Peace Corps/Niger Community Health Agent Pre-Departure Country & Technical Training Summer 2007

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27 June 2007 Welcome to our American friends who have made the choice to serve for two years in a hard-core country called Niger. Once you become a Peace Corps Volunteer you will have to face many challenges, especially in the health sector. You will hear over and over that Niger is ranked 177 out of 177 on the most recent United Nations Human Development Index with indicators of poor health range from high rates of malnutrition, maternal mortality, diarrhea, malaria and conjunctivitis, as well as significant rates of infection with sexually transmitted diseases (STDs) including AIDS. You will read grim statistics pertaining to the health sector such as: the child mortality rate among children under 5 is 152 per 1,000, or say, for every four babies born alive, at least one will die before age 5; Niger’s maternal mortality rate – more than 1 death per 100 live births – is the highest in the world; Niger’s fertility rate (7.8), is among the highest in the world and is far higher than the sub-Saharan African average of 5.4. These statistics should not deter you from your mission to help Niger fight against poverty and contribute to the improvement of the health status of its populations. You will be expected to help alleviate and reduce Niger’s most common health problems by encouraging behavioral changes such as seeking preventive and treatment from a health clinic (e.g., pre- and post-natal check-ups and immunizations), hand washing, and administering home remedies for conjunctivitis or dehydration. Peace Corps/Niger collaborates with the Government of Niger’s Ministry of Public Health (MOPH) in addressing the country’s basic health care issues. Volunteers work with community leaders, local community groups (e.g., women’s small-business associations, youth groups, men’s groups), health clinics (Centres de Santé Intégrés), and one-on-one with individual community members to raise awareness about behavior changes that can improve health and prevent disease. Peace Corps Niger’s health project includes three primary goals: • • • Improving household nutritional status. Improving maternal and infant health. Improving communities ability to prevent and treat disease.

This document you will be given outline some aspects of Peace Corps/Niger health project, including not only specific objectives and target numbers for each of the above goals, but also a look at how this project was developed; relevant historical background; specifics on project strategy, implementation, and monitoring and evaluation; and finally project management, including volunteer support and training. We really trust that you have already started learning your Zarma and Hausa languages on “My Toolkit” at www.peacecorps.gov. We also definitely expect you to read the documents that we are sending prior to your coming to Niger, as you will be “tested” on the knowledge pulled out from the documents. We look forward to your contribution to improving the health and nutrition of men, women and children in Niger and will do our best to provide the best training possible to prepare you for your two years of service.

Gaston KABA Associate Peace Corps Director Health

Souleymane MAINA Program and Training Assistant-Health

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Table of Contents
Cover page Greetings from Niger Table of Contents Bibliography Country profile Main public health issues and concerns Water Supply and Sanitation Major water and Sanitation related illnesses in Niger Maternal and infant health Family planning Malnutrition HIV/AIDS in Niger What does a Community Health Volunteer do? For more resources on health in Niger please visit: www.unicef.org/infobycountry/niger. www.unfpa.org/profile/niger.cfm www.who.int/countries/ner/en/ www.fews.net/resources/gcontent/pdf/ www.wfp.org/country_brief/indexcountry www.fews.net/resources/gcontent/ www.doctorswithoutborders.org/news/malnutrition/ 1 2 3 4 5-15 16-17 18-20 21-22 23-27 28-36 37-42 43-44 45

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Bibliography Contry profile The World Health Organization and UNICEF, Joint Monitoring Programme for Water Supply and Sanitation, January 2005 (http://www.childinfo.org/areas/water/status.php). Main public health concerns Health actions in crises http://www.who.int/hac/crises/ner/background/profile/en/index.html Water Supply and Sanitation Peace Corps Niger technical manual for community health volunteers Major water and Sanitation related illnesses in niger Peace Corps Niger technical manual for community health volunteers Maternal and infant health Peace Corps Niger technical manual for community health volunteers Family planning Peace Corps Niger technical manual for community health volunteers Malnutrition Peace Corps Niger technical manual for community health volunteers HIV/AIDS in Niger Peace Corps Niger technical manual for community health volunteers

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COUNTRY PROFILE OFFICIAL NAME: Republic of Niger The Republic of Niger is a landlocked country in the Sahel region of West Africa. Niger is bordered by Algeria, Mali, Libya, Burkina Faso, Benin and Nigeria1. The country is plagued by frequent droughts which adversely impact the subsistence–based economy of its large agrarian population. GEOGRAPHY Area: 1,267,000 sq. km (490,000 sq. mi.); about three times the size of California. Cities: Capital--Niamey (pop. approx. 1 million). Other cities--Tahoua, Maradi, Zinder, Diffa, Dosso, Arlit, and Agadez. Terrain: About two-thirds desert and mountains, one-third savanna. Climate: Hot, dry, and dusty. Rainy season: June - September. GOVERNMENT Type: Republic. Independence: August 3, 1960. Constitution: The constitution of December 26, 1992 was revised by national referendum on May 12, 1996 and again by referendum on July 18, 1999. Branches: Executive--president and prime minister. Legislative--unicameral National Assembly (113 MPs). Judicial--Constitutional Court, Supreme Court, Court of Appeals, High Court of Justice. Political parties: Seven are represented in the National Assembly. Suffrage: The constitution provides for universal suffrage for Nigeriens aged 18 or older. Administrative subdivisions: Eight regions subdivided into 36 districts (departments) and 265 communes (local councils). Central government budget: $320 million. PEOPLE Nationality: Noun and Adjective--Nigerien(s). Population (2005 EST.) 13,957,000. Annual growth rate1 (2005): 3.4%. Ethnic groups: Hausa 56%, Djerma 22%, Fulani 8.5%, Tuareg 8%, Beri Beri (Kanuri) 4.3%; Arab, Toubou, and Gourmantche 1.2%. Religions: Islam (95%); remainder traditional and Christian. Languages: French (official), Hausa, Djerma, Fulfulde, Kanuri, Tamachek, Toubou, Gourmantche, Arabic. Education: Years compulsory--6. Attendance--45% (men), 31% (women). Literacy (2004 est.)--28.7%. Health: Infant mortality rate (2000)--152/1,000. Life expectancy--45 yrs. The largest ethnic groups in Niger are the Hausa, who also constitute the major ethnic group in northern Nigeria, and the Djerma-Songhai, who also are found in parts of Mali. Both groups, along with the Gourmantche, are sedentary farmers who live in the arable, southern tier of the country. The remainder of Nigeriens are nomadic or semi-nomadic livestock-raising peoples--Fulani, Tuareg, Kanuri, Arabs, and Toubou. With rapidly growing populations and the consequent competition for meager natural resources, lifestyles of agriculturalists and livestock herders have come increasingly into conflict in Niger in recent years.

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Niger's high infant mortality rate is comparable to levels recorded in neighboring countries. However, the child mortality rate (deaths among children between the ages of 1 and 4) is high (152 per 1,000) due to generally poor health conditions and inadequate nutrition for most of the country's children. Nonetheless, Niger's fertility rate (7.8%), is among the highest in the world, and is far higher than the sub-Saharan African average of 5.4. It means that two-thirds (66.7%) of the Nigerien population is under age 25. Primary school net enrollment rate is 45% for men and 31% for women. Additional education occurs through Koranic schools. HISTORY Considerable evidence indicates that about 600,000 years ago, humans inhabited what has since become the desolate Sahara of northern Niger. Long before the arrival of French influence and control in the area, Niger was an important economic crossroads, and the empires of Songhai, Mali, Gao, Kanem, and Bornu, as well as a number of Hausa states, claimed control over portions of the area. During recent centuries, the nomadic Tuareg formed large confederations, pushed southward, and, siding with various Hausa states, clashed with the Fulani Empire of Sokoto, which had gained control of much of the Hausa territory in the late 18th century.

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In the 19th century, contact with the West began when the first European explorers--notably Mungo Park (British) and Heinrich Barth (German)--explored the area searching for the mouth of the Niger River. Although French efforts at pacification began before 1900, dissident ethnic groups, especially the desert Tuareg, were not subdued until 1922, when Niger became a French colony. Niger's colonial history and development parallel that of other French West African territories. France administered its West African colonies through a governor general at Dakar, Senegal, and governors in the individual territories, including Niger. In addition to conferring French citizenship on the inhabitants of the territories, the 1946 French constitution provided for decentralization of power and limited participation in political life for local advisory assemblies. A further revision in the organization of overseas territories occurred with the passage of the Overseas Reform Act (Loi Cadre) of July 23, 1956, followed by reorganizational measures enacted by the French Parliament early in 1957. In addition to removing voting inequalities, these laws provided for creation of governmental organs, assuring individual territories a large measure of self-government. After the establishment of the Fifth French Republic on December 4, 1958, Niger became an autonomous state within the French Community. Following full independence on August 3, 1960, however, membership was allowed to lapse. For its first 14 years as an independent state, Niger was run by a single-party civilian regime under the presidency of Hamani Diori. In 1974, a combination of devastating drought and accusations of rampant corruption resulted in a military coup that overthrew the Diori regime. Lieutenant Colonel Seyni Kountche and a small group of military ruled the country until Kountche's death in 1987. He was succeeded by his Chief of Staff, Brigadier General. Ali Saibou, who released political prisoners, liberalized some of Niger's laws and policies, and promulgated a new constitution. However, President Saibou's efforts to control political reforms failed in the face of union and student demands to institute a multi-party democratic system. The Saibou regime acquiesced to these demands by the end of 1990. New political parties and civic associations sprang up, and a national conference was convened in July 1991 to prepare the way for the adoption of a new constitution and the holding of free and fair elections. The debate was often contentious and accusatory, but under the leadership of Prof. Andre Salifou, the conference developed consensus on the modalities of a transition government. A transition

