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    The Birthday Party at the End of the World

    Matthew Loftus

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    It would take a posting in one of the poorest and most violence-torn places on earth to open my eyes to the lived reality of food insecurity back home in Baltimore.

    Living in South Sudan was trying in many ways – the heat that got up to 110 degrees Fahrenheit, the malaria-carrying mosquitoes that showed up at the first sign of dusk, and the lack of basic infrastructure that made just going to town for groceries an adventure. And caring for patients at a basic maternity and pediatrics hospital had unique challenges of its own. During a bad malaria season, we were seeing one child out of twenty die almost every night out on the pediatrics ward, and as South Sudan’s civil war worked its way from the capital to us, we began to see more gruesome injuries in children, as well as soul-wrenching cases of malnutrition.

    To be entirely honest, though, I never forgot about the luxuries of home and never stopped longing for them. I thought a lot about food. “You know, we haven’t had tortilla chips in six months. Do you ever think about that?” My wife once asked me. Not wanting to be dishonest with her, I replied: “Uh… yes. Actually, I think about it every day.”

    It was a strange lifestyle: our small houses with cracking tile and no air conditioning, well below what we would ever think of living in back home, were palaces compared to our patients’ mud huts. We subsisted on beans and rice and ate meat only once or twice a week, but having three full meals a day put us far ahead of our neighbors. We were constantly concerned about the threat of war or armed robbery, but we had a fence and guards on patrol day and night, unlike families who could be hacked to death merely for  the accusation of harboring rebels. We had to fly to Uganda to get real butter, but … well, whenever we flew to Uganda, we brought back a cooler of butter.

    Thus, we tended to hoard certain food items. Candy and chocolate were kept in the freezer (powered by a giant solar array that also kept the lights on in the hospital operating room) and eaten one piece at a time. Precooked, nonperishable bacon came over with visiting teams and was brought out at parties. We ourselves brought several canisters of parmesan cheese that we sprinkled carefully on pasta so as not to use it up too fast.

    Food became even more precious when violence began breaking out around us. Prices rose, and we began to hear about shortages in the market. With that came more cases of child malnutrition. We ordered more and more from an Ethiopian restaurant in town, paying an extravagant two dollars per person for a big tub of shiro wot and roasted goat meat with injera. We had begun to habitually meet together as a compound once a week and ordered out then, too, as it became less safe to go into town. During those meetings, we discussed the tensions that kept rising and tried to discern whether the news of nearby fighting was real or just gossip. I had never really appreciated how unsettling “rumors of war” could be, but we came to understand that a constant stream of whispers about when the fighting would reach us was enough to keep us feeling on edge most of the time. It was impossible to build anything to last, but we couldn’t bear to leave in case the rumors died down and the war never came.

    When a stray bullet flew over our house and whistled past the ear of one of our South Sudanese nurses, we knew it was time to go. We could no longer guarantee anyone’s safety, and half of our patients had already fled. During that short and painful weekend, all the families with children packed up the lives we had established in the middle of the old teak forest and prepared to leave as quickly as we could.

    Sunday night was my daughter’s fourth birthday, and in the midst of our grief at leaving the people and work we loved, we threw a party. With nothing left to save, and having received a bounty from a family visitor just weeks before, we went all-out: a beautiful cake with chocolate ganache frosting that used up our supply of chocolate chips, followed by a smorgasbord of the salami, M&Ms, and crackers that we’d been squirreling away for weeks and months. It was the sort of spread that would be mediocre at a house party in America, but for us it was a feast. We ate until we were sick.

    We gave away our chickens and the remaining food in our pantries to the guards and the domestic workers on our compound. We gave away our extra South Sudanese currency – growing ever more worthless by the day – to the hospital staff who had stayed and served faithfully despite the ever-encroaching threats of violence. We said goodbye and promised to keep in touch by WhatsApp. And then we flew away with the bags that would fit on a small plane.


    My family’s experience with food insecurity was mercifully brief, but for many people, struggles with food are life long. For years, people who care about public health and nutrition have told a story about poverty and food that goes something like this: many poor people in America live in “food deserts,” places where chips and soda are plentiful but fresh fruits and vegetables aren’t. Because people in these places don’t have access to fresh and healthy foods, they eat a lot of prepared and junk foods, which in turn puts them at higher risk of disease and death. If we could change this access issue, then we could make people healthier!

