The Trouble With Poverty, The Second Mile Approach

A few days ago, while putting together a status for our Facebook page, I found myself captivated by one family in particular. 

To learn more about them I took a quick spin through our electronic database, chasing the answer to one question after another and marking my journey with mental bullets.  

For the next 24 hours, those mental Post-Its persisted to flash in my brain like internet pop-ups, beckoning to be made into a story that could be shared. To buy time, I wrote them down in a notebook. But now here I am, not two days later, engaging in the most permanent form of note-taking: blogging.

I don't even have to open my notebook because this story — this family stuck themselves to my heart. 

Kely, the boy, is 8 years old. He recently recovered from malnutrition at Second Mile Haiti alongside a few other kids his age. 

We almost always have at least one "big kid" recovering at the center amongst a dozen or more smaller children less than half their age. They look out out of place as they walk circles around one-year-olds who can't sit, two-year-olds who can't stand, and three-year-olds who can't talk. Children who develop malnutrition in the first two years of life often present with significant developmental delays. Because the big kids developed malnutrition later in life, after these milestones were already achieved, they can walk and talk. Yet somehow, it's the babies rolling on the floor and grabbing for toes and noses that appear more alive than their waist-high counterparts. 

My method for categorizing these children isn't particularly scientific, but for clarity's sake — big kids are walkers and talkers and they are at least 5-years-old. 

Their presence at the center is as fun as it is heavy. 

Everyone seems to enjoy watching them change color and come into their personality. At arrival, they are ashen, sullen and silent. But as antipyretics and antibiotics work to calm their fevers and fight their offenders, their eyes lift and clear. With the energy that comes from therapeutic nutrition, their too small hands lift next, slowly but with purpose, for high-fives and fist-pumps. And finally, the corners of their mouths lift. They have something to smile about. 

Kely (8), Ednica (5), Jameson (6)

Kely (8), Ednica (5), Jameson (6)

These glimmers of childlike behavior are like strings we pull to aid in the unravelling of their condition. Within weeks, nourished becomes their new identity. We find out they are sweet and sarcastic, curious and naughty, eager to learn, and suckers for play. They are kids, afterall. 

Jameson (6), Wilkend (11)

Jameson (6), Wilkend (11)

The heaviness is felt only when we first see them, when we ask their parents when they were born and discover that their age does not match their shape. Malnutrition on a big kid isn't any worse than than malnutrition in an infant or toddler. But we are more surprised because we see it less often. Malnutrition in a big kids feels especially unnerving because, in this line of work, we have become desensitized to malnutrition in babies and young children. It is common.  

As I sort through recent graduation photos, I am reminded that December was a heavy month for "big kids."

Since using the word "heavy" doesn't sound very impressive, I decide to look at the actual numbers.

I open the database and perform a search. I search for admission year: 2016 and date of birth < 2012. These parameters will give me the names of children admitted to the center in the year 2016 who were at least 4 years old when we met them. The walkers and the talkers. 

When I see the list, one name is noticeably missing. 

Kely Valestin isn't listed. 

At 8 years old, Kely is the fourth oldest child to recover at Second Mile Haiti. He is definitely a big kid. 

I begin to suspect that Kely's caregiver did not know his birthdate. 

In fact, I'm certain this is true because I designed our system and the birthdate field has always been more trouble than it's worth. When a birthdate is entered, the child's age is generated automatically. But this new "age" box is not modifiable. 

We can't write "roughly 8, or maybe 9 — hard to say..." in this space. 

This is problem, of course, because not every caregiver can provide an accurate date of birth for their child. This is most often true when an aunt or a grandmother becomes the child's caregiver after a mother's death, or when the mother herself is cognitively incapacitated.

I flip to Kely's chart, and then click on the tab marked "Justine Valestin", his caregiver's first and last name. It reads: "Relationship to child: Tant (Aunt)." 