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government was installed in November 1991 to manage the affairs of state until the institutions of the Third Republic were put into place in April 1993. While the economy deteriorated over the course of the transition, certain accomplishments stand out, including the successful conduct of a constitutional referendum; the adoption of key legislation such as the electoral and rural codes; and the holding of several free, fair, and nonviolent nationwide elections. Freedom of the press flourished with the appearance of several new independent newspapers. Rivalries within a ruling coalition elected in 1993 led to governmental paralysis, which provided Col. Ibrahim Baré Maïnassara a rationale to overthrow the Third Republic and its President, Mahamane Ousmane, in January 1996. While leading a military authority that ran the government (Conseil de Salut National) during a 6-month transition period, Bare enlisted specialists to draft a new constitution for a Fourth Republic announced in May 1996. After dissolving the national electoral committee, Bare organized and won a flawed presidential election in July 1996 and his party won 90% of parliament seats in a flawed legislative election in November 1996. When his efforts to justify his coup and subsequent questionable elections failed to convince donors to restore multilateral and bilateral economic assistance, a desperate Bare ignored an international embargo against Libya and sought Libyan funds to aid Niger's economy. In repeated violations of basic civil liberties by the regime, opposition leaders were imprisoned; journalists often arrested, beaten, and deported by an unofficial militia composed of police and military; and independent media offices were looted and burned with impunity. In the culmination of an initiative started under the 1991 national conference, however, the government signed peace accords in April 1995 with all Tuareg and Toubou groups that had been in rebellion since 1990, claiming they lacked attention and resources from the central government. The government agreed to absorb some former rebels into the military and, with French assistance, help others return to a productive civilian life. In April 1999, Bare was overthrown and assassinated in a coup led by Maj. Daouda Mallam Wanke, who established a transitional National Reconciliation Council to oversee the drafting of a constitution for a Fifth Republic with a French style semi-presidential system. In votes that international observers found to be generally free and fair, the Nigerien electorate approved the new constitution in July 1999 and held legislative and presidential elections in October and November 1999. Heading a coalition of the National Movement for a Developing Society (MNSD) and the Democratic and Social Convention (CDS), Mamadou Tandja won the presidency. In July 2004, Niger held municipal elections nationwide as part of its decentralization process. Some 3,700 people were elected to new local governments in 265 newly established communes. The ruling MNSD party won more positions than any other political party; however, opposition parties made significant gains. In November and December 2004, Niger held presidential and legislative elections. Mamadou Tandja was elected to his second 5-year presidential term with 65% of the vote in an election that international observers called generally free and fair. This was the first presidential election with a democratically elected incumbent and a test to Niger's young democracy. In the 2004 legislative elections, the National Movement for the Development of Society (MNSD), the Democratic and Socialist Convention (CDS), the Rally for Social Democracy (RSD), the Rally for Democracy and Progress (RDP), the Nigerien Alliance for Democracy and Progress (ANDP), and the Social Party for Nigerien Democracy (PSDN) coalition, which backed Tandja, won 88 of the 113 seats in the National Assembly.

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Niger's new constitution was approved in July 1999. It restored the semi-presidential system of government of the December 1992 constitution (Third Republic) in which the president of the republic, elected by universal suffrage for a 5-year term, and a prime minister named by the president share executive power. As a reflection of Niger's increasing population, the unicameral legislature was expanded in 2004 to 113 deputies elected for a 5-year term under a proportional system of representation. Political parties must attain at least 5% of the vote in order to gain a seat in the legislature. Niger's independent judicial system is composed of four higher courts--the Court of Appeals, the Supreme Court, the High Court of Justice, and the Constitutional Court. In January 2007, the National Assembly voted to divide the Supreme Court into three high courts--an Administrative Court, a Supreme Court of Justice, and an Audit Court. The constitution also provides for the popular election of municipal and local officials, and the firstever successful municipal elections took place July 24, 2004. The National Assembly passed in June 2002 a series of decentralization bills. As a first step, administrative powers have been distributed among 265 communes (local councils); in later stages, regions and departments will be established as decentralized entities. A new electoral code was adopted to reflect the decentralization context. The country is currently divided into 8 regions, which are subdivided into 36 districts (departments). The chief administrators in each region (Governor) and department (Prefect) are appointed by the government and function primarily as the local agents of the central authorities. The current legislature elected in December 2004 contains seven political parties. President Mamadou Tandja was re-elected in December 2004 and reappointed Hama Amadou as Prime Minister. Mahamane Ousmane, the head of the CDS, was re-elected President of the National Assembly (parliament) by his peers. The new second term government of the Fifth Republic took office on December 30, 2004. In August 2002, serious unrest within the military occurred in Niamey, Diffa, and Nguigmi, but the government was able to restore order within several days. PRINCIPAL GOVERNMENT OFFICIALS President and Chief of State--Mamadou Tandja Prime Minister—Seyni Oumarou Minister of Foreign Affairs, Cooperation & African Integration—Aichatou Mindaoudou Ambassador to the United States--Aminata Maiga Djibrilla Toure Niger maintains an embassy in the United States at 2204 R Street, NW, Washington, DC 20008 (tel. 202-483-4224/25/26/27) and a permanent mission to the United Nations at 417 East 50th Street, New York, NY 10022 (tel. 212-421-3260). NEXT ELECTIONS SCHEDULED Presidential elections--November/December 2009, two rounds; no date selected. Legislative elections--December 2009; no date selected. Local elections--Not scheduled, but expected in 2008. Last local election was in July 2004. ECONOMY GDP (2005): $3.4 billion. Annual growth rate (2005): 4.5%. Per capita GDP (2005): $280. Avg. inflation rate (2005): 6.6% Natural resources: Uranium, gold, oil, coal, iron, tin, and phosphates. Agriculture (41% of GDP): Products--millet, sorghum, cowpeas, peanuts, cotton, and rice.

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Industry (11.5% of GDP): Types--textiles, cement, soap, and beverages. Trade (2005): Exports (freight on board--f.o.b.)--$505 million. Types--uranium, livestock, cowpeas, and onions. Major markets--France 45.7%, Nigeria 20.4%, US 19.4% Switzerland 4.6%. Imports (f.o.b.)--$664 million. Types--consumer goods, petroleum, foodstuffs, and industrial products. Major suppliers--France 16.5%, Côte d'Ivoire 10%, Nigeria 6.3%, China 5.4%. One of the poorest countries in the world, ranking last on the United Nations Human Development Index in both 2005 and 2006, Niger's economy is based largely on subsistence crops, livestock, and some of the world's largest uranium deposits. Drought cycles, desertification, a 3.4% population growth rate, and the uncertainty of world demand for uranium keep Niger's already marginal economy vulnerable to crisis. Traditional subsistence farming, herding, small trading, seasonal migration, and informal markets dominate an economy that generates few formal sector jobs.

Niger's agricultural and livestock sectors are the mainstay of all but 20% of the population. Fourteen percent of Niger's GDP is generated by livestock production--camels, goats, sheep, and cattle--said to support 29% of the population. The 15% of Niger's land that is arable is found mainly along its southern border with Nigeria. Rainfall varies and when insufficient, Niger has difficulty feeding its population and must rely on grain purchases and food aid to meet food requirements. In 2004 localized drought and locust infestations contributed to a drop in global harvests of 11% and led the Embassy to make a disaster declaration. This decrease, combined with chronic structural food insecurity, high malnutrition, and other market factors, triggered a food crisis which began in May-June of 2005. Although food security continues to be a concern, the food crisis has ended thanks to good cereal harvests in 2005 and 2006. Millet, sorghum, and cassava are Niger's principal rain-fed subsistence crops. Cowpeas and onions are grown for commercial export, as are limited quantities of garlic, peppers, gum arabic, and sesame seeds. In the past, foreign exchange earnings from livestock, were second only to those from uranium. As a result of the recent drought, however, earnings from livestock dropped to fourth place behind uranium, onion, and gold exports. Because earnings from livestock exports are difficult to quantify, in all likelihood actual exports far exceed official statistics, which often fail to detect large herds of animals informally crossing into Nigeria. Some hides and skins are exported, and some are transformed into handicrafts. Therefore, livestock continues to be one of Niger's most important trade commodities.

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Recent rapid global price increases have led to higher revenues for Niger's uranium sector, which provides approximately 30% of national export proceeds. The nation enjoyed substantial export earnings and rapid economic growth during the 1960s and 1970s after the opening of two large uranium mines near the northern town of Arlit. When the uranium-led boom ended in the early 1980s, however, the economy stagnated, and new investment since then has been limited. As a result of higher world prices, Niger's two uranium mines--COMINAK's underground mine and SOMAIR's open-pit mine--are expected to increase uranium output in 2007. These two companies are owned by a Frenchled consortium and operated by French interests; however, Canadian and Chinese companies are currently studying the feasibility of opening mines in Niger. Output from any potential new mines probably could not occur until the end of 2008 at the earliest. Exploitable deposits of gold are known to exist in Niger in the region between the Niger River and the border with Burkina Faso. On October 5, 2004 President Tandja announced the official opening of the Samira Hill Gold Mine in the region of Tera and the first Nigerien gold ingot was presented to him. This marked a historical moment for Niger as the Samira Hill Gold Mine represents the first commercial gold production in the country. Samira Hill is owned by a company called SML (Societe des Mines du Liptako), which is a joint venture between a Moroccan company--Societe SEMAFO Inc.-and a Canadian company--ETRUSCAN. Both companies own 80% (40% - 40%) of SML and the GON 20%. In 2005, gold was Niger's third most important export, accounting for 12.8% of the country's total exports. Substantial deposits of phosphates, coal, iron, limestone, and gypsum also have been found in Niger. Niger has oil potential. In 1992, the Djado permit was awarded to Hunt Oil, and in 2003 the Tenere permit was awarded to the China National Petroleum Company. An Exxon MobilPetronas joint venture holds the rights to the Agadem block, north of Lake Chad, but ceased exploration activities in 2006. The parastatal SONICHAR (Société Nigérienne de Charbon) in Tchirozerine (north of Agadez) extracts coal from an open pit and fuels an electricity generating plant that supplies energy to the uranium mines. There are additional coal deposits to the south and west that are of a higher quality and may be exploitable. The economic competitiveness created by the January 1994 devaluation of the “Communauté Financière Africaine” (CFA) franc contributed to an annual average economic growth of 3.5% throughout the mid-1990s. But the economy stagnated due to the sharp reduction in foreign aid in 1996 (which gradually resumed from 2000) and poor rains in 2000. Reflecting the importance of the agricultural sector, the return of good rains was the primary factor underlying economic growth of 5.1% in 2000, 3.1% in 2001, 6.0% in 2002, and 3.0% in 2003. In 2005, the economy showed strong growth (7.1% real GDP growth) as a result of the agricultural sector's recovery from the poor harvests of 2004, and the continued growth of non-agricultural sectors. In 2006, real GDP growth rates stabilized at an estimated 4.5%. In recent years, the Government of Niger drafted revisions to the investment code (1997 and 2000), petroleum code (1992 and 2007), and mining code (1993), all with attractive terms for investors. The present government actively seeks foreign private investment and considers it key to restoring economic growth and development. With the assistance of the United Nations Development Program (UNDP), it has undertaken a concerted effort to revitalize the private sector. Niger shares a common currency, the CFA franc, and a common central bank, the Central Bank of West African States (BCEAO), with seven other members of the West African Monetary Union. The Treasury of the Government of France supplements the BCEAO's international reserves in order to maintain a fixed rate of 656 CFA to the euro.

