagenda bakegera imiryango, mu ibanga, babikorana gukunda gufasha ababaye, kandi biyumvisha bimwe mu byabuza ababyeyi kubarurwa muri gahunda yacu  (imwe mu miryango ntago iba ishaka kwitabira gahunda). Kubera iki?

“Iyo ufite umwana ufite ibibazo by’imirire mibi, abantu batekereza ko uri umukene. Mbere yo kujya muri gahunda ya GHI, Natekerezaga ko umubyeyi wese ufite umwana uri mu mirire mibi agomba kuba ari umukene.  Igihe cyose nabonaga umwana uri mu mirire mibi, nasangaga akenshi ava mu muryango ukennye. Ntago nashoboraga gutekereza ko umuntu ufite ibyo kurya, umuntu ufite ibyo guteka yahura n’ibibazo by’imirire mibi. Mu minsi ya mbere numvaga mfite ipfunwe ryo kujyana umwana wanjye muri gahunda.” (Theonile Uwamariya, umufatanyabikorwa wa GHI, Kayanga, Gasabo)

“Hafi y’abaturanyi banjye bose bamenye ko umukobwa wanjye Patience yari afite ibibazo by’imirire mibi. Ibi nabibonye nk’ikibazo, kuko baramvugaga. Ndi umukene, bityo byari umutwaro undemereye kumva ko abantu bamvuga.” (Joseline Nyizayimana, umufatanyabikorwa wa GHI, Gasiza, Musanze)

Ibipimo by’ubukene biratandukanye kandi birihariye ukurikije umuco; mu miryango migari yo mu Rwanda nk’uwa Theonile n’uwa Joseline, abantu benshi bahuza imirire mibi n’ubukene. Muri America no mu bindi bihugu byateye imbere, nyamara, ubushakashatsi bukomeza  kwemeza isano riri hagati yo kutagira ubushobozi n’umubyibuho udasanzwe. Ku isi yose, ibibazo by’ubukene birushaho kuba bibi kubera akato gakorwa n’abagize umuryango mugari. Kuri benshi mu bafatanyabikorwa ba GHI, bashobora kuvugwaho ikimwaro bitewe n’uruhare umuryango ugira mu guhaha no gutegura ibyo kurya: 

“Nkimenya ko batubaruye muri gahunda narababaye kuko bambwiye ko umwana wanjye afite ikibazo cy’imirire mibi. Ibi byari ikimwaro ku mubyeyi w’umugabo nka njye kuko mba mfite ibyo kurya mu murima kandi mfite inka nshobora kumukamira amata.” (Leonard Baziruhoze, umufatanyabikorwa wa GHI, Kinigi, Musanze)

Mu miryango y’abahinzi-borozi, abagabo bita ku bana bakunze kwanga guhangana n’ibibazo by’ubuzima bw’abana ku bijyanye n’imirire. Umwe mu babyeyi dukorana Aline Mukamana wo mu Gasiza avuga ko uburyo abakozi ba GHI bakorera mu muryango mugari baganirirje umugabo we bwamufashije gucururuka ashira umuhangayiko yari afite awuterwa no kuba barabaruwe muri gahunda.

“Narababaye,” David Sebazungu umufatanyabikorwa wa GHI i Kabere, Musanze. “Nararakaye. Narabazaga nti, ‘Ni gute umwana wanjye yagira ikibazo cy’imirire mibi mu gihe duhorana ibiryo mu rugo?’”

Nyuma yo kwitabira gahunda ya GHI nyamara, bose hamwe ari abagabo n’abagore batangaza ko habayeho impinduka mu buryo batekerezaga ndetse banafataga imirire mibi, impamvu ziyitera ndetse no mu buryo bwo kuyivura. Mu bibazo byose bisaba ko abantu batandukanye bita ku mwana bafatanya gukemura, ibyemezo bafata byo kwitabira ibarura bigaragaza ko babiganiraho hagati mu muryango. Hamwe na hamwe, abagabo bita ku bana barabavuganira kugira ngo bigire icyo bitanga bagire ubuzima bwiza, bagakangurira abagore babo kwitabira gahunda y’umurima w’ubuzima.

“Igihe umugore wanjye Theonile yambwiraga uko umwana wacu Joshua ameze, naravuze nti, ‘Oya, komeza ugende wibaruze. Aya mahugurwa yaba meza ku muryango wacu.  Azafasha abana bacu kandi natwe ubwacu azadufasha. Icyaba cyose, tugomba kukibonera umuti.’”

Imiryango ibangamirwa n’ipfunwe n’ibindi bintu bitandukanye  ku buryo bibabuza kujya gusuzumisha abana babo.  Bamwe mu barera abana bagaragaza ko biteye ikimwaro ku rwego rwo hasi, mu gihe abandi bavuga beruye imbogamizi ziterwa n’abantu baba bari aho bapimira. Hariho kandi n’abandi bemera ko biteye ikimwaro ariko nanone bakiyemeza guhangana n’ayo marangamutima uko biri kose bafite icyizere cyo guteza imbere ubuzima bwiza bw’abana atari  ukuvuga abana babo gusa ahubwo abana muri rusange mu miryango migari baturukamo.

“Ntago nigeze mpisha uko Joshua yari ameze. Natekereje ko ahari hari abandi bana bafite ikibazo nk’icye, bityo nasabye abandi babyeyi ko nabo bazana abana babo bakabasuzuma imirire mibi.  Benshi mu baje, kandi batekerezaga ko abana babo batahura n’imirire mibi, basanze abana babo nabo bafite ibibazo by’imirire mibi.  Hari umubyeyi umwe nasabye ko yajyana umwana kumusuzumisha, hanyuma arambwira ati, ‘Ibyo ni uguta igihe’. Ibyo bikorwa gusa n’abantu badafite ikindi bakora.’ Namubwiye ko niba yumva adashaka kujyayo, ko yampa umwana we nkamujyana ku kigo nderabuzima. Nyuma mbikoze nasanze umwana we afite ibibazo by’imirire mibi.  Nasubiyeyo maze mbibwira nyina, ‘Nti urabona, ibi ni ingenzi. Umwana yari arwaye kandi ntiwari ubizi.’”

Abagore nka Theonile Uwamariya banga guterera iyo ngo ntibagire icyo bakora mu mirire y’abana babo. Banga kuba indorerezi ku birebana n’imibereho myiza mu miryango migari baturukamo. Iyo Theonile ahisemo kwerekana ku mugaragaro imibereho y’umuryango we, ntago aba yarafashe uyu mwanzuro kuko ari ibintu byoroshye. Yafashe uyu mwanzuro kuko ari ingirakamaro, kandi yagize ubutwari.