My suspicions are confirmed, but now I have some new questions: Aside from being his aunt, what is her realationship to Kely? Is she a "cool" aunt? Does she have children of her own? Is Kely's mother deceased or just missing? 

But first, I need to know this boy's age, this "big kid" in a sweater made for a baby. 

Kely, during his 3rd week of rehabilitation (Second Mile Haiti)

Kely, during his 3rd week of rehabilitation (Second Mile Haiti)

I knew that if his aunt had any idea of his age, it would be recorded in the nursing notes. 

I click back over to Kely's file, scroll to the first nursing entry, and find what I was looking for. 

"This child came with his aunt at the referral of another mother. The aunt says he is 8 years old but she does not know his date of birth. She does not have all of his details. His mother and father are dead. She took him in when he was 4 years old. He is 16.21 kg, 117 cm... He is calm. Small...We admit them to the center."

Kely sitting before.jpg

Four years with his aunt. This makes sense. I'd see the pair interact and they seemed close. 

Back on the caregiver page, I learn that Kely's mother did die. She was in a moto accident while pregnant with her third child. After the accident she was taken to the hospital. She gave birth to the baby, but died shortly thereafter. 

Was it the accident that killed her? Was it childbirth? Was it a matter of insufficient medical facilities or inadequate care? Was there no blood to save her? 

I have many more questions than I'll ever have answers. 

I learn that Kely's aunt is a street vendor. In the past, she sold food and cosmetic products. And for awhile she sold peanut butter and bread in the morning, and rum in the evenings. She always sells food from her garden when she has it. But charcoal, at a profit of $9 each month, earns her the most cash. 

She has four children (including Kely) and the two that are school-aged attend school. She pays the tuition. She lives alone with the children. 

I'm curious about their ages so I flip to a different template which provides these details. My eyes catch the portion of the questionnaire that addresses childhood mortality. 

Through past analysis of this information we learned that 46% of caregivers — that is, the aunts, mothers, and grandmothers who arrive at Second Mile with a child who is near-death — have already lost at least one child. 

Juslaine had already lost three. 

*Fill if history of deceased children: 

Age of death        Cause of death

1. 18 months         Vomitting and diarrhea

2. 24 months        Diarrhea and vomitting 

3. 24 months        Diarrhea and vomitting 


I'm hit with something, a reminder maybe? Can you get hit with a reminder? 

Regardless, I'm jolted into remembering that the program is less about the Kely's and more about the Juslaine's. Apart from the most extreme cases, the kids we see are pretty resilient and their treatment is pretty straightforward. But our program, with all of it's classes and idosyncracies, was designed so that women like Juslaine don't ever have to bury any more children — at least not for reasons like diarrhea and vomiting. 

Kely's aunt wipes his nose, during a nutrition demonstration

Kely's aunt wipes his nose, during a nutrition demonstration

Second Mile is actually less about recovery and more about preventing the need for a future recovery. Daily education classes let mothers know that someone is investing in them. Pre and post education tests help them feel confident in what they have learned.

Juslaine (center) with Kely and other mothers as they prepare to leave the center for the weekend&nbsp;

Juslaine (center) with Kely and other mothers as they prepare to leave the center for the weekend 

Our nurses spend time daily with each mother until diarrhea and vomiting stop meaning death and start to trigger actions: Hygiene, Hydration, Hospital. 

By the end of it, every caregiver gets it. She understands how malnutrition works, but also how nutrition works. She's well aware of the dangers that can make her children sick and she knows how to prevent these illnesses. She learns to identify health emergencies and she knows what to do about them.

And during the weeks of recovery, where children often get worse before they get better, she has plenty of time to practice approaching the Haitian Healthcare System — her local hospitals and clinics — confidently and in time. 

But health has a cost. Food isn't free and neither is transportation.

We design the program with her success in mind, as best we know how.