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ECONOMIC REFORM In January 2000, Niger's newly elected government inherited serious financial and economic problems, including a virtually empty treasury, past-due salaries (11 months of arrears) and scholarship payments, increased debt, reduced revenue performance, and lower public investment. In December 2000, Niger qualified for enhanced debt relief under the International Monetary Fund (IMF) program for Highly Indebted Poor Countries (HIPC) and concluded an agreement with the Fund on a Poverty Reduction and Growth Facility (PRGF). In January 2001, Niger reached its decision point and subsequently reached its completion point in 2004. Total relief from all of Niger's creditors is worth about $890 million, corresponding to about $520 million in net present value (NPV) terms, which is equivalent to 53.5% of Niger's total debt outstanding as of 2000. The debt relief provided under the enhanced HIPC initiative significantly reduces Niger's annual debt service obligations, freeing about $40 million per year over the coming years for expenditures on basic health care, primary education, HIV/AIDS prevention, rural infrastructure, and other programs geared at poverty reduction. The overall impact on Niger's budget is substantial. Debt service as a percentage of government revenue was slashed from nearly 44% in 1999 to 10.9% in 2003 and will average 4.3% during 2010-19. The debt relief cut debt service as a percentage of export revenue from more than 23% to 8.4% in 2003, and decreases it to about 5% in later years. In 2005, the IMF canceled all of Niger's debts to it (approximately $111 million), incurred before January 2005. In 2006, the African Development Fund canceled $193 million in debt for Niger. Furthermore, the World Bank announced that approximately $745 million in debt relief for Niger would be phased in over the next 37 years. In addition to strengthening the budgetary process and public finances, the Government of Niger has embarked on an ambitious program to privatize 12 state-owned companies. As of January 2005, seven had been fully privatized, including the water and telephone utilities, with the remainder to be privatized in 2005. A newly installed multisectoral regulatory agency will help ensure free and fair competition among the newly privatized companies and their private sector competitors. In its effort to consolidate macroeconomic stability under the PRGF, the government is also taking actions to reduce corruption, and as the result of a participatory process encompassing civil society, has devised a Poverty Reduction Strategy Plan that focuses on improving health, primary education, rural infrastructure, agricultural production, environmental protection, and judicial reform. FOREIGN AID The most important donors in Niger are France, the European Union, the World Bank, the IMF, and UN agencies--UNDP, UNICEF, FAO, WFP, and UNFPA. Other donors include the United States, Belgium, Germany, Switzerland, Japan, China, Italy, Libya, Egypt, Morocco, Iran, Denmark, Canada, and Saudi Arabia. While the U.S. Agency for International Development (USAID) does not have an office in Niger, the United States is a major donor, contributing on average $12 million each year to Niger's development. In 2006 Niger qualified for Millennium Challenge Account threshold status, raising the prospect of significant U.S. Government investment in sectors including basic education. The United States also is a major partner in policy coordination in food security, education, water management and HIV/AIDS sectors. The importance of external support for Niger's development is demonstrated by the fact that about 45% of the government's FY 2002 budget, including 80% of its capital budget, derived from donor resources. FOREIGN RELATIONS Niger pursues a moderate foreign policy and maintains friendly relations with the West and the Islamic world as well as nonaligned countries. It belongs to the United Nations and its main specialized agencies and in 1980-81 served on the UN Security Council. Niger maintains a special relationship with France and enjoys close relations with its West African neighbors. It is a charter member of the African Union and the West African Monetary Union and also belongs to the Niger River and Lake

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Chad Basin Commissions, the Economic Community of West African States, the Nonaligned Movement, and the Organization of the Islamic Conference.

NIGER’S DEVELOPMENTAL CONTEXT

During more than a decade (1970–1980), Niger benefited from significant financial resources generated by a high demand for uranium. This situation changed drastically following the economic crisis of the early 1980s, which was caused by a decline in demand for uranium and two severe droughts. Niger then endured a period of political unrest in 1990–2000 that was detrimental to its society and economy. This unrest led to political and institutional instability, which was not conducive to remedial action or economic recovery, exacerbating poverty in urban, as well as rural, communities. Nevertheless, Niger’s economy, dominated by subsistence farming, rearing livestock, informal trade, and a declining mining sector, experienced slight growth during the 1990–2000 decade, with annual average real growth of 1.9 percent. The political situation has improved markedly in the past three years. The instatement of the first government of the Fifth Republic in December 1999, after presidential and legislative elections, ended a ten-year period of political and institutional instability. Interrupted in February 1999, the

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decentralization process was relaunched by the government in 2001 to strengthen democracy, improve the management of public resources, and promote good governance. Laws for the re-establishment of decentralized power in Niger were approved by the National Assembly in April 2002, after the government entered into discussions with the public and negotiations with elected officials (both the presidential majority and the opposition). The government’s adoption of the PRS in January 2002 strengthened the authorities’ commitment to combating poverty efficiently and consistently while furthering good governance. The strides made in sub-regional integration, environmental conservation, and the creation of conditions conducive to furthering the role of women all augur well for the country’s commitment to sustainable development. Nevertheless, the level of underdevelopment, the weak economy, and the reduced prospects for markets of uranium and other raw materials will continue to pose serious challenges for the country and its technical and financial partners. (Text from Plan International Web site, reprinted here with permission of Plan Niger) Topic Total area : Population : Population density : Capital city : Population distribution : Arable land : Ethnic groups : Niger numbers 489,189 sq. mi (1,267,000 sq. mi.) 11,972,000 (2003) 9 people per square kilometer Niamey, 748,6003 89% in rural areas or towns4 Only 4% of total Hausa, 56% Djerma, 22% Fula, 8.5% Tuareg, 4.3% Beri Beri, 1.2% Other, 8% (e.g., Arab, Toubou, Gourmantche) In perspective Slightly less than twice the size of Texas. Five times the size of the United Kingdom. Roughly half of Texas’s population (spread over twice its area). In the United Kingdom (population 60 million), an average of 244 people live in each square kilometer – making the UK 27 times as densely populated as Niger.2 Over 10 million Nigeriens live in rural, pastoral areas or towns. Only one in 10 Nigeriens (11%) live in its six largest cities— Niamey, Zinder and Maradi (population > 100,000), as well as Agadez, Arlit and Tahoua (population: 50,000 to 100,000).5 Much of the population lives along the narrow fertile belt south of the Niger River. The rest is dominated by the Sahara and the Sahel, and is not able to be cultivated.
Ethnic Groups in Niger

Hausa Djerma Fula Tuareg Beri Beri Other

Per capita
2

US$200/year

Niger’s per capita income is 40% of the average Sub-Saharan

Tageo.com, a database of geographic coordinate information which provides information on more than 2.6 million cities around the world. 3 Ibid. 4 Ibid. 5 Ibid.

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Topic income : Life expectancy : Under 5 mortality rate : Access to safe water :

Niger numbers (2003) 46 years (2003) 262/1,000 live births (2003) 46% (2005)6

In perspective African’s annual income (US$496). Only three West African countries have a lower per capita income than Niger. Only three West African countries have a lower life expectancy than Niger. Niger is second only to Sierra Leone (284) out of 195 countries on the United Nations human development index.

Fewer than half of Nigeriens have access to an improved drinking water source. The rest rely on exposed wells, rivers or ponds, which tend to be contaminated. Source (unless otherwise indicated by footnote): UNICEF’s State of the World’s Children Report 2005. Monetary unit: CFA Franc Languages: French (official), Hausa, Djerma Religions: Islam 80%, indigenous beliefs and Christian 20% Transportation: Railways: 0 km. Highways: total: 10,100 km; paved: 798 km; unpaved: 9,302 km (1999 est.). Waterways: the Niger is navigable 300 km from Niamey to Gaya on the Benin frontier from mid-December through March. Ports and harbors: none. Airports: 27 (2002).

The World Health Organization and UNICEF, Joint Monitoring Programme for Water Supply and Sanitation, January 2005 (http://www.childinfo.org/areas/water/status.php).

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Main public health issues and concerns HEALTH STATUS

Infant and under-five mortality rates are 156 and 265 per 100,000 live births respectively. Nationwide, 40% of under-five children suffer from malnutrition, 40% suffer from stunting and 14% from wasting. Only 2% of children aged less than four months are exclusively breastfed. The situation of women is characterized by the highest fertility rate in the region (8 children per woman), a wide gender gap in terms of health, education and literacy and a high maternal mortality rate at 1,600/100,000 live births (UNDP 2004). Only 16% of births take place in health facilities and 15% with skilled attendance. Regular outbreaks of vaccine preventable diseases (measles, meningitis) and of water-borne and diarrhoeal diseases (cholera, shigellosis, typhoid) are reported. Acute respiratory infections, vector-borne diseases (malaria, yellow fever, African sleeping sickness, lymphatic filariasis, onchocerciasis), tuberculosis and HIV/AIDS are important public health problems in the country. Malaria, of which 90-95% is due to P. falciparum, is responsible for 30% of outpatient consultations and is one of the first causes of morbidity with an average of 850,000 cases per year, or an incidence of 80 per 1,000. Children under five – 50% of under-five deaths are due to malaria – and pregnant women are the most vulnerable. (Chloroquine is still first line drug for uncomplicated malaria). Measles outbreaks are recurrent with an average of 43,000 cases per year. The last outbreak in 2004 affected over 62,000. A survey showed that the fatality rate is around 9%. Meningitis is endemic and the number and frequency of outbreaks is increasing. Cholera appears every winter in the south of the country, threatening around 83% of the total population and killing between 1 and 5% of its victims. Only 43% of the population has access to clean water and only 18% to sanitation. The national HIV/AIDS prevalence is estimated at 1.2% for the adult population, 25.6% for commercial sex workers and 3.6% for soldiers. About 4,800 persons died of AIDS in 2003. Tuberculosis prevalence is estimated at 3% and incidence at 1.5 per 1,000.

