Blood and Milk

There is a woman who works for a friend of mine. I’ll call her Gulia since half the women in this country go by Gulia, so it’s safely anonymous. Every winter, all winter long, Gulia wears the same pair of battered brown ankle boots. They are too small for her, and they have no insulation. We know this because Gulia complains about her boots every day, all winter long. Her feet get cold, and her toes hurt.

My friend is a good person and a caring employer. She pays Gulia well enough that she could buy herself a pair of boots, but Gulia never does. She also gives Gulia boots.

She has given Gulia knee-high black boots to go with a dress. She has given her insulated fuzzy boots to fight the cold. She has given her cheery yellow rain boots to splash through the puddles that cover the roads here. Gulia does not wear these boots. When my friend asks about these boots, Gulia thanks her warmly for her generosity and insists that she wears the boots all the time, just not to work. We are quite sure that Gulia is lying about this.

Now, Gulia likes me. She is supporting her parents on her salary, and she likes that I am doing the same for my parents. She is ethnically Uzbek, and I speak Uzbek, so we can chat in her mother tongue. We get along. My friend asked me to try and find out what exactly was going on with the boots.

So, the other day I asked. And Gulia actually told me what was going on with the boots.

The answer? She’s short, and she’s a mom. Because she’s a mom, when she has cash she can spare, she doesn’t spend it on boots for herself. She spends it on her kids. Because she’s short, she only wears shoes with heels. And since my friend has been trying to give her practical, durable boots, she’s been buying flats. The ankle boots may hurt, but they have heels. Gulia can’t face life without the extra two inches. She’d rather have pinched toes and cold feet.

My friend’s gift boots are sitting at home in Gulia’s closet, waiting for Gulia to get so old she can’t wear heels any more, except for the fuzzy pair, which her mother now wears in cold weather.

The moral? There are several, I think. 1) Gulia wants other things, like school supplies for her kids, more than she wants new boots, so maybe we should stop giving her boots. 2) People want what they want, whether or not it makes sense to me. 3) And donated shoes need to actually meet people’s needs, as people themselves see them.

(This story is mostly true. I have changed some elements to make it totally anonymous.)

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(photo credit: KayVee.Inc)
Chosen because I suspect those are Gulia’s dream boots.

Tags: basics, field life
Posted in Uncategorized | 1 Comment »

Hello to everyone coming in from metafilter. For the record, I don’t consider myself to be an iconoclast. I am fairly certain that my ideas are 1) very ordinary and 2) shared by most people who work in international development. I’m just the person who’s willing to take the time to blog about it. And while I know I am critical, I do believe that international development can - and does - work. If I didn’t believe that, I wouldn’t be working in this field.

I know this blog isn’t all that searchable (I am working to fix that) so here are some links that might help you get a sense of what I am about:

Positive deviance, and why I like it

Why we should care about global health

Oral rehydration solution

The list of things I believe in

Learning from failure

Monitoring and evaluation

I am working a lot right now, so I don’t update that often. I have been blogging for a long time, though, so the archives run deep. (if you do go into the archives, you’ll notice I occasionally contradict myself. That’s because I’m still learning.) The best way to keep up with this blog is the RSS feed.

If you want fresh content, these are some international development blogs that say everything more eloquently than I do, use data more effectively, or both:

Tales from the Hood (currently blogging from Haiti)

Good Intentions Are Not Enough

Owen Barder’s Blog

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photo credit: Jason-Morrison

Tags: About
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In the rush to engage on Haiti, a lot of well-meaning groups are jumping in to help. Some are brand new, and some have never worked on a disaster like this before. Most of these groups are going to be useless. Some will actually do harm to themselves or others. A tiny minority will have a positive impact. I wish those odds were better, but they’re not.

I’ve seen three bad ideas for helping in Haiti floating around recently. I don’t want to single anyone out for criticism – after all, everyone is trying to do good here. But in this case, the culture of nice may be letting bad programs hurt people. I need to say something.

Bad idea #1 – 50,000 Shoes The idea is to donate 50,000 shoes in 50 days for Haiti. They are asking for a $5 donation for each pair of shoes. The problem with this idea is that it’s based on an assumption – that lots and lots of shoes are what Haitians need right now. What if they need clothes? Or food? Or water purifiers? Should they sell their new shoes and use the money to buy those things? Has anyone done an assessment to find out if shoes are needed? To decide what kind of shoes are needed?