    Unfortunately, this isn’t the whole picture. Even if there is a correlation between food deserts and unhealthy eating habits, it’s impossible to say that the one has always caused the other. Furthermore, studies show that expanding access to affordable fresh fruits and vegetables in a neighborhood doesn’t necessarily make people consume more of either. Instead, there’s a strong connection between family income and eating habits, one that has far more to do with the psychosocial effects of poverty and wealth than the simple question of access.

    Priya Fielding-Singh, now a postdoctoral fellow in sociology at Stanford University, writes about this powerfully in an op-ed for the LA Times:

    An overwhelming majority of the wealthy parents told me that they routinely said “no” to requests for junk food. In 96% of high-income families, at least one parent reported that they regularly decline such requests.

    Parents from poor families, however, almost always said “yes” to junk food. Only 13% of low-income families had a parent that reported regularly declining their kids’ requests.

    Fielding-Singh goes on to describe how parents in poverty are constantly saying “no” to their kids’ requests – and perhaps, implicitly or explicitly, even to their kids’ questions on whether or not their future might be more hopeful than their present. Thus, indulging their kids’ small requests for junk food was a way of feeling like as though they are worthwhile parents.  For parents who can’t give their kids a decent school or a neighborhood free of violence, being able to give their children something they can enjoy is deeply valuable.

    Investing time and energy in being healthy is simply more difficult for people who have less money. Many poor people struggle with a shortage of time to prepare healthy food, find it difficult to store fresh foods in places often infested with vermin, and do not know what balance of foods is healthy. Even more, though, I think that because people mired in poverty are less likely to see their investments in anything pay off, taking care of one’s body becomes less worthwhile. Having spent just a small amount of time living with the possibility of violence overtaking myself, my kids, and the people I worked with, I can say that it’s hard to feel motivated to do anything but survive in such a situation.

    Of course, the nihilism and despair induced by poverty do not obliterate the agency that poor people can, should, and do exercise. However, it does make that sense of agency feel inadequate and impotent, creating a negative feedback cycle wherein people are less likely to try things that might pay off in the long term, and more likely to indulge in behaviors that ameliorate their immediate needs or wants. This makes long-term success even more elusive.

    There is a deeply complex web of influences that shape the communities that we live in and the choices we make within them. Adverse childhood events such as physical or sexual abuse, exposure to violence, or even divorce are sadly common in poor communities. Such events put a person at a higher risk of dying early from causes like cardiovascular disease (regardless of the choices that they make), and it also increase the likelihood that people will make unhealthy choices like having multiple sexual partners or using drugs.


    Through our relatively brief experience with relative deprivation when in South Sudan, our family’s relationship with food became fraught with emotional energy. When we saw the place we had come to love fall apart, when we felt that there was no hope for the future, we ate ourselves sick. While our experience was just a fraction of what my friends in Baltimore or my patients in South Sudan lived with for the rest of their lives, the birthday party at the end of our world helped me to understand that the relationship we have with food is a lot more affected by our circumstances than we might think.

    Those of us who have power and privilege and care about the health of others should not stop encouraging others to eat better, and we should not be hesitant to embrace policy changes like soda taxes that might help shape the environment in which people live and make decisions. But, even more importantly, we must listen to what our friends on the other side of the table have to say. Without those relationships and the willingness to listen, we will never learn from those who have the greatest insight into why things are the way they are in poor communities.

    People who feel like they have been written off by society are deprived of hope, and those who feel that they have no future will not care for their bodies as the gifts that they are. Ultimately, caring for our bodies can only be done as a body. Our membership in one another not only shapes our individual actions but also determines things as diverse as the quality of the food we eat to the health care that’s available to those who are sick. If one part of the Body is suffering from too much obesity, diabetes, and high blood pressure … should we not ensure those brothers and sisters are cared for as friends and neighbors, and share our table with them?

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    Contributed By Matthew Loftus Matthew Loftus

    Matthew Loftus teaches and practices family medicine in Baltimore and East Africa.

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