Although Nuru’s healthcare program focuses primarily on maternal and child health, we think it’s extremely important to involve men in all of our programming. In Kuria, Kenya, men are traditionally the primary decision makers. This still holds true in most households. Before getting married, a man has to pay a dowry in cows to his potential wife’s father. The woman’s father can demand as many cows as he wants, essentially setting the “selling price” for his daughter. Sometimes a man will continue paying off his dowry for years after the wedding. Once the couple gets married, the woman almost always moves into at the man’s homestead to live with his family. The husband makes all household decisions and the wife is expected to follow whatever her husband says, whether she agrees with it or not. Marriages without this gender imbalance are rare.
These regimented gender roles mean that a woman is often not allowed to make decisions about her own health or that of her children. This includes important health behaviors like delivering her baby at a health center, vaccinating her children, or using birth control. Since the man controls the household’s money, a woman will sometimes have to wait many hours until he returns home with the necessary cash before she can take their children to the health center when they’re sick. It also means she might not be able to buy the mosquito net that could save her children from malaria or the Water Guard that will protect her family from diarrhea.
With women as the primary caretakers and men as the primary decision makers, both need to understand and prioritize the behaviors that will keep their children healthy and alive. Many established CHW programs specifically recruit female CHWs to train female community members. While this works in some societies, at Nuru we have made a conscious decision to include both male and female CHWs to train men and women in the community. When Nuru’s CHWs visit a house, they try to talk to all adult family members. This often means that a husband and wife receive the same information from the CHW at the same time, giving both an opportunity to choose healthy behaviors for themselves and their children.
Unfortunately, sometimes a father makes a decision that negatively impacts his family, and his wife feels like she cannot defy his decision even if she disagrees. This happened recently when Isire, one of our field officers, came across an extremely undernourished child, not yet two years old, during a home visit. He urged the mother to rush her son to the health center immediately. The mother complied with his referral. When the nurse explained that the child would need to be admitted for one week, the mother said she needed to talk to her husband first. The health center agreed to waive the 100 shillings per day fee (almost $8 total for the week) because of the family’s financial situation. (Waiving fees is common practice in this area because 100 shillings is a lot of money for a family. It’s the amount one can earn from a full day of work as a day laborer on a farm or in seasonal work; it’s also equal to the full-term public school fees for a primary school student – fees which many families have difficulty paying.) The father refused to allow his son to be treated for free with the therapeutic food needed for survival because he wanted his wife home to cook for him every morning and night. If the mother accompanied the child to the clinic, the father would need to cook for himself. Without treatment, the severe acute malnutrition was sure to kill this little boy.
When Isire returned to the house the following week, he discovered that the child had not received treatment. Isire unsuccessfully tried to convince the father to allow his child to spend a week at the health center. After numerous refusals by the father over the next few weeks, Isire involved the assistant chief of the area. The assistant chief sent a village elder to deliver a letter to the father. The father was quite upset that the assistant chief was requiring him to send his child to the clinic immediately. After an argument with the elder, the father acquiesced. One week later he finally allowed his wife to bring their son to the clinic where he was able to be treated. Thankfully, the little boy has improved immensely from the week of therapeutic food and is almost ready to return home from the clinic.
Stories like this are heartbreaking. It reminds me why our work is so important. While this is an extreme example, it clearly illustrates why we need to make sure our programs work within established societal gender roles. Men need to understand and practice disease prevention behaviors just as much as women do. The more Nuru’s CHWs can increase awareness of how to prevent the diseases and conditions (like undernutrition, pneumonia, and diarrhea) that are killing children in this area, the more children will live to become adults. We need to educate and convince all of the men and women in Kuria that adopting healthy behaviors – like delivering their baby at the clinic, washing their hands with soap, breastfeeding their baby exclusively until it’s 6 months old, and sleeping under a mosquito net – can and will allow their children to live healthy, productive lives.