The shoes could end up wasted and useless, absorbing people’s donations without providing any benefit. They could clog supply lines that also bring in desperately needed medicines. They could keep the local shoe suppliers from rebounding after the earthquake, and if badly chosen for the Haitian climate they can give people disgusting fungus.

This is almost a good idea. The time-delimited fundraising with easy to remember numbers will drive people to donate, and they’ve got celebrity endorsements that are raising their profile.

How it could be a good idea – call it $500,000 in 50 days instead of 50,000 shoes. That would double their fundraising goal (since they are trying to provide $250,000 of shoes) but I think they could pull it off, considering their level of media attention. Then they could make a high profile donation, including a ceremony with one of those oversize checks on poster board to Partners in Health.

Bad idea #2 – Flight to Crisis Volunteer doctors and nurses are banding together to charter a flight to Haiti and help with medical care. It’s brave, it’s scrappy, and it shows amazing initiative. It’s also a horrible idea. The people don’t seem to have any plan from bringing in their own supplies and haven’t set up a place to stay in Haiti. They don’t have a hospital to work out of or any background in responding to this kind of disaster. This is exactly the kind of misguided effort I was afraid we’d see, because Haiti is close enough to the US to make it possible. For more information on why this is such a bad idea, read this account of another group of health care providers that chartered a plane.

How it could be a good idea - in about three months, when rebuilding gets serious and Haitians have time to think, this group could choose a Haitian hospital to partner with. They could fundraise to help it rebuild, and donate supplies and equipment. They could visit the hospital quarterly to train the providers there as needed, and make sure that the equipment is in good shape and well maintained.

Bad Idea #3 – The Global Volunteer Network Haiti Project This project, which volunteers pay to support, is seeking people to volunteer for the following projects: working with children, teaching, health/medical efforts, building and construction, counseling, and business development. They say that volunteer trips can run from one week long to six months. This list seems designed to please volunteers, not meet the needs of people in Haiti. You already know that I am not a supporter of trips where you pay to volunteer.

This, however, is even worse than usual. This isn’t just useless feel-goodery for rich people. This will hurt people in Haiti. Traumatized children should not be making emotional attachments to volunteers who will be gone in six months. Volunteer labor for building and construction will keep Haitians from getting paid jobs to do the work themselves. And no outsider volunteer has any business providing counseling; counseling needs a background in local culture and context that a visitor won’t have.

How it could be a good idea - It’s almost impossible to rescue this one, but short-term volunteers could offer brief, targeted English or French classes to Haitians who needed them. They could cover technical topics that local teachers might not be able to offer. Not in a week. There really isn’t anything useful you can do in a week. But two months might work. It really wouldn’t qualify as disaster response – or rebuilding – but it would at least be useful.

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Photo credit: simminch

Tags: Haiti, relief
Posted in Uncategorized | 12 Comments »

I’m writing less often for Blood & Milk because I am writing in other places now. Some recent stuff that might interest you:

The Lancet is Off-Base About Aid Agencies at UN Dispatch

Nobody Wants Your Old Shoes - How Not to Help Haiti - at Aid Watch

Teaching Americans What Haiti Needs - The New York Times (I didn’t write that one, I’m just quoted)

Should We Be Vacationing in Haiti Right Now? - at UN Dispatch

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Right now, the immediate emergency stage is already over, barring severe earthquake aftershocks. Tales From the Hood has some great posts up on Haiti and disaster relief. One excellent point:

I have a post at UN Dispatch on the health impact of an earthquake. Here’s the fast version – after the initial injuries are over, you need clean water, good toilets, and decent housing as fast as possible to prevent typhoid, dengue, and malaria.

Tales From the Hood, Aid Watch and Good Intentions are Not Enough all have suggestions for who to give to for Haiti. My own suggestion is this – the single most important thing you can do when choosing where to donate is to pick an organization with a history in Haiti. That will make all the different in the speed and quality of their work.

