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.


The next morning at dawn, pinks and reds illuminated my mud-caked jeep, and the sight of it reminded me of the mosquito nets and birthing kits inside, and of the clinic to be built. I worked straight through until noon, unable to stop thinking of Zarah.

The sun had reached a fierce, scorching peak when I spotted Meg approaching across a clearing.

“We’ve got another one,” she said breathlessly, indicating a group of women in colorful dresses huddled around a body stretched out on a kente cloth.

“How bad?” I asked.

“She’s thirty-two weeks and bleeding. Went through three pads. If she doesn’t get to a hospital right away, she’ll lose the baby.”

Twenty-four hours earlier I would have done the cost-benefit analysis and left her behind. But something had changed during that sleepless night.

I walked across the clearing and looked into the girl’s pained eyes. I bent down and listened to her breath rise and fall. A cloud moved across the sun, the heat eased, and a breeze blew across the treetops. The women gathered around me, and I could feel their collective energy. No theory I’d learned seemed applicable. “We’ll take her,” I said.

As we bumped along the road toward the state capital, I felt doubts grow inside me. I’d leapt into unknown waters. It was impossible to run both an ambulance service and our long-term programs, but the very impossibility of it gave me renewed energy. As French poet and philosopher Paul Valéry wrote, “A difficulty is a light; an insurmountable difficulty is a sun.” I’d work on Sunday, my day off, to make up for the villages I’d miss today. The boundaries of the possible suddenly seemed flexible. I told the driver to take a detour back to Zarah’s village.

Zarah was still alive when we reached Fabalah, though she was moaning more now and had bloated further. As I rode on through the jungle terrain, a pregnant girl on each side of me, the only challenge was getting these women to a hospital before either of them, or their babies, died. The two women hadn’t been washed in days, and their smell was overpowering. We opened our windows and let the humidity pour in.

Not an hour later, one of our tires burst with a pop. In the time it took to change it, Zarah’s moaning stopped. I tried to nudge her awake. No use, though she was still breathing.

We were quickly back on the road again. I’d radioed ahead to the state capital for a jeep, and one was waiting to transport the pregnant girls to the Bo hospital and take Meg and some other health officers to a distant project site. Though the new girl was no longer losing blood, Zarah was barely conscious. Using old foam mattresses, we improvised a cramped bed in the back of the new jeep. I put one arm under Zarah’s leg and another under her neck and lifted her. She felt surprisingly light, as if bloated with air. Or had my strength mysteriously increased? The smell of decay filled my nostrils. Could I be exposing myself to some unknown disease? I thought. Who cares, I answered, as I placed Zarah gently onto the mattress. The more intimate, the better.

As their jeep raced on toward the hospital, I headed back into the interior, where another clinic was ready for inauguration. When I pulled up to the whitewashed building, a brilliant orange sun was already low in the west, and stars and planets were peeking through the darkening sky. I stepped out into a dancing crowd and the sound of drums and voices singing joyfully. They pulled me into the celebration, and we danced right into the marvelous new clinic. When the music had stopped, the chief gave thanks for the simple cinder-block structure, which had a well for safe water, a latrine to eliminate feces from underfoot, and a solar-powered refrigerator for life-preserving vaccines.

But I couldn’t fully join the celebration. These folks didn’t see beyond their village to the ten thousand other villages in Sierra Leone without clinics. The rates were back at the forefront of my mind. The rates.

I got up early the next morning and headed back into the bush, toward another village. On the way I raised Meg on the radio and asked what had happened with Zarah. The response was garbled. I made out only a faint “Zarah,” and then static.

Hours later Meg’s voice drifted into the jeep, sounding wavy, as if underwater: “When we dropped her off at the hospital Zarah was —” Silence, then static.

“Negative copy,” I said. “Please repeat that.”

After an interminable pause, I heard Meg’s voice: “Zarah was still breathing.”

There was so much to do in that country that I ended up helicoptering out without learning of Zarah’s fate. After walking through Central Park this morning, I sat on a bench and wondered: Did Zarah survive, or did my delay cost her her life?

I do know this much: since then, maternal mortality in Sierra Leone has dropped from 1 in 50 to 1 in 80. This means that two thousand more women will live through childbirth this year.

But this work isn’t tidy accounting. It’s a contradiction that can’t be untangled from the larger paradox of love. I want to save these future Zarahs, but I also keep my heart open to the starfish on the beach, and heave as many seaward as I can.