Things I’ve been thinking 6/17/2014


“Don’t think about where the lines are drawn, think about who draws the lines.” I rarely agree with The Last Psychiatrist, but it’s my go-to source for question assumptions and making the world look different. I found this post especially thought-provoking. 

This long blog post about disease diagnostics got me wondering if we’ve been prioritizing all the wrong things when we talk about improving laboratory skills. 

And, then, finally, these two pieces about children in the US just flat out devastated me. It’s conclusive evidence that we cant go around doing development work as though the US is the top of a pyramid we want everyone else to ascend in a similar way. 1) One American child in eight will experience maltreatment (abuse or negligence) in their lifetime that is confirmed by authorities. ONE IN EIGHT. and 2) One American child in four is born into poverty.  There is something deeply, deeply wrong in the way the US values (or doesn’t) children.

(photo credit: me)

Beautiful Poverty

old bus

This is an unusual post for me. It’s old, first of all – I wrote it in my personal journal, on actual paper, about six years ago, while on a work trip to a country I’m not going to name here. It’s moodier than I tend to be now. And it kind of reminds me of something that would be on Tales from the Hood, not Blood and Milk. But I still agree with it, so I thought I’d post.

In Uzbekistan I never really felt like taking pictures when I drove through rural areas. Uzbek villages are made of corrugated pre-fab boxes, no matter how small they here. The houses and barns all look the same, too, with their pale cement walls. This isn’t like that. Houses and barns are different shapes and sizes and materials and colors. And, as I looked at them, I realized why.

Here, it’s poor. Considerably poorer than Uzbekistan. That’s why there are thatched roofs and unusual buildings, why you can see cows grazing next to lean-to’s and buildings painted thirteen different colors.

And the poverty makes for great photography. Poverty has texture. Clean modern buildings give you a feeling of smoothness – they’re bland and unremarkable and rarely worth the film. The homes of the poor have none of that. Each one is unique, based on what people could afford and what they could find. They’re full of color, they’re rough, and there is nothing bland about them.

In other words, a good synonym for picturesque is desperate.

Aesthetics are seductive. It is hard not to like something because it’s pretty. That can lead you all sorts of terrible places; it can lead you to mistake tragedy for authenticity. It can make you think there is some value to authenticity when people are starving. It can lead you to take gorgeous pictures of the countryside without ever realizing that you are documenting a quiet horror.

Why you can’t understand global health

This is another reprint from my sadly abandoned Global Health Basics blog.

If you are reading this blog post, you can’t really understand the most important dynamic in global health: poverty and ill-health. They go together in a powerful vicious cycle. When you are poor you lack access to medical care and are you exposed to environmental factors that put you at a hugely increased risk of getting sick.

If you can read this, that’s not you. By definition, you speak English and you have access to the internet. You earn more than a dollar a day. You can’t understand.

It’s all well and good for people to opine and analyze global health issues. We can obsess about behavior change, system strengthening, and maximizing the value of dollars spent on health. But when you are poor, your life is a zero-sum game. Everything you do has a trade-off somewhere. There is no give in the system. It’s a level of decision management that is impossible to fully understand from the outside.

Among other things, that’s why bad treatments are destructive, even when they aren’t physically harmful. They cost money that is needed elsewhere, and take time that poor people need to spend doing things that support their basic survival. There is nothing unimportant that they can give up. Everything opportunity cost is brutal.

I can’t actually understand what it’s like to live that. Neither can you.* It is very important to remember that when we design programs. That’s the real reason that consulting with your communities is best practice. It’s not a new trend, a way to appease the donor or local government, or a belief in social justice. It’s because nobody except the poor knows what their lives are like. There is a role for outside experts to see opportunities and combinations, using their larger base of outside-the-system knowledge. But they don’t know what it’s like to live in poverty. Nobody does, except poor people.

*Unless you started your life that poor and accumulated wealth now. My dad did that; it’s not impossible. It is, however, rare.


(photo credit: cooperniall)

What Poor People Have

view of Indian slum home

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.

Photo credit: Jonas Bendiksen

Does poverty make people cruel?

A Tajik colleague told me, quite a while ago, that poverty makes people cruel. It stuck in my mind. The way she said it, as an absolute truism, resonated and reminded me of the cruel things I have seen poor people do. Mothers who sell their daughters in sex slavery, for example, or the horrors exerted on child laborers in Bangladesh. Or even, on a level down, the awful treatment of animals in many developing countries.