HEALTH SYSTEM

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The health system is organized in three levels, corresponding to the administrative division of the country: • The central administration decides on the general strategy and runs the national hospitals and health centres; • The second regional level covers the eight Directions générales de la santé publique (DRSP), represented by the six regional hospitals and two reference maternities; and, • The third level includes 42 Equipes cadres du district (ECD) in 42 district hospitals and the associated network of 578 Centre de santé intégrés and 1,201 cases de santé. The private sector includes around 200 health establishments, seven supply centres and 42 private pharmacies. The health system is under-resourced. More than 50% of the population does not have access to health services. The quality of available health services and their coverage are both severely limited. Public health programmes are overstretched. Health service users have to pay substantial charges. Nationwide, there is one health centre per 25,000 persons, one pharmacy per 22,500 persons, one maternity bed per 577 births and one paediatric bed per 13,540 children under 15 years of age. The ratios vary depending on the region and very populous areas such as Maradi, Tahoua, Zinder and Tillaberi are the least covered.

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Main sector priorities The recent Flash Appeal lists the following health priorities to ensure the survival of the population:
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• • •

Ensuring that essential, reliable and affordable health care services are available for all; Strengthening the existing surveillance and early warning and response system to monitor communicable diseases, assessing survival rates and nutritional status and improving the health system performance; Recuperating malnourished children under five and pregnant and lactating women through therapeutic and supplementary feeding; Supporting existing health services to prevent malnutrition and communicable diseases, and Strengthening health sector coordination and information management.

Niger is also covered by the CAP 2005 for West Africa, which calls for a regional strategy to complement on-going health programmes in individual countries and target the unmet needs of vulnerable populations, especially women and children. The CAP puts emphasis on the provision of:
• • • •

Quality preventive and curative health care for vulnerable populations through strengthening of primary health care services, routine immunization services and nutrition supplementation; Reliable laboratory services for diagnosing Lassa fever and other infectious diseases; Strengthened reproductive health services, including SGBV case management, especially for women and youth; and Strengthened Sexually Transmitted Infections (STI) case management, HIV/AIDS prevention and awareness-raising programmes.

The CAP also advocates for a reinforced national capacity to monitor and respond to disease outbreaks and for greater coordination among different actors (including uniformed forces) both within countries and across borders. Health actions in crises http://www.who.int/hac/crises/ner/background/profile/en/index.html

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Water supply and sanitation Water supply and sanitation are fundamental to the development process, influencing economic development, agriculture, employment, housing, health and numerous other sectors. These benefits are spread broadly across societal concerns. However, support and financing for water supply and sanitation projects are usually most effectively justified on health grounds. As Dr. Halfdan Mahler, former Director-General of the World Health Organization, said, “The number of water taps per 1,000 persons is a better indicator of health than the number of hospital beds.”

Health benefits result from improved quality and increased quantities of water, adequate sanitation facilities, and changes in hygiene behavior. For a number of waterborne diseases (e.g., guinea worm and cholera), transmission occurs as a direct result of drinking contaminated water. In other cases, the transmission cycle is through contact with it (schistosomiasis). Water also provides a breeding site for disease carrying vectors, such as malaria-bearing mosquitoes. Inadequate water for washing hands and cooking utensils and poor sanitation practices often result in diarrheal diseases. Disease and poor health exact a heavy burden on the economy, the community, the family, and the individual. Improvements in water supply and sanitation can reduce the incidence of many of these diseases or eliminate them entirely. Study after study indicates that children benefit greatly from improvements in water supply and sanitation. Improved water supplies and sanitation practices are instrumental in reducing infant mortality, preventing diarrhea, and improving child nutrition and overall health, and this fact can and should be used as a powerful lever in garnering support for water supply and sanitation improvements. In addition, unlike many other types of health interventions, water supply and sanitation improvements result in a whole range of secondary, non-health benefits. They provide economic benefits for the population as a whole and for women in particular by reducing the time spent in getting water. Unfortunately, it can be difficult to demonstrate the many benefits of improved water and sanitation conclusively through conventional cost effectiveness techniques. Water supply and sanitation facilities are necessary but not always sufficient by themselves to achieve substantial disease reduction. Rather than showing an immediate and direct impact on disease reduction, water supply and sanitation facilities appear to have a long-run “multiplier” effect that reduces mortality as a result of environmental improvement. One of the few sets of data available corroborates this effect. It indicates that in urban France in the nineteenth century, sharp drops in mortality patterns coincided with the introduction of piped water and sewer systems. Evidence also suggests that negative health effects multiply upon the decline of adequate water and sanitation. For example, the return of cholera to Latin America in 1991 may be seen as an indication that water and sanitation conditions are worsening as increased population and urbanization stretch the resources of already poor countries to the breaking point.

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Sanitation in Niger Sanitation, the use of hygienic measures such as drainage, ventilation, pure water supply, etc., in Niger plays a major role in health, as in the rest of the world. Where and how often water is obtained impacts health since it determines the quantity and quality of water. Overall, only 43% of Nigeriens have access to safe drinking water and this figure drops to 36% in rural areas. The main source of water for rural Nigeriens is the community well (traditional or cement) located within walking distance to a majority of people. About one fifth of rural Nigeriens obtain their drinking water from cement or protected wells/pumps. Pumps are more rare than wells and they vary between foot, hand, solar, generator run, etc.; all found in various villages. Less than 7% of the population benefits from drinking water faucets at their homes and the majority of these are found in larger cities. The remainder of the population obtains their water from traditional wells, seasonal ponds, the river and seasonal rivers, and ‘Garua’ (water delivery from city faucets) in larger cities. There are sanitation issues with each form of water. The most obvious are seasonal ponds and rivers, the Niger river, and traditional wells. None of these are considered to be sites of safe drinking water due to various contamination sources (soil, animal/human urine/feces, parasites, etc.). Sources of contamination are less evident with regard to cement community wells. Consider this, the community well is the source of all water for people and animals in the area. Women and men walk, sometimes long, distances to the well. When they reach the well they bring disease to it on the bottoms of their shoes. They place their buckets/canneries on the ground where they have stepped, then they extract the water from the well using rubber bucket-like containers attached to rope. Often there are only a handful of these containers to extract water, so several families will use the same one. As they pull the water up by the rope from the well they drop the extra rope on the ground and they’ll often step on it while they go about filling their buckets/canneries, chatting, etc. at the well. Each time the container goes into the well it is contaminated with the dirt, bacteria, etc. that people bring to it on the bottoms of their shoes/feet. Also, animals will often approach the well (right next to it) looking for water. They also bring dirt and other diseases with them. Sometimes animals large and small will fall in the well, further contaminating this precious source of water. Once they get this water it is then carried back to the family household, along with the diseases, where it is stored in large canneries, or left in buckets exposed to the wind, animals, etc. Pump water is by far the cleanest, and unfortunately the least available source, but it still can be contaminated if it is not stored properly (covered in a clean container). Concerning other sanitation issues, such as access to latrines/toilets and waste disposal, only 4% of the rural population have access to adequate sanitation compared with 69%

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in urban settings. The vast majority of Nigeriens do not have access to latrines and instead utilize the family shower area and the fields closest to their house to meet their needs for urine and excrement disposal. Refuse is disposed of at the edge of the village often near or on footpaths. Runoff from family shower areas remains stagnant and open to the environment. Thus, wind, animals and people carry disease from these areas of disposal back into the family environment or to the water source. Cultural considerations in Niger The left hand – The Nigerien population overall avoids using the left hand as the left hand is considered the hand of the devil and most importantly because Nigeriens do not use toilet paper, they use only the left hand to clean themselves after urination or defecation Teapot – A plastic teapot filled with water, buta in Zarma or sahani in Hausa, is used to clean oneself after urination or deification. Often, Nigeriens do not pay attention or think about it as it relates to hygiene. The teapot is used to be hygienic, but it also is a potential source or transport of contamination. Nigeriens use the shower area behind or next to their house to shower and to urinate, and the shower area is never cleaned. The teapot, therefore, carries the microbes and germs from the shower area into the family compound. These same teapots are also used for ablutions before prayer and, most interestingly, as a source of drinking water for children and adults. Unfortunately, education about the transport of microbes by the teapot is not recommended by volunteers because of the teapots link with religion, thereby the belief that anything that comes from it is purified by God.

Latrines, such as these being built for a school in the Gothéye area, can drastically improve the sanitation of a village. Unfortunately, the vast majority of Nigeriens cannot afford or do not see the importance of sanitation improvements such as these.

What volunteers can promote to improve Sanitation in Niger Many maladies in Niger are directly linked to hygiene and sanitation. Here are some things volunteers can educate about or encourage. • Washing hands before and after eating or going to the bathroom • Washing utensils and cooking pots • Keeping all food (prepared or not) covered to protect it from flies, etc. • Encourage different spaces to shower and urinate • Not to allow children to play in dumping/trash pit areas of the village • Sweeping and burning dirty or dumping areas of the village. • Community meetings to establish a village health or sanitation committee

• Can use shame as a means of motivating people, but use it with caution 20

Major water and sanitation related illnesses in Niger
There are several diseases seen in Niger that are directly related to water or sanitation. And, as mentioned above, improvements in sanitation in Niger can either greatly reduce the level of incidence or completely eliminate these diseases. Diarrhea The major health risk to children under five in Niger is diarrhea and it is mainly linked to poor hygiene or sanitation and caused either by an illness below, malnutrition, or other childhood illnesses. In Niger 38% of children suffer from diarrhea at any given time. Technically, diarrhea is characterized by loose, watery stools passed more than 3 or 4 times a day. There are two types, acute and chronic. Acute diarrhea starts suddenly and may continue for several days and is usually caused by an intestinal infection. Chronic diarrhea can vary from day to day and lasts more than three weeks. It is caused by under-nutrition, infection, and parasites and worms in the stomach. Diarrhea is so dangerous because of the possibility of malnutrition, dehydration, and possible death.