We discharge the family only when the child has fully recovered. Our gardens provide caregiviers with seeds and seedlings so that nutritious greens, are always available. The business program provides an income-earning opportunity for each caregiver because we all need cash.

Cash for emergency trips to the hospital...

Cash for medicine when sick... 

Cash for life.

Instead of borrowing money to pay for the morgue, she will have the money to keep her child out of it. 

I have one more thing to look up. 

I head back to the database to check out Juslaine's test scores. I remember seeing that she had never been to school and could neither read nor write. I check her literacy exam first, the one we have caregivers complete when they first arrive at Second Mile. 50% of caregivers can read and write but for those who can't our resident teacher is a ready and willing tutor. 

Caregivers at Second Mile Haiti take part in afternoon literacy class.

Caregivers at Second Mile Haiti take part in afternoon literacy class.

Sure enough, the page was blank. 

I flip to her exit-test. 

I find a photo of piece of paper, evidence of Juslaine's progress. Shaky but legible, she has written her name. 

But this isn't the most important exam. I am more interested in her health education test scores. 

A score of 24% is cited next to her pre-test, taken day one. 88% is listed next to the post-test, taken on her last day at the center.

After 8 weeks of education, that's a difference of 64%

I call Kerline, the Manager of the Recovery Program, to learn more about Juslaine's journey. 

I'm not surprised by what she has to stay: 

"Kely's aunt was exemplary. She didn't give us any trouble. She was always on time, even though it was a sacrifice for her to be here. She found someone to look after her charcoal business and someone to look after her other children. 

She was attentive in all of the classes even though she struggled to comprehend the material and was often unable to answer questions about the topics. She told us she had a "tough head" and difficulty learning. We persisted and so did she. We were shocked when she did so well on the final exam. She was too.

She couldn't stop smiling on her last day. We asked her about it. And she said 'I can't not smile after all you've done for me, smiling is the biggest thing I can do.'

Juslaine and Kely Valestin&nbsp;

Juslaine and Kely Valestin 

Kely and his Aunt before and after rehabilitation for Severe Acute Malnutrition

Kely and his Aunt before and after rehabilitation for Severe Acute Malnutrition

This true, too true, story of Kely and Juslaine might serve as a launching board for a discussion on poverty & health inequalities, education & economics, or child psychology & family preservation. 

We could talk about how Kely didn't have to go to an orphanage when his mother died because he already had a family, but that the trauma of losing a loved one might have something to do with his poor health now. We could talk about his mother's death, how death by motorcycle might make more sense than death by childbirth but that for women in Haiti the liklihood of the later is 1 in 245. 

We could talk about how Juslaine's struggle to earn money and to raise healthy children is all mixed up in her parent's poverty and the fact that she didn't have educational opportunities as a girl. We could speculate and say that she prioritizes her children's education as a result but that sending Kely and her oldest daughter to school, comes with sacrifices in other areas. 

Kely (8) and Jameson (6) practice their school lessons while recovering from Severe Acute Malnutrition at Second Mile Haiti

Kely (8) and Jameson (6) practice their school lessons while recovering from Severe Acute Malnutrition at Second Mile Haiti

We could talk about the injustice of death by diarrhea — and the systemic disadvantages that make it so easy for one mother to lose three children in the exact same way. 

We could talk about all the healthful ways an 8-year-old could be spending his time, and how eating therapeutic food at a malnutrition center shouldn't have to be one of them. 

Kely with Medika Manba (RUTF)&nbsp;produced by Meds and Foods for Kids (Cap Haitien). Typical treatment 8-10 weeks.

Kely with Medika Manba (RUTF) produced by Meds and Foods for Kids (Cap Haitien). Typical treatment 8-10 weeks.

But since the issues intersect, why don't we just say that. The issues intersect and the problems are as inter-related as the solutions should be. 

At Second Mile we strive to be holistic in our approach. And it is the very least we can do. 


Written by Amy Syres

Program Director, Second Mile Haiti


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