I gave my own Haiti donations to two groups: Partners in Health (PiH), and Architecture for Humanity. PiH, founded by Paul Farmer, has an excellent reputation and a long history in Haiti. It’s also big enough to absorb as many donations as it gets. Architecture for Humanity has longstanding ties to Haiti, and strong relationships in country. They will be focused on the rebuilding effort, which is very important. Experience with the Tsunami showed that it’s easy to waste funds on building new structures that are culturally and environmentally wrong. I trust Architecture for Humanity to help make sure that Haiti builds back better.

Edited to add one more thing - Haiti doesn’t need donated goods right now. It’s difficult and expensive to ship donated stuff, and most donations will not be appropriate for Haiti. Now is the time to give cash.

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Photo credit: American Red Cross

Tags: Haiti
Posted in Uncategorized | 6 Comments »

Well, I didn’t win the CSIS Smart Global Health Essay Contest, possibly because I argued against innovation in a contest that was explicitly looking for new ideas. I liked my essay, though, so I am sharing it here. CSIS was asking how the US government should spend their money on global health, and specifically looking for new and exciting ideas.

An Argument Against Innovation

Now is not the time for programming innovation. Instead, we should focus the next fifteen years on expanding the programs that work. Innovation is aimed at system-changing efforts that will lead to huge success or major failure; that’s not what we need right now. US government resources are not limitless, and we have a deep body of research in what works in global health. We have highly effective programs that are begging for funding; that is where our money should go. The government is well suited for the role of supporting boring but effective health interventions.

Global health research is full of solid, evidence evidence-based interventions that can have been proven to improve health. These include increasing access to contraception, increasing vaccination coverage, home visits by nurses or community health workers, and strengthening primary health care and training health care providers in Integrated Management of Childhood Illness (IMCI).

There are many effective pilot projects - proven to work - that have not been broadly implemented. Three examples:

Incorporate IMCI into physician and nurse education in every developing country. IMCI prevents stunting, promotes breastfeeding, and gets mothers to support child development by talking to their children more. It provides inexpensive, effective care for children. We know how train health care works in the strategy, and we know how to include it in medical education. The only thing stopping global adoption is money.

Meet the unmet demand for contraception. Studies have shown that giving couples access to contraception reduces child mortality rates, maternal mortality rates, and deaths from unsafe abortion. Letting women control their fertility also helps to promote gender equality and improve a family’s income. And contraception can be provided by trained health workers; a physician is not needed.

Put more resources into tropical diseases. Onchocerciasis control is a demonstrated success story, but 18 million people are still infected with the nematode that causes it. The African Programme for Onchocerciasis Control seeks to control the illness through universal treatment by 2010, but it will require financial support to keep providing the necessary drugs.

If we want to innovate, we should innovate with our funding models. The United States should start a fund that is devoted to supporting pilot projects that want to expand their reach. That would be an effective counterpoint to the many funding programs that provide “venture capital” for innovative efforts. Governments, NGOs, or UN agencies could apply for funding to scale up pilot programs with a certain number of years of experience, and a certain level of proven effectiveness.

Individuals and foundations love to fund innovative ideas and exciting new programs are easily marketed to foundations and philanthropic individuals. The Gates Foundation, for example, has a clear focus on innovation. In contrast, there is an important role for the US government in supporting the interventions that have been proven to succeed. The American government doesn’t does not need to sell its ideas to fickle donors or get intensive publicity for the work it does. Instead, it can commit to the slow and steady underpinnings of global health. It’s good for global health efforts to have reliable donors supporting programs that work, and it’s good for the American taxpayer to know that their money is going to projects that will definitely have an impact in improving global health.

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photo credit: Photo Denbow

Tags: rants
Posted in Uncategorized | 8 Comments »

These photos were published a couple of months ago, but I just ran into them today. A Norwegian photojournalist spent six weeks living in the slums of Nairobi, Caracas, and Jakarta. He took panoramic photographs of the homes that he saw there.

I found them extremely moving, in an unexpected way. This is not the usual set of poverty pity tragic pictures. That element is there – what do you say about the family in Jakarta living in a house you can’t stand up in? But what struck me was just how homey many of these slum dwellings are. No matter how small or desperate the structure was, people were doing their best to make it a home. The pictures feature decorations, family photos – efforts to make the spaces personal and welcoming.

It was a strong reminder of just how similar we humans are at our core. It was also a strong reminder that no matter how poor a person might be, you can never say they have nothing.