It seems impossible to argue that poverty leads to cruel things. Not really an interesting or disputed point. The real question, I suppose, is whether wealth also leads to cruelty. When you consider systemic cruelty, the answer is yes. The factory owner who benefits from child labor is as culpable as the parents who give their children to the factory. Probably more culpable, since the factory owner could make money in another way.

I posed the question of poverty and cruelty on Twitter, and I think that Ian Thorpe gave me the best answer. He suggested that inequality makes people cruel. That explains the people on the bottom end of the pyramid forced into cruel actions and cruel choices, and the people on the top end, so far from poverty that poor people and their problems no longer seem real to them. It’s easy to be cruel when you can’t see your victims. Or when you think their problems are inevitable and can’t be solved. Or when you think poor people make themselves poor or even aren’t quite human. Inequality creates the kind of distance that makes that happen.


(photo credit: myradphotos)

Chosen because it shows one of the cruelest forms of child labor.

Anger, control, and finding the zone

I have, once again, given up substantial amounts of control over my life.

Living overseas does that to you. Part of it is the expatriate experience. The language barrier makes it hard to know what’s going on much of the time, and the cultural gap means that even when you’ve got the language skills, you’re still missing most of the nuance of everything that’s happening around you. You don’t get to customize your environment like you would in your home country – you accept whatever flavor of juices is offered to you, and you let them paint the walls any color your landlord likes. Doing anything else is an exhausting and unpleasant way to spend your time. People who can’t give up control should stay home.

The loss of control runs deeper than being an outsider, though. The fact is that poor people have less control over their lives. This is the damage done by poverty. They cannot easily change jobs or locations, they are less resilient in the face of crisis, and they are at the mercy of often autocratic governments.

And when you go to live in a poor country, you accept those same limitations. You get special treatment for being an expat, yes, but there are limits to this. The police officer will do what he wants regardless of the facts of the situation. There is no treatment for HIV. The government just repossessed your house and now it will be torn down. Women can be beaten for undercooking dinner. That is how it is and your foreign passport can’t fix it.

It’s a fine line between realistically facing limitations, and accepting the very conditions that you are there to change. If you’re working for an anti-corruption project, you need to stay angry at cops who require bribes. If you’re trying to improve health, you need to identify the obstacles to HIV treatment (generally lack of funds and inability to write decent Global Fund grant, coupled with provider inexperience) and find a way around them.

If you push too hard and get too angry, you burn out, fast. It hurts you and it doesn’t do much for your projects. It could get you kicked out of the country. But if you are too laid back and do too little, you’re just a waste of funding that could be used for something that matters. You have to find that sweet spot, somewhere in between, where you don’t mind a late plane but you do mind physicians who must be bribed to provide care.

Finding that mental space is hard. Staying in it is harder. But it’s one of the many things you have to manage if you want to do things well.


(photo credit: Ko:(char *)hook)

Chosen because it’s a nice harmless photo of a control room – searching Flickr for “control” brings you freaky, freaky things.

Blog Action Day 2008: Poverty

Everything that matters in international development comes back to poverty. Poverty saps your ability to affect the path of your life, stay (or start out) healthy, find a job, or invest in education or a small business.

Information on global poverty:

Dani Rodrik talks about international poverty.

A nice Foreign Affairs article on reducing global poverty.

The World Bank’s most recent numbers on global poverty.

Oxfam’s take on reducing global poverty.

You will notice that not all of the sources I have listed agree with each other. Poverty is a complex topic, and there are no obvious answers on what to do. If you want to get involved in fighting global poverty, I suggest the ONE campaign. If you’d like to donate money to help alleviate global poverty, give to an NGO you already know and trust. Poverty is part of all our major problems, and fighting it is part of every solution. Donate to a food pantry in your home town, to Feeding America, International Medical Corps, or the Treatment Action Campaign or Oxfam. Every NGO trying to make the world a better place is fighting poverty one way or another; choose one that is credible and give what you can.

Blog Posts I’ve written that touch on poverty:

Briefing: Tuberculosis

Suffering does not make you special

Your money does not make you special

Keep your banana to yourself

Why health matters (if you only read one of my posts, read this one)