It is most important to prevent and treat dehydration when treating diarrhea, as it is the dehydration and salt loss that causes death. Diarrhea is prevented by drinking more fluids(such as increased breastfeeding, home made sugar/salt solutions, etc.) at the onset of diarrhea. Treatment of dehydration is best done at a health clinic, as they have oral rehydration salts (ORS), but it can be done at home with sugar/salt solutions or ORS packets. How to make ORS at home. • • • • • Take a sauce bowl and fill it with one liter of clean water Add 8 cubes or 2.5 table spoons of sugar Add two pinches of salt, using three fingers for each pinch Stir the solution until all ingredients have dissolved Give this solution to the child tablespoon by tablespoon after each episode of diarrhea to replace lost fluids. • Keep the solution covered to keep it clean, throw it out at the end of each day, and make a new one the next day.

Waterdiseases

borne

Amoebiasis (protozoa) Amoebiasis is an infection with pathogenic amoebae. Infection with amoebae is usually symptom-less. Clinical amoebiasis is endemic in areas where sanitary conditions are poor. Under certain circumstances the amoeba may invade the large intestinal wall causing the

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disease amoebiasis. If left untreated, the infection can spread to other organs, specifically the liver. Incidence of liver amoebiasis is strongly correlated with alcohol consumption, thus the majority of cases found in men are related to alcohol intake. Whereas in women the incidence of liver amoebiasis is increased during pregnancy, the postnatal period, and alcohol intake (study in Tanzania). Transmission occurs when cysts are excreted in the feces of humans. Others are infected through feco-oral transmission (contaminated water) of these cysts. The amoebae themselves cannot directly infect a person, because they cannot withstand gastric juices in the stomach. Therefore, amoebic dysentery cannot occur through direct contact with a sick individual, as with cholera or other bacillary dysentery.

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Maternal and infant health
Pregnancy Pregnancy and children are the pinnacle of life for Nigerien women, who are the care-givers of the family. In Niger the average number of children that women will have is about 8, which is the highest fertility rate in the world. Child-birth is difficult for all women, but it is especially difficult in Niger. The maternal mortality rate is the highest in the world at 700 deaths per 1000 live births. Thus, a basic understanding about pregnancy and child-birth is essential to helping decrease this staggeringly high rate of maternal death. Not to assist in births or take an active role in observing pregnancy, but to be available as a resource person to women and men about pregnancy and its dangers. Signs of pregnancy There are several symptoms that are associated with pregnancy, such as: nausea, vomiting, tiredness, tender breasts, the pregnant woman has a certain “glow” about her, etc. But the single most important sign of pregnancy is missing a monthly menstrual cycle or period. This is the most important factor in determining pregnancy. Once a woman suspects that she is pregnant she should visit the health clinic so that the clinic staff and mother can ensure a healthy pregnancy. Care during pregnancy The mother needs to take special care of herself during pregnancy to protect the baby, help its development, and maintain her body. The first and most important thing for a mother to be to do during pregnancy is to eat well. The baby is developing at a rapid pace and is in need of several nutrients to grow and develop to its full potential. For example, both iron and iodine are essential for mental and motor development (see chapters3 and 6 for more information). Proper nutrition also helps prevent illness and prevents excessive bleeding during childbirth. Nigerien Women work extremely hard through out the day to provide for their household. Whether it be pulling and carrying water back to the house, pounding millet, collecting fire wood/fuel, cooking, or taking care of the children, mothers are continually at work during the average day. All of this hard work must continue, even when pregnant in Niger. So the best advice, for women during pregnancy, is to be sure to rest and sleep whenever possible and to encourage more resting than usual, even before fatigue is felt. And when resting, recommend lying down on the left side of the body and placing a pillow or cloth between the legs to alleviate back pain. Practicing good hygiene is always important, but it is especially important during pregnancy to help prevent infections and to keep the growing baby healthy. Pregnant women should avoid drinking alcohol, smoking, using snuff, and caffeine (tea, coffee, coke, and cola nuts). Most of these are not an issue for Nigerien women, however in some areas of the country, women use snuff or smoke and caffeine is always an issue with the popularity of cola nuts.

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Common complaints during pregnancy C There are several issues that can develop during pregnancy and it is important to distinguish between what are common complaints and danger signs.

The most common complaint is nausea or morning sickness, but this will usually only last through the first 3 to 4 months of pregnancy. Women should continue eating frequent, small meals during this period.

Lower back pain is due to the extra weight of the growing baby. To ease this pain, have the mother-to-be: place a pillow between her legs while sleeping, try to get help with any heavy work, and stretch out the back for a few minutes, two times each day.

Toxemia, a danger sign

Swelling of feet and Legs is normal during pregnancy, especially when women ar standing or working all day. Encourag several rest breaks and when resting lie on th left side. If feet, hands or face are swollen in the morning, this is a danger sign (toxemia and this woman should visit her local health clinic.

Leg Cramps are common during pregnancy, especially at night. This could be due to a lack of dietary calcium. To alleviate cramps, pregnant women should eat foods containing calcium (milk, cheese, and bones are good sources) and stretch or rub the cramped area.

Another common complaint is heartburn or indigestion. This is most common late in pregnancy and is usually felt after eating or while lying down. Eating small meals, drinking plenty of water, and not lying down right after eating or lying down with the head higher than the stomach all help to alleviate indigestion.

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Danger signs At any sign of danger, a woman should visit her health clinic and likely give birth there, but she needs to know what the signs are. The first is fatigue, a sign of anemia. Women who are anemic are more likely to have heavy bleeding while giving birth. Anemic women should eat foods rich in iron (see chapter 3) or take iron supplements until the baby is born. Another sign is pain in the lower abdomen and there are three types: 1. Strong constant pain during the first few months may be a tubal (fallopian tube) pregnancy. This is highly dangerous because, as the pregnancy progresses, the tube will burst causing internal bleeding or possibly death. 2. Strong cramping pain that comes and goes during the first six months could mean a miscarriage. 3. Strong constant pain late in pregnancy may mean the placenta has detached from the uterine wall causing internal bleeding and possibly death. Vaginal Bleeding can be another danger sign during pregnancy. It is normal to have a little during the first few months, but if it occurs later in pregnancy it is a sign that the placenta is damaged (mentioned above). Swelling of the hands, feet and face are signs of toxemia and can cause seizures or death. Finally any fever, especially high with shivering, headache, and body aches can be malaria and should be treated as soon as possible to avoid damage to the baby or abortion. High risk pregnancies Some women are at a higher risk for delivery complications and women with any of the following histories or conditions should give birth at a health clinic. These are: women with anemia, diabetes, high blood pressure, or toxemia; older women; women who have given birth multiple times; women with disabilities; young women under age 17; women with past birthing complications; women with previous operations; and women with fetuses that are not in the proper delivery position at the end of pregnancy. Prenatal Consultations at the Health Clinic (dispensaire) Why should women go to prenatal consultations? Many of the dangers of pregnancy and childbirth can be avoided if a woman goes to prenatal consultations at the health clinic as soon as she believes that she is pregnant. Women should have at least three consultations during their pregnancy, one in each trimester, to assure a healthy pregnancy and birth. Most of the time in Niger, women don't understand the importance of the prenatal consultations during the first trimester. They wait until the pregnancy becomes visible before going to the health clinic or they don’t go at all. This is due to several factors such as accessibility of clinic and fear of clinic staff.

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What a health worker does during a prenatal consultation • • • • • Checks the progress of the pregnancy, Determines differences between common complaints, warning signs and high risks, Checks for anemia and toxemia, Determines the number of tetanus vaccinations given to the mother, and gives vaccination if necessary. Counsels about the delivery, breastfeeding, family planning, etc.

Steps of the consultation The first step: Interview, to obtain the woman's health background they will ask for the woman’s age, the date of her last period, ask about previous pregnancies, ask about sickness especially STDs, tuberculosis etc…
Check for anemia by looking below the eye. If pale, then anemic.

If red or pink, then normal.

Second step: Physical or general examination, to assess development and progress of pregnancy (1) Take weight, height measurements (2) Ask about nutrition (3) Ask about common complaints nausea, constipation etc...

Take blood pressure (tension arterial) it shouldn’t be over 120/80 (12/8 here) higher blood pressure increases the possibility of getting toxemia. Check for anemia. Third step: obstetrical exam, examine the baby. Fourth step: education, counseling Proper nutrition for mother Family planning Breastfeeding.
9 months 8 months 7 months 6 months 5 months 4 months 3 months

At 4.5 months it will be at the level of the navel

How the nurse assesses the duration of the pregnancy. Fifth step: vaccination against tetanus, a disease that usually enters the body when the skin is punctured or cut with a dirty piece of metal, and can cause death (see chapter 4). Girls or women of child-bearing age should receive a minimum of five tetanus vaccinations (vaccin anti-tétanique or VAT). • • • • • VAT Number 1: at the first visit VAT Number 2: at least four weeks after first injection VAT Number 3: at least six months after second injection VAT Number 4: at least one year after third injection VAT Number 5: at least one year after fourth injection

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Birth Process The birth of a baby is far beyond anything that a Peace Corps volunteer needs to be familiar with for Community Health Agent work. Every village has at least one older woman who assists with births whether she has been formally trained as a midwife or if she has just had a lot of experience with birthing. These women are heavily relied on for any assistance village women may need during this time. Also, local health clinic personnel are trained in normal and difficult deliveries. One issue is that traditional birthing attendants often wait until it is too late for the mother and/or baby to travel the distance (up to 15 Km) to the health clinic for help and the mother and/or baby die. This is one of the factors contributing to the high mortality rate in Niger. For more information on the birth process, see the books, Where women have no doctor by David Werner and A Book for Midwives by Susan Klein. Postnatal care for mother and child After the birth the mother should be encouraged to breastfeed immediately. The reasoning for this is that it will help stop the mother’s bleeding, followed by the fact that the baby greatly benefits from the colostrum found in the first few days of mother’s milk. Also, since breast milk is the ONLY food that is appropriate for a newborn, the baby should always breastfeed, plus in addition to the above it helps develop the mother to baby bond. The newborn should be kept clean by regularly bathing, taking special care to clean around the neck, the eyes, ears, nose, etc. The stump of the umbilical cord should be kept clean and dry until it turns black and falls off; within the first week after birth.

A woman in the developing world is twenty times more likely to die from pregnancy, than a woman in the developed world.
Forty days after the baby’s birth (sooner if either the baby or mother develops an infection), both mother and child should go to the health clinic for a postnatal visit. Postnatal visits are usually conducted on growth monitoring/baby weighing days. The purpose of this visit is to: 1) weigh and vaccinate the new baby, 2) assess the new mother’s condition, 3) Counsel the mother on how to care for the baby (hygiene, breastfeeding, growth monitoring, vaccinations, etc.), and 4) counsel the mother on how to take care of herself (nutrition, hygiene, breasts, etc.).

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Planning a family
According to Ortho Pharmaceutical Corporation, authors of the book Understanding Conception and Contraception, men and women have understood the need to balance the number of children they produce with their ability to provide for them for centuries. Ancient hieroglyphics tell of powders and potions preventing pregnancy. Centuries ago, Hindu physicians reported theories similar to the rhythm method describing how intercourse should be avoided at certain periods of the month due to increased fertility, while other days were considered times that women would be unlikely to conceive. And today, women have prevention methods available that have been proven safe and effective. The number of children a family has may depend on their culture or religion, but the need to plan for this family is essential regardless of these factors. In essence, family planning is the need to properly plan for children economically, as well as to space their births several years apart with the use of some form of contraception. There are many reasons to practice family planning (or birth spacing) the most important of which is giving each child adequate time to develop, thereby decreasing the likelihood that they will become malnourished and increasing their overall health. In our world today, 3 to 4 million children die because they are not given this chance, a chance of two years of life before their next sibling is born.

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The correlation between the death of children and the amount of time between pregnancies is clear. The more time that passes between births, the better the chance for survival. Another important reason to space births is the mother’s recovery, this two to three year period of rest allows the mother’s body to recuperate, nourish the present baby, and prepare for the next one.

Economic concerns should also play a major role in planing a family. A woman in the developing world is twenty times more likely to die from pregnancy, than a woman in the developed world. Unfortunately, poverty in the underdeveloped world is a major challenge to family planning as, with poverty come other concerns such as availability of family planning methods, transportation to places where family planning methods are available, and the inability to purchase these methods. Family planning in Niger Niger, like other underdeveloped countries, faces several challenges with family planning. These are both cultural as well as geographical in nature. The main ones are tradition, low status of women, ignorance, distance, the health staff themselves, time involved, availability, and cost. Traditions in Niger serve as a major barrier to the practice of Family planning. Cultural tradition encourages every married man and woman to have as many children as possible for several reasons. The mortality rate for children under the age of five in Niger is 280 deaths for every 1,000 children. This high mortality rate means that it is likely that a mother will lose some of her children by age five, which leads to the high fertility rate of 8 children per woman. In addition, Nigeriens are sustenance farmers so they rely on their family as a workforce to help with fieldwork as well as other household chores. A woman’s worth is also determined by how many children, more specifically sons, she has. Another cultural belief is that it is God who gives people children, so by refusing to have children one is going against religion. Also, one does not have to worry about feeding many children because ‘people don’t feed themselves, it is God that feeds them.’ Only 18.7% of Nigerien women and 19% of men have ever used some form of modern contraception in their lives.

In addition there is an enormous amount of pressure put on women by their in-laws to have children and if a new wife fails to produce children she is considered sterile and her husband will take a second wife. The low status of women also impacts the practice of family planning. Women have little power in Nigerien culture and are bound by the decisions of their husbands. This not only applies to whether or not she will take contraceptive methods for family planning, but also to whether she will even be given permission to seek out these methods, as well as whether she will be given the money to help pay for them. Men are in control of monetary and other decisions in the household and women obey their husbands’ wishes. This lower status in combination with the fact that there is little communication

between husbands and wives makes it virtually impossible for a wife to approach her husband about any sexual matters, let alone those of family planning. Assuming that cultural barriers and women’s status does not impede the desire for family planning, ignorance of family planning often does, either because men and women are not aware that family planning exists or because they do not understand how to properly use the methods available. Men and women seeking family planning methods must be educated to ensure that they are used correctly, thereby eliminating this ignorance. Distance, time, availability and cost are other challenges to family planning in Niger. Distance is an important issue because it will determine whether it is even possible for a woman to have access to family planning. Many women live 15 to 20 KM away from the nearest health clinic, meaning to go to this clinic for family planning they must either pay for transportation by bush taxi, go by donkey/cow cart, or walk these long distances. Also, the time involved poses another challenge. A woman going for family planning must take one half to an entire day to go to the health clinic, which takes away from the time she has to accomplish her daily household duties. Finally, even if women do get to the clinic, the health clinic staff pose another problem. Staff at the health clinic do not understand the importance of ‘customer service’ or making people feel welcomed. Instead they, often men, treat women TERRIBLY, give them no respect, and demean or marginalize those that come to them for help. No one will take all of the extra effort to go the distance, spend the necessary time and money to be treated abominably, especially if they can have no confidence in these people that are supposed to help them. Also, health clinic personnel (majore and possibly the nurse) are only trained in the principles of family planning methods and do not necessarily understand how it works themselves, making it difficult to effectivley educate others about their proper usage. Finally, health clinics are currently in a time of change in terms of family planning method supplies. For several years USAID was responsible for funding almost all of the family planning methods available in Niger. Through USAID the methods were simply given to rural clinics and dispensed free of charge to clients interested in family planning. However, after the coup d’état in 1996 USAID began to shut down their support to Niger and in 1998 pulled out completely, thereby leaving a family planning void in Niger. At this point FNUAP (Fond des Nations Unis pour la Population) decided to begin supporting family planning in Niger. This, however, is an extremely modest assistance in comparison with what USAID had provided. The Center for Reproductive Health in Niamey has turned all family planning supplies over to the National Pharmacy, who in turn sells them to rural dispensaires and others interested in buying the methods. As they are still in this state of uncertainty, health clinic staff may be unaware that it is left up to each individual clinic to purchase and sell family planning methods under a cost recovery system (like the Bamako initiative in Appendix F). So, in order to reinitiate family planning in rural Niger, the staff needs to be aware that it must be purchased and then purchase it when they get their other medications. Until a better method is established, the health clinics will often be out of family planning methods making them unreliable. Hopefully something will be done in the near future to correct the situation. Family planning methods available in Niger There are many contraceptive methods that exist in Niger, but not all are practical for use in a rural setting. Abstinence, oral contraceptives, injectable contraceptives, condoms and spermicides are all methods that are generally available and effective for women and men in rural Niger. As explained above, Family Planning methods (that incur costs) are or can be available at the health clinic. The prices for various family planning methods are listed in the chart below. Please keep in mind that this is the price at the National Pharmacy, thus they may cost slightly more due to transportation costs, etc. (One

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example of inflated costs is with Depo-provera. It is sold at the National Pharmacy for 300cfa, but other pharmacies charge 2,000 for it. Thus, this price guide is just that, a guide, and cost is likely to be more than what is listed.

Cost of Family Planning methods at the National Pharmacy Method Oral contraceptives (Lo-femenal or ovrette) Depo-Provera Condoms (2) Spermicide Price 100 cfa 300 cfa 15 cfa 100 cfa

Abstinence This method is advocated for all single men and women, as well as during the 40 day period after a woman gives birth. Oral Contraceptives All things considered, oral contraceptives are the best method available to women in rural Niger. There are two types of oral contraceptives available, low-dose combined (estrogen/progesterone) or progesterone-only pills that both work by preventing a woman from ovulating. They are highly effective (99.9%) when used correctly* with only 1 out of 1,000 women becoming pregnant. As they are commonly used, the result is a pregnancy rate of 8% or 1 in 17 women. • • Low-dose combined pills are an effective means of family planning for most women (common brand name: Lo-femenal). Progesterone-only pills (common name brand in Niger: Ovrette) are given to breastfeeding women with children between the ages of six weeks and six months. They work in conjunction with the Lactational Amenorrhea Method (mentioned below) to prevent pregnancy. After the baby is six months old, women are generally switched to the combined oral contraceptive pills, since breastfeeding is no longer exclusive

RESTRICTIONS Oral contraceptives cannot be given if a woman has: high blood pressure, heart problems, hepatitis, breast lumps/cancer, or may be pregnant.

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*Challenges: There are several challenges with taking oral contraceptives. The biggest of which is helping women to understand how and when to take them. Women often believe that they do not need to take the pills when they or their husbands travel, even if it’s just for a few days. It is important for a woman to understand that she needs to take oral contraceptives every day, regardless of her or her husband’s activities, in order for them to be effective.

Explaining how to take Oral Contraceptives START ---->---->---->---->---->--->----> ----<----<----<----<----<---<----< ---->---->---->---->---->--->----> ----<----<----<----<----<---<----< END

If a woman is having difficulty understanding how to take the pills, it is often useful to explain to her that the pills are taken once a day (at the same time). She should take the pills as millet is planted - going down one row and then up the next until all pills have been taken. Initially, packets are given out individually until the woman can prove she understands how to take it properly. At this point, several packets will be given together. What to do if a pill is missed: 1Pill 2 Pills Take it as soon as it is remembered Can become pregnant (possible to take two pills a day for two days, but this is too complicated for practicality in the bush).

The majority of women using family planning methods in Niger did not start until they already had four or more children.
Depo-provera (injectable contraceptive) Depo-provera is a long-acting synthetic hormone used in over 90 countries of the world. It inhibits pregnancy by preventing ovulation as well as implantation in the uterus. It is given by injection every three months and is as effective as a combined oral contraceptive pill.

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Most clinics will not give Depo-Provera to women who have had fewer than 3-4 pregnancies. The reasoning behind this is related to the cultural importance of producing children and the fact that fertility returns slower than with oral contraceptives (infertility last up to 4 months after Depo-provera injections are stopped). Restrictions Injectable contraceptives cannot be given if a woman has: high blood pressure, heart problems, hepatitis, breast lumps/cancer, or may be pregnant. Male condom and spermicide Condoms can be an effective means of birth control if used in conjunction with a spermicide. Condoms alone are about 88% effective, but when used in conjunction with spermicide the prevention rate climbs to almost 100%. The acceptability and use of condoms in Niger requires the full participation of the man and usually is initiated by him.

Women’s general knowledge of condoms and spermicide is somewhat limited, according to the Enquête Démographique et de Santé 1998, 42% of Nigerien women know about them but only 0.7% have used them at any point in their lives to prevent pregnancy. Nigerien men have much more knowledge of condoms with 78% knowing about them and 8% who have used them. A wife will not discuss sexual relations with her husband, so essentially, the only way that a rural woman would present condoms to her husband would be if he had sent her to obtain them.

What does Islam Say About Family Planning?
• • • • • It sanctions the forty-day washing period after the birth of a new baby, which stipulates that the woman is to rest at home and there is no sexual intercourse during this period. It provides for a “retirement” of a woman once she reaches a certain age, number of children, or level of stress that her body cannot surpass. It advocates the use of breastfeeding to prevent pregnancy. On an individual level, family planning is permitted to take care of the family and ensure the health of the mother and children. Other than that, it says nothing clear about family planning or birth spacing.

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Other methods available (less effective in Niger) Other methods exist, but are either impractical or not highly effective. These are natural methods such as cervical secretions, lactational amenorrhea, rhythm, or modern methods such as intrauterine devices or sterilization. Lactational Amenorrhea Method (LAM) LAM is practicing exclusive breastfeeding as a means of birth control. This is a natural method and highly effective if used correctly and consistently with less than 1% of women getting pregnant. Correct use of this method requires that the newborn baby receive virtually all of its nutrients from breast milk, breastfeeding occurs on a regular basis throughout the day and night, the new mother has not yet begun to menstruate again, and her breastfed infant is less than six months of age. Once any of the above factors changes, LAM can no longer be used as an effective means of birth control. As this method is commonly used 2% of women become pregnant before their newborn child is six months old. In Niger, LAM is unreliable due to several factors. First of all, women do not give colostrum to their newborn baby, so LAM does not begin directly after birth. Secondly, most women have demanding work schedules, which requires longer periods between feedings. And, finally, the introduction of other foods or water into a child’s diet before six months of age decreases the amount of breast milk being consumed which also decreases LAM’s effectiveness.
IUDs available

Intrauterine Devices (IUDs) An IUD is a small, flexible plastic frame that often has a copper wire or sleeve on it. The IUD is inserted into a woman’s uterus and remains there as long as fertility is to be inhibited.

i It works by preventing the sperm and egg from meeting and it could also prevent the egg from implanting into the uterine wall. IUDs are 99% effective as commonly used (1 in 125 become pregnant). Unfortunately, there is a chance of damaging the uterine wall, it can cause pelvic inflammatory disease (leads to infertility), and it requires a medical facility that can insert the IUD. In Niger, IUDs are rarely used for several reasons, but most importantly because the woman must travel to a medical center (centre medicale) to have it inserted and removed.

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Rhythm method The rhythm or calendar method is used to identify the start and end of a woman’s fertile period during each monthly cycle. It requires women to track the length of their cycles for six months before beginning to use it as birth control. This method not likely to be used or effective by Nigerien women, as it requires women to keep track of their cycles and then figure out days when they’re fertile or not. It could be useful for literate women who can record this information every month. With consistent use it is 91 % effective, meaning one in eleven women will become pregnant if using only it. Menstrual Cycle (for use with Rhythm method)

Cervical Secretions (mucus) method With this method, a woman must be very aware of her cervical secretions and willing to test them with her finger. Some days after menstrual bleeding, cervical secretions begin to be secreted, at this point the couple refrains from having unprotected sex until four days after the peak day (day where secretions are the most slippery, stretchy, and wet as seen in the picture). From four days after the peak day until the next menstrual cycle, the couple can have unprotected sex. When this method is used by itself it is 97% effective, meaning 1 in 33 women will become pregnant with it as the only method. Women in Niger are highly unlikely to be receptive to this method.

Women in Niger are as likely to use Traditional methods of Family Planning (like LAM or asking a Marabou to give them medicine – gri-gri) as they are to use
Modern methods (like oral contraceptives).
The Rhythm and cervical secretions method can be used in conjunction with withdrawal in order to increase its effectiveness as a birth control method to 98% where 1 woman in 50 will become pregnant.

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Sterilization Methods of sterilization are available for both men (vasectomy) and women (tubal ligation) in Niger. Both of these methods require surgery (always dangerous, especially in Niger) which must take place in a medical center (usually in an arrondissement or department capital). Culturally, fertility is VERY IMPORTANT and no one – man or woman – would agree to becoming permanently infertile. Also of note, there has never been a vasectomy performed on a Nigerien man, thus sterilization is not a viable method at this time in Niger. Family planning education Whatever method, men and women in Niger should be encouraged to practice family planning. The challenges, listed above, can be over come with appropriate education. Education about birth spacing should be directed to both women and men. However as men are in control of this issue, every effort should be made to help educate them about the importance of spacing the births of their children.

One educational method is to introduce the concept that children are like millet. If millet is planted too close together, none of the stocks will thrive and produce. It is the same with children, if they are born too close together they have to fight to survive, they aren’t able to get the nutrients they need, they often grow slower, and have a higher chance of illness. Through education, men and women can begin making informed decisions about family planning, eventually decreasing the mortality rate of children under five in Niger.

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Malnutrition
One of the main dangers to health in Niger is malnutrition. Most simply, malnutrition happens when a person’s body does not get enough nutrients (chapter 3) for its development and maintenance. Malnutrition can affect anyone, but certain people are more prone to it than others, such as: pregnant and breastfeeding women, children, the elderly, and those who are sick. These people are at risk for malnutrition because their bodies have extra nutritional demands to maintain their health. The causes of malnutrition are mainly attributed to diet and illness. When considering diet, unless there is a famine childhood malnutrition is not due to a lack of food, but instead due to: 1. 2. 3. 4. A lack of variety of food (not enough protective and body building foods), Poor breast feeding practices (children do not get enough nutrients overall), Poor weaning practices (aren’t properly or are abruptly weaned), or Poor care practices (lack of hygiene, are not helped when eating, illnesses are left untreated).

Illness causes malnutrition by affecting the body’s ability to digest and use food. It affects a person’s appetite, reducing the amount of food eaten. An example of this is diarrhea, one of the most common childhood illnesses. First, diarrhea reduces the absorption of food in the intestines. Then, it reduces the amount of food eaten, as a person with diarrhea is less interested in eating. These two acts reduce the overall nutrients available to the body. And, thus, the level of nutrition is greatly reduced especially since the body also has increased demands for food during times of illness. This is all compounded by the parent’s desire to give the child less food because the child is sick or doesn’t act like they want to eat. All of this contributes to the cycle of malnutrition, because once low food intake and illness cause malnutrition, then malnutrition, in turn, will either increase the severity/duration of the current illness or lead to other illnesses.

The Cycle of Malnutrition

Low Food Intake

llness

Malnutrition

And, thus the cycle repeats itself, making the child weaker, even more susceptible and more likely to die. Therefore it is essential to recognize and treat malnutrition before it becomes severe. Types of malnutrition Mild protein – energy malnutrition

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Protein – energy malnutrition (PEM) develops in children who are undernourished in energy and body building (protein) foods. This under nutrition leads to growth failure or growth at a rate that is unhealthy. Growth failure is visible as mild PEM where children are thin. Many children in Niger exhibit signs of mild PEM: a prominent belly, listlessness or apathetic even when given special attention, reach development milestones (chapter 4) later than normal, and sleep more often than well nourished children. Children with mild PEM can easily ‘catch up’ if they are adequately nourished and are stimulated to reach their development milestones, otherwise mild PEM can lead to severe PEM. Severe protein – energy malnutrition There are two types of severe PEM, these are kwashiorkor/marasmus Kwashiorkor is less severe than marasmus. It usually occurs in children between 1 and 3 years old when they are abruptly or partially weaned without adequate substitution of other energy and protein containing foods. The name ‘kwashiorkor’ is derived from a term used by a tribe in Ghana and is said to mean the sickness an older child gets when the next baby is born. (i.e. commonly occurs when pregnancy causes the older child to be abruptly or semi-abruptly weaned.)

thin, pale, weak hair mild anemia

Characteristic Symptoms: (more difficult to recognize)
thin upper arm

apathetic child
your finger leaves a hole when you press oedema

Oedema/swelling of the face, feet, legs, hands, etc. Child has a ‘moon face’. Muscles are weak and wasted but still have some subcutaneous fat. flaking Skin/Hair changes – ‘Flaky paint’ skin rash, hair is usually paint rash thinner, reddish in color, brittle and easy to pull out. Growth failure – seen in height for weight for age chart

Behavioral Changes – Children have increased irritability, apathy, lack of appetite, they’re difficult to feed, and are miserable overall.

Marasmus is the most severe form of protein-energy malnutrition. It is usually seen in children under one year of age, unless a drought or famine occurs. A marasmic child is extremely deficient of energy and protein to the point of starvation. They are very thin and their skin seems to hang off of their bodies. A marasmic child is usually more alert than a child with kwashiorkor, wants to eat, and is much more interested in what is going on around him.

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Characteristic Symptoms: (Easy to recognize) Wasting of muscles and fat - skin hangs off of the body because there is almost no fat or muscle underneath. They have an ‘Old Man’ or ‘Monkey Face’ look to them. Severe growth failure – They have a low body weight and almost no height change. Usually very hungry – and interested in what’s going on in their environment Hair is usually normal and there is no Oedema or Swelling.

“Little old man” look”

Normal hair
Gross muscle wasting

No fat

Extremely underweigh

Hungry

Behavioral Changes – Alert, irritable, strong appetite, anxious to eat, but still miserable. Complications of severe PEM Children with severe protein – energy malnutrition run a high risk of death. They are much more likely to become ill and often become this way through illness. Once in this condition, they are very susceptible to other illnesses. Severe PEM children will most likely have chronic diarrhea, making them much more difficult to treat. Malnutrition and diarrhea are usually accompanied by dehydration, which requires immediate treatment and increases the likely-hood of death. Severe PEM children are often extremely deficient in micronutrients (below), such as vitamin A, and this contributes to their susceptibility to illness. Recovery Recovery from severe PEM is a slow, labor intensive process requiring special foods and drugs. Thus, it is advised that these children recuperate at a malnutrition facility or at a health clinic where continual supervision is available. Unfortunately, this prospect is very costly to any family in Niger and treatment at a clinic is usually far from home, so it is not an option often utilized. If children do recover from severe PEM their growth could be stunted and they may have permanent mental disabilities, especially if it occurred during their first six months of life. Micronutrient malnutrition Micronutrient malnutrition or deficiency is due to inadequate intake of vitamins or minerals. The major micronutrient deficiencies are in vitamin A, iron and iodine. Others mentioned below are less severe (see chapter). Vitamin A deficiency Vitamin A deficiency affects 43 million or 7% of the world’s children under the age of five. It effects the eyes and the lining of the intestinal and respiratory tracts. It is most severe in children as they are growing quickly and are often ill. These factors give them greater vitamin A needs. Children and adults deficient in vitamin A can develop xerophtnalmia.

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Xeropthalmia is a range of eye disorders culminating in complete blindness. It has the following signs, usually in this order: night blindness, bitot’s spots, conjunctival xerosis, active corneal lesions, corneal xerosis, corneal ulcers, keratomalacia and corneal scars. Night blindness occurs when it is difficult to see in dim light or at dusk and is seen when children trip over things at night. It is easily treated in one to two days with a dose of/eating food rich in vitamin A. First signs of corneal xerosis Bitot’s spots

First sign of zeropthalmia

Keratomalacia
(A burst
Cornea)

Bitot’s spots are foamy, soapy, whitish patches in the white part of the eye. They do not effect eyesight and disappear after treatment. Corneal xerosis is seen when the surface of the cornea becomes dry (xerosis) and cloudy. It can be cured in one to two weeks with vitamin A, but can deteriorate quickly into corneal ulcers and this may affect the eye sight (eye needs protection from sunlight). If corneal ulcers/xerosis are not treated the entire cornea becomes cloudy and may burst exposing part of the eye (usually worse in one eye).

This is keratomalacia and some eyesight can be saved if a full dose of vitamin A is given immediately. Otherwise corneal scars develop, the cornea turns white and the child can see little through it. Vitamin A deficiency is not the only cause of corneal scarring, so it’s important to ask questions to determine what has caused it. Vitamin A is stored in the liver and the human body can store up to a six-month supply. However, vitamin A is used more quickly when illness occurs, thereby rapidly depleting this storage. The easiest way to replace vitamin A is to eat vitamin A rich foods (liver, carrots, mangoes, etc.) on a daily basis, however this is not always possible. In this case vitamin A capsules are available at health clinics around Niger and vitamin A doses are given during vaccination campaigns. A vitamin A capsule contains a full six-month supply for any child who is not noticeably vitamin A deficient. It is suspended in oil with vitamin E and both help the body in vitamin A absorption. Usually, the vitamin A in oil capsules contain 200,000 IU and can be given to children every three to six months, unless you are treating xerophthalmia, sever PEM, or measles. Children under one year of age should not be given the full dose instead, they should get a half dose or 100,000IU. Measuring Malnutrition If malnutrition is suspected, and a health clinic is nearby it is best to do height/weight or weight/age measurements and compare it with a normal growth monitoring chart (discussed in chapter 4). However, the nearest health clinic may be too far away or the family might not have the money or willingness to go. In this case, you can obtain a rough estimate of malnutrition by using an arm circumference band.

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Arm Circumference Bands Effective only on children between the ages of 1 and 5 years. Under one year of age, the bands are ineffective because during the first year of life the circumference of the upper arm increases rapidly in healthy children as muscle and fat tissues are laid down. After age one, the arm circumference remains fairly constant at or around 16 cm. A malnourished child’s arm will begin to waste away as fat and muscle disappears, thereby reducing their arm circumference.

An example of an arm circumference band

0.5

NUTRITION
13.5 12.5

(Yellow)

• These armbands are easy to use, especially if the child’s age is not really known. Unfortunately, they are not as accurate as weight for age, weight for height, or height for age measurements and they are not a good way to measure progress, but it is a good way to begin to recognize malnourished children. Community health workers can also use them to become aquatinted with malnourished children in their area. Making arm circumference bands is easy and can be done with various items such as string, reinforced paper, or other materials. It is important that the band be approximately 17 – 18 cm long with measured portions marked by lines, knots or other methods. These measured points indicate: the start or 0 cm, the brink of severe malnutrition at12.5 cm, moderate malnutrition at 13.5 cm, and adequate to good nutrition from 13.5 to 16 cm.

MALNOURISHED (red)

0

Some concerns and suggestions regarding malnutrition The best way to prevent malnutrition is through education and other prevention activities such as growth monitoring sessions (chapter 4) which include weight measurement and nutritional counseling. Malnourished children need to be carefully monitored and treated with recuperation foods or enriched village foods (adding oil, sugar or peanut butter), in addition, snacks should be encouraged for both healthy and malnourished children. When counseling about nutrition malnutrition recuperation techniques it is important to take the following into consideration: Existence of certain food taboos, such as not giving eggs to children for fear that they’ll grow up to be thieves. Apathy of parents towards actively treating malnourished children, especially if a child is fussy as they will not force them to eat.

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Will of God, if God wants the child to die/live it will happen, The month of Ramadan (fasting), many pregnant and breastfeeding women fast during this period.

Note: for information on recuperation techniques, please request it from the Health Technical Trainer, as recuperation techniques are beyond the scope of a volunteer’s work.

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HIV/AIDS IN NIGER Niger Sero prevalence study Financing: 80% World Bank loan (Sante II) and 20% CARE Study: The study was managed and implemented by 2 CARE/Niger staff members, 4 consultants7, and 2 CERMES staff members (Centre de Recherche medicale et Sanitaire).8 Time Frame: June – July 2002, by eight 5-person teams Survey Protocol: The survey population was all people between the ages of 15 – 49 years of age. Data was disagregated by rural vs urban population, and male vs female population. In addition, general information regarding age, education level, marital status, occupation and surgical history was collected. They used a cluster sampling protocol based on 9000 clusters from the May 2001 census, in 120 subsamples divided between rural (4000 HH) and urban (2000 HH) zones, 20 HH (50 adults) per sampled cluster. For each cluster selected, a list of households was established, and the households sampled were divided into men and women between the ages of 15 – 49 (50% of each were surveyed). Quality control of samples was done in a double blind test by Centre Pasteur du Cameroun and the Institut Pasteur de Bangui9. Positive and inconclusive results were subjected to three additional tests to confirm results. Overall Results: 6140 participants10 were randomly sampled throughout the country11. 98.9% of those randomly selected agreed to participate12. The team used a simple questionnaire and took blood samples from each participant; 6056 blood samples were ultimately used (threw out bad samples or incomplete surveys), 68 were HIV positive (0.87%). A 0.87% sero-prevalence rate corresponds to a total number of 22,134 to 57,735 (based on an estimated population of 10.5 million people, with the given confidence interval) people between the ages of 15 – 49 years of age. Because of the very small number of HIV positive cases, it is very difficult to establish any patterns or relationships between HIV positive status and other factors. Number Rural Urban Men Women Total 4037 2019 2994 3063 6056 HIV + 26 42 29 39 6813 Percentage 0.64 2.08 CI (conf. Interval) .35 - .94% 1.19 – 2.96%

0.87

0.5 – 1.3%

SUMMARY CONCLUSIONS 1. There was no statistical difference between the HIV+ rates of men (1.5%) and women (2.6%) in urban or rural zones
7
9 8 The report was issued by CERMES. Their contact number is 75-20-40/45, www.cermes.ne, or cermes@cermes.ne 10

Jean-Patrick LOUBOUTIN-CROC, Pascal BOISIER, Amina AMADOU HAMIDOU, Odile OUKEM

10 positive samples, 10 negative samples, and 10 inconclusive samples were sent to each site. The total number of samples required for statistical precision of 0.5% and 95% CI was 4531. 11 The characteristics of the sampled population conform to national socio-demographics, which indicates the sample was representative. 12 More urban (1.5%) than rural (0.9%) people refused to participate in the sample. More military (8%), government workers (5.9%) and polygamous married participants (2.1%) refused to take the survey than other types of participants. 13 64 were positive for HIV 1, 3 for HIV 2 and 1 for both HIV 1 and HIV 2

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2. Sero-prevalence increases with age; 15 – 19 year olds are practically not infected (0.21%) 3. In rural areas, sero-prevalence was highest in college level students (2.5%, 162 cases), but in urban areas, it was highest in people with no education (3.4%, 559 cases). 4. Professional activities were not related to prevalence, but results were difficult to interpret because of the limited number of HIV + cases, and the varied number of different professions in urban zones. 5. Divorced women and widows had the highest HIV+ rates; single people were rarely infected. 6. There was no association between HIV+ cases and people who had blood transfusions or surgery14 7. The variables significantly associated with positive sero-prevalence include matrimonial status (4.6 for formerly married people), zone (3.1 for urban residents) and age (5.1 for 20 – 29 years of age, 7.9 for 30 – 39, and 9.8 for 40 – 49 years of age). The results of the tests were not given to participants, because district medical staff were not adequately trained in psychological counseling and treatment. However, it is important and interesting to note that the results were often requested, and members of households not sampled often asked to be included in the survey. The Evolution of HIV in Niger (results of previous studies) 1991 505 In Niamey 1.1% (1992) In Tahoua 1.4 In Zinder 0.6% (1994) Sex Workers in Niamey In Niamey 6% (1987-88) In Dirkou 27.9 (1995) Komabangou Comparison with other countries Country Niger (2002) Mali (2001) Tchad (estimate, 2000) Burkina (estimate, 2000) Nigeria (estimate, 2000) Benin (estimate, 2000) Libyan (estimate, 2000) HIV + rates for 15 – 49 year olds (%) 0.87 1.7 (1.5 rural, 2.2 urban) 2.69 6.44 5.06 2.45 0.05 21% (1997) 50% (2001) 2000 5598 2% (2001) 5% (1999) 2% (2001)

Total number of HIV positive cases in Niger Pregnant women

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69 rural participants (1.7%) and 85 urban participants (4.2%) had blood transfusions. Twice as many rural women as men and three times as many urban women as men had transfusions. 58 rural participants (1.4%) and 74 urban participants (3.7%) had surgery. 1.5 times as many women as men had surgery (in both rural and urban populations).

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What does a CHA (Community Health Agent volunteer) do? Here are small samples of the kind of work health volunteers do in the field: ● Encourage women to get prenatal exams ● Demonstrate how to make Oral Rehydration Solution ● Assist with Polio Vaccination campaigns ● Talk to women and men about birth control options ● Give presentation on health and hygiene at the local clinic ● Organize a baby weighing day ● Teach women how to make nutritious foods ● Present lessons on health in the local school ● Talk to men and women about HIV/AIDS ● Participate in bike ride to promote Aids awareness ● Do weekly radio show promoting a healthy lifestyle ● Teach young girls how to care for the health of the kids they baby-sit ● Train villagers how to keep their well more sanitary ● Train villagers in malaria prevention.

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