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Photo credit: Jonas Bendiksen

Tags: poverty
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1. It focuses on AIDS, TB, or malaria but is not coordinating or harmonized with global fund activities in country.
2. The staff are all clinicians, with no public health people.
3. The staff are all public health people, with no clinicians.
4. There is no plan to involve local or national health authorities in the project.
5. The project director is a clinician with no management experience.
6. It is planning on developing its own training content instead of adapting existing curricula to the current situation.
7. It depends on practicing physicians to serve as trainers, but has no plan to teach them the skills they will need to become trainers
8. There are no women on staff
9. It ignores the role of nurses in health care
10. The underlying conceptual model doesn’t make any sense or staff have trouble explaining it in a way that makes sense
11. The only monitoring indicator is how many people were trained
12. Training success is identified by pre and post tests of participant knowledge instead of testing their skills and whether they are actually using new skills in practice

Special guest additions:
13.Local partners/beneficiaries cheerfully insist that another expat program manager is the ONLY WAY to make the next phase sustainable…(from Tales from the Hood)
14. It’s a two-year contract and the only local staff are secretaries and drivers (from Texas in Africa)
15. You visit the public health office and they want to know why you’re taking away their public health volunteers (from Good Intentions Are Not Enough)

16. The per diem for your capacity building event is less than that for the World Bank project just down the road. (from Ian Thorpe)

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Photo Credit: REDRUM AYS
Chosen because searching for “doom” on flickr gets scary quickly, and my initials are AYS

Tags: common sense
Posted in Uncategorized | 6 Comments »

The Christmas story is one of the defining stories of American culture. The fact that I’m Muslim didn’t keep this story from shaping me. On Christmas, I think about the story and what it means for my own life.

Sometimes I think the story is about being just good enough. The innkeeper didn’t throw out an important customer to give Mary and Joseph a room - he wasn’t a hero. But he didn’t send them back outside, either. Instead, he offered them something small. A warm place to sleep. The best he could do without trying too hard, and that was all it took. Jesus was born out of the cold, somewhere safe and friendly. Somewhere good enough.

But the story could be about the animals, whose friendly presence makes the barn a warm and loving place instead of cold and frightening. About the way that ordinary beings, be they people or livestock, can offer extraordinary help to others when they get the chance to do so.

Maybe the story is about the wise men, and the shepherds. The ones with the perception to recognize a miracle when it occurred. How many of us are actually recognize the important things right when they happen?

Mary and Joseph might be the heart of the story – poor, struggling parents just trying to do their best for their child.

I’m not really sure who the most important character in the Christmas story is (beyond the obvious), and I’m not sure there is just one. All great stories have multiple meanings.

I wonder, though, which character I am. I suspect I’m the innkeeper, just trudging along at good enough. Or the parents, since I’m a mother. Or both; I can be more than one character. But most importantly, who do I want to be?

–Merry Christmas to all who celebrate it–

Tags: basics
Posted in Uncategorized | 8 Comments »

Speaking of cars, some things I have observed about cars and driving. They may or may not generalize:

1. When your project owns the cars, your drivers will be happy, enthusiastic types who show real commitment to your work. When you hire contract drivers who own the cars, you get cranky hard-cases who begrudge every extra mile they drive. Of course, contract drivers are also a much better financial choice.

2. The polite thing to do is to sit in front next to the driver, unless you’re in a high threat environment. In that case, sit in back so you can both dive to safety if there’s gunfire.

3. If you’re sitting in a parked car on a hot day, the best way to keep cool is to open your door and roll up the window, to divert any breeze you get into the car.

4. How to get into an ancient Landcruiser while wearing a skirt: Stand next to the car, facing forward. Put your left foot up onto the running board, and hold the grab handle with your left hand. Step up and pivot into the car, leading with your left hip. Slide into the seat. If you need to get out at some point, you are on your own. I haven’t mastered that yet.

5. Earplugs are a nice solution to the open window = noise, closed window = stifling hot dilemma. I like the kind you squish with your fingers. Obviously, this is a bad choice if you are the driver. In that case, roll up your own window and make your passengers open theirs.

6. You can back a 4×4 surprisingly far into an open drainage ditch without breaking an axle.

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Photo Credit: tjflex2
Chosen because I really hope I never have to do that with a car.

Tags: field life
Posted in Uncategorized | 7 Comments »