Future Zarahs

DID MY actions lead to Zarah’s death? The question surfaced today while I was walking in Central Park. I was savoring a sunny spring morning in New York City, where I live between humanitarian-aid contracts, when the scent of something decomposing wafted out of the bushes. I moved quickly along, but I couldn’t escape the memory of Zarah’s sickbed in the West African country of Sierra Leone. While serving there as an aid worker, I’d been forced to make an impossible choice, the kind of choice that results in someone’s death either way.

There’s a popular story, inspired by the writings of Loren Eiseley, in which two friends arrive at a beach covered to the horizon with marooned starfish. “Their numbers are so vast,” one friend remarks. “Nothing we do could make a difference.”

The other reaches down, picks up a single starfish, and heaves it into the sea, saying, “It makes a difference to this one.”

This kind of story got hacked to pieces in my graduate classes in international relations. I know what my professors would say: Forget those doomed starfish! Don’t waste time tossing back a few; instead prevent future starfish from getting marooned in the first place. Cut the starfish death rate by 10 percent, and you’ll have rescued a hundred thousand instead of a handful.

I chose aid work because I wanted to ease suffering — others’ and my own. As a Catholic kid growing up in a Long Island suburb in the 1980s, I’d been brought to tears by Live Aid’s images of starving babies. How could I live happily in a world where I had so much and others so little? Or, as I’d later come to phrase the same question: how could I lessen the dull ache of estrangement I felt between myself and the rest of humanity? On an unconscious level I wanted to experience empathy with people in pain; to get free of my narrow, self-seeking ego and stretch toward my larger self.

But five years as an aid practitioner had turned this yearning into something mechanical. I’d been sent abroad to lower rates of starvation, infant mortality, and hiv transmission, and  I’d come to focus on numbers, not individuals’ pain. Human beings had become statistics to me — and not without reason. If I’d seen every starving child as an actual starving child, I’d have left the business. Relief organizations aren’t the Peace Corps. The Peace Corps doesn’t send volunteers to the countries where we work, those anarchic Fourth World places where the globalization beast barely pauses to wipe its lips — places like Sierra Leone in 2004.

That’s where I met Zarah. I’d been hired as program manager by a U.S. aid group, which helicoptered me into Sierra Leone with a mandate to help rebuild the country’s demolished healthcare system and reduce maternal mortality. A ten-year civil war had just ended, but women in Sierra Leone continued to die in childbirth at a rate two hundred times higher than that of American women. In fact, the country had the world’s highest maternal-mortality rate, worse than Iraq’s and Afghanistan’s: a shocking two dead mothers for every hundred births. My job was to put together a team of twenty people to build clinics and train birth attendants so that more mothers would live to raise their children.

My team was put in charge of Sierra Leone’s poorest region, the hilly rain-forest state of Koinadugu. It had no public utilities, only a few paved roads, and spiking hiv, tb, and malaria rates. Imagine trying to build from scratch a healthcare system for a Vermont-sized area with only four jeeps and half a million dollars at your disposal.

We had been working ourselves to the point of exhaustion for two months when my mud-covered jeep passed through the village of Fabalah, and a man suddenly stepped in front of us, waving his arms. Our driver narrowly avoided hitting him.

“The girl dying!” the man said in English.

My colleague Meg and I jumped out and followed him between mud huts with zinc or thatched roofs. Meg was a twenty-seven-year-old from Illinois with a newly acquired master’s degree in public health, and her energy and idealism were far more intact than mine.

As I entered a hut behind the man, the swollen silhouette of a girl took shape. This was Zarah. Meg brushed by me and fell to one knee at the girl’s bedside. Zarah’s big belly looked ready to burst from her pregnancy, and bright red bumps covered her swollen legs. Sucking at the air, she strained to answer Meg’s questions. Meg took Zarah’s pulse. It was all she could do; the village had no medicine or equipment.

“This girl is going to die,” Meg said.

“How long does she have?” I asked.

“Hard to say. She’s basically allergic to being pregnant. She needs to get to a hospital with a blood bank. She needs a cesarean.”

I rushed back to the jeep and got on the radio to our office in Kabala, Koinadugu’s capital, but the situation there wasn’t much better: the state’s sole ambulance was presently in the nation’s capital, Freetown, along with Koinadugu’s only two doctors. It was as if Oregon had no doctors, and you had to go to Idaho for treatment.

I felt lightheaded. My joints ached, and I hoped I wasn’t getting malaria again, not out here, beyond drugs and iv drips. (The irony of this thought, in light of Zarah’s plight, would strike me later.) Palm trees swayed in the hot breeze, and I looked down to find a small child petting my arm hair as if I were an exotic animal. He giggled and ran.

Back inside, Meg was whispering into Zarah’s ear and stroking her forehead. I led Meg into the adjoining room.

“Should we turn back, take her to a hospital?” I asked.

“Your call.”

She was right: it was my call. I was the senior official. As I’d learned on similar occasions in the field, nobody was going to make this decision for me. The dilemma would provide an ethics professor with enough material for a thirty-page journal article, but I had just minutes to make a decision. I looked through the doorway at Zarah. A hundred villagers had gathered around the hut and were staring in the windows, as if awaiting my verdict. Though contorted in agony, Zarah’s face was beautiful. Only nineteen. Where was the
father of her baby? I knew that, during the war, rape had been as common as a handshake, and that most women in Sierra Leone still wore tight canvas shorts under their skirts to make it more difficult for would-be rapists.

I wanted to turn our vehicle around and take Zarah to the nearest hospital, six hours away in a city called Bo. But the hardened professional in me said: Forget about the doomed starfish at your feet. Cut the starfish death rate, and you’ll save so many more. This country had an average life expectancy of just thirty-three — my own age. I couldn’t run an ambulance service here. I needed to be realistic. If I turned the jeep back, I’d be abandoning our work in another village: training birth attendants, distributing malaria-preventing mosquito nets, and overseeing the construction of a clinic — activities that could save dozens, even hundreds, of future women from Zarah’s fate.

The three other jeeps that belonged to our program were too far afield to assist us. One had been stuck for a week on the far side of a flood-stage river, where our staff members were now subsisting on what they could hunt or forage. Only one other vehicle passed through Fabalah each week: a lorry from Guinea spilling over with goods and people — no room for Zarah. I could either go on with my work and leave her to die, or save her only to agonize later over the dozens of unknown women I’d likely condemned to death.

I knelt beside Zarah’s bed and touched her forehead: hot as fire. I felt the heat build in my own face, and — despite years of experience with this kind of situation — tears rose to the surface. I tried to envision the faces of all the women we’d save by continuing with our mission, but the only one I could see was Zarah’s. I whispered to her that I was sorry. It was impossible to turn back. There was nothing we could do.

THAT EVENING I spent a hot, sleepless night in Mongotown, three hours from Zarah’s village. I imagined Zarah’s body swelling. I imagined her, conscious and suffering, aware of her own imminent death and of her child’s. I felt like a failure — or, worse, a killer.

I cursed the way international aid is hard-wired for failure, like putting a drop of iodine on a full-body burn. The U.S. spends roughly a hundred thousand times as much on the war in Iraq as it does on development in Sierra Leone. We aid workers are fig leaves for a wicked foreign policy: round up a few idealists, give them a few bucks and some jeeps, and maybe somebody will think we care.

To survive as an aid worker, you must wear blinders. Over the years I’ve noticed that there are two types who last: cowboys and statisticians. Both approach the work with an absolute sense of certainty. The cowboy’s motto is “Save every Zarah.” While making not the slightest dent in rates of hiv or infant mortality, cowboys become demigods, galloping into town and handing out bags of bulgur wheat. One cowboy I knew in Liberia hated to see people sleeping on the ground and espoused the mattress theory of international development. “Just give them mattresses,” he’d say, tearing up his long-term program plans. When he left Liberia, three hundred grateful people attended his going-away party.

Statisticians have poorly attended farewell parties, because the people they help don’t exist yet. Statisticians look right past every Zarah in their path, toward that future utopia of .001 percent maternal mortality. Devoted to reason, they are all brain and little heart. In a world beset with widespread ills, the statistician insists, the only ethical choice is the lesser evil.

My training had turned me into a reluctant statistician.

That long night in Mongotown, the forest around the village was silent. The infamous Colonel Cut Hands had terrorized this area during Operation Feed Yourself. Rebels kept the population in line by cutting off kids’ hands. Rumor of their barbarity caused villages to empty out even before the advancing rebel forces arrived. That’s how they secured their objective: control of the lucrative diamond fields.

There’s a kind of mythology around African wars that turns them all into ethnic battles, but Sierra Leone’s was much more about the global economy than about local tribes. The country — including the healthcare system that could have saved Zarah — had collapsed into chaos in part because Westerners want to adorn their ring fingers with diamonds. We effectively finance the warlords by buying so-called “conflict diamonds.” With a little political will, we could boycott or even actively embargo diamonds from Sierra Leone, Angola, and other war-torn countries, but we don’t. “Embargo diamonds? Are you nuts? Diamonds are a girl’s best friend.”

Tell that to Zarah.

As the night wore on, I felt I was playing a fool’s game, sent into impossible situations with comically inadequate tools. What had happened to my American life over the years? I owned no home and was single with no prospects in sight. My engagement to a beautiful woman I’d met in grad school had unraveled, partly over my relief work. “I’m a Third World person,” she’d told me before the relationship fell apart, “not a Fourth World person.” Costa Rica, Thailand, or South Africa she could do. But not Afghanistan, Liberia, Sierra Leone.

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