Julie Carney is broadening the scope of healthcare centers at the village level in Rwanda to include healthcare and agriculture in a bid to provide long-term, homegrown and community-led solutions to the endemic problem of malnutrition. Julie is demonstrating a powerful new way of leveraging synergies between two sectors—which have traditionally operated independently of each other and, at some level, counterproductively—to address a complex problem that to her, requires a multi-sector approach.
The New Idea
Through Julie’s organization, Gardens for Health International (GHI), she is transforming healthcare centers so that they are able to provide—in addition to medical services—education, psychosocial support, and agricultural extension services to mothers affected by malnutrition and, in effect, is empowering them to become part of the solution. Julie sees that when mothers—who traditionally have the responsibility of deciding what food their families’ eat—are empowered to make better dietary choices, malnutrition can be sustainably rooted out of Rwanda. She has developed a groundbreaking training model, co-created by the mothers themselves. The simplicity of her training material, the fact that it is co-created by her beneficiaries, and the engaging and fun way in which it is administered, completely demystify complex nutritional concepts, making them accessible and easy to understand even to the most primitive rural communities.
Malnutrition afflicts over 45 percent of children under five in Rwanda, resulting in retarded growth, reduced mental function, and low productivity. In rural areas, where prevalence of malnutrition is particularly high due to a comparatively greater rate of poverty and illiteracy, mothers—unaware of the signs of malnutrition—often don’t notice it until their children are in critical condition. More than 90 percent of the cases of malnutrition that make it to the village healthcare centers, only do so in emergency cases. Widespread ignorance at the community level and a reactive stance taken by health centers means that most children who receive emergency treatment are often re-exposed to the same high-risk environment that led to their condition in the first place. Moreover, a small but good number of mothers attribute their children’s “strange” condition to witch craft and rarely seek any professional help, preferring instead to visit traditional doctors. The risk for children living in nutritionally risky environments under the care of uneducated mothers is particularly dire for those living with HIV/AIDS. Without a proper diet, the use of ARVs or other medicines in the case of other common diseases becomes less effective, drastically increasing the risk of a fatal outcome.
The Government of Rwanda—one of the most progressive in Africa—has made an effort to combat the endemic malnutrition that threatens a significant portion of its young population. Among the strategies implemented is the national distribution of emergency food supplements targeted at health centers for the treatment of emergency cases. The mass distribution of food supplements was done off the backs of military personnel dispersed across the country with little or no health expertise to train health workers. In addition, the government promoted the concept of “kitchen gardens” and distributed vegetable seeds to a few farmers but without any further support, in much the same way as the few farmers who received a cow through the “one cow per poor family campaign.” Through the Ministry of Health, the government designed a nutrition protocol to guide health workers on how to address malnutrition in rural communities. This protocol was, however, published only in English without any follow-up training, making its contents inaccessible and hard for most health workers to use. The common trait among all the cited government interventions is that they are short-term, top-down, and unsustainable.
A closer look at policies in different government ministries reveals that, while they are well-meaning when considered individually, together they tend to be counterintuitive. Take for example priorities at the Ministry of Health, which include proper nutrition and advocacy for kitchen gardens and food crop farming, compared to policies at the Ministry of Agriculture which advocates for commercial farming of cash crops aimed at poverty eradication. Agricultural extension workers, typically attached to the Ministry of Agriculture, are expected to give farmers advice and guidance on commercial farming with little or no attention paid to food crop farming for dietary purposes. Private sector players in the agricultural value chain too fail to see the connection between nutrition and their business. Take the Northern Province of Rwanda for example; the area is the most productive in agricultural production of major cash crops, like coffee and cotton, yet shows the highest prevalence of malnutrition in the country.
Village healthcare centers are at the core of Julie’s strategy because a center is the first place that rural communities go to for healthcare services. It also helps that there is one government healthcare center for every single village in Rwanda. Julie was deliberate in her strategy to work within the existing healthcare system, as it was the most sustainable and cost-effective approach to transforming the way the system worked. Starting with three strategically selected health centers in three villages, she set out to transform their culture and scope of operations by introducing two new roles, including an education officer and an agricultural extension agent. GHI recruits, trains and pays the two new staff members for the first three years of GHI’s partnership with the health center. All other staff members are trained too by GHI and continue to benefit from ongoing GHI mentorship and support. Community health workers are trained on how to identify and call in cases of malnutrition in the community before they reach critical status. When a malnutrition case is received at the health center, the child is treated and the affected mother is immediately enrolled in a 14-week nutrition education program run by the education officer. The curriculum for the training was co-designed by the women in the program and ended in the development of engaging, drama-based training modules. Materials are prepared using pictures, colors, and a language that the women understand and relate to. Each 14-week class enrolls at least 40 women and offers a network of support to each of them. After a thorough but fun education experience, the mothers are given inputs and ongoing support through a dedicated extension worker, based at the health center, to set up and manage the best kitchen garden for their families’ dietary needs. Kitchen gardens are tailored to each family depending on land size, family size, income level, and special dietary needs.
Julie seeks to create a long-term solution to malnutrition, which explains her focus on building systems for sustainability within her approach. When entering a partnership with a healthcare center, Julie makes it clear that GHI will exit in three years. The three years then become an intense capacity-building run, designed to transform how the center works. One of the centers working with GHI is approaching the three-year mark and has added the salaries and activities under the two new roles to their annual budget to the government, a clear sign that Julie’s work is taking root systemically. As she works with mothers through her education program, her focus is on empowering them to become active decision-makers in control of their families’ diet-related health outcomes. But what’s more, these same women have become watch dogs for malnutrition in their communities. They are quick to identify signs of malnutrition in their neighbors’ children and are able to offer advice, and where cases are advanced, they refer the women to the health center. Julie’s education program is unique, easy to understand and so effective that the government has taken notice and is considering national adoption. Julie’s team is often invited to sit in on government strategic meetings related to healthcare provision in rural communities.
Julie’s simple yet powerful demonstration of using highly valuable synergies between healthcare and agriculture to solve one of Rwanda’s most important social-economic problems sets a useful precedent for the integration of social, economic and environmental planning across different sectors. Beyond inspiring transformation in government planning, Julie is introducing private sector players to the conversation on nutrition. GHI just signed a partnership with Rwanda’s largest coffee trading company to enroll their enormous network of out growers in their nutrition education program. Training will be carried out at the company coffee roasting premises and will serve to educate not only the farmers but company staff too. The Rwanda Trading Company is GHI’s first private sector partner taking responsibility for the nutrition and well-being of their most vulnerable stakeholders. Julie sees this as a step toward influencing the behavior and actions of private sector players that work with vulnerable communities.
Julie was born to a hardworking and passionate father, a doctor who resisted the allure of joining a mainstream practice to operate as a sole practitioner in order to spend more time with his patients. Her mother, a university teacher, showed extraordinary commitment to her students and often hosted them at their family home, because they couldn’t afford to live at the university hostel. The selfless nature of her parents and their commitment to serve others rubbed off on Julie, who served on the student council and in many cases as president all through her education. In addition to student council positions, Julie started several initiatives while in school, including a book club, a “secret poem of the week” project and a scholarship program that raised money to educate disadvantaged children in South Africa.
Julie went to Yale University, where she studied political science, and it was during this time that she was exposed to the inequities between developing and developed countries. During an election-monitoring mission she led in Nairobi during the 2007 elections, she witnessed firsthand the series of events that sparked the post-election violence that led to the death of over 3,000 people. Following her experience in Kenya, Julie went on an exchange to Mali and experienced yet another facet of the gross equities that characterize developing nations. She recalls finding it strange to see that poor families, who did all the hard work growing crops, exported their yields to developed countries; Kenya then imported a processed version of the same crops, at much higher prices. What she saw sparked an interest in American food AID policy, and she went on to do her research around the Millennium Villages, to analyze their level of success as a development model.
During a class with her good friend Emily Morrel—who had spent a summer in Rwanda working with the Clinton Foundation—they got talking and the idea of Gardens for Health was born. The idea was to work with people with HIV/AIDS in Rwanda to help them grow their own food for consumption and sale. With initial funding from a business planning competition, Julie moved to Rwanda two days after her graduation to make their idea happen. After two years of interacting with rural communities, and understanding the development space in Rwanda, Julie was convinced that they were focused on the wrong problem. Malnutrition seemed, to her, what they needed to be tackling. Gardens for Health evolved accordingly, and is now trailblazing a whole new way of addressing this